Summary Given the dual epidemics of HIV and tuberculosis in sub-Saharan Africa and evidence suggesting a disproportionate burden of these diseases among detainees in the region, we aimed to ...investigate the epidemiology of HIV and tuberculosis in prison populations, describe services available and challenges to service delivery, and identify priority areas for programmatically relevant research in sub-Saharan African prisons. To this end, we reviewed literature on HIV and tuberculosis in sub-Saharan African prisons published between 2011 and 2015, and identified data from only 24 of the 49 countries in the region. Where data were available, they were frequently of poor quality and rarely nationally representative. Prevalence of HIV infection ranged from 2·3% to 34·9%, and of tuberculosis from 0·4 to 16·3%; detainees nearly always had a higher prevalence of both diseases than did the non-incarcerated population in the same country. We identified barriers to prevention, treatment, and care services in published work and through five case studies of prison health policies and services in Zambia, South Africa, Malawi, Nigeria, and Benin. These barriers included severe financial and human-resource limitations and fragmented referral systems that prevent continuity of care when detainees cycle into and out of prison, or move between prisons. These challenges are set against the backdrop of weak health and criminal-justice systems, high rates of pre-trial detention, and overcrowding. A few examples of promising practices exist, including routine voluntary testing for HIV and screening for tuberculosis upon entry to South African and the largest Zambian prisons, reforms to pre-trial detention in South Africa, integration of mental health services into a health package in selected Malawian prisons, and task sharing to include detainees in care provision through peer-educator programmes in Rwanda, Zimbabwe, Zambia, and South Africa. However, substantial additional investments are required throughout sub-Saharan Africa to develop country-level policy guidance, build human-resource capacity, and strengthen prison health systems to ensure universal access to HIV and tuberculsosis prevention, treatment, and care of a standard that meets international goals and human rights obligations.
Screening household contacts of TB patients and providing TB preventive therapy (TPT) is a key intervention to end the TB epidemic. Global and timely implementation of TPT in household contacts, ...however, is dismal. We adapted the 7-1-7 timeliness metric designed to evaluate and respond to infectious disease outbreaks or pandemics, and assessed the feasibility, enablers and challenges of implementing this metric for screening and management of household contacts of index patients with bacteriologically-confirmed pulmonary TB in Karachi city, Pakistan.
We conducted an explanatory mixed methods study with a quantitative component (cohort design) followed by a qualitative component (descriptive design with focus group discussions).
From January-June 2023, 92% of 450 index patients had their household contacts line-listed within seven days of initiating anti-TB treatment ("first 7"). In 84% of 1342 household contacts, screening outcomes were ascertained within one day of line-listing ("next 1"). In 35% of 256 household contacts eligible for further evaluation by a medical officer (aged ≤5 years or with chest symptoms), anti-tuberculosis treatment, TPT or a decision for no drugs was made within seven days of symptom screening ("second 7"). The principal reason for not starting anti-tuberculosis treatment or TPT was failure to consult a medical officer: only 129(50%) of 256 contacts consulted a medical officer. Reasons for poor performance in the "second 7" component included travel costs to see a medical officer, loss of daily earnings and fear of a TB diagnosis. Field staff reported that timeliness metrics motivated them to take prompt action in household contact screening and TPT provision and they suggested these be included in national guidelines.
Field staff found "7-1-7" timeliness metrics to be feasible and useful. Integration of these metrics into national guidelines could improve timeliness of diagnosis, treatment and prevention of TB within households of index patients.
Task shifting is common in high-income countries, examples include nurse practitioners in the USA, nurse clinicians in Sweden,1 and expert patients for diabetes care.2 In several countries in ...sub-Saharan Africa, specific cadres of non-physician health workers have been created to do clinical tasks in places where physicians are scarce, such as in rural areas.3-5 Besides these non-physician clinicians, well known examples of the use of lay workers include the community health worker and the community-based volunteer for giving guardian-based directly observed treatment, short course (DOTS), for tuberculosis.6 In developing countries, and especially in sub-Saharan Africa, the lack of qualified health workers is recognised as a crisis by the international community7 (table). The scale-up of HIV/AIDS care, in particular, poses challenges for health systems that are already struggling with an absolute shortage of qualified health staff.8,9 Within WHO's Treat, Train, Retain (TTR) initiative, task shifting is receiving increasing attention as a measure to allow ART roll-out in contexts with shortages of human resources.
Objective
To describe Ebola cases in the district Ebola management centre of in Kailahun, a remote rural district of Sierra Leone, in terms of geographic origin, patient and hospitalisation ...characteristics, treatment outcomes and time from symptom onset to admission.
Methods
Data of all Ebola cases from June 23rd to October 5th 2014 were reviewed. Ebola was confirmed by reverse‐transcriptase‐polymerase‐chain‐reaction assay.
