All Articles

Payam Sheikhattari^1,2, Rifath Ara Alam Barsha¹, Jummai Apata¹, Shervin Assari^3,4*

¹Center for Urban Health Disparities Research and Innovation, Morgan State University, Baltimore, MD, USA

²The Prevention Sciences Research Center, School of Community Health and Policy, Morgan State University, Baltimore, MD, USA

³Department of Family Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

⁴Department of Urban Public Health, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

Objective: This study aimed to examine the intersectional effects of race and educational attainment on tobacco advertising exposure among adults in Baltimore, given the growing evidence on differential influence of education for Black and White populations.

Methods: A survey was conducted in Baltimore, collecting data on educational attainment, demographics, and tobacco advertising exposure among adults (n = 3028, 22.7% 18 – 29, 17.9% 30 – 39, 23.4% 40 – 49, 20.9% 50–59, and 11.1% 60+ years old). The sample included both Black and White adult individuals. Logistic regression analyses were employed to assess the association between educational attainment and tobacco advertising exposure, without and with interaction with race, adjusting for relevant covariates such as age, gender, and employment. Sensitivity analysis also controlled for smoking status.

Results: The study results indicated that while high educational attainment is associated with less exposure to tobacco ads, highly educated Black adults report significantly higher tobacco advertising exposure compared to highly educated White adults. Same results were observed after controlling for smoking status.

Conclusion: Educational attainment may not exhibit a large protective effect against environmental risks such as tobacco ad exposure for Black populations, possibly because of segregation and racism that hinder highly educated Black people ability to move to low-risk neighborhoods.

Shervin Assari^1,2,3*, Payam Sheikhattari^4,5

¹Department of Urban Public Health, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

²Department of Family Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

³Department of Internal Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

⁴Center for Urban Health Disparities Research and Innovation, Morgan State University, Baltimore, MD, USA

⁵The Prevention Sciences Research Center, School of Community Health and Policy, Morgan State University, Baltimore, MD, USA

Shervin Assari^1,2,3,4*, John Ashly Pallera⁵, Babak Najand⁶

¹Department of Urban Public Health, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

²Department of Family Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

³School of Nursing, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

⁴Department of Internal Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

⁵Department of Biomedical Sciences, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

⁶Marginalization-related Diminished Returns Center, Los Angeles, CA, USA

Background: While previous research has established the role of depression as a correlate of tobacco use, limited research has been conducted on potential racial variations in these associations.

Aims: This study had two objectives: (1) to investigate the associations between depression and smoking conventional and vaping e-cigarettes, and (2) to explore the role of race in modifying these associations.

Methods: Data from the Health Information National Trends Survey (HINTS-2022) survey, which is a national probability sample of US adults, were analyzed. Variables of interest included lifetime and current smoking status, e-cigarette use, depression (PHQ-4), socioeconomic status (SES), and demographic characteristics. Binary logistic regression models were applied to assess the associations between depression as the independent variable and current and ever smoking conventional cigarettes and vaping e-cigarettes as dependent variables, adjusting for covariates (age, gender, education, marital status, and employment). We tested potential interactions between race/ethnicity (non-Hispanic Whites, non-Hispanic Blacks, Hispanic Whites and any other/mixed race/ethnicity) and depression on our outcomes.

Results: The study findings indicated significant associations between depression and use of conventional cigarettes and e-cigarettes. Although individuals who were experiencing depression were more likely to use conventional cigarettes (p < 0.05) and e-cigarettes (p < 0.05) compared to those non-depressed, the positive associations between depression and lifetime and current smoking were stronger for Black than White individuals.

Conclusions: This study suggests that depression may have a more salient role in smoking cigarettes and e-cigarette use for Black than White adults. It is unclear if Black adults are more likely to smoke if they are depressed, or if Black adults who smoke cigarettes are more likely to be depressed because of higher stigma and lower access to mental health care services.

