Serological Testing Versus Other Strategies for Diagnosis of Active Tuberculosis in India: A Cost-Effectiveness Analysis

This cost-effectiveness study shows that sputum smear microscopy is the most cost-effective test for active tuberculosis (TB) in India, and liquid culture plus microscopy is more cost-effective for TB diagnosis than serological tests

Weight Variation over Time and Its Association with Tuberculosis Treatment Outcome: A Longitudinal Analysis

OBJECTIVE: Weight variation during therapy has been described as a useful marker to predict TB treatment outcome. No previous study has used longitudinal analysis to corroborate this finding. The goal of this study was to evaluate change and trends of patients' bodyweight over time depending on TB treatment outcome. METHODS AND FINDINGS: A retrospective cohort study with all TB cases diagnosed from 2000 to 2006 was carried out. Information from 5 public tuberculosis treatment facilities at Pampas de San Juan de Miraflores, Lima, Peru was analyzed. Poor outcome was defined as failure or death during TB therapy, and compared to good outcome defined as cured. Longitudinal analysis with a pre-specified marginal model was fitted using Generalized Estimating Equations to compare weight trends for patients with good and poor outcome adjusting for potential confounders. A total of 460 patients (55.4% males, mean age: 31.6 years) were included in the analysis: 42 (9.1%) had a poor outcome (17 failed and 25 died). Weight at baseline was not different comparing outcome groups (p = 0.17). After adjusting for age, gender, type of TB, scheme of treatment, HIV status and sputum variation during follow-up, after the first month of treatment, patients with good outcome gained, on average, almost 1 kg compared to their baseline weight (p<0.001), whereas those with poor outcome lost 1 kg (p = 0.003). Similarly, after 4 months, a patient with good outcome increased 3 kg on average (p<0.001), while those with poor outcome only gained 0.2 kg (p = 0.02). CONCLUSIONS: Weight variation during tuberculosis therapy follow-up can predict treatment outcome. Patients losing weight during TB treatment, especially in the first month, should be more closely followed as they are at risk of failure or death

Delayed consultation among pulmonary tuberculosis patients: a cross sectional study of 10 DOTS districts of Ethiopia

<p>Abstract</p> <p>Background</p> <p>Delays seeking care increase transmission of pulmonary tuberculosis and hence the burden of tuberculosis, which remains high in developing countries. This study investigates patterns of health seeking behavior and determines risk factors for delayed patient consultation at public health facilities in 10 districts of Ethiopia.</p> <p>Methods</p> <p>New pulmonary TB patients ≥ 15 years old were recruited at 18 diagnostic centres. Patients were asked about their health care seeking behaviour and the time from onset of symptoms to first consultation at a public health facility. First consultation at a public health facility 30 days or longer after onset of symptoms was regarded as prolonged patient delay.</p> <p>Results</p> <p>Interviews were held with 924 pulmonary patients. Of these, 537 (58%) were smear positive and 387 (42%) were smear negative; 413 (45%) were female; 451 (49%) were rural residents; and the median age was 34 years. Prior to their first consultation at a public health facility, patients received treatment from a variety of informal sources: the Orthodox Church, where they were treated with holy water (24%); private practitioners (13%); rural drug vendors (7%); and traditional healers (3%). The overall median patient delay was 30 days (mean = 60 days). Fifty three percent [95% Confidence Intervals (CI) (50%, 56%)] of patients had delayed their first consultation for ≥ 30 days. Patient delay for women was 54%; 95% CI (54%, 58%) and men 51%; 95% CI (47%, 55%). The delay was higher for patients who used informal treatment (median 31 days) than those who did not (15 days). Prolonged patient delay (≥ 30 days) was significantly associated with both patient-related and treatment-related factors. Significant patient-related factors were smear positive pulmonary disease [Adjusted Odds Ratio (AOR) 1.4; 95% CI (1.1 to 1.9)], rural residence [AOR 1.4; 95% CI (1.1 to 1.9)], illiteracy [AOR 1.7; 95% CI (1.2 to 2.4)], and lack of awareness/misperceptions of causes of pulmonary TB. Significant informal treatment-related factors were prior treatment with holy water [AOR 3.5; 95% CI (2.4 to 5)], treatment by private practitioners [AOR 1.7; 95% CI (1.1 to 2.6)] and treatment by drug vendors [AOR 1.9; 95% CI (1.1 to 3.5)].</p> <p>Conclusion</p> <p>Nearly half of pulmonary tuberculosis patients delayed seeking health care at a public health facility while getting treatment from informal sources. The involvement of religious institutions and private practitioners in early referral of patients with pulmonary symptoms and creating public awareness about tuberculosis could help reduce delays in starting modern treatment.</p