Results
Of 489 confirmed cases (51% male, median age 28 years), 166 (34%) originated outside Kailahun district. Twenty‐eight (6%) were health workers: 2 doctors, 11 nurses, 2 laboratory technicians, 7 community health workers and 6 other cadres. More than 50% of patients had fever, headache, abdominal pain, diarrhoea/vomiting. An unusual feature was cough in 40%. Unexplained bleeding was reported in 5%. Outcomes for the 489 confirmed cases were 227 (47%) discharges, 259 (53%) deaths and 3 transfers. Case fatality in health workers (68%) was higher than other occupations (52%, P = 0.05). The median community infectivity time was 6.5 days for both general population and health workers (P = 0.4).
Conclusions
One in three admitted cases originated outside Kailahun district due to limited national access to Ebola management centres – complicating contact tracing, safe burial and disinfection measures. The comparatively high case fatality among health workers requires attention. The community infectivity time needs to be reduced to prevent continued transmission.
Objectif
Décrire les cas d'Ebola dans le Centre de prise en charge Ebola à Kailahun, un district rural reculé de la Sierra Leone, en termes d'origine géographique, des caractéristiques des patients et d'hospitalisation, des résultats du traitement et du temps entre l'apparition des symptômes et l'admission.
Méthodes
Les données de tous les cas d'Ebola du 23 juin au 5 octobre 2014 ont été examinées. Ebola a été confirmé par un test de réaction en chaîne de la polymérase couplée à la transcriptase inverse.
Résultats
Sur 489 cas confirmés (51% de sexe masculin, âge médian: 28 ans), 166 (34%) provenaient de l'extérieur du district de Kailahun. Vingt‐huit (6%) cas étaient des agents de la santé: 2 médecins, 11 infirmières, 2 techniciens de laboratoire, 7 agents de la santé communautaires et 6 autres cadres. Plus de 50% des patients avaient de la fièvre, des maux de tête, des douleurs abdominales, de la diarrhée et des vomissements. Une caractéristique inhabituelle était la toux chez 40% des cas. Des saignements inexpliqués ont été rapportés chez 5% des cas. Les résultats pour les 489 cas confirmés étaient: 227 (47%) guérisons, 259 (53%) décès et 3 transferts. Le taux de létalité chez les agents de la santé (68%) était plus élevé que pour les autres professions (52%, P = 0,05). Le délai médian d'infectivité dans la communauté était de 6,5 jours, à la fois dans la population générale et chez les agents la santé (P = 0,4).
Conclusions
Un cas admis sur trois provenaient de l'extérieur district de Kailahun à cause de l'accès limité aux centres nationaux de prise en charge Ebola – compliquant ainsi la recherche des contacts, les mesures d'inhumation et de désinfection sûres. Le taux de létalité relativement élevé chez les agents de la santé nécessite une attention particulière. Le délai d'infectivité dans la communauté devrait être réduit afin de pouvoir prévenir la transmission continue.
Objetivo
Describir los casos de Ébola en el Centro para el Manejo del Ébola del distrito Kailahun, un distrito rural remoto de Sierra Leona, en términos de origen geográfico, características del paciente y de la hospitalización, resultados del tratamiento y tiempo desde el comienzo de los síntomas hasta ser admitido.
Métodos
Se revisaron los datos de todos los casos de Ébola entre el 23 de Junio y el 5 de Octubre del 2014. El Ébola se confirmó mediante un ensayo de reacción en cadena de la polimerasa con transcriptasa inversa.
Resultados
De 489 casos confirmados (51% eran hombres, con una edad media de 28 años) y 166 (34%) se habían originado fuera del distrito de Kailahun. Veintiocho (6%) eran trabajadores sanitarios: 2 doctores, 11 enfermeras, 2 técnicos de laboratorio, 7 trabajadores sanitarios comunitarios y 6 tenían otros perfiles. Más de un 50% de los pacientes presentaban fiebre, dolor de cabeza, dolor abdominal, diarrea/vómito. Una característica inusual era la tos en un 40%. Se reportó sangrado sin explicación aparente en un 5%. Los resultados de los 489 casos confirmados fueron: 227 (47%) dados de alta, 259 (53%) decesos y 3 transferencias. La tasa de letalidad entre trabajadores sanitarios (68%) era mayor que entre otras ocupaciones (52%, P= 0.05). El tiempo medio de infectividad en la comunidad era de 6.5 días, tanto para la población general como para los trabajadores sanitarios.
Conclusiones
Uno de cada tres casos ingresados se habían originado fuera del distrito de Kailahun, debido al acceso limitado a nivel nacional a los Centros para el Manejo del Ébola – lo cual complica el seguimiento de contactos, un entierro seguro y el control de las medidas de desinfección. La mortalidad comparativamente mayor entre trabajadores sanitarios requiere de atención. El tiempo de infectividad en la comunidad debería reducirse para prevenir la transmisión continuada.
