The factors associated with PTB were size and poverty level of the locality of residence.
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In this study we found a rate of According to the logistic regression model fitted, the main variables associated with MDR were: having received anti-TB treatment previously, cough of three years or more of duration and not being indigenous. This is the only occasion in all our studies, which the condition of being indigenous appeared as a protective factor [ 12 ].
In our team, together with Right to Health Defense Group and Physicians for Human Rights, carried out a population-based study to assess health conditions, and access to health services in the conflict zone initiated in between the EZLN and the Mexican government [ 6 ]. We found that the most affected regions by the armed conflict have fared even worse than the rest of Chiapas State. We performed a household survey in the municipalities most affected by the armed conflict among three types of communities: opposition communities, pro-government communities, and divided communities, i.
This investigation identified serious deficiencies in both detection and treatment of PTB. This means a rate of PTB of Of these 13 cases, one had not received any anti-TB treatment and six had defaulted from anti-TB treatment. We also carried out two evaluations of a cohort of patients aged over 14 years diagnosed with PTB from January to July , and found poor survival among them.
In the second follow-up carried out in , the factors associated with PTB mortality were age 45 years and over and anti-TB treatment duration of under six months. The median survival time of those patients aged 45 and over who died was days range 0 to 3, , while the median survival time in the reference group consisting of patients aged years, was days range , With regard to the duration of anti-TB treatment, the median survival time among patients with incomplete treatment was days range , , whereas among those dying in the reference group with treatment completed , the median survival time was 1, days range , [ 14 ].
The mortality rate in the patients studied was 4. The most important features of these studies are shown in Table 1. During the decade from to , inequalities of wealth and human development were extremely marked in Ecuador. The indigenous population, such as that residing in the central Andean province of Cotopaxi, has the highest poverty rates, and has many of its basic needs unmet. In Ecuador, up until , the TB Prevention and Control Program was based on passive case finding of patients with respiratory symptoms health personnel would check whether a patient visiting a health center had a productive cough of more than 15 days of duration.
In contrast to what happens in cities, in rural areas the organization and functioning of the program relies on the presence of basic rural health teams; this means that is not uncommon for health personnel to be absent. This situation, among others, has resulted in TB notification being irregular. It is situated at an altitude of 3,m above sea level and is two hours walk from the nearest health center, which during the period to was practically without staff. One of the co-authors of the present work Natalia Romero collaborated with the health team of this parish, during her period of rural medical training several years earlier.
Following the diagnosis of one PTB case the schoolmaster in , we conducted a study between and , and found a prevalence rate of PTB-positive cases of 6. The data collected was analyzed using the technique of multiple correspondence analyses, which allowed us to ascertain the risk and exposure factors in the community. All persons with chronic productive cough were asked to provide three sputum specimens. Given the degree of social and geographical exclusion of the community, PTB was diagnosed only by smear test.
Two hundred and two persons were identified with chronic cough fifteen days or more , of them, productive. Among men, the highest prevalence was in the 35—44 age group Although TB prevention and control programs encourage patients to visit health services and follow instructions, if they continue in their tendency to give little attention to socioeconomic, cultural and anthropological aspects, the results will be the same. How can better outcomes be expected if health services persist in acting as they always they do, including opening for restricted hours from 8 am to 12 pm and from 2 to 6 pm?
In our intervention in Chine, symbolic referents, the religious dimension and rituals, as well as aspects of daily life working hours, school, community and family calendar, seasonal migration, and traditional medical practices, among others were taken into account. The main results obtained in Ecuador, are shown in Table 2. Given this situation combined with a feeling that the number of patients was rising at a higher rate than that calculated based on national rates, it was decided to perform a study to detect coughers of 15 days or more making use of the structure of the health system itself.
