Population-Based Tuberculosis Disease Prevalence Survey in Ghana: The Role and Lessons Learnt from the Laboratory

Background: Bacteriologically-confirmed tuberculosis (TB) cases used in calculating TB prevalence in a country are obtained through laboratory examination of sputum specimens. Objective: This article describes laboratory processing of specimens, results overview, conclusions and key lessons learnt from the perspective of laboratory personnel involved in the conduct of TB disease prevalence survey in Ghana in 2013. Methods: Symptoms screening and Chest X-ray suggestive of TB were used to select participants who produced sputum to confirm TB cases using microscopy, culture and Xpert®MTB/RIF assay (GeneXpert). Results: A total of 15,935 single and paired sputum specimens were received from eligible participants. About half of Ziehl-Nielsen (129/263) and Auramine O (122/246) stained smear positives were scanty positive. Culture positivity rate for Mycobacterium tuberculosis complex was 266/14,994 (1.7%) and 100/15,179 (0.7%) in Mycobacterial Growth Indicator Tube (MGIT) and Lowenstein-Jensen (LJ) media respectively;while non-tuberculous mycobacterium was 294/14,994 (1.96%) and 167/15,179 (1.1%). Total contamination rates in MGIT (5.4%) were higher than in LJ (1.7%). Prevalence of smear positive TB and bacteriologically confirmed TB among adult population (≥15 years) was estimated at 111 (95% CI: 76 - 145) and 356 (95% CI: 288 - 425) per 100,000 population respectively. Conclusions and Lessons Learnt: Direct supervision of specimen collection by well-trained laboratory personnel, timely transportation of specimens from field to laboratory, prompt specimen processing and use of electronic data management systems are essential for a reliable TB disease prevalence survey data. More importantly, strengthening human and logistical capacity of the laboratory must be of utmost priority.

First Nationwide Survey on the Resistance to First Line Anti-Tuberculosis Drugs in Ghana

Background/objective: A nationwide survey on the resistance to first line anti-tuberculosis (anti-TB) drugs was conducted in Ghana from 2007-2008 by Noguchi Memorial Institute for Medical Research in collaboration with the National Tuberculosis Control Programme. We aimed to characterize mycobacterial species causing pulmonary tuberculosis (PTB) and determine the resistance pattern to first line anti-TB drugs among newly diagnosed and previously treated PTB patients in Ghana. Methods: Two sputum samples from consented new smear positive PTB patients who had never been treated for TB or had been on anti-TB treatment for less than a month and patients who had been treated for TB previously for more than a month in selected diagnostic centres nationwide were collected for culture, identification and drug susceptibility test. Culture positive isolates were tested against streptomycin (S), isoniazid (H), rifampicin (R) and ethambutol (E) using the simplified proportion method and line probe assay (LPA). The LPA was performed in mid-2017. Results: Among 410 samples, 345 positive cultures were obtained and identified as Mycobacterium tuberculosis complex (MTBC). Of the 345 isolates, 133 were further differentiated by GenoType MTBC®as M. tuberculosis, 126 (94.7%) and M. africanum 7 (5.3%). The overall drug resistance patterns were as follows: 43/345 (12.5%), 6/345 (1.7%), 9/345 (2.6%) and 71/345 (20.6%) were resistant to H, R, E and S respectively and 5/345 (1.4%) were multi-drug resistant (MDR). Conclusion: The results indicate high levels of resistance to S and H among new and previously treated TB patients. We recommend adequate surveillance systems including periodic national anti-TB drug resistance surveys.

低收入国家常规条件下抗酸杆菌痰涂片标准记录方法的评价

背景:贝宁、马拉维、尼加拉瓜和塞内加尔的实验室开展的结核菌痰涂片检查。方法:通过实验室登记进行计算机分析确定工作量、连续痰涂片的检出率及受检人群的人口分布特征结果:42个实验室的60000多个受检查者的资料显示,每个国家每天涂片检测的数量一般为4—19(平均6)。发现一例结核病人平均检查可疑者痰涂片21个(8—50)。所有至少一次阳性结果的病例中,87％的病例在第一次检测中就呈阳性结果。病例人群分布的不同在国家和性别之间变化很大。在42个实验室中的35个实验室里,男性病例的检出率要高于女性。随着年龄的增长,女性要比男性更多数量的可疑者检查方能确诊为一个病例。结论:该研究证实抗酸杆菌涂片结果标准化记录系统具有很好的用途,它能为规程实施和了解受检人群的分布特征方面提供必要的信息。

