Can the number of patients with presumptive tuberculosis lost in the general health services in Pakistan be reduced?

The frequency of patients with presumptive tuberculosis (TB) who are not investigated by sputum smear microscopy is unknown in Pakistan. Using a simple intervention comparing patient and laboratory registers, patients with presumptive TB were identified in two districts from July to December 2013, a list of missing patients was prepared and the patients traced. The intervention significantly reduced the number of patients with presumptive TB lost, from 8.5% before the intervention to 6.9% after. A systematic comparison of out-patient and laboratory registers, followed by tracing missing persons, can reduce the proportion of patients with presumptive TB lost before diagnosis.

Investigation of presumptive tuberculosis cases by private health providers: lessons learnt from a survey in Pakistan.

Pakistan's National Tuberculosis Control Programme (NTP) is missing data on many tuberculosis (TB) cases who visit private providers. A survey on the incidence and under-reporting of TB in Pakistan provided a database for exploring the investigation and referral of presumptive TB cases by private health providers. The survey showed that private health providers requested both sputum smear and X-ray for diagnostic investigations. Of 2161 presumptive TB cases referred, 1189 (55%) were sent for investigations to a district NTP TB centre, of whom only 314 (26.4%) were registered. This indicates an urgent need to strengthen the link between private health providers and NTP to enhance TB notification.

Le Programme national de lutte contre la tuberculose (PNT) du Pakistan manque de nombreux cas de tuberculose (TB) soignés par des prestataires de soins privés. Une enquête sur l'incidence et la sous-déclaration de la TB au Pakistan a fourni une base de données afin d'explorer les investigations réalisées en cas de présomption de TB et leur référence par les prestataires de soins privés. L'enquête a montré que les prestataires privés demandaient à la fois un frottis de crachats et une radiographie pour le diagnostic. Sur 2161 cas suspects de TB référés, 1189 (55%) ont été envoyés pour investigations à un centre anti-tuberculeux de district (PNT), parmi lesquels seulement 314 (26,4%) ont été enregistrés. Ceci met en évidence le besoin urgent de renforcer les liens entre les prestataires privés et les PNT afin d'améliorer la déclaration de la TB.

En el Programa Nacional contra la Tuberculosis (PNT) del Pakistán se están pasando por alto muchos casos de tuberculosis (TB) que acuden a los profesionales del sector privado. A partir de una encuesta sobre la incidencia de TB y la tasa de subnotificación en el país, se examinó la investigación de los casos y la remisión de las personas con presunción diagnóstica de TB por parte de los profesionales del sector privado. Se puso en evidencia que en el sector privado, los profesionales investigan la TB mediante la solicitud de la baciloscopia del esputo y además la radiografía de tórax. De los 2161 casos referidos por presunción diagnóstica, 1189 (55%) se remitieron para estudio al centro distrital PNT de TB y de ellos solo se registraron 314 (26,4%). Estos resultados indican la urgencia que existe de fortalecer los vínculos entre los profesionales del sector privado y el PNT, con el fin de mejorar la notificación de los casos de TB.

Estimating tuberculosis burden and case detection in Pakistan.

BACKGROUND: The National Tuberculosis Control Programme (NTP) in Pakistan has officially achieved a tuberculosis (TB) case detection rate of 64% in 2011, with an estimated incidence rate of 230 per 100 000 population, but is likely to be missing an unknown number of patients, particularly in the private sector. SETTING: All public and private sector providers in 12 randomly selected districts of Pakistan were included. OBJECTIVE: To estimate TB incidence and TB notification rates in Pakistan in 2012. DESIGN: A surveillance system was established among all eligible non-NTP providers in selected districts from January to March 2012. Record linkage and capture-recapture analysis was conducted. RESULTS: Of 8346 TB cases identified after record linkage, 6061 were registered with the NTP. The estimated number of unobserved TB cases was 10 030 (95%CI 7800-12 910), which meant that the proportion of notified cases was 32% (95%CI 17-49). The calculated annual incidence was 878 000 cases (95%CI 573 000-1 675 000), corresponding to a rate of 497/100 000 (95%CI 324-948) annually in the population. CONCLUSION: The study estimated that the proportion of cases notified to the NTP was low, with actual incidence rates being higher than official estimates. TB surveillance should be strengthened to reduce under-reporting.

