TUBERCULOSIS:

THE LINKS WITH POVERTY

Anthony D HarriesThe Union, Paris, France

Poverty

MalnutritionImmune deficiency

Tuberculosis

Malnutrition and low body weight

Immune deficiency and low CD4 cell count

Tuberculosis

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)

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

BUT……

No evidence that nutritional supplementation on its own can improve

TB treatment outcomes

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

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

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

Thyolo district, Malawi: 550,000

A patient’s journey with TB

Patient Access to Health Facilities

Long distances

Lack of faith in allopathic sectorBelief in traditional healers

Traditional Healers in Malawi

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

TB of the abdomen

Some forms of TB difficult to diagnose in RLS

Disseminated TB

Submitting sputum specimens for AFB

This may be a long process

Laboratories where TB is diagnosed are over-burdened and under staffed

It may be a long time to get results

Standardised TB Treatment“Short course” [6 months]

New Cases:

2RHZE/ 4RH is standard first line treatment

WHO recommended regimens - 2009

TB Programmes like their treatment given by direct observation

The main road to Chitipa District Hospital

Poor urban settings – same problems

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