The missing cases of tuberculosis in Malawi: the contribution from cross-border registrations

Low case detection rates of new smear-positive pulmonary tuberculosis (PTB) patients globally are a cause for concern. The aim of this study was to determine for patients registered for TB in Malawi the number and percentage who lived in a neighbouring country and the registration, recording and reporting practices for these 'foreign' patients. All 44 non-private hospitals, which register and treat all TB patients in the public health sector in Malawi, were visited. Ten (23%) hospitals in 2001 and 14 (32%) in 2002 maintained a separate register for cross-border TB cases. Patients recorded in these registers were not formally reported to the Malawi National TB Programme (NTP), the neighbouring country's NTP, nor to WHO. They therefore constitute missing cases. In Malawi, the number of cross-border new smear-positive PTB cases was 77 in 2001 and 91 in 2002, constituting about 3% of missing smear-positive cases in those hospitals that maintain cross-border registers and about 1% of missing cases nationally.     

Tuberculosis in health care workers in Malawi.

Although sub-Saharan Africa has the highest rates of tuberculosis (TB) and human immunodeficiency virus (HIV) infection in the world, the rates of TB amongst its health care workers (HCWs) are poorly documented. We therefore conducted a country-wide investigation. All district/government and mission hospitals in Malawi that diagnose and care for TB patients were visited in order to obtain information on hospital-based HCWs and their incidence of TB in 1996. Hospital TB case loads, country-wide TB notification numbers and national population estimates for 1996 were obtained, which enabled TB case notification rates to be calculated. In 1996, 108 (3.6%) of 3042 HCWs from 40 hospitals were registered and treated for TB: 22 with smear-positive pulmonary TB (PTB), 40 with smear-negative PTB and 46 with extrapulmonary TB. The overall case fatality rate was 24%. Compared with the adult general population aged > or = 15 years, the relative risk [95% confidence interval (CI)] in HCWs of all types of TB was 11.9 [9.8-14.4], of smear-positive PTB 5.9 [3.9-9.0], of smear-negative PTB 13.0 [9.5-17.7] and of extrapulmonary TB 18.4 [13.8-24.6], P < 0.05. The 1996 hospital TB case load ranged from 29 to 915: there were no cases of TB in HCWs in hospitals whose case load was < or = 100 patients, while the TB case rate among HCWs was similar in hospitals with annual case loads of 101-300 or > 300. The annual risk of TB was high among all categories of HCW, especially clinical officers. This study shows a high rate of TB in HCWs in Malawi, and emphasizes the need for practical and affordable control measures for the protection of HCWs from TB in low-income countries.     

综合性医院归口诊治肺结核病的改革实践

目的:充分发挥综合医院作用,提高肺结核病人发现率。方法:通过全面推行结核病控制策略(DOTS),改革防制模式,实行以一所综合医院为归口诊治、其他医院机构为归口转诊、疾控中心为归口管理模式,建立转诊制度,明确各自职责和分工。结果:全县传染源发现率平均已达96.7%;新发涂阳肺结核病新登记率从1995年~1999年30.1/10万上升到2000年~2005年44.50/10万,增长了47.8%;转诊率从1995年~1999年82.1%上升到2005年的98.5%,增长了20%。结论:改革后的结核病归口诊治管理模式,利用现有医疗资源,有效提高了肺结核病人的转诊率和涂阳病人的发现率,发挥了综合性医院对结核病控制工作的重要作用。     

Comprehensiveness of primary services in the care of infectious tuberculosis patients in Rawalpindi,Pakistan

Setting:

All tuberculosis (TB) diagnostic centres of Rawalpindi District, Pakistan, including five tertiary care hospitals and 16 rural health centres.

Objective:

To identify among sputum smear-positive patients registered during 2009 in the laboratory register those who had not been recorded in a treatment register, defined in the study as ‘initial loss to follow-up’.

Design:

A retrospective record review of routine TB data.

Results:

There were 16 145 suspects screened for TB and recorded in the laboratory registers. Of 1698 smear-positive patients identified in the laboratory registers, 101 (6%) could not be identified in the treatment registers. Eighty-six (10%) of 842 patients in tertiary care hospitals and 15/856 (2%) in rural health centres were not recorded (OR 6.4, 95%CI 3.6–11.6, P < 0.01).

