TB control programme in India

The National Tuberculosis Control Program (NTP) in India has used effective ambulatory treatment since 1962, employing multidrug therapy consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol. The NTP organization consists of 390 district TB centers in charge of case detection through clinical examination, sputum and X-ray examinations, case management, as well as monitoring, reporting, and supervision. 330 clinics also belong to NTP in the urban areas, providing 47,300 beds for serious TB cases. The number of new TB cases has increased from 1.13/1000 population in 1981 to 1.80/1000 in 1991. Therefore, the NTP strategy has been revised to achieve a high cure rate (85%) and treat at least 100 sputum-positive patients per 100,000 population, thereby reducing morbidity and mortality. The estimated annual risk of infection ranges from 0.6% to 2.3%, while in rural South India the risk of infection decreased from 1% in 1961 to 0.61% in 1985. The poorly functioning control program has resulted in a large number of chronic cases and drug resistance to both rifampicin and isoniazid, with the potential of development of an incurable form of TB. At least 50% of the population above the age of 20 is infected, and the current risk of infection for India is 1.7-2%. The proportion of smear-positive cases decreased from 25% in 1980 to about 20% in the late 1980s; however, failures and partially treated patients are included in these reported figures. At the current average annual risk of infection of 1.7%, 1.6 million new TB cases occur every year, of which 710,000 are smear-positive. About 75% of cases diagnosed occur between 15 and 44 years of age, with two-thirds of them occurring among males; however, 50% of female cases occur before the age of 34 years. TB mortality is estimated at 420,000 deaths per year (i.e., 50/100,000 population). HIV seropositivity is high among TB patients: at the end of 1993 there were 331 (60%) patients with active TB among 559 AIDS cases. Operations research of the NTP is underway to improve efficiency.     

High death rates in health care workers and teachers in Malawi

High death rates are reported in health care workers (HCWs) and teachers in urban areas of Malawi. The present study was carried out to determine the annual death rate in HCWs and primary school teachers working in semi-urban and rural areas of Malawi, and to try to ascertain the main causes of death. Forty district and mission hospitals in Malawi were visited. A record was made of the number of clinical and nursing-based HCWs in each hospital in 1999, the number of deaths in that calendar year and reported causes of death. A record was also made of the number of teachers working in 4 primary schools nearest to each hospital in 1999, the number of deaths in that calendar year and reported causes of death. There were 2979 HCWs, of whom 60 (2.0%) died. There were 4367 teachers of whom 101 (2.3%) died. Annual death rates, calculated per 100,000 people, were significantly higher in male HCWs compared with female HCWs (2495 versus 1770, RR 1.17, 95% CI 1.14-1.20, P < 0.001), and significantly higher in female teachers compared with male teachers (2521 versus 1934, RR 1.14, 95% CI 1.11-1.17, P < 0.001). In male HCWs and teachers the highest death rates were in those aged 35-44 years. In female HCWs and teachers, the highest death rates were in those aged 25-34 years and 35-44 years, respectively. Reported causes of death in HCWs were tuberculosis (TB) in 47%, chronic illness in 45% and acute illness in the remainder, while in teachers the causes were TB in 27%, chronic illness in 49% and acute illness in 25%. Chronic illness, thought to be due to AIDS, and TB were the common causes of death. The current high death rates from AIDS and TB will have a crippling toll on the health and education sectors, and effective ways of reducing these death rates must be found.     

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.     

HIV seropositivity and tuberculosis in a rural Malawi hospital

This study was undertaken to determine the extent to which human immunodeficiency virus (HIV) infection has increased hospital admissions for tuberculosis (TB) in a rural population of southern Malawi. The notes and chest X-rays of TB patients admitted to Malamulo hospital in 1983 and 1984, before the recognition of acquired immune deficiency syndrome (AIDS) in Malawi, were compared with those of patients admitted in 1987 and 1988. We found a 160% increase in TB admissions between the 2 periods. Extrapulmonary TB, especially pleural TB, was much commoner in 1987-1988 and occurred in a younger age group. HIV seroreactivity was measured in a third group of 152 tuberculosis patients admitted during 1988-1989. HIV seropositivity was found in 52% of all tuberculosis admissions and in 75% of those with extrapulmonary disease. There was no difference in clinical response to TB therapy between the HIV seropositive patients and those who were seronegative. Extrapulmonary TB should be considered in all HIV seropositive patients, especially in areas where the prevalence of TB is high. Health personnel involved in TB programmes where HIV and TB infections are prevalent should plan for a large increase in the TB case load secondary to the HIV pandemic.     

