Efficiency of a third serial sputum smear examination in the diagnosis of tuberculosis in Moldova and Uganda.

SETTING: Twenty-four and 30 tuberculosis (TB) microscopy laboratories in Moldova and Uganda, respectively. OBJECTIVE: To estimate the workload required to identify one additional case of TB with a third serial sputum smear examination. METHODS: Retrospective laboratory register study to determine the prevalence and the incremental yield of TB cases from a third serial sputum smear examination among suspects in Moldova and Uganda, with the reciprocal of the product of these two fractions providing the number of examinations required to identify one additional TB case. RESULTS: In Moldova, 9% (1141/12525) and in Uganda 20% (7280/36054) of suspects met the TB case definition with at least one positive sputum smear. The incremental yield from the third examination was 4% in Moldova and 3% in Uganda. To detect one additional TB case on a third smear, 273 examinations (95%CI 200-389) in Moldova and 175 (95%CI 153-222) in Uganda were thus required. This corresponded to an average of 11 days (8-16) and 7 days (6-9), respectively, to diagnose one additional case of TB. CONCLUSION: In both countries, the third serial sputum smear examination was inefficient in diagnosing sputum smear-positive TB.     

Could clinical audit improve the diagnosis of pulmonary tuberculosis in Cuba,Peru and Bolivia?

Objectives To assess the effectiveness of clinical audit in improving the quality of diagnostic care provided to patients suspected of tuberculosis; and to understand the contextual factors which impede or facilitate its success. Methods Twenty‐six health centres in Cuba, Peru and Bolivia were recruited. Clinical audit was introduced to improve the diagnostic care for patients attending with suspected TB. Standards were based on the WHO and TB programme guidelines relating to the appropriate use of microscopy, culture and radiological investigations. At least two audit cycles were completed over 2 years. Improvement was determined by comparing the performance between two six‐month periods pre‐ and post‐intervention. Qualitative methods were used to ascertain facilitating and limiting contextual factors influencing change among healthcare professionals’ clinical behaviour after the introduction of clinical audit. Results We found a significant improvement in 11 of 13 criteria in Cuba, in 2 of 6 criteria in Bolivia and in 2 of 5 criteria in Peru. Twelve out of 24 of the audit criteria in all three countries reached the agreed standards. Barriers to quality improvement included conflicting objectives for clinicians and TB programmes, poor coordination within the health system and patients’ attitudes towards illness. Conclusions Clinical audit may drive improvements in the quality of clinical care in resource‐poor settings. It is likely to be more effective if integrated within and supported by the local TB programmes. We recommend developing and evaluating an integrated model of quality improvement including clinical audit.     

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.     

HTLV-1 infection is frequent among out-patients with pulmonary tuberculosis in northern Lima, Peru.

SETTING: Tuberculosis (TB) and human T-lymphotropic virus 1 (HTLV-1) are frequent in Peru. The prevalence of HTLV-1 among Peruvian TB patients is unknown. OBJECTIVE: To determine the prevalence of HTLV-1, HTLV-2 and the human immunodeficiency virus (HIV) in out-patients with TB and to compare HTLV-1-infected patients with seronegative patients. DESIGN: Cross-sectional study including subjects aged 18-65 years diagnosed with smear-positive pulmonary TB at health centres in northern Lima from November 2004 to August 2005. HTLV and HIV screening was performed using enzyme-linked immunosorbent assay; HTLV-1 and HTLV-2 were confirmed using line immunoassay. RESULTS: There were 311 participants with a median age of 29 years; 173 (56%) were men. HTLV-1 prevalence was 5.8% (18/311, 95%CI 3.2-8.4) and HIV prevalence was 1.3% (4/304, 95%CI 0.4-3.3). HTLV-2 was not diagnosed. In comparison with HIV- and HTLV-seronegative patients, HTLV-1-infected subjects were older (median age 44 vs. 28, P < 0.001) and were more likely to have been born in the southern Andes (OR 4.4, 95%CI 1.6-11.9). They were also more likely to report a history of TB deaths in the family (OR 5.4, 95%CI 1.7-16.8) and had more sputum smear results graded as 3+ (OR 4.1, 95%CI 1.5-11.2). CONCLUSION: HTLV-1 screening among Peruvian TB patients is important. Because 3+ sputum smears are frequent and mortality is high among relatives, families of HTLV-1/TB-positive cases merit special attention.     