The district of Ate-Vitarte was chosen to be targeted, since it consists mainly of lands occupied by migrants from the interior of the country, many forced off their lands due to violence between Peruvian armed forces and guerrilla movements from the interior, in particular Sendero Luminoso. For this study, as in the cases of Chiapas, Mexico and of Chine, Ecuador, the health system approved and participated in order to guarantee anti-TB treatment and medical care for possible new cases identified by the study. We interviewed persons over 14 years of age who had productive chronic cough fifteen days or more seeking care in health services primary care and hospitals.
Of these, we obtained sputum samples from None of the demographic or socioeconomic indicators analyzed were associated with PTB. Given the high prevalence of PTB in peripheral areas of Lima, as is the case of Ate-Vitarte District, and the results mentioned in the previous paragraph, we planned a study to determine whether the use of minibuses was associated with the spread of PTB.
Commuting in these minibuses means that people travel in overcrowded situations with closed windows regardless of the weather, making trips of at least 30 minutes duration every day, in the company of TB patients going to a health center to receive DOTS treatment. Furthermore, if there is a strong association between using microbuses and the risk of infection, what would be expected among microbus drivers and fare-collectors that spend more than 8 hours per day in this environment?
Based on these precedents, we decided to carry out a study to assess infection by Mycobacterium tuberculosis and working conditions among workers of public transport [ 19 ]. In we performed a cross-sectional study with workers from two public transport minibus companies of the Ate-Vitarte District. These minibus workers were interviewed and a tuberculin skin test TST administered. An induration greater than or equal to 10 mm was considered positive. From these workers, TST results were obtained for 73 Furthermore, strict revision of clinical histories of active TB patients in the health centers associated to the health districts of these workers, showed that standardized incidence rates for transport sector workers were 2.
These results indicate that the use of informal public transport is a risk factor for TB infection and an occupational risk in countries with characteristics similar to those in Peru [ 20 ]. A summary of the main results obtained in Lima, is presented in table 3. There is no doubt that TB is an outcome indicator of the socioeconomic, cultural and political structure of a population. TB is a historical reflection of the forms of social construction, particularly of the post-industrial revolution era experienced in capitalist countries. TB in this sense feeds, to a greater or lesser degree, depending on circumstances, on the social context in order to reproduce, and this fact finds expression, as documented in the present studies, in various gradients of exposure and susceptibility to the disease, in which the more socioeconomically disadvantaged groups are the ones most affected by the disease, but the ones which, paradoxically, usually receive least attention, whether in terms of prevention, diagnosis, or treatment, and hence cure rates are low.
The Global Plan to Stop TB aims to treat 50 million people, save 14 million lives, and expand equitable access to quality diagnosis and treatment. However, the World Health Organization, Pan-American Health Organization and Governments in general, establishing targets for TB control programs, take as their basis the reports they receive from the countries themselves, with the result that programs elaborated are eminently political, whose objectives and information basis constitute a kind of feedback system which rapidly departs from reality. TB control programs thus planned are designed as though the social structure of the countries was homogeneous, and this impedes acting in such a way as to take account of the particularities of marginal populations, which are the ones presenting the highest rates of prevalence of this disease.
The usual ways of working lead to government planning and actions being based on central estimates and tackling of global objectives. For example, the global medium-term goal for TB control is to halve TB prevalence and death rates by as compared to levels, and to achieve a reduction in its incidence, as part of the Millennium Development Goals number six [ 22 , 23 ].
This type of planning and programming of objectives apparently does not take account of the particular situations affecting the population, above all those aspects which are notably different from the global mean values. In fact the few population based studies available, some involving Latin American countries, likewise fail to treat marginal populations specially.
BRAC’s Tuberculosis Program: Pioneering DOTS Treatment for TB in Rural Bangladesh
For example, if it was not for international support, few governments would have sufficient resources to conduct national health surveys, which are usually carried out through household interviews, based on self-perceived morbidity, and which hardly ever include laboratory tests to identify diseased individuals TB in our case. Generally, the level of disaggregation of surveys of this type goes no further than large geographical regions north, south, east, etc , tending to disguise inter- and intra-regional heterogeneity, and the data are analyzed based on artificially created convenience categories, not based on observed patterns of disease or deaths.