The logistics of delivery will be improved, the risks of running out of stocks lessened, the need for multiple guidelines and training eliminated, and the likelihood of successful implementation ...increased. ... the proposed regimen is available in a fixed-dose combination of one tablet per day, can be safely used with antituberculosis drugs, is effective against hepatitis B virus, and can be used without routine laboratory monitoring of toxic effects.9 We propose to offer all HIV-infected pregnant women lifelong ART.
Summary Despite policies, strategies, and guidelines, the epidemic of HIV-associated tuberculosis continues to rage, particularly in southern Africa. We focus our attention on the regions with the ...greatest burden of disease, especially sub-Saharan Africa, and concentrate on prevention of tuberculosis in people with HIV infection, a challenge that has been greatly neglected. We argue for a much more aggressive approach to early diagnosis and treatment of HIV infection in affected communities, and propose urgent assessment of frequent testing for HIV and early start of antiretroviral treatment (ART). This approach should result in short-term and long-term declines in tuberculosis incidence through individual immune reconstitution and reduced HIV transmission. Implementation of the 3Is policy (intensified tuberculosis case finding, infection control, and isoniazid preventive therapy) for prevention of HIV-associated tuberculosis, combined with earlier start of ART, will reduce the burden of tuberculosis in people with HIV infection and provide a safe clinical environment for delivery of ART. Some progress is being made in provision of HIV care to HIV-infected patients with tuberculosis, but too few receive co-trimoxazole prophylaxis and ART. We make practical recommendations about how to improve this situation. Early HIV diagnosis and treatment, the 3Is, and a comprehensive package of HIV care, in association with directly observed therapy, short-course (DOTS) for tuberculosis, form the basis of prevention and control of HIV-associated tuberculosis. This call to action recommends that both HIV and tuberculosis programmes exhort implementation of strategies that are known to be effective, and test innovative strategies that could work. The continuing HIV-associated tuberculosis epidemic needs bold but responsible action, without which the future will simply mirror the past.
Among adults started on antiretroviral treatment (ART) in a rural district hospital (a) to determine the cumulative proportion of deaths that occur within 3 and 6 months of starting ART, and (b) to ...identify risk factors that may be associated with such mortality.
A cross-sectional analytical study set in Thyolo district, Malawi.
Over a 2-year period (April 2003 to April 2005) mortality within the first 3 and 6 months of starting ART was determined and risk factors were examined.
A total of 1507 individuals (517 men and 990 women), whose median age was 35 years were included in the study. There were a total of 190 (12.6%) deaths on ART of which 116 (61%) occurred within the first 3 months (very early mortality) and 150 (79%) during the first 6 months of initiating ART. Significant risk factors associated with such mortality included WHO stage IV disease, a baseline CD4 cell count under 50 cells/mul and increasing grades of malnutrition. A linear trend in mortality was observed with increasing grades of malnutrition (chi for trend = 96.1, P </= 0.001) and decreasing CD4 cell counts (chi for trend = 72.4, P </= 0.001). Individuals who were severely malnourished body mass index (BMI) < 16.0 kg/m had a six times higher risk of dying in the first 3 months than those with a normal nutritional status.
Among individuals starting ART, the BMI and clinical staging could be important screening tools for use to identify and target individuals who, despite ART, are still at a high risk of early death.
This study aimed to determine the performance of infection prevention and control (IPC) programs in eight core components in level 2 and level 3 hospitals across all provinces in Colombia.
This ...cross-sectional study used self-assessed IPC performance data voluntarily reported by hospitals to the Ministry of Health and Social Protection during 2021. Each of the eight core components of the World Health Organization's checklist in the Infection Prevention and Control Assessment Framework contributes a maximum score of 100, and the overall IPC performance score is the sum of these component scores. IPC performance is graded according to the overall score as inadequate (0-200), basic (201-400), intermediate (401-600) or advanced (601-800).
Of the 441 level 2 and level 3 hospitals, 267 (61%) reported their IPC performance. The median (interquartile range IQR) overall IPC score was 672 (IQR: 578-715). Of the 267 hospitals reporting, 187 (70%) achieved an advanced level of IPC. The median overall IPC score was significantly higher in private hospitals (690, IQR: 598-725) than in public hospitals (629, IQR: 538-683) (
< 0.001). Among the core components, scores were highest for the category assessing IPC guidelines (median score: 97.5) and lowest for the category assessing workload, staffing and bed occupancy (median score: 70). Median overall IPC scores varied across the provinces (
< 0.001).
This countrywide assessment showed that 70% of surveyed hospitals achieved a self-reported advanced level of IPC performance, which reflects progress in building health system resilience. Since only 61% of eligible hospitals participated, an important next step is to ensure the participation of all hospitals in future assessments.
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