Aamir J. Khan

WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update

The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens.

Search for poliovirus carriers among people with primary immune deficiency diseases in the United States, Mexico, Brazil, and the United Kingdom.

OBJECTIVE To estimate the rate of long-term poliovirus excretors in people known to have B-cell immune deficiency disorders. METHODS An active search for chronic excretors was conducted among 306 persons known to have immunoglobulin G (IgG) deficiency in the United States, Mexico, Brazil, and the United Kingdom, and 40 people with IgA deficiency in the United States. Written informed consent or assent was obtained from the participants or their legal guardians, and the studies were formally approved. Stool samples were collected from participants and cultured for polioviruses. Calculation of the confidence interval for the proportion of participants with persistent poliovirus excretion was based on the binomial distribution. FINDINGS No individuals with long-term excretion of polioviruses were identified. Most participants had received oral poliovirus vaccine (OPV) and almost all had been exposed to household contacts who had received OPV. Polioviruses of recent vaccine origin were transiently found in four individuals in Mexico and Brazil, where OPV is recommended for all children. CONCLUSION Although chronic poliovirus excretion can occur in immunodeficient persons, it appears to be rare.

Engaging the private sector to increase tuberculosis case detection: an impact evaluation study

BACKGROUND In many countries with a high burden of tuberculosis, most patients receive treatment in the private sector. We evaluated a multifaceted case-detection strategy in Karachi, Pakistan, targeting the private sector. METHODS A year-long communications campaign advised people with 2 weeks or more of productive cough to seek care at one of 54 private family medical clinics or a private hospital that was also a national tuberculosis programme (NTP) reporting centre. Community laypeople participated as screeners, using an interactive algorithm on mobile phones to assess patients and visitors in family-clinic waiting areas and the hospitals outpatient department. Screeners received cash incentives for case detection. Patients with suspected tuberculosis also came directly to the hospitals tuberculosis clinic (self-referrals) or were referred there (referrals). The primary outcome was the change (from 2010 to 2011) in tuberculosis notifications to the NTP in the intervention area compared with that in an adjacent control area. FINDINGS Screeners assessed 388,196 individuals at family clinics and 81,700 at Indus Hospitals outpatient department from January-December, 2011. A total of 2416 tuberculosis cases were detected and notified via the NTP reporting centre at Indus Hospital: 603 through family clinics, 273 through the outpatient department, 1020 from self-referrals, and 520 from referrals. In the intervention area overall, tuberculosis case notification to the NTP increased two times (from 1569 to 3140 cases) from 2010 to 2011--a 2·21 times increase (95% CI 1·93-2·53) relative to the change in number of case notifications in the control area. From 2010 to 2011, pulmonary tuberculosis notifications at Indus Hospital increased by 3·77 times for adults and 7·32 times for children. INTERPRETATION Novel approaches to tuberculosis case-finding involving the private sector and using laypeople, mobile phone software and incentives, and communication campaigns can substantially increase case notification in dense urban settings. FUNDING TB REACH, Stop TB Partnership.

Using NFC-Enabled Mobile Phones for Public Health in Developing Countries

One of the largest IT challenges in the health and medical fields is the ability to track large numbers of patients and materials. As mobile phone availability becomes ubiquitous around the world, the use of Near Field Communication (NFC) with mobile phones is emerging as a promising solution to this challenge. The decreasing price and increasing availability of mobile phones and NFC allows us to to apply these technologies to developing countries in order to overcome patient identification and disease surveillance limitations, and permit improvements in data quality, patient referral, and emergency response. In this paper, we present a system using NFC-enabled mobile phones for facilitating the tracking and care of patients in a low-resource environment. While our system design has been inspired by the needs of an ongoing project in Karachi, Pakistan, we believe that it is easily generalizable and applicable for similar health and medical projects in other places where mobile service is available.

Data for action: Collection and use of local data to end tuberculosis

Accelerating progress in the fight against tuberculosis will require a drastic shift from a strategy focused on control to one focused on elimination. Successful disease elimination campaigns are characterised by locally tailored responses that are informed by appropriate data. To develop such a response to tuberculosis, we suggest a three-step process that includes improved collection and use of existing programmatic data, collection of additional data (eg, geographic information, drug resistance, and risk factors) to inform tailored responses, and targeted collection of novel data (eg, sequencing data, targeted surveys, and contact investigations) to improve understanding of tuberculosis transmission dynamics. Development of a locally targeted response for tuberculosis will require substantial investment to reconfigure existing systems, coupled with additional empirical data to evaluate the effectiveness of specific approaches. Without adoption of an elimination strategy that uses local data to target hotspots of transmission, ambitious targets to end tuberculosis will almost certainly remain unmet.

