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[post_date] => 2021-04-07 11:27:43
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Abstract
Global tuberculosis incidence has declined marginally over the past decade, and tuberculosis remains out of control in several parts of the world including Africa and Asia. Although tuberculosis control has been effective in some regions of the world, these gains are threatened by the increasing burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. XDR tuberculosis has evolved in several tuberculosis-endemic countries to drug-incurable or programmatically incurable tuberculosis (totally drug-resistant tuberculosis). This poses several challenges similar to those encountered in the pre-chemotherapy era, including the inability to cure tuberculosis, high mortality, and the need for alternative methods to prevent disease transmission. This phenomenon mirrors the worldwide increase in antimicrobial resistance and the emergence of other MDR pathogens, such as malaria, HIV, and Gram-negative bacteria. MDR and XDR tuberculosis are associated with high morbidity and substantial mortality, are a threat to health-care workers, prohibitively expensive to treat, and are therefore a serious public health problem. In this Commission, we examine several aspects of drug-resistant tuberculosis. The traditional view that acquired resistance to antituberculous drugs is driven by poor compliance and programmatic failure is now being questioned, and several lines of evidence suggest that alternative mechanisms-including pharmacokinetic variability, induction of efflux pumps that transport the drug out of cells, and suboptimal drug penetration into tuberculosis lesions-are likely crucial to the pathogenesis of drug-resistant tuberculosis. These factors have implications for the design of new interventions, drug delivery and dosing mechanisms, and public health policy. We discuss epidemiology and transmission dynamics, including new insights into the fundamental biology of transmission, and we review the utility of newer diagnostic tools, including molecular tests and next-generation whole-genome sequencing, and their potential for clinical effectiveness. Relevant research priorities are highlighted, including optimal medical and surgical management, the role of newer and repurposed drugs (including bedaquiline, delamanid, and linezolid), pharmacokinetic and pharmacodynamic considerations, preventive strategies (such as prophylaxis in MDR and XDR contacts), palliative and patient-orientated care aspects, and medicolegal and ethical issues.
[post_title] => The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis
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[post_date] => 2021-04-07 10:34:43
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Abstract
Multidrug-resistant tuberculosis (MDR-TB), the prevalence of which has increased across the globe in recent years, is a serious threat to public health. Timely diagnosis of MDR-TB, especially among new TB cases, is essential to facilitate appropriate treatment, which can prevent further emergence of drug resistance and its spread in the population. The present case report from India aims to address some operational challenges in diagnosing MDR-TB among new cases and potential measures to overcome them. It argues that even after seven years of implementing the DOTS-Plus program for controlling MDR-TB, India still lacks the technical capacity for rapid MDR-TB diagnosis. The case report underscores an urgent need to explore the use of WHO-endorsed techniques such as Xpert MTB/Rif and commercial assays such as Genotype MTBDR for rapid diagnosis of MDR-TB among new cases. Suitable applications may be found for other TB high-burden countries where MDR-TB is a major concern.
[post_title] => An urgent need for building technical capacity for rapid diagnosis of multidrug-resistant tuberculosis (MDR-TB) among new cases: A case report from Maharashtra, India
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Abstract
Background
Multidrug-resistant TB (MDR-TB) has emerged as a major threat to global TB control efforts in recent years. Facilities for its diagnosis and treatment are limited in many high-burden countries, including India. In hyper-endemic areas like Mumbai, screening for newly diagnosed cases at a higher risk of acquiring MDR-TB is necessary, for initiating appropriate and timely treatment, to prevent its further spread.
Objective
To assess risk factors associated with MDR-TB among Category I, new sputum smear-positive cases, at the onset of therapy.
Materials and Methods
The study applied an unmatched case-control design for 514 patients (106 cases with MDR-TB strains and 408 controls with non-MDR-TB strains). The patients were registered with the Revised National Tuberculosis Control Program (RNTCP) in four selected wards of Mumbai during April 2004-January 2007. Data were collected through semi-structured interviews and drug susceptibility test results.
