Prevalence of smear-positive pulmonary tuberculosis in a rural district of Ethiopia.

SETTING: A rural district in Southern Ethiopia. OBJECTIVE: To estimate the prevalence of smear-positive pulmonary tuberculosis (TB). DESIGN: In this cross-sectional study, adults aged >14 years were surveyed by home-to-home visit, and asked about cough of > or = 2 weeks with or without sputum, chest pain or difficulty in breathing. Symptomatic suspects submitted three sputum samples for standard smear microscopy. RESULTS: Of 16697 adults surveyed, 436 (2.6%) were symptomatic and submitted sputum samples. Thirteen (3%) were positive for acid-fast bacilli, and the prevalence of smear-positive TB was 78 per 100 000 population (95%CI 36-120). Twenty-four smear-positive cases identified through the existing health care delivery were on anti-tuberculosis medication at the time of the survey. The ratio of smear-positive cases on treatment to those newly detected by the survey was 2:1. CONCLUSION: The prevalence of TB in this rural setting was unexpectedly low. For every two cases of smear-positive TB on treatment, there was one undetected infectious case in the community. However, as our screening technique did not allow detection of cases who did not report symptoms, the true prevalence may have been underestimated.     

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.     

Increasing TB case detection through intensive referral of TB suspects by village doctors to county TB dispensaries.

OBJECTIVE: To explore new approaches to increase the detection of tuberculosis cases (TB). DESIGN: Thirty counties participated in the study. Patients with TB symptoms were surveyed and referred by trained village doctors to county dispensaries, designated township health centres or general hospitals for free sputum examination. TB patients and suspects notified by general hospitals were traced by TB staff if they defaulted during the transfer. RESULTS: A total of 12,091 new smear-positive TB cases were detected. The registration rate of new smear-positives increased from 36.2 per 100,000 population before the project to 49.9/100,000 after the project, and the case detection rate under the DOTS strategy reached 86%. Of 43,464 registered TB suspects, 15,363 (35.3%) were referred by village and hospital doctors. The referral rate increased significantly (P < 0.01). Of the 15,363 referred patients, 3870 were diagnosed as new smear-positive TB cases. Among three different microscopy centres, there was a statistically significant difference in the sputum examination rates of TB suspects and in the smear-positive rates among the suspects examined. The follow-up rate was 70.9%, but the follow-up success rate was only 33.1%. CONCLUSIONS: Intensive referral of patients with TB symptoms by village doctors to TB dispensaries is an effective way of increasing detection. At the same time, incentives are necessary for patients and village doctors.     

Effectiveness of urban community volunteers in directly observed treatment of tuberculosis patients: a field report from Haryana, North India.

A tuberculosis (TB) unit covering a population of 600000 in Gurgaon District of Haryana State, India, where the DOTS-based RNTCP has been implemented since April 2000. Treatment success rate, as recorded in the TB register, of new sputum smear-positive patients receiving directly observed treatment (DOT) from community volunteers was comparable with that of patients receiving DOT from government health workers (78% vs. 77%). The proportion of patients with community volunteers increased significantly with time (13% in 2000 to 25% in 2002), even in the absence of financial incentives. In this model of community volunteer involvement in an urban TB control programme, the primary responsibility for returning late patients to treatment was with the staff of the District TB Centre.     

Evaluation of sputum smear microscopy in the National Tuberculosis Control Programme in the north of Vietnam.

OBJECTIVE: To assess the yield of sputum smear microscopy and sex differences in the National Tuberculosis Control Programme in the north of Vietnam. METHODS: Review of registers of 30 randomly selected laboratories (26 district, 4 provincial level). RESULTS: The average daily workload per technician was 4.4 examinations in district and 5.3 examinations in provincial laboratories. To find one smear-positive case, 9.7 suspects were examined and 29.3 smears done. The smear-positive rate (mean 10.3%) was higher among men (11.6%) than among women (8.4%, P < 0.001). There were more men than women among tuberculosis (TB) suspects (male:female ratio 1.36, 95%CI 1.19-1.54), but even more so among smear-positive patients (1.89, 95%CI 1.64-2.14), irrespective of specimen quality and number of smears examined. Three smears were examined for 18,055 suspects (61.7%). The incremental gain was 33.5% and 4.9% for the second and third smear examination, respectively; 186 (95%CI 160-221) smears needed to be examined to find one additional case of TB with a third serial examination. CONCLUSION: The diagnostic process seemed generally efficient. The male:female ratios suggest higher TB incidence in men rather than lower access to TB facilities for women. The third smear examination could be omitted.     