Estimating the tuberculosis burden in resource-limited countries: a capture-recapture study in Yemen.

BACKGROUND: The lack of applicable population-based methods to measure tuberculosis (TB) incidence rates directly at country level emphasises the global need to generate robust TB surveillance data to ascertain trends in disease burden and to assess the performance of TB control programmes in the context of the United Nations Millenium Development Goals and World Health Organization targets for TB control. OBJECTIVE: To estimate the incidence of TB cases (all forms) and sputum smear-positive disease, and the level of under-reporting of TB in Yemen in 2010. METHODS: Record-linkage and three-source capture-recapture analysis of data collected through active prospective longitudinal surveillance within the public and private non-National Tuberculosis Programme sector in twelve Yemeni governorates, selected by stratified cluster random sampling. RESULTS: For all TB cases, the estimated ratio of notified to incident cases and completeness of case ascertainment after record linkage, i.e., the ratio of detected to incident cases, was respectively 71% (95%CI 64-80) and 75% (95%CI 68-85). For sputum smear-positive TB cases, these ratios were respectively 67% (95%CI 58-75) and 76% (95%CI 66-84). CONCLUSION: We estimate that there were 13 082 (95%CI 11 610-14 513) TB cases in Yemen in 2010. Under-reporting of TB in Yemen is estimated at 29% (95%CI 20-36).

Estimating tuberculosis burden and reporting in resource-limited countries: a capture-recapture study in Iraq.

BACKGROUND: The global target for tuberculosis (TB) control set by the Millennium Development Goals is a decrease in TB incidence by 2015. Direct measurement of country-level TB incidence using population-based methods is impractical, emphasising the need for well-performing surveillance systems and, where these are not available, accurate quantification of incidence and under-reporting of TB. OBJECTIVE: To estimate TB incidence and TB under-reporting in Iraq in 2011. METHODS: Prospective longitudinal surveillance was established among all eligible public and private non-National TB Programme (NTP) providers in a random sample of eight of the 18 Iraqi governorates from May to July 2011. Record linkage with the NTP and three-source capture-recapture analysis of data were then conducted using log-linear modelling. RESULTS: A total of 1985 TB cases were identified after record linkage. The NTP registered 1677 patients (observed completeness 84%). The estimated total number of TB cases was 2460 (95%CI 2381-2553), with identified TB cases representing 81% (95%CI 69-89) after adjusting for sampling design. The estimated ratio of notified to incident cases was 69% (95%CI 58-76). CONCLUSIONS: We estimate 14 500 TB cases in Iraq in 2011, of which 31% (95%CI 24-42) were unreported. TB surveillance needs to be strengthened to reduce under-reporting.

A nested case-control study on relapse predictors among tuberculosis patients treated in Yemen's NTCP.

SETTING: The National Tuberculosis (TB) Control Programme in Yemen. OBJECTIVE: To identify risk factors associated with TB relapse. METHODS: In a prospective nested case-control study, relapse cases were recruited from a cohort of pulmonary TB patients registered between July 2007 and June 2008. Four controls per case were randomly selected from the list of non-relapse patients. Three forms were used for data collection, which included interviews with the participants and review of their medical cards and TB registers. Multivariate logistic regression analysis was performed to identify independent risk factors for relapse. RESULTS: A relapse rate of 5.7% was found. Multivariate logistic regression analysis showed that unemployment, smoking, presence of cavitations, weight gain, weight loss, non-adherence during the continuation phase and diabetes were significantly associated with relapse (P < 0.05). CONCLUSION: Relapse rates can be reduced by ensuring that patients take their treatment regularly and are counselled effectively to stop smoking. Reinforcing the implementation of the DOTS strategy and strengthening the anti-smoking campaigns are important actions. Action to help unemployed patients, including free services and the creation of new job opportunities, should be adopted. Using rifampicin-based regimens in the treatment of cavitary TB and bi-directional screening in TB and diabetes patients are recommended.

Tuberculosis case finding in twenty-two countries of the Eastern Mediterranean Region.

