新发涂阳肺结核患者就诊和诊断延误的影响因素研究

目的 分析新发涂阳肺结核患者就诊和诊断延误的影响因素，为制定减少延误发生的干预措施提供科学依据。方法 采取典型调查的方法，在东、中、西部各选择1个县作为研究现场，采用编制的《新发涂阳肺结核患者诊疗过程调查表》对研究现场结核病防治（简称“结防”）机构2010年5-9月登记发现的329例初治涂阳肺结核患者全部进行了面对面的问卷调查，获得有效个案调查表329份。使用t检验比较就诊延误、诊断延误等不同指标间差异有无统计学意义，使用Cox比例风险回归模型分析影响患者就诊延误的因素，使用非参数检验比较不同医疗机构患者的发现和转诊延误。结果 患者就诊延误15d(0~594d)，诊断延误10d(0~429d)，就诊延误与诊断延误的差异无统计学意义(t=1.596, P=0.111)。与自费相比较，有其他医疗保险（除外新农合）的患者就诊延误更短（β=0.701，Waldχ²=6.223，P=0.013，RR=2.015），有发热症状的患者更易就诊（β=0.430，Waldχ²=11.556，P=0.001，RR=1.537），而有咳嗽症状（β=-0.711，Waldχ²=9.314，P=0.002，RR=0.491）或咯痰症状（β=-0.429，Waldχ²=8.549，P=0.003，RR=0.651）的患者就诊延误更长。不同医疗机构发现结核病可疑者的能力差异有统计学意义（χ²=115.134，P=0.000），其中药店的延误时间最长（26d，四分位间距66.5d），县级及以上医院(0d，四分位间距0d)、乡镇卫生院(0d，四分位间距6d)和结防机构(0d，四分位间距0d)延误时间最短；不同医疗机构转诊结核病可疑者的能力上差异有统计学意义（χ²=55.476，P=0.000），其中结防机构延误时间最短（0d，四分位间距1d），个体诊所延误时间最长（9d，四分位间距19.5d）。结论 新发涂阳肺结核患者的延误包括患者和医疗机构两方面的因素，其中缺乏对结核病可疑症状的相关知识或对症状不重视是导致患者延误的主要因素，而基层医疗机构结核病可疑者的发现和转诊延误是导致医疗机构延误的主要因素。     

新发涂阳肺结核患者就诊与诊断延误对产生耐药的影响

目的了解新发涂阳肺结核患者就诊与诊断延误对产生耐药的影响,为制定耐药结核病防治策略提供科学依据。方法采取典型调查的方法。在我国东、中、西部各选1个省,每省各选择1个县作为研究现场;采用课题组编制的《新发涂阳肺结核患者诊疗过程调查表》对研究现场结核病防治机构2010年59月登记发现的329例初治涂阳肺结核患者进行面对面的问卷调查,共收回329份,有效率100．0％。对329人份痰标本进行痰培养检查,并对痰培养阳性的标本进行包括异烟肼、利福平、乙胺丁醇和链霉素4种抗结核药物的药敏试验;使用非参数检验比较耐药患者和非耐药患者的延误时间,以P〈0．05为差异有统计学意义。结果患者痰培养阳性率为88．8％（292／329）,痰培养阳性的标本中总耐药率为12．7％（37／292）,耐多药率为2．8％（8／292）。耐药患者总延误、就诊延误和诊断延误分别为37d（8～465d）、15d（0～462d）和12d（0～218d）;非耐药患者总延误、就诊延误和诊断延误分别为38d（1～597d）、16d（0～594d）和10d（0～429d）,耐药与非耐药患者在总延误、就诊延误和诊断延误水平上差异均无统计学意义（Z值分别为0．377、0．142、0．069,P值均〈0．05）。结论延误与耐药发生问没有直接的因果关系。     

