Knowledge, health seeking behavior and perceived stigma towards tuberculosis among tuberculosis suspects in a rural community in southwest Ethiopia

Background

Perceived stigma and lack of awareness could contribute to the late presentation and low detection rate of tuberculosis (TB). We conducted a study in rural southwest Ethiopia among TB suspects to assess knowledge about and stigma towards TB and their health seeking behavior.

Methods

A community based cross sectional survey was conducted from February to March 2009 in the Gilgel Gibe field research area. Any person 15 years and above with cough for at least 2 weeks was considered a TB suspect and included in the study. Data were collected by trained personnel using a pretested structured questionnaire. Logistic regression analysis was done using SPSS 15.0 statistical software.

Results

Of the 476 pulmonary TB suspects, 395 (83.0%) had ever heard of TB; “evil eye” (50.4%) was the commonly mentioned cause of TB. Individuals who could read and write were more likely to be aware about TB [(crude OR = 2.98, (95%CI: 1.25, 7.08)] and more likely to know that TB is caused by a microorganism [(adjusted OR = 3.16, (95%CI: 1.77, 5.65)] than non-educated individuals. Males were more likely to know the cause of TB [(adjusted OR = 1.92, (95%CI: 1.22, 3.03)] than females. 51.3% of TB suspects perceived that other people would consider them inferior if they had TB. High stigma towards TB was reported by 199(51.2%). 220 (46.2%) did not seek help for their illness. Individuals who had previous anti-TB treatment were more likely to have appropriate health seeking behavior [(adjusted OR = 3.65, (95%CI: 1.89, 7.06)] than those who had not.

Conclusion

There was little knowledge about TB in the Gilgel Gibe field research area. We observed inappropriate health seeking behavior and stigma towards TB. TB control programs in Ethiopia should educate rural communities, particularly females and non-educated individuals, about the cause and the importance of early diagnosis and treatment of TB.     

New acylated triterpenoid saponins from Maesa lanceolata

Ten new acylated triterpenoid saponins were isolated from the leaves of Maesa lanceolata. For their structure elucidation extensive use was made of homo- and heteronuclear 2D NMR techniques such as COSY, NOESY, HSQC and HMBC. All saponins identified contained the same tetraglycosidic side chain, but the triterpenoid moiety showed a variable esterification pattern. Monoester, diester and triester derivatives were present. Maesasaponin I was a 21-monoester derivative, i.e. ?3 beta-O-[alpha-L-rhamnopyranosyl-(1-->2)-beta-D-galactopyranosyl- (1-->3)]-[beta-D-galactopyranosyl-(1-->2)]-beta-D-glucuronopyranosyl+ ++?-21 beta-angeloyloxy-13 beta, 28-oxidoolean-16 alpha, 22 alpha, 28 alpha-triol. Maesasaponins III, IV3, V3 and VI2 had an additional acetyl, propanoyl, n-butanoyl and angeloyl substituent, respectively, in position 22. Maesasaponins II, IV2, V2, VI3 and VII1 were characterised as the 16-acetyl derivatives of maesasaponins I, III, IV3, V3 and VI2, respectively. Structures of saponins previously reported in M. lanceolata had to be revised.     

Characterisation of new oligoglycosidic compounds in two Chinese medicinal herbs

A series of caffeic acid derivatives (3,5-dicaffeoyl-quinic acid, 3,4-dicaffeoyl-quinic acid, and 4,5-dicaffeoyl-quinic acid), and the new compound beta,3,4-trihydroxyphenethyl-O-[beta-apiofuranosyl-(1-->4)-alpha- rhamnopyranosyl-(1-->3)]-(4-O-caffeoyl)-beta-glucopyranoside (wedelosin), as well as three known flavonoid glycosides (quercetin 3-O-beta-glucoside, kaempferol 3-O-beta-apiosyl-(1-2)-beta-glucoside, and astragalin or kaempferol 3-O-beta-glucoside) were isolated from the Chinese medicinal herb Wedelia chinensis. Wedelosin showed an inhibitory activity on both the classical and the alternative activation pathway of the complement system. Another Chinese medicinal herb, Kyllinga brevifolia, yielded two known flavonoid glycosides [kaempferol 3-O-beta-apiosyl-(1-2)-beta-glucoside and isorhamnetin 3-O-beta-apiosyl-(1-2)-beta-glucoside], and a new quercetin triglycoside [quercetin 3-O-beta-apiofuranosyl-(1-->2)-beta-glucopyranoside 7-O-alpha-rhamnopyranoside]. The latter compound showed a moderate anti-viral activity.     

