Completeness and timeliness of treatment initiation after laboratory diagnosis of tuberculosis in Gaborone, Botswana.

SETTING: Gaborone, the capital of Botswana. OBJECTIVE: To determine the time from positive sputum smear microscopy for acid-fast bacilli (AFB) to initiation of therapy, and to identify risk factors for delays. DESIGN: Retrospective cohort study of medical records and surveillance data for patients with positive smear microscopy and newly diagnosed tuberculosis (TB) from January to May 1997. Treatment delay was defined as more than 2 weeks from the first positive sputum smear to the initiation of TB treatment. RESULTS: Of 127 patients identified, 15 (11.8%) had treatment delay, 13 (10.2%) had an incomplete workup (only one smear performed) and were not registered for TB treatment, and six (4.5%) had two or more positive smears but were not registered for TB treatment. Risk factors for treatment delay or non-registration included TB patients who had been diagnosed in a hospital outpatient setting vs. a clinic (RR 2.9, 95% CI 1.2-3.6, P = 0.02), or in a high volume vs. low volume clinic (RR 2.2, 95% CI 1.2-5.3, P = 0.01). CONCLUSION: More than a quarter of the smear-positive TB patients identified had treatment delay or no evidence of treatment initiation. Proper monitoring of laboratory sputum results and suspect TB patient registers could potentially reduce treatment delays and patient loss.     

Pathology and causes of death in a group of 128 predominantly HIV-positive patients in Botswana, 1997-1998.

BACKGROUND: Little is known about causes of death in countries of southern Africa seriously affected by the HIV/AIDS epidemic. METHODS: After obtaining informed consent, autopsies were performed on 128 mainly hospitalised adults in Francistown, Botswana, between July 1997 and June 1998. Criteria for case selection included those who died before a diagnosis could be established, those whose condition deteriorated unexpectedly during hospitalization, and those who had respiratory disease. This represented 14% of adult medical patients who died in hospital during the study period. RESULTS: Of the 128 patients, 104 (81%) were HIV-positive. Among HIV-positive patients, the most common pathologic findings were tuberculosis (TB) (40%), bacterial pneumonia (23%), Pneumocystis carinii pneumonia (11%), and Kaposi's sarcoma (11%); these conditions were the cause of death in 38%, 14%, 11%, and 6%, respectively. Of the 40 pulmonary TB cases, 90% also had disseminated extra-pulmonary TB. Chest radiology could not reliably distinguish the pathologies pre-mortem. CONCLUSIONS: TB was the leading cause of death in our series of HIV-positive adults in Botswana, selected towards those with chest disease; in most, it was widely disseminated. Bacterial pneumonia also played an important role in mortality. Pneumocystis carinii pneumonia was present, but relatively uncommon.     

The significance of the persistent presence of acid-fast bacilli in sputum smears in pulmonary tuberculosis.

STUDY OBJECTIVES: Identification of acid-fast bacilli (AFB) in the sputum smear at the completion of tuberculosis therapy is in some settings considered evidence of treatment failure. However, some patients with pulmonary tuberculosis (TB) will have positive smear results with negative sputum culture results at the end of therapy. The objectives of this study were to estimate the prevalence of persisting positive sputum smear results in patients with TB and to identify characteristics that distinguish patients with persistently positive sputum smear results who also had negative sputum culture results from patients identified as treatment failures. DESIGN: A population-based, historical cohort study with nested case control study. SETTING: British Columbia Division of Tuberculosis Control central case registry. PATIENTS: All 428 patients with culture-proven pulmonary TB in British Columbia over 7 years with sputum that was positive for AFB. METHODS: Review of laboratory data of all 428 patients, as well as clinical data of a subset of 30 patients with persistently positive smear results beyond 20 weeks. RESULTS: Sputum smears were positive for AFB in 205 patients (48%) at 4 weeks, in 30 patients (7%) at 20 weeks, and in 12 patients (3%) at 36 weeks. Of the patients with smear results that were persistently positive at 20 weeks, 23 (77%) had negative sputum culture results and 7 (23%) had positive sputum culture results (ie, they were treatment failures). Patients identified as treatment failures had more localized disease as shown on chest radiographs, had less radiographic improvement at follow-up, had a higher prevalence of drug resistance, and were less compliant with medications than patients with persistently positive smear results and negative culture results. No subject with a negative culture result relapsed over the 6- to 48-month observation period. CONCLUSION: Sputum that is persistently positive for AFB in patients in developed countries is more likely to be associated with negative culture results than with treatment failure.     