83例肺结核患者延误诊断分析

目的 分析肺结核患者延误诊断的相关因素。方法 收集2006-2009年河南传染病院结核科就诊的延误诊断的肺结核患者83例,对其延误诊断的原因进行分析。结果 83例延误诊断的患者中,男性45例,女性38例;年龄16～87岁,中位年龄46岁。患者≤60岁60例,平均延误时间2.43个月;＞60岁23例,平均延误时间4.13个月,差异有统计学意义（t=2.13,P=0.036）。就诊延迟35例,占42.17%,平均误诊时间3.59个月;确诊延迟48例,占57.83%,平均误诊时间2.40个月,差异无统计学意义（t=1.63,P=0.145）。确诊延迟患者中误诊为上呼吸道感染11例（占22.92%）,肺炎9例（占18.75%）,陈旧性肺结核4例（占8.33%）。48例确诊延迟患者初次就诊于非结核专科医院41例（占85.42%）,其中就诊私人诊所及社区医院17例,占35.42%。确诊延迟患者在诊断肺结核前未行胸部X线检查者23例,占47.92%;未行结核菌素试验检查者29例,占60.42%;未行痰涂片找抗酸杆菌检查者33例,占68.75%。结论 误诊是延误诊断的主要因素,就诊延误也不可忽视。     

河北省承德市35个乡镇查痰点实施效果探讨

边远山区、自然条件差的地区病人到县结防机构就诊较远、花费较大,交通不便是影响涂阳病人发现的主要原因之一^[1]。痰涂片检查是肺结核病人诊断与鉴别诊断、制订化疗方案、疗效考核的主要方法或手段^[2]。2004年6月,卫生部决定在部分乡镇卫生院设置痰涂片检查点:在以县（市）为单位实施现代结核病控制策略（DOTS）的地区,通过在乡镇卫生院设置结核病痰涂片检查点（以下简称查痰点）,方便肺结核可疑症状者和疑似肺结核病人的就诊查痰,以达到提高涂阳肺结核病人发现率,缩短就诊延误和治疗延误时间,降低结核病传播的目的^[3]。     

湖南省长沙市1O个县肺结核患者费用分析

目的了解涂阳肺结核患者从开始就诊到结束治疗整个过程中发生的各种费用，为国家制定、完善结核病防治策略和措施提供科学依据。 方法对湖南省长沙市10个县共100名涂阳肺结核患者进行问卷调查，对调查所得数据进行分析。 结果（1）涂阳肺结核患者出现症状首次就诊医疗机构依次为综合医院、结防机构、乡镇医院和个人诊所，所占比例分别为43%、20%、16%和11%；（2）整个患病过程的费用约为3678.8元，其中直接费用为2724.8元，间接费用为954.0元，有近一半的费用是在确诊后治疗过程中花费的；（3）确诊肺结核后，多数患者及其家庭经济收入受到不同程度的降低；（4）就诊延误为1.5个月，诊断延误为1.6个月。 结论加强结核病防治工作的经费投入，以减轻结核病患者的经济负担。     

肺结核病患者痰涂片及痰培养检测结果分析

目的 分析肺结核患者痰涂片及痰分离培养抗酸杆菌检验情况,为确诊和控制结核病提供科学诊断依据。方法 2008-06/2011-05四川省双流县结核病门诊就诊的可疑肺结核（可疑者）2 418例及化疗期间肺结核患者（治疗者）649例,总计3 067例,分别对每例就诊者进行痰涂片和培养检测。结果 3 067例就诊者中查出抗酸杆菌阳性777例,总阳性率为25.33%（777/3067）,其中痰涂片阳性（涂阳）524例,痰培养阳性（培阳）651例,阳性率分别为17.09%和21.23%。2 418例可疑者涂阳383例,培阳619例,阳性率分别为15.84%（383/2418）和25.60%（619/2418）,培阳高于涂阳,差异有统计学意义（P〈0.01）。649例肺结核治疗者涂阳141例,培阳32例,阳性率分别21.73%（141/649）和4.93%（32/649）,涂阳高于培阳,差异有统计学意义（P〈0.01）。结论 可疑肺结核者痰培阳高于涂阳,而肺结核治疗者涂阳高于培阳,痰涂片抗酸杆菌检测特异性高而敏感性低,分离培养敏感性、特异性均较高。     