使用二次痰涂片法筛查结核可疑者

背景:马拉维Ntcheu地区医院目的:评估使用二次痰涂片法筛查结核病可疑者的方法。设计:将1998年7月1日～12月31日共6个月使用的二次痰涂片法筛查结核病可疑者的方法与同年1月1日～6月30日使用的三次痰涂片法筛查结核病可疑者的方法进行比较。对所有痰涂片阴性病人的胸片进行评估,对其中肺空洞及有弥漫性病变者进行第三次查痰。从实验室痰登记者和结核登记者中获得数据。将两个6月期进行比较。结果:在实验室登记者中,使用二次痰涂片法,1152名结核病可疑者中有186名(16%)涂片阳性,而使用三次痰涂片法的1106名可疑者中有173名(16%)涂片阳性,二者结果没有区别。在临床上使用不同的筛查方法结果相似,用二次查痰法的登记病人中58％涂片阳性,而用三次查痰法的登记病人中54%涂片阳性。在前6个月中检查的3177个痰涂片与后6个月中检查的2266个痰涂片进行比较,检查数量下降了29%,三次查痰法的消耗品费用是731美元,而二次查痰法为251美元。结论:用二次查痰法筛查结核病可疑者与三次查痰法一样有效,且减少了实验室的工作量,节省了开支。

战争条件下国家结核病控制规程的成功实施

目的:对采用短程化疗前、后的治疗效果进行比较,探讨影响疗效的因素。设计/背景:1984年尼加拉瓜利用外部的经济支援,对涂阳肺结核采用一项8个月的化疗方案。我们进行了回顾性资料复查以比较采用短程化疗前、后的治疗效果。对两个时期有关援助机构及规程管理的状况,可能为结核病人提供的医院床位的可能性,纳入保健服务以及经济和战争状况做了评估。结果:尽管在经济恶化及内战不断升级,两个时期相比,其总成功率仍提高了39％。成功率达到71％,我们估计80～90％的登记病人已停止结核病的传播。使用8个月化学治疗对初治和复发病人的治疗均取得了最佳效果,不合作的复治病人的疗效最差。本地区调查结果显示短程化疗是重要的,但只靠短程化疗尚不能保证成功。可能影响治疗效果的因素是:卫生行政当局对人员及医院病床保证的承诺,工作人员培训及服务工作的监督,对进一步改进的可能性加以讨论。结论:在贫困和战争的条件下,采用短程化疗,结核病控制取得了良好的效果。在低收入国家采用短程化疗时,政府的承诺、支援单位的同步改进与规程管理是重要的。

化疗使得结核病疫情下降:摩洛哥案例分析

背景:摩洛哥从20世纪90年代初期就开始实施世界卫生组织(WHO)推荐的DOTS策略,但在1996—2005年间结核病人报告率的年递降率仅为3%～4%。以目前的疫情下降趋势,到2050年(即实现全球消灭结核病的目标年),摩洛哥仍将新发生1万例以上的结核病人。方法:对1996—2005年间国家结核病控制规划报告的病人,按年龄、性别、临床分型和地区进行分析。以4个标准判断观察结果的准确性:统计学有效性、测量精度、生物学合理性,以及不同证据链显示的一致性和关联强度。结果:城市地区的结核病发病(病人数和发病率)高于农村,成年男性的发病率高于女性。男性结核病人中,痰涂片阳性(最具传染性)的比例高于女性。2005年,在所有痰涂片阳性病人中, 15～44岁的男性占了近一半。男性的发病率下降速度低于平均水平,但女性发病率的下降速度也较预期的慢。结论:在摩洛哥,城市男性人群是结核病防治的重点对象。就总体而言,应对常规监测数据进行深入研究,以发挥其对结核病控制活动的指导作用。

