Tuberculosis Nursing Research Articles

Evaluating the electronic tuberculosis register surveillance system in Eden District, Western Cape, South Africa, 2015

ABSTRACT Background: Tuberculosis (TB) surveillance data are crucial to the effectiveness of National TB Control Programs. In South Africa, few surveillance system evaluations have been undertaken to provide a rigorous assessment of the platform from which the national and district health systems draws data to inform programs and policies. Objective: Evaluate the attributes of Eden District’s TB surveillance system, Western Cape Province, South Africa. Methods: Data quality, sensitivity and positive predictive value were assessed using secondary data from 40,033 TB cases entered in Eden District’s ETR.Net from 2007 to 2013, and 79 purposively selected TB Blue Cards (TBCs), a medical patient file and source document for data entered into ETR.Net. Simplicity, flexibility, acceptability, stability and usefulness of the ETR.Net were assessed qualitatively through interviews with TB nurses, information health officers, sub-district and district coordinators involved in the TB surveillance. Results: TB surveillance system stakeholders report that Eden District’s ETR.Net system was simple, acceptable, flexible and stable, and achieves its objective of informing TB control program, policies and activities. Data were less complete in the ETR.Net (66–100%) than in the TBCs (76–100%), and concordant for most variables except pre-treatment smear results, antiretroviral therapy (ART) and treatment outcome. The sensitivity of recorded variables in ETR.Net was 98% for gender, 97% for patient category, 93% for ART, 92% for treatment outcome and 90% for pre-treatment smear grading. Conclusions: Our results reveal that the system provides useful information to guide TB control program activities in Eden District. However, urgent attention is needed to address gaps in clinical recording on the TBC and data capturing into the ETR.Net system. We recommend continuous training and support of TB personnel involved with TB care, management and surveillance on TB data recording into the TBCs and ETR.Net as well as the implementation of a well-structured quality control and assurance system.

Knowledge and Attitude about Multidrug-Resistant Tuberculosis among Healthcare Workers in Public Health Centres

Background : Multidrug-resistant Tuberculosis (MDR-TB) is a significant public health problem and poses a threat to global tuberculosis (TB) control. In 2015, at least 504 new MDR-TB cases were identified in Indonesia. Treating MDR-TB patients is very challenging. It may take more than two years for MDR-TB treatment. Therefore, it is crucial healthcare workers (HCWs) are knowledgeable about MDR-TB. The aim of this study was to measure level of knowledge and attitude regarding MDR-TB among HCWs in public health centres. Methods : A cross-sectional study was conducted at 73 Public Health Centres in Bandung the capital of West Java Province from August until November 2015. The samples were 73 TB nurses and 32 laboratory staff. A self-administered questionnaire was given comprising 27 knowledge questions and 29 attitude questions. Correlation between knowledge and attitude scores was calculated by Pearson correlation test. Results : The majority of study participants were women (82.9%), married (92.4%), nursing staff (65.7%) with history of TB training (98.1%). Most of the participants were 40-59 years old (69.5%) with working experience in TB programme < 10 years (69.5%). Less than half (38.1%) of study participants had good knowledge. In terms of attitude, more than half (53.3%) of study participants had a positive attitude towards MDR-TB. Conclusions : The level of knowledge among HCWs about MDR-TB is still at an unacceptable level. Certain educational interventions aim to ensure prompt diagnosis, implement infection control and accurate treatment should be established among those HCWs. [AMJ.2016;3(4):509–13] DOI: 10.15850/amj.v3n4.932

Investigation on clinical application of nutritional risk screening in tuberculosis department nurses

Objective To describe the clinical application of nutritional risk screening in tuberculosis department nurses, and explore the related factors that affect the clinical application of nutritional risk screening. Methods Totally 110 tuberculosis nurses were investigated about the clinical application of nutritional risk screening by self-design questionnaire. The questionnaire content totally included 20 items: general information, knowledge of nutritional risk screening (5 questions), the degree of attention to nutritional risk screening (5 questions), clinical development situation of nutritional support (5 questions) and clinical application of nutritional risk screening (5 questions). Results The nutritional risk screening score of tuberculosis department nurse was (13.200±2.841). Multiple linear regression analysis found that education background, attention to nutritional risk screening, clinical development situation of nutritional support were related factors that affect the nutritional risk screening score of tuberculosis nurses. Conclusions We should improve the ability of tuberculosis department nurse in nutritional risk screening and the consciousness of nutritional risk screening, and increase the clinical application of nutritional risk screening of tuberculosis department nurses. Key words: Tuberculosis; Clinical nurses; Nutritional risk; Clinical application

