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Worldwide, Drug-resistant Tuberculosis (DR-TB) remains a big problem; the diagnostic capacity has superseded the clinical management capacity thereby causing ethical challenges.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.

Indications for Rituximab Use in an Integrated Health Care Delivery System.

BACKGROUND: Rituximab is a top-selling biologic that was first approved by the FDA in 1997 for a non-Hodgkin lymphoma orphan indication. It has since been approved for additional orphan indications, with rheumatoid arthritis as the only FDA-approved, nonorphan indication. Evidence suggests that rituximab is frequently used off-label, but information on its use over time and indications for use in the United States is limited. OBJECTIVE: To assess incident rituximab use over time in an integrated health care delivery system. METHODS: This was a cross-sectional, retrospective study. Data were collected from administrative databases and manual chart reviews. Patients who received their first rituximab infusion between October 1, 2009, and December 31, 2017, and who were not a part of a clinical trial were included. Indication for use (FDA-approved orphan/nonorphan, off-label) was determined. Proportions of use were assessed over time. Multivariable logistic regression modeling was performed to assess factors associated with receiving rituximab for an FDA-approved indication. RESULTS: A total of 1,674 patients were included. The majority (66.4%) of patients had an FDA-approved indication, with lymphoma being the most common approved indication (66.4%). The most common indication for off-label use was neurologic conditions (72.7%), predominantly demyelinating diseases. Off-label indication use increased from 1.2% in 2009 to 55.6% in 2017. Factors associated with rituximab use for an FDA-approved indication included increased age (adjusted odds ratio [AOR] = 1.05, 95% CI = 1.04-1.07) and increased burden of chronic disease (chronic disease score: AOR = 1.07, 95% CI = 1.02-1.12; Charlson Comorbidity Index score: AOR = 3.52, 95% CI = 3.03-4.10). CONCLUSIONS: Off-label use of rituximab grew dramatically over the course of the study. With the recent FDA approval of the rituximab biosimilar and its expected lower price, off-label use will likely continue to rise. Opportunities for cost savings and to ensure appropriate use of these medications should be evaluated. DISCLOSURES: This study was funded by Kaiser Permanente. All authors except Hansen are employed by Kaiser Permanente. Hansen has nothing to disclose. Preliminary results were presented at the Mountain States Conference for Residents and Preceptors in May 2019 in Salt Lake City, UT, and at an encore presentation October 2019 at the American College of Clinical Pharmacy Annual Meeting in New York, NY.

Setting targets for HIV/AIDS-What lessons can be learned from other disease control programmes?

In a Collection Review, Richard Hayes and colleagues discuss metrics for assessing progress in control of the HIV/AIDS epidemic in the context of prior disease control programmes.

One year follow up of a cohort of suspected leprosy cases: findings from a leprosy 'Selective Special Drive' in Gadchiroli district, Maharashtra, India.

OBJECTIVES: The study involves a follow-up visit in 2010, to hyper-endemic Gadchiroli district of Maharashtra, India, to evaluate the current status of those suspected in 2009 of having skin/nerve lesions suggestive of leprosy, and to study the interactions between such people and the State leprosy programme. DESIGN: The study cohort comprised of those confirmed with leprosy (n = 151 and 157/233 absentee 'suspects' who were not examined by the study team in 2009 in 14 of 45 Primary Health Centres (PHCs). At follow-up, the treatment status of the confirmed cases was checked from PHC registers and cross-checked by direct questioning of patients and their views were sought on PHC leprosy services. The 157 absentee 'suspects' were queried about the reasons for their absence. RESULTS: Thirty nine 'absentee suspects' were found to have leprosy. A notable feature of the follow-up visit was that 114 people in the communities, other than those listed as 'suspects' by Community Health Workers (CHWs), voluntarily sought out the team for their opinion on hypopigmented/anaesthetic lesions, which resulted in a further 39 new cases being brought to light. (Total new cases = 78). The follow-up revealed discrepancies (100% vs. 75%) between PHC records and testimonies of the registered patients about regularity of treatment; irregularity of MDT supply was cited by some for dropping out of treatment. Other reasons proffered for irregularity were lepra reaction, fear of stigma, ignorance about leprosy and preference for faith healers. Medical Officers of PHCs were not trained in the management of lepra reactions; that task, along with disability care being entrusted to a paramedical worker of an NGO during periodic visits. CONCLUSIONS: There are remediable lacunae in the recording and dispensing of MDT by the State apparatus, as well as a need for refresher training in leprosy diagnosis for PHC staff, and in lepra reaction management for medical officers. The large number (78) of new cases detected in the follow-up, in part of Gadchiroli district strongly suggests more to-be-discovered cases in the communities.

La detección de la lepra y la humanización de la atención: acciones de enfermería en el programa de salud de la familia / No disponible

El municipio de São Gonçalo, en la Región Metropolitana de Río de Janeiro - Brasil es considerado una zona endémica de la lepra de acuerdo con el Ministerio de Salud. De esta observación, hemos tratado de identificar con este trabajo cuáles son las acciones realizadas por las enfermeras en El Programa de Salud Familiar (PSF) para detectar la lepra y qué tipo de atención prestan a las personas afectadas por la enfermedad, centrándose en la humanización. Así, se realizó investigación descriptiva, cualitativa y de campo en las unidades de salud de la familia de esa ciudad, con treinta y un enfermeros a través de entrevistas con preguntas abiertas. Emergiendo dos categorías: las acciones de detección de la enfermera del PSF, la atención prestada a las personas afectadas y la necesaria humanización de esos cuidados. Se concluyó que las medidas adoptadas por las enfermeras no siguen un estándar único y que algunas no tienen la capacitación necesaria para desenvolverse con los usuarios del PSF afectadas por la lepra (AU)

The Municipality of São Gonçalo in the Metropolitan Region of Rio de Janeiro - Brazil is considered an endemic area for leprosy according to the Ministry of Health. From this observation, we sought to identify with this work which actions are performed by nurses from Family Health Program (PSF) to detect leprosy and what care they provide to people affected by the disease, with the focus on humanization. Thus, we performed descriptive, qualitative and field units in the health of the family of that city, with thirty-one nurses through interviews with open questions. Two categories emerged: the detection actions made by the nurse, the care given to people affected and the humanization of care needed. It was concluded that the actions taken by the nurses do not follow a single standard and that some lack the necessary training to function with users of PSF affected by leprosy (AU)

Counselling of leprosy affected persons and the community.

"Counselling is a helping process where one person explicitly and purposefully gives his/her time, attention and skills to assist a client to explore their situation, identity and act upon solutions within the limitations of their given environment". The GATHER (greet, ask, tell, help, explain, return visit) technique can be useful in successful counselling. Counselling services have been proven successful in reducing stigma. While the scope for counselling is quite enormous, it will vary according to the specific need. The few common points which have been detailed in the text must be followed by all while providing counselling in different situations. The points as specified are: (1) Counselling of new patients. (2) Counselling of patients under treatment for few months. (3) Counselling of patients on completion of treatment. (4) Counselling of family members. (5) Counselling of community members. The points mentioned are about issues on which counselling should be centred.

La asistencia a los enfermos en Mallorca durante el antiguo regimen

Se relata la endemia de esta enfermedad en la isla entre lso años de 1456 y 1719. Se hace hincapié en el aislamiento voluntario o forzoso del enfermos, teniédole recluido en precarias condiciones. Estos hospitales, aunque a veces se intentó, nunca se unieron a los destinados a otras enfermedades, por ser considerada la lepra como enfermedad/castigo.