In other words, it is usual that global policies emanating from the international agencies and institutions ignore the true situation, applying criteria of homogeneity in the calculation of targets, costs of equipment and supplies and staffing levels, among other aspects. Curiously, despite it being well known that social factors are related with TB, they are not taken into consideration in order to improve the quality of plans to control it.
In order to identify, analyze and ideally contribute alternative solutions to the problem of unmet needs of socioeconomically excluded populations, means working with samples which are not representative of the general population, but rather focused on these sub-populations, biased precisely due to their conditions.
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In this sense, our team has been employing the patchwork approach, involving studies focusing on marginal or susceptible populations, those with the worst socioeconomic and health conditions. In the case of TB, these circumstances poverty, social vulnerability, and shortage of health facilities are well recognized as one of the basic determinants of the presence and spread of the disease, but its characterization usually is not considered by health systems in their solution proposals [ 24 ].
For example, in marginalized rural areas, in the best case, active TB case finding is limited in practice, to identifying chronic coughers among users who seek health care. This results in at least three possible situations: a there may be delays in the TB diagnosis patients arrive in an advanced stage of the disease ;  - if the medical consultation is for reasons other than respiratory symptoms, TB may not even be detected;  - and, c that a certain proportion of patients do not use the health services due to accessibility barriers which may be geographical, economic or cultural  - and hence are not even diagnosed [ 10 ].
In this context, women living in remote and marginalized regions, have a more pronounced lack of access to health services due to gender reasons: there are differences in the process of seeking medical care, and in the quality of the care received between women and men [ 25 ].
Furthermore, in Chiapas, Ecuador and Peru, as in many other regions of Latin America, TB cases notified to the information systems of the health sector, and from which incidence rates are estimated, correspond to cases detected in health services by acid-fast bacilli. This is an important aspect to consider because health system detection of TB cases is based on smear testing, meaning that in marginalized communities many cases are not detected.
The suboptimal case detection rate reflects an inadequate of quality medical care, probably health personnel are often overwhelmed by daily activities, as well as insufficiently trained, motivated, aware, and remunerated [ 10 ]. In order to increase detection rates, as it was demonstrated, the health system must take into account the considerable difficulties involved in obtaining and analyzing sputum samples in marginalized areas: cultural barriers language spoken, world view and economic barriers, as well as technical problems to be overcome in order to obtain adequate quantity and quality of sputum samples.
It is therefore necessary to reduce the cultural and socioeconomic barriers between health care providers and people [ 10 ]. Not surprisingly, some results of our investigations show that apart from cultural barriers, there are also structural barriers [ 11 ]. In the same way, we have found that a very low proportion of patients eligible for anti-TB treatment effectively receive such treatment, and very high proportions of treatment failures and incomplete follow-up [ 10 ]. Two further aspects deserve special attention in the context of the studies conducted in Chiapas, Mexico, as well as in Peru: the problem of MDR, and the high mortality among patients diagnosed of PTB.
Both indicators constitute expressions of the complete failure of the health system which, for whatever reason, did not manage to adequately treat these people, who consequently either died of TB, or were left as chronic MDR cases which would lead to their death also, sooner or later. In the case of MDR, it is well documented that the vast majority of cases of this type result from inappropriate treatment and follow up by the health system. According to official statistics, worldwide, the rates of MDR recorded in and were the highest ever, and trends in MDR rates are unclear in the majority of countries [ 28 ].
The observed rates of MDR in Chiapas suggest that in marginalized and excluded regions, it is a serious public health problem of alarming proportions. Although our results were made known to the health authorities, there are no signs to suggest that the TB situation has improved: the health system continues failing to diagnose cases appropriately and application of the DOTS strategy is very deficient: even if TB patients are diagnosed, in many cases they begin, but do not complete their anti-TB treatment.