Conclusion:

The study shows a significant association between type of health facility and initial loss to follow-up. In rural health centres, the proportion lost to follow-up is low, reflecting more efficient care than in tertiary care hospitals. Strategies are urgently needed to improve the registration and follow-up of smear-positive cases in tertiary care institutions.     

Relapse and recurrent tuberculosis in the context of a national tuberculosis control programme

The proportion of patients with recurrent tuberculosis (TB) is reported to be increased in TB patients with human immunodeficiency virus (HIV) infection after they have completed treatment. Despite rising HIV seroprevalence amongst TB patients in Malawi, notifications of patients with relapse smear-positive pulmonary TB (PTB) and recurrent smear-negative TB have remained stable during the past 12 years. We suspected that patients with recurrent or relapse TB were being missed under routine programme conditions. Forty-three hospitals in Malawi were visited in 1999, and TB inpatients who had been registered as 'new' cases in the TB register and treatment card were interviewed about previous episodes of TB. A previous history of TB was elicited in 94 (7.5%) of 1254 patients who were being treated as new cases. Compared with patients with smear-positive PTB, a previous episode of TB was significantly more common in patients with smear-negative PTB (OR 3.5, [95% CI 2.1-5.7], P < 0.001) and patients with extrapulmonary TB (OR 2.0, [95% CI 1.1-3.7], P < 0.05). Of 94 patients with a previous episode of TB, 76 had completed treatment and 18 had defaulted from treatment during this episode. Patients with recurrent or relapse TB are being incorrectly registered within the Malawi TB Control Programme, and in the case of smear-positive PTB patients this is associated with administration of incorrect treatment. Measures have been put in place to rectify the situation, and further operational research is planned to monitor treatment outcomes of patients with recurrent smear-negative TB.     

Are official reports sufficient? Official registration rates of patients with tuberculosis in Sivas, Middle Anatolia

PURPOSE: The main goal of this retrospective study was to re-evaluate all available records of clinical and laboratory data of patients with tuberculosis (TB) in Sivas province, Middle Anatolia, Turkey. METHODS: TB registration data held at health institutions in Sivas province were compared and matched with data obtained from the local official TB registries from January 2000 to December 2001. RESULTS: Of the 536 TB cases found in 2000 and 2001, 255 (47.6%) were officially registered. Of the 127 cases with smear-positive pulmonary TB (PTB), only nine cases labelled as smear-positive were registered in local dispensaries. The incidence of unregistered cases with smear-positive PTB found by this study was approximately 40-fold and eightfold greater than the incidence of registered cases for 2000 and 2001, respectively. CONCLUSION: There were many more unofficially recorded TB patients compared with officially recorded cases in Sivas province between 2000 and 2001. The results of this study are disappointing and alarming for Turkey's national TB control programme, at least for its regional applications.     

2004～2010年保山市结核病控制项目实施效果评价

[目的]了解保山市2004～2010年结核病控制项目工作成效。[方法]对保山市2004～2010年结核病就诊查痰情况、归口管理(发现登记情况)、病人来源渠道、涂阳病人转归情况进行分析。[结果]2004～2010年,累计可疑肺结核者初诊16 210例,平均可疑初诊率为0.94‰;平均查痰率为63.65%,痰检平均阳性率为42.55%。累计登记涂阳肺结核病人4 276例,平均登记率为24.89/10万;累计登记新涂阳肺结核病人3 842例,平均新涂阳登记率为22.35/10万;累计登记活动性肺结核病人4 838例。涂阳肺结核病人中,来源渠道为转诊追踪的占77.70%,因症就诊的占9.61%,因症推荐的占11.32%,其他占1.38%。累计检出3 842例初治涂阳病人,其中,男性占68.32%,15～64岁占91.51%;累计检出434例复治涂阳病人,其中,男性占68.20%,15～64岁占94.26%。治疗1年时,初治涂阳肺结核病人平均治愈率为93.54%,平均结核病病死率为1.12%;复治涂阳病人平均治愈率为88.94%,结核病平均病死率为0.99%。[结论]保山市实施结核病控制项目效果显著。     

Expanding tuberculosis case notification among marginalized groups in Bangladesh through peer sputum collection

Case notification rates of tuberculosis (TB) in Bangladesh remain poor despite a high burden of disease. Peer sputum collection among underserved populations was implemented to expand case notification and to provide socially empowering roles in society for often excluded members of marginalized populations. Over the 55 months of the evaluation, 32 587 members of key populations were screened for TB, with 1587 smear-positive TB cases detected. Broadening TB services at human immunodeficiency virus drop-in centers using peer sputum collection to target high-risk populations for TB may be an effective way to increase TB case notification among key populations in Bangladesh.     