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.     

武汉市社区肺结核可疑症状者求医行为及其影响因素分析

目的 了解武汉市社区肺结核可疑症状者的求医行为及其影响因素,为提高肺结核患者发现率提供依据。 方法 采用整群等比例随机抽样方法,抽取4个调查点,每个调查点15岁以上常住人口共5878名。2010年5-7月,筛选出调查前6个月内连续咳嗽、咯痰2周以上或咯血、痰中带血者作为调查对象（共270名）,进行面访式问卷调查。270份调查问卷中,259份合格,合格率95.9%。对270名调查对象进行X线胸片检查、3次痰涂片和2次痰培养检查。用卡方检验及logistic回归对肺结核可疑症状者求医行为的影响因素进行分析。 结果 259例中,79例（30.5%）没有任何求医行为,86例（33.2%）曾去社区及以上医疗机构正式就诊,89例（34.4%）曾自我药疗,5例（1.9%）曾去私人诊所就诊。多因素logistic回归分析显示,有无医疗保障与可疑症状者是否正式就诊相关,差异有统计学意义（β=1.225,Wald χ²=3.955,OR=3.405, 95%CI＝1.018~11.392,P<0.05）;有无严重或慢性呼吸道症状与可疑症状者是否正式就诊高度相关,差异有统计学意义（β=1.601,Wald χ²=22.210,OR=4.959, 95%CI＝2.548~9.652,P<0.01）;是否感到羞耻与可疑症状者是否正式就诊高度相关,差异有统计学意义（β=0.927,Wald χ²=7.767,OR=2.528, 95%CI＝1.317~4.853,P<0.01）。 结论 武汉市社区肺结核可疑症状者主动就诊率不高,有无医疗保障、有无严重或慢性呼吸道症状及是否感到羞耻是影响肺结核可疑症状者求医行为的主要因素。     

Relation of grading of sputum smears with clinical features of tuberculosis patients in routine practice in Sudan.

SETTING: Health services in Khartoum, Red Sea, Gadarif, Kassala, Bahr el Jebel, Gezira and North Kordofan States of Sudan. OBJECTIVE: To investigate the association of presenting symptoms and clinical history with grade of sputum smear positivity in tuberculosis patients. METHODS: The 5338 tuberculosis suspects aged 15 to 49 years who consulted between March 1998 and March 1999 underwent sputum smear microscopy, with smears graded by a standardised method. Patients who gave consent had a structured interview concerning the nature and duration of their symptoms and whether they had a sick relative at home. Statistical analysis determined the association of symptoms and home characteristics with the results of smear examination. RESULTS: A total of 514 suspects (9.6%) demonstrated acid-fast bacilli: 45 (8.8%) grade +1, 167 (32.5%) grade +2 and 302 (58.8%) grade +3. Most of the patients had a duration of symptoms of 6-9 weeks, while 100 had symptoms of more than one year's duration, many (n = 47) with other chronic respiratory diseases. Multiple chest symptoms were positively, and duration of symptoms negatively associated with grade of positivity (P = 0.018 and 0.028, respectively). A high grade of smear positivity (+3) and the longest duration of symptoms, among those reporting symptoms of less than one year's duration, were significant predictors of the presence of a sick household member (OR = 1.99, 95%CI 1.12-3.55; OR = 1.004, 95%CI 1.000-1.008). CONCLUSION: This study demonstrates a relation between the grade of smear positivity and the clinical features of tuberculosis patients.     