马拉维常规方案下复发结核病患者的特点、管理及治疗结局

背景:1999年7月1日到2000年6月30日马拉维的所有非私立性医院(共43家)进行了结核病登记。目的:了解1)复发结核病的特点、管理以及治疗结局,2)上一次发生结核病的时间,以及3)登记复发涂阳肺结核病人的耐药情况。设计:根据结核病登记资料、实验室培养以及药敏实验的登记资料进行相关数据的回顾性收集。结果:共确定了748名复发患者;收集到其中747名患者的资料。其中,487例(65％)成功完成了复治方案,185人(25％)死亡,其余为其他结局。491名患者(66％)有以前患结核病的病史记录。上次治疗结束后2年或2年内开始复治者286人(58％)。 只有307名病人(41％)送痰标本进行培养及药敏试验检测。在培养分离出结核分枝杆菌的164名患者中,122例(81％)为敏感性病人,25例(15％)耐异烟肼和/或链霉素,6例(4％)耐异烟肼和利福平(MDR-TB)。结论:复发结核病患者的治疗结局尚可,大多数患者的病原体为敏感菌。半数以上的结核病复发发生在完成治疗后2年或2年内。需要对结核病复发的防治手段进行现场调研和实施。

越南的家庭支出与结核病患病率:通过一套家庭指标进行预测

目的:使用9项家庭特征,在越南全国结核病患病率调查过程研究结核病与家庭支出之间的关系。方法:为评估越南的结核病患病情况,于2006—2007年开展了全国分层整群抽样调查。在第二次越南生活水平调查中采用的9项家庭特征均以户为单位给予了评分。在越南生活水平调查数据库中,我们对这9项特征按人均家庭支出进行了回归分析;在我们的调查中,以系数来预测家庭支出水平(5分位级别),并评估其与结核病患病率的关系。结果:15岁以上人群的细菌学确诊结核病患病率为307/10万(95%可信区间为249～366)。经过对干扰因素的调整,发现结核病患病率与家庭支出水平相关:五分位为最低家庭支出水平人群的患病率比五分位为最高家庭支出水平人群高2.5倍(95%可信区间为1.6～3.9)。结论:通过9项家庭特征,我们能够非常准确地预测家庭支出水平。结核病患病率与估算的家庭支出水平之间存在显著相关性,提示在越南结核病与贫困相关。

The contribution of a non-governmental organisation’s Community Based Tuberculosis Care Programme to case finding in Myanmar:trend over time

Background:It is estimated that the standard,passive case finding(PCF)strategy for detecting cases of tuberculosis(TB)in Myanmar has not been successful:26%of cases are missing.Therefore,alternative strategies,such as active case finding(ACF)by community volunteers,have been initiated since 2011.This study aimed to assess the contribution of a Community Based TB Care Programme(CBTC)by local non-government organizations(NGOs)to TB case finding in Myanmar over 4 years.Methods:This was a descriptive study using routine,monitoring data.Original data from the NGOs were sent to a central registry within the National TB Programme and data for this study were extracted from that database.Data from all 84 project townships in five regions and three states in Myanmar were used.The project was launched in 2011.Results:Over time,the number of presumptive TB cases that were referred decreased,except in the Yangon Region,although in some areas,the numbers fluctuated.At the same time,there was a trend for the proportion of cases treated,compared to those referred,that decreased over time(P=0.051).Overall,among 84 townships,the contribution of CBTC to total case detection deceased from 6%to 4%over time(P<0.001).Conclusions:Contrary to expectations and evidence from previous studies in other countries,a concerning reduction in TB case finding by local NGO volunteer networks in several areas in Myanmar was recorded over 4 years.This suggests that measures to support the volunteer network and improve its performance are needed.They may include discussion with local NGOs human resources personnel,incentives for the volunteers,closer supervision of volunteers and improved monitoring and evaluation tools.

Different challenges,different approaches and related expenditures of communitybased tuberculosis activities by international non-governmental organizations in Myanmar