The diagnosis of smear-negative pulmonary tuberculosis: the practice of sputum smear examination in Malawi.

SETTING: Forty hospitals in Malawi (3 central, 22 district and 15 mission) performing smear microscopy and registering tuberculosis patients. OBJECTIVE: To determine, in patients aged 15 years or above, 1) the proportion with smear-negative pulmonary tuberculosis (PTB) who had sputum smears examined, 2) the number of sputum smears examined per patient, and 3) the proportion of patients registered with smear-positive and smear-negative PTB. DESIGN: Data collection during three 6-month periods, from January 1997 to June 1998, using tuberculosis registers, laboratory sputum registers and quarterly reports. RESULTS: Of 6301 smear-negative PTB patients, 84% had sputum smears examined, the rate increasing from 76% in January-June 1997, to 85% in July-December 1997, to 89% in January-June 1998. Of patients who submitted sputum (where the number of smears was recorded), 99% had two or more smears examined and 93% had three smears examined. In district and mission hospitals performance improved over time, while in central hospitals results were more variable. During the same 18-month period 21 422 patients aged 15 years or more were registered with PTB: 59% with smear-positive PTB and 41% with smear-negative PTB; this pattern was similar in each 6-month period. CONCLUSION: The study suggests that it is reasonable to aim for a target of 90% or more of smear-negative PTB patients having sputum smears examined.     

Value of smear and PCR in bronchoalveolar lavage fluid in culture positive pulmonary tuberculosis.

At present, further investigations are needed in patients with suspected pulmonary tuberculosis (TB) and either negative sputum smear or without sputum. The aim of the present study was to analyse the yield of bronchoalveolar lavage fluid (BALF) smear and PCR in patients with confirmed pulmonary TB. Patients with a positive culture for Mycobacterium tuberculosis complex in sputum or BALF were analysed over 5 yrs. In total, 90 out of 230 (39%) patients with culture-positive pulmonary TB had a positive sputum smear, and 120 patients underwent bronchoscopy. BALF smear was positive in 56 (47%), BALF PCR in 93 (78%) patients, and BALF smear and/or PCR was positive in 83%. In total, 71 patients who underwent bronchoscopy and had complete clinical records were further analysed. BALF (smear or Mycobacterium tuberculosis complex-PCR) allowed a rapid diagnosis in 10 (59%) out of 17 patients who had a negative sputum smear, and 49 (91%) out of 54 patients without sputum production. Of these 71 patients, 12 (17%) were only culture positive. Rapid diagnosis of pulmonary TB by smear and/or PCR was made in 190 out of 210 patients (90%) in sputum or BALF. In conclusion, combined use of bronchoalveolar lavage fluid smear and Mycobacterium tuberculosis complex-PCR has a good diagnostic yield in patients with sputum smear-negative tuberculosis or without sputum production.     

Combined bronchoalveolar lavage and polymerase chain reaction in the diagnosis of pulmonary tuberculosis in smear-negative patients.