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.     

A rural public-private partnership model in tuberculosis control in south India.

SETTING: A rural tuberculosis (TB) unit in South India, 2001-2003. OBJECTIVE: To evaluate a rural public-private partnership model (PPPM) within the TB control programme (RNTCP). DESIGN: All of the private practitioners trained in modern medicine (PPs, n = 52) and the private laboratories (PLs, n = 13) in the area were listed. The PPs underwent training about the RNTCP, and PL staff were trained in sputum microscopy. PPPM included referral of TB suspects to the smear microscopy centres (government or PLs) for diagnosis and treatment of patients as per RNTCP guidelines. Patients were back-referred to the PPs. The directly observed treatment providers and centres were chosen by the PPs in consultation with their patients. The case detection rate, cure rate and profile of patients referred by the PPs were compared with those of self-reported patients. RESULTS: Of 489 TB suspects referred by the PPs, 24% were smear-positive compared to 10% of 15 278 self-reported patients (P < 0.001). Of 319 referred to PLs, 7% were smear-positive. The annual average case detection rate increased from 66 to 75 per 100 000 population. The cure rates of patients referred by the PPs were comparable to those of self-reported patients. CONCLUSIONS: This rural PPPM is effective and does not require additional staff or any direct financial incentives.     

A community-based TB drug susceptibility study in Mimika District, Papua Province, Indonesia.

SETTING: A district level tuberculosis (TB) control programme in Papua Province, Indonesia. OBJECTIVE: To determine the nature and extent of drug-resistant TB in newly diagnosed sputum smear-positive patients. METHODS: Sputum was collected from previously untreated smear-positive pulmonary TB patients diagnosed in the district over a 10-month period. Sputum specimens were processed and inoculated into a BACTEC MGIT960 tube. Isolates were identified by Ziehl-Neelsen staining, hybridisation with nucleic acid probes and biochemical investigations. Susceptibility testing was performed using the radiometric proportion method. Pyrazinamide testing was performed using the Wayne indirect method. RESULTS: One hundred and seven patients had sputum sent to a reference laboratory; 101 (94.4%) were culture-positive for Mycobacterium tuberculosis, with 87 (86.1%) fully sensitive to first-line anti-tuberculosis drugs. Two per cent were multidrug-resistant (MDR-TB) and 12 (11.9%) had other drug resistance. Each of the MDR-TB isolates was susceptible to amikacin, capreomycin, ciprofloxacin and para-aminosalicylic acid (PAS), but were resistant to rifabutin. One isolate was also resistant to ethionamide. CONCLUSIONS: MDR-TB is present in Indonesia but is not a major problem for TB control in this district. Generalisability to other districts in Indonesia, particularly large urban areas, needs to be confirmed by future studies.     

Gender disparity amongst TB suspects and new TB patients according to data recorded at the South African Institute of Medical Research laboratory for the Western Cape Region of South Africa.

OBJECTIVE: To describe the sex and age distribution of sputum submission and smear positivity in the Western Cape Province of South Africa. METHOD: Laboratory registers of the South African Institute of Medical Research were examined retrospectively for the year 1999. RESULTS: Male tuberculosis (TB) suspects outnumbered females by 1.45:1, whereas amongst confirmed TB cases the ratio was 2.08:1. The odds ratio (OR) for smear positivity amongst males and females was 1.544. The proportion of male sputum positives significantly exceeded the proportion of males in the general population, as measured by the 1996 census. Not only did the number of male TB suspects and confirmed cases exceed that of females in absolute terms, but the proportion of male suspects proving smear-positive exceeded that of females. The age by sex distribution of new smear-positive patients followed the trend reported in recent literature. CONCLUSION: The gendered incidence of tuberculosis identified from this census is consistent with that of other developing countries. However, the smaller proportion of female TB suspects proving smear-positive suggests a higher index of suspicion in females and/or longer delays prior to care seeking amongst males.     

Treatment outcome among Rwandan and Burundian refugees with sputum smear-positive tuberculosis in Ngara, Tanzania.