The Malawi National Tuberculosis Programme: an equity analysis

<p>Abstract</p> <p>Background</p> <p>Until 2005, the Malawi National Tuberculosis Control Programme had been implemented as a vertical programme. Working within the Sector Wide Approach (SWAp) provides a new environment and new opportunities for monitoring the equity performance of the programme. This paper synthesizes what is known on equity and TB in Malawi and highlights areas for further action and advocacy.</p> <p>Methods</p> <p>A synthesis of a wide range of published and unpublished reports and studies using a variety of methodological approaches was undertaken and complemented by additional analysis of routine data on access to TB services. The analysis and recommendations were developed, through consultation with key stakeholders in Malawi and a review of the international literature.</p> <p>Results</p> <p>The lack of a prevalence survey severely limits the epidemiological knowledge base on TB and vulnerability. TB cases have increased rapidly from 5,334 in 1985 to 28,000 in 2006. This increase has been attributed to HIV/AIDS; 77% of TB patients are HIV positive. The age/gender breakdown of TB notification cases mirrors the HIV epidemic with higher rates amongst younger women and older men. The WHO estimates that only 48% of TB cases are detected in Malawi. The complexity of TB diagnosis requires repeated visits, long queues, and delays in sending results. This reduces poor women and men's ability to access and adhere to services. The costs of seeking TB care are high for poor women and men – up to 240% of monthly income as compared to 126% of monthly income for the non-poor. The TB Control Programme has attempted to increase access to TB services for vulnerable groups through community outreach activities, decentralising DOT and linking with HIV services.</p> <p>Conclusion</p> <p>The Programme of Work which is being delivered through the SWAp is a good opportunity to enhance equity and pro-poor health services. The major challenge is to increase case detection, especially amongst the poor, where we assume most 'missing cases' are to be found. In addition, the Programme needs a prevalence survey which will enable thorough equity monitoring and the development of responsive interventions to promote service access amongst 'missing' women, men, boys and girls.</p

Resources for controlling tuberculosis in Malawi.

OBJECTIVE: To document resources for controlling tuberculosis (TB) in Malawi. METHODS: We performed a countrywide study of all 43 hospitals (3 central, 22 district and 18 mission) which register and treat patients with TB. To collect data for 1998 on the TB-related workload, diagnostic facilities, programme staff and treatment facilities, we used laboratory, radiographic and TB registers, conducted interviews and visited hospital facilities. FINDINGS: The data show that in 1998, 88,257 TB suspects/patients contributed approximately 230,000 sputum specimens for smear microscopy, 55,667 chest X-rays were performed and 23,285 patients were registered for TB treatment. There were 86 trained laboratory personnel, 44 radiographers and 83 TB programme staff. Of these, about 40% had periods of illness during 1998. Approximately 20% of the microscopes and X-ray machines were broken. Some 16% of the hospital beds were designated for TB patients in special wards, but even so, the occupancy of beds in TB wards exceeded 100%. Although stocks of anti-TB drugs were good, there was a shortage of full-time TB ward nurses and 50% of district hospitals conducted no TB ward rounds. In general, there was a shortage of facilities for managing associated HIV-related disease; central hospitals, in particular, were underresourced. CONCLUSION: Malawi needs better planning to utilize its manpower and should consider cross-training hospital personnel. The equipment needs regular maintenance, and more attention should be paid to HIV-related illness. The policies of decentralizing resources to the periphery and increasing diagnostic and case-holding resources for central hospitals should be continued

Design of regimens for treating tuberculosis in patients with HIV infection, with particular reference to sub-Saharan Africa.