Duration of cough, TB suspects' characteristics and service factors determine the yield of smear microscopy

Objective To determine the efficiency of routine tuberculosis (TB) case detection by examining sputum smear positivity for acid‐fast bacilli in relation to duration of cough, characteristics of TB suspects examined and health service factors. Method We combined patient interviews with routine data from laboratory registers in 6 health care facilities in San Juan de Lurigancho district, Lima, Peru. A TB case was defined as a TB suspect with at least one positive sputum smear. We calculated adjusted odds ratios with 95% confidence intervals for the association between smear positivity and health service and patient’s characteristics. Results Smear positivity was 7.3% (321/4376). Of the 4376 adults submitting sputa, 55.3% (2418) reported cough for <14 days. In this group, smear microscopy yielded 3.2% (78/2418) positive results vs. 12.4% (243/1958) in patients coughing for 14 or more days. Having cough for >2 weeks, being referred by health care staff, attending a secondary‐level health care facility, male sex and age between 15 and 44 years were independent determinants of smear positivity. Conclusions Routine case detection yields a low proportion of smear‐positive cases because of the inclusion of a high proportion of patients without cough or coughing for <2 weeks. Adherence to the national TB control programme guidelines on the selection of TB suspects would have a positive impact on the smear positivity rate, reduce laboratory costs and workload and possibly improve the reading quality of smear microscopy.     

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.     

The cost of medical care and people's health-seeking behaviour before being suspected of tuberculosis in three local health systems, Nicaragua.

OBJECTIVE: To assess the medical costs incurred by users and delay between first contact with a care provider and sputum test for acid-fast bacilli (AFB) in three areas of Nicaragua. METHODS: Directed interviews of consecutive series of tuberculosis (TB) suspects whose sputum had been examined for AFB. RESULTS: Of 252 TB suspects interviewed, 52% used more than one type of care giver and 35% used private practitioners. As a consequence, 18%, 21% and 29% of the interviewees in Carazo, El Viejo and Matagalpa, respectively, spent more than 1 month of the country's median income per inhabitant on medical care between the first visit to a care provider and the first sputum examination. Furthermore, more than 3 months elapsed on that part of the care pathway for 30%, 17% and 3% of interviewees in Matagalpa, El Viejo and Carazo, respectively. CONCLUSION: This study sheds light on the costs and delays incurred by TB suspects before reaching a laboratory for sputum smear examination. Both costs are lower for those suspects who exclusively use first-line governmental health services (FLGHS). This has been relatively little documented in Latin America to date and could be used as an argument to develop strategies to strengthen the credibility of FLGHS.     

Health-seeking behaviour among adults with prolonged cough in Vietnam

Objective To assess health‐seeking behaviour among adults with prolonged cough in a population‐based, nationally representative sample in Vietnam. Methods Cross‐sectional survey conducted from September 2006 to July 2007. All inhabitants aged ≥15 years were invited for screening for cough, history of tuberculosis (TB) treatment and chest X‐ray (CXR) examination. TB suspects, defined as any survey participant with CXR abnormalities consistent with TB, or productive cough for more than 2 weeks or TB treatment either currently or in the preceding 2 years submitted sputum specimens for smear examination and culture and provided information on health‐seeking behaviour in an in‐depth interview. Results Of 94 179 persons participating in the survey, 4.6% had prolonged productive cough. Forty‐four percentage of those had sought health care and reported pharmacies (35%), commune health posts (29%), public hospitals (24%) and private physicians (10%) as first point of contact. Only 7% had undergone sputum smear examination. Of TB suspects with prolonged productive cough, 2.9% were diagnosed with TB; 10.2% of these reported smear and 21.9% reported X‐ray examination when visiting a health care facility. The average patient delay was 4.1 weeks (95% CI: 3.9–4.4) among cough suspects and 4.0 weeks (95% CI: 3.1–4.9) among TB cases. Conclusions In this Vietnamese survey, nearly half of persons with cough for more than 2 weeks had visited a health care provider. The commonest first health facility contacted was the pharmacy. Sputum smears were rarely examined, except in the provincial TB hospital. Our findings highlight the need to improve diagnostic practices by retraining health staff on the performance of sputum examination for TB suspects.     