SETTING: Tuberculosis programme in six camps (Benaco, Musuhura, Lumasi, Lukole, Keza and Kitali) for Rwandan and Burundian refugees in Ngara district, Tanzania, where treatment was directly observed throughout. OBJECTIVES: To evaluate the treatment outcome of sputum smear-positive tuberculosis cases recruited in refugee camps in Ngara, and to determine the cumulative frequency of conversion of sputum smears by direct microscopy. DESIGN: Retrospective review of tuberculosis registers from January 1995 to December 1999. RESULTS: Of 546 patients with smear-positive tuberculosis who were notified in the programme, 363 (66.5%) had completed treatment and were bacteriologically cured after 7 months, 10.9% had died, 7.1% had defaulted and 14.5% had transferred out. Sputum conversion after the 2-month intensive phase was 88%, and increased to 99% after 7 months of chemotherapy. CONCLUSION: The involvement of the Tanzania NTLP in collaboration with health NGOs has led to a satisfactory outcome. These data suggest that it is possible for tuberculosis control programmes to perform successfully in refugee settings.     

Implementation of the DOTS strategy in prisons at provincial level, Thailand.

SETTINGS: Sixteen prisons located in four geographic regions in Thailand. OBJECTIVES: To assess treatment outcomes of tuberculosis (TB) patients under the DOTS strategy in a prison programme. METHOD: The programme prospectively included 1412 consecutive TB patients registered during Year 1 (June 1999-May 2000), Year 2 (June 2000-May 2001) and Year 3 (June 2001-May 2002). DOTS implementation consisted of government commitment; passive detection by sputum smear microscopy; standardised short-course chemotherapy, including directly observed treatment by prison nurses; maintenance of drug stocks at provincial health offices; and a recording and reporting system. Data were collected using prison TB registers. RESULTS: The number of TB patients increased from 348 in Year 1 to 490 in Year 2 and to 574 in Year 3. New smear-positive patients accounted for 82.0% of the total. Of the 1158 new smear-positive cases, 68.7% were cured, 17.6% died, 10.6% were transferred out, 2.6% failed, and 0.5% completed treatment. CONCLUSIONS: DOTS implementation in these prisons could not achieve the national target to cure 85% of new smear-positive cases. More interventions are needed to help reduce the deaths and transferred cases that mainly affected the treatment outcomes in these settings.     

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。     

Evaluation of a unified treatment regimen for all new cases of tuberculosis using guardian-based supervision.

SETTING: Ntcheu District, Malawi, using an oral antituberculosis treatment regimen. OBJECTIVE: To determine whether directly observed treatment (DOT) during the initial phase of treatment supervised either in hospital, at health centres or by guardians in the community, was associated with 1) satisfactory 2-month and 8-month treatment outcomes, and 2) with a reduction of in-patient hospital-bed days. DESIGN: Prospective data collection of all tuberculosis (TB) patients registered between 1 April 1996 and 30 June 1997, with 2-month and 8-month treatment outcomes, sputum smear conversion in smear-positive pulmonary TB patients (PTB) and in-patient hospital-bed days. RESULTS: Among the 600 new patients, 302 had smear-positive PTB, 150 smear-negative PTB and 148 extrapulmonary TB (EPTB). Eight-month treatment completion was 65% for smear-positive PTB patients, which was significantly higher than in patients with smear-negative PTB (45%) and EPTB (54%), due mainly to high 8-month mortality rates. The site of the intensive phase was determined in 596 patients: 178 (30%) received DOT from guardians, 115 (19%) from a health centre and 303 (51%) in hospital. At 2 months, mortality rates were significantly higher in hospitalised patients. Two-month treatment outcomes (including sputum smear conversion rates in smear-positive PTB patients) were similar between patients receiving DOT at health centres or from guardians. Decentralised DOT resulted in a 25% reduction in hospital-bed days in patients alive at 2 months compared with that predicted using the old regimens. CONCLUSION: Decentralising DOT to health centres and to guardians during the intensive phase is associated with satisfactory treatment outcomes.     

Tuberculosis in east timorese refugees: implications for health care needs in East Timor.

SETTING: East Timorese refugees evacuated to Darwin, Australia, September 1999. OBJECTIVE: Presentation of the process and results of tuberculosis (TB) screening in a previously unscreened refugee population. DESIGN: Screening for TB by clinical examination (all persons) and chest X-ray (CXR) (persons over 12 years of age and those of any age with respiratory symptoms) and sputum microscopy and mycobacterial culture (abnormal CXR). RESULTS: Seventy-six patients were diagnosed with TB (38 culture-positive for Mycobacterium tuberculosis, including 11 sputum smear-positive). Of 89 positive mycobacterial cultures, 51 were non-tuberculous mycobacteria (NTM). Of the M. tuberculosis isolates, 82.2% were fully sensitive, 17.2% were resistant to isoniazid and 8.6% were resistant to isoniazid and streptomycin. Fifty-three consecutively diagnosed patients with TB were HIV-negative. The TB burden in this population was very high (point prevalence of 542/100,000 for smear-positive and 2,060/100,000 for culture-positive cases). Rates of culture for NTM were also high. Information from this study assisted the implementation of a National TB Control Programme for East Timor in February 2000. CONCLUSION: The challenges for public health authorities in East Timor to provide a successful TB control programme are enormous. The apparently low prevalence of drug resistance and HIV co-infection in the population is encouraging.     