In this sense, we must emphasize the following aspects:. It is extremely difficult to perform culture analysis, in order to determine MDR status, in a patient with less than six months of treatment, due to poor quality sputum samples. The main obstacles to obtaining good quality sputum samples are: barriers in communication with indigenous people, distance of the communities from the centers where samples are processed, unsuitable transport conditions of samples risk of exposure to sunlight or lack refrigeration , among others. It is very plausible that in indigenous populations, due to their having less contact with health services, there are more undiagnosed TB cases and that, among non-indigenous patients, more TB cases are diagnosed but not necessarily treated adequately [ 12 ].
A patient confirmed with MDR condition, is practically impossible to treat, given the high cost of the secondary treatment, and because if the health system is incapable of guaranteeing the follow up of a patient sensitive to the four primary drugs during six months, it is probably even less able to follow up a MDR patient not only in terms of the time required from 6 months to 1.
In this sense, if a program cannot guarantee appropriate follow up and compliance with treatment among TB patients, it should not initiate their treatment, thus condemning them to a situation of no hope of cure, with all that this implies, not only for the patient, but also for his family, who apart from watching their family member suffer, are also exposed to the possibility of their catching the disease. With regard to mortality due to TB, we have found unacceptably high rates.
In addition, a considerable proportion of TB patients die without having received any medical care. Whereas the life expectancy in Chiapas is According to official statistics, while in the PTB mortality for the country was 1. Our findings have provided evidence that in the area studied, patients being aged 45 years and over, not having completed the established six months of treatment, and not having been treated via the DOTS strategy, are all associated with a higher risk of the patient dying from PTB. Based on our findings, we can say that people from rural and indigenous communities suffer mistreatment by the health services [ 30 ], meaning, among other aspects, deficient application of the DOTS strategy sometimes due to shortages in the supply of anti-TB drugs [ 31 ], or poor follow up , leading to higher mortality and increasing their chances of becoming MDR cases [ 12 , 13 ].
Another fact that reduces the chances of successfully carrying out patient follow up, is migratory movements. Migration in the region is mainly due to economic factors, but can also be for health reasons.
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Sometimes patients are registered by health services as urban patients when in fact they are not, or they give a false address in order to obtain the first consultation, but subsequently return to their rural communities or find another place to live without notifying the health services. In addition, health services give little consideration to socio-cultural and anthropological aspects. For example, in indigenous medicine the process of health and illness involves their world view, their personal and community histories, in an atmosphere of trust in which supernatural intervention, transgression of social norms, culpability, or malice on the part of enemies, are all admissible possible causes of the disease [ 16 , 32 , 33 ].
In this sense, patients may seek care from traditional medicine practitioners, who attend them in accordance with their age-old diagnostic and therapeutic rituals. In this sense, a worker with active PTB is a source of infection not only for co-workers but also for passengers. In countries where TB is endemic with increased circulation of resistant mycobacteria, the situation could be even worse. In a situation of this kind, the health system should be implementing, at very least, home-based DOTS to avoid exposure as far as possible, as well as implementing specifically designed occupational health programs [ 19 , 20 , 34 ].
Observation of the particular facts which determine the appearance of TB and its prognosis, shows that the diagnosis and treatment strategies employed by the health services are just that, strategies, rather than ends in themselves, something which, unfortunately, is frequently emphasized. If more clearly focused measures are not taken, TB will not disappear in marginalized areas, despite the fact that trends in the ecological indices suggest that TB is tending to decline in Latin American countries; rather, it will persist as a greater public health problem for years to come.
