1. TUBERCULOSIS: THE LINKS WITH POVERTY Anthony D Harries The Union, Paris, France

2. Poverty Malnutrition Immune deficiency Tuberculosis

3. Malnutrition and low body weight Immune deficiency and low CD4 cell count Tuberculosis

4. In the TB patient: Wasting Lack of vitamins Lack of trace elements Low levels of protein These deficiencies are worse in those with the lowest body mass index (BMI)

5. Nutrition - clinical outcomes study in Malawi -1181 patients risk factors for early death = age >35, HIV, low BMI In first 4 weeks of TB therapy: BMI<17 = 11% death BMI >17 = 6.5% death Zachariah et al, 2002

6. BUT…… No evidence that nutritional supplementation on its own can improve TB treatment outcomes

7. Poverty and TB… The poor are at greater risk for TB –Poor housing, poor diet, poor education, risky behaviours The poor face barriers to accessing care:- –Financial – user fees, diagnostic tests, transport –Geographic - distance to health services –Cultural – stigma, poor education, traditional –Health system – no choice, poor treated worse than the rich

8. UKMalawi Population60M13M Health expenditure$2,500$15 Physicians135,000270 Nurses700,0007,300 PLHIV70,000950,000 Annual TB cases6,700 26,000

9. Household characteristics of 770 smear- positive Pulmonary TB patients in Malawi Live in mud-built houses36% No piped water in house75% No electricity in house92% Household income (<$10/m)45% Claessens et al, IJTLD, 2002

10. Thyolo district, Malawi: 550,000 A patient’s journey with TB

11. Patient Access to Health Facilities Long distances Lack of faith in allopathic sector Belief in traditional healers

12. Traditional Healers in Malawi

13. Health care provision at District Hosptial clinics Undermanned Busy, especially in central and district hospitals New disease such as TB can be overlooked Mangochi District Hospital ART Clinic: 4,500 patients on ART

14. TB of the abdomen Some forms of TB difficult to diagnose in RLS Disseminated TB

15. Submitting sputum specimens for AFB This may be a long process

16. Laboratories where TB is diagnosed are over-burdened and under staffed It may be a long time to get results

17. Standardised TB Treatment “Short course” [6 months] New Cases: 2RHZE/ 4RH is standard first line treatment WHO recommended regimens - 2009

18. TB Programmes like their treatment given by direct observation

19. The main road to Chitipa District Hospital

20. Poor urban settings – same problems

21. Make it easier for TB suspects and TB patients Better education about TB and how it is transmitted (air-borne disease) Diagnostic services closer to homes Treatment services closer to homes Shorter treatment for Tuberculosis