The purpose of this paper is to present a global update of drug-resistant tuberculosis (TB) and explore trends in 1994–2010. Data on drug resistance among new and previously treated TB patients, as reported by countries to the World Health Organization, were analysed. In 2007–2010, 80 countries and eight territories reported surveillance data. In South Africa, more than 10% of the cases of multi-drug resistant (MDR) TB were extensively drug-resistant. Globally, in 1994 to 2010 multidrug resistance was observed in 3.4% of all new TB cases and in 19.8% of previously treated TB cases. No overall associations between MDR-TB and HIV infection or sex were found. Between 1994 and 2010, MDR-TB rates in the general population increased in various countries, including Botswana. In conclusion, the highest global rates of MDR-TB ever reported were documented in 2009 and 2010. Trends in MDR-TB are still unclear in most settings. Better surveillance or survey data are required, especially from Africa and India.
Equitable health services
A targeted mass distribution of free LLINs to children under five and pregnant women was implemented in Zanzibar between August 2005 and January 2006. The outcomes of this distribution among children under five are evaluated in this study, four to nine months after implementation. Two cross-sectional surveys were conducted in May 2006 in two districts of Zanzibar: Micheweni (MI) on Pemba Island and North A (NA) on Unguja Island. Household interviews were conducted with 509 caretakers of under-five children, who were surveyed for socio-economic status, the net distribution process, perceptions and use of bed nets. The overall proportion of children under five sleeping under any type of treated net was 83.7% in MI and 91.8% in NA. The LLIN usage was 56.8% in MI and 86.9% in NA. Overall system effectiveness was 49% in MI and 87% in NA, and equity was found in the distribution scale-up in NA. In both districts, the predicting factor of a child sleeping under an LLIN was because caretakers had received a LLIN or considered LLINs to be better than conventional nets. In conclusion, targeted free mass distribution of LLINs can result in high and equitable bed net coverage among children under five. However, in order to sustain high effective coverage, there is need for complimentary distribution strategies between mass distribution campaigns. Considering the community's preferences prior to a mass distribution and addressing the communities concerns through information, education and communication, may improve the LLIN usage.
Many practitioners may dismiss systems thinking as too complicated or unsuited for any practical purpose or application. But many developing countries are looking to scale-up ‘what works’ through major systems strengthening investments. With leadership, conviction and commitment, systems thinking can accelerate the strengthening of systems better able to produce health with equity and deliver interventions to those in need. Systems thinking does not mean that resolving problems and weaknesses will come easily or naturally or without overcoming the inertia of the established way of doing things. But it will identify, with more precision, where some of the true blockages and challenges lie. It will help to: explore these problems from a systems perspective; show potentials of solutions that work across sub-systems; promote dynamic networks of diverse stakeholders; inspire learning; and foster more system-wide planning, evaluation and research.
This report offers a fresh and practical approach to strengthening health systems through ‘systems thinking’. It first decodes the complexity of a health system, and then applies that understanding to design better interventions to strengthen health systems, increase coverage, and improve health. The report suggests ways to more realistically forecast how health systems might respond to strengthening interventions, while also exploring potential synergies and dangers among those interventions. Additionally, it shows how better evaluations of health system strengthening initiatives can yield valuable lessons about what works, how it works and for whom. It is hoped that this report will deepen understanding and stimulate fresh thinking among stewards of health systems, health systems researchers, and development partners.
In this paper the author argues that antibiotic resistance is now recognized as a major global health security issue that threatens a return to the pre-antibiotic era, with potentially catastrophic economic, social and political ramifications. An extra burden is likely to hit resource-poor countries. Although bacteria naturally adapt to outsmart antibiotics, human actions accelerate the development and spread of resistance. Antibiotics need to be used judiciously, with effective stewardship and infection prevention and control, and a harmonized approach to their use in animal and human health should be fostered. There is also a need for practical economic models to develop new products that avoid rewarding researchers for what they do already. Choosing the right paradigms for sustainably stimulating R&D requires new measures to align the financial incentives for drug and diagnostic test development with public health needs. Incentives for infection control and appropriate stewardship are equally important. Integrated efforts involving academia, policy-makers, industry and interest groups will be required to produce a global political response with strong leadership, based on a coherent set of priorities and actions.