Strengthening TB infection control in specialized health facilities in Romania – using a participatory approach

IntroductionIn 2012, the tuberculosis (TB) notification rate among Romanian TB facility doctors and nurses was 7.2 times higher than in the general population. This indicates that transmission is ongoing inside TB facilities and that TB infection control measures are insufficient. To help prevent nosocomial TB transmission a project was implemented that aimed at providing nationwide tailor-made technical assistance in TB infection control (TB-IC) in TB treatment facilities, including the development of TB infection control plans.The objective of the present article is to describe the implementation of the project and to discuss successes and challenges. Study DesignThe project was an implementation study using two methods of evaluation: (1) a cross sectional questionnaire study; and (2) collection of information, during the training, on challenges related to infection control and to the project implementation. MethodsThe project team developed a TB facility infection control (TB-IC) plan template, together with the Romanian experts. The template was discussed and agreed upon with the experts at a meeting and thereafter distributed by email to all TB facilities. Afterwards, a training of trainers (TOT) seminar was organized which included the provision of information about different training methods, as well as information about TB-IC. The TOT was followed by training for key TB-IC providers. Information about use of the TB-IC template was gathered through a self-administered questionnaire sent to all participants of the expert meeting and the training (42 people). Additionally, non-systematized discussions were held on broader challenges in TB-IC implementation during the training. ResultsWithin the project 42 key TB-IC service providers were trained in TB-IC, including 9 who were trained at a TOT seminar. The trainees were specialists working at the national level, such as country TB coordinators, or at the TB facility level: TB doctors, epidemiologists, laboratory specialists and maintenance engineers.Out of 42 key TB-IC service providers who were trained, only eighteen responded to the questionnaire (no reminders were sent). Out of these, 14 had used the TB-IC plan template after the project team disseminated it to them by email. The remaining four TB-IC service providers indicated that they were planning to use the template to develop or update their facility TB-IC plans.Related to the use of TB-IC plan template, the following broader challenges in TB-IC were identified: a lack of authority of the individuals responsible for TB-IC to implement the TB-IC measures, lack of training among facility epidemiologists on TB, underdeveloped system for reporting TB in healthcare workers, difficulties with triage of the TB suspects, and poor facility infrastructure hampering implementation of TB-IC measures. DiscussionImplementing TB-IC plans in Romanian health care facilities proved to be challenging, mainly due to the fact that the national infection control plan for TB was not yet adopted at the time of project implementation, and therefore there was neither a regulatory framework to support TB facility-IC planning nor any related budget allocations for the implementation of the facilities' TB-IC plans. Nonetheless, most respondents who answered the questionnaire (18 of 42 responded) indicated that they had started using the TB-IC plan template, which represents a full package of infection control measures that, when implemented effectively and in its entirety, may be expected to reduce nosocomial transmission.The study's limitations are: very low survey response rate, thus there is a likelihood of responder bias.

Knowledge and Attitude about Multidrug-Resistant Tuberculosis among Healthcare Workers in Public Health Centres

Background : Multidrug-resistant Tuberculosis (MDR-TB) is a significant public health problem and poses a threat to global tuberculosis (TB) control. In 2015, at least 504 new MDR-TB cases were identified in Indonesia. Treating MDR-TB patients is very challenging. It may take more than two years for MDR-TB treatment. Therefore, it is crucial healthcare workers (HCWs) are knowledgeable about MDR-TB. The aim of this study was to measure level of knowledge and attitude regarding MDR-TB among HCWs in public health centres. Methods : A cross-sectional study was conducted at 73 Public Health Centres in Bandung the capital of West Java Province from August until November 2015. The samples were 73 TB nurses and 32 laboratory staff. A self-administered questionnaire was given comprising 27 knowledge questions and 29 attitude questions. Correlation between knowledge and attitude scores was calculated by Pearson correlation test. Results : The majority of study participants were women (82.9%), married (92.4%), nursing staff (65.7%) with history of TB training (98.1%). Most of the participants were 40-59 years old (69.5%) with working experience in TB programme &lt; 10 years (69.5%). Less than half (38.1%) of study participants had good knowledge. In terms of attitude, more than half (53.3%) of study participants had a positive attitude towards MDR-TB. Conclusions : The level of knowledge among HCWs about MDR-TB is still at an unacceptable level. Certain educational interventions aim to ensure prompt diagnosis, implement infection control and accurate treatment should be established among those HCWs. [AMJ.2016;3(4):509–13] DOI: 10.15850/amj.v3n4.932

Testing for latent tuberculosis infection using interferon gamma release assays in commercial sex workers at an outreach clinic in Birmingham.

