Implementing Joint TB and HIV Interventions in a Rural District of Malawi: Is There a Role for an International Non-governmental Organisation?

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1 ABSTRACTS' SERVICE [Indian J Chest Dis Allied Sci 2005; 47: 60-64] Implementing Joint TB and HIV Interventions in a Rural District of Malawi: Is There a Role for an International Non-governmental Organisation? R. Zachariah, R. Tech, A.D. Harries and P. Humblet The International Journal of Tuberculosis and Lung Disease 2004; 8: In a rural district in Malawi, poorly motivated health personnel, shortages of human and financial resources, weak dialogue between existing tuberculosis (TB) and human immunodeficiency virus (HIV) programmes and poor community involvement are constraints to establishing joint TB-HIV interventions. The presence of a non-governmental organisation (NGO), Medecins Sans Frontieres (MSF), in the health care delivery system provided an opportunity to bridge some of these gaps. The main inputs provided by MSF included additional staff, supplementary drugs including antiretroviral drugs, technical assistance and infrastructure development. The introduction of a scheme of monthly performance-linked incentives for health personnel proved successful in improving their performance, as judged by attendance rates as well as the quality and quantity of activities. This initiative also provided the district management with a tool for exerting pressure on health staff to improve their performance. The availability of independent NGO funds and a logistics team for construction of new infrastructure allowed the rapid initiation of new interventions at the district level without having to wait for disbursements of funds from the central level. This introduced a new dynamic of decentralised operational flexibility at the district level which improved access to care and support for people with TB-HIV. Interstitial Lung Disease Induced by Drugs and Radiation Philippe Camus, Annlyse Fanton, Philippe Bonniaud, Clio Camus and Pascal Foucher Respiration 2004; 71: An ever-increasing number of drugs can reproduce variegated patterns of naturally occurring interstitial lung disease (ILD), including most forms of interstitial pneumonias, alveolar involvement and, rarely, vasculitis. Drugs in one therapeutic class may collectively produce the same pattern of involvement. A few drugs can produce more than one pattern of ILD. The diagnosis of drug-induced ILD (DI-ILD) essentially rests on the temporal association between exposure to the drug and the development of pulmonary infiltrates. The histopathological features of DI-ILD are generally consistent, rather than suggestive or specific to the drug etiology. Thus, the diagnosis of DI-ILD is mainly made by the meticulous exclusion of all other possible causes. Drug dechallenge produces measurable improvement in symptoms and imaging in the majority of patients, whereas corticosteroid therapy is indicated if symptoms are present or drug dechallenge is without an effect. Rechallenge is justified in a minority of patients, and is discouraged for diagnostic purposes only. Pneumotox ( com) provides updated information on druginduced respiratory disease.

2 2005; Vol. 47 The Indian Journal of Chest Diseases & Allied Sciences 61 Simple, Phage-based (FASTPlaque) Technology to Determine Rifampicin Resistance of Mycobacterium tuberculosis Directly from Sputum H. Albert, A. Trollip, T. Seaman and R.J. Mole The International Journal of Tuberculosis and Lung Disease 2004; 8: Setting. Cape Town, South Africa. Objective. To evaluate the performance of a simple, manual, phage-based test for determining rifampicin (RMP) resistance of Mycobacterium tuberculosis directly from smearpositive sputum specimens. Design. A comparative study of the performance of the FASTPlaque (phage amplification) technology to determine RMP resistance directly from smear-positive sputum compared with isolation and the conventional indirect Middlebrook 7H11 agar proportion method. Results. The FASTPlaque direct RMP test achieved sensitivity, specificity and overall accuracy of 100% (11/11), 100% (134/134) and 100% (145/145), respectively, compared with the conventional indirect susceptibility test method (resolved data). The FASTPlaque direct RMP test reported results within two days from receipt of the specimen, while the conventional method took between 27 and 103 days (mean ± SD 33.2 ± 7.2 days). Conclusion. FASTPlaque technology applied directly to smear-positive sputum offers performance comparable to conventional methods, with results available in two days instead of weeks to months. The test may form a useful part of DOTS-Plus programmes to combat multidrug-resistant tuberculosis, improving patient prognosis and reducing ongoing transmission of disease. It does not require specialised equipment, making it appropriate for high-burden countries. A Normal FEV 1 /VC Ratio Does Not Exclude Airway Obstruction Dan C. Stanescu and Claude Veriter Respiration 2004; 71: Background. A decreased forced expiratory volume in 1 s/vital capacity (FEV 1 /VC) ratio is the hallmark of the definition of airway obstruction. We recently suggested that a lung function pattern, we called small airways syndrome (SAOS), has a normal FEV 1 /VC and total lung capacity (TLC) and reflects obstruction of small airways. Objectives. To substantiate our hypothesis we measured and compared lung function tests including maximal expiratory flow rates (MEFR), sensitive indicators of airway obstruction, in SAOS subjects and in matched controls. Methods. We selected 12 subjects with the pattern of SAOS, but without chronic lung or heart disease (average age: 40.7 ± 7.8 years) and 36 age-matched subjects with normal lung function (42.8 ± 6.3 years). We measured static and dynamic lung volumes, MEFR and lung diffusing capacity (DL CO ). Results. SAOS subjects were heavier smokers (p<0.05) and body mass index was less than in control subjects (p<0.01). Both FEV 1 /VC ratio and TLC were comparable in the two groups. However, FEV 1, VC, DL CO, and MEFR were lower and residual volume (RV) and RV/TLC ratio were higher (p<0.05) in the SAOS group than in the control one. Furthermore, the MEFR curve of the SAOS group was displaced to the left without any change in slope, suggesting premature airway closure. Conclusions. Our results suggest that a normal FEV 1 /VC ratio does not exclude airway obstruction. A decrease of FEV 1, provided TLC is normal, reflects small airway obstruction.

