TUBERCULOSIS: SOUTH AFRICA: What the world's largest preventative TB study taught us

JOHANNESBURG, 13 March 2012 (PlusNews) -

 Photo: WHO
Slow implementation of IPT

Even though the world's largest study of preventative tuberculosis therapy indicated that community-wide isoniazid preventative TB therapy (IPT) failed to lower community TB levels among 27,000 South African gold miners, that was not Thibela’s only result. We review some of the others over its seven years:

1. You do not always need an X-ray: In southern Africa, health workers and patients in rural areas often cannot access X-rays to confirm or rule out active pulmonary TB. Without X-rays to verify that patients did not have active TB, many physicians were unwilling to start patients on IPT. Thibela found that health workers could exclude at least 90 percent of active TB cases through sputum testing and symptom screening – asking patients if they were experiencing night sweats, a persistent cough or weight loss. Based in part on these findings, South Africa's latest IPT guidelines issued in June 2010 no longer require chest X-rays and TB skin tests to start HIV-positive patients on IPT.
However, in high TB prevalence settings, researchers noted that chest X-rays increased TB case detection.

2. IPT and HIV: People living with HIV, which compromises the immune system, are up to 37 times more likely to develop active TB. Findings from Thibela were able to confirm what many had long suspected but had failed to prove: that IPT provision to people living with HIV reduced their likelihood of dying. In fact, Thibela researchers showed it halved the risk of death among HIV-positive patients on or just starting antiretrovirals (ARVs). Based on this finding, South African guidelines no longer discourage the use of IPT in ARV patients.

3. Slamming side-effects: Although the World Health Organization had been recommending IPT since 1999, implementation has been slow, partly due to challenges in TB screening and doctors' fears of possible side-effects, most notably liver damage. Thibela researchers, however, found only a small number of cases of liver damage and these were among heavy drinkers. The most commonly reported side-effect of IPT was increased appetite.

4. Ignorance is not always bliss: IPT roll-out has been slow globally but in South Africa, coverage was below 1 percent in 2010 - eight years after the country introduced the preventative therapy. Zambia has only recently begun piloting IPT.
Thibela researchers found that doctors were unwilling to prescribe the drug to patients because they did not know about the drug's TB prevention benefits and did not have experience in prescribing it. Some doctors said they preferred to wait to treat TB with more familiar drug courses than to prevent it.

5. Mobilizing men: Although Thibela eventually included about 27,000 mine workers, mostly men - 80,000 indicated they would be willing to participate in the study. Thibela published research on the community mobilization and education strategies it used to get men on board in a November 2010 supplement of the medical journal, AIDS.
"The uptake we achieved was truly remarkable, especially when you consider it was almost an exclusively male population and men are notoriously poor adopters of health strategies," said Thibela's lead researcher and chief executive officer of South Africa's Aurum Institute for Health, Gavin Churchyard. "We've shown that it is possible to mobilize an entire population to adopt a health prevention strategy."
Strategies that worked well to drive up men's willingness to participate included the use of peer educators, community events and incentives tied to project phases. Less popular were the use of mobile-phone messaging due to frequent phone number changes, and treatment buddies, which sparked privacy concerns among actual trial participants.
http://www.plusnews.org/Report/95064/SOUTH-AFRICA-What-the-world-s-largest-preventative-TB-study-taught-us

MALARIA: Battling Africa’s Number One Killer

April 22nd, 2011
Jennifer Weiss – health advisor for Concern Worldwide, an international humanitarian organization. She currently manages Concern’s Child Survival programs in Rwanda, Burundi, and Niger. A former Peace Corps volunteer in Honduras, she holds a Masters in Public Health from Tulane University.





Mukarurangwa Cecile, a community health worker in Marebe, Rwanda visits the home of Valentine, 3, to examine the cause of his fever. Photo: Esther Havens, Rwanda.

According to estimates from the United Nations and the World Health Organization (WHO), nearly one million children do not reach their fifth birthday because they die from malaria each year. Ninety percent of these deaths occur in Africa, where malaria remains the number one killer of young children. An additional 30 million pregnant women and their newborns are also at risk of malaria infection, which may lead to stillbirth, spontaneous abortion, low weight, and neonatal death.
Pregnant women and children die from malaria because they lack access to low-cost, effective solutions to both prevent and treat the disease. Concern is working to change this through our USAID-funded Child Survival programs in Rwanda, Burundi, and Niger, which provide life-saving malaria prevention and control to a total of 1.2 million women and children.