2000—2009年天津市监狱系统在押犯人中结核病患者发现情况分析

摘要：目的 了解天津市监狱系统在押犯人中结核病患者发现情况和变动趋势。方法 天津市结核病控制中心自2000年起对监狱系统在押犯人采取入监体检、普查和因症就诊相结合的方式,2000-2009年间确诊结核患者1811例。收集这10年间监狱结核患者登记资料,对结核患者发现方式、发病特征及其变动趋势进行分析。 结果 1811例患者中,涂阳肺结核占9.7%(176/1811),涂阴肺结核占82.9%(1502/1811),结核性胸膜炎占7.3%(133/1811);以男性和青壮年占多数,男性占98.3%(1780/1811),25~54岁患者占84.0%（1522/1811）。复治患者比例由2000年的39.0%(144/369),至2009年下降至3.3%(7/211);患者发现方式看,普查所占比例由2001年时占70.2%(207/295),至2009年下降至19.4%(41/211);入监体检和因症就诊比例2001年分别占7.5%(22/295)和22.4%(66/295),至2009年分别上升至38.4%(81/211)和42.2%(89/211);具有肺结核主要症状（咳嗽、咯痰≥2周或咯血、血痰）的患者所占比例2000年56.9%,至2009年下降至28.4%;因症就诊患者平均就诊延误时间2000年为38.38 d,至2009年缩短至8.41 d。 结论 监狱患者的发现以入监体检、普查和因症就诊为主,10年间普查所占比例下降,入监体检和因症就诊所占比例升高;复治比例和具有肺结核主要症状者比例下降;因症就诊患者就诊延误时间缩短。证明监狱结核患者发现更为及时,患者发现取得良好效果,今后监狱系统结核病控制工作还应该坚持3种方式相结合的患者发现方法。     

阿勒泰市新型结核病防治服务体系工作进展分析

目的了解新疆阿勒泰市新型结核病防治服务体系工作进展情况,为完善新型结核病防治服务体系提供科学依据。方法根据定点医院(阿勒泰地区人民医院)各类结核病登记本和统计监测资料,分析新型结核病防治服务体系实施后患者发现、追踪、治疗管理等各项数据。结果 2012年6月—2013年6月未实施新疆结核病防治服务体系,综合医疗机构报告(不包括疾病预防控制中心就诊可疑肺结核病患者)可疑肺结核病患者195例,转诊到位73例(37.43%),追踪到位80例(65.57%),总体到位153例(78.46%);到位患者拍胸片153例(100.00%),痰涂片检查153例(100.00%),阳性检出率43.79%,发现活动性肺结核病患者114例,初治涂阳患者67例,初治涂阴患者35例,复治涂阳患者12例;自2013年6月8日以后阿勒泰地区人民医院(定点医院)共报告可疑肺结核病患者242例,到位228例,转诊到位率19.29%,追踪到位率80.70%,总体到位率94.20%;到位结核病患者拍胸片224例(98.24%),痰涂片检查228例(100.00%),阳性检出率10.76%,发现活动性肺结核患者131例,涂阳患者24例,涂阴患者105例,复治2例,两组总体到位(χ2=4.91)和痰涂片检查结果(χ2=319.49)差异均有统计学意义(P0.05)。结论新型结核病防治服务体系实施以来患者到位率明显提高,痰涂片阳性检出率有所下降,政策支持与经济补偿是顺利实施新型结核病防治服务体系建设的重要前提。     