Background:International non-governmental organizations(INGOs)have been implementing community-based tuberculosis(TB)care(CBTBC)in Myanmar since 2011.Although the National TB Programme(NTP)ultimately plans to take over CBTBC,there have been no evaluations of the models of care or of the costs of providing CBTBC in Myanmar by INGOs.Methods:This was a descriptive study using routinely-collected programmatic and financial data from four INGOs during 2013 and 2014,adjusted for inflation.Data analysis was performed from the provider perspective.Costs for sputum examination were not included as it was provided free of charge by NTP.We calculated the average cost per year of each programme and cost per patient completing treatment.Results:Four INGOs assisted the NTP by providing CBTBC in areas where access to TB services was challenging.Each INGO faced different issues in their contexts and responded with a diversity of strategies.The total costs ranged from US$140754 to US$550221 during the study period.The cost per patient completing treatment ranged from US$215 to US$1076 for new cases and US$354 to US$1215 for retreatment cases,depending on the targeted area and the package of services offered.One INGO appeared less costly,more sustainable and patient oriented than others.Conclusions:This study revealed a wide variety of models of care and associated costs for implementing CBTBC in diverse and challenging populations and contexts in Myanmar.Consequently,we recommend a more comprehensive evaluation,including development of a cost model,to estimate the costs of scaling up CBTBC country-wide,and cost-effectiveness studies,to best inform the NTP as it prepares to takeover CBTBC activities from INGOs.While awaiting evidence from these studies,model of CBTBC that have higher sustainability potential and allocate more resources to patient-centered care should be given priority support.

679例肺外结核病6个月化疗方案继续期间歇给药治疗研究

背景:目前尚无大数量研究证明 6 个月化疗方案对各类型肺外结核病(EPTB)的疗效。方法:回顾性观察分析方法评估委内瑞拉 Caracas市 1998 年 1 月 1 日至 2000 年 12 月 31 日期间诊断的所有EPTB患者的6个月化疗方案(2HRZE/4H3R3)直接督导治疗结果。结果:共有 679 例纳入研究,其中 101 例(14.9%)合并 AIDS。83.2%患者的诊断依据是微生物学、组织学或基因扩增试验。612 例(90.1%)患者接受了 90%以上规定的治疗总剂量。有 6 例(1%)因药物不良反应而改变了治疗。在接受 90%以上规定治疗总剂量的其余 606 例中,603 例(99.5%)治愈,3 例治疗失败。在治疗结束后的2年随访中,仅有6例复发(1%)。24 例中枢神经系统结核病、27 例骨关节结核病及42 例粟粒性结核病及/或播散性结核病患者治愈后均无复发。结论:继续期周 3 次服药的 6 个月化疗方案治疗各类型肺外结核病是高效的。

International non-governmental organizations’provision of communitybased tuberculosis care for hard-to-reach populations in Myanmar,2013-2014

Background:National tuberculosis(TB)programs increasingly engage with international non-governmental organizations(INGOs),especially to provide TB care in complex settings where community involvement might be required.In Myanmar,however,there is limited data on how such INGO community-based programs are organized and how effective they are.In this study,we describe four INGO strategies for providing community-based TB care to hard-to-reach populations in Myanmar,and assess their contribution to TB case detection.Methods:We conducted a descriptive study using program data from four INGOs and the National TB Program(NTP)in 2013-2014.For each INGO,we extracted information on its approach and key activities,the number of presumptive TB cases referred and undergoing TB testing,and the number of patients diagnosed with TB and their treatment outcomes.The contribution of INGOs to TB diagnosis in their selected townships was calculated as the proportion of INGO-diagnosed new TB cases out of the total NTP-diagnosed new TB cases in the same townships.Results:All four INGOs implemented community-based TB care in challenging contexts,targeting migrants,post-conflict areas,the urban poor,and other vulnerable populations.Two recruited community volunteers via existing community health volunteers or health structures,one via existing community leaderships,and one directly involved TB infected/affected individuals.Two INGOs compensated volunteers via performance-based financing,and two provided financial and in-kind initiatives.All relied on NTP laboratories for diagnosis and TB drugs,but provided direct observation treatment support and treatment follow-up.A total of 21995 presumptive TB cases were referred for TB diagnosis,with 7383(34%)new TB cases diagnosed and almost all(98%)successfully treated.The four INGOs contributed to the detection of,on average,36%(7383/20663)of the total new TB cases in their respective townships(range:15-52%).Conclusion:Community-based TB care supported by INGOs successfully achieved TB case detection in hard-toreach and vulnerable populations.This is vital to achieving the World Health Organization End TB Strategy targets.Strategies to ensure sustainability of the programs should be explored,including the need for longer-term commitment of INGOs.

