Protocol for a national, mixed-methods knowledge, attitudes and practices survey on non-communicable diseases

Background Mongolia is undergoing rapid epidemiological transition with increasing urbanisation and economic development. The lifestyle and health of Mongolians are changing as a result, shown by the 2005 and 2009 STEPS surveys (World Health Organization's STEPwise Approach to Chronic Disease Risk Factor Surveillance) that described a growing burden of Non-Communicable Diseases and injuries (NCDs). This study aimed to assess, describe and explore the knowledge, attitudes and practices of the Mongolian adult population around NCDs in order to better understand the drivers and therefore develop more appropriate solutions to this growing disease burden. In addition, it aimed to provide data for the evaluation of current public health programs and to assist in building effective, evidence-based health policy. Methods/design This national survey consisted of both quantitative and qualitative methods. A quantitative household-based questionnaire was conducted using a nationally representative sample of 3854 rural and urban households. Participants were selected using a multi-stage cluster sampling technique in 42 regions across Mongolia, including rural and urban sites. Permanent residents of sampled households were eligible for recruitment, if aged between 15-64 years. This quantitative arm was then complemented and triangulated with a qualitative component: twelve focus group discussions focusing on diet, exercise and alcohol consumption. Discussions took place in six sites across the country, facilitated by local, trained health workers. These six sites were chosen to reflect major Mongolian cultural and social groups. Discussion KAP surveys are well represented in the literature, but studies that aim to explore the knowledge, attitudes and practices of a population around NCDs remain scarce. This is despite the growing number of national epidemiological surveys, such as STEPS, which aim to quantify the burden of these diseases but do not explore the level of population-based awareness, understanding, risk-perception and possible motivation for change. Therefore this paper will contribute to building a knowledge base of NCD KAP survey methodology for future use in epidemiology and research worldwide

High yield of culture-based diagnosis in a TB-endemic setting

BACKGROUND: In most of the world, microbiologic diagnosis of tuberculosis (TB) is limited to microscopy. Recent guidelines recommend culture-based diagnosis where feasible. METHODS: In order to evaluate the relative and absolute incremental diagnostic yield of culture-based diagnosis in a high-incidence community in Cape Town, South Africa, subjects evaluated for suspected TB had their samples processed for microscopy and culture over a 21 month period. RESULTS: For 2537 suspect episodes with 2 smears and 2 cultures done, 20.0% (508) had at least one positive smear and 29.9% (760) had at least one positive culture. One culture yielded 1.8 times more cases as 1 smear (relative yield), or an increase of 12.0% (absolute yield). Based on the latter value, the number of cultures needed to diagnose (NND) one extra case of TB was 8, compared to 19 if second specimens were submitted for microscopy. CONCLUSION: In a high-burden setting, the introduction of culture can markedly increase TB diagnosis over microscopy. The concept of number needed to diagnose can help in comparing incremental yield of diagnosis methods. Although new promising diagnostic molecular methods are being implemented, TB culture is still the gold standard

Addressing the double-burden of diabetes and tuberculosis : Lessons from Kyrgyzstan

Background: The incidence of diabetes and tuberculosis co-morbidity is rising, yet little work has been done to understand potential implications for health systems, healthcare providers and individuals. Kyrgyzstan is a priority country for tuberculosis control and has a 5% prevalence of diabetes in adults, with many health system challenges for both conditions. Methods: Patient exit interviews collected data on demographic and socio-economic characteristics, health spending and care seeking for people with diabetes, tuberculosis and both diabetes and tuberculosis. Qualitative data were collected through semi-structured interviews with healthcare workers involved in diabetes and tuberculosis care, to understand delivery of care and how providers view effectiveness of care. Results: The experience of co-affected individuals within the health system is different than those just with tuberculosis or diabetes. Co-affected patients do not receive more care and also have different care for their tuberculosis than people with only tuberculosis. Very high levels of catastrophic spending are found among all groups despite these two conditions being included in the Kyrgyz state benefit package especially for medicines. Conclusions: This study highlights that different patterns of service provision by disease group are found. Although Kyrgyzstan has often been cited as an example in terms of health reforms and developing Primary Health Care, this study highlights the challenge of managing conditions that are viewed as "too complicated" for non-specialists and the impact this has on costs and management of individuals

Tuberculosis laboratory biosafety manual

Following a technical consultation held between the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC) in Atlanta, GA, in September 2008 on strategies, approaches and partnerships that could be implemented to improve laboratory biosafety worldwide, an Expert Group meeting was convened at WHO's Headquarters in Geneva, Switzerland, in April 2009 to elaborate guidance on biosafety related to laboratory procedures for diagnosing tuberculosis (TB). Members of the Expert Group submitted Declarations of Interest. These were reviewed by WHO's legal department prior to the meeting. The purpose of the meeting was to reach consensus on the basic principles of laboratory practices and design necessary to establish minimum criteria to ensure biosafety during TB microscopy, culture, drug-susceptibility testing (DST) and molecular testing in different countries and epidemiological settings. This manual was developed from the Expert Group meeting. The recommendations are based on assessments of the risks associated with different technical procedures performed in different types of TB laboratories; the manual describes the basic requirements for facilities and practices, which can be adapted to follow local or national regulations or as the result of a risk assessment. Risk assessments require careful judgement: on the one hand, underestimating risks may lead to laboratory staff being exposed to biological hazards but, on the other hand, implementing more rigorous risk mitigation measures than are needed may result in an unnecessary burden on laboratory staff and higher costs to establish and maintain the laboratory's infrastructure. Risk assessments should consider the bacterial load of materials (such as specimens and cultures), the viability of the bacilli, whether the material handled is prone to generate aerosols during the activity being assessed, the laboratory's workload, the epidemiology of the disease, and the health of laboratory workers; assessments should also consider other factors that may infl uence the likelihood or the consequence of exposure to TB. The intended audience for these recommendations are directors and managers of laboratories and TB programmes as well as the laboratory technicians who test for TB, especially in high-burden, lowresource settings. In this document, the laboratory or section of the laboratory conducting TB testing is referred to as the TB laboratory. The recommendations are specifi c to laboratories that follow well defi ned procedures to test samples potentially containing Mycobacterium tuberculosis. For any other combination of pathogen and procedures, a process similar to the one used here could be used to defi ne biosafety precautions. This manual was approved by WHO's Guidelines Review Committee in May 2012, and explanations are provided throughout the manual where it differs from WHO's Laboratory biosafety manual, 3rd edition. It is intended to inform rather than replace country-level requirements and standards for biosafety. The recommendations do not supersede any local or national rules or regulations.Executive summary -- Participants in the guideline development process -- Abbreviations -- Introduction -- 1. Risk assessment and the classification of TB laboratories -- 2. Essential biosafety measures for TB laboratories -- 3. Low-risk TB laboratories -- 4. Moderate-risk TB laboratories -- 5. High-risk TB laboratories (TB -containment laboratories -- 6. Safety equipment -- 7. Personal protective equipment and clothing -- 8. Plans for emergency preparedness and response -- 9. References -- Annex 1: Meeting participants -- Annex 2: Declarations of interest -- Annex 3: Peer review panel.WHO/HTM/TB/2012.11Development and publication of this document have been made possible with fi nancial support from the United States Agency for International Development (USAID) and the United States Centers for Disease Control and Prevention.Mode of access: World Wide Web as an Acrobat .pdf file (1.7 MB, 60 p.).Includes bibliographical references (p. 44-45)