Excess mortality and tuberculosis among individuals with prolonged cough: a population-based study from Vietnam.

SETTING: A demographic surveillance site in north-west Vietnam. OBJECTIVES: To compare notification rates of sputum smear-positive tuberculosis (TB) and mortality rates between the general population and individuals with prolonged cough. DESIGN: A cohort study of 559 prolonged cough cases in a total population of 35,832, observed over 2.5 years. Outcome measures were sputum smear-positive TB and death. RESULTS: The age-standardised smear-positive TB notification rate among cough cases (553/100,000 person-years [py], 95%CI 268-1143) was significantly higher than in the general population (50/100,000 py, 95%CI 43-57), with a relative risk of 11.06 (95%CI 8.28-14.77). Among those who had a chest X-ray suggestive of TB but negative sputum smears prior to the study start, the rate was 6542/100,000 py (95%CI 2906-12,511). The cough cohort had a 2.61 (95%CI 2.38-2.87) times higher risk of dying than the general population. CONCLUSIONS: Individuals with prolonged cough in this study run a significantly increased risk of developing infectious TB and of dying. We recommend further evaluations of improved follow-up systems aimed at identifying and treating sputum smear-negative TB cases before they convert to an infectious stage.     

Public-private mix for improved TB control in Ho Chi Minh City, Vietnam: an assessment of its impact on case detection.

SETTING: Ho Chi Minh City (HCMC), Vietnam. OBJECTIVE: To assess the impact on case detection of a public-private mix (PPM) project linking private providers (PPs) to the National Tuberculosis Programme (NTP). METHOD: Nine-month monitoring of referral and diagnostic data recorded in new referral forms and treatment cards for PPs and upgraded NTP registers. RESULTS: A total of 1549 TB suspects were referred, of whom 1090 (70%) actually went to the NTP for sputum examination. A total of 569 cases were detected through referrals or notification, of whom 45% were new sputum smear-positive cases. The case detection of new sputum smear-positive cases in PPM districts increased by 18% (21/100,000, 95%CI 0-42) compared to the previous year, while a slight decrease occurred in control districts. In HCMC as a whole, case detection increased by 7% (7/100,000, 95%CI 2-11/100,000). Among sputum smear-positive cases detected in NTP through referrals from PPs, 58% defaulted before initiating treatment. CONCLUSIONS: The tendency towards increased case detection associated with this PPM indicates a potential for utilising PPs to improve case detection. However, the NTP and PPs should jointly address the problem of initial default before considering expansion of this PPM model.     

Risk factors associated with default among new pulmonary TB patients and social support in six Russian regions.

SETTING: Tuberculosis (TB) services in six Russian regions in which social support programmes for TB patients were implemented. OBJECTIVE: To identify risk factors for default and to evaluate possible impact of social support. METHODS: Retrospective study of new pulmonary smear-positive and smear-negative TB patients registered during the second and third quarters of the 2003. Data were analysed in a case-control study including default patients as cases and successfully treated patients as controls, using multivariate logistic regression modelling. RESULTS: A total of 1805 cases of pulmonary TB were enrolled. Default rates in the regions were 2.3-6.3%. On multivariate analysis, risk factors independently associated with default outcome included: unemployment (OR 4.44; 95%CI 2.23-8.86), alcohol abuse (OR 1.99; 95%CI 1.04-3.81), and homelessness (OR 3.49; 95%CI 1.25-9.77). Social support reduced the default outcome (OR 0.13; 95%CI 0.06-0.28), controlling for age, sex, region, residence and acid-fast bacilli (AFB) smear of sputum. CONCLUSION: Unemployment, alcohol abuse and homelessness were associated with increased default outcome among new TB patients, while social support for TB patients reduced default. Further prospective randomised studies are necessary to evaluate the impact and to determine the most cost-effective social support for improving treatment outcomes of TB in patients in Russia, especially among populations at risk of default.     