Chromatographic profiling and identification of two new iridoid-indole alkaloids by UPLC–MS and HPLC-SPE-NMR analysis of an antimalarial extract from Nauclea pobeguinii

The total 80% EtOH extract of stem bark of Nauclea pobeguinii (Rubiaceae), which is active against uncomplicated falciparum malaria as shown in previous clinical studies, was analysed by means of UPLC–MS and HPLC-SPE-NMR. Apart from the main constituent, strictosamide, a series of minor constituents was identified, including two new iridoid-indole alkaloids, i.e. naucleidinic acid and 19-O-methyl-3,14-dihydroangustoline, together with 8 known iridoid-indole alkaloids, i.e. naucleidinal, magniflorine, naucleofficine D, two diastereoisomers of 3,14-dihydroangustoline, strictosidine, desoxycordifoline, 3α,5α-tetrahydrodeoxycordifoline lactam, and a phenol glycoside 3,4,5-trimethoxyphenol β-d-apiofuranosyl-(1-6)-β-d-glucopyranoside (kelampayoside A).     

Saponin production is not qualitatively changed upon callus regeneration in the medicinal shrub Maesa perlarius

Maesa perlarius is a medicinal plant that produces maesabalides, which possess selective and strong anti-leishmania activity. In this study, M. perlarius plants were regenerated from leaf-derived calli. Shoots were induced in Murashige and Skoog medium in the presence of thidiazuron in combination with α-naphthalene acetic acid. In contrast to seed-derived plants, callus-derived regenerants were tetraploid showing typical characteristics of higher ploidy phenotypes. We assessed the impact of indirect plant regeneration and associated increase in ploidy on the production of saponin by means of LC–MS analysis. Tetraploid M. perlarius produce a saponin profile, which was not significantly different from seed grown plants. Based on this study, we concluded that saponin production in M. perlarius is not qualitatively changed by a genome-doubling event.     

Determination of saponins in Maesa lanceolata by LC-UV: development and validation

Triterpene saponins are a class of plant natural products with a wide range of bioactivities, which makes them an interesting research subject. The small tree Maesa lanceolata, growing in African countries, is used in traditional medicine against various diseases. In previous work a triterpenoid saponin mixture was isolated from the leaves of M. lanceolata and the compounds were identified as closely related oleanane type triterpenes [Apers, S., Foriers, A., Sindambiwe, J.B., Vlietinck, A., Pieters, L., 1998. Separation of a triterpenoid saponin mixture from Maesa lanceolata: semi preparative reversed-phase wide pore high performance liquid chromatography with temperature control. J. Pharm. Biomed. Anal. 18, 737; Apers, S., De Bruyne, T.E., Claeys, M., Vlietinck, A.J., Pieters, L.A.C., 1999. New acylated triterpenoid saponins from Maesa lanceolata. Phytochemistry 52, 1121]. The compounds showed virucidal, haemolytic, molluscicidal and antiangiogenic activity [Apers, S., Baronikova, S., Sindambiwe, J.B., Witvrouw, M., De Clercq, E., Vanden Berghe, D., Van Marck, E., Vlietinck, A., Pieters, L., 2001. Antiviral, haemolytic and molluscicidal activities of triterpenoid saponins from Maesa lanceolata: establishment of structure-activity relationships. Planta Med. 67, 528; Apers, S., Bürgermeister, J., Baronikova, S., Vermeulen, P., Paper, D., Van Marck, E., Vlietinck, A.J., Pieters, L.A.C., 2002. Antiangiogenic activity of natural products: in vivo and in vitro test models. J. Pharm. Belg. 57 (Hors-série 1), 47]. Here we report the development of an extraction and quantification method to analyse saponin compounds in roots and leaves of M. lanceolata. After a purification step using C(18) solid phase extraction (SPE) cartridges, the samples were analysed on a LC-UV/MS system. The identification of the peaks from the different saponins was confirmed based on the retention time and mass spectrum. The quantification was performed using the UV signals. The standard oleanolic acid curve was linear over a concentration range of 2.8-140.0mug/mL. The recovery from the leaves was 94.5%. The precision of the method with respect to time and concentration was acceptable, with relative standard deviation (RSD%) values of 4.9 and 4.3, respectively.     

