23 Mar 2018

How to help people with tuberculosis avoid the medical poverty trap

File 20180321 165580 i4eyto.jpg?ixlib=rb 1.1
Shantytown near Lima, Peru. Inspired By Maps/Shutterstock.com
Tom Wingfield, University of Liverpool 
Rosario hacks into a handkerchief, coughing up the bloodstained phlegm that plagues her chest in the mornings. On hearing the noise, two heads pop up from under a blanket – Rosario’s twins, Gonzalo and Bruno. A wail starts up from the crib in the corner of the one-room shack. As she puts baby Angelita to her breast, Rosario ponders her situation.

It’s been half a year since her husband Samuel passed away, two months since this horrible cough started, and six days since the doctor told her she had tuberculosis and she started the medicines. Nearly every day since then, Rosario has had to make the hour-long, bumpy minibus journey to the tuberculosis clinic – Angelita in hand – so the nurse can witness her taking the drugs.
But Rosario just can’t get to the clinic today. Her neighbour can’t look after the twins, and Rosario has no money to pay for the minibus ride. More pressingly, there is no food left to cook nor kerosene to cook with.

Rosario quickly calculates that, after deducting two packets to feed the twins, she has enough biscuits left to sell for a small profit at the minibus stop. For today, at least, that will stop the family going hungry. But it will also mean not arriving at the clinic until after it shuts – too late to take her medicines.

A social disease

Rosario’s situation in a Peruvian shantytown is not fictional, not isolated, and not new. Nearly a century and a half ago, Rudolf Virchow, the father of social medicine, recognised that tuberculosis (TB) and poverty were inseparably linked in a vicious cycle. He called TB “a social disease”. Indeed, the improvements in poverty levels, living conditions and nutrition that occurred during the Industrial Revolution in Europe were associated with a fall in TB rates, many years before the discovery of the TB bacteria or TB medicines. Today, the poorest households continue to suffer the highest levels of infectious diseases and, in trying to access healthcare, can be pushed deeper into poverty and ill health – the so-called “medical poverty trap”. There is no disease that better typifies this trap than TB.

Rudolf Virchow, the father of social medicine. Wikimedia Commons

Despite this, recent global TB control strategy has been disproportionately focused on medicines and tests rather than addressing the social causes of the TB epidemic. And so, today, Rosario’s terrible dilemma continues to be faced by many of the roughly 10m people worldwide who will develop tuberculosis this year (1.3m of whom will die).

This is one of the reasons why the global response to TB is not working. A more holistic approach to TB control is needed that addresses not just the disease but also the person who has the disease and the circumstances in which they live.

In its 2015 End TB Strategy, the World Health Organisation (WHO), for the first time in the modern era of TB control, called for social support and poverty alleviation strategies for people with TB to reduce the hidden costs of treatment, reduce stigma, empower patients, and increase TB prevention, the number cured and their overall well-being. But evidence that this type of strategy works was limited.

Testing the theory in Peru

The multi-disciplinary Innovation For Health and Development research team, which I joined in 2010, has been working for the past two decades in shantytowns near Lima, Peru, to generate new evidence to fill this knowledge gap and support TB-affected households.
One of our first tasks was to measure households’ hidden costs of TB treatment. Hidden costs (like those Rosario faces) included travel to clinics, food and lost income.

We found that when these hidden costs exceeded a fifth of a household’s annual income, the patient in the household was more likely to abandon treatment, fail treatment or die. In essence, the threshold of costs that we had measured had been catastrophic, not only to household finances but also to the TB patients’ health. This threshold, among others, was subsequently endorsed by WHO in their TB patient costs survey, which is being deployed around the world.

Our findings had identified a crucial factor explaining why medicines alone were not controlling TB. In response, we provided social and financial support for TB-affected households. Financial support consisted of bank transfers (up to US$40 per month) to reduce the hidden costs of TB and enable access to TB care. Social support included household visits by our research nurses and mentoring from mutual support groups led by former TB patients to empower households to access care and reduce stigma.

The intervention was a success. Supported TB patients were significantly more likely to complete their treatment or be cured, and their children were more likely to take medicine to prevent TB.
Rosario (not her real name) was one of the patients who received this support. Using the money she received throughout her treatment, she was able to keep going to the clinic and ensure that Gonzalo, Bruno and Angelita were fed regularly, and took medicine to prevent TB. She is now cured of TB and able to work.