对涂片阴性结核病可疑者随访1个月提高结核病患者发现

背景:在几内亚比绍共和国比绍实施的Bandim卫生项目。目的:对最初就诊时已被排除患有结核病的既往结核病可疑者进行结核病筛查。设计:这是一个队列随访研究,对初次就诊时痰涂片检查为阴性的"结核病阴性可疑者"在其初次就诊后1个月内进行结核病症状筛查,并将有症状者转诊接受临床复查和HIV检测。结果:2007年的10个月期间共登记结核病可疑者428例,其中80%(343例)为痰涂片阴性,而21例涂片阴性者被诊断为涂阴肺结核患者。在余下的322例结核病阴性可疑者中,对212例进行了随访,并在初诊后1个月内对有症状者进行了复查。在接受随访的患者中,89例(42%)仍然有症状;经复查痰涂片和胸部X线,5例被确诊为患有结核病。44例有症状且接受HIV检测的患者中,39%(17例)为HIV感染者。322例结核病阴性可疑者中,13例(4%)在随访前已经死亡。结论:很大一部分结核病阴性患者在初诊后一个月仍有症状。几例结核病患者初诊时未被诊断,结核病患者的HIV感染率较高。结核病阴性可疑者死亡率较高,这就需要结核病和艾滋病防治规划均应提高对此问题的重视程度。     

中国四个项目地区耐多药肺结核患者筛查率、检出率与发现及时性的比较

目的分析医院和疾病预防控制系统（简称“医防”）合作模式下耐多药肺结核患者发现情况,为耐多药肺结核患者发现提供政策建议。方法收集整理中国疾病预防控制中心结核病预防控制中心与比尔及梅琳达·盖茨基金会合作项目在2011-2012年实施1年期间4个项目地区（开封市、连云港市、重庆市永川区、呼和浩特市）耐多药肺结核可疑者筛查的常规记录,使用筛查率、检出率和发现时间间隔等指标,评价耐多药肺结核患者的发现情况。4个项目地区登记涂阳肺结核患者共2816例,接受快速耐药筛查2365例,其中开封市774例、连云港市761例、重庆市永川区700例、呼和浩特市581例;有完整发现时间信息的来源于结核病防治（简称“结防”）机构的涂阳肺结核患者1608例。使用Kruskal-Wallis H 秩和检验对4个项目地区的发现情况进行组间比较,显著性水平设定为α=0.05。结果项目地区涂阳肺结核患者总体筛查率为83.98%(2365/2816);使用快速诊断技术耐多药肺结核患者检出率为6.22%(147/2365)。4个项目地区结防机构来源患者发现时间间隔的中位数为7d,送痰、快速诊断和反馈时间间隔的中位数分别为2、5和0d。开封市、连云港市、重庆市永川区和呼和浩特市结防机构来源的耐多药肺结核患者发现时间间隔的中位数分别为6、7、9和14d（H=275.19,P<0.001）;送痰时间间隔的中位数分别为1、2、2和2d（H=104.92,P<0.001）;快速诊断时间间隔的中位数分别为5、4、5和6d（H=8.19,P=0.042）;反馈时间间隔的中位数分别为0、0、0和5d（H=580.32,P<0.001）。结论在医防合作模式下使用快速诊断技术对所有涂阳肺结核患者进行筛查,筛查率较高,检出率处于比较理想的水平,并且患者发现较为及时,这种发现方式是值得借鉴推广的。     

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.     

Factors affecting time delay to treatment in a tuberculosis control programme in a sub-Saharan African country: the experience of The Gambia.

SETTING: Rural and urban health centres in The Gambia, West Africa. OBJECTIVES: To estimate the time delay between onset of symptoms and initiation of treatment and identify the risk factors influencing the delay in patients with tuberculosis (TB). DESIGN: Structured interviews with newly diagnosed TB patients aged over 15 years presenting to TB control staff in four health centres. RESULTS: A total of 152 TB patients were interviewed. The median delay from onset of symptoms to commencement of treatment was 8.6 weeks (range 5-17). Delay to treatment was independent of sex, but was shorter in young TB patients. The median delay was longer in rural than in urban areas (12 weeks [range 8.5-17] vs. 8 [4-12], P < 0.01) and in those who did not attend school, but this effect disappeared after adjusting for age and area of residence. Patients who reported haemoptysis as one of their initial symptoms had shorter delays to treatment. There was no relation between duration of delay to treatment and cure rate, but longer delay did increase the risk of death. CONCLUSION: Starting TB patients on treatment as early as possible plays a major role in reducing disease transmission in the community. Key to this is increasing awareness of the signs and symptoms of TB and ensuring easy access to diagnostic facilities and treatment.     