James Patrick Finnerty

Department of Respiratory Medicine, Countess of Chester Hospital NHS Trust, Liverpool Road, Chester, UK

Jennifer D. Duke¹, Janani Reisenauer^1,2*

¹Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA

²Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA

With recent advancements in robotic bronchoscopy for peripheral pulmonary nodule biopsy, there has been notable improvements in reach, stability, and precision. Since 2017, the United States Food and Drug Administration (FDA) has approved two robotic devices, the Ion™ Endoluminal System (“Ion”) (Intuitive Surgical©, Sunnyvale, CA, USA) and the Monarch robotic system (Auris Health Inc, Redwood City, CA), for peripheral navigation and biopsy of lung lesions. We review these two robotic bronchoscopy systems and the literature that supports their use.

Serenydd Everden, Jack West

Department of Emergency Medicine, Coffs Harbour Base Hospital, Coffs Harbour, NSW, Australia

Fatima Mahmood¹*, Moiz Ehtesham¹, Syed Muhammad Mashhood Ali Bokhari², Ruben A. Peredo-Wende³

¹Department of Internal Medicine, Albany Medical College, Albany, NY, USA

²University of Texas Southwestern Medical Center, Dallas, TX, USA

³Rheumatology Stratton Veteran Medical Center, Albany, NY, USA

Moiz Ehtesham^1*, Fatima Mahmood², Muhammad Asim Shabbir¹, Ruben-Wende Peredo¹

¹Department of Internal Medicine, Division of Rheumatology, Albany Medical College, Albany, NY, USA

²Department of Medicine, Albany Medical College, Albany, NY, USA

Gonzalo Segrelles-Calvo¹*, Estefanía Llopis-Pastor¹, Glauber Ribeiro de Sousa Araújo², Inés Escribano¹, Esther Antón¹, Laura Rey¹, Nestor Rodriguez Melean¹, Marta Hernández¹, Javier Carrillo¹, Celia Zamarro¹, Mercedes García-Salmones¹, Susana Frases².

¹Respiratory Intermediate Care Unit, Respiratory Department, University Rey Juan Carlos Hospital, Madrid, Spain

²Laboratorio de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Brasil

Introduction: The study aimed to analyse the clinical response and short-term outcomes with the use of high-flow oxygen therapy (HFOT), non-invasive mechanical ventilation (NIMV) with bilevel positive airway pressure, or continuous positive airway pressure (CPAP) in severe COVID-19 patients.

Methods: We conducted an observational, prospective, single-center study, approved by Ethics Committee of “Instituto de Investigación Sanitaria Fundación Jiménez Díaz” (EO102-20-HRJC).

We included a total of 130 patients ≥18 years-old, with proved SARS-CoV-2 infection and secondary Acute Respiratory Failure (ARF) that required treatment with Non-invasive Respiratory Support (NIRS). We collected data about population demographic characteristics, clinical factors, and evolution during the incoming. A baseline of patients treated with HFO, CPAP and NIMV were compared with one-way ANOVA test, while categorical variables were expressed as numbers and percentages and were compared using the chi-square test or Fisher’s exact test when appropriate.

Results: The cohort was distributed as follows: CPAP 54.6% (n = 71), NIMV 30% (n = 39), HFO 15.4% (n = 20). There were no differences between NIRS subgroups regarding age, comorbidity, or functional status. At the beginning of NIRS treatment, PaO₂/FiO₂ value was 149.3 ± 69.7. After 24 hours, PaO₂/FiO₂ was significantly higher in the CPAP group (CPAPvsNIMV, p-value = 0.0042; CPAPvsHFO, p-value = 0.000169).

The overall ICU admission evaded rate was 69.1% and TF rate was 43.8%, without differences between the three therapies (p-value = 0.281). The mortality rate was 37.2%, without significant differences between subgroups.

