"Home is where the patient is": a qualitative analysis of a patient-centred model of care for multi-drug resistant tuberculosis.

BACKGROUND: Ambulatory, community-based care for multi-drug resistant tuberculosis (MDR-TB) has been found to be effective in multiple settings with high cure rates. However, little is known about patient preferences around models of MDR-TB care. Médecins Sans Frontières (MSF) has delivered home-based MDR-TB treatment in the rural Kitgum and Lamwo districts of northern Uganda since 2009 in collaboration with the Ministry of Health and the National TB and Leprosy Programme. We conducted a qualitative study examining the experience of patients and key stakeholders of home-based MDR-TB treatment. METHODS: We used semi-structured interviews and focus-group discussions to examine patients' perceptions, views and experiences of home-based treatment and care for MDR-TB versus their perceptions of care in hospital. We identified how these perceptions interacted with those of their families and other stakeholders involved with TB. Participants were selected purposively following a stakeholder analysis. Sample size was determined by data saturation being reached within each identified homogenous category of respondents: health-care receiving, health-care providing and key informant. Iterative data collection and analysis enabled adaptation of topic guides and testing of emerging themes. The grounded theory method of analysis was applied, with data, codes and categories being continually compared and refined. RESULTS: Several key themes emerged: the perceived preference and acceptability of home-based treatment and care as a model of MDR-TB treatment by patients, family, community members and health-care workers; the fear of transmission of other infections within hospital settings; and the identification of MDR-TB developing through poor adherence to and inadequate treatment regimens for DS-TB. CONCLUSIONS: Home-based treatment and care was acceptable to patients, families, communities and health-care workers and was seen as preferable to hospital-based care by most respondents. Home-based care was perceived as safe, conducive to recovery, facilitating psychosocial support and allowing more free time and earning potential for patients and caretakers. These findings could contribute to development of an adaptation of treatment approach strategy at national level.

Tuberculosis extremadamente resistente (TB-XDR), historia y situación actual / Extremely resistant tuberculosis (XDR-TB), history and current situation

Las enfermedades ocasionadas por micobacterias constituyen sin duda un capítulo importante de la patología infecciosa en la historia de la humanidad encontrandose desde sus albores enfermedades tan antiguas como la tuberculosis y la lepra, asi como otras las producidas por otras micobacterias. La tuberculosis es una micobacteriosis causada por el Complejo Mycobacteria Tuberculosis, en la que se encuentra comprendida el Mycobacterium tuberculosis. Este evolutivamente al igual que la humanidad ha afinando sus mecanismos de sobrevivencia y resistencia a sustancias antibioticas. Como otros microorganismos, la base de la resistencia del Mycobacterium tuberculosis es la selección de bacterias mutantes con resistencia innata a las drogas antituberculosas existentes, asi en virtud a este fenómeno adaptativo-evolutivo surge una subpoblación de Mycobacteria Tuberculosis extremadamente resistentes al tratamiento antibioterápico múltiple, con un pronostico de sobrevida sobre los pacientes pobre y diferente al de las subpoblaciones catalagadas como tbc multidrogo resistente o TB-MDR. Hasta junio de 2008 la TB XDR se ha reportado en 49 países, entre ellos el Perú. Un solo caso de TB XDR y el estudio de sus contactos deben ser enfocados como una emergencia sanitaria. El desarrollo de la TB XDR revela debilitamiento de los servicios asistenciales en el primer nivel de atención. Los dos factores de riesgo más fuertemente asociados con la TB XDR son: 1) Fracaso a un régimen antituberculoso que contiene drogas de segunda línea que incluye un inyectable y una fluoroquinolona y 2) Contacto estrecho con un individuo con TB XDR documentada o que viene fracasando a un esquema con drogas de segunda línea. El enfoque que debe darse a la TB-XDR, desde un punto de vista de salud pública, es el de una emergencia sanitaria, por lo que se debe lograr los recursos financieros necesarios para controlar su diseminación, lo que pasa por diagnósticos precoces, tratamientos oportunos, ...