Help-seeking behavior of marginalized groups: a study of TB patients in Harlem, New York.

SETTING: Harlem Hospital Directly Observed Therapy (DOT) Program, New York City. OBJECTIVE: To identify various pathways to tuberculosis (TB) diagnosis, and determine time to diagnosis and reasons for delay, to ensure rapid diagnosis of TB and prompt initiation of appropriate treatment. DESIGN: Cross-sectional survey of the help-seeking behavior of TB patients within 2 months of their enrollment into DOT from May 2001 to December 2004. RESULTS: The average total delay between symptom onset and a patient's diagnosis of TB was 18 weeks among 39 patients. The average delay to diagnosis attributed to patient delay and health care system delay were 10.5 and 7.5 weeks, respectively. Patients visited on average 1.6 sources of care prior to receiving a TB diagnosis. Foreign-born patients in particular were found to have more complex paths to diagnosis. The most common reason for delaying seeking care reported by patients was that they didn't think it was serious' (29.1%). CONCLUSION: There was a substantial time interval between the onset of symptoms and TB diagnosis due to both patient and health care system delay. Foreign-born status, economic and social factors, and missed opportunities for diagnosis by the health care system played important roles in delaying TB diagnoses for the marginalized patients in this study.     

影响肺结核治疗转归的因素分析

目的分析影响肺结核患者治疗转归的有关因素,为结核病防治提供理论依据。方法收集1993—2001年世界银行贷款结核病控制项目期间涟源市卫生防疫站4 747份肺结核病历资料,对影响肺结核患者治疗转归的有关因素进行单因素分析和多因素非条件Logistic回归分析。结果单因素分析表明,年龄、性别、疾病治疗之初有咯血症状(χ²=10.20,P=0.01)及临床症状超过3种、合并其他结核、就诊延误、既往用药、空洞、非全程督导管理方式、治疗2个月末痰菌阳性、初治涂阳病人不含链霉素治疗方案对肺结核患者的治疗转归有影响。多因素分析结果显示:治疗之初痰菌阳性及乏力症状为促进患者治愈的有利因素;治疗初相关临床症状及体征如发热、肺部空洞的存在非全程督导为影响肺结核患者治疗转归的不利因素。结论加强宣传教育以减少患者的就诊延误现象,提高对结核病患者的全程督导率,提高患者正确服药依从性将有利于患者的预后。     

不同地区新发涂阳肺结核患者延误水平的变化趋势分析

目的 了解不同地区新发涂阳肺结核患者延误水平的变化趋势,为制定减少延误发生的干预措施提供科学依据。方法 采取典型调查的方法,在东、中、西部各选1个省,共3个省,每省各选择1个县作为研究现场,通过全国结核病网络专报系统获得各调查点2005-2009年患者的个案信息5066例,同时查阅患者病案记录进行核实。使用非参数检验方法,比较各调查点总延误水平的差异和各调查点2005-2009年总延误水平的变化。结果 患者中男性占74.7%(3783/5066),女性占25.3%(1283/5066),平均年龄48.1岁(95% CI:47.6~48.6岁),农民占85.5%(4331/5066)。东、中、西部地区患者2005-2009年的平均延误水平分别为24d(0~404d)、42d(0~730d)和62d(0~587d),各调查点延误水平差异有统计学意义(χ²=1095.981,P=0.000);东部地区2005-2009年延误水平的中位数分别为28d(0~398d)、19d(0~387d)、22d(1~404d)、22d(0~219d)和22d(0~96d),差异有统计学意义(χ²=117.840,P=0.000);中部地区2005-2009年延误水平的中位数分别为54d(0~712d)、40d(1~730d)、38d(1~471d)、44d(1~709d)和44d(1~711d),差异无统计学意义(χ²=6.310,P=0.177);西部地区2005-2009年延误水平的中位数分别为91d(5~501d)、67d(0~521d)、42d(4~435d)、51d(3~587d)和59d(4~268d),差异有统计学意义(χ²=166.120,P=0.000)。结论 2005-2009年各调查点延误水平总体上呈下降趋势,但中、西部地区仍有下降的空间。     