Conclusions: Our data suggest that CPAP versus treatment with NIMV or HFO improves PaO₂/FiO₂ rate in severe ARF patients, significantly reducing ICU admission. No differences were observed in mortality or therapeutic failure.

Dewansh Goel, MD, MPH^*, Kenneth Iyamu, MD, FACP

University of Central Florida/HCA GME Consortium, Ocala Regional Medical Center, Florida, USA

Usage of vaping and electronic cigarettes products is a growing trend among young adults, with rising rates worldwide. Such products are gaining popularity for many reasons including an alternative to smoking cigarettes, trying something new, or as a means to relax. While users may feel that these products are less harmful or a safer substitute to smoking traditional products, the side effect profile of vape inhalation has the potential for profound injury to the lung tissue and significant respiratory failure. We would like to present a case in which a young male who was evaluated at our Emergency department for acute onset respiratory failure subsequently requiring invasive mechanical ventilation in the setting of vaping associated lung injury (VALI). In the case report, we will highlight the patient’s clinical course as well as a summary of the current evidence surrounding evaluation, diagnosis and management of this emerging pathology. We want to emphasize the importance of a detailed history which should include the use of vaping products when a young patient presents with acute respiratory failure, allowing VALI to be in the differential diagnosis. Additionally, we want to compare the clinical presentation of VALI to that of COVID-19 pneumonia as they both have many similar attributes including symptoms and findings on lung imaging studies.

Stephanos Patsiris^1,2*, Grigoris Stelios², Ilias Papanikolaou¹, Themis Exarchos², Panayiotis Vlamos²

¹General Hospital of Corfu, Corfu, Greece

²Bioinformatics & Human Electrophysiology Laboratory, Dept. of Informatics, Ionian University, Corfu, Greece

Chronic obstructive pulmonary disease (COPD) is a respiratory disease with high prevalence. Many factors contribute to its development, and probably that leads to its various clinical pictures. Inflammation is the mechanism responsible for the structural alterations in the lungs. Despite its heterogeneity, there are a couple of primary symptoms characterizing it, which are chronic and productive cough and dyspnea.

The understanding of dyspnea in COPD is based on theories deriving from the interaction of a network formed between the cardiorespiratory and the neuromuscular system and their receptors. Many factors contribute to its occurrence, making it complex and giving it a very subjective character for a person to perceive.

Various methods are used to study COPD. Non-invasive ones seem to attract attention nowadays. One of them is the exhaled breath condensate. It is a biofluid with rich content, which can capture a picture of the pathological processes happening in the lungs. Its study has shown that some markers of inflammation and oxidative stress, such as 8-isoprostane and H₂O₂, are elevated and able to connect dyspnea and inflammation. Additionally, they seem to provide information of the ongoing inflammatory process in the lungs as well as a picture of the severity of the symptoms. This evidence may enhance the association of dyspnea with dysfunctional breathing.

Despite these interesting findings, further research is necessary both in dyspnea and inflammation in COPD to clarify their mechanisms and connective pathways. The utility of non-invasive techniques such as the exhaled breath condensate could be of significant help, but its establishment in the medical field requires extra studies.

Farhan Ali

PGY 2, Internal medicine resident, North Alabama Medical Center, Florence, Alabama, USA

We present a 25-year-old Hispanic man with left-sided pleuritic chest pain and dyspnea for three days. His Chest radiograph and CT^A revealed bilateral apical bullous disease with a 2.5 cm deep left sided pneumothorax. He was managed with 100% oxygen via non-rebreather mask and did not require invasive decompression. Patient reported a one-year history of vaping along with tobacco and cannabis smoking exposure from his late teen years. The pneumothorax improved and he was discharged to the pulmonary clinic. The authors review the multiplicative effect of vaping on smoking cannabis and tobacco leading to early apical bullous lung disease. Patients with such significant smoking/vaping history may benefit from prolonged pulmonary and addiction medicine follow-up given the clinical bullous lung disease and risk for continued smoking/vaping. The case emphasizes the potential exponential effect of combining vaping with tobacco and marijuana smoke on lung health leading to disease at extremely young ages.