DOTS-based tuberculosis treatment and control during civil conflict and an HIV epidemic,Churachandpur District,India

OBJECTIVE: To pilot the WHO guidelines on DOTS for tuberculosis (TB) among displaced people affected by conflict in Churachandpur District, Manipur State, north-east India, which has endured an HIV epidemic, injecting drug use, civil unrest, high levels of TB, and poor TB treatment and prevention services for many years. METHODS: Prerequisites for TB control programmes were established. WHO guidelines and protocols were adapted for local use. Outreach workers were appointed from each ethnic group involved in the conflict, and training was conducted. Quality control and evaluation processes were introduced. FINDINGS: TB was diagnosed in 178 people between June and December 1998. Of the 170 with pulmonary disease, 85 were smear-positive. Successful outcomes were recorded in 91% of all patients and in 86% of smear-positive cases of pulmonary TB. The default rate and the mortality rate were low at 3% each. HIV positive serostatus was the only factor associated with a poor treatment outcome. CONCLUSION: TB treatment and control were possible in a conflict setting and WHO targets for cure were attainable. The factors associated with the success of the programme were strong local community support, the selection of outreach workers from each ethnic group to allow access to all areas and patients, the use of directly observed therapy three times a week instead of daily in the interest of increased safety, and the limiting of distances travelled by both outreach workers and patients.     

2004-2010年保山市结核病控制项目实施效果评价

[目的]了解保山市2004-2010年结核病控制项目工作成效。[方法]对保山市2004-2010年结核病就诊查痰情况、归口管理（发现登记情况）、病人来源渠道、涂阳病人转归情况进行分析。[结果]2004～2010年,累计可疑肺结核者初诊16210例,平均可疑初诊率为0．94‰;平均查痰率为63．65％,痰检平均阳性率为42．55％。累计登记涂阳肺结核病人4276例,平均登记率为24．89／10万;累计登记新涂阳肺结核病人3842例,平均新涂阳登记率为22．35／10万;累计登记活动性肺结核病人4838例。涂阳肺结核病人中,来源渠道为转诊追踪的占77．70％,因症就诊的占9．61％,因症推荐的占11．32％,其他占1．38％。累计检出3842例初治涂阳病人,其中,男性占68．32％,15～64岁占91．51％;累计检出434例复治涂阳病人,其中,男性占68．20％,15～64岁占94．26％。治疗1年时,初治涂阳肺结核病人平均治愈率为93．54％,平均结核病病死率为1．12％;复治涂阳病人平均治愈率为88．94％,结核病平均病死率为0．99％。[结论]保山市实施结核病控制项目效果显著。     

2007—2011年莱芜市涂阳肺结核患者密切接触者筛查情况分析

目的了解对涂阳肺结核患者密切接触者进行筛查的意义。方法对莱芜市2007—2011年间登记的2 487例涂阳患者密切接触者,均进行痰涂片(夜间痰、晨痰和即时痰)检查和X线胸部拍片检查,对年龄≤15岁者进行PPD试验。结果 2 487例密切接触者发现活动性肺结核19例,检出率0.764%。密切接触者中患活动性肺结核的几率与所接触的涂阳患者的排菌量呈正相关关系。结论对涂阳患者密切接触者进行痰涂片和X线胸片检查,有助于肺结核患者的发现,对此人群开展结核病预防工作具有重要意义。     

广西南宁市世行贷款中国结核病控制项目中期效果评价

目的评价南宁市世行贷款／英国赠款中国结核病控制项目（2002—2005年）中期执行的效果。方法根据卫生部的中期评估调查表，收集南宁市2002—2005年8个项目单位常规监测等相关资料，汇总分析。结果南宁市2004年DOTS策略覆盖率达到100％，4年来共接诊可疑肺结核症状者42358例，发现活动性肺结核病人16067例，其中涂阳病人6012例，涂阳病人登记率从2002年的11．51／10万上升到2005年的37．03／10万，初治涂阳病人治愈率从2002年的76．7％提高到2005年的92．4％。结论通过实施世行贷款结核病控制项目，实现了南宁市结核病控制中期目标，初步建立了结核病控制可持续发展机制，但仍需进一步加强结核病控制工作。     