This report demonstrates that using interferon gamma release assays to screen for latent tuberculosis infection in female commercial sex workers in an outreach sexual health clinic is feasible and acceptable. Routine interferon gamma release assay use successfully identified high numbers of latent tuberculosis infection. Innovative approaches to treatment and follow up were required to improve treatment adherence in this group. Direct observation of therapy within the sexual health clinic was also feasible. Successful follow up was dependent on the support of outreach workers, interpreters and tuberculosis nurses.

HIV Testing in US Tuberculosis Care Settings

Extent of and challenges to implementation of the Centers for Disease Control and Prevention (CDC) 2006 recommendation for routine HIV testing have not been reviewed specifically within tuberculosis (TB) care settings. To determine current adherence to the CDC's HIV testing recommendations in TB care settings and identify barriers. An online survey was designed and distributed via Survey Monkey. The 2011 National TB Conference attendees, National TB Nurse Controllers, and the CDC's TB-educate mailing list were invited to participate via e-mail. A total of 153 respondents from US states: 30 physicians, 91 nurses, 19 public health practitioners, and 13 other. Perceived importance of HIV testing, current HIV testing practices, perceived barriers to HIV testing, and understanding of state HIV testing laws. One hundred forty-one of 153 (92.2%) reported that patients with TB disease were "always" or "almost always" HIV tested; 65 of 153 (42.5%) reported the same for patients with latent TB infection (LTBI). Among those not routinely testing LTBI patients, "patient refusal of test" (53/88; 60.2%), "cost" (41/88; 46.6%), and "prevalence too low to justify" (33/88; 37.5%) were the most commonly identified barriers to opt-out testing. Forty-seven of 59 providers (79.7%) who reported that their state required written consent for HIV testing had incorrect knowledge regarding HIV testing legislation. Rates of HIV testing are high for patients with TB disease, but fewer than half of providers' care settings routinely test LTBI patients. Knowledge of HIV status is required to appropriately interpret TST results and make decisions regarding treatment in TB infection, since HIV coinfection increases risk of progression to active TB. Lack of HIV testing in LTBI patients represents a missed opportunity to prevent TB disease and its resultant morbidity and mortality. In addition, incorrect knowledge regarding testing legislation was a common problem among our TB providers. Further work is necessary to improve HIV testing rates in patients who have not yet progressed to active TB disease.

P192 Aside From Age, Do Other Factors Increase The Risk Of Hepatotoxicity In Patients Treated For Latent Tb Infection?

Background Reactivation of latent tuberculosis infection (LTBI) occurs in a number of at-risk groups including: tuberculosis (TB) contacts, migrants from high prevalence countries and those who are immunosuppressed. The risk of hepatotoxicity in treating LTBI is thought to be low but much of this evidence is in patients treated with 6 months of isoniazid (6H) rather than 3 months of rifampicin and isoniazid (3RH). Equally, other than age, there is limited data on other factors which may contribute to the risk of developing hepatotoxicity. Methods A retrospective study was performed at our centre. We analysed all patients treated with chemoprophylaxis, regardless of indication, between 2009 and 2013. Demographic data, treatment regimens and adverse drug reactions, including hepatotoxicity, were recorded. Severe hepatotoxicity was defined as either a rise in ALT five times greater than the upper limit of normal, or as any change in liver function that required an interruption or alteration in treatment. Liver function tests (LFTs) were routinely measured at baseline and then again at two weeks. Results 290 cases were identified. 84.5% of patients were treated with 3RH, 12.1% were treated with 6H. 2.1% experienced severe hepatotoxicity 2 weeks into treatment. None had symptoms which prompted blood tests prior to our standard 2 week LFTs. Gender, age, documented co-existing liver disease, regimen choice, concomitant use of hepatotoxic drugs and reason for giving chemoprophylaxis were not significantly associated with an increased risk of hepatotoxicity. LTBI treatment was case managed by TB nurses with 91.7% of patients successfully completing treatment. There was no significant difference in treatment completion or adherence rates in those who developed hepatotoxicity compared with those who did not. Conclusions Our review demonstrates a low incidence of hepatotoxicity associated with treatment of LTBI and highlights the difficulty in predicting those in whom it will occur. If management of LTBI moves from primary to secondary care it will remain important to perform LFTs at two weeks.