SETTING: The polymerase chain reaction (PCR) may be sensitive and specific for the diagnosis of tuberculosis, but most reports are of studies conducted in well-controlled laboratories. A study to evaluate the clinical value of bronchoalveolar lavage (BAL) combined with PCR was necessary. OBJECTIVE: One hundred and thirty one patients were recruited into the study from March 1994 to February 1997. DESIGN: Patients with a positive acid-fast stain on sputum smear were recruited into group A as positive controls, patients with lung cancer and a negative acid-fast stain on sputum smear were put into group B as negative controls, and patients who had clinical symptoms of pulmonary TB without sputum or with negative smear results were the investigating group. PCR was performed on the sputum samples from group A and B patients and on the BAL fluid from those in group C. RESULTS: The sensitivity of PCR was 96% in group A, and the specificity was 100% in group B. The sensitivity of PCR in the BAL fluid from the group C patients was 36% and the specificity was 96%; the positive predictive value was 94% and the negative predictive value was 45%. CONCLUSION: BAL plus PCR is useful in the rapid diagnosis of pulmonary TB in non-productive or smear-negative patients.     

Tuberculosis annual report 2009 --series 10. Treatment outcome and TB deaths

Evaluation of the treatment outcome by the cohort analysis method is an important part of tuberculosis (TB) control. In the Japanese TB surveillance system, the treatment outcome is automatically classified by computer according to a pre-set algorithm, so the treatment outcome is evaluated very rigidly. In the case of new sputum smear positive pulmonary TB cases (n = 8,999) newly notified in 2008, the patients' treatment outcomes based on the annual report 2009 database were as follows: "success," which combined "cured" and "completed," was 47.7%, "died" was 19.1%, "failed" was 1.1%, "defaulted" was 3.8%, "transferred out" was 2.8%, "on treatment after 12 months" was 11.8% and "not evaluated" was 13.6%. In addition to evaluation of the treatment outcome by the cohort method, the proportion of deaths was observed among all forms of TB patients (n = 24,571) who were newly registered in 2008. In total, 17.3% of all forms of TB cases died within one year after the beginning of treatment. The proportion corresponding to this was 23.7% for new sputum smear positive pulmonary TB and 23.5% for re-treatment sputum smear positive pulmonary TB. Among the new sputum smear positive pulmonary TB patients (n = 2,136) who died within one year after the beginning of treatment, 37.0% of them died within one month after the beginning of treatment, 51.6% died within two months and 61.9% died within three months.     

Screening tuberculosis suspects using two sputum smears.

SETTING: Ntcheu district hospital, Malawi. OBJECTIVE: To assess a screening strategy for tuberculosis (TB) suspects using two sputum smears. DESIGN: A strategy of screening all TB suspects with two sputum smears for 6 months (1 July-31 December 1998) was compared with the period 1 January to 30 June 1998 during which the strategy of screening TB suspects with three sputum smears was in use. All chest radiographs of patients with negative sputum smears were assessed, and in those with pulmonary cavities and extensive disease a third sputum smear was examined. Data were collected from the laboratory sputum register and the TB register. The two 6-month periods were compared. RESULTS: In the laboratory register, using a two-sputum strategy, 186 (16%) of 1152 TB suspects were smear-positive, a result that was no different than when the three-sputum strategy was used, where 173 (16%) of 1106 TB suspects were smear-positive. The clinical pattern of TB using the different screening strategies was similar, with 58% of registered patients smear-positive with the two-sputum strategy and 54% smear-positive with the three-sputum strategy. In the first 6 months 3177 sputum smears were examined compared to 2266 smears in the second 6 months, a 29% reduction in the number of smears examined. The cost of consumables using the strategy of three sputum smears was USD $731 compared with USD $521 using the strategy of two sputum smears. C O N C L U S I O N S: Screening TB suspects using two sputum smears is as effective as screening using three sputum smears, and is associated with less laboratory work and savings in costs.     

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.     