Camila Silva Barbosa*, Hye Ju Lee

Radiology Department, Sírio Libanês Hospital, Sao Paulo, Brazil

On October 15^th 2020, the Emergency Radiology Journal published our article entitled “COVID-19 pneumonia in the emergency department: correlation of initial chest CT findings with short-term outcome”, that evaluated clinical, laboratorial and imaging findings of laboratory confirmed COVID-19 patients as predictors of severe disease. In this paper, we will explore the context and significance of the early recognition of the disease severity on patients’ management.

Malgorzata Kloc^1,2,3*, Rafik Mark Ghobrial^1,2, Jacek Z. Kubiak^4,5*

¹The Houston Methodist Research Institute, Houston, Texas, USA

²The Houston Methodist Hospital, Department of Surgery, Houston, Texas, USA

³The University of Texas, M.D. Anderson Cancer Center, Department of Genetics, Houston Texas, USA

⁴Department of Regenerative Medicine and Cell Biology, Military Institute of Hygiene and Epidemiology (WIHE), Warsaw, Poland

⁵UnivRennes, UMR 6290, CNRS, Institute of Genetics and Development of Rennes, Cell Cycle Group, Faculty of Medicine, Rennes, France

COVID-19 pandemic has frightened people and governments all around the world. The common opinion is that there are no efficient preventive measures but masks, isolation, and social distancing. The deliverance is hoped from the SARS-CoV-2-specific vaccine, which must be efficient and cheap. But, so far nobody knows when, and if such a vaccine will be developed and mass-produced. Trained immunity with oral polio vaccine (OPV) was recently proposed as a temporal solution against the heavy course of COVID-19. However, politics do not seem to follow, and the scientific world should react because humanity has no time to lose. Below, we support this with our thoughts.

Ivane Kiladze¹*, Elene Mariamidze¹, Branislav Jeremic²

¹Oncology and Hematology Department, Research Institute of Clinical Medicine after academician F.Todua, Tbilisi, Georgia

²Radiation Oncology Department, Research Institute of Clinical Medicine after academician F.Todua, Tbilisi, Georgia

Lung cancer (LC) continues to be a significant worldwide public health issue. There are several publications addressing specifics of LC worldwide, but none concerning Georgia- a country with high number of smoking population and LC cases.

Based on the above facts we conducted the first study in the country that aims both evaluating current pretreatment LC challenges, including barriers for early diagnostics and indicating the future strategies for improved LC care

We first analyzed LC statistics and the smoking patterns in the country. Further, we identified other challenging issues in pretreatment diagnostics and staging aspects and finally, provided a survey among LC specialists all over the country to evaluate the situation regarding access and use of radiology investigations and other staging procedures. The survey questionnaire was distributed among LC specialists in main cancer hospitals (n=13) across the country.

We identify multiple health challenges. Still there are a high number of smokers in the country which clearly indicates that additional measures focusing on smoking cessation are urgently needed. This is further materialized in the fact that the majority of patients with LC are diagnosed with either locally advanced or metastatic disease. Activation of preventive programs and implementation of LC screening for early detection should hopefully lead to further reduction of national LC mortality rates.

We underline the urgent need for implementation of country-adapted diagnostic and therapeutic guidelines and protocols as well as enforcing multidisciplinary team meetings. The great need to introduce screening programs in high risk groups, improve access to modern treatment modalities and standardize national diagnostic and treatment protocols are of paramount importance for better LC care.

Mohammad Abdallat¹*, Mazhar Khalil¹, Ghayth Al-Awwa¹, Ravi Kothuru², Charles La Punzina²

¹Department of Surgery, Brookdale University Hospital and Medical Center, USA

²Cardiothoracic Surgery, Brookdale University Hospital and Medical Center, USA

Background: This case series assessed the clinical outcomes and characteristics of barotrauma in COVID19 patients.

