Strengthening public health surveillance and response using the health systems strengthening agenda in developing countries

There is increased interest in strengthening health systems for developing countries. However, at present, there is common uncertainty about how to accomplish this task. Specifically, several nations are faced with an immense challenge of revamping an entire system. To accomplish this, it is essential to first identify the components of the system that require modification. The World Health Organization (WHO) has proposed health system building blocks, which are now widely recognized as essential components of health systems strengthening

Commonization of HIV/AIDS services in Nigeria: the need, the processes and the prospects

Introduction: with the first case of Human Immunodeficiency Virus infection/Acquired Immunodeficiency Syndrome (HIV/AIDS) identified in 1986, the management of HIV/AIDS in Nigeria has evolved through the years. The emergency phase of the HIV/AIDS program, aimed at containing the HIV/AIDS epidemic within a short time frame, was carried out by international agencies that built structures separate from hospitals’ programs. It is imperative that Nigeria shifts from the previous paradigm to the concept of Commonization of HIV to achieve sustainability. Commonization ensures that HIV/AIDS is seen as a health condition like others. It involves making HIV services available at all levels of healthcare. Methods: Excellence & Friends Management Consult (EFMC) undertook this process by conducting HIV tests in people’s homes and work places, referring infected persons for treatment and follow up, establishing multiple HIV testing points and HIV services in private and public primary healthcare facilities. EFMC integrated HIV services within existing hospital care structures and trained all healthcare workers at all supported sites on HIV/AIDS prevention, care and treatment modalities. Results: commonization has improved the uptake of HIV testing and counseling and enrolment into HIV care as more people are aware that HIV services are available. It has integrated HIV services into general hospital services and minimized the cost of HIV programming as the existing structures and personnel in healthcare facilities are utilized for HIV services. Conclusion: commonization of HIV services i.e. integrating HIV care into the existing fabric of the healthcare system, is highly recommended for a sustainable and efficient healthcare system as it makes HIV services acceptable by all

Factors associated with interruption of treatment among Pulmonary Tuberculosis patients in Plateau State, Nigeria. 2011

Introduction: Nigeria has one of the highest tuberculosis (TB) burdens in the world with estimated  incidence of 133 per 100,000 populations. Multi-drug resistant TB (MDR-TB) is an emerging threat of the  TB control in Nigeria caused mainly by incomplete treatment. This study explored factors that affect  adherence to treatment among patients undergoing direct observation of TB treatment in Plateau state,  Nigeria.Methods: Between June and July 2011, we reviewed medical records and interviewed randomly selected pulmonary TB patients in their eighth month of treatment. Information on patients? clinical, socio- demographic and behavioral characteristics was collected using checklist and structured questionnaire for knowledge of treatment duration and reasons for interruption of treatment. We conducted focus group discussions with patients about barriers to treatment adherence. Data were analyzed with Epi Info  software. Results: Of 378 records reviewed, 229 (61%) patients were male; mean age 37.6 ±13.5 years and 71 (19%) interrupted their treatment. Interruption of treatment was associated with living > 5 km from TB treatment site (AOR: 11.3; CI 95%: 5.7-22.2), lack of knowledge of duration of treatment (AOR: 6.1; CI 95%: 2.8-13.2) and cigarette smoking (AOR: 3.4; CI 95%: 1.5- 8.0). Major reasons for the interruption were lack of transport fare (40%) and feeling well (25%). Focused group discussions revealed unfriendly attitudes of health care workers as barriers to adherence to treatment. Conclusion: This study revealed knowledge of the patients on the duration of treatment, distance and health workers  attitude as the major determinants of adherent to TB treatment. Training for health care workers on  patient education was conducted during routine supportive supervision.Key words: Interruption, treatment, Tuberculosis, Nigeri

Antifungal Susceptibilities of Cryptococcus neoformans

Susceptibility profiles of medically important fungi in less-developed countries remain uncharacterized. We measured the MICs of amphotericin B, 5-flucytosine, fluconazole, itraconazole, and ketoconazole for Cryptococcus neoformans clinical isolates from Thailand, Malawi, and the United States and found no evidence of resistance or MIC profile differences among the countries

Clinical and Immune Impact of Mycobacterium bovis BCG Vaccination Scarring

The World Health Organization recommends Mycobacterium bovis BCG vaccination in areas of high tuberculosis prevalence. BCG's clinical and immune effects, not necessarily Mycobacterium tuberculosis specific, are unclear. BCG vaccine scarring often is used as a surrogate marker of vaccination or of effective vaccination. We evaluated BCG scarring status in relation to clinical findings and outcome in 700 hospitalized Malawians, of whom 32 had M. tuberculosis bloodstream infections (BSI) (10 of whom had cellular immune studies done) and of whom 48 were infants <6 months old and therefore recently vaccinated (19 of whom had immune studies). In the patients ≥6 months old, scarring was not related to the presence of pulmonary symptoms (35 versus 30%), chronic cough or fever, mortality, or M. tuberculosis BSI. In M. tuberculosis BSI patients, scarring was unrelated to mortality, vital signs, or clinical symptoms but those with scarring had higher proportions of memory and activated T cells and more type 2-skewed cytokine profiles. Infants with either BCG scarring (n = 10) or BCG lesional inflammation (n = 5) had no symptoms of sepsis, but 18 of 33 infants without BCG vaccination lesions did. Those with BCG lesions had localized infections more often than did those without BCG lesions. These infants also had lower median percentages of lymphocytes spontaneously making interleukin-4 (IL-4) or tumor necrosis factor alpha (TNF-α) and lower ratios of T cells spontaneously making IL-4 to T cells making IL-6. Thus, we found that, in older patients, BCG vaccine scarring was not associated with M. tuberculosis-specific or nonspecific clinical protection. Those with M. tuberculosis BSI and scarring had immune findings suggesting previous M. tuberculosis antigen exposure and induction of a type 2 cytokine pattern with acute reexposure. It is unlikely that this type 2 pattern would be protective against mycobacteria, which require a type 1 response for effective containment. In infants <6 months old, recent BCG vaccination was associated with a non-M. tuberculosis-specific, anti-inflammatory cytokine profile. That the vaccinated infants had a greater frequency of localized infections and lesser frequency of sepsis symptoms suggests that this postvaccination cytokine pattern may provide some non-M. tuberculosis-specific clinical benefits