A hypothetical model has been developed to evaluate the efficiency of the case-finding process in 22 countries of the Eastern Mediterranean Region. The model is based on the patient's pathway to care in a stepwise approach from the community to the tuberculosis (TB) management units. Performance was measured using indicators for each of the components of the Stop TB strategy, and a scoring system was developed. The indicators significantly associated with TB case detection were then reported. This tool can assist countries in evaluating the efficiency of their surveillance system in detecting cases.

Estimating tuberculosis case detection rate in resource-limited countries: a capture-recapture study in Egypt.

SETTING: Most countries endemic and highly endemic for tuberculosis (TB) still do not have reliable TB surveillance systems. Indirect estimation of TB incidence is needed to monitor the performance of the National Tuberculosis Programme (NTP) in the context of the World Health Organization implementation and impact targets for TB control. OBJECTIVE: To estimate the case detection rate (CDR) of all TB cases and sputum smear-positive TB cases in Egypt in 2007. METHODS: Record linkage and three-source capture-recapture analysis of data collected through active prospective longitudinal surveillance within the public and private non-NTP sector in four Egyptian governorates selected by stratified cluster random sampling. RESULTS: For all TB cases, the estimated CDR of NTP surveillance and completeness of case ascertainment after record linkage was respectively 55% (95%CI 46-68) and 62% (95%CI 52-77). For sputum smear-positive TB cases, these proportions were respectively 66% (95%CI 55-75) and 72% (95%CI 60-82). CONCLUSION: This pilot study shows that representative sampling, prospective surveillance in the non-NTP sector, record linkage and capture-recapture analysis can improve CDR estimation. For global, standardised and reliable use, this methodology should be further developed. Until then, all resource-limited countries should strengthen their national surveillance systems in the context of the Stop TB strategy.

Management of TB in the Private Sector in Khartoum; Sudan: Quality and Impact on TB Control

Introduction: Sudan has a large and growing private health sector. No survey was done in Sudan to show the extent of the use of private health care services by the population. Also precise data on tuberculosis (TB) diagnosis and treatment in the private sector are not available. Material and methods A facility-based cross-sectional survey was carried out during February2007-June 2007 in Khartoum state; whereby consented private physicians working in the all private clinics (n=110) were interviewed. Results This study showed that a large private sector exist in the country and deliver care to TB patients and reported the non-adherence of this sector to National Tuberculosis Program (NTP) guidelines. 59.1of the interviewed physicians correctly mentioned the TB treatment regimens; only 8(12.3) physicians that reported management of TB patients actually prescribed these regimens to their patients. Similarly; only 10(15.4) physicians requested sputum smear examination for TB diagnosis. Conclusion A considerable proportion of cases is inadequately managed by the private sector and is not notified to NTP. The information delivered by this study can be used to develop a workable Public-private mix (PPM) model with the private sector

Malaria preventive measures, health care seeking behaviour and malaria burden in different epidemiological settings in Sudan.

OBJECTIVES: To provide information about preventive measures and treatment seeking behaviour as well as an estimate of the malaria burden in different epidemiological settings for effective monitoring and evaluation of the ongoing efforts. METHODS: Cross-sectional survey carried out in four areas representing different levels of transmission to explore the use of preventive measures, care-seeking behaviour and accessibility in addition to point prevalence was followed by a follow-up phase in which the health workers registered and reported all fever cases including malaria. The relation between the reported malaria incidence, the product of symptomatic/asymptomatic ratio and the prevalence of confirmed malaria cases was used to develop the equation that could predict the true malaria incidence. RESULTS: Thousand households and 3628 individuals were surveyed. The presence of any net varied between 6.6% and 40%; the percentage of people who reportedly slept under mosquito nets in the previous night varied between 35 and 80. Prompt use of medications ranged between 14 and 48% with a delay of more than 24 h noticed in different areas. The mean number of individuals per household who reported use of anti-malarial drugs in the last 2 weeks ranged between 0.6 (SD = 0.92) and 1.2 (SD = 1.1), with variable cost per treatment and affordability. The prevalence of asymptomatic parasitaemia, fever and confirmed malaria at time of the survey differed by area. The incidence of malaria during the follow-up period was estimated to be 8.5, 178.6, 23.7 and 10.3 episodes per 1000 population in Malakal, Elrank, Elhosh and El Matama, respectively. Based on this, a prediction equation was developed. CONCLUSION: We found suboptimal health care seeking behaviour, coverage and use of preventive measures with a high malaria burden. We developed a model for future estimation of malaria episodes.