Methods: The electronic medical records of all patients admitted with confirmed COVID 19 infection who eventually developed barotrauma between March 17^th, 2020 and April 17^th, 2020 were reviewed, information about patient characteristics, pattern and characteristic of barotrauma were analyzed and reported in a descriptive manner.

Results: 25 patients developed evidence of barotrauma on Chest Xray or Computed tomography (CT) with a mean age of 60.1 at the time of diagnosis, 12 (48%) developed severe ARDS with PaO2/FiO2 ratio of <100. 14 (56%) patients developed pneumothorax, 7 had evidence of subcutaneous emphysema and 6 developed pneumomediastinum. More barotrauma occured in the first day of ventilation than any other day, the median time between mechanical ventilation and development of barotrauma is 3.5 days.

Conclusion: Barotrauma in COVID 19 is associated with an increased mortality (64%) which may reflect worse acute lung injury in these cases. The median time to develop barotrauma in these patients is similar to the one described in ARDs literature.

Juan Pablo Reig Mezquida¹*, Alilis Fontana Bellorín², Alberto García Ortega³, Gabriel Anguera de Francisco¹

¹Lung Transplant Unit, Hospital Universitario la Fe, Valencia, Spain

²Department of Thoracic Surgery, Hospital Universitario la Fe, Valencia, Spain

³Department of Pulmonology, Hospital Universitario la Fe, Instituto de Investigación Sanitaria “La Fe”. Valencia, Spain

The clinical course of Coronavirus disease 2019 (covid-19) in lung transplant recipients remains unknown. We present the fatal clinical course of a 63-year old double lung transplant recipient with severe Covid-19 pneumonia. She had stable graft function before Covid-19 infection. Despite all the supportive care and treatment graft injury progressed, causing patient death. Therefore, the prognosis in lung transplant recipients with Covid-19 infection is not optimistic.

Paul Andrew Lilburn^1,2*, Patrick Bazin², Alexander Beveridge², Emma Goeman³, Hazel Goldberg^1,3,4,5

¹Prince of Wales Hospital, Barker Street, Randwick, Sydney, NSW, 2031, Australia

²St Vincent’s Hospital, 390 Victoria Street, Darlinghurst, Sydney, NSW, 2010, Australia

³Royal Prince Alfred, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia

⁴Sydney Hospital, 8 Macquarie Street, Sydney, NSW, 2000, Australia

⁵St George Hospital, Kogarah, NSW 2017, Australia

Bacillus Calmette-Guerin (BCG) is a live-attenuated strain of Mycobacterium bovis (M bovis), originally developed as a vaccine against tuberculosis. It is also used in the treatment of bladder cancer. We present a case of disseminated BCG-osis which was only discovered at post-mortem. An 89-year-old male was admitted to a tertiary referral centre in inner Sydney in December 2015 with fevers, night sweats, exertional dyspnoea and 8 kg weight loss. The patient developed progressive type 1 respiratory failure requiring non-invasive positive pressure ventilation and treatment for heart failure, but he died eleven days into his admission. On microbiological testing Mycobacterium. tuberculosis complex (MTBC) DNA was detected in lung tissue, by polymerase chain reaction (PCR), using the Xpert® MTB/RIF (Cepheid) platform, the day after the patient’s death. Later mycobacterial culture and genomic deletion analysis identified the specific organism as M bovis. This report describes an unusual presentation of systemic BCG-osis appearing more than three years after the last BCG instillation. This reinforces the fact that BCG instillation of the bladder for transitional cell carcinoma poses a potential risk of systemic spread even years after.

