TB remains a significant global health threat, claiming 1.3 million lives annually. The COVID-19 pandemic disrupted progress in the global TB response. Most patients with TB initially seek care from private providers, whereas only a small proportion are engaged by national programmes. The Global Fund is the major international source of funding for TB responses and supports the scale-up of innovative private-public mix (PPM) models in TB.We collected programmatic and financial data on TB from 11 priority countries implementing PPM activities. Country examples and trends in the budget of Global Fund grants were analysed.These countries account for 60% of the global TB burden and Global Fund TB portfolio. PPM contributed 29% of national TB notifications in 2022 (range: 8% to 49%). During 2021–2023, US$1.4 billion was allocated for TB and US$155 million (11%) for PPM, while PPM contributed to 35% of national TB notification targets. PPM budgets increased over time from US$43 million (2002 to 2014) to US$129 million (2024 to 2026).The Global Fund’s investments facilitated the expansion of innovative PPM models, improved access, and enhanced TB responses. Our indicative analysis underscores the need for evidence-based planning, collaboration, and increased domestic investment to accelerate the end of TB.

As we observe the rising incidence of TB in marginalized communities, it becomes crucial to question why this malice persists in an evolving society. Historically TB was the leading cause of death among the various infectious diseases prevalent in the 19th century in high-income countries. There was a dramatic decline in TB incidence and mortality even before effective TB medicines were introduced in the 1950s, mainly due to better living conditions, public health measures and nutrition.1Cegielski J.P. McMurray D.N. The relationship between malnutrition and tuberculosis: evidence from studies in humans and experimental animals.Int J Tuberc Lung Dis. 2004; 8: 286-298PubMed Google Scholar However, TB remains a major infectious disease killer in low- and middle-income countries today, and it disproportionately affects poor people living in high-income countries as well. Undernutrition is one of the main risk factors for progression from TB infection to disease and poor treatment outcomes.2Lönnroth K. Jaramillo E. Williams B.G. Dye C. Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and social determinants.Soc Sci Med. 2009; 68: 2240-2246Crossref PubMed Scopus (724) Google Scholar In 2022, about 2.2 million (20%) of incident TB cases were attributable to undernutrition, while about 0.9 million (9%) were attributable to HIV.3Global Tuberculosis Report 2023 Geneva: World Health Organization.https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2023Google Scholar Underweight individuals (BMI <18.5 kg/m2) could be up to five times more likely to develop TB compared to individuals within a normal weight range (BMI 18.5–24.9 kg/m2).1Cegielski J.P. McMurray D.N. The relationship between malnutrition and tuberculosis: evidence from studies in humans and experimental animals.Int J Tuberc Lung Dis. 2004; 8: 286-298PubMed Google Scholar,4Bhargava A. Bhargava M. Beneditti A. Kurpad A. Attributable is preventable: corrected and revised estimates of population attributable fraction of TB related to undernutrition in 30 high TB burden countries.J Clin Tuberc Other Mycobact Dis. 2022; 27100309https://pubmed.ncbi.nlm.nih.gov/35308808/PubMed Google Scholar People with undernutrition lack critical macro- and micro-nutrients that modulate the immune system and protect them from developing the disease.5Dauphinais M.R. Koura K.G. Narasimhan P.B. et al.Nutritionally acquired immunodeficiency must be addressed with the same urgency as HIV to end tuberculosis.BMC Global Public Health. 2024; 2: 4Crossref Google Scholar, 6Gombart A.F. Pierre A. Maggini S. A review of micronutrients and the immune system–working in harmony to reduce the risk of infection.Nutrients. 2020; 12: 236Crossref PubMed Scopus (708) Google Scholar, 7Munteanu C. Schwartz B. The relationship between nutrition and the immune system.Front Nutr. 2022; 91082500https://doi.org/10.3389/fnut.2022.1082500Crossref PubMed Scopus (41) Google Scholar Young children and pregnant women are particularly vulnerable to the effects of undernutrition and TB. TB patients who miss most of their meals are unlikely to visit health facilities and may lack motivation to take their daily medicines for months. Nutritional supplements had been used widely to prevent TB until the introduction of multi-drug treatment in the 1960s, when global attention shifted towards biomedical treatment and away from nutrition. The data from recent studies clearly indicate that nutrition plays a significant role in fighting against TB. For instance, studies like the RATIONS Trial and the current modelling paper by Mandal et al. have highlighted the positive impact of proper nutrition on TB prevention and treatment outcome.8Bhargava A. Bhargava M. Meher A. et al.Nutritional supplementation to prevent tuberculosis incidence in household contacts of patients with pulmonary tuberculosis in India (RATIONS): a field-based open-label, cluster-randomised, controlled trial.Lancet. 