Addressing the drug-resistant tuberculosis challenge through implementing a mixed model of care in Uganda.

Worldwide, Drug-resistant Tuberculosis (DR-TB) remains a big problem; the diagnostic capacity has superseded the clinical management capacity thereby causing ethical challenges. In Sub-Saharan Africa, treatment is either inadequate or lacking and some diagnosed patients are on treatment waiting lists. In Uganda, various health system challenges impeded scale-up of DR-TB care in 2012; only three treatment initiation facilities existed, with only 41 of the estimated 1010 RR-TB/MDR-TB cases enrolled on treatment yet 300 were on the waiting list and there was no DR-TB treatment scale-up plan. To scale up care, the National TB and leprosy Program (NTLP) with partners rolled out a DR-TB mixed model of care. In this paper, we share achievements and outcomes resulting from the implementation of this mixed Model of DR-TB care. Routine NTLP DR-TB program data on treatment initiation site, number of patients enrolled, their demographic characteristics, patient category, disease classification (based on disease site and human immunodeficiency virus (HIV) status), on co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART) statuses, culture results, smear results and treatment outcomes (6, 12, and 24 months) from 2012 to 2017 RR-TB/MDR-TB cohorts were collected from all the 15 DR-TB treatment initiation sites and descriptive analysis was done using STATA version 14.2. We presented outcomes as the number of patient backlog cleared, DR-TB initiation sites, RR-TB/DR-TB cumulative patients enrolled, percentage of co-infected patients on the six, twelve interim and 24 months treatment outcomes as per the Uganda NTLP 2016 Programmatic Management of drug-resistant Tuberculosis (PMDT) guidelines (NTLP, 2016). Over the period 2013-2015, the RR-TB/MDR-TB Treatment success rate (TSR) was sustained between 70.1% and 74.1%, a performance that is well above the global TSR average rate of 50%. Additionally, the cure rate increased from 48.8% to 66.8% (P = 0.03). The Uganda DR-TB mixed model of care coupled with early application of continuous improvement approaches, enhanced cohort reviews and use of multi-disciplinary teams allowed for rapid DR-TB program expansion, rapid clearance of patient backlog, attainment of high cumulative enrollment and high treatment success rates. Sustainability of these achievements is needed to further reduce the DR-TB burden in the country. We highly recommend this mixed model of care in settings with similar challenges.

Public-private mix for TB and TB-HIV care in Lagos, Nigeria.

SETTING: Private and public tuberculosis (TB) treatment centres in Lagos State, Nigeria. OBJECTIVE: To assess the contribution of private health care providers to TB and TB-HIV (human immunodeficiency virus) case finding in Lagos State. DESIGN: A retrospective review of programme data submitted to the Lagos State TB and Leprosy Control Programme in 2011 by public, private for-profit (PFP) and private not-for-profit (PNFP) health care providers. RESULTS: A total of 8425 TB cases were notified by 31 private (11 PFP and 20 PNFP) and 99 public health facilities in Lagos State. Overall, the private facilities were responsible for 10.3% (866/8425) of the total TB cases notified. The proportion of TB patients tested for HIV was respectively 86.2%, 53.1% and 96.5% among public, PFP and PNFP facilities. Overall, 22.4% of the TB patients were HIV-positive. The HIV positivity rate among public, PFP and PNFP facilities was respectively 23.8%, 7.8% and 9.9%. Uptake of cotrimoxazole preventive therapy was respectively 69.6%, 25% and 38.2% among public, PFP and PNFP facilities, while that of antiretroviral therapy was respectively 23.8%, 8.3% and 9.1% in public, PFP and PNFP facilities. CONCLUSION: There is a need to scale up collaboration with the private sector, and particularly PNFP health providers.

HIV testing and treatment among tuberculosis patients --- Kenya, 2006-2009.

In resource-limited settings, high case-fatality rates are seen among tuberculosis (TB) patients with human immunodeficiency virus (HIV) infection, especially during the early months of TB treatment. HIV prevalence among TB patients has been estimated to be as high as 80%--90% in some areas of sub-Saharan Africa. In 2004, the World Health Organization (WHO) recommended increasing collaboration between HIV and TB programs. Since then, many countries, including Kenya, have worked to increase TB/HIV collaborative activities. In 2005, the Kenya Division of Leprosy, Tuberculosis, and Lung Disease (DLTLD) added questions regarding HIV testing and treatment to the existing TB surveillance system.* This report summarizes HIV data collected from Kenya's extended TB surveillance system during 2006--2009. During this period, HIV testing among TB patients increased from 60% in 2006 to 88% in 2009, and the prevalence of HIV infection among TB patients tested decreased from 52% to 44%. In 2009, 92% of HIV-infected TB patients received cotrimoxazole prophylaxis for the prevention of opportunistic infections. Although these data highlight the increase in HIV services provided to TB patients, only 34% of HIV-infected TB patients started antiretroviral therapy (ART) while being treated for TB. Innovative interventions are needed to increase HIV treatment among TB patients in Kenya, especially considering the 2009 WHO guidelines recommending that all HIV-infected TB patients be started on ART as soon as possible, regardless of CD4 count. Although these guidelines have not yet been implemented in Kenya, officials are working to identify methods of increasing access to ART for TB patients.