An exploration of NHS staff views on tuberculosis service delivery in Scottish NHS boards.

Tuberculosis (TB) is a bacterial disease and major worldwide killer with an increased UK incidence rate. This study aimed to explore the views of National Health Service (NHS) staff on TB service delivery models of care in NHS boards across Scotland. Eighteen semi-structured interviews were conducted with 13 nurse specialists and five consultants in public health medicine (CPHM) across five Scottish NHS boards. Five main themes emerged and findings showed that: directly observed treatment (DOT) was provided only to patients assessed to be at high risk of poor treatment adherence; contact tracing was conducted by participating NHS boards but screening at ports was thought to be weak; all NHS boards implemented TB awareness campaigns for TB health professionals; three NHS boards conducted team meetings that monitored TB patient progress; participants believed that TB funding should be increased; contact tracing was routinely conducted by TB nurses. Improved TB screening at airports was recommended and a need for TB health education for high risk groups was identified.

Tuberculosis infection control practices in primary healthcare facilities in three districts of South Africa

South Africa has one of the highest incidence of tuberculosis in the world, which can partly be attributed to poor infection control in public healthcare (PHC) facilities. The aim of the study was to explore the extent of tuberculosis and infection control training, as well as facility-level managerial, administrative, environmental and personal protection, infection control measures, at PHC facilities. Cross-sectional surveys were conducted at 127 PHC facilities across three districts of South Africa. Data collection was achieved through interviews with tuberculosis nurses, observations of infection control practices and a review of the clinic records. Univariate analysis was performed using SPSS® version 17. Limited implementation of World Health Organization infection control measures was identifed. In terms of facility controls, 43.3% of the clinics did not have an infection control committee and 40.9% did not have a clinic specifc infection control plan. In terms of administrative controls, 94.5% of...

A whole-genome sequencing approach to targeting Mycobacterium tuberculosis outbreak management

BackgroundEpidemiological investigations into Mycobacterium tuberculosis outbreaks use 24-locus genotyping (MIRU-VNTR typing). Where no epidemiological link can be found between patients, the importance of shared genotypes remains unclear. This issue is especially problematic and time-consuming when tracing contacts within some social groups at high tuberculosis risk, in which unwillingness to volunteer information is common. We investigated whether whole-genome sequencing (WGS) could delineate outbreaks with greater resolution than MIRU-VNTR typing has done. MethodsWe sequenced 390 M tuberculosis isolates from 254 patients from the UK Midlands (1994–2011) using Illumina technology (appendix). We estimated the expected genomic diversity between isolates within a transmission chain by measuring pairwise nucleotide differences between genomes within hosts (79 individuals with pulmonary and extrapulmonary disease, or multiple pulmonary episodes) and between hosts within 25 household outbreaks (63 individuals). We then investigated 11 MIRU-VNTR-based community clusters (168 patients, 157 transmission events) to assess whether WGS could delineate outbreaks more effectively. For each cluster we reconstructed the most plausible transmission chain based on epidemiological data collected by tuberculosis nurses, pairwise nucleotide distances, and times of diagnosis, and compared the genomic diversity across these constructed links with that within individuals and within household outbreaks. Findings109 (96%) of 114 isolates were within five SNPs of another isolate taken from the same individual or from an individual in the same household outbreak. On the basis of longitudinal isolates from individuals or households, we estimated an evolutionary rate of 0·5 SNPs per genome per year, consistent with a maximum of five SNPs between related isolates 3 years or less apart. Using a greater than five SNP threshold to assess 11 MIRU-VNTR-based community clusters, we found that none of 69 epidemiologically related pairs of MIRU-VNTR-matched cases plausibly related by transmission, two of 13 possibly related pairs, and 13 of 75 pairs with no known epidemiological relation were separated by more than five SNPs (p<0·0001). Seven MIRU-VNTR-matched pairs with no epidemiological relation had more than 30 SNPs, five of seven belonging to the same immigrant community cluster. WGS also showed that 62 of 75 MIRU-VNTR-matched pairs for which no epidemiological relation had been identified from contact tracing were highly likely to indicate transmission: in one substance misuse cluster, 38 individuals were linked by five or fewer SNPs without a single epidemiological link having been established previously. Further analysis suggested that microevolutionary divergence of lineages within outbreaks could signal possible super-spreaders, corroborated by clinical and epidemiological data in two clusters. InterpretationWGS can delineate tuberculosis outbreaks with greater resolution than has previously been possible. These findings offer public health teams the potential to limit outbreak investigations to patients who are likely to be linked by recent transmission, irrespective of whether it has been possible to identify epidemiological links, and to save resources where they are not, even in the context of matched MIRU-VNTR genotypes. Uniquely, WGS also provides information about the genetic structure of outbreak clusters, thereby providing the potential to direct public health resources towards individuals most likely to have infected the largest number of secondary cases. As a consequence, the Health Protection Agency is considering introduction of WGS technology for routine tuberculosis public health practice in England. FundingNIHR Oxford Biomedical Research Centre and the UKCRC Modernising Medical Microbiology Consortium (UKCRC Translational Infection Research Initiative supported by MRC, Biotechnology and Biological Sciences Research Council, and NIHR on behalf of the Department of Health [grant G0800778] and the Wellcome Trust [087646/Z/08/Z]).