3 62 Abstracts' Service 2005; Vol. 47 Incomplete Forced Expiration-Estimating Vital Capacity by a Mathematical Method Holger Steltner, Michael Vogel, Eva Sprung, Jens Timmer, Josef Guttmann and Stephan Sorichter Respiration 2004; 71: Background. Vital capacity is a key parameter in the determination of lung function, usually assessed by means of a forced expiration maneuver. This maneuver can be exhausting, and patients often cannot complete it. Objectives. This study evaluates a method to estimate forced vital capacity (FVC) based on the extrapolation of volume-time curves from forced expiration. Methods. The algorithm was applied to 2,363 volume-time curves from patients with and without respiratory disease. Four hundred sixteen of these spirograms originated from incomplete maneuvers. For each spirogram, estimated (FVC est ) and measured FVC were compared with inspiratory vital capacity. Results. Reliable FVC est were obtained for 82% of all and for 76% of the incomplete maneuvers. Regardless of the category of respiratory disease and acceptability of forced expiration, FVC est were close to inspiratory vital capacities. Conclusions. When assessing the lung function of patients who cannot complete forced expiration, this method could help to reduce the duration of maneuvers required to provide a reliable estimate for vital capacity. Relationship Between Peripheral Airway Dysfunction, Airway Obstruction, and Neutrophilic Inflammation in COPD R.A. O Donnell, C. Peebles, J.A. Ward, A. Daraker, G. Angco, P. Broberg, S. Pierrou, J. Lund, S.T. Holgate, D.E. Davies, D.J. Delany, S.J. Wilson and R. Djukanovic Thorax 2004; 59: Background. Considerable research has been conducted into the nature of airway inflammation in chronic obstructive pulmonary disease (COPD) but the relationship between proximal airways inflammation and both dynamic collapse of the peripheral airways and HRCT determined emphysema severity remains unknown. A number of research tools have been combined to study smokers with a range of COPD severities classified according to the GOLD criteria. Methods. Sixty five subjects (11 healthy smokers, 44 smokers with stage 0-IV COPD, and 10 healthy non-smokers) were assessed using lung function testing and HRCT scanning to quantify emphysema and peripheral airway dysfunction and sputum induction to measure airway inflammation. Results. Expiratory HRCT measurements and the expiratory/inspiratory mean lung density ratio (both indicators of peripheral airway dysfunction) correlated more closely in smokers with the severity of airflow obstruction (r=-0.64, p<0.001) than did inspiratory HRCT measurements (which reflect emphysema severity; r= 0.45, p<0.01). Raised sputum neutrophil counts also correlated strongly in smokers with HRCT indicators of peripheral airway dysfunction (r=0.55, p<0.001) but did not correlate with HRCT indicators of the severity of emphysema. Conclusions. This study suggests that peripheral airway dysfunction, assessed by