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.     

HIV and tuberculosis in rural sub-Saharan Africa: a cohort study with two year follow-up.

The objective was to examine the effect of HIV seropositivity on outcomes in tuberculosis (TB) patients in a rural African setting, including rates of TB relapse, other morbid events and mortality. The study setting was a district level hospital in Mzuzu, Malawi. Adult TB patients presenting between November 1991 and May 1993 were included in the study. Treatment was given according to national guidelines. Patients with smear-positive TB received 8 months of rifampicin-containing short-course chemotherapy. Patients with smear-negative or extrapulmonary TB received 12 months of 'standard' treatment. Subjects were followed until they died or until the study concluded (December 1994). There were 225 eligible patients; 187 were tested for HIV and enrolled in the study (66.8% HIV seropositive). Ninety-four percent had complete follow-up information. The cure rate in smear-positive patients who survived to the end of treatment was over 90% and not significantly affected by HIV. Disorders of the gastrointestinal, neurological and dermatological systems were significantly more common in HIV-seropositive patients. HIV had a significant effect on the risk of relapse of TB (hazard ratio [HR] = 10.55 [95% CI 1.38, 80.93]) and on all-cause mortality (HR = 2.81 [95% CI 1.63, 4.64]). Despite high HIV prevalence, high rates of TB cure are achievable using the usual treatment protocols. However, excess TB relapse, other illnesses and mortality associated with HIV seropositivity have serious implications for TB control. There is an urgent need to identify effective intervention strategies aimed at prevention, early diagnosis and treatment of these illnesses.     

The burden and outcomes of childhood tuberculosis in Cotonou,Benin

Setting:

The National Tuberculosis Programme (NTP) and the paediatric ward of the General Hospital (GH), Cotonou, Benin.

Objective:

To describe the burden of tuberculosis (TB), characteristics and outcomes among children treated in Cotonou from 2009 to 2011.

Design:

Cross-sectional cohort study consisting of a retrospective record review of all children with TB aged <15 years.

Results:

From 2009 to 2011, 182 children with TB were diagnosed and treated (4.5% of total cases), 153 (84%) by the NTP and 29 (16%) by the GH; the latter were not notified to the NTP. The incidence rate of notified TB cases was between 8 and 13 per 100 000 population, and was higher in children aged >5 years. Of 167 children tested, 29% were HIV-positive. Treatment success was 72% overall, with success rates of 86%, 62% and 74%, respectively, among sputum smear-positive, sputum smear-negative and extra-pulmonary patients. Treatment success rates were lower in children with sputum smear-negative TB (62%) and those with HIV infection (58%).

Conclusion:

The number of children being treated for TB is low, and younger children in particular are underdiagnosed. There is a need to improve the diagnosis of childhood TB, especially among younger children, and to improve treatment outcomes among HIV-TB infected children, with better follow-up and monitoring.     

2000—2009年上海市金山区活动性肺结核流行病学分析

目的了解上海市金山区肺结核病人发病情况、分布、临床特征及治疗转归情况,为制定结核病防治策略提供依据。方法对2000—2009年金山区活动性肺结核病报告登记管理资料进行分析。结果金山区2000—2009年共新登记该区活动性肺结核病例1 808例,合计发病率为34.42/10万,其中菌阳884例,菌阳率48.89%。金山区共新登记外来流动人口活动性肺结核病例556例,其中菌阳230例,菌阳率41.37%;该区肺结核患者以60岁以上老年人为主,占38.66%,男女性别比为3.26∶1。外来流动人口以青壮年为主,19～40岁占总病例数70.14%,男女性别比为1.79∶1,患者分型以Ⅲ型为主,该区查痰率97.79%,外来流动人口查痰率95.32%。2000—2009年该区涂阳肺结核患者治愈率89.29%,涂阴患者完成疗程率92.73%;2007—2009年外来流动人口涂阳肺结核患者治愈率为67.95%,涂阴患者完成疗程率为81.51%。结论该区活动性肺结核发病率总体趋势略有下降,而菌阳发病率下降趋势不明显;外来流动人口活动性肺结核发病人数呈现上升趋势,菌阳也呈现上升趋势。加强外来流动人口结核病管理,有必要采取切实有效的措施落实外来流动人口的结核病管理。     