Results
Multivariate analysis indicated that infection with the Beijing strain (OR = 3.06; 95% C.I. = 1.12-8.38; P = 0.029) and female gender (OR = 1.68; 95% C.I. = 1.02-2.87; P = 0.042) were significant predictors of MDR-TB at the onset of therapy.
Conclusion
The study provides a starting point to further examine the usefulness of these risk factors as screening tools in identifying individuals with MDR-TB, in settings where diagnostic and treatment facilities for MDR-TB are limited.
[post_title] => Risk Factors Associated with MDR-TB at the Onset of Therapy among New Cases Registered with the RNTCP in Mumbai, India
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Abstract
This article reexamines medical anthropology theories of symptom, illness, and disease to consider unregulated medical care in India. It builds on clinical observations, an inventory of the pharmaceuticals used by men who call themselves “Bengali doctors,” and their patients to understand medical care in a context that privileges symptom not disease. It draws on Derrida's use of pharmakon to outline the complexities of care and embodiment and helps locate local and medical anthropology theories of symptom and pharmaceuticals within theories of the experiential body. It asks two key questions: What is medical care without disease and what are its implications on a local biology in which disease‐based biomedicine is modified? Searching for a tentative answer, it works to bring medical anthropology's interest in symptom back to the body without losing symptoms’ connection to political economies, individual experience, and localized biomedicine.
[post_title] => Mohit's Pharmakon: Symptom, Rotational Bodies, and Pharmaceuticals in Rural Rajasthan
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[post_modified] => 2021-04-06 12:43:38
[post_modified_gmt] => 2021-04-06 16:43:38
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Abstract
Triage is a process of categorizing potential health and guiding care. It is based on the idea that all bodies are equal while potential vitality is not. I examine the triage processes used by Indian physicians as they collaborated with global health researchers to identify patients for a free, cutting-edge tuberculosis test. As I argue, triage forms and reforms social difference within global health despite its aspirations of standardization and experimentality. Problematizing triage as part of global health’s ordinary affect of affordability reveals local biologies, class biopolitics, and clinical speculation in the field. I conclude by considering new avenues of ethnographic inquiry that are opened by attending to the practiced and depoliticized biopolitics that occurs within clinics as everyday, nonreflexive decisions about how to organize resources and speculate on vitalities.
[post_title] => Dr. Ram’s triage: Categorization, speculation, and granting access to global health technologies in Indian private clinics
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[post_date] => 2021-04-06 12:26:09
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Abstract
Public health experts often describe care in India’s private sector as ‘chaotic,’ ‘substandard,’ ‘profit-driven,’ and ‘arbitrary.’ Discourse tends to focus on the ‘predatory behavior' of doctors who demand consultation fees and kickbacks for everything from medicine, to laboratory tests, to specialist referrals, and even hospital stays. These practices are ethnographically observable. However, this discourse does not take into account the multiple uncertainties, ethical complexity, and personal relationships involved in providing care in exchange for money in a setting of scarce personal and public resources. Situated at the very end of a value chain designed to make money from health, or the lack thereof, private physicians find themselves embroiled in moral peril. In this article, I engage what it means to make a livelihood in a context such as this by considering the economic, moral, and epistemic practices that physicians and their patients use to create and evaluate the value of pharmaceuticals in Mumbai’s slums. Based on over a year of clinic ethnography and interviews with family physicians, specialists, pharmacists, and pharmaceutical wholesalers, I trace how physicians manage the effects of a pharmaceutical value chain that produces profit by fulfilling patient’s health needs and desires.
[post_title] => Dr. Zahir’s dilemma: money and morals in India’s private medical networks
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About the book
Neoliberalism has been the defining paradigm in global health since the latter part of the twentieth century. What started as an untested and unproven theory that the creation of unfettered markets would give rise to political democracy led to policies that promoted the belief that private markets were the optimal agents for the distribution of social goods, including health care.