The decline of tuberculosis in Yemen: evaluation based on two nationwide tuberculin surveys.

SETTING: Yemen. OBJECTIVE: To review the epidemiological situation of tuberculosis (TB) in Yemen by conducting a tuberculin survey and by comparing the results obtained with those of a previous tuberculin survey from 1991. DESIGN: A nationwide tuberculin survey enrolling 31,276 schoolchildren aged between 7 and 12 years. RESULTS: Skin indurations were recorded for 28,499 schoolchildren, of whom 16,927 (59.4%) had no bacille Calmette-Guérin (BCG) scar. Analysis of the distribution of indurations was difficult as it did not show any bimodal pattern. Prevalence of infection and annual risk of tuberculosis infection (ARTI) were thus estimated using the mirror image and mixture methods, and not the cut-off point method. The two methods indicated similar results: respectively 0.45% and 0.51% for prevalence of infection, and 0.05% and 0.05% for ARTI. In comparison with the 1991 tuberculin survey, the average annual decline of ARTI was 9.0% by the mirror method and 5.5% by the mixture method. CONCLUSION: Yemen seems to have a low ARTI (0.05%), and TB infection seems to be declining considerably. Analysis of the survey results highlighted the limitations of tuberculin surveys in countries with comparable epidemiological situations.

Measuring tuberculosis burden, trends, and the impact of control programmes.

The targets for tuberculosis control, framed within the United Nations' Millennium Development Goals, are to ensure that the incidence per head of tuberculosis is falling by 2015, and that the 1990 prevalence and mortality per head are halved by 2015. In monitoring progress in tuberculosis control, the ultimate aim for all countries is to count tuberculosis cases (incidence) accurately through routine surveillance. Disease prevalence surveys are costly and laborious, but give unbiased measures of tuberculosis burden and trends, and are justified in high-burden countries where many cases and deaths are missed by surveillance systems. Most countries in which tuberculosis is highly endemic do not yet have reliable death registration systems. Verbal autopsy, used in cause-of-death surveys, is an alternative, interim method of assessing tuberculosis mortality, but needs further validation. Although several new assays for Mycobacterium tuberculosis infection have recently been devised, the tuberculin skin test remains the only practical method of measuring infection in populations. However, this test typically has low specificity and is therefore best used comparatively to assess geographical and temporal variation in risk of infection. By 2015, every country should be able to assess progress in tuberculosis control by estimating the time trend in incidence, and the magnitude of reductions in either prevalence or deaths.

Performance of IgG avidity in an area endemic for schistosomiasis in Egypt.

We assessed the performance of IgG avidity in the diagnosis of acute, chronic and recent (reinfection) on top of chronic schistosomal infections in patients treated with praziquantel. Immunoglobulin levels were studied in 111 patients with Schistosoma mansoni infection and 28 partially cured patients (not responding to the first dose of praziquantel treatment and almost cured after a second one). Before treatment all patients with schistosomiasis had elevated IgG levels, 75% of them also had increased IgM levels. Avidity index was high among all age groups. The increased IgM/IgG ratio and avidity index among children with schistosomiasis before treatment support the idea of reinfection. Treatment had no significant effect on the studied parameters. We conclude that unlike IgM and IgG antibody levels, IgG avidity test cannot be used to distinguish between recent and chronic infections.