Rapid assessment of tuberculosis in a large prison system--Botswana, 2002

Prisons are settings in which tuberculosis (TB) transmission occurs, and TB rates in prisons are often five to 10 times higher than national rates. Data on the prevalence of TB in prisons in Africa are limited; however, studies from Malawi, Ivory Coast, and Tanzania that used active screening found TB rates > or = 10 times higher than national rates. During 1989-2001, TB rates in Botswana increased threefold, from 199 cases per 100,000 population to 620 (Botswana National TB Program, unpublished data, 2002). This increase has been associated with the human immunodeficiency virus (HIV) epidemic. In Botswana, prisoners are not screened routinely for TB. To determine the prevalence of TB and drug-resistant TB in the Botswana prison system and to improve future screening for TB among prisoners and guards, CDC, in collaboration with the Botswana Ministry of Health and the Division of Prisons and Rehabilitation, screened prisoners and guards at four prisons during April-May 2002. This report summarizes the results of the survey, which indicate a high point prevalence of TB among prisoners in Botswana of 3,797 cases per 100,000 population and support the need for improved screening.     

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.     

Local problems, local solutions: improving tuberculosis control at the district level in Malawi

OBJECTIVE: To examine the causes of a low cure rate at the district level of a tuberculosis (TB) control programme and to formulate, implement, and evaluate an intervention to improve the situation. METHODS: The study setting was Mzuzu (population 60,000), where the annual smear-positive pulmonary TB incidence was 160 per 100,000 and the human immunodeficiency virus (HIV) seroprevalence was 67% among TB patients. There is one TB treatment unit, but several other organizations are involved with TB control. An examination of case-holding activities was carried out, potential areas for improvement were identified, and interventions performed. FINDINGS: In 1990-91, the cure rate was 24% among smear-positive cases (29% among survivors to end of treatment). Problems identified included a fragmented TB control programme; inadequate training and supervision; suboptimal recording of patients' addresses; and nonadherence to national TB control programme protocols. These problems were addressed, and in 1992-93 the cure rate rose to 68% (relative risk (RR) = 2.85 (95% confidence interval (CI) = 1.63, 4.96)) and to 92% among survivors to the end of treatment (RR = 3.12 (95% CI = 1.84, 5.29)). High cure rates are therefore achievable despite high HIV prevalence. CONCLUSIONS: Simple, inexpensive, local programmatic interventions can dramatically improve TB case holding. This study demonstrates the need for evaluation, training, and supervision at all levels of the programme.     

The National Tuberculosis Programme and its implementation

India has formulated a nationally applicable, socially acceptable, and epidemiologically effective National Tuberculosis Program (NTP), which served as an example for many other countries. In the 1940s, the New Delhi Tuberculosis Center pioneered organized domiciliary treatment of TB cases; the Union Mission Tuberculosis Sanatorium, Madanapalle, had started conducting epidemiological surveys in the late 1930s; the 1954-56 national sample survey of TB is still considered a classic; and this was followed by outstanding longitudinal surveys and epidemiological studies demonstrating that BCG does not provide protection to adults against TB. Halfdan Mahler joined P.V. Benjamin in launching the National BCG Campaign in the 1950s. India demonstrated in the 1950s that home treatment of patients is as efficacious as sanatorium treatment. The National Tuberculosis Institute was set up in 1959 with the specific mandate of making TB services available to larger masses of people. Social science data were also collected to show that TB patients were seeking help from health institutions; they helped diagnose patients in remote rural areas, they proved that the TB program had to be part of the general health services, and they demonstrated the epidemiological potential of a felt-need oriented TB program. The NTP diagnosed TB cases in rural institutions by sputum examination and treated them with chemotherapy. The Tuberculosis Center at district headquarters (DTC) was responsible for providing training to health workers, keeping track of all TB cases and referring them. By 1983-84, the NTP program had been implemented in 353 districts and during that year 1,308,880 cases were treated. Nevertheless, hundreds of thousands of infectious patients are not treated because health authorities put priority on child immunization and are preoccupied with malaria and family planning. The indifference of the bureaucracy and public health leadership is to be blamed for thousands of TB deaths. The solution lies in strengthening the practice of public health.     

