Re-Treatment Tuberculosis Cases Categorised as “Other”: Are They Properly Managed?

BACKGROUND: Although the World Health Organization (WHO) provides information on the number of TB patients categorised as "other", there is limited information on treatment regimens or treatment outcomes for "other". Such information is important, as inappropriate treatment can lead to patients remaining infectious and becoming a potential source of drug resistance. Therefore, using a cohort of TB patients from a large registration centre in Lilongwe, Malawi, our study determined the proportion of all TB re-treatment patients who were registered as "other", and described their characteristics and treatment outcomes. METHODS: This retrospective observational study used routine program data to determine the proportion of all TB re-treatment patients who were registered as "other" and describe their characteristics and treatment outcomes between January 2006 and December 2008. RESULTS: 1,384 (12%) of 11,663 TB cases were registered as re-treatment cases. Of these, 898 (65%) were categorised as "other": 707 (79%) had sputum smear-negative pulmonary TB and 191 (21%) had extra pulmonary TB. Compared to the smear-positive relapse, re-treatment after default (RAD) and failure cases, smear-negative "other" cases were older than 34 years and less likely to have their HIV status ascertained. Among those with known HIV status, "other" TB cases were more likely to be HIV positive. Of TB patients categorised as "other", 462 (51%) were managed on the first-line regimen with a treatment success rate of 63%. CONCLUSION: A large proportion of re-treatment patients were categorised as "other". Many of these patients were HIV-infected and over half were treated with a first-line regimen, contrary to national guidelines. Treatment success was low. More attention to recording, diagnosis and management of these patients is warranted as incorrect treatment regimen and poor outcomes could lead to the development of drug resistant forms of TB

Not just pretty pictures: Geographical Information Systems in TB control

Geographical Information Systems (GIS) is becoming a useful tool in disease control by health planners. However little is known about its potential in tuberculosis (TB) control. In 2000 the National TB Programme (NTP) in Malawi assessed its usefulness. Routinely collected case-finding data from the 3 previous years (1997 to 1999) were entered into a system containing a digital map of Malawi. District performance was mapped. We concluded that GIS may be complementary in monitoring TB programme performance, and may be useful for target setting, advocacy, and research. World Health Organisation (WHO) now provides free GIS software (Health Mapper) and training. However, the use of GIS in TB control still needs further piloting and expansion without constraining the locally available resources or disrupting the present TB data management system. Malawi Medical Journal Vol. 17(2) 2005: 33-3

The diagnosis of extrapulmonary tuberculosis in Malawi.

There is little information on a country-wide basis in sub-Saharan Africa about how the diagnosis of extra-pulmonary tuberculosis (EPTB) is made. A country-wide cross-sectional study was carried out in 40 non-private hospitals in Malawi which register and treat (TB) patients in order to assess diagnostic practices in adults registered with EPTB. All patients aged 15 years and above in hospital on treatment for EPTB were reviewed usingTB registers, case note files and clinical assessment. There were 244 patients, 132 men and 112 women whose mean age was 36 years. In 138 (57%) patients, all appropriate procedures and investigations, commensurate with hospital resources, had been carried out. Of 171 EPTB patients with cough for 3 weeks or longer, 138 (81%) submitted sputum specimens for smear microscopy of acid-fast bacilli (AFB). A confirmed diagnosis ofTB was made in 15 (6%) patients based on finding AFB or caseating granulomas in specimens. In 157 (64%) patients, the diagnosis of EPTB was considered to be correct. In 46 (19%) patients the diagnosis was considered to be TB, although different from the type of EPTB with which the patient was registered. In 39 (16%) patients an alternative non-TB diagnosis was made and in two (1%) patients it was not possible to make a decision. Diagnostic practices need to be improved, and ways of doing this are discussed

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

Distribution of patient characteristics by re-treatment category (n = 1,384).

¥<p>Chi-square test for the differences in the distribution of the categorical characteristic across patient re-treatment categories.</p

Factors associated with binary treatment success rate among TB treatment classification (n = 663).

*<p>P-value for likelihood ratio test,</p><p>^F-Adjusted for sex, age and patient category, RAD = Re-treatment after default.</p

Distribution of patient characteristics by treatment category (n = 11,663 cases).

¥<p>2 cases had unknown smear status.</p