2023; 402: 627-640https://doi.org/10.1016/S0140-6736(23)01231-XSummary Full Text Full Text PDF PubMed Scopus (29) Google Scholar,9Mandal S. Bhatia V. Bhargava A. Rijal S. Arinaminpathy N. The potential impact on tuberculosis of interventions to reduce undernutrition in the WHO South-East Asian Region: a modelling analysis.Lancet Reg Health Southeast Asia. 2024; https://doi.org/10.1016/j.lansea.2024.100423Summary Full Text Full Text PDF Scopus (0) Google Scholar Nutritional supplementation will be particularly important, as factors such as the COVID-19 pandemic, climate change, and conflict further threaten food security.10Carwile M.E. Hochberg N.S. Sinha P. Undernutrition is feeding the tuberculosis pandemic: a perspective.J Clin Tuberc Other Mycobact Dis. 2022; 27100311PubMed Google Scholar Several studies have shown that providing nutritional support to TB patients and those at risk can significantly reduce TB incidence and improve treatment outcomes by strengthening the immune system and enhancing overall health.7Munteanu C. Schwartz B. The relationship between nutrition and the immune system.Front Nutr. 2022; 91082500https://doi.org/10.3389/fnut.2022.1082500Crossref PubMed Scopus (41) Google Scholar,11Du Y. He Y. Zhang H. et al.Declining incidence rate of tuberculosis among close contacts in five years post-exposure: a systematic review and meta-analysis.BMC Infect Dis. 2023; 23: 373Crossref PubMed Scopus (1) Google Scholar Policymakers and health care providers must prioritize nutritional interventions alongside the scale-up and use of new and existing tools to achieve the WHO End TB Strategy targets. While nutritional supplementation has been a commendable effort and should be continued, it is essential to recognize that it alone cannot address the root causes of TB. Micronutrient supplementation to TB patients and vulnerable populations provide short-term relief, but they do not tackle the systemic issues. TB is not merely a medical challenge; it is a social scourge perpetuated by economic disparities. While nutritional deficiency is one of the key drivers of TB, it is also an important symptom of the deeper issue of poverty and inequality, which exert an even more profound influence on TB. Poverty remains the main driving factor for sustained TB burden and addressing poverty is crucial in the fight against TB and should therefore receive much more concerted attention.12Saunders M.J. Evans C.A. Fighting poverty to prevent tuberculosis.Lancet Infect Dis. 2016; 16: 395-396Summary Full Text Full Text PDF PubMed Google Scholar Through studies such as the food RATIONS trial in India, we are starting to understand what works: there is an urgent need to scale up these interventions at the country level, while also generating similar evidence for other dimensions of poverty, and likewise translating this evidence rapidly into public health action.8Bhargava A. Bhargava M. Meher A. et al.Nutritional supplementation to prevent tuberculosis incidence in household contacts of patients with pulmonary tuberculosis in India (RATIONS): a field-based open-label, cluster-randomised, controlled trial.Lancet. 2023; 402: 627-640https://doi.org/10.1016/S0140-6736(23)01231-XSummary Full Text Full Text PDF PubMed Scopus (29) Google Scholar,9Mandal S. Bhatia V. Bhargava A. Rijal S. Arinaminpathy N. The potential impact on tuberculosis of interventions to reduce undernutrition in the WHO South-East Asian Region: a modelling analysis.Lancet Reg Health Southeast Asia. 2024; https://doi.org/10.1016/j.lansea.2024.100423Summary Full Text Full Text PDF Scopus (0) Google Scholar,12Saunders M.J. Evans C.A. Fighting poverty to prevent tuberculosis.Lancet Infect Dis. 2016; 16: 395-396Summary Full Text Full Text PDF PubMed Google Scholar It is time to shift our focus. Poverty alleviation and eliminating inequalities and hunger (part of the Sustainable Development Goals) require multi-sectoral collaborations, concerted efforts, and renewed commitments from local and international communities.13United NationsSustainable development goals.https://www.un.org/sustainabledevelopment/sustainable-development-goalsGoogle Scholar Let us recognize poverty and hunger as the true adversaries in the fight against TB and work collectively to eradicate them. Only then can we truly combat TB. We must engage in an open dialogue and explore innovative and sustainable solutions. Our efforts should extend beyond nutritional supplements and delve into systemic changes that empower communities and ensure access to nutritious food. TB is just one consequence of poverty, but an important one: achieving progress towards the End TB goals will be a powerful indication of success in alleviating poverty and hunger. MAY—conceptualization and preparation of the first draft. AB—critical inputs and revising of the drafts. MAY and AB—finalization and approval of the manuscript. Both authors declare no conflict of interest. Dr Mohammed A. Yassin is the Senior TB Advisor, the Global Fund to fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland and Dr Arvind Betigeri is the Regional Food Fortification Advisor, UN World Food Programme, Regional Bureau for Asia and the Pacific, Bangkok, Thailand. The views and recommendations expressed in the Commentary are the authors' only. The potential impact on tuberculosis of interventions to reduce undernutrition in the WHO South-East Asian Region: a modelling analysisNutritional interventions could cause substantial reductions in TB burden in the Region. Their health benefits extend well beyond TB, underlining their importance for public health. Full-Text PDF Open Access