Response to empirical anti-tuberculosis treatment in patients with sputum smear-negative presumptive pulmonary tuberculosis

BACKGROUND: In many cases, physicians initiate anti-tuberculosis (TB) treatment based only on symptoms or radiographic findings without confirmation of pulmonary TB by acid-fast bacilli (AFB) smear. It has not been well known which clinical characteristics could be used as predictors for positive culture or real TB in patients with sputum smear-negative presumptive pulmonary TB. OBJECTIVE: We tried to elucidate treatment outcomes in patients with sputum smear-negative presumptive pulmonary TB and to find predictors of positive culture results. METHODS: We reviewed data of the patients who had been treated as presumptive TB with negative AFB smear on the basis of clinical and radiographic features from December 1998 to December 2000 at a university hospital in Korea. We reviewed medical records and radiographs of patients and analyzed possible predictors for positive culture. RESULTS: One hundred and one patients were enrolled. Among them, pulmonary TB was confirmed by culture in 32 patients (31%). Thirty-one (96.9%) out of 32 culture-positive patients showed clinical or radiographic improvement as did 50 (72.5%) out of 69 culture-negative patients. The predictor for a positive culture result is the presence of patchy consolidation in an initial radiograph (p = 0.025; OR 2.89; 95% CI 1.14-7.28). CONCLUSIONS: The empirical anti-TB treatment in patients with sputum smear-negative presumptive pulmonary TB was effective and adequate, especially presented with patchy consolidation in initial chest radiographs in Korea.     

Identifying pulmonary tuberculosis in patients with negative sputum smear results

BACKGROUND: Clinicians need to decide whether to begin empiric therapy for patients who are suspected of having tuberculosis (TB) but have negative sputum smear results. Culture results may take weeks, and delaying treatment may allow further transmission of disease. Study objective: To identify the clinical, demographic, and radiographic characteristics that identify smear-negative patients who have TB, and to create a TB prediction rule. DESIGN: Retrospective chart review. SETTING: University-affiliated public hospital in San Francisco, CA, between 1993 and 1998. PATIENTS: Forty-seven patients with TB and 141 control patients who were hospitalized with a suspicion of pulmonary TB; all had negative sputum smear results. Measurements and results: Demographic, clinical, and radiographic variables were determined by chart review. In multivariate analysis, a positive tuberculin skin test result (odds ratio [OR], 4.8; 95% confidence interval [CI], 2.0 to 11.9) was independently associated with an increased risk of a positive TB culture finding. A radiographic pattern not typical of pulmonary tuberculosis (OR, 0.3; 95% CI, 0.1 to 0.7) and expectoration with cough (OR, 0.3; 95% CI, 0.1 to 0.6) were predictive of a decreased risk. An interaction between HIV seropositivity and mediastinal lymphadenopathy on the chest radiograph was also associated with a positive TB culture result (OR, 7.2; 95% CI, 1.4 to 36.0). The TB prediction score (TPS) was created with widely ranging likelihood ratios that could affect the posterior probability of TB by 30-fold. CONCLUSION: The TPS put into context with the overall prevalence of TB in a given area may help clinicians decide if a patient with negative sputum smear results should start empiric antituberculous therapy or wait for culture results. These results need prospective validation.     

新疆维吾尔自治区综合医疗机构痰检质控工作评价

目的分析新疆维吾尔自治区综合医疗机构痰检质控工作情况,探讨提高痰检质量的有效措施。方法根据自治区疾病预防控制中心结核病控制中心对全区综合医疗机构的督导记录和痰涂片复检质控结果、进行综合分析和评价。结果2007年53家基层综合医疗机构,共登记可疑肺结核症状者21313例,查痰6989例发现涂阳肺结核403例,涂阳检出率5.8％。未查痰病人转至结防机构查痰5972例,发现涂阳肺结核2030例,涂阳检出率34.0％。涂阴病人转至结防机构再查痰3940例,涂阳肺结核893例,涂阳检出率22.7％。结防机构查痰29048例,涂阳9896例,涂阳检出率34.1％,与综合医疗机构比较差异有统计学意义（P<0.05）。结论加强综合医疗机构与结防机构的合作。对综合医疗机构痰涂片检查人员进行业务培训及复训,提高痰检质控质量,保证检出率,以达到提高涂阳病例发现的目的。     