First Nationwide Survey of the Prevalence of TB/HIV Co-Infection in Ghana

Background: To better understand the extent of the magnitude of tuberculosis (TB) and Human Immunodeficiency Virus (HIV) co-infection in Ghana, a baseline study was conducted to establish the national prevalence of the dual infection. The study aimed to determine the most prevalent HIV serotype (HIV-1 or HIV-2) in TB patients (new and old cases);genotype mycobacterial species causing TB/HIV co-infection and determine their drug susceptibility patterns. Methods: Sputum and dried blood samples were collected from 503 TB patients from 67 health facilities nationwide between December 2007 and November 2008. All samples were processed for mycobacterial and HIV testing using conventional and molecular methods. Results: A total of 517 paired sputum samples were received from 517 patients. A total 503 patients [335 (66.6%) males;168 (33.4%) females] had at least one culture positive sample. Majority (93.0%) of the patients were new cases while 7.0% were old cases. All 503 TB isolates were Mycobacterium tuberculosis complex. Of 503 blood samples, 74 were positive for HIV (14.7%), comprising 71 (14.1%) and 3 (0.6%) for HIV-1 and HIV-1 & 2 respectively;none was positive for HIV-2 alone. The seroprevalence of HIV in newly diagnosed TB patients and those already on treatment, was 69/468 (14.7%) and 5/35 (14.3%) respectively (p > 0.05). Differentiation of isolates from TB/HIV co-infected patients showed that 70/74 (94.6%) were Mycobacterium tuberculosis while 4/74 (5.4%) were Mycobacterium africanum. Monoresistance to isoniazid and rifampicin were 4/74 (5.4%) and 1/74 (1.4%) respectively;resistance to both drugs (multi-drug resistant-MDR) was not observed. Sixty nine (93.2%) isolates were susceptible to both drugs. Conclusion: The prevalence of HIV infection in TB patients was 14.7%. TB/HIV was common among the sexually active age group (25 - 34 years). Majority of the TB isolates were M. tuberculosis which were susceptible to both isoniazid and rifampicin. HIV-1 was the common serotype infecting TB patients in Ghana.

南非成年黑人结核病人中的原发性和获得性耐药:参加一项全国耐药连续监测规程的结果

耐药是结核病治疗的一个主要问题,因此在控制该病中监控规程是必不可少的。一个社区内原发性耐药的规模,是治疗程序效能的重要标志。自1965年以来,南非医学研究委员会的结核病研究所(TBRI)已完成了25次在结核病流行最广的成年黑人中进行的结核病人耐药情况的年度调查。病人的挑选方法,标本采集,化验手续和耐药标准,都得到严格遵守。全部标本都在一个中心化验室相同的两位技术专家监督下进行处理。在1965至1988年间,一共从新病例中分离出33 111株结核分支杆菌,从旧病例中分离出19 134株。对于5种主要抗结核药物的原发和获得性耐药都有极其显著的下降。性别和年龄对耐药率无影响,但病人的种族和地理居处却与之有关。调查结果表明当前治疗结核病的作法是令人满意的。目前南非黑人中原发性耐药的发生率介乎消灭结核病工作相当先进的国家与结核病仍是公共卫生问题的国家之间。还有,可以证明的是,可比且有临床意义的资料,能由中心化验室利用不复杂而又化费不多的药物敏感测验方法获得。

治疗5个月后痰涂片阳性结核病人的特征及治疗转归

马拉维开展了一项全国性调查以评价治疗 5 个月或更长时间后痰涂片仍然为阳性新发涂阳肺结核病人的管理情况。2000 年到 2001 年,共有此类病人 250 例,其中161 例(64%)在治疗 5 个月后查痰阳性,另 89 例在治疗7 个月后查痰阳性。该研究发现了治疗管理上数个需要改进的不一致和不充分之处,包括 7%的评价病人只有一份痰涂片,而不是两份,17%的病人根据一份阳性结果作出结论;47%的5 个月阳性病人和 52%的7 个月阳性病人存在痰涂片检查过早或过晚的现象;14%的 5 个月阳性病人在继续治疗,但其中超过 60%者却记录为“治愈”。