A vivid illustration of the infiltration of neoliberal ideology into the design and implementation of development programs, this case study, set in post-Soviet Tajikistan’s remote eastern province of Badakhshan, draws on extensive ethnographic and historical material to examine a “revolving drug fund” program—used by numerous nongovernmental organizations globally to address shortages of high-quality pharmaceuticals in poor communities. Provocative, rigorous, and accessible,
Blind Spot offers a cautionary tale about the forces driving decision making in health and development policy today, illustrating how the privatization of health care can have catastrophic outcomes for some of the world’s most vulnerable populations.
[post_title] => Blind Spot How Neoliberalism Infiltrated Global Health
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[post_name] => blind-spot-how-neoliberalism-infiltrated-global-health
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[7] => WP_Post Object
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[post_date] => 2021-04-06 11:42:30
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Abstract
Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health. This correspondence article seeks to assess how developments over the past 5 years have contributed to the state of programmatic knowledge—both approaches and methods—regarding interventions to reduce stigma in health facilities, and explores the potential to concurrently address multiple health condition stigmas. It is supported by findings from a systematic review of published articles indexed in PubMed, Psychinfo and Web of Science, and in the United States Agency for International Development’s Development Experience Clearinghouse, which was conducted in February 2018 and restricted to the past 5 years. Forty-two studies met inclusion criteria and provided insight on interventions to reduce HIV, mental illness, or substance abuse stigma. Multiple common approaches to address stigma in health facilities emerged, which were implemented in a variety of ways. The literature search identified key gaps including a dearth of stigma reduction interventions in health facilities that focus on tuberculosis, diabetes, leprosy, or cancer; target multiple cadres of staff or multiple ecological levels; leverage interactive technology; or address stigma experienced by health workers. Preliminary results from ongoing innovative responses to these gaps are also described.
The current evidence base of stigma reduction in health facilities provides a solid foundation to develop and implement interventions. However, gaps exist and merit further work. Future investment in health facility stigma reduction should prioritize the involvement of clients living with the stigmatized condition or behavior and health workers living with stigmatized conditions and should address both individual and structural level stigma.
[post_title] => Stigma in health facilities: why it matters and how we can change it
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Chapter 1 introduces readers to stigma theory and some basic definitions of types of stigma. Chapter 2 (methodology) offers an overview of the scientific and operational considerations for matching your stigma measurement method to your question. Chapter 3 teaches formative qualitative research techniques to and out why the TB stigma takes a particular form, where the stigma comes from, and how stigma operates in your setting. Chapter 4 focuses on the measurement of TB stigma at the community level. This chapter details special considerations for embedding TB stigma measures in household surveys (e.g., scale length), and in settings with concentrated vs. generalized HIV epidemics. Chapter 5 focuses on measurement of TB discriminatory attitudes and behaviors in institutions such as prisons, schools, and health facilities, and has a special focus on measuring enacted TB stigma (discriminatory behaviors) through observational methods. The TB stigma literature has focused more on discrimination and disparagement of individual TB patients and less on the structural forms of discrimination. Chapter 6 covers the measurement of structural stigma. Chapter 7 teaches the basic principles of TB stigma measurement among TB patients. This is a relatively well-developed field with validated TB stigma scales robust in a variety of settings. Nevertheless, there are statistical and sampling challenges that require special consideration. Techniques for measuring secondary stigma are introduced in Chapter 8. This chapter describes the best practices for measuring stigma among healthcare workers (HCW), family members, and those in TB-affected industries. HCW stigma measurement is a high priority because HCW are often stigmatized for their vital TB care work, and yet may simultaneously mistreat TB patients. Chapter 9 explores how to measure TB stigma among socially networked populations who are already marginalized and socially excluded for other reasons. It outlines the efforts required to obtain reliable and unbiased estimates. State-of-the-art methods for capturing self-stigma, resilience, and self-efficacy are covered in Chapter 10. It is vital to measure the strengths and forms of 8resistance of people affected by TB. Documenting how some groups successfully detect stigma can inform interventions. Chapter 11 teaches how to deconstruct the language of TB programs to identify stigmatizing rhetoric and discourse. This chapter explores methods for policy analysis to pinpoint stigma embedded in norms and guidelines. Chapter 12 describes how to engage civil society and TB patients meaningfully in TB stigma measurement efforts. This text provides useful tips on participatory strategies that prevent further stigmatization and ensure dignity. Chapter 13 lays out the methodological foundations for incorporating the costs of TB stigma and social disadvantage into a cost-effectiveness analysis. Policy and strategy debates in TB control may have unintended consequences that should be anticipated. Chapter 14 involves intersectional and compound stigmas, such as the double stigma of TB/HIV. It is widely understood that TB stigma can be enmeshed with other kinds of social exclusions and marginalities. This creates analytical challenges that must be managed carefully to prevent bias and confusion. Chapter 15 describes how to study the impact of TB on complex behaviors, such as health-seeking, adherence, and mortality. This is a field of particular interest to TB programs seeking to understand the impact of TB stigma on their program. Chapter 16 gives concrete advice for those who want to develop and validate their own TB stigma scales. Chapter 17 gives step-by-step instructions for analyzing qualitative data from formative stigma research.