The quantification of ellagic acid in the crude extract of Phyllanthus amarus Schum. & Thonn. (Euphorbiaceae)

Introduction – Phyllanthus amarus Schum. & Thonn. (Euphorbiaceae), already well known for its antiviral, antihyperglycaemic and antihepatotoxic effects, is also investigated for its antimalarial activity. The major constituent of the crude extract of the whole plant was isolated and identified in this research to be ellagic acid, for which antiplasmodial activity already has been reported. Objective – Because of the potential of the plant and the interesting properties of ellagic acid, an analytical method can be useful for the standardisation of the extracts to allow further biological and pharmacological investigations. In order to obtain an easily performable and inexpensive method, an HPLC analysis was developed and validated. Methodology – The samples were dissolved in DMSO, ultrasonicated for 15 min, and diluted with 50% methanol. Analysis was performed using water and methanol containing 0.06% TFA and the peaks were detected at 254 nm. Results – Ellagic acid showed a linear relationship in the range of 1.74–20.91 µg/mL and a single‐point calibration was allowed. The method was shown to be precise with respect to time (RSD of 1.84%, 3 days, n = 6) and concentration (RSD of 2.54%, 3 levels, n = 6). The overall mean content of ellagic acid was 2.06%. A recovery experiment was performed and it showed an accuracy of 100.4%. Conclusion – Based on the obtained results, it can be concluded that the newly developed method is suitable for its purpose, namely the determination of ellagic acid in the crude extract of P. amarus. Copyright © 2010 John Wiley & Sons, Ltd.     

Evaluation of the 2007 WHO guideline to improve the diagnosis of tuberculosis in ambulatory HIV-positive adults

Background

In 2007 WHO issued a guideline to improve the diagnosis of smear-negative and extrapulmonary tuberculosis (EPTB) in HIV-positive patients. This guideline relies heavily on the acceptance of HIV-testing and availability of chest X-rays.

Methods and Findings

Cohort study of TB suspects in four tuberculosis (TB) clinics in Phnom Penh, Cambodia. We assessed the operational performance of the guideline, the incremental yield of investigations, and the diagnostic accuracy for smear-negative tuberculosis in HIV-positive patients using culture positivity as reference standard. 1,147 (68.9%) of 1,665 TB suspects presented with unknown HIV status, 1,124 (98.0%) agreed to be tested, 79 (7.0%) were HIV-positive. Compliance with the guideline for chest X-rays and sputum culture requests was 97.1% and 98.3% respectively. Only 35 of 79 HIV-positive patients (44.3%) with a chest X-ray suggestive of TB started TB treatment within 10 days. 105 of 442 HIV-positive TB suspects started TB treatment (56.2% smear-negative pulmonary TB (PTB), 28.6% smear-positive PTB, 15.2% EPTB). The median time to TB treatment initiation was 5 days (IQR: 2–13 days), ranging from 2 days (IQR: 1–11.5 days) for EPTB, over 2.5 days (IQR: 1–4 days) for smear-positive PTB to 9 days (IQR: 3–17 days) for smear-negative PTB. Among the 34 smear-negative TB patients with a confirmed diagnosis, the incremental yield of chest X-ray, clinical suspicion or abdominal ultrasound, and culture was 41.2%, 17.6% and 41.2% respectively. The sensitivity and specificity of the algorithm to diagnose smear-negative TB in HIV-positive TB suspects was 58.8% (95%CI: 42.2%–73.6%) and 79.4% (95%CI: 74.8%–82.4%) respectively.

Conclusions

Pending point-of-care rapid diagnostic tests for TB disease, diagnostic algorithms are needed. The diagnostic accuracy of the 2007 WHO guideline to diagnose smear-negative TB is acceptable. There is, however, reluctance to comply with the guideline in terms of immediate treatment initiation.     

Evaluation of the in vivo anti-inflammatory activity of a flavonoid glycoside from Boldoa purpurascens

The anti-inflammatory effect of 4′,5-dihydroxy-6,7-methylenedioxyflavonol 3-O-α-l-rhamnopyranosyl-(1 → 2)-β-d-xylopyranoside, a constituent of the leaves of Boldoa purpurascens Cav. (Nyctaginaceae), was evaluated for its anti-inflammatory activity in the dextran 1% induced rat paw oedema model (acute inflammation) and the cotton pellet induced granuloma rat model (chronic inflammation). Flavonoid glycoside at doses of 2.5, 5 and 10 mg/kg, indomethacin at a dose of 7 mg/kg and the vehicle were administered orally. The compound showed significant anti-inflammatory activity in the acute phase in a dose dependent manner, most notably at the highest test dose 10 mg/kg. Also in the cotton pellet induced granuloma model, the compound showed a dose-dependent anti-inflammatory activity, with the highest effect at 10 mg/kg. In both assays, the test compound was more active than indomethacin tested at 7 mg/kg.