Performance of IgG avidity in an area endemic for schistosomiasis in Egypt

We assessed the performance of IgG avidity in the diagnosis of acute, chronic and recent [reinfection] on top of chronic schistosomal infections in patients treated with praziquantel. Immunoglobulin levels were studied in 111 patients with Schistosoma mansoni infection and 28 partially cured patients [not responding to the first dose of praziquantel treatment and almost cured after a second one]. Before treatment all patients with schistosomiasis had elevated IgG levels, 75% of them also had increased IgM levels. Avidity index was high among all age groups. The increased IgM/IgG ratio and avidity index among children with schistosomiasis before treatment support the idea of reinfection. Treatment had no significant effect on the studied parameters. We conclude that unlike IgM and IgG antibody levels, IgG avidity test cannot be used to distinguish between recent and chronic infections

Profile of familial breast cancer in Alexandria, Egypt.

Nearly two thirds of the cancers which will appear in the next 25 years will occur due to unawareness of the public. In a population genetic study in Alexandria, Egypt, we found that the parents of 20% of the population are first degree cousins. Out of 9,587 female cancer cases registered in the last 10 years by the Alexandria Cancer Registry, 3250 (33%) were breast cancer. Twelve percent of breast cancer patients had a positive first-degree relative family history of cancer. Familial breast cancer (FBC) occurred at a younger age, ranging from 23-74 years, with a median equal to 46.5 years compared to 35-76 years, with a median of 54.5 years, in non-familial cases. The aim of this work was to show how familial cancer registries can produce useful data, helping to develop a data base of familial cancer, for the primary care program to control the morbidity of breast cancer in females by identification of those with a positive family history of cancer who are at a high risk of developing breast cancer.

The adequacy of diabetic care for children in a developing country.

UNLABELLED: A cross-sectional study was conducted over 4 months evaluating the quality of care provided to diabetic children in public children's hospitals in Alexandria, Egypt. RESULTS: Adult diabetologists were the main healthcare providers (HCP) (60.4%) in the School Health Insurance Hospital followed by paediatric diabetologists in the University Hospital. Insured children had a significantly higher frequency of physical examination, investigations and diabetes education compared to uninsured children. One-quarter of insured and 22% of uninsured children were performing self monitoring of blood glucose, while 45.2% of insured children were checking glucosuria at home compared to 34.0% of uninsured children. Premixed suspensions of biosynthetic human insulin, administered mainly via a syringe, was the most commonly prescribed insulin type with little possibility for personal initiative. Acute diabetic complications were also higher in uninsured compared to insured children. The frequency of these life threatening acute diabetic complications in the school health insurance system is estimated to be approximately 12.7 severe hypoglycaemic and 57.2 hyperglycaemic/ketoacidotic episodes per 1000 diabetic children per year. Recurrence of diabetic emergencies was significantly higher among children of parents with lower educational levels and children living in semiurban and rural residence. Children with recurrent diabetic emergencies had lower educational achievement, and more grade repeating and school absence during the year. CONCLUSION: The results of this study appear to reflect marked deficiencies in the provision of information to children with diabetes and their parents in a developing country. A need for public-education strategies, consensus about treatment recommendations, use of more flexible insulin regimens, and devices for home monitoring is identified.

Current treatment modalities of breast-cancer patients in Alexandria, Egypt.

Despite great advances in the treatment of breast cancer during recent years, many breast cancer patients still do not receive appropriate treatment. Data were collected during a 1-year period from nine general hospitals aiming at evaluating the quality of care delivered to breast cancer patients in Alexandria, Egypt. A total of 565 breast cancer patients were involved. The highest frequency of cases was diagnosed in stage II followed by stage III. Patey's modified radical mastectomy was the most commonly performed operation (82.65% of cases), regardless of the clinical stage or health facilities. Hormonal receptor status was rarely performed. There was no consensus regarding the type of systemic therapy (hormonal, chemotherapy or combined) to be administered for each clinical stage and menopausal status. Concerning postoperative radiotherapy, it was invariably the rule, regardless of the clinical stage. We conclude that, despite some improvement over the last few years (shorter diagnostic delay, larger use of standard classifications, and less radical surgery), the quality of management of breast cancer in Egyptian general hospitals is still not satisfactory.

Quality of care of children with chronic diseases in Alexandria, Egypt: the models of asthma, type I diabetes, epilepsy, and rheumatic heart disease. Egyptian-Italian Collaborative Group on Pediatric Chronic Diseases.