Detection of pulmonary tuberculosis in patients with a normal chest radiograph

OBJECTIVES: To describe the early symptoms of pulmonary tuberculosis (TB) when the chest radiograph (CXR) is normal. SETTING: Centralized, provincial TB control program. SUBJECTS: Twenty-five patients with culture-positive pulmonary TB and a normal CXR were identified from a review of 518 consecutive patients with culture-positive pulmonary TB in the province of Saskatchewan from January 1, 1988 to March 31, 1997. Patients with abnormal CXRs at the time of diagnosis were excluded from the analysis. RESULTS: Twenty-three of the 25 patients (92%) were symptomatic at the time of diagnosis, with cough/sputum (76%) being reported most commonly. Eleven patients were identified because of contact tracing from cases of infectious pulmonary TB, while the other 14 patients were identified because of an investigation of symptoms. Twenty-four patients (96%) exhibited one or more symptoms of cough for > 1 month, fever for > 1 week, or skin-test conversion after contact with infectious TB. The sputum smear of only one patient was positive. Two patients were pregnant at the time of diagnosis, one patient was HIV-positive, and one patient demonstrated isoniazid-resistant organisms on sensitivity testing. Five patients were diagnosed as having primary TB associated with Mantoux skin-test conversion. The incidence of culture-positive pulmonary TB with a normal chest radiograph was < 1% in the period from 1988 to 1989 and steadily increased to 10% in the period from 1996 to 1997. CONCLUSIONS: Culture-positive pulmonary TB with a normal CXR is not uncommon, and the incidence of this presentation is increasing. Patients with this presentation of TB are typically symptomatic and/or are detected by contact tracing to infectious cases of pulmonary TB. The results suggest that patients presenting with a cough for > 1 month, with a fever for > 1 week, or with documented skin-test conversion < 2 years after known exposure to infectious TB should have sputum submitted for a Mycobacterium tuberculosis smear and culture despite a normal CXR.     

Sputum smear-positive tuberculosis: empiric evidence challenges the need for confirmatory smears.

OBJECTIVE: To determine the frequency of single scanty or positive sputum smear results and its impact on the surveillance definition of sputum smear-positive tuberculosis (TB). SETTING: Moldova, Mongolia, Uganda and Zimbabwe. METHODS: A representative sample of laboratories was selected in each country. Data were double-entered and discordances resolved by rechecking the register. RESULTS: The dataset comprised 128808 examinees with valid information from 23 laboratories in Moldova, all 31 in Mongolia, 30 in Uganda and 23 in Zimbabwe, each covering at least one calendar year. The reason for the examination was diagnostic for 89362, of which 15.2% (n = 13577) were defined as laboratory cases with at least one bacillus on at least one examination. Cases were confirmed by another examination in 72.6% (n = 9861). Of the 9014 cases who had a full set of three examinations, confirmation was obtained in 92.4% (n = 8325). CONCLUSION: One quarter of laboratory cases had no confirmatory result, almost entirely attributable to not examining another specimen. The current definition of sputum smear-positive TB requires two positive smears or one positive smear result plus more complex confirmatory evidence. Accepting a single positive examination as sufficient for the definition would greatly increase the sensitivity of the surveillance definition without sacrificing its specificity.     

Female-male differences at various clinical steps of tuberculosis management in rural Bangladesh

A registry data-based study of 3,600 patients systematically drawn from out-patient clinic, laboratory and tuberculosis (TB) treatment registers (1200 from each) examined female-male differences at various clinical steps of TB management and compared selective indicators with published results. Female-to-male ratios (FMR) declined at the following clinical steps: respiratory patients seeking out-patient care (0.81), TB suspects submitting sputum for testing (0.52) and smear-positive test results (0.38), but the decline ceased at treatment initiation (0.41). Compared to 1997, the FMR in 2000 had decreased for out-patient clinics and sputum submission for testing, but had increased for smear-positive test results and treatment initiation. More female than male patients who underwent treatment achieved cure (93% vs. 89%). Lower female representation at the different clinical steps of TB management persists.     