A.Alaga*, M.A Fairous, M.K. Razul

Pulmonology Department, Hospital Sultanah Bahiyah, Alor Setar, Malaysia

Ronit Aloni-Grinstein^1,2#, Yan Stein^1# and Varda Rotter¹*

¹Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot 7610001, Israel

²Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona, Israel

Influenza A is a very common cause for respiratory infections, which constitutes a major public health concern due to high rates of morbidity and mortality in high-risk population. In our previous publication, ‘p53 and the Viral Connection: Back Into the Future’, we discussed the involvement of the p53 tumor suppressor in the response to non-tumorigenic viruses, among which is the Influenza virus. In the current comment, we focus on the interplay between p53 and the influenza viral cycle. We discuss recent publications that provide evidence for the potential antiviral and pro-viral roles of p53 and its isoforms towards influenza, both in the host cell, as well as in the immune system. On the other side of the coin, we also discuss how the influenza virus may manipulate p53 to promote its own replication and spreading. An understanding of the interplay between p53 and the virus may lead to the development of a host-based influenza virus therapy.

L.V.Klochkova*, M.E.Lozovskaya, E.B.Vasilyeva, Yu.A.Yarovaya

Saint Petersburg State Pediatric Medical University, Ministry of Health of the Russian Federation, Saint Petersburg, Russia

Background: The study aimed to identify causes of delayed diagnosis and define features of tuberculous meningitis in children in the Russian Federation.

Materials and Methods: The study is based on data from 2000 to 2016 on frequency of meningitis in children in Russia. Further analysis of disease features and diagnostics of tuberculous meningitis in children in St. Petersburg over 12 years (2005-2016) is presented.

Results and Discussion: The number of cases of tuberculous meningitis in children in Russia decreased from 51 to 13 per year from 2000 to 2016. In St. Petersburg, from 2005 to 2016 there were 7 registered cases; 4 died, 3 survived. Predisposing factors of development of tuberculous meningitis were young age, presence of tuberculosis in the family, absence of BCG vaccination, and unfavorable social conditions. Three out of 7 children infected with HIV developed tuberculosis. However, a low frequency of cases has led to absence of phthisis vigilance, delayed diagnosis and deaths. Two illustrative cases are presented from clinical practice.

Conclusion: Improving outcomes of tuberculous meningitis requires enhanced phthisis vigilance, detection of mycobacterium tuberculosis infection by modern methods, use of all methods of etiological diagnostics, including PCR and Baсtec, and immediate administration of antituberculous therapy.

Alizamin Sadigov*, Irada Mamedova, Kamran Mammmadov

Pulmonary Medicine Department, Azerbaijan Medical University, Baku

Background: Ventilator-associated pneumonia (VAP) remains a common case of intensive care unite (İCU) and hospital morbidity and mortality despite advances in diagnostic techniques and manegment. One of most important point for such patients is identification of predictors for mortality in term for futher their modification and reduction of mortality rate.

Objective: We aimed to determine the most important risk factors for short-term mortality in patients with VAP in mechanically ventilated patients.

Methods: This retrospective study was carried out from February 2014 to January 2019. One hundred twenty one adults patients with VAP maintained on mechanical ventilation for more than 48 h in our ICU department were enrolled in the study. VAP was diagnosed as new persistent pulmonary infiltrates on chest radiographs and a least two of following: (1) Fever of ≥38.3C (2) leukocytosis of ≥ 12.000/mm³ and (3) purulent tracheobronchial secretions. Endotracheal aspirate (ETA) samples and blood samples of suspected case were collected and processed as per standard protocols.

Results: The primary underlying diagnosis and comorbidities were acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in 42 patients, congestive heart failure in 32, neurological disease in 28, and renal disease in 19 patients. Gram-negative agents were the major of finding pathogen (Acinotebacter baumannii accounting for 37.1 %). This infection in 43 case (95.5%) was multi-dying resistant (MDR) pathogen and associated with significantly higher length of ventilation (LOV) and the length of ICU stay (LOS_icu) (p=0.01 respectively). Severe sepsis/septic shock, acute respiratory distress syndrome (ARDS), malnutrition, pulmonary complications such as pleural effusions and bilateral, multi- lobar lung infiltrates were most common findings in VAP patients which were associated with higher mortality (p<0.01).Acinotebacter baumannii MDR pathogens was associated with higher mortality rate compare with other MDR pathogens (p<0.01).