 Josepine Mukahirwa, a community health worker of 3 years, visits the home of Tuyishime Sylvie, 26, in Gasambu to educate on the importance of using a bed net. Photo: Esther Havens, Rwanda

The most obvious way to control malaria is to protect people from being bitten by malaria-carrying mosquitoes in the first place. People are at the highest risk of being bitten at night, while they are sleeping. Therefore, sleeping under a mosquito net, which is treated with a long-lasting insecticide, is a simple solution with dramatic results: at an average cost of about $10, long-lasting insecticide treated bed nets have been shown to reduce malaria transmission by 90 percent.
Concern works with local partner and governments to provide long-lasting insecticide treated nets to the people that need them the most: pregnant women and children under 5 years of age. Concern’s cadre of Community Health Workers then provides one-on-one counseling during household visits to further encourage parents to have their young children sleep under the bed net, and answer any questions or address any challenges the family may be facing in their use.
In Rwanda, Concern’s Child Survival Program is on target to ensure that 85 percent of all households own at least one bed net, and that pregnant women and children under the age of five are sleeping under them each night.
Another life-saving prevention technology recommended by WHO is to provide all pregnant women with at least two preventive treatment doses of an effective anti-malarial drug during routine antenatal clinic visits. Intermittent preventive treatment (IPT), as it is called, has been shown to dramatically reduce maternal anemia and low birth weight, and other adverse effects of malaria during pregnancy. However, many country governments are struggling to provide this service to all pregnant women during their antenatal care visits.
In Niger, Concern’s Community Health Workers are educating mothers about the importance of IPT, and the program is training health facility staff to provide IPT, in order to ensure that 70 percent of all mothers received the recommended two doses of IPT during their last pregnancy.

 Early diagnosis of malaria is critical to ensure prompt access to life-saving treatment. Photo: Esther Havens, Rwanda

However, in 2009, only 35 percent of malaria cases were confirmed with a diagnostic test, which requires a skilled laboratory technician and appropriate equipment. Therefore, the majority of malaria diagnoses in sub-Saharan Africa are based on symptoms alone—many of which (fever, difficulty breathing, reduced appetite) are also symptoms of pneumonia. Treatment of pneumonia alone may result in death from malaria, while the unnecessary, ‘presumptive’ treatment of malaria may result in malarial drug resistance.
However, in 2010, the World Health Organization, approved the use of a a new technology, called Rapid Diagnostic Tests (RDTs), which health facility staff may use to make malaria diagnosis without the use of sophisticated laboratory technologies.
In Rwanda, Concern is partnering with the Ministry of Health to conduct the initial roll-out of this ground-breaking tool, and is already seeing improved results: from December 2010-February 2011, Community Health Workers saw a total of 2,944 cases of fever. With the help of RDT, 33 percent were confirmed as cases of malaria and treated accordingly.
For many people, even if a child has been diagnosed with malaria, the nearest health facility is a several hours’ walk away, and parents may not seek treatment until it is too late. Concern’s Child Survival programs bring malaria treatment directly to people who are most vulnerable through an approach called “Community Case Management.” Concern trains Community Health Workers to screen for and treat simple cases of malaria with locally available, effective and safe anti-malarial drugs.
Through the Community Case Management approach in Burundi, Concern is working to increase the percentage of children treated with an effective anti-malaria drug within 24 hours of registering a fever from 26 percent to 60 percent.


 Bahomwana care group meets in Gasambu village, Rwanda where they exchange ideas and discuss ways to overcome challenges to improve their work as Community Health Workers. Photo: Esther Havens, Rwanda

Following treatment, the Community Health Worker monitors sick children, and, if they are not improving, ensures that they seek further treatment from the health facility immediately.
Much work remains to be done if we are to significantly reduce the rate of death from malaria worldwide. Concern is contributing to the fight against malaria through the application of proven solutions, as well as new technologies, to reach those most vulnerable to malaria. Preventing the huge numbers of child deaths from malaria that occur each year is no longer an impossible dream.