Impact of sputum gross appearance and volume on smear positivity of pulmonary tuberculosis: a prospective cohort study

ABSTRACT: BACKGROUND: Although checking specimen quality upon sputum collection for acid-fast smear of suspected tuberculosis (TB) cases is recommended, this procedure is based on expert opinion. The purpose of this study was to elucidate the impact of sputum gross appearance and volume on smear positivity among patients with suspected pulmonary TB, according to sex. METHODS: From November 2010 through June 2011, we enrolled consecutive patients suspected to have active pulmonary TB. The association of sputum gross appearance and volume with smear positivity, along with other variables possibly affecting smear positivity such as symptoms, disease extent, and cavity on chest radiograph, were investigated. RESULTS: Among 2,439 patients undergoing TB examination, 170 (113 men, 57 women) with active pulmonary TB were enrolled in the final analysis. They submitted 492 sputa. There were 73 smear-positive patients (42.9%) and 164 smear-positive sputa (33.3%). While gross appearance was associated with smear positivity in both sexes (purulent or blood-tinged sputum (rather than mucoid sputum or saliva); odds ratio (OR), 2.05, 95% confidence interval (CI), 1.21-3.47 in men; OR, 2.78, 95% CI, 1.23-6.26 in women), the amount of sputum specimens was associated with smear positivity in only female patients (4 ml or more versus less than 4 ml; OR, 4.96, 95% CI, 1.98-12.37). CONCLUSIONS: Sputum gross appearance and volume were associated with smear positivity. A volume of 4 ml seems to be the the minimum sputum volume acceptable for smear microscopy in females suspected of TB. Those suspected of TB should be encouraged to expectorate grossly qualified sputum specimens.     

Number of negative acid-fast smears needed to adequately assess infectivity of patients with pulmonary tuberculosis

STUDY OBJECTIVES: To investigate the relationship between the number of negative acid-fast bacilli (AFB) smear results and infectivity of pulmonary tuberculosis (TB). DESIGN: Retrospective analysis. METHODS AND SUBJECTS: We examined 122 index cases in Harris County, TX, reported in 1998 and 1999. All cases had only negative AFB smear results during the infectious period and were categorized in two groups: group A consisted of cases with only one or two sputum specimens collected and processed, and group B consisted of cases with at least three sputum specimens or at least one bronchoscopic specimen. Tuberculin skin test (TST) results of contacts were ascertained from the results of contact investigations performed by the City of Houston Department of Health and Human Services, Tuberculosis Control Division. Univariate and multivariate analyses were done to explore index case and contact attributes associated with tuberculosis (TB) transmission using positive TST results of contacts as a measure of recent transmission. RESULTS: We found male gender and younger age of index cases along with Hispanic ethnicity of contacts to be independently associated with positive TST results, while younger contacts were less likely to be TST positive. Smear category of the index case (group A vs group B) was not independently associated with transmission. We also found that the first two sputum specimens in cases where three or more were performed yielded 90% of all positive culture results for Mycobacterium tuberculosis (MTB). CONCLUSIONS: We conclude that two sputum specimens negative for AFB stain are adequate for both assessing infectivity and for isolating MTB from patients with pulmonary TB.     

What causes smear-negative pulmonary tuberculosis in Malawi, an area of high HIV seroprevalence?