Leishmaniasis is a vector-borne disease against which there are no approved vaccines, and the treatment is based on highly toxic drugs. The alkaloids consist of a chemical class of natural nitrogen-containing substances with a long history of antileishmanial activity. The present study aimed [...] Read more.

BACKGROUND:Tanzania is 1 of the 30 high TB burden countries and 1 of the 13 countries in which 75% of people with TB are unaccounted for and that is prioritized for the Global Fund Catalytic investment and Strategic Initiative support. Tanzania decided to strengthen its National TB Programme to find these people with TB who are unaccounted for by identifying evidence-driven innovations to deliver high-quality services and to improve the efficiency of TB case-finding. A quality improvement (QI) initiative was implemented by the National Tuberculosis and Leprosy Programme to enhance TB case-finding. The initiative involved identifying gaps in the quality of services, introducing new tools, improving the work capacity of health care workers through training and mentorship sessions, strengthening laboratory and referral services, and implementing mandatory TB screening of all patients attending health facilities. We aimed to assess the effectiveness of QI initiative to enhance TB case-findings at the health facility level.METHOD:A cross-sectional design, and intervention and control facilities randomly selected for an evaluation of the QI initiative were used. Twenty facilities from the Dodoma region across all health care system levels (dispensaries, health centres, and hospitals) were involved in this evaluation. The facilities were randomly divided into either the intervention or control groups at a 1:1 ratio (10 intervention and 10 control facilities). Data routinely collected from program registers from January 2016 to June 2017 were used.RESULT:The evaluation registered a 52% increase in TB case notification in Q1 of 2017 compared with in Q1 of 2016 and, similarly, a 52% increase in Q2 of 2017 compared with in Q2 of 2016, with 9 out of 10 intervention sites reporting increases in their quarterly TB case notifications. There were no positive changes in the 'control facilities' where routine services were provided, with half of the facilities showing a decrease in TB case notification from baseline.CONCLUSION:This QI initiative has the potential to support a long-term comprehensive approach to ending TB and to improve the quality of the foundations of the health care system. This initiative sets a reliable pace for health facilities to efficiently respond to and manage TB case-finding interventions put into action. Tanzania's experience with implementing QI interventions could serve as a model for improving TB case notifications in other settings.