Study of treatment outcomes of multidrug-resistant tuberculosis under programmatic conditions and factors influencing the outcomes in Hyderabad District

BackgroundTreatment outcomes for Multidrug-Resistant Tuberculosis (MDR TB) is generally poor. The study aims to know about the treatment outcomes of MDR-TB under programmatic conditions in Hyderabad District and to analyze the factors influencing the treatment outcomes.MethodsThis is a retrospective study in which 377 patients of Hyderabad district, Telangana state who were diagnosed with MDR TB and registered at Drug Resistance TB Treatment site of Government General & Chest Hospital, Hyderabad from 4th quarter 2008 to 4th quarter 2013 were included in the study. Impact of Demographic factors (age, sex; Nutritional status (BMI); Co-morbid condition (Diabetes, HIV, Hypothyroidism); Programmatic factors (time delay in the initiation of treatment); Initial Resistance pattern on the outcomes were studied and analyzed.ResultsThe treatment outcomes of Multidrug-Resistant Tuberculosis under Programmatic Conditions were: 57% cured, 21.8% died, 19.6% defaulted, 1.1% failed and 0.5% switched to XDR. Age, Sex, BMI had a statistically significant impact on treatment outcomes. Hypothyroidism and Delay in the initiation of treatment >1 a month had an impact on the outcomes though not statistically significant. NO impact on treatment outcomes was found when Rifampicin resistance & INH sensitive patients were compared with those resistant to both INH and Rifampicin.ConclusionTo reduce MDR-TB transmission in the community, improvement of treatment outcomes, via ensuring adherence, paying special attention to elderly patients is required. The Programmatic Management of Drug Resistance Tuberculosis (PMDT) should seriously think of providing Nutritional support to patients with low BMI to improve outcomes. In the programmatic conditions if we could address the problems like delay in initiation of treatment and proper management of comorbidities like HIV, Diabetes, Hypothyroidism would definitely improve the treatment outcomes.     

Pre-treatment delay and out of pocket expenses by notified new tuberculosis patients in an Indian mega city

BackgroundStudy was carried out to find out delay from onset of symptoms and out of pocket expenditure (OOPE) until initiation of anti-TB treatment (ATT) by new Tuberculosis (TB) patients registered in public health facilities in Bengaluru.MethodsNotified patients (N = 228) selected purposively were interviewed at initiation of ATT regarding number and type of facilities visited and delay in initiating ATT. OOPE was elicited separately for in- and out-patient visits, towards consultation, purchase of medicines, diagnostic tests, transportation, hospitalization and food. Dissaving or money borrowed was ascertained.ResultsTwo-thirds of participants were 15–44 years of age and 56% were males, mean annual household income was $4357.About 75% first visited a private health facility; 68% and 87% respectively were diagnosed and started on ATT in public sector after visiting an average of three facilities and after a mean delay of 68 days; the median delay was 44 days.Of mean OOPE of $402, 54% was direct medical expenditure, 5% non-medical direct and 41% indirect. OOPE was higher for Extra-pulmonary TB compared to PTB and when number of health facilities visited before initiating treatment was >3 compared to those who visited ≤3 and when the time interval between onset of symptoms and treatment initiation (total delay) was >28 days compared to when this interval was ≤28 days. About 20% suffered catastrophic expenditure; 34% borrowed money and 37% sold assets.ConclusionConcerted efforts are needed to reduce delay and OOPE in pre-treatment period and social protection to account for indirect expenditure.     