Conclusion: Ventilator-associated pneumonia is a serious ICU complication that is associated with increased in hospital mortality.In patients with VAP malnutrition ,severe sepsis/septic shock, ARDS, MDR Acinotebacter baumannii infection ,bilateral pulmonary infiltrates ,and underlying chronic obstructive pulmonary disease(COPD) are associated with increased risk in-hospital mortality in such patients. Identification of risk factor for in hospital mortality in such patents is important in term on further their modification and reduction of mortality rate.

Hala Jassim AlMossawi¹, Colleen Longacre¹, Yogan Pillay², Neeraj Kak¹*

¹University Research Co, Chevy Chase, MD, USA

²National Department of Health, South Africa

Social and behavior change (SBC) communication strategies and interventions have been used to successfully promote positive health behaviors and health outcomes, yet there is little evidence in the published literature on SBC frameworks for tuberculosis (TB) care and treatment. In this article, we outline a high-level generalized framework for the development, deployment, and evaluation of SBC communication strategies in high TB burden settings and how it could be employed to address TB treatment delays. The framework describes the contextual factors that will impact the design of a program, the spheres of influence, and details some of the outcomes to be achieved within each sphere that will lead to improved knowledge and substantive changes in behaviors at each prescribed level of the system. Improved design and delivery of SBC interventions can assist countries in meeting the Sustainable Development and Global End TB goals of reduced TB incidence, increased TB cure rates, reduced TB deaths, prevention of catastrophic out-of-pocket costs for TB care, and integration of health systems for patient-centered care.

Hala Jassim AlMossawi¹, Neeraj Kak¹*, Yogan Pillay², Refiloe Matji¹, Sharanya Joshi¹

¹Center for Innovations and Technology, University Research Co., LLC, Chevy Chase, MD, USA

²National Department of Health, Pretoria, South Africa

Background: Increasingly lower- and middle-income countries have moved towards the adoption of National Health Insurance (NHI) models as a means to support sustainable financing for Universal Health Care. National Health Insurance in the form of government-led, publicly supported and/or centrally managed insurance programs in various forms have been introduced in countries such as Brazil, Cambodia, China, Rwanda, Mexico, South Africa, and Thailand and have demonstrated important successes. The impact of these insurance programs on the use of tuberculosis (TB) services and outcomes is unclear.

Objectives: This assessment examines how TB is included (or neglected) in the service delivery package in NHI programs and how effectively NHI programs interact with National TB Programs (NTP) and other TB control stakeholders to plan, implement, and measure TB service use. This assessment aims to analyze the extent to which several NHI programs currently in place or in development in high-burden TB countries have integrated TB services. It synthesizes the findings of assessments in four countries - Thailand, Peru, Philippines, and India - which have adopted publicly supported health insurance programs.

Results: The four case studies demonstrate that the integration of TB services with national health insurance can have a positive effect on access to services and their quality. On the other hand, each of the models assessed impose different types of restrictions which can limit the utilization of services. Some restrictions are planned and are part of the design of the insurance model. Others, however, are indirect or unintended consequences of implementation. As it relates to TB, the findings of the assessment have highlighted the need to carefully examine the impact of restrictions in terms of access and use of TB services. In Thailand, the case study found that long wait times at facilities discouraged patients from obtaining services through national health insurance. In the Philippines, the case study found that many patients perceive that they will have to pay direct and indirect costs for TB services in the public sector and prefer instead to seek treatment in the private sector, including pharmacies, to reduce costs. The primary goal of publicly-supported health insurance programs is to improve access to care for a vulnerable segment of the population and, especially as it relates to TB, have the potential to play an important role in improving public health. However, specific objectives for health insurance programs are not typically defined in terms of disease objectives. In countries with significant burdens of key diseases like TB which threaten to jeopardize overall population health (as well as long term growth and development), specific considerations should be made to ensure that the NHI program is designed to be a driving force for controlling the epidemic. The decision to develop and adopt a publicly-supported insurance model should ideally form part of broader health systems reform efforts, and the design of the insurance model should, therefore, include features geared at reinforcing and advancing the country’s health systems strengthening objectives. An issue facing each country, in different degrees, is the separation between the functions of the NTP and the insurance planning and implementation agency. The addition of an insurance program, and possibly other agencies with financing or regulatory functions, adds another level of complexity in terms of planning, organizing, and delivering health services.