Tuberculosis (TB) is one of humanity’s oldest and deadliest pandemics, accounting for an estimated 10 million cases and 1.5 million deaths globally each year [1]. Drug-sensitive TB (DS-TB) can be treated effectively and inexpensively with a six-month, four-drug treatment regimen. Drug-resistant TB (DR-TB), however, represents roughly 5% of TB cases [1], but has traditionally required outsized human and financial resources to treat, placing tremendous burden on already overtaxed patients, families, health systems, governments, and other payers. Before recent innovations in DR-TB therapy, conventional DR-TB treatment often required 5–7 drugs and more than 14,000 pills over a duration of up to 18 months, or sometimes longer [2]. Shorter DR-TB treatment regimens of 9–11 months have also been recommended recently, but uptake by health systems has been modest. Of those who are able to access therapy, more than 40% were unable complete it successfully [1] due in part to the lengthy and complex treatment that presents significant challenges both to compliance and to healthcare systems who must administer the therapy and follow up with patients for up to an additional 18 months or more. The recently developed BPaLM and BPaL drug regimens (BPaLM/BPaL) have demonstrated success rates of approximately 90% among people with multidrugor rifampicin-resistant tuberculosis (MDR/RR-TB) and pre-extensively drug-resistant tuberculosis (preXDR-TB) in clinical research studies [3–5]–the drug-resistance profiles that represent the vast majority of the DR-TB burden. These regimens hold promise to improve treatment outcomes and experiences in these groups of historically difficult-to-cure patients, simplify care for patients at multiple levels throughout the cascade of care, and improve the currently low treatment success rates. If scaled, there is now potential to align the duration and management of drug-sensitive and drug-resistant forms of TB for the first time in the history of TB treatment. Doing so could alleviate many significant constraints and costs typically related to the management of most forms of drug resistant TB. The all-oral, 6-month BPaLM/BPaL regimens comprise three to four drugs: the new drug pretomanid (developed by the non-profit TB Alliance), used in combination with bedaquiline and linezolid, with or without moxifloxacin. The World Health Organization, in its May 2022 Rapid Communication has informed that BPaLM may be used programmatically for all people with rifampicin-resistant TB who are�14 years and have not had previous exposure of>1 month to bedaquiline, pretomanid and linezolid, while moxifloxacin may be dropped in case PLOS GLOBAL PUBLIC HEALTH

Abstract Background Household Contacts (HHCs) of patients with pulmonary tuberculosis (PTB) have a higher risk of developing TB. Contact investigation is recommended to reach this group and identify undiagnosed cases. In this study, we have determined the yield of contact investigation among HHCs of patients with smear-positive PTB, and estimated TB burden. Methods We conducted retrospective record review for the occurrence of TB among HHCs of Index PTB+ cases treated between November 2010 and April 2013 in 12 public health facilities in Boricha district. HHCs were followed up monthly and revisited between March and June 2015. Information on additional TB cases diagnosed and treated among HHCs were documented. HHCs who were diagnosed as having TB after the index cases were diagnosed and treated were considered as ‘incident cases’. Presumptive TB case was defined as those having cough for ≥2 weeks or enlarged lymph node. Diagnosis of TB among HHCs were made using smear-microscopy and/or X-rays, and clinically for Extra-pulmonary TB (EPTB). Results One thousand five hundred and seventeenth HHCs of 344 index cases were visited and screened for TB and followed up for a median of 37 months. 77 (5.1% - 72 with PTB and 5 with EPTB) HHCs developed TB during 4713 person-years of follow-up with an estimated incidence of 1634 (95% CI: 1370-2043) per 100,000 person-years follow-up which is much higher than the estimated TB incidence for the general population in Ethiopia of 210/100,000. Half (41/77) of incident TB cases were diagnosed within the first year of diagnosis of the index cases and 88% (68/77) were adults (Hazard Ratio: 4.03; 95% CI: 2.00–8.12). Conclusion HHCs of index PTB+ cases have high risk of developing active TB. Long term follow-up of HHCs could help improve TB case finding depending on country contexts. Further studies on effectiveness and feasibility of the approach and integration in routine settings are needed.