[post_title] => TB StigmaMeasurement Guidance
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[post_content] => For whom is this book made?
This book is made for…health care workers responsible for TB clinics, out-patient and in-patient departments who are responsible for HIV counseling and testing for TB patients but may lack experience in or do not recognize the importance of HIV testing. Some staff may want to offer HIV testing but the policymakers do not support it.
This book is made for…facilitating government and private health facilities to adhere to the “International Standards for Tuberculosis Care for HIV high prevalent settings.
This book is made for…promoting every TB patient’s access to HIV counseling and testing so that they can have equal access to HIV prevention and care which ultimately lead to reducing deaths and increasing survival of people infected by TB and HIV
[post_title] => HIV-Testing for Life…HIV Testing for All Tuberculosis Patients: an entry point for TB patients to access to HIV prevention and care
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Abstract
Global tuberculosis incidence has declined marginally over the past decade, and tuberculosis remains out of control in several parts of the world including Africa and Asia. Although tuberculosis control has been effective in some regions of the world, these gains are threatened by the increasing burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. XDR tuberculosis has evolved in several tuberculosis-endemic countries to drug-incurable or programmatically incurable tuberculosis (totally drug-resistant tuberculosis). This poses several challenges similar to those encountered in the pre-chemotherapy era, including the inability to cure tuberculosis, high mortality, and the need for alternative methods to prevent disease transmission. This phenomenon mirrors the worldwide increase in antimicrobial resistance and the emergence of other MDR pathogens, such as malaria, HIV, and Gram-negative bacteria. MDR and XDR tuberculosis are associated with high morbidity and substantial mortality, are a threat to health-care workers, prohibitively expensive to treat, and are therefore a serious public health problem. In this Commission, we examine several aspects of drug-resistant tuberculosis. The traditional view that acquired resistance to antituberculous drugs is driven by poor compliance and programmatic failure is now being questioned, and several lines of evidence suggest that alternative mechanisms-including pharmacokinetic variability, induction of efflux pumps that transport the drug out of cells, and suboptimal drug penetration into tuberculosis lesions-are likely crucial to the pathogenesis of drug-resistant tuberculosis. These factors have implications for the design of new interventions, drug delivery and dosing mechanisms, and public health policy. We discuss epidemiology and transmission dynamics, including new insights into the fundamental biology of transmission, and we review the utility of newer diagnostic tools, including molecular tests and next-generation whole-genome sequencing, and their potential for clinical effectiveness. Relevant research priorities are highlighted, including optimal medical and surgical management, the role of newer and repurposed drugs (including bedaquiline, delamanid, and linezolid), pharmacokinetic and pharmacodynamic considerations, preventive strategies (such as prophylaxis in MDR and XDR contacts), palliative and patient-orientated care aspects, and medicolegal and ethical issues.
[post_title] => The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis
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[post_modified] => 2021-04-07 11:27:43
[post_modified_gmt] => 2021-04-07 15:27:43
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