发光二极管荧光显微镜检测结核分枝杆菌在基层实验室的应用评价

目的 评价发光二极管（light-emitting diodes,LED）荧光显微镜在基层实验室痰涂片中检测结核分枝杆菌的应用效果。 方法 收集2011年7月至2011年9月在青海省西宁市7个县（区）级结核病防治机构（简称“结防机构”）就诊的所有肺结核可疑症状者592例（1738份痰标本）。对每份痰标本涂片2张,分别进行萋-尼（Ziehl-Neelsen, Z-N）抗酸染色和金胺O（auramine O）荧光染色,然后以盲法用传统光学显微镜和LED荧光显微镜进行检测,以简单法固体罗氏培养（L-J）结果为金标准,比较两种显微镜阳性检出率的差异、诊断的准确性及检出时间的差异。 结果 LED荧光显微镜痰涂片阳性检出率为14.90%（259/1738）,比传统光学显微镜13.75%（239/1738）提高1.15%,差异有统计学意义（Z=5.88,P〈0.05）。以简单法固体罗氏培养结果为金标准,传统光学显微镜的敏感度为79.60%（199/250;95%CI=74.60％～84.60%）,特异度为97.31%（1446/1486;95%CI=96.49％～98.13%）;ROC曲线下面积为0.8878（95%CI=0.8623～0.9133）。LED荧光显微镜的敏感度为84.80%（212/250;95%CI=80.30%～89.25%）,特异度为96.84%（1439/1486;95%CI=95.95%～97.73%）,ROC曲线下面积为0.9118（95%CI=0.8890～0.9347）。传统光学显微镜的平均读片时间为（185.600±79.271）s,LED荧光显微镜的平均读片时间为（144.19±62.173）s,时间差异有统计学意义（t=15.32, P〈0.01）。 结论 应用LED荧光显微镜可明显提高痰涂片中结核分枝杆菌的阳性检出率,较传统光学显微镜有更高的敏感度,但特异度相当,诊断肺结核患者的价值更高,且能明显缩短读片时间。     

Bodyweight gain to predict treatment outcome in patients with pulmonary tuberculosis in Peru

SETTING: Tuberculosis control programmes of two health care centres in the central rainforest of Peru. OBJECTIVE: To evaluate if bodyweight gain (BWG) predicts treatment outcome in patients with pulmonary tuberculosis (PTB). DESIGN: Retrospective cohort study of adults with PTB diagnosed between 1995 and 2004. BWG was assessed after month 1 of treatment, after the initial phase and at the end of treatment. Patients were stratified into two BWG categories, < or = 5% and >5%. Failures and relapses were grouped together as unsuccessful treatment outcome. RESULTS: A total of 650 patients were included: 7.2% (n = 47) had an unsuccessful outcome. Unsuccessful outcome was associated with BWG < or = 5% at the end of treatment (RR 2.05, 95%CI 1.10-3.80), but not at the completion of month 1 (RR 0.99, 95%CI 0.52-1.88) or at completion of the initial phase (RR 1.46, 95%CI 0.82-2.57). Median BWG at completion of the initial phase was higher in cured patients (P = 0.007). BWG < or = 5% at end of treatment (RR 2.35, 95%CI 1.17-4.72), initial sputum smear 2+ (RR 2.48, 95%CI 1.14-5.31) and positive smear microscopy at month 2 (RR 4.0, 95%CI 1.30-12.31) were independent predictors of unsuccessful treatment outcome. CONCLUSION: BWG < or = 5% at the end of treatment, high bacterial load and lack of sputum conversion correlate with unsuccessful treatment outcome in this setting. New discriminative cut-offs for BWG are proposed.     

Drug-resistant tuberculosis and HIV in Ukraine: a threatening convergence of two epidemics?

