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  • In this issue of Mark Nicol and

    2019-05-15

    In this issue of , Mark Nicol and colleagues report the diagnostic accuracy of two commercially available rapid urine tests to identify active tuberculosis in children. Lipoarabinomannan is a unique component of the mycobacterial Z-YVAD-FMK that is excreted in the urine of some patients with tuberculosis. Findings of studies to assess the diagnostic ability of urine lipoarabinomannan assays in adults suspected of having tuberculosis showed poor sensitivity but good specificity. Test utility was greatly improved when the assay was used in combination with other tests to screen HIV-positive patients for tuberculosis before initiation of antiretroviral therapy; sensitivity increased in severely immune-compromised individuals and specificity remained high. These findings provided the rationale to assess the value of urinary lipoarabinomannan assays in children suspected of having tuberculosis because the collection of respiratory specimens is arduous in young children who are unable to expectorate, and occult haematogenous dissemination associated with primary infection might increase urinary lipoarabinomannan excretion.
    According to WHO global health estimates, chronic non-communicable diseases (NCDs) are the second leading cause of death in Africa. In 2011, NCDs accounted for 30% of the 9·5 million deaths, and 25·8% of the 675·4 million disability-adjusted life years (DALYs) recorded in Africa. NCDs are emerging in both rural and urban areas, most prominently in people living in low-income urban settings, and are resulting in increasing pressure on acute and chronic health-care services. Within the broad category of NCDs, stroke, hypertensive heart disease, diabetes, and chronic kidney disease have been identified as the leading disorders in the region. In Africa, between 2000 and 2011, the relative contribution of NCDs to death increased by 7·1% points and to DALYs increased by 6·4% points. WHO has projected that by 2030 NCDs will exceed communicable diseases as the most common cause of death in Africa. The increasing trend in the age-adjusted incidence of major NCDs in Africa and other developing countries contrasts with the decreasing patterns observed in high-income countries. This contrast partly results from differences in the capacity of countries to respond adequately to the emergence of NCDs. Health and demographic transitions leading to the surge of NCDs in Africa are occurring faster than those observed in developed countries, thereby compressing the timeline for effective adaptation. The epidemic of NCDs is occurring in African countries that are still yet to develop economically, and still confronted with vital priorities in areas such as maternal and child health and major infectious diseases, and seem unprepared to cope with the growing challenge of providing preventive and curative care for NCDs. According to WHO NCD country profiles for 2011, the capacity of countries to address NCDs varies substantially across Africa, with suggestions that NCDs are increasingly receiving attention across the continent. For instance, as of 2009–10, about 89% of African countries had dedicated departments in charge of NCDs within the national ministry of health. However, only about 26% of the countries had a functional programme or action plan for diabetes, for instance. Therefore, the good will of decision makers regarding NCDs has yet to be translated into concrete actions to better the health of populations at the interfaces of health-care delivery. In , Robert Peck and colleagues report the results of a cross-sectional evaluation of the preparedness of 24 public and not-for-profit Tanzanian health facilities to provide routine care for selected NCDs. Chronic diseases accounted for 58% of outpatients adult visits, of which about half were for HIV care and a quarter for three NCDs (hypertension, diabetes, and epilepsy). Chronic disease visits overwhelmingly occurred at hospitals as opposed to primary-care facilities. Compared with care for HIV, health facilities at all levels were ill-prepared to address the diagnosis, treatment, and ongoing monitoring needs of patients with NCDs. Low-level facilities were least prepared. Peck and colleagues make some recommendations to strengthen the health system to face the rising NCDs in the country.