Drug-resistant tuberculosis (DR-TB) constitutes a global threat and a major contributor to deaths related to antimicrobial resistance. Despite progress in DR-TB detection and treatment over the last decade, huge gaps remain in treatment coverage, access to quality care and treatment outcome. Global Fund investments have been critical to scaling up the existing and new diagnostic tools, treatment coverage and people-centred service delivery. The United Nations General Assembly (UNGA) high-level meeting represents unprecedented opportunities to accelerate towards addressing DR-TB. Established in 2000 and funded by the Global Fund since 2009, the Green Light Committee (GLC) mechanism has evolved from project approval to providing demand-based technical assistance to countries to scale up response to DR-TB based on their need and priorities. Lessons learnt from the GLC mechanism over 10 years demonstrate that a result-based, systematic and accountable technical assistance model to support scale-up of DR-TB response is critically important. Meeting the UNGA declaration targets requires major scale-up of current efforts and new tools, and hence the need for predictable, consistent and sustained technical support to countries, including through the regional GLC mechanism. The application of the principles and processes of this model could be adapted and replicated to design a similar performance-based and quality-assured technical support mechanism.

Tuberculosis (TB) is one of the major causes of morbidity and mortality in Tanzania. A quality improvement (QI) initiative was implemented by the National Tuberculosis Programme with support from The Global Fund to enhance TB case finding. The initiative involved identifying gaps in the quality of services, introducing tools, building capacity of health workers, and strengthening laboratory and referral services. The initiative was piloted at sub-national level and subsequently scaled-up nationally. Overall, 1280 health workers were trained, leading to an 81% cumulative increase in notified TB cases in the pilot region and 4000 additional TB cases notified nationally. The QI initiative could serve as a model for the improvement of TB case notification in other settings.

Drug-resistant tuberculosis (DR-TB) is a global challenge and a major contributor of death from anti-microbial resistance. With the main aim to determine factors contributing to treatment outcomes observed among DR-TB patients in the countries in Eastern Europe and Central Asia (EECA), a multi-method study was conducted in: Azerbaijan, Belarus, Romania, Tajikistan and Ukraine. Both quantitative and qualitative methodologies were used for data collection and analysis. The quantitative approaches included a desk review of documents related to the DR-TB responses and an analysis of clinical records of DR-TB patients in selected health facilities of the five countries. Qualitative methods included in-depth interviews with national TB programme (NTP) managers, other healthcare providers and non-governmental organizations (NGOs) workers, as well as interviews and Focus Group Discussions (FGDs) with DR-TB patients. The desk review of 38 reports identified as the main challenges to address DR-TB financial and/or management issues and adverse events of the medicines. The most common recommendations related to treatment outcome focussed on general programme management, treatment regimen composition, clinical management and social support for the patients. In all the five countries the NTPs still have a vertical structure. Some integration into the primary health care system (PHC) already exists but further involvement of PHC facilities is feasible and recommended. Interviews with stakeholders indicated that alcoholism and homelessness and a lack of appropriate response to these issues remain as major challenges for a sub-set of patients. Civil society groups, NGOs and communities are substantially engaged in providing different services to DR-TB patients, especially in Ukraine, Romania and Tajikistan. Data from clinical records of 212 patients revealed that independent risk factors for unfavourable treatment outcome (death, loss to follow-up, failure) were culture-positivity at two months of treatment, history of treatment with second-line drugs and homelessness. More powerful, less toxic and shorter oral treatment regimens as well as comprehensive patient support are needed to improve treatment outcome of patients with DR-TB.