OBJECTIVE: To investigate anti-tuberculosis (TB) drug resistance rates in Donetsk Oblast, Ukraine, and to explore the association between the epidemics of human immunodeficiency virus (HIV) and multidrug-resistant TB (MDR-TB). METHODS: All consecutive newly diagnosed and previously treated patients with sputum smear-positive TB presenting to all TB units in Donetsk Oblast over 12 months were invited to take part in the study. A total of 1293 and 203 patients with TB were tested for HIV and MDR-TB in the civilian and penitentiary sectors, respectively. RESULTS: Of those enrolled for the study, 307 were HIV-positive, 379 had MDR-TB, and 97 had MDR-TB and HIV co-infection. MDR-TB rates in the civilian sector were respectively 15.5% (95%CI 13.1-17.8) and 41.5% (95%CI 36.4-46.5) in newly diagnosed and previously treated TB patients. Among prisoners, MDR-TB rates were 21.8% (95%CI 12.4-31.2) in new cases and 52.8% (95%CI 43.9-61.7) in previously treated TB cases. HIV status was significantly associated with MDR-TB (OR 1.7, 95%CI 1.3-2.3). CONCLUSIONS: High MDR-TB rates and a positive association between MDR-TB and HIV epidemics were found in Donetsk Oblast. Urgent measures to improve HIV prevention, control of drug-resistant TB and collaboration between HIV and TB control activities need to be implemented without further delay.     

Three-fold reduction in the prevalence of tuberculosis over 25 years in Indonesia.

BACKGROUND: Tuberculosis (TB) remains the principal cause of death from a curable infectious disease. Indonesia is estimated to have the third highest case load worldwide, but TB prevalence has not been measured for 25 years. METHODS: In 2004, 20000 households were selected in all 30 provinces. All adults (aged >/=15 years) in every household were screened for symptoms of pulmonary tuberculosis (PTB). Among those with symptoms, TB was diagnosed by sputum smear microscopy and sputum culture. RESULTS: Eighty adults were positive on at least two sputum smears (104 per 100000 population, 95%CI 66-142). Prevalence was lower in Central Indonesia (Java-Bali, 59/100000) than in the Western (Sumatra, 160/100000) or Eastern regions (189/100000), but the estimated 225000 prevalent cases were distributed evenly among the three regions. The national per capita prevalence in 2004 was lower than in 1979-1982 by a factor of three (3.1, 95%CI 1.2-4.9), and the total number of cases was lower by a factor of two. CONCLUSIONS: Although the 2004 national survey may have underestimated the prevalence of smear-positive TB in Indonesia, there is strong evidence that it fell markedly between 1979-1982 and 2004.     

Risk factors for death during tuberculosis treatment in Orel, Russia.

SETTING AND METHODS: In Orel, high tuberculosis (TB) case fatality rates have persisted despite successful implementation of the World Health Organization (WHO) global TB control strategy. We conducted a case control study to identify risk factors for mortality among Orel TB patients reported from October 1999 through June 2001. Cases were patients who died within 8 months of treatment initiation. We analyzed data abstracted from medical records using conditional logistic regression. RESULTS: Over the 21-month period, 63/1069 (5.9%) TB patients overall and 45/521 (8.6%) sputum smear-positive patients died during treatment. Compared to 192 controls, independent risk factors for death for both smear-positive and smear-negative patients included unemployment (adjusted odds ratio [AOR] 4.9, 95% confidence interval [CI] 1.9-12.9), homelessness (AOR 9.5, 95% CI 1.3-70.9), congestive heart failure (AOR 5.4, 95% CI 1.9-15.9), chronic lung disease (AOR 2.4, 95% CI 1.1-5.4), cancer (AOR 7.2, 95% CI 1.2-45.0), bilateral disease on chest X-ray (AOR 6.3, 95% CI 2.3-17.1), and hyperbilirubinemia (AOR 5.2, 95% CI 1.1-25.3). Among deaths, the median time from treatment initiation to death was 35 days. CONCLUSIONS: The diagnosis and treatment of TB in suspects with the observed comorbidities and risk factors should be aggressively pursued. The association of unemployment and homelessness with mortality suggests a contribution of poverty to death during TB treatment.     

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.