Moderate to severe malnutrition in patients with tuberculosis is a risk factor associated with early death

A study was conducted in new patients registered with tuberculosis (TB) in a rural district of Malawi to determine (i) the prevalence of malnutrition on admission and (ii) the association between malnutrition and early mortality (defined as death within the first 4 weeks of treatment). There were 1181 patients with TB (576 men and 605 women), whose overall rate of infection with human immunodeficiency virus (HIV) was 80%. 673 TB patients (57%) were malnourished on admission (body mass index [BMI] < 18.5 kg/m2). There were 259 patients (22%) with mild malnutrition (BMI 17.0-18.4 kg/m2), 168 (14%) with moderate malnutrition (BMI 16.0-16.9 kg/m2) and 246 (21%) with severe malnutrition (BMI < 15.9 kg/m2). 95 patients (8%) died during the first 4 weeks. Significant risk factors for early mortality included increasing degrees of malnutrition, age > 35 years, and HIV seropositivity. Among all the 1181 patients, 10.9% of the 414 patients with moderate to severe malnutrition died in the first 4 weeks compared with 6.5% of the 767 patients with normal to mild malnutrition (odds ratio 1.8, 95% confidence interval 1.1-2.7). In patients with TB, BMI < 17.0 kg/m2 is associated with an increased risk of early death.     

The impact of routine infant immunization with Haemophilus influenzae type b conjugate vaccine in Malawi, a country with high human immunodeficiency virus prevalence

Malawi has extreme poverty and a high-human immunodeficiency virus (HIV) prevalence. Following Haemophilus influenzae type b (Hib) conjugate vaccine introduction during 2002, we evaluated vaccine impact by reviewing hospital surveillance data for acute bacterial meningitis in Blantyre district among children age 1-59 months admitted during 1997-2005. Documented annual Hib meningitis incidence rates decreased from 20-40/100,000 to near zero among both rural and urban residents despite no change in pneumococcal meningitis incidence rates. Before vaccine introduction, an average of 10 children/year had Hib meningitis and HIV infection compared to 2/year during 2003-2004 and none during 2005. Vaccine effectiveness was high following two or more doses of vaccine. The most urgent future need is for a sustainable routine infant immunization program, including a less expensive vaccine that preferably is delivered in a multivalent form.     

Sexually transmitted infections among prison inmates in a rural district of Malawi

As part of a comprehensive human immunodeficiency virus (HIV) prevention strategy targeting high-risk groups, sexually transmitted infection (STI) clinics are offered to all prisoners in Thyolo district, southern Malawi. Prison inmates are not, however, allowed access to condoms as it is felt that such an intervention might encourage homosexuality which is illegal in Malawi. A study was conducted between January 2000 and December 2001 in order to determine the prevalence, incidence, and patterns of STIs among male inmates of 2 prisons in this rural district. A total of 4229 inmates were entered into the study during a 2-year period. Of these, 178 (4.2%) were diagnosed with an STI. This included 83 (46%) inmates with urethral discharge, 60 (34%) with genital ulcer disease (GUD), and 35 (20%) inmates with epididymo-orchitis. Fifty (28%) STIs were considered incident cases acquired within the prisons (incidence risk 12 cases/1000 inmates/year). GUD was the most common STI in this group comprising 52% of all STI. This study shows that a considerable proportion of STIs among inmates are acquired within prison. In a setting of same-sex inmates, this suggests inter-prisoner same-sex sexual activity. The findings have implications for HIV transmission and might help in developing more rational policies on STI control and condom access within Malawi prisons.     