Tuberculosis is a major public health problem with varying prevalence in different settings. National prevalence surveys provide evidence for planning and decision making. However, they lack the capacity to estimate subnational magnitude that affected the capacity to make selected intervention based on the prevalence. Ethiopia is among high TB burden countries with estimated prevalence of 108 per 100,000 population varying by regions. We aimed to study sub national prevalence of smear-positive TB in rural communities of southern Ethiopia. This cross-sectional study, enrolled community members aged over 14 years who had cough of at least two weeks duration. Two sputum samples were collected and examined by using smear microscopy. 38,304 eligible people were enumerated (10,779 from Hadiya, 10,059 from Gurage and 17,466 from Sidama) and indentified 960 presumptive cases. 16, 14 and 14 smear-positive pulmonary TB cases were identified respectively. The point prevalence of smear-positive TB were 148 per 100,000 population (95% CI: 91–241) in Hadiya, 139 per 100,000 population (95% CI: 83–234) in Gurage and 80/100,000 population (95%CI: 48–135) in Sidama zone. Gurage zone had the highest prevalent to notified cases of seven to one. The prevalence of smear positive TB varies by districts and is high in rural southern Ethiopia compared to the estimated national prevalence. More TB patients remain missed and unreached, impacting negatively on health outcomes. TB case finding approaches should be revisited and innovative approaches and tools to identify missing people with TB should be scaled up.

Introduction: Tuberculosis (TB) remains a leading infectious cause of morbidity and mortality worldwide. A key contributor to this burden is poor diagnosis as only 60% of new pulmonary tuberculosis (TB) cases in Africa are ever detected. Therefore, this study aimed to assess the feasibility of Xpert MTB/RIF test implementation in the region, and the performance of the assay to increase case detection on the selected rural health care setting. Objective: To assess the feasibility of Xpert MTB/RIF test implementation in the rural health care setting in Southern Ethiopia. Methods: Two Xpert MTB/RIF machines were brought in 2012 through TB REACH project. It was placed at Yirgalem hospital and at Aletawondo health centre. The instruments were installed after formal training was provided to laboratory technologists for three days. We collected sputum sample from participants who repeatedly had negative smear microscopy and those who had not responded to first-line anti-TB drugs. Result: Of the total participants tested, 1828 have valid result (MTB-, MTB+/RIF-, MTB+/RIF+, MTB+/RIF Indeterminate). From the participants with valid results, 217 (11.9%) were Xpert-positive of which were 165 (9.0%) RIF-negative, 6 (0.3%) RIF-indeterminate and 46 (2.5%) RIF-positive. Among TB suspects with previous treatment history and positive by Xpert, RIF resistance was detected in 10 (2.2%). From the new TB suspects with positive Xpert, RIF resistance was detected in 29 (2.7%). All cases identified were linked with TB/MDR-TB treatment centers. Conclusion: Xpert provides an additional tool for the diagnosis of TB and drug resistance, with almost 12% of new and retreatment cases obtaining information that is useful for clinical management. To enhance its efficient utilisation, operational challenges should be minimized particularly in relation to availing robust alternative power source.

Background: The Global Fund encourages operational research (OR) in all its grants; however very few reports describe this aspect. In India, Project Axshya was supported by a Global Fund grant to improve the reach and visibility of the government Tuberculosis (TB) services among marginalised and vulnerable communities. OR was incorporated to build research capacity of professionals working with the national TB programme and to generate evidence to inform policies and practices. Objectives: To describe how Project Axshya facilitated building OR capacity within the country, helped in addressing several TB control priority research questions, documented project activities and their outcomes, and influenced policy and practice. Methods: From September 2010 to September 2016, three key OR-related activities were implemented. First, practical output-oriented modular training courses were conducted (n = 3) to build research capacity of personnel involved in the TB programme, co-facilitated by The Union, in collaboration with the national TB programme, WHO country office and CDC, Atlanta. Second, two large-scale Knowledge, Attitude and Practice (KAP) surveys were conducted at baseline and mid-project to assess the changes pertaining to TB knowledge, attitudes and practices among the general population, TB patients and health care providers over the project period. Third, studies were conducted to describe the project's core activities and outcomes. Results: In the training courses, 44 participant teams were supported to develop research protocols on topics of national priority, resulting in 28 peer-reviewed scientific publications. The KAP surveys and description of project activities resulted in 14 peer-reviewed publications. Of the published papers at least 12 have influenced change in policy or practice. Conclusions: OR within a Global Fund supported TB project has resulted in building OR capacity, facilitating research in areas of national priority and influencing policy and practice. We believe this experience will provide guidance for undertaking OR in Global Fund projects.