Diseases caused by Mycobacteria are an important area within infectious diseases in mankindÆs history, and since early times conditions such as tuberculosis (TB) and leprosy (HansenÆs disease) had already been described. This also holds true for diseases caused by other Mycobacteria. Tuberculosis is a mycobacterial disease caused by Mycobacteria tuberculosis complex, being Mycobacterium tuberculosis one of its most conspicuous components. This microorganism has perfected its mechanisms for survival, allowing it to develop resistance against antituberculous therapy. As it is the case for other microorganisms, the basis for M. tuberculosis resistance is the selection of mutant bacteria with innate resistance to currently available antituberculous drugs; so, by virtue of this adaptive and evolutive phenomenon, there is the emergence of a subpopulation of M. tuberculosis that is extremely resistant to multiple antituberculous drugs, and the survival prognosis for patients with TB disease caused by these particular microorganism is quite poor, so different to that in subpopulations with TB disease caused by multidrug-resistant (MDR-TB) M. tuberculosis. Until June 2008, XDR-TB had been reported in 49 countries, Peru amongst them. The occurrence of a single case of XDR-TB and its contacts must be approached as a sanitary emergency. The development of XDR-TB reflects a weakening of healthcare services, particularly those at the first level or primary care. The two most important risk factors associated with the occurrence of XDR-TB are: 1) failure with a second-line antituberculous drug regimen including one injectable drug and a fluoroquinolone, and 2) close contact with any individual with documented XDR-TB who is failing with a second-line antituberculous drug regimen. XDR-TB must be approached as a sanitary emergency, so adequate financial resources must be allocated for controlling its spread, which means having early diagnosis, timely therapy, integral ...

Immunotherapy with Mycobacterium vaccae in the treatment of tuberculosis.

All the trials of immunotherapy of tuberculosis with killed Mycobacterium vaccae, published or not, that are known to the authors are reviewed here. Following an introduction giving a brief account of some earlier immunotherapies for tuberculosis, the origins of the concept of immunotherapy with M.vaccae are considered. Progress is traced from the early work with irradiation-killed organisms in leprosy to the study in London of modulation of tuberculin skin-test responses, and the first comparative trials in The Gambia and Kuwait. In the last of these studies, dosages and different preparations were compared. As a result of this subsequent studies have used 109 heat-killed organisms, equivalent to 1mg wet-weight of bacilli, as a standard dose. A series of small trials in Argentina, India, Nigeria, Romania, South Africa and Vietnam have pioneered the way forward, disclosing geographic variability, with South Africa as the only country where almost no effects were recorded. Together the studies have shown that a single dose may not be sufficient. These studies have confirmed the mode of action of M.vaccae to be regulation of cell-mediated immunity with enhancement of Th1 and down-regulation of Th2, and they have shown benefits in faster bacteriological conversion, reduction in ESR, recovery of body weight and resolution of radiological opacities, leading to better recovery from the disease even when given to patients receiving directly observed therapy, short-course (DOTS). Three major randomised, placebo-controlled and partly blinded trials have been carried out in Africa. The first, in South Africa showed no M.vaccae-related effects. The second trial, in Uganda, confirmed the observations made in the earlier studies of faster sputum conversion and better radiological clearance. The third trial, in Zambia and Malawi, showed a trend towards benefits in the treatment of HIV seronegative patients but failed to show beneficial effects in HIV seropositive patients. Studies in patients with multi-drug-resistant tuberculosis have shown that multiple doses of immunotherapy are required in most cases, and that these markedly improve cure-rates for these patients. This is especially so when they are also treated with chemotherapy tailored to the resistance pattern of their infecting organisms. A small study has just commenced in which repeated doses of M.vaccae are being administered to a group of patients who have failed treatment with DOTS-Plus (directly observed therapy with drugs selected on the basis of drug susceptibility profiles). Late in the investigation came publications from China supporting and confirming the data in both drug-sensitive and drug-resistant disease, by the use of multiple injections of their own different preparation of M.vaccae. The trial that is now beginning in Vietnam of 3 doses of M.vaccae in the treatment of newly diagnosed pulmonary tuberculosis, is accompanied by a chemotherapeutic regimen with a shortened continuation phase. If this important study is successful, immunotherapy with killed M.vaccae should be introduced into the treatment regimens for tuberculosis worldwide.