4 2005; Vol. 47 The Indian Journal of Chest Diseases & Allied Sciences 63 expiratory HRCT measurements, is a determinant of COPD severity. Airway neutrophilia, a central feature of COPD, is closely associated with the severity of peripheral airway dysfunction in COPD but is not related to the overall severity of emphysema as measured by HRCT. Occupational Asthma in the Furniture Industry: Is It Due to Styrene? Ferda Öner, Dilsad Mungan, Numan Numanoglu and Yavuz Demirel Respiration 2004; 71: Background. Styrene, a volatile monomer, has been reported as a cause of occupational asthma in a few case reports. Objective. The aim of this study was to investigate the risk for asthma in relation to exposure to styrene in a large number of workers. Methods. A total of 47 workers with a history of exposure to styrene were included in the study. To establish whether asthma was present, each patient underwent a clinical interview, pulmonary function testing and bronchial challenge with methacholine. Specific bronchial challenges with styrene and serial peak expiratory flow (PEF) measurement at home and at work were carried out in subjects with a diagnosis of asthma to evaluate the relationship between their asthma and exposure to styrene in the workplace. Results. Among the 47 subjects, five workers had given a history of work-related symptoms, and three of them had a positive methacholine challenge test. Specific bronchial challenges with styrene and serial PEF measurement were subsequently carried out in these three subjects. Although provocation tests with styrene were negative in the three workers, one worker had PEF rate records compatible with occupational asthma. Conclusions. We established one patient with occupational asthma from a group of people who have excessive styrene exposure. This finding may be suggestive but is not conclusive about the causative role of styrene in occupational asthma. Since styrene is a frequently used substance in the furniture industry, it is worth performing further studies to investigate the relationship between styrene and occupational asthma. Burden of Disease Attributable to Selected Environmental Factors and Injury Among Children and Adolescents in Europe Francesca Valent, D Anna Little, Roberto Bertollini, Leda E. Nemer, Fabio Barbone and Giorgio Tamburlini Lancet 2004; 363: Background. Environmental exposure contribute to the global burden of disease. We have estimated the burden of disease attributable to outdoor and indoor air pollution, inadequate water and sanitation, lead exposure, and injury among European children and adolescents. Methods. Published studies and reports from international agencies were reviewed for calculation of risk-factor exposure in Europe. Disability-adjusted life years (DALYs) or deaths attributable to each factor, or both, were estimated by application of the potential impact fraction to the estimates of mortality and

5 64 Abstracts' Service 2005; Vol. 47 burden of disease from the WHO global database of burden of disease. Findings. Among children aged 0-4 years, between 1.8% and 6.4% of deaths from all causes were attributable to outdoor air pollution; acute lower-respiratory-tract infections attributable to indoor air pollution accounted for 4.6% of all deaths and 3.1% of DALYs; and mild mental retardation resulting from lead exposure accounted for 4.4% of DALYs. In the age-group 0-14 years, diarrhoea attributable to inadequate water and sanitation accounted for 5.3% of deaths and 3.5% of DALYs. In the agegroup 0-19 years, injuries were the cause of 22.6% of all deaths and 19.0% of DALYs. The burden of disease was much higher in European subregions B and C than subregion A. There was substantial uncertainty around of the estimates, especially for outdoor air pollution. Interpretation. Large proportion of deaths and DALYs in European children are attributable to outdoor and indoor air pollution, inadequate water and sanitation, lead exposure, and injuries. Interventions aimed at reducing children s exposure to environmental factors and injuries could result in substantial gains. The pronounced differences by subregion and age indicate the need for targeted action. Lung Cancer Epidemiology and Risk Factors in Asia and Africa W.K. Lam, N.W. White and M.M. Chan-Yeung The International Journal of Tuberculosis and Lung Diseases 2004; 8 : In industrialised countries, lung cancer is the most common form of cancer among males and it is growing among females. For both sexes, rates reflect smoking behaviours. The pattern appears to be different in Asia, particularly in China, where lung cancer rates in men reflect high smoking rates but high rates among non-smoking women appear to be related to other factors. The incidence of lung cancer is low in most African countries, but it is increasing. In addition to tobacco smoking, a number of etiological factors have been identified for lung cancer: indoor exposure to environmental tobacco smoke, cooking oil vapour, coal burning, or radon out-door air pollution and occupational exposure to asbestos and other carcinogens. Recent studies have shown that dietary factors may be important, with high consumption of vegetables and fruits being protective while pre-served food and fatty food are harmful, and certain infections such as Mycobacterium tuberculosis, human papilloma virus and Microsporum canis are associated with a high risk of lung cancer. Among non-smokers, the probable role of genetic predisposition in lung cancer by increasing the individual s susceptibility to environmental carcinogens is currently being studied actively. As the single most important cause for lung cancer is tobacco smoke and, with increased sales, a major epidemic is predicted for both Asia and Africa, all health care professionals, government health authorities and national and international health organisations must join in a concerted effort against tobacco.