Trends of ambulatory management of pulmonary tuberculosis: experience in Mehalla El Kobra chest center, Egypt

ABSTRACT

A major chest center, in Mehalla El Kobra, Egypt, was chosen to carry out the present study. A total of 812558 individuals attended the dispensary during the 25 years covered in the study; starting from 1971 and ending in 2001, inclusive our of these, 5179 cases were diagnosed as being turberculous The pulmonary cases were 4831 and the extra-pulmonary were 348. The trend in the incdenee of pulmonary cases was declining, being 99.2%, of all T.B. cases, at the starting year, 1971, while it dropped to 77.1% in the last year, 2001. The analogous figures for extrapulmonary cases are rising i.e. 0.8% and 22.8%, respectively. The positive yield on sputum smear, rose from 12.1% of the pulmonary cases in the year 1977 to 70.4% in the year 2001, Hence there is prompt and active case finding at the center, by sputum microscopy, among the pulmonary T.B. patients. Before the year 1992 short-term therapy was used only in hospitalized and not in ambulatory chest center patients. It was instituted, for some cases together with other cases who received only the old standard treatment in the center, for ambulatory cases in the year, 1992. It was thus decided to further analyze the data of the trends of tuberculosis treatment, in the chest center, starting from this year; 1992 and for the following 10 year; up to 2001; inclusive. The initial number of pulmonary T.B. cases during this period was 946. Their contacts; presenting for examination in the dispensary, were 3942, viz 4.1 contacts for every index case. The overall rate of detection of T.B. among the contacts, was 4.7%. Out of the 946 original pulmonary T.B. cases during the 10 studied years, the outcome of management could be traced in 634 patients; at the time of the study during 2002, i.e. 67% 40.6% of the traced cases received the older traditional standard therapy, before the nation-wide application of the recent short-term therapy. Thus short-term therapy was prescribed to 59.6% of the whole traced cases. The favourable outcome; namely cured and completed treatment cases, was achieved in 70.6% of those on short-term therapy, while the analogous figure for cases on standard therapy, was 60.6% [p < 0.05]. The analogous figures for unfavourable outcome were 20.3% and 34.1% for short-term and standard therapy cases, respectively [p < 0.05]. Cases referred on their own request, to other centers, for further management were not included. The application of DOTS therapy definitely improved the outcome. The defaulting rate, thanks to DOTS, dropped to 7.6% as whole, when compared to 21.5% in the era before DOTS application [p <0.005]. The same beneficial trend could not be demonstrated, as far as treatment failure is concerned, possibly due to such cases being resistant, which may need DOTS PLUS; as a policy. Such policy is not yet applicable, at the surveyed area. The over-all look is promising and hence perfect combat, on the way of irradication, may be expected and even foreseen, in our local circumstances