Tuberculosis: a snap shot picture

In India almost 40% of the population is infected with tuberculosis (TB); 0.4% are sputum-positive infectious cases, 2-2.5 million new cases occur annually, and mortality amounts to 50/100,000 population. The National Tuberculosis Program (NTP) and its District TB Program (DTP) aim to detect all TB cases and treat them effectively as part of the general health services, to vaccinate most children with bacillus Calmette-Guerin, to manage planning and implementation, and to carry out proper recording and reporting of cases. Health education is also carried out in order to enlighten the community, patients, children, students, and medical personnel on various aspects of TB using booklets, pamphlets, TV, and newspaper advertisements. Among resources rendering anti-TB services are 390 district TB centers, 17,850 rural health centers, 330 other clinics, and 17 TB demonstration and training centers; there are approximately 47,000 beds available. International assistance has been obtained from the Swedish International Development Agency, who has supplied X-ray units, anti-TB drugs, and vehicles, since 1979. The World Health Organization (WHO) has assisted by providing consultants, fellowships, and equipment for the National TB Institute in Bangalore and the TB Research Center in Madras. These are also helped by WHO to conduct short courses and training courses for health administrators and college teachers. Some of the problems the NTP faces include: completion of implementation of the DTP in 80 districts and in 25% of peripheral health institutions; nonavailability of trained personnel and vehicles in DTP clinics; overburdened laboratory technicians in 25-30% of primary health care; lack of adequate quantities of drugs, material, and equipment for TB treatment; and lack or shortage of beds. The trends of TB demonstrate that cases tend to concentrate in higher age groups; prevalence in younger people and in newborn children is low and on the decline; and there is a shift from the acute type to the chronic fibrotic type.     

TB and AIDS

The Indian National Tuberculosis Survey has indicated that 10 million persons above 5 years of age have pulmonary tuberculosis (TB), of whom 2.5 million are infectious. The annual infection rate amounts to 1.5%. In an average district with a population of 1.5 million, there are about 500 active, infectious TB cases and about 20,000 radiologically active cases. The World Health Organization has declared TB a global health emergency. The pandemic of AIDS had infected 13 million people worldwide by early 1993, and by the year 2000 over 40 million will be infected. In May 1986 only 1 AIDS case was reported, but by May 31, 1994, 728 cases of AIDS and 15,325 cases of HIV infections were reported. At the present rate of infection, there will be 5 million people infected with HIV by 2000 in India. HIV infection is the greatest risk factor for developing TB because of the multiplication of tubercle bacilli in quiescent foci, the progression of dormant infection to disease, and superinfection. The incidence of TB has doubled in the course of 5 years in some countries where HIV is epidemic. 30-70% of TB patients in these countries are estimated to be HIV-positive, imposing significant burden on national health services. On the other hand, efficient health services can still cure TB in HIV-positive patients and forestall the spread of the diseases. One-third of the world's population is infected with TB, and the lives of these people are shortened if they contract HIV. Worse still, for HIV-infected people exposure to TB means death, often within weeks. The only protection against the airborne TB germ is the complete cure of TB patients. At a 1993 conference in London several TB control measures were suggested: national TB control programs offering affordable treatment; faster diagnosis; education and incentives to increase patient compliance; proper drug supplies and quality control; education of influential people; and fight against poverty.     

Tuberculosis notifications in Australia, 2001.

In 2001, there were 997 cases of tuberculosis (TB) reported to the National Notifiable Diseases Surveillance System, of which, 967 were new cases of TB and 30 cases were relapses. The incidence rate of TB in Australia in 2001 was 5.1 cases per 100,000 population. The highest incidence of TB was reported in people born overseas (19.3 cases per 100,000 population), followed by Indigenous Australians (9.8 cases per 100,000 population). In contrast, the incidence rate of TB in the non-Indigenous Australian-born population was 1.0 cases per 100,000 population. This pattern of TB incidence rates amongst the sub-populations of Australia has been observed for over 10 years. Eighty-six per cent of TB cases completed treatment in 2001. Treatment was unsuccessful in 7 cases and only 22 cases defaulted. The National Tuberculosis Advisory Committee has published a National Strategic Plan with performance indicators to ensure that this enviable record of TB control is maintained and improved.     

Tuberculosis notifications in Australia, 2002.

In 2002, there were 1,028 cases of tuberculosis (TB) reported to the National Notifiable Disease Surveillance System, of which 997 were new cases, 30 were relapses and 1 unknown. The incidence rate of TB in Australia in 2002 was 5.2 cases per 100,000 population. The highest incidence of TB was reported in people born overseas (20.2 cases per 100,000 population), followed by Indigenous Australians (8.5 cases per 100,000 population). By contrast, the incidence rate of TB in the nonIndigenous Australian-born population was 1.1 cases per 100,000 population. This pattern of TB incidence rates amongst the sub-populations of Australia has been observed for over 10 years. The rates were evaluated against the performance indicators set by the National Tuberculosis Advisory Committee to ensure that Australia's record of TB control is maintained and improved.