Successful treatment of immune reconstitution inflammatory syndrome in Whipple's disease using thalidomide.

A patient with classic Whipple's disease developed erythema nodosum leprosum-like lesions and fever one month after the beginning of an accurate therapy with trimethoprim-sulfamethoxazole. Immune reconstitution inflammatory syndrome was suspected, but corticosteroid therapy failed to improve the patient. Finally, thalidomide was used and successfully induced rapid improvement.

National scale-up of HIV testing and provision of HIV care to tuberculosis patients in Kenya.

SETTING: Kenya, one of the 22 tuberculosis (TB) high-burden countries, whose TB burden is fuelled by the human immunodeficiency virus (HIV). OBJECTIVE: To monitor and evaluate the implementation of HIV testing and provision of HIV care to TB patients in Kenya through the establishment of a routine TB-HIV integrated surveillance system. DESIGN: A descriptive report of the status of implementation of HIV testing and provision of HIV interventions to TB patients one year after the introduction of the revised TB case recording and reporting system. RESULTS: From July 2005 to June 2006, 88% of 112835 TB patients were reported to the National Leprosy and TB Control Programme, 98773 (87.9%) of whom were reported using a revised recording and reporting system that included TB-HIV indicators. HIV testing of TB patients increased from 31.5% at the beginning of this period to 59% at the end. Of the 46428 patients tested for HIV, 25558 (55%) were found to be HIV-positive, 85% of whom were provided with cotrimoxazole preventive treatment and 28% with antiretroviral treatment. CONCLUSION: A country-wide integrated TB-HIV surveillance system in TB patients can be implemented and provides essential data to monitor and evaluate TB-HIV related interventions.

Granulomatose de Wegener / Wegener's granulomatosis

A granulomatose de Wegener (GW) é considerada vasculite sistêmica granulomatosa necrotizante de vasos de pequeno e médio calibres, idiopática, com envolvimento multissistêmico, geralmente afetando trato respiratório e rins. Pode ser dividida em duas formas: clássica e limitada. Nesta última inexiste comprometimento renal. Os pacientes habitualmente apresentam febre, artralgias, nódulos esparsos na pele, ulceraçäo mucosa e tosse improdutiva. Os sintomas pulmonares podem variar desde sinusites até hemorragia pulmonar difusa e insuficiência respiratória. O envolvimento renal é comumente expresso pela insuficiência renal crônica (IRC). Dados laboratoriais inespecíficos refletem alteraçöes urinárias e anemia, pela IRC, e atividade inflamatória aguda. Em contraposiçäo, considera-se o ANCA o mais específico no diagnóstico. A radiografia de tórax pode mostrar infiltrados, nódulos ou cavitaçöes pulmonares. Nas biópsias observam-se vasculite neutrofílica ou granulomatosa necrotizante, com células gigantes nos granulomas epitelióides. O tratamento com corticosteróides e imunossupressores melhorou significativamente o prognóstico da doença. Uma revisäo da clínica, da histopatologia e dos achados laboratoriais da GW é apresentada, e, particularmente, as manifestaçöes cutâneas, pulmonares e renais säo discutidas.

Mycoserological study of the treatment of paediatric cystic fibrosis patients with Saccharomyces boulardii (Saccharomyces cerevisiae Hansen CBS 5926).

Saccharomyces boulardii (SB) (Saccharomces cerevisiae Hansen CBS 5926) is a yeast widely used in humans for the prevention and treatment of infectious enterocolitis. SB is said also to antagonize Candida albicans when given orally to living organisms. This double-blind trial was performed to determine the effect and tolerance of SB as an oral therapeutic in patients suffering from cystic fibrosis receiving long-term treatment with cephalosporins or cotrimoxazole, by examining C. albicans counts in the intestine. Extensive mycoserological examinations for drug safety evaluation were also performed. To be selected for the study patients had to present C. albicans in their intestinal flora. None of the patients enrolled exhibited clinical symptoms of candidosis. A daily dose of 750 mg (250 mg t.i.d.) of lyophilized SB given for 21 days did not affect the number of C. albicans commensals in those patients. However, the mycoserological data confirmed the safety of SB treatment with respect to a hypothetically possible SB fungaemia and a possible falsification of Candida serology.

A new short-term combination therapy of leprosy.

Report on the results with a new therapy with a complex combination (rifampicin + co-trimoxazole + isoniazid) for the treatment of leprosy. High tolerance. Duration of treatment 2 months.