User engagement with and attitudes towards an interactive SMS reminder system for patients with tuberculosis

We conducted a qualitative study to understand user perceptions, acceptability and engagement with an interactive SMS reminder system designed to improve treatment adherence for patients with tuberculosis (TB). Patients received daily reminders and were asked to respond after taking their medication. Non-responsive patients were sent up to three reminders a day. We enrolled 30 patients with TB who had access to a mobile phone and observed their engagement with the system for a one-month period. We also conducted semi-structured interviews with 24 patients to understand their experience with the system. Most patients found the reminders helpful and encouraging. The average response rate over the study period was 57%. However, it fell from a mean response rate of 62% during the first ten days to 49% during the last ten days. Response rates were higher amongst females, participants with some schooling, and participants who had sent an SMS message the week prior to enrolment. Non-responsiveness was associated with a lack of access to the owner of the mobile phone, problems with the mobile phone itself and literacy. Our pilot study suggests that interactive SMS reminders are an acceptable and appreciated method of supporting patients with TB in taking their medication.

Effect of food coupon incentives on timely completion of DTP immunization series in children from a low-income area in Karachi, Pakistan: A longitudinal intervention study

This study introduced food/medicine vouchers as an incentive to mothers of infants visiting Expanded Program on Immunization (EPI) centers in a low socio-economic area. The timely completion of diphtheria, tetanus and pertussis vaccines combined (DTP) series immunization rates between intervention and control cohorts were compared. The DTP up-to-date immunization coverage at 18 weeks of age increased two-fold (RR 2.20, 95% CI: 1.95-2.48, p<0.001) in the incentive cohort compared to the no-incentive cohort. While increasing immunization coverage is a complex structural and behavioral process, food/medicine coupon may improve routine immunization coverage in developing countries.

The Burden of Non-Communicable Disease in Transition Communities in an Asian Megacity: Baseline Findings from a Cohort Study in Karachi, Pakistan

Background The demographic transition in South Asia coupled with unplanned urbanization and lifestyle changes are increasing the burden of non-communicable disease (NCD) where infectious diseases are still highly prevalent. The true magnitude and impact of this double burden of disease, although predicted to be immense, is largely unknown due to the absence of recent, population-based longitudinal data. The present study was designed as a unique ‘Framingham-like’ Pakistan cohort with the objective of measuring the prevalence and risk factors for hypertension, obesity, diabetes, coronary artery disease and hepatitis B and C infection in a multi-ethnic, middle to low income population of Karachi, Pakistan. Methods We selected two administrative areas from a private charitable hospital’s catchment population for enrolment of a random selection of cohort households in Karachi, Pakistan. A baseline survey measured the prevalence and risk factors for hypertension, obesity, diabetes, coronary artery disease and hepatitis B and C infection. Results Six hundred and sixty-seven households were enrolled between March 2010 and August 2011. A majority of households lived in permanent structures (85%) with access to basic utilities (77%) and sanitation facilities (98%) but limited access to clean drinking water (68%). Households had high ownership of communication technologies in the form of cable television (69%) and mobile phones (83%). Risk factors for NCD, such as tobacco use (45%), overweight (20%), abdominal obesity (53%), hypertension (18%), diabetes (8%) and pre-diabetes (40%) were high. At the same time, infectious diseases such as hepatitis B (24%) and hepatitis C (8%) were prevalent in this population. Conclusion Our findings highlight the need to monitor risk factors and disease trends through longitudinal research in high-burden transition communities in the context of rapid urbanization and changing lifestyles. They also demonstrate the urgency of public health intervention programs tailored for these transition communities.

Predictors of delayed culture conversion in patients treated for multidrug-resistant tuberculosis in Pakistan.

Culture conversion is an interim monitoring tool for treatment of multidrug-resistant tuberculosis (MDR-TB). We evaluated the time to and predictors of culture conversion in pulmonary MDR-TB patients enrolled in the community-based MDR-TB management program at the Indus Hospital in Karachi, Pakistan. Despite strict daily directly observed therapy, monthly food incentives and patient counseling, the median time to culture conversion was 196 days (range 32-471). The cumulative probabilities of culture conversion by 2, 4, 6 and 12 months were respectively 6%, 33%, 47%, and 73%. Smoking, high smear grade at baseline and previous use of second-line drugs delayed culture conversion.

Economic analysis of childhood pneumonia in Northern Pakistan

OBJECTIVES This study estimates household costs for treatment of pneumonia, severe pneumonia and very severe febrile disease. Combined with reported costs from the health care provider perspective, an estimate of the overall financial burden of these diseases has been developed for the Northern Areas of Pakistan. METHODS Data on the duration and economic implications of the illnesses for households were collected from caretakers of children under 3 years of age enrolled in a surveillance study who sought care at a health facility. Trained study physicians and health workers identified children with pneumonia, severe pneumonia and very severe febrile disease--as defined by protocols for the Integrated Management of Childhood Illness (IMCI). RESULTS From January to December 2002, 141 health facility visits for pneumonia (n = 41, 29%), severe pneumonia (n = 65, 46%) and very severe febrile disease (n = 35, 25%) were recorded for 112 children who sought care at various levels of health facilities in the Northern Areas of Pakistan. The total societal average cost per episode was US