非洲大城市直接督导治疗的分散化管理:吉布提市的经验评价

背景:2000年4月起,吉布提市3个公共卫生中心结核病人直接督导治疗(DOT)的分散化管理。目的:根据治疗地点、某些关键变量,以治疗成功率为指标对分散化管理进行评价。方法:对 2000年5月1日至 2001年3月31日期间,在所有治疗中心随访的涂阳病人治疗成功率进行比较评价。结果:主要治疗中心(Paul Faure中心)的成功率为58％,其它所有地方中心的成功率为84％(P<10^(-6)。3所新建治疗中心的成功率为80％,已建中心的成功率为85％(P>0.05)。在20岁以下年龄组,女性与治疗中心是成功率的相关因素。经 分层分析,性别显示为混杂交量。多变量分析显示,非吉布提国籍与治疗成功相关(P=0.02)。在已建治疗中心与新建治疗中心,治疗成功率与工作负荷呈负线性相关,已建治疗中心的工作能力较强。结论:城区DOT的分散化管理提高了涂阳病人治疗成功的机会。需要在吉布提市的公共卫生中心再建立一所结核病督导治疗中心。

利用结核菌素进行的柬埔寨结核病流行病学调查

目标:评价1995年柬埔寨城市和农村地区的结核年感染率(ARTI)以及1955年以来的下降趋势。根据ARTI推算结核病发病率,并与主动病人发现项目以及结核病报告数据进行比较。方法:对两项全国性代表样本共计3524和4407名在校儿童分别进行了ITU的结核菌素——PPD-RT23/Tween80的结核感染皮肤试验。根据ARTI推算的结核病发病率估计值并与主动病人发现项目以及1994年以来采用WHIQ／IUATLD推荐的季度报表病人全国数据进行比较。结果:以10mm硬结反应为界点,1995年柬埔寨的ARTI估计值为0．75％(0．56-0．96％)。1955-1995年Phnom Penh市的ARTI年平均递降率为4．2％,在省级地区为4．9％。根据ARTI推算的结核病发病率估计值比1995年的结核病报告率低2．4倍,比根据人群筛查结果估计的发病率低4．3倍。结论:ARTI随时间推移规律下降。在柬埔寨,根据ARTI推算的结核病发病率数据应该得到正在实施的患病率调查数据的补充。为了获得对国家结核病规划连续的政治支持,需要有更准确的估计。

马拉维的监狱结核病控制:相关政策与实践研究

在1996年马拉维松巴市中心监狱进行的一项实施性研究之后,国家结核病控制规程(NTP)和监狱医疗服务机构为提高监狱内结核病(TB)的诊断和治疗水平进行了合作。对入狱以及在押犯人进行结核病筛查。根据NTP指南建立监禁期间以及出 狱后的病人治疗体系。由区级和地区级结核病官员进行监测和评价,每6个月召开一次所有资助者和中心机构参加的会议以核查数据并对监狱内结核病控制工作进行评价。

分享的观点—一个为加强规律治疗结核病而设计的健康教育项目

背景:在南非开普敦选择了两个相邻的开普敦地方当局卫生诊所,指定诊所A为‘干预诊所’,诊所B为‘对照诊所’。目的:为评价一个以病人为核心的会谈加上分发病人教育小册子,这种结合的措施是否对提高登记的肺结核病人坚持规律治疗起作用。设计:实施对照的干预研究,在诊所A和诊所B各选择首批连续登记的肺结核病人队列60例,两组共120例病人。结果:干预诊所不坚持抗结核治疗的病人的危险度比对照诊所显著地减少。结论:本研究结果表明,有必要进行进一步实施性研究以便协助卫生工作人员去开发标准化健康教育方案,以加强那些需要长期治疗方案的病人坚持规律治疗。

刚果(布拉柴维尔)由于战争导致结核病肆虐

刚果(布拉柴维尔)是一个拥有300万人口的国家,1997年至1999年经历了战争劫难,在此之前结核病例数每年平均增长20％;2000年增长84％。这种情况已经严重影响了国家结核病规划活动。在战争之前,诊疗中心几乎登记100％的新结核病例;2000年登记降至76.19％,而结核病人数几乎翻了一番,从1999年的5125例增至2000年的9436例。新涂阳肺结核病例占45％,相比之下,战前平均为55％,战后肺外结核占30％而战前为21％。复发率没有显著变化,约为2％,而不合作率明显升高,从20％升至26％。新涂阳肺结核病例治愈率或完成治疗率仍然没有变化(70％),而战后死亡率则从6％降至1.23％。 战争导致了结核病发病率的增加,特别是在两个主要城市布拉柴维尔和黑角,农村的难民涌到了这两个城市,致使卫生工作者的劳动负荷过量。需要持续的财政支持来减少结核病在刚果居民中的传播。