SETTING: The Central Hospital and the District Tuberculosis (TB) Registry in Lilongwe, the capital of Malawi. In this setting smear-negative pulmonary tuberculosis (PTB) is diagnosed using clinical and radiographic criteria for TB, and mycobacterial cultures are not routinely available. OBJECTIVE: To determine the proportion of patients being registered for smear-negative PTB treatment in Lilongwe who have TB that can be confirmed microbiologically. DESIGN: Prospective cohort study of patients about to start treatment under operational conditions for smear-negative PTB in Lilongwe between October 1997 and June 1998. Patients referred to the study team underwent a detailed clinical re-assessment, testing for human immunodeficiency virus (HIV), repeat sputum smear microscopy for acid-fast bacilli and mycobacterial cultures of sputum and blood. Bronchoscopy and bronchoalveolar lavage (BAL) were performed and BAL fluid was examined for TB, Pneumocystis carinii and other fungi. RESULTS: Of 352 smear-negative PTB suspects assessed, the diagnosis of TB was confirmed in 137 (39%) cases. Eighty-nine per cent of patients assessed were HIV-positive, of whom 81% met the expanded case definition for the acquired immune-deficiency syndrome (AIDS). CONCLUSION: TB was the most commonly confirmed diagnosis amongst patients about to start treatment for smear-negative PTB in an area of high background HIV seroprevalence.     

短程化疗结束后痰菌阴性肺结核患者复发情况随访观察

目的：评价WHO西太区结核病控制示范区项目（江苏）的控制效果，分析患的有关复发因素。方法：对西太区项目发现、登记的涂阳肺结核患，在治愈后的2－3年进行痰结核分支杆菌厚涂片检查，观察细菌学复发情况；对涂阳患治疗前的排菌情况和痰菌转阴时间与复发的关系，进行历史性队列研究。结果：随访观察的1730例治毹涂阳肺结核患，经痰涂片检查，痰菌复阳57例，复发率为3．29％。治疗后第2个月、第3个月和大于3个月转阴的初治涂阳患复发率分别是2．1％、5．3％和8．8％（P＜0．01）。治疗前不同排菌量患的复发率有一定差异，但差异无显性（P＞0．05）。结论：WHO西太区结核病控制示范区项目（江苏）的远期治疗效果是满意的。治疗后第3个月及大于3个月开始痰菌转阴的初治涂阳患复发率明显高于第2个月转阴的患。     

Predictors of delayed sputum smear conversion among pulmonary tuberculosis patients in Kota Kinabalu,Malaysia: A retrospective cohort study

Smear-positive pulmonary tuberculosis (SPPTB) is the major contributor to the spread of tuberculosis (TB) infection, and it creates high morbidity and mortality worldwide. The objective of this study was to determine the predictors of delayed sputum smear conversion at the end of the intensive phase of TB treatment in Kota Kinabalu, Malaysia.This retrospective study was conducted utilising data of SPPTB patients treated in 5 TB treatment centres located in Kota Kinabalu, Malaysia from 2013 to 2018. Pulmonary TB (PTB) patients included in the study were those who had at least completed the intensive phase of anti-TB treatment with sputum smear results at the end of the 2nd month of treatment. The factors associated with delayed sputum smear conversion were analyzed using multiple logistic regression analysis. Predictors of sputum smear conversion at the end of intensive phase were evaluated.A total of 2641 patients from the 2013 to 2018 periods were included in this study. One hundred eighty nine (7.2%) patients were identified as having delayed sputum smear conversion at the end of the intensive phase treatment. Factors of moderate (advanced odd ratio [aOR]: 1.7) and advanced (aOR: 2.7) chest X-ray findings at diagnosis, age range of >60 (aOR: 2.1), year of enrolment 2016 (aOR: 2.8), 2017 (aOR: 3.9), and 2018 (aOR: 2.8), smokers (aOR: 1.5), no directly observed treatment short-course (DOTS) supervisor (aOR: 6.9), non-Malaysian citizens (aOR: 1.5), and suburban home locations (aOR: 1.6) were associated with delayed sputum smear conversion at the end of the intensive phase of the treatment.To improve sputum smear conversion success rate, the early detection of PTB cases has to be fine-tuned so as to reduce late or severe case presentation during diagnosis. Efforts must also be in place to encourage PTB patients to quit smoking. The percentage of patients assigned with DOTS supervisors should be increased while at the same time ensuring that vulnerable groups such as those residing in suburban localities, the elderly and migrant TB patients are provided with proper follow-up treatment and management.