医疗单位肺结核病归口管理方法的探讨

目的探索结核病人归口管理途径与方法,提高结核病人发现率,规范病人治疗管理。方法结合湖南省实际,制订切实可行的结核病人归口管理实施办法与措施;对全省2003年未实施结核病人归口管理与2004年实施结核病人归口管理的结果进行对照分析。结果全省2003年初诊病人为108 734例,2004年为159 534例,2004年比2003年增加50 800例,增长46.7%。其中全省2003年因症就诊、医疗单位转诊、和其他方式(集中推荐和因正推荐等)分别为80 150例、10 988例和17 596例,2004年分别为108 515例、27 116例和23 903例,2004年比2003年分别增长了35.4%、146.8%和35.8%。2001~2003年各年登记的涂阳病人数为20 000例左右,新涂阳病人登记率在23.6/10万~24.6/10万之间;2004年发现涂阳病人35 455例,比2003年增加了15 052例,增长率高达73.8%。新涂阳病人登记率增长至44/10万。其中,因症就诊、转诊和其他分别为20 403例1、0 794例和4 424例,分别比2003年增加6 552例、6 883例和1 617例,分别增长了47.9%、176.0%和239.7%;分别占43.5%、45.7%和10.7%。2004年涂阳病人的增多和新涂阳病人登记率的增高,主要是医疗单位的结核病人转诊病人数增加的结果。结论《湖南省结核病人归口管理工作规范》的实施方法与措施是一个可行的结核病人归口管理办法;做好结核病归口管理是提高病人发现率的有效措施。     

湖北省网络直报疑似肺结核病人转诊追踪工作分析

[目的]分析综合医院疑似肺结核病人报告、转诊、追踪和定诊情况,探讨提高涂阳肺结核病人发现措施。[方法]根据2005年6月～2006年5月,60个FIDELIS项目县结核病控制工作月报表和FIDELIS项目相关报表数据,进行综合分析和评价,统计分析采用SAS软件。[结果]在FIDELIS项目实施期间,60项目县综合医院实际报告疑似肺结核24 666例,转诊到结防机构8 006例,转诊到位率为32.5%;结防机构追踪到位7 049例,追踪到位率为47.1%;转诊追踪到位共计15 055例病例,其中4 994例（33.2%）在结防机构重新定诊为涂阳肺结核,4 542例（30.2%）定诊为涂阴肺结核,3 756例（24.6%）被排除肺结核。[结论]加强综合医院痰检质量控制和转诊,提高结防专业机构对综合医院网络直报疑似肺结核病人的追踪工作,是提高肺结核病人发现水平的有效途径。     

加强转诊在提高肺结核病人发现中的作用

目的探索加强行政干预等措施对肺结核病人转诊工作的影响。方法对广东省湛江市区等20个县区采取加强病人转诊的干预措施，分析比较干预前后病人登记率、病人转诊到位率和追踪率。选择信宜县等20个县区作为对照组，比较两组肺结核病人发现情况。结果干预后，干预地区新涂阳肺结核登记率为36．6／10万，病人转诊到位率为76．2％，病人追踪率为88．9％，均较干预前有明显提高。干预地区病人追踪到位率为41．5％，高于对照地区的20．9％。结论在病人发现工作开展较好地区，通过加强病人转诊工作仍可在一定程度上提高肺结核病人发现水平。     

2016—2020年南京市老年人群与非老年人群肺结核流行特征对比分析

目的 了解2016—2020年南京市60岁及以上老年人群肺结核流行特征,分析其与非老年人群的不同,为制定有针对性的老年结核病防治措施提供科学依据。方法 收集2016—2020年“中国疾病预防控制信息系统”子系统“结核病信息管理系统”登记的南京市肺结核病例数据信息, 采用描述流行病学方法统计分析60岁及以上老年人群肺结核疫情登记及治疗转归情况并与非老年人群进行对比分析。结果 2016—2020年南京市共报告60岁及以上老年肺结核患者4 078例,占同期全人群报告病例数的35.43%,年平均报告发病率为57/10万,高于非老年人群 (χ2 = 552.545,P＜0.001)。老年人群肺结核报告发病率随年份呈下降趋势,平均每年下降7.50% (APC = -7.50,95%CI: -10.09～-4.82,P = 0.003)。老年肺结核患者中男性数多于女性,男女性别之比为3.01∶1,年平均报告发病率男性为88/10万,女性为28/10万。老年肺结核发病率随年龄增加呈上升趋势（χ2趋势 = 247.809,P＜0.001）。10.30%的老年肺结核患者为复治患者,高于非老年患者（χ2 = 141.578,P＜0.001）。病原学阳性比例在老年肺结核患者中为55.20%,高于非老年患者（χ2 = 158.501,P＜0.001）,64.72%的老年病原学阳性肺结核患者进行了耐药检测,耐药率为12.29%。因症就诊是老年肺结核患者最主要的发现方式（50.57%）,其次为转诊（32.17%）和追踪（9.24%）。老年患者就诊延误率为64.47%,高于非老年患者(χ2 = 104.446,P＜0.001),成功治疗率为87.54%,低于非老年患者(χ2 = 267.191,P＜0.001)。结论 南京市老年人群肺结核疫情严峻,患者发现方式单一,就诊延误现象严重,治疗转归相对较差,应加强这一人群的主动筛查力度,以做到早发现、早干预、早治疗。     

