Anthony D Harries The Union, Paris, France


Immune deficiency



Malnutrition and low body weight

Immune deficiency and low CD4 cell count


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


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 Population Health expenditure Physicians Nurses 60M $2,500

Malawi 13M $15

135,000 270 700,000 7,300

PLHIV Annual TB cases

70,000 6,700

950,000 26,000

Household characteristics of 770 smearpositive Pulmonary TB patients in Malawi
‡ Live in mud-built houses ‡ No piped water in house ‡ No electricity in house ‡ Household income (<$10/m) 36% 75% 92% 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 sector Belief in traditional healers

Traditional Healers in Malawi

Health care provision at District Hosptial clinics
Mangochi District Hospital ART Clinic: 4,500 patients on ART Undermanned

Busy, especially in central and district hospitals

New disease such as TB can be overlooked

Some forms of TB difficult to diagnose in RLS TB of the abdomen 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 ³Short 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

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