Pan-London tuberculosis services: a service evaluation

BackgroundLondon has the largest proportion of tuberculosis (TB) cases of any western European capital, with almost half of new cases drug-resistant. Prevalence varies considerably between and within boroughs with research suggesting inadequate control of TB transmission in London. Economic pressures may exacerbate the already considerable challenges for service organisation and delivery within this context. This paper presents selected findings from an evaluation of London’s TB services’ organisation, delivery, professional workforce and skill mix, intended to support development of a strategic framework for a pan-London TB service. These may also interest health service professionals and managers in TB services in the UK, other European cities and countries and in services currently delivered by multiple providers operating independently.MethodsObjectives were: 1) To establish how London’s TB services are structured and delivered in relation to leadership, management, organisation and delivery, coordination, staffing and support; 2) To identify tools/models for calculating skill mix as a basis for identifying skill mix requirements in delivering TB services across London; 3) To inform a strategic framework for the delivery of a pan-London TB service, which may be applicable to other European cities. The multi-method service audit evaluation comprised documentary analysis, semi-structured interviews with TB service users (n = 10), lead TB health professionals and managers (n = 13) representing London’s five sectors and focus groups with TB nurses (n = 8) and non-London network professionals (n = 2).ResultsFindings showed TB services to be mainly hospital-based, with fewer community-based services. Documentary analysis and professionals’ interviews suggested difficulties with early access to services, low suspicion index amongst some GPs and restricted referral routes. Interviews indicated lack of managed accommodation for difficult to treat patients, professional workforce shortages, a need for strategic leadership, nurse-led clinics and structured career paths for TB nurses and few social care/outreach workers to support patients with complex needs.ConclusionsThis paper has identified key issues relating to London’s TB services’ organisation, delivery, professional workforce and skill mix. The majority of these present challenges which need to be addressed as part of the future development of a strategic framework for a pan-London TB service. More consistent strategic planning/co-ordination and sharing of best practice is needed, together with a review of pan-London TB workforce development strategy, encompassing changing professional roles, skills development needs and patient pathways. These findings may be relevant with the development of TB services in other European cities.

The Many Sided Opportunity of Field Nursing

AbstractIn 1916, when Annie Brainard published this paper, there was an ongoing discussion in the journal about specialization versus generalization of public health nursing (PHN) work. This discussion revolved around issues such as the size of communities (rural versus urban), population density, and cost effectiveness. For geographically large rural communities with low population density, specialization could be costly, while for urban, densely populated communities specialization based on scientific knowledge could have a stronger impact on population health. As Brainard indicates in this paper, specialization in PHN was not about additional education, but rather concentration of effort. Early specialization usually focused on tuberculosis, baby care, and school nursing. In this article, Brainard argued that there was a need for both specialist and generalist public health nurses, and co‐operation was needed between the two groups to avoid costly duplication of efforts.