OBJECTIVES: To evaluate the quality of care delivered to children suffering from index chronic diseases using specific indicators of health care delivery and to study the predictors of suboptimal quality of care (SQC) and its outcome on children. DESIGN: Over a 9-month period, guidelines for optimal care were formulated. A specific questionnaire for every studied chronic disease was prepared in collaboration with the clinicians in charge of the diseased children (66% pediatricians and pediatric specialists and 34% adult specialists). The clinicians were asked to write the details of daily practice, ie, how these children were managed on a routine basis as well as in an emergency situation. A cross-sectional study was conducted over a 4-month period and included 953 children suffering from bronchial asthma (BA), childhood epilepsy (CE), type I diabetes mellitus (IDDM), and rheumatic heart disease (RHD). A systematic random sample of children was selected from children visiting the ambulatory settings of all children's hospitals. Every fourth child was selected on 2 randomly chosen days each week, while all diseased children admitted in the hospital settings of the children's hospitals during the study were included. A general form describing the impact of the diseases on the child was prepared. A network of clinicians was created in all children's hospitals; seminars were held during which the content validity of the questionnaire was tested. Items were evaluated for their internal consistency using the Cronbach alpha. According to the degree of adherence to the recent therapeutic guidelines concerning selected indicators of the quality of care specific to every disease, children were categorized as receiving optimal quality of care or SQC. These indicators were: the use of inhaled bronchodilators in acute asthmatic attacks in mild asthma and the use of the prophylactic drugs (inhaled sodium cromoglycate or inhaled beclomethasone) in moderate to severe chronic BA in between acute asthmatic attacks; compliance with antiepileptic drugs in epileptic children; regular performance of self-monitoring of blood glucose and/or urine testing in diabetic children; and compliance with prophylactic antibiotics in children suffering from RHD. The records of the outpatient clinics for ambulatory and hospitalized cases were reviewed to assess the degree of compliance with the prescribed management before the index visit. Sociodemographic characteristics and health care system-related predictors of SQC were analyzed via stepwise logistic regression analysis. The impact of illness on the child was assessed by 7 items which were: dependence on parents in domestic activities, level of activity compared with peers, mood compared with peers, level of socializing, degree of discomfort attributable to illness, level of physical disadvantage, and urinary incontinence. Factor analysis with Varimax rotation was performed on items related to the impact of illness. Parental satisfaction with care was rated as excellent, very good, fair, or poor. Information on school outcome was obtained by asking the caretakers whether the child was able to attend school regularly despite his sickness. Scholastic achievement was also rated as excellent, very good, good, and acceptable. Parents were asked whether the child had ever repeated a grade because of his sickness. SETTING: Ambulatory and hospital settings of all children's hospitals in Alexandria, Egypt. RESULTS: Only 52% of mild asthmatics were given inhaled bronchodilators during acute attacks and 6.84% of moderate to severe asthmatics were taking prophylactic drugs (inhaled sodium cromoglycate and/or inhaled beclomethasone) between acute attacks. Similarly, only 53 of 134 (39.6%) of diabetic children were regularly performing self-monitoring of blood glucose and/or urine testing. In contrast, in epileptic children, 121 of 173 (69.9%) were judged as being compliant by their managing clinicians and more than two

Congenital heart disease among school children in Alexandria, Egypt: an overview on prevalence and relative frequencies.

A study was undertaken to determine the prevalence and relative frequencies of congenital heart diseases diagnosed by echocardiography among school children in Alexandria, Egypt. The study was conducted during a 1-year period (1 May 1995-1 May 1996) at the Students' Health Insurance Hospital, which is a referral center for all health insurance units, providing an echocardiography service. The prevalence of congenital heart diseases (CHD) among school children accounted for 1.01/1,000. There was a male predominance in cases of pulmonary stenosis and single ventricle, while in cases of patent ductus arteriosus, mitral valve prolapse, and partial atrioventricular canal there was a female predominance. The commonest cardiac defects were ventricular septal defects, pulmonary stenosis, and atrial septal defects. Pulmonary stenosis ranked the second commonest defect and is a peculiar finding in our Egyptian population. The mere presence of these cardiac defects in school children is an indicator of the poor quality of care provided to this growing childhood population.