http://blogs.concernusa.org/2011/04/22/world-malaria-day/

TUBERCULOSIS: TB and HIV in children-advances in prevention and management

Paediatric Respiratory Reviews, 01/09/2011
Marais BJ et al. – In addition, careful scrutiny for TB exposure should occur at every health care visit, with provision of isoniazid preventive therapy (IPT) following each documented exposure event. Knowing the HIV infection status of child TB suspects is essential to optimize case management. Although multiple difficulties remain, recent advances demonstrate that the management of children with TB and/or HIV can be vastly improved by well focused interventions using readily available resources.

http://www.mdlinx.com/internal-medicine/newsl-article.cfm/3428796/ZZ880582144096849473028/?news_id=1604&newsdt=010911&subspec_id=1009

TUBERCULOSIS: SOUTH AFRICA: Preventative TB therapy halves risk of death among ARV patients

JOHANNESBURG, 11 November 2010 (PLUSNEWS) -
Preventative tuberculosis (TB) therapy can reduce death among patients on antiretroviral (ARV) treatment by about half, according to new research from South Africa.
Based on an observational study, researchers found that patients newly initiated on ARV treatment who had also been given Isoniazid Preventative TB therapy (IPT) had about a 50 percent lower risk of death after their first year of treatment than patients not given IPT. Isoniazid is a standard first-line TB drug that has more commonly been given as preventative therapy to HIV-infected patients not yet eligible for ARVs.
According to lead author Salome Charalambous, research director with the Aurum Institute, a South African health research NGO, the study provides much-needed evidence to back the effectiveness of IPT use for ARV patients.
"Until now, the use of IPT in combination with ARVs has been thought to reduce mortality but it had not been established," said Charalambous, adding that these assumptions were based largely on the small reductions in mortality found among HIV-positive people who had started IPT but not ARVs.
Charalambous said she expected the findings to be confirmed by early next year when two randomized controlled trials on the use of IPT within ARV programmes report their findings.
The study is one of several IPT-themed papers published in a supplement of the journal AIDS by the Consortium to Respond Effectively to the AIDS/TB Epidemic (CREATE) in anticipation of the expected 1 December 2010 release of new IPT guidelines by the World Health Organization. Much of the research featured in the supplement comes from Aurum's ongoing Thibela TB study involving 80,000 gold miners, which is looking at whether high IPT uptake can help reduce new TB cases at community level.
TB remains one of the leading killers of HIV-positive people. About 70 percent of South African TB patients are co-infected with HIV.
South Africa introduced national IPT guidelines in 2002 that recommended IPT for people living with HIV, but discouraged health workers from giving it to ARV patients. Implementation has been poor and by March 2010, fewer than 1 percent of patients eligible to receive IPT were accessing it.
Myth-busters
According to results of research also published in the AIDS journal supplement, the greatest barriers to IPT uptake in South Africa could be traced to health workers, many of whom were either unaware or unconvinced of IPT's benefits. Many were also deterred by the perceived difficulty of ruling out active TB infection in HIV-positive patients. Patients given IPT who have undetected active TB can develop resistance to Isoniazid, complicating treatment. Health workers also worried that the side-effects and additional pill burden for patients would discourage adherence.
"It's actually quite crazy that most clinicians will routinely prescribe multi-vitamins when there is no evidence [to support their therapeutic effect] but with IPT, where there is so much evidence, there's so much more worry," Charalambous told IRIN/PlusNews.
She added that the mandatory use of X-rays to diagnose TB, according to South Africa's 2002 IPT guidelines, could be a barrier as they may not be available everywhere. In reality, health workers could exclude at least 90 percent of active TB cases through sputum testing and symptom screening - asking patients if they are experiencing night sweats, a persistent cough or weight loss.
Research by Alison Grant from the London School of Hygiene and Tropical Medicine, also included in the supplement, found that serious side-effects related to IPT were rare and largely tied to excessive alcohol consumption.
Charalambous said she hoped the research - and the new guidelines - would be enough to convert the unconverted, some of whom she said ranked among the country's most respected experts.
As part of a new push to scale up the use of IPT by South African Health Minister Aaron Motsoaledi, the government updated its IPT guidelines in June 2010. In response to some of the research produced by Aurum, the new guidelines no longer discourage the use of IPT in ARV patients and have done away with the mandatory chest X-rays and TB skin tests previously needed to start HIV-positive patients on IPT.
Http://www.plusnews.org/report.aspx?ReportID=91055