Contact tracing in pulmonary and non-pulmonary tuberculosis

The aim of our study was to determine the effectiveness of contact tracing for both pulmonary and non-pulmonary tuberculosis (TB). The authors studied contact tracing in South East of Scotland, Edinburgh TB Clinic, UK, for 3 years. New index cases of both pulmonary and non-pulmonary TB were identified from reviewing TB nurses records. Pulmonary involvement was excluded from all non-pulmonary cases. Active TB was diagnosed as per the national TB guidelines. Latent TB was diagnosed based on history, tuberculin skin test and interferon γ release assay. TB contacts were identified from reviewing TB nurses notes on index TB patients. A positive screening episode was defined as identification of either active or latent TB in a contact following relevant investigations. Total number of positive screening episodes for pulmonary TB was 43.1% and non-pulmonary TB was 26.1%. Of these, 78.8% were household contacts and 21.2% were casual contacts. Contact tracing in low-prevalence TB countries, for both pulmonary and non-pulmonary TB, is an essential intervention to identify and reduce the number of infected patients that will progress to active disease. This is the key for effective TB control.

Four Responsibilities of the Tuberculosis Nurse, Circa 1919

Specialization in public health nursing practice was beginning to occur early in the 20th century. In a 1919 paper published in The Public Health Nurse, Mary Van Zile argued that there were four essential functions of the tuberculosis nurse. Later that year, Janet Scott reported on the results of a partnership between the tuberculosis dispensary, the Lions Club, and other Oklahoma City community organizations, which illustrated the application of Van Zile's principles, and the expanding scope of public health nursing practice.

Welcome intrusions: An interpretive phenomenological study of TB nurses’ relational work

Background Nurse–client relationships are valued in descriptions of public health practice and require consideration as work involving knowledge, skill, and personal engagement. Even so, in public health, they are largely taken-for-granted, particularly in the area of tuberculosis (TB). Instead, TB nursing is often structured by a population focus, which at times challenges individually focused relationship ideals. Purpose and design This paper describes an interpretive phenomenological study which was undertaken to understand the nature of TB nurses’ relational work. Methods Data were collected over an eight month period through observations of usual nurse–client visits and semi-structured interviews. Setting and participants The study took place in the TB program of a public health department of a large multicultural Canadian city with nine nurses and 24 clients. Results The phrase ‘welcome intrusions’ represents the nature of relational work and along with three key themes, ‘getting through the door’, ‘doing TB but more than that’, and ‘beyond a professional’, speaks to the central tension in this relational work: balancing its dual surveillance-care focus. Conclusions Together these themes emphasize the importance of nurses’ skill of involvement in two key domains of TB nursing practice: providing comfort and being watchful.

Accuracy of Tuberculosis Routine Data and Nurses’ Views of the TB-HIV Information System in the Free State, South Africa

Christo Heunis, PhD, is an Associate Professor, Centre for Health Systems ResearchD and Research Associate, Centre for Health Systems Research & Development, University of the Free State, Bloemfontein. Gladys Kigozi, MSc, is a Junior Researcher and Doctoral Student, Centre for Health Systems Research & Development, University of the Free State, Bloemfontein. Michelle Engelbrecht, PhD, is a Senior Researcher, Centre for Health Systems Research&Development, University of the Free State, Bloemfontein. Yolisa Tsibolane, BA Cur, is a Senior Manager, TB Management Programme, Free State Department of Health, Bloemfontein. Sonja van der Merwe, B Soc Sc, is an Assistant Director, TB Programme Surveillance, Free State Department of Health, Bloemfontein. Seipati Motlhanke, BA Cur, is an Assistant Director, TB-HIV/AIDS Programme Integration, Free State Department of Health, Bloemfontein. Reliable data are a prerequisite for evidence-based decision making in health care policy (AbouZahr & Boerma, 2005). Accurate measurement is crucial in evaluating epidemic trends, as well as in planning and monitoring disease-specific service provision. On the basis of a systematic review of descriptive and comparative studies and previous reviews of health information technologies, Chaudhry et al. (2006) demonstrated the efficacy of information gathered using health information technologies, such as electronic health records, to improve both quality and efficiency of health care. Sound data are especially vital for the success of large-scale public sector health programs in developing countries where limited human and financial resources require their optimal use (Fraser et al., 2005). Lippeveld (in AbouZahr & Boerma, 2005) defined a health information system (HIS) as an “integrated effort to collect, process, report and use health information and knowledge to influence policy-making, programme action and research” (p. 579). HISs are especially important when responses need to be urgent, as in the case of epidemic diseases such as

