tuberculosis: the links with poverty anthony d harries the union, paris, france
TRANSCRIPT
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TUBERCULOSIS:
THE LINKS WITH POVERTY
Anthony D HarriesThe Union, Paris, France
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Poverty
MalnutritionImmune deficiency
Tuberculosis
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Malnutrition and low body weight
Immune deficiency and low CD4 cell count
Tuberculosis
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In the TB patient:
• Wasting
• Lack of vitamins
• Lack of trace elements
• Low levels of protein
These deficiencies are worse in those with the lowest body mass index (BMI)
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Nutrition - clinical outcomes
• study in Malawi -1181 patients
• risk factors for early death =
age >35, HIV, low BMI
In first 4 weeks of TB therapy:
• BMI<17 = 11% death
• BMI >17 = 6.5% death
Zachariah et al, 2002
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BUT……
No evidence that nutritional supplementation on its own can improve
TB treatment outcomes
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Poverty and TB…
• The poor are at greater risk for TB– Poor housing, poor diet, poor education, risky behaviours
• The poor face barriers to accessing care:-– Financial – user fees, diagnostic tests, transport
– Geographic - distance to health services
– Cultural – stigma, poor education, traditional
– Health system – no choice, poor treated worse than the rich
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UK Malawi
Population 60M 13M
Health expenditure $2,500 $15
Physicians 135,000 270
Nurses 700,000 7,300
PLHIV 70,000 950,000
Annual TB cases 6,700 26,000
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Household characteristics of 770 smear-positive Pulmonary TB patients in Malawi
• Live in mud-built houses 36%• No piped water in house 75%• No electricity in house 92%
• Household income (<$10/m) 45%
Claessens et al, IJTLD, 2002
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Thyolo district, Malawi: 550,000
A patient’s journey with TB
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Patient Access to Health Facilities
Long distances
Lack of faith in allopathic sectorBelief in traditional healers
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Traditional Healers in Malawi
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Health care provision at District Hosptial clinics
Undermanned
Busy, especially in central and district hospitals
New disease such as TB can be overlooked
Mangochi District Hospital ART Clinic: 4,500 patients on ART
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TB of the abdomen
Some forms of TB difficult to diagnose in RLS
Disseminated TB
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Submitting sputum specimens for AFB
This may be a long process
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Laboratories where TB is diagnosed are over-burdened and under staffed
It may be a long time to get results
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Standardised TB Treatment“Short course” [6 months]
New Cases:
2RHZE/ 4RH is standard first line treatment
WHO recommended regimens - 2009
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TB Programmes like their treatment given by direct observation
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The main road to Chitipa District Hospital
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Poor urban settings – same problems
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Make it easier for TB suspects and TB patients
• Better education about TB and how it is transmitted (air-borne disease)
• Diagnostic services closer to homes
• Treatment services closer to homes
• Shorter treatment for Tuberculosis