Re-treatment tuberculosis cases categorised as "other": are they properly managed?

BACKGROUND: Although the World Health Organization (WHO) provides information on the number of TB patients categorised as "other", there is limited information on treatment regimens or treatment outcomes for "other". Such information is important, as inappropriate treatment can lead to patients remaining infectious and becoming a potential source of drug resistance. Therefore, using a cohort of TB patients from a large registration centre in Lilongwe, Malawi, our study determined the proportion of all TB re-treatment patients who were registered as "other", and described their characteristics and treatment outcomes. METHODS: This retrospective observational study used routine program data to determine the proportion of all TB re-treatment patients who were registered as "other" and describe their characteristics and treatment outcomes between January 2006 and December 2008. RESULTS: 1,384 (12%) of 11,663 TB cases were registered as re-treatment cases. Of these, 898 (65%) were categorised as "other": 707 (79%) had sputum smear-negative pulmonary TB and 191 (21%) had extra pulmonary TB. Compared to the smear-positive relapse, re-treatment after default (RAD) and failure cases, smear-negative "other" cases were older than 34 years and less likely to have their HIV status ascertained. Among those with known HIV status, "other" TB cases were more likely to be HIV positive. Of TB patients categorised as "other", 462 (51%) were managed on the first-line regimen with a treatment success rate of 63%. CONCLUSION: A large proportion of re-treatment patients were categorised as "other". Many of these patients were HIV-infected and over half were treated with a first-line regimen, contrary to national guidelines. Treatment success was low. More attention to recording, diagnosis and management of these patients is warranted as incorrect treatment regimen and poor outcomes could lead to the development of drug resistant forms of TB.

The diagnosis of extrapulmonary tuberculosis in Malawi.

There is little information on a country-wide basis in sub-Saharan Africa about how the diagnosis of extra-pulmonary tuberculosis (EPTB) is made. A country-wide cross-sectional study was carried out in 40 non-private hospitals in Malawi which register and treat (TB) patients in order to assess diagnostic practices in adults registered with EPTB. All patients aged 15 years and above in hospital on treatment for EPTB were reviewed usingTB registers, case note files and clinical assessment. There were 244 patients, 132 men and 112 women whose mean age was 36 years. In 138 (57%) patients, all appropriate procedures and investigations, commensurate with hospital resources, had been carried out. Of 171 EPTB patients with cough for 3 weeks or longer, 138 (81%) submitted sputum specimens for smear microscopy of acid-fast bacilli (AFB). A confirmed diagnosis ofTB was made in 15 (6%) patients based on finding AFB or caseating granulomas in specimens. In 157 (64%) patients, the diagnosis of EPTB was considered to be correct. In 46 (19%) patients the diagnosis was considered to be TB, although different from the type of EPTB with which the patient was registered. In 39 (16%) patients an alternative non-TB diagnosis was made and in two (1%) patients it was not possible to make a decision. Diagnostic practices need to be improved, and ways of doing this are discussed.

Communicable disease control programmes in Malawi.

A series of half-day meetings were held between the Malawi National TB Control Programme and the other seven disease control programmes housed in the Community Health Science Unit (CHSU) to look at the structure and function of these programmes. Data were collected into a structured proforma on human resources, sources of international funding, policies and disease control activities, supportive activities, management organization, monitoring and evaluation and operational research. A number of constraints were identified, particularly in the areas of technical supervision, monitoring and evaluation and operational research. Serious consideration should be given to allow CHSU to have a more centralised and unifying role, with the aim of creating a more efficient and better-funded national communicable disease control service.