In our view, to remain with the idea that TB is decreasing in Latin America, tends to conceal the failure which the rise in MDR patients represents. In any case, countries are alarmed by the rise in MDR because of the cost of treatment and its inefficiency, not necessarily for the health and welfare of TB patients, particularly if they are poor, as our studies suggest. One discussion point is clear. If, together with these data we take into account cases in areas enjoying lower TB incidence, and if this total was the true number of existing cases, the result would necessarily be a systematic reduction in incidence rates, leading to false optimism, whose historical cost has been a relaxation of efforts to prevent and control TB worldwide during the decade of the s of last century.
Imagine the simple case that we have an incidence rate of X, in a given country. This figure conditions the work plan for the coming year in terms of supplies, staff, anti-TB treatment drugs, etcetera. The final rate for this country, based on these hypothetical figures, would be 0. In other words, not receiving reports from the areas with the worst conditions provokes an apparent reduction in the global rate.
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Unfortunately, even without questioning the figures declared, we know that areas which do not report or report, but at best with high levels of under-notification are the ones with the poorest conditions, both in terms of the socioeconomic conditions of the population which theoretically must be cared for, and in terms of the lack of resources and other failures in the organization and functioning of the program. Thus, by apparently having fewer cases, the resources dedicated to the TB prevention and control program are also cut back, and this creates a vicious circle which is difficult to break, so that program outcomes may be false, i.
There is therefore a clear need to promote studies specifically aiming to analyze the population groups most vulnerable to TB, and in this way ascertain more precisely their situation, even when they are not representative of what happens in a given country. Continuing to carry out representative population based studies can only yield the probably already known rate for the country as a whole, and the situation of marginal groups will not be reflected in such rate.
In this sense, the patchwork studies contribute very valuable elements which help to make more visible and understandable the situation of population groups which go unnoticed in the global rates utilized in public health.
We would encourage potentiating studies which break with the classical schemes, and use methods appropriate for the analysis of samples considered too small by classical approaches, but without renouncing the maximum of scientific rigor, as demonstrated by the doctoral theses developed in projects conducted in the three settings we have dealt with, Chiapas Mexico , Chine Cotopaxi, Ecuador , and Lima Peru , and whose results have been published in journals of medium and high impact factor.
It will be fundamental to perform studies which evaluate possible effects of such changes. As the studies have shown, a failure to introduce changes in the structure and functioning of TB prevention and control programs would have as a consequence that this disease will continue to severely affect the most marginalized sectors of society:. In the field of TB prevention, several authors recognize that effective efforts have not yet been fully considered, and that it is necessary to improve this issue, for example through better vaccines and better chemotherapy for preventive treatment [ 22 ].
In the field of TB diagnosis, efforts must be made to reinforce active case finding of coughers, as for example, incorporating other diagnostic tests which allow better detection of the disease from the use of cultures, and conducting molecular tests, to the search for faster diagnostic methods, such as biosensors. It is not unusual to find, within a given Latin American country, that while highly developed regions have advanced technologies available for TB diagnosis, in others the only possibility for diagnosis is the smear test.
Though we work in a variety of sectors—including agriculture , health, education, and microfinance—community organization is a pillar of our model. And across our 12 countries of operation, including Bangladesh where we have our global headquarters, more than 95 percent of our staff members are based in the field. Consequently, like many community-based organizations in Bangladesh, BRAC is deeply skeptical about emerging technologies: They seem to lack the critical human dimension of grassroots interaction that has proven instrumental for decades.
If we move to dispersing loans and stipends via mobile money, for example, will staff and clients still have the same quality of rapport that weekly home visits and community meetings foster? Could algorithms and data-driven decisions replace field smarts and experience? We invited practitioners, including many from South Asia and East Africa who were utilizing or considering utilizing technology, digital financial services, or data in innovative ways, to share their experiences with us.
We also shared some of our early experiences on these themes from BRAC. Here are some of our takeaways:. Photo courtesy of BRAC. Throughout the event, others turned to this definition as they considered digital financial services and their potential benefits. Shameran Abed of BRAC discusses opportunities for development organizations to adopt digital financial services without putting clients at risk. New data sources create opportunities for new financial inclusion strategies.