Jules Schevitz (1897–1922): Boy Wonder From Brooklyn

JULES SCHEVITZ WAS A brilliant young man who died at the age of 24, at the very beginning of a most promising career. At the age of 20, the young man was appointed general secretary of the Oklahoma Public Health Association where, as described in the extract, he proceeded to build a remarkably effective public health and antituberculosis program. Immediately after his arrival in Oklahoma, he was given the task of selling tuberculosis seals—then a significant way of raising money for the campaign against tuberculosis. Schevitz raised over $40 000—an increase of 2000% over the amount that had been raised in the previous year.1 Schevitz appointed executive committees of the Association first in larger towns, then in rural areas across the state. He selected trained tuberculosis nurses and visiting nurses from across the United States and put them to work. Schevitz established tuberculosis clinics across Oklahoma, initiated infant and child welfare work, and introduced school nursing into the school system. He gave special attention to the African American and American Indian populations and to soldiers being discharged from the armed services. Schevitz conducted the first statewide survey of urban health conditions, and he printed and distributed thousands of public health pamphlets on infant and child care, tuberculosis, and communicable diseases.2 He also succeeded in convincing the Oklahoma legislature to build and maintain three tuberculosis sanatoria. Schevitz encouraged local newspapers to print articles about his public health campaigns, edited and distributed a popular monthly bulletin, and also served as contributing editor to the Nation's Health. In this extract from an article published in an early issue of the American Journal of Public Health, he explains how he effectively used the techniques of advertising to “sell” his public health campaigns. Within 4 years, he was able to transform Oklahoma into one of the leading states in public health progress. Schevitz was born in Brooklyn and educated at public schools and at City College, New York, where he specialized in biological sciences and public health. While still in college, he had developed pulmonary tuberculosis and then spent a year in the Trudeau sanatorium under the care of Edward Livingston Trudeau, the pioneer in the sanatorium treatment of tuberculosis. Much impressed by Trudeau, Schevitz spent the following summer conducting a tuberculosis survey of New Jersey.3 Sadly, the disease to which he would devote so much time and energy would also be the cause of his very premature death.

South African TB nurses' experiences of provider-initiated HIV counseling and testing in the Eastern Cape Province: a qualitative study

This study addressed factors that played a role in the limited but effective implementation of provider-initiated HIV counseling in tuberculosis (TB) clinics in the Eastern Cape Province, South Africa, as part of a clinical trial. The Eastern Cape is a region with some of the highest TB and HIV rates in the world. The parent study was a pragmatic, cluster-randomized trial designed to measure the impact of provider-initiated (“opt-out”) counseling on the uptake of HIV counseling and testing in newly registered TB patients. Key informants were interviewed and clinic nurses who participated in the study were invited to participate in focus group discussions (FGDs). Thematic content analysis of transcriptions was conducted on data collected during interviews and FGDs. Three major themes regarding nurse experiences were derived from analysis, indicating that multiple structural and personal factors influence the success of provider-initiated HIV counseling of TB patients in primary care settings: (1) chronic frustration with knowing what TB tasks need to be accomplished but not having the resources, including staff, to accomplish them; (2) conflict between the appreciation of the need and importance of HIV counseling and testing and the health system's recognition of their difficulties implementing it; and (3) ambivalence in their roles as care providers and educators in the context of HIV counseling and testing. Innovative and coordinated strategies are needed in this environment to facilitate greater number of patients receiving HIV counseling and testing services.

Factors that influence treatment adherence of tuberculosis patients living in Java, Indonesia

Due to nonadherence of tuberculosis (TB) patients to treatment, complications may arise and if remaining infectious, these patients may infect other people with TB. To obtain information about factors associated with nonadherence, we performed a study comparing adherent and nonadherent TB patients. Adherent and nonadherent patients randomly selected from hospital records in one urban and two rural districts were interviewed using semi-structured questionnaires. Key informant interviews were done with TB nurses and doctors. The most frequently mentioned reason for nonadherence to treatment was feeling better. Although the drugs were given free of charge, many patients were nonadherent because of lack of money. Social support was considered very important for adherence. The study indicated that some patients had a negative image about the health care staff, treatment, and quality of medication. Treatment adherence of TB patients receiving treatment in hospitals in Central Java might be improved by providing health education about treatment duration and side effects, facilitating procedures for receiving treatment free of charge and reducing costs of transportation and consultation. Qualified friendly health care staff able to motivate patients might further improve adherence.