In this interview with Dr Lucica Ditiu, newly appointed executive secretary of the Stop TB Partnership, she reports that global tuberculosis (TB) control is reaching a plateau, especially in case detection, due to the fact that the most vulnerable, marginalised, high-risk populations are still not being reached. She argues that TB cannot be tackled without looking at the bigger picture, as it is a disease of poverty and is directly linked to poor nutrition and living conditions, as well as other social determinants of health, like education. These factors, combined with a lack of awareness and the stigma of TB, mean people often delay seeking care. Countries still face problems in planning, forecasting their needs, with supply shortages throughout the developing world, and Ditiu calls on civil society organisations and activists to continue to help flag these shortages. She praised current collaboration and integration efforts for HIV and TB health services, which were already showing results, but pointed to the need to scale up services and funding.
Tanzanian Prime Minister Edward Lowassa has given Dar es Salaam regional administrative officials two weeks to eradicate cholera or lose their jobs. "I give you up to December 3," he told the officials on Monday during a brief health inspection of the city's cholera-infected neighbourhoods of Temeke, Buguruni and Mburahati. Over the past 12 months, the disease has killed 117 people in the city, the nation's commercial capital.
Malaria importation from neighbouring high-endemic Mozambique through Swaziland’s eastern border remains a major factor that could prevent elimination from being achieved. A nationwide formative assessment was conducted over eight weeks to determine if the imported cases of malaria identified by the Swaziland National Malaria Control Programme could be linked to broader social networks and to explore methods to access these networks. Interviews were carried out with malaria surveillance agents (6), health providers (10), previously identified imported malaria cases (19) and people belonging to the networks identified through these interviews (25). Network members and key informants revealed common congregation points, such as the urban market places in Manzini and Malkerns, as well as certain bus stations, where people with similar travel patterns and malaria risk behaviours could be located and tested for malaria. The authors of this study conclude that imported cases of malaria belong to networks of people with similar travel patterns. This study may provide novel methods for screening high-risk groups of travellers using both snowball sampling and time-location sampling of networks to identify and treat additional malaria cases. The authors argue that implementation of a proactive screening programme of importation networks may help Swaziland halt transmission and achieve malaria elimination by 2015.
Several countries in eastern Africa have a high incidence of tuberculosis but have yet to develop effective national strategies to curtail the disease, the United Nations World Health Organization said in its 2007 global TB report, ‘Global tuberculosis control - surveillance, planning, financing’. Citing Democratic Republic of Congo, Kenya and Tanzania as among the 22 countries with a high tuberculosis burden, WHO said their national plans were not effective enough to combat it. Nigeria and Mozambique are the other African countries on the list. While noting the provision of free TB the report cites constraints in plans for human resource development made by national TB control programmes, inadequate screening of HIV-positive people for TB, and limited facilities for diagnoses and treatment of multi-drug resistant TB.
Poor ventilation, overcrowding and HIV co-infection make prison an ideal breeding-ground for tuberculosis (TB), but a new study will be among the first in South Africa to quantify TB among inmates and personnel. ‘Herisa Rifuba’, or ‘Stop TB’ in Setswana, will include about 3,500 prisoners and staff at the Johannesburg Central Prison, with around 12,000 existing inmates and about 500 new prisoners arriving daily. So far this year, the prison has recorded more than 100 cases of TB (an infection rate of about 10%). In 2006, Johannesburg Central became one of the first prisons accredited to offer antiretroviral (ARV) treatment on site. About 530 of were receiving treatment from the prison clinic, said Joyce Lethoba, a project manager at The Aurum Institute, which helped the prison obtain accreditation. If a prison does not have its own clinic, inmates on ARVs have to be transported to nearby state hospitals to fetch their medication, which carries a greater risk of escapes.