Background Tuberculosis (TB) is a major cause of death in Ethiopia. One of the main barriers for TB control is the lack of access to health services. Methods We evaluated a diagnostic and treatment service for TB based on the health extension workers (HEW) of the Ethiopian Health Extension Programme in Sidama Zone, with 3.5 million population. We added the services to the HEW routines and evaluated their effect over 4.5 years. 1024 HEWs were trained to identify individuals with symptoms of TB, request sputum samples and prepare smears. Smears were transported to designated laboratories. Individuals with TB were offered treatment at home or the local health post. A second zone (Hadiya) with 1.2 million population was selected as control. We compared TB case notification rates (CNR) and treatment outcomes in the zones 3 years before and 4.5 years after intervention. Results HEWs identified 216 165 individuals with symptoms and 27 918 (12%) were diagnosed with TB. Smear-positive TB CNR increased from 64 (95% CI 62.5 to 65.8) to 127 (95% CI 123.8 to 131.2) and all forms of TB increased from 102 (95% CI 99.1 to 105.8) to 177 (95% CI 172.6 to 181.0) per 100 000 population in the first year of intervention. In subsequent years, the smear-positive CNR declined by 9% per year. There was no change in CNR in the control area. Treatment success increased from 76% before the intervention to 95% during the intervention. Patients lost to follow-up decreased from 21% to 3% (p<0.001). Conclusion A community-based package significantly increased case finding and improved treatment outcome. Implementing this strategy could help meet the Ethiopian Sustainable Development Goal targets.

The lack of healthcare access contributes to large numbers of tuberculosis (TB) cases being missed and has led to renewed interest in outreach approaches to increase detection. It is however unclear whether outreach activities increase case detection or merely identify patients before they attend health facilities. We compared adults with cough of >2 weeks' duration recruited in health facilities (1202 participants) or in urban slums (2828 participants) in Nigeria. Participants provided demographic and clinical information and were screened using smear microscopy. The characteristics of smear-positive and smear-negative individuals were compared stratified by place of enrolment. Two hundred nine health facility participants (17.4%) and 485 community-based participants (16.9%) were smear positive for pulmonary TB. Community-based smear-positive cases were older (mean age, 36.3 vs. 31.8 years), had longer cough duration (10.3 vs. 6.8 weeks) and longer duration of weight loss (4.6 vs. 3.6 weeks) than facility-based cases; and they complained more of fever (87.4% vs. 74.6%), chest pain (89.0% vs. 67.0%) and anorexia (79.5% vs. 55.5%). Community smear-negative participants were older (mean, 39.4 vs. 34.0 years), were more likely to have symptoms and were more likely to have symptoms of longer duration than smear-negative facility-based participants. Patients with pulmonary TB identified in the community had more symptoms and longer duration of illness than facility-based patients, which appeared to be due to factors differentially affecting access to healthcare. Community-based activities targeted at urban slum populations may identify a different TB case population than that accessing stationary services.