Characteristics of adults and children diagnosed with tuberculosis in Lilongwe,Malawi: findings from an integrated HIV/TB clinic

Objectives To describe initial registration characteristics of adult and paediatric TB patients at a large, public, integrated TB and HIV clinic in Lilongwe, Malawi, between January 2008 and December 2010. Methods Routine data on patient with TB category and TB type, stratified by HIV and ART status, were used to explore differences in proportions among TB only, TB/HIV co‐infected patients not on ART and TB/HIV co‐infected patients on ART using chi‐square tests. Trends over time illustrate strengths and weaknesses of integrated service provision. Results Among 10 143 adults, HIV ascertainment and ART uptake were high and increased over time. The proportion of relapse was highest among those on ART (5%). The proportion of smear‐positive pulmonary TB (PTB) was highest among HIV‐negative patients with TB (34.9%); extra‐pulmonary TB (EPTB) was lowest among TB only (16.2%). Among 338 children <15 years, EPTB and smear‐positive PTB were more common among TB‐only patients. Time trends showed significant increases in the proportion of adults with smear‐positive PTB and the proportion of adults already on ART before starting TB treatment. However, some co‐infected patients still delay ART initiation. Conclusions HIV ascertainment and ART uptake among co‐infected patients are successful and improving over time. However, delays in ART initiation indicate some weakness linking TB/HIV patients into ART during TB follow‐up care. Improved TB diagnostics and screening efforts, especially for paediatric patients, may help improve quality care for co‐infected patients. These results may aid efforts to prioritise TB and HIV prevention, education and treatment campaigns for specific populations.     

Current issues in the diagnosis and management of tuberculosis and HIV coinfection in the United States

Approximately 10% of new cases of tuberculosis (TB) in the United States occur in HIV-infected persons. HIV infection dramatically increases the risk of TB, and this increased risk is present throughout the course of HIV infection. TB and HIV coinfection complicates the course and treatment of both diseases. Isoniazid preventive therapy and antiretroviral therapy both substantially reduce the risk of developing active disease in persons with latent TB infection. Antiretroviral therapy should be given during treatment for active TB, as mortality was reduced by 56% with initiation of antiretroviral therapy before the completion of TB therapy. In addition, for patients with low CD4+ cell counts (less than 200/microm3), starting antiretroviral therapy during the intensive phase of TB treatment reduced mortality by 34% compared with delaying antiretroviral therapy until 8 weeks after TB treatment initiation.     

Assessing health seeking behaviour among tuberculosis patients in rural South Africa.

SETTING: South Africa's rural Northern Province. OBJECTIVES: To examine patterns of health seeking behaviour among hospitalised tuberculosis patients. DESIGN: Information on personal characteristics, health seeking behaviour and delays to presentation and hospitalisation was collected from hospitalised TB patients. Analysis of rates was used to investigate factors associated with delay. RESULTS: Among 298 patients, median total delay to hospitalisation was 10 weeks, with patient delay contributing a greater proportion than service provider delay. Patients more often presented initially to public hospitals (41%) or clinics (31 %) than to spiritual/traditional healers (15%) or private GPs (13%). Total delay was shorter amongst those presenting to hospitals than those presenting to clinics (rate ratio 1.33, 95%CI 1.13-1.85), with a significantly smaller proportion of the total delay attributable to the health service provider (18% vs. 42%). Those exhibiting a conventional risk profile for TB (migrants, alcohol drinkers, history of TB) were diagnosed most quickly by health services, while women remained undiagnosed for longer. CONCLUSION: Considerable delay exists between symptom onset and treatment initiation among pulmonary tuberculosis patients. While a substantial delay was attributable to late patient presentation, an important, preventable period of infectiousness was caused by the failure of recognised clinical services to diagnose tuberculosis among symptomatic individuals.