From suspect to patient: tuberculosis diagnosis and treatment initiation in health facilities in South Africa

SETTING: Thirteen primary health care (PHC) facilities in the Stellenbosch District, South Africa. OBJECTIVE: To assess the use of a sputum register to evaluate the tuberculosis (TB) diagnostic process and the initiation of TB treatment in selected PHC facilities in a country with a centralised laboratory system. DESIGN: This prospective study was conducted between April 2004 and March 2005. The names of all individuals submitting sputum samples for TB testing were noted in a newly introduced sputum register. We classified all TB suspects with two positive smears as TB cases and consulted TB treatment registers until 3 months after sputum submission to determine how many had started treatment. RESULTS: A total of 4062 persons aged > or =15 years submitted sputum samples, of whom 2484 were TB suspects. There were 2037 suspects with at least two results, 367 (18%) had at least two positive smears and 64 (17%) of these did not start treatment (initial defaulters). Over the entire diagnostic process, up to 5% of TB cases were missed, and up to 26% did not start treatment and were not reported. CONCLUSION: By correcting diagnostic weaknesses identified in the sputum register, PHC facilities will be able to detect, treat and cure a higher percentage of TB patients.     

Tuberculosis and patient gender in Bangladesh: sex differences in diagnosis and treatment outcome.

SETTING: The public health sector of Bangladesh. OBJECTIVE: To assess gender differences in access to tuberculosis diagnosis and in tuberculosis treatment outcome in Bangladesh. METHODS: Information on the age and sex of a sample of patients in 1997 was collected from out-patient registers and tuberculosis laboratory and treatment registers in 59 thanas in three divisions in Bangladesh. RESULTS: The female/male ratio was 0.79 among 42,877 out-patients with respiratory complaints, 0.51 among 5,665 tuberculosis suspects undergoing sputum smear microscopy, 0.36 among 869 tuberculosis suspects with positive sputum smears, and 0.35 among 5,632 patients registered for tuberculosis treatment. Treatment was successful (cured or treatment completed) in 86% of female and 84% of male patients. CONCLUSION: Women in Bangladesh appear to have less access to public out-patient clinics than men, and if they present with respiratory symptoms they are less likely to undergo sputum smear examination. If examined, women are less likely than men to be smear-positive. No gender bias was observed in tuberculosis treatment outcome. It is recommended to focus further research on exploration of sex differences in the incidence of respiratory conditions, identification of constraints among women in accessing out-patient clinics and verification of the quality of sputum submitted by women for examination.     

Gender disparities in tuberculosis: report from a rural DOTS programme in south India.

SETTING: Tiruvallur District, south India. OBJECTIVES: To examine gender differences in tuberculosis among adults aged >14 years with respect to infection and disease prevalence, health care service access, care seeking behaviour, diagnostic delay, convenience of directly observed treatment (DOT), stigma and treatment adherence. METHODS: Data were collected from 1) community survey, 2) self-referred out-patients seeking care at governmental primary health institutions (PHIs), 3) tuberculosis suspects referred for sputum microscopy at PHIs, and 4) tuberculosis patients notified under DOTS. Community survey results were compared with those for patients notified at PHIs. RESULTS: In the community, 66% of males and 57% of females had tuberculosis infection. The prevalence of smear-positive tuberculosis was 568 and 87/100,000, respectively, among males and females. Fewer males than females attended PHIs (68 men for every 100 women). Females constituted 13% of all smear-positive patients detected in the community survey, and 20% of those detected at PHIs (P < 0.05). The probability of notification decreased significantly with age among both males and females. Significantly more females than males felt inhibited discussing their illness with family (21% vs. 14%) and needed to be accompanied for DOT (11% vs. 6%). Males had twice the risk of treatment default than females (19% vs. 8%; P < 0.01). CONCLUSIONS: Despite facing greater stigma and inconvenience, women were more likely than men to access health services, be notified under DOTS and adhere to treatment. Men and elderly patients need additional support to access diagnostic and DOT services.     