The ConversationHelping households affected by TB to avoid the medical poverty trap, and providing them with moral support and hope, can enhance TB care and prevention. Without it, we won’t achieve the End TB Strategy goal of eliminating the disease by 2050, and millions more vulnerable households, like Rosario’s, could continue to suffer an entirely avoidable downward spiral of poverty and ill health.
Tom Wingfield, NIHR Academic Clinical Lecturer in Infection and LIV-TB Collaboration Lead, University of Liverpool

This article was originally published on The Conversation. Read the original article.

14 Mar 2018

Five diseases you can catch from pets

File 20180312 30972 vw8rut.jpg?ixlib=rb 1.1

Love them or hate them, it is hard to get away from pets. And even if you don’t own one yourself, you are likely to come across them (or things they have left behind) regularly.

Most interactions between humans and pets are likely to be overwhelmingly positive. But pets can carry some diseases that affect us. Such diseases, termed zoonoses, are usually very mild, but the rarer ones can be more severe.

Here are some of the infections people can catch from their pets:

1. Rabies

Rabies is perhaps the archetypal zoonosis. A virus whose name alone has the potential to cause fear. The virus is largely found in unvaccinated dogs and other canine populations.

In areas that still have rabies, people – often children – usually become infected when they are bitten by an affected dog. The virus attacks the brain, and once symptoms develop, there is sadly no cure, and those affected die. The good news is, it can be prevented by vaccinating dogs and other wild carnivores. Many parts of the world are now free of the virus, including the UK and large parts of the rest of Europe, and in many others, national campaigns are under way to achieve this.

2. Ringworm

Some zoonotic skin infections are not uncommon in pets but usually mild in humans. These can be shared with owners because of our love for warm houses, and close contact with our pets. Ringworm is one such infection.

Ringworm is actually a misnomer. It is not a worm at all but a microscopic fungus, closely related to the cause of athlete’s foot in people. Affected cats, dogs and other animals may show very few signs. However, in its classical form, pets with ringworm usually have circular areas of hair loss. The affected area of skin becomes scaly, flaky and itchy. It is very treatable, but can occasionally cause scarring.

3. Salmonella

A variety of potentially zoonotic bugs live in the intestines of pets. These rarely affect humans. However, when they do, they can be severe. We have all probably heard of salmonella, largely because of risks, now thankfully much diminished, from eggs. Dogs and cats can also carry salmonella, sometimes causing diarrhoea. Salmonella is also quite commonly present in pet reptiles and amphibians, as well as in so-called “feeder mice” that are fed by some to pet reptiles.
It’s always a good idea to wash your hands after handling both pets and raw pet food. It is also a good idea to have separate areas for preparing raw animal food and human food.

Pet reptiles can carry salmonella. SGr/Shutterstock.com

4. Toxoplasma

Toxoplasma is a common parasite in cats that they can also shed in their faeces. For most humans, it is entirely benign. However, if a woman first becomes infected during pregnancy, it can, albeit rarely, have severe complications for the developing foetus.

Pregnant women should take simple additional precautions around hand hygiene, avoiding cat litter trays, especially those not cleaned regularly, and avoiding eating uncooked garden produce where cats may have had access to the soil.

5. Bites and scratches

Some argue for bites and scratches to be included as a zoonosis. If we do include them, they are likely to be among the most common zoonoses. Never nice, always painful, and in disturbing, rare cases – usually involving children – they can be fatal.

Cat bites and scratches can transmit a bacterium called Bartonella henselae, the cause of “cat-scratch disease”. Both bites and scratch wounds can become badly infected causing further pain. Scars, both mental and physical, can be lifelong in those that have been attacked. Children and those exposed occupationally, such as postmen, are perhaps most at risk.

As with most infections, zoonotic infections have a greater potential to do harm in people whose immune systems are compromised, such as the elderly and those suffering from immunosuppressive diseases (such as HIV/AIDS), or undergoing immunosuppressive therapies (such as chemotherapy). However, even if your immune system is compromised, you can still benefit from owning a pet. And with care and a little knowledge of the risks, you can avoid infections.

The ConversationThankfully, zoonotic infections are not common. Most infections we get are likely to come from other humans. However, the risks of zoonosis can be minimised by being aware of them and by taking simple hygiene precautions at home. And, if in doubt about the risks, you can always consult your GP or a veterinary surgeon.

Alan Radford, Professor of Veterinary Health Informatics, University of Liverpool
This article was originally published on The Conversation. Read the original article.
The Institute of Infection and Global Health. Powered by Blogger.