The highest burden of human immunodeficiency virus (HIV) related tuberculosis (TB) is in sub-Saharan Africa. HIV complicates several areas of TB control, one of which involves treatment and treatment outcome. Large patient numbers cause congestion on TB wards, there is increased morbidity, an increased risk of adverse drug reactions, an increased case fatality, and an increased recurrence of TB after treatment completion. TB Control Programmes have responded to these problems by taking actions such as abolishing thioacetazone and decentralising the initial phase of treatment to peripheral health centres and the community. Despite this response, there are three major on-going concerns which need to be addressed by research studies. There is a need to reduce case fatality rates focusing on 1) stronger treatment regimens, 2) adequacy of rifampicin levels when intermittent treatment regimens are used, and 3) adjunctive treatments. There is a need to reduce recurrent rates of TB by 1) determining the relative role of re-infection and reactivation as a cause of recurrence, 2) assessing the importance of duration and type of anti-TB treatment for the first episode of TB, and 3) determining the role of secondary isoniazid preventive therapy. There is a need to evaluate how best to decentralise treatment from the perspective of the health service and the patient. Research studies should be relevant to the needs and resources of TB control programmes, and should include pharmacokinetic studies, controlled clinical trials and operational research, including economic analysis and social science evaluation

Prescriptions and dosages of anti-tuberculosis drugs in the National Tuberculosis Control Programme of Malawi.

SETTING: All 44 non-private hospitals in Malawi treating pulmonary tuberculosis (PTB) patients with an oral regimen (0.5RHZE/1.5R3H3Z3E3/6HE). OBJECTIVES: In new smear-positive PTB patients, to determine whether: 1) numbers of tablets were correctly prescribed according to pre-treatment weights, and 2) medication dosages were adequate, too low or too high. DESIGN: Retrospective review of TB registers and TB treatment cards for patients registered with new smear-positive PTB between 1 October and 31 December 2001. RESULTS: Of 1970 patients aged > or = 15 years, 1211 (62%) had treatment cards and pre-treatment weights. Incorrect prescriptions were given to 88 (7%), and many of these received dosages of anti-tuberculosis drugs that were too high or too low. For those receiving correct prescriptions, daily treatment in the initial and continuation phases was generally associated with adequate dosages of drugs. However, in the initial intermittent phase, between 3% and 40% of patients received anti-tuberculosis drug dosages that were too low. CONCLUSION: A small percentage of patients receive incorrect prescriptions, which can be resolved by training and supervision. In those receiving correct prescriptions, intermittent treatment provides dosages that are sometimes too low. Weight bands for intermittent treatment should be re-examined

When are follow-up sputum smears actually examined in patients treated for new smear-positive pulmonary tuberculosis?

SETTING: All 44 non-private hospitals (four central, 22 district and 18 mission) in Malawi that registered and treated tuberculosis (TB) cases, October-December 2001. OBJECTIVES: To determine, in new smear-positive pulmonary tuberculosis (PTB) patients, for the 2-, 5- and 7-month smear examinations, 1) the proportion with smears examined and 2) the actual timing of smear examination. STUDY DESIGN: Retrospective data collection using TB registers, TB treatment cards and laboratory sputum registers. Timing of smear examinations was judged acceptable if 2-month smears were examined at 2 or 3 months, 5-month smears at 4, 5 or 6 months and 7-month smears at 6, 7, 8 or 9 months. RESULTS: Of 1994 patients, for those alive and on treatment, 78% had smears definitely examined at 2 months, 75% at 5 months and 74% at 7 months. Of these, 82% had smears examined at an acceptable time for the 2-month smear, 71% for the 5-month smear and 78% for the 7-month smear. Smears were examined after the 8-month treatment regimen for the 2- and 5-month smear in respectively 2% and 9% of patients. Smears were done more frequently in female than male patients, and in district/mission hospitals than central hospitals. Smears were done at acceptable times more frequently in younger than older patients and in mission/central hospitals than district hospitals. CONCLUSION: During supervision, the actual time of follow-up sputum smear examinations needs to be monitored more closely

Developing operational research capacity in hospital tuberculosis control officers in Malawi.

SETTING: The National TB Control Programme (NTP) of Malawi. OBJECTIVES: To describe 1) the way in which a generic operational research project was developed and implemented by hospital TB officers (TBOs), 2) the outcome in terms of research work completed, data analysed and papers written up, and 3) the results of the research project. DESIGN: A descriptive study of assessing diagnostic processes in patients labelled as TB suspects who had been admitted to general hospital wards over 4 weeks. RESULTS: A total of 25 TBOs were trained in developing the research protocol: 19 performed satisfactory work, 17 attended an analysis/paper writing workshop and 11 submitted a research paper. The data of five papers were collated. Of 900 hospital admissions, 153 (17%) were TB suspects, of whom 37% were diagnosed with TB, 38% were discharged with another diagnosis and 25% died or absconded during investigations. CONCLUSION: This first attempt at developing a research capacity in hospital TB officers in Malawi was partially successful, and may, through local dissemination and feedback, help to improve the speed of TB diagnosis in hospital in-patients