Additional risk of developing TB for household members with a TB case at home at intake: a 15-year study.

OBJECTIVE: To assess the additional risk to household contacts from an infectious case of tuberculosis (TB) at home in a rural community in south India. METHODS: In all, 3506 contacts of smear-positive (S+C+) and 2910 contacts of smear-negative TB cases (S-C+) and 246 845 persons with no TB case at home were followed for 15 years, with a repeat survey every 2.5 years consisting of radiographic and sputum examination, selective follow-up of high-risk individuals and passive surveillance. If a case developed during follow-up, all household members were subsequently considered as contacts. Cox's proportional hazards model (multivariate) was employed to compare incidences. RESULTS: The annual incidence of culture-positive TB was respectively 526 and 271 per 100000 population for contacts of smear-positive and smear-negative patients, and 198/100000 in non-contacts. The adjusted hazard rate was 3.4 for contacts of smear-positive patients (95% CI 3.0-3.9) and 1.7 for contacts of smear-negative patients (95% CI 1.4-2.0) as compared to non-contacts. Of 3942 incident cases, 337 (8.5%) came from households with a TB case. CONCLUSION: Although family contacts had a significantly higher incidence, their contribution to total new caseload was meagre. Contact chemoprophylaxis as a public health measure would therefore have limited impact on community TB incidence.     

Treatment results of DOTS in 1797 Sudanese tuberculosis patients with or without HIV co-infection.

SETTING: Consecutive new tuberculosis (TB) patients, from eight states in Sudan, who had never been previously treated for as much as 1 month between 1998 and 2000. OBJECTIVE: To determine the impact of human immunodeficiency virus (HIV) co-infection on tuberculosis treatment outcome. DESIGN: All patients presenting with symptoms suggestive of tuberculosis underwent sputum microscopy for acid-fast bacilli (AFB). Treatment is free of charge, and directly observed for all smear-positive patients. Treatment outcomes were those defined by the World Health Organization. All patients were tested anonymously for human immunodeficiency virus (HIV) using the Bionor test. RESULTS: Of 10 494 patients suspected of TB and referred for sputum microscopy, 1797 were TB cases; 983 had smear-positive pulmonary tuberculosis, 521 smear-negative pulmonary tuberculosis, and 293 extra-pulmonary tuberculosis. Smear-positive cases showed a cure rate of 77.2% and a failure rate of 1%. Smear-negative and extra-pulmonary patients had a completion rate of 79.4%. Cure rates for the smear-positive cases were 68.3% for HIV-positive and 77.6% for HIV-negative patients (P = 0.164). Case fatality was significantly higher among HIV-positive (12%) than among HIV-negative cases (1.8%) (OR 7.7, 95% CI 3.51-16.8). CONCLUSION: To date, a relatively low proportion of tuberculosis patients in Sudan also have HIV infection. These patients are substantially more likely to die while on treatment for their tuberculosis, a fact that underlines their need for more comprehensive care if their lives are to be prolonged. In addition, every effort is required to diminish the transmission of HIV infection to prevent the tragedy this infection represents to the community.     

A public-private partnership for TB control in Timika, Papua Province, Indonesia.

SETTING: A district-level tuberculosis (TB) control programme in Papua Province, Indonesia. OBJECTIVE: To describe a successful partnership between the District Health Department, a private company and non-governmental health care providers. METHODS: Routinely collected surveillance data were analysed. A conceptual model was constructed to describe TB control in the district. Data were compared with the National TB Control Programme (NTP) performance indicators. RESULTS: Funding for the programme's TB clinic is provided by a private company (PT Freeport Indonesia). The NTP provides the policy framework, treatment guidelines and some supplies. TB clinic staff are included in training programmes and the TB laboratory in the provincial quality assurance system. TB clinic staff are responsible for diagnosis, treatment, default tracing, recording and reporting, health education and community mobilisation. The largest proportion of TB patient referrals came from the community hospital (41%). The TB notification rate (311/100000), TB-HIV (human immunodeficiency virus) co-infection (12%) and multidrug-resistant (MDR) TB (2%) are significantly higher in Mimika, but the treatment success rate for smear-positive patients (91%) is similar to Indonesian national figures. CONCLUSIONS: For true progress in attaining the United Nations Millennium Development Goals for TB in Indonesia, innovative local solutions utilising public-private partnerships are essential. The Mimika model is one such solution that should be tested elsewhere.