Worldwide, the clinical syndrome of pneumonia remains the leading cause of death in children in the post-neonatal period and presents a significant burden on in-patient services [2, 3]. Over 70% of these deaths occur in South East Asia and sub-Saharan Africa . The World Health Organization (WHO) recommends presumptive antibiotic treatment based on clinical syndromic definitions of pneumonia plus oxygen for those with clinically very severe pneumonia (VSP) or hypoxia – defined as oxygen saturation (SaO2) <90% . Even with recommended treatment, there is substantial evidence that current syndromic management guidelines are not working in practice, resulting in high mortality (9-16%) [6, 7]. Hypoxia is present in 9.4% and 13.3% of children hospitalised with severe pneumonia (SP) and VSP respectively and is both an important indicator of disease severity and a key predictor of mortality . The targeted use of oxygen and simple, non-invasive methods of respiratory support may be a highly cost-effective means of improving outcome, but both the optimal oxygen saturation threshold which results in benefit and the best strategy for delivery are yet to be tested in adequately powered randomised controlled trials (RCT). Oxygen as a potentially life-saving treatment, though advocated by the WHO technologies group, has not been afforded a high enough priority at either country or global levels . Systematic and policy reviews indicate the need for a formal evaluation of the hypoxia threshold at which oxygen should be targeted and of how oxygen is best administered [8, 10, 11]. The COAST trial aims to address these key research gaps to provide a better evidence base for future guidelines, with a view to improving poor outcomes.
Human immunodeficiency virus (HIV) associated tuberculosis (TB) remains a major global public health challenge, with an estimated 1.4 million patients worldwide. Co-infection with HIV leads to challenges in both the diagnosis and treatment of tuberculosis. Further, there has been an increase in rates of drug resistant tuberculosis, including multi-drug (MDR-TB) and extensively drug resistant TB (XDRTB), which are difficult to treat and contribute to increased mortality. Because of the poor performance of sputum smear microscopy in HIV-infected patients, newer diagnostic tests are urgently required that are not only sensitive and specific but easy to use in remote and resource-constrained settings. The treatment of co-infected patients requires antituberculosis and antiretroviral drugs to be administered concomitantly; challenges include pill burden and patient compliance, drug interactions, overlapping toxic effects, and immune reconstitution inflammatory syndrome. Also important questions about the duration and schedule of anti-TB drug regimens and timing of antiretroviral therapy remain unanswered. From a programmatic point of view, screening of all HIV-infected persons for TB and vice-versa requires good co-ordination and communication between the TB and AIDS control programmes. Linkage of co-infected patients to antiretroviral treatment centres is critical if early mortality is to be prevented. We present here an overview of existing diagnostic strategies, new tests in the pipeline and recommendations for treatment of patients with HIV-TB dual infection.
The scale-up of treatment for HIV and multidrug-resistant tuberculosis (MDR-TB) in developing countries requires a long-term relationship with the patient, accurate and accessible records of each patient’s history, and methods to track his/her progress. Recent studies have shown up to 24% loss to follow-up of HIV patients in Africa during treatment and many patients not being started on treatment at all. Some programs for prevention of maternal–child transmission have more than 80% loss to follow-up of babies born to HIV-positive mothers. These patients are at great risk of dying or developing drug resistance if their antiretroviral therapy is interrupted. Similar problems have been found in the scale-up of MDR-TB treatment.
In this investigation 43 cases of smear positive patients undergoing TB treatment at satellite treatment centres situated within
Mombasa municipality were observed and interviewed retrospectively. The span of the study was five months commencing
from April 1997. The study was carried out in collaboration with the National Leprosy and Tuberculosis Programme at Port Reitz,
Coast General and Ganjoni centres of infectious and contagious diseases in Mombasa district. The data seem to indicate that the
highest number (97%) of persons affected by TB come from the economically productive age (15-50 years). The possible cause of
recurrence ofTB in Mombasa district is lifestyle. The majority of the people with sputum smear positive earn below the poverty line.
They live in rented or overcrowded houses with inadequate ventilation, insufficient sanitary and transport facilities and poor health systems. In addition, there is a general lack of awareness of dangers of infection, spread and prevention ofTB. Areas arranting"closer attention by future research are highlighted in the study.
Traditionally, prevention and control of diseases of public health importance were considered a responsibility of the public health sector. As a consequence, tuberculosis(TB) control services including DOTS programmes in most low-income countries have been planned and designed almost exclusively by National TB Programmes (NTP) and implemented through the available network of public health services. Most countries however have two major sets of health care providers – public, owned by the State and private, comprising a range of institutions and individuals. These include formal and informal as well as fee-for-service or voluntary providers. Over the years, the private health sector has grown considerably in most low-income countries and has outgrown the public health sector in some. For a variety of reasons, all sections of the population including the poor seek care from private practitioners despite
availability of free or subsidized services in the public health sector. The private sector varies considerably between and within countries in size, composition, distribution, level of organization, types of services delivered and socio-economic groups served.
Evidence from countries as diverse as India, Kenya, Mexico, Pakistan, Philippines, Republic of Korea, Uganda shows that private practitioners do detect and treat a significant proportion of TB cases (1). Recognising the importance of private health care providers in TB control and realizing the missing emphasis on engaging the private sector among local, national and international TB control planners and programme managers, WHO recently began addressing the issue. This paper presents WHO’s approach to help initiate private provider (PP) involvement in TB care delivery. A global situational assessment, debate and discussion on the findings of the assessment and observations from field-level initiatives in diverse settings have contributed to an evolving global strategy. The
strategy takes into account barriers to and enablers of collaboration. While the strategy remains global, the aim is to help address the issue that is, in many ways, local, better, speedier and sustainable TB control remain the ultimate goal.