Treatment outcome of patients with smear-negative and smear-positive pulmonary tuberculosis in the National Tuberculosis Control Programme, Malawi

National tuberculosis control programmes (NTPs) in sub-Saharan Africa do not routinely record or report treatment outcome data on smear-negative pulmonary tuberculosis (PTB) patients. Twelve-month treatment outcome on patients with smear-negative PTB registered in all district and mission hospitals in Malawi during the year 1995 was collected, and was compared with 8-month treatment outcome in smear-positive PTB patients registered during the same period. Of 4240 patients with smear-negative PTB, 35% completed treatment, 25% died, 9% defaulted and 7% were transferred to another district with no treatment outcome results available. In 24% of patients treatment cards were lost and treatment outcome was unknown. These results were significantly inferior to those obtained in 4003 patients with smear-positive PTB in whom 72% completed treatment, 20% died, 4% defaulted, 2% were transferred and 1% had positive smears at the end of treatment. These differences between patients with smear-negative and smear-positive PTB were similar when analysed by sex and by most age-groups. Higher mortality rates in patients with smear-negative PTB are probably attributable to advanced HIV-related immunosuppression, and higher default and treatment unknown rates probably reflect the lack of attention paid by TB programme staff to this group of patients. As a result of this country-wide study the Malawi NTP has started to record routinely the treatment outcomes of smear-negative TB patients and has set treatment completion targets of 50% or higher for this group of patients.     

健康促进干预对公众和结核病患者结核病知识知晓率的影响

目的了解健康促进对提高公众和结核病患者结核病知识知晓率的效果。方法在全省173个县区中随机抽取2县，通过电视和村广播室播放结核病有关知识、粉刷墙体标语、颁发和张贴政府布告、在各级医疗机构制作宣传栏、印发宣传单／画、制作发放印有结防知识手提包等方式实施为期一年的健康促进干预。干预前后分别对两县400名群众和40例正在治疗肺结核病人进行问卷调查。结果干预前普通群众和正在接受治疗的病人相关知识知晓率分别为53．5％和71．2％，干预后两类调查对象相关知识知晓率均明显提高，分别为72．9％和83．4％。但是文盲和小学文化程度者知晓率仍较低，均低于70％；从不同职业看，农民和在校师生知晓率提高显著，机关干部知晓率无明显提高；不同干预方法对公众知晓率影响不同，电视、村级广播、墙体广告、宣传栏（板报）效果较好。结论实施健康促进干预，可明显提高公众结核病知识知晓率。     

1992～2001年全国肺结核病人登记情况分析及评价

目的:通过分析1992～2001年中国结核病人登记情况,回顾评价过往十年结核病控制工作进展。方法:回顾性分析1992～2001年卫统14肺结核病人年报表资料。结果:活动性肺结核病人登记率在十年间呈上升趋势,最低为1992年的28.72/10万,最高为2000年的40.26/10万,新涂阳登记率和涂阳登记率,在十年间均呈上升趋势,最低为1992年的7.83/10万和8.54/10万,最高为1998年的19.40/10万和20.81/10万;全国新发涂阳病人治愈率逐年上升,治愈率最低为1992年的81.02%,最高为1999年的95.63%。结论:以DOTS策略作为主要干预措施的卫V项目的实施是1992～2001年全国发现结核病人数逐步上升的主要保证;鉴于卫V项目的经验教训,在新的规划开展过程中应该重视可持续发展机制的贯彻。