Background 3 years before the 2015 deadline, Ethiopia achieved Millennium Development Goal 4. The under-5 mortality decreased 69%, from 205 deaths per 1000 livebirths in 1990 to 64 deaths per 1000 livebirths in 2013. To understand the underlying factors that contributed to the success in achieving MDG4, Ethiopia was selected as a Countdown to 2015 case study. Methods We used a set of complementary methods to analyse progress in child health in Ethiopia between 1990 and 2014. We used Demographic Health Surveys to analyse trends in coverage and equity of key reproductive, maternal health, and child health indicators. Standardised tools developed by the Countdown Health Systems and Policies working group were used to understand the timing and content of health and non-health policies. We assessed longitudinal trends in health-system investment through a financial analysis of National Health Accounts, and we used the Lives Saved Tool (LiST) to assess the contribution of interventions towards reducing under-5 mortality. Findings The annual rate of reduction in under-5 mortality increased from 3.3% in 1990-2005 to 7.8% in 2005-13. The prevalence of stunting decreased from 60% in 2000 to 40% in 2014. Overall levels of coverage of reproductive, maternal health, and child health indicators remained low, with disparities between the lowest and highest wealth quintiles despite improvement in coverage for essential health interventions. Coverage of child immunisation increased the most (21% of children in 2000 vs 80% of children in 2014), followed by coverage of satisfied demand for family planning by women of reproductive age (19%vs63%). Provision of antenatal care increased from 10% of women in 2000 to 32% of women in 2014, but only 15% of women delivered with a skilled birth attendant by 2014. A large upturn occurred after 2005, bolstered by a rapid increase in health funding that facilitated the accelerated expansion of health infrastructure and workforce through an innovative community-based delivery system. The LiST model could explain almost 50% of the observed reduction in child mortality between 2000 and 2011; and changes in nutritional status were responsible for about 50% of the 469 000 lives saved between 2000 and 2011. These developments occurred within a multisectoral policy platform, integrating child survival and stunting goals within macro-level policies and programmes for reducing poverty and improving agricultural productivity, food security, water supply, and sanitation. Interpretation The reduction of under-5 mortality in Ethiopia was the result of combined activities in health, nutrition, and non-health sectors. However, Ethiopia still has high neonatal and maternal morbidity and mortality from preventable causes and an unfinished agenda in reducing inequalities, improving coverage of effective interventions, and strengthening multisectoral partnerships for further progress. Copyright (C) The Author(s). Published by Elsevier Ltd.

BACKGROUND: Although children in contact with adults with tuberculosis (TB) should receive isoniazid (INH) preventive therapy (IPT), this is rarely implemented. OBJECTIVE: To assess whether a community-based approach to provide IPT at the household level improves uptake and adherence in Ethiopia. METHODS: Contacts of adults with smear-positive pulmonary TB (PTB+) were visited at home and examined by health extension workers (HEWs). Asymptomatic children aged <5 years were offered IPT and followed monthly. RESULTS: Of 6161 PTB+ cases identified by HEWs in the community, 5345 (87%) were visited, identifying 24 267 contacts, 7226 (29.8%) of whom were children aged <15 years and 3102 (12.7%) were aged <5 years; 2949 contacts had symptoms of TB and 1336 submitted sputum for examination. Ninety-two (6.9%) were PTB+ and 169 had TB all forms. Of 3027 asymptomatic children, only 1761 were offered (and accepted) IPT due to INH shortage. Of these, 1615 (91.7%) completed the 6-month course. The most frequent reason for discontinuing IPT was INH shortage. CONCLUSION: Contact tracing contributed to the detection of additional TB cases and provision of IPT in young children. IPT delivery in the community alongside community-based TB interventions resulted in better acceptance and improved treatment outcome.

Tuberculosis (TB) patients with multidrug-resistant (resistance to isoniazid and rifampicin) (MDR-TB) or rifampicin-resistant strains (MDR/RR-TB) do not respond to the standardised first-line TB regimen which is highly effective in other TB patients, requiring much longer and toxic second-line treatment [1]. In fact, only about a half of all MDR/RR-TB patients placed on these regimens worldwide complete them successfully, attesting to the difficulties in scaling up such regimens satisfactorily [2]. Even if only about 4% of new TB patients globally have MDR/RR-TB, they account for over half a million new individuals annually, challenging the constrained resources available for TB care in the low- and middle-income countries where most of them live. Donor support of innovative interventions such as operational research can reap rapid benefits for TB control Authors’ contributions: all authors contributed substantively to the ideation and writing of the manuscript and approved its final version. M.A. Yassin, E. Wandwalo, A. Scardigli and O. Kunii are staff members of the Global Fund to Fight AIDS, Tuberculosis and Malaria. D. Falzon, E. Jaramillo and K. Weyer are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of WHO and the Global Fund.