Conclusion: A key overarching conclusion from the assessment is that strong coordination is needed between health policymakers and program managers to carefully design models for integration of TB services under national health insurance. Careful planning is needed to ensure that all parties understand their roles and responsibilities within the systems and that health providers are motivated to provide high-quality TB services, and patients have incentives to utilize the services.

Pankaj Sadaphal¹, Krishnapada Chakraborty¹, Hala Jassim-AlMossawi¹, Yogan Pillay², Giorgio Roscigno³, Anil Kaul⁴, Neeraj Kak¹*, Refiloe Matji¹, Lindiwe Mvusi², Anthony DeStefano¹

¹University Research Co. LLC, Maryland, USA

²Department of Health South Africa, Pretoria, South Africa

³NEXT2People Foundation, Geneva, Switzerland

⁴Center for Health Sciences, Oklahoma State University, Tulsa, OK

Purpose: The pharmacokinetics (PK) of anti-tuberculosis drugs, including their bioavailability (BA), significantly impacts the efficacy and effectiveness of tuberculosis (TB) treatment regimens. Rifampicin, one of the most important drugs in the treatment of drug-sensitive tuberculosis, has been used increasingly in fixed-dose combinations (FDCs). This paper reviews and analyzes available data on BA and PK of rifampicin with a focus on FDCs, from published studies and reports.

Methods: Using PubMed as the primary database, Cochrane and other relevant databases, a systematic review of literature was conducted to identify studies on the bioavailability and efficacy of rifampicin in FDCs versus single drug formulations. A number of keywords including “bioavailability”, “rifampicin”, “fixed dose combinations”, and “pharmacokinetics” were used in various combinations. The search covered the period 1980 to 2016. Priority was given to articles on rifampicin bioavailability in fixed dose combinations used in the program setting, and human studies that used the World Health Organization (WHO) approved BA/PK protocol and sample size (≥22 patients).

Findings: More than 450 original peer-reviewed articles, reviews and reports, were assessed for this analysis. Eleven papers, which included data from high-TB-burden countries (South Africa, India, and China), raised significant concerns about rifampicin bioavailability within FDCs; the authors of the studies discussed multiple factors associated with low bioavailability, including drug formulation and quality, storage environment, patient factors, and concomitant diseases.

Implications: Recent studies and reviews point to the problem of low bioavailability of rifampicin in fixed dose combinations. However, in the field, it remains a hidden or unrecognized factor leading to poor treatment outcomes. It is difficult to study the issue thoroughly unless there is awareness among TB program personnel of its existence, and adequate laboratory and research support is available to national tuberculosis programs (NTPs). In stemming the tide of tuberculosis multi-drug resistance (MDR) and extensive drug resistance (XDR), it is paramount to ensure that rifampicin bioavailability is adequate in FDCs, and to detect and address any deviation from recommended target ranges. There is a need for strategies to minimize the undesirable clinical effects of reduced rifampicin bioavailability in FDCs, and for effective utilization of quality-assured drugs within NTPs programs; these can help NTPs support effective case management in line with the international TB care standards, while taking into consideration the factors affecting drug absorption and therapeutic concentration.