Utility of Paired BACTEC MYCO/F LYTIC Blood Culture Vials for Detection of Bacteremia, Mycobacteremia, and Fungemia

In previous bloodstream infection studies in Malawi, we inoculated blood from a single venesection into a single BACTEC MYCO/F LYTIC (MFL) vial. Inoculation of one vial, however, would be expected to reduce the sensitivity of bloodstream pathogen detection with MFL vials. To ascertain the degree of this loss of sensitivity, blood was drawn from each of 228 febrile, adult inpatients in Malawi and 5 ml of each blood sample was inoculated into each of two MFL vials. Of 228 paired vials, 51 (22%) were both positive, 172 (75%) were both negative, and 5 (3%) had discordant results. Bloodstream infection would have been detected in 11 (92%) of 12 patients with mycobacteremia and 38 (92%) of 41 patients with bacteremia had only one MFL vial been inoculated. Our study shows that a second MFL vial does not significantly increase diagnostic sensitivity

Vitamin A Levels and Immunity in Humans

In animal studies, vitamin A deficiency induces a shift from type 2 (humoral) to type 1 (cellular) cytokines; there are no similar data for humans. Control of human immunodeficiency virus (HIV) and Mycobacterium tuberculosis infections requires type 1 cytokine (cellular) immunity. These infections and vitamin A deficiency are highly prevalent in Africa. We therefore examined the interactions among serum vitamin A levels, immune parameters, HIV infection status, Mycobacterium bovis BCG vaccine scarring (as an indicator of a type 1 cytokine profile), and clinical findings for 70 hospitalized children in Malawi, Africa. Directly conjugated monoclonal antibodies and flow cytometry were used to assess cell-specific cytokine production by peripheral blood monocytes and lymphocyte subpopulations. The statistical techniques employed included nonparametric statistics and logistic regression analyses. Thirty percent of the participants had severe vitamin A deficiency (<10 μg/dl), 34% had moderate deficiency (10 to <20 μg/dl), and 36% had normal levels (≥20 μg/dl). Vitamin A levels were lower for HIV-positive than for HIV-negative children (median, 10 and 17 μg/dl, respectively). Vitamin A-deficient children (<20 μg/dl) were more likely than non-vitamin A-deficient children to have higher proportions of natural killer (NK) cells (median, 8.3 and 5.2%, respectively) and lower ratios of interleukin-10-producing monocytes to tumor necrosis factor alpha-producing monocytes after induction (median, 1.0 and 2.3, respectively). Vitamin A-deficient children were also more likely than non-vitamin A-deficient children to exhibit respiratory symptoms (47% versus 12%) and visible BCG vaccine scars (83% versus 48%), which are indicative of a type 1 response to vaccination. Vitamin A status did not vary with gender, age, incidence of malaria parasitemia, blood culture positivity, or rates of mortality (6% of vitamin A-deficient children died versus 20% of non-vitamin A-deficient children). Lower vitamin A levels were associated with a relative type 1 cytokine dominance and proportionately more NK cells, both of which may be somewhat beneficial to persons who are exposed to HIV, M. tuberculosis, or other type 1 pathogens

Spontaneous Cytokine Production and Its Effect on Induced Production

Cytokines regulate cellular immune activity and are produced by a variety of cells, especially lymphocytes, monocytes, and macrophages. Multiparameter flow cytometry is often used to examine cell-specific cytokine production after in vitro phorbol 12-myristate 13-acetate and ionomycin induction, with brefeldin A or other agents added to inhibit protein secretion. Spontaneous ex vivo production reportedly rarely occurs. We examined the spontaneous production of interleukin 2 (IL-2), IL-4, IL-6, IL-8, IL-10, tumor necrosis factor alpha (TNF-α), and gamma interferon (IFN-γ) by peripheral-blood B lymphocytes, T cells, CD8(−) T cells, CD8(+) T cells, CD3(−) CD16/56(+) lymphocytes (natural killer [NK] cells), CD3(+) CD16/56(+) lymphocytes (natural T [NT] cells), and/or monocytes of 316 acutely ill hospitalized persons and 62 healthy adults in Malawi, Africa. We also evaluated the relationship between spontaneous and induced cytokine production. In patients, spontaneous TNF-α production occurred most frequently, followed in descending order by IFN-γ, IL-8, IL-4, IL-10, IL-6, and IL-2. Various cells of 60 patients spontaneously produced TNF-α; for 12 of these patients, TNF-α was the only cytokine produced spontaneously. Spontaneous cytokine production was most frequent in the immunoregulatory cells, NK and NT. For IL-2, IL-4, IL-6, IL-8, and IL-10, spontaneous cytokine production was associated with greater induced production. For TNF-α and IFN-γ, the relationships varied by cell type. For healthy adults, IL-6 was the cytokine most often produced spontaneously. Spontaneous cytokine production was not unusual in these acutely ill and healthy persons living in an area where human immunodeficiency virus, mycobacterial, malaria, and assorted parasitic infections are endemic. In such populations, spontaneous, as well as induced, cell-specific cytokine production should be measured and evaluated in relation to various disease states