Evaluation of a short training course of chest X-ray interpretation for the diagnosis of paediatric TB.

BACKGROUND: Chest X-ray (CXR) interpretation is challenging for the diagnosis of paediatric TB. We assessed the performance of a three half-day CXR training module for healthcare workers (HCWs) at low healthcare levels in six high TB incidence countries. METHODS: Within the TB-Speed Decentralization Study, we developed a three half-day training course to identify normal CXR, CXR of good quality and identify six TB-suggestive features. We performed a pre-post training assessment on a pre-defined set of 20 CXR readings. We compared the proportion of correctly interpreted CXRs and the median reading score before and after the training using the McNemar test and a linear mixed model. RESULTS: Of 191 HCWs, 43 (23%) were physicians, 103 (54%) nurses, 18 (9.4%) radiology technicians and 12 (6.3%) other professionals. Of 2,840 CXRs with both assessment, respectively 1,843 (64.9%) and 2,277 (80.2%) were correctly interpreted during pre-training and post-training (P < 0.001). The median reading score improved significantly from 13/20 to 16/20 after the training, after adjusting by country, facility and profession (adjusted ß = 3.31, 95% CI 2.44-4.47). CONCLUSION: Despite some limitations of the course assessment that did not include abnormal non-TB suggestive CXR, study findings suggest that a short CXR training course could improve HCWs' interpretation skills in diagnosing paediatric TB.

CONTEXTE: L'interprétation de la radiographie thoracique (CXR) est un défi pour le diagnostic de la TB pédiatrique. Nous avons évalué la performance d'un module de formation de trois demi-journées sur la CXR destiné aux agents de santé (HCWs) dans six pays où l'incidence de la TB est élevée et où les ressources en services de santé sont limitées. MÉTHODES: Dans le cadre de l'étude de décentralisation TB-Speed, nous avons mis au point un cours de formation de trois demi-journées pour identifier une CXR normale, une CXR de bonne qualité et six caractéristiques suggestives de la TB. Nous avons effectué une évaluation avant et après la formation sur un ensemble prédéfini de 20 clichés radiologiques. Nous avons comparé la proportion de CXR correctement interprétées et le score médian de lecture avant et après la formation à l'aide du test de McNemar et d'un modèle linéaire mixte. RÉSULTATS: Sur les 191 HCWs, 43 (23%) étaient des médecins, 103 (54%) des infirmières, 18 (9,4%) des techniciens en radiologie et 12 (6,3%) d'autres professionnels. Sur 2 840 CXR avec les deux évaluations, respectivement 1 843 (64,9%) et 2 277 (80,2%) ont été correctement interprétées avant et après la formation (P < 0,001). Le score médian de lecture s'est amélioré de manière significative, passant de 13/20 à 16/20 après la formation, après ajustement par pays, établissement et profession (ß ajusté = 3,31; IC 95% 2,44­4,47). CONCLUSION: Malgré certaines limites de l'évaluation du cours qui n'incluait pas de CXR anormale non évocatrice de TB, les résultats de l'étude suggèrent qu'une formation courte sur la CXR pourrait améliorer les compétences d'interprétation des HCWs dans le diagnostic de la TB pédiatrique.

Revising the tuberculosis recording and reporting information system.

OBJECTIVE: The tuberculosis recording and reporting information system (TB R&R), one of the five pillars of the DOTS strategy, has undergone a revision to comply with the new elements of the Stop TB Strategy and to ensure standardisation of essential TB information. DESIGN: An expert group on TB R&R, including the main technical partners, held a series of consultations with the Stop TB Working Groups and countries. Draft revised forms were field tested by countries with the participation of technical partners. A survey was conducted by the World Health Organization (WHO) in 105 countries. RESULT: The main changes in the TB R&R are the inclusion of TB-HIV activities (the leading reason for change at the country level), smear examinations and culture for settings performing this test routinely and the management of patient drug kits. The revised forms help monitor contributions from all care providers and community workers. The package of forms is presented in three sets: 1) essential data, 2) setting with routine culture and 3) additional data. CONCLUSION: The revised R&R forms were endorsed by the WHO, the KNCV Tuberculosis Foundation, the International Union Against Tuberculosis and Lung Disease and the US Centers for Disease Control and Prevention in 2007. They are now available in English, French and Spanish, and are adopted in most countries.

From tuberculin to prevalence survey in Cambodia.

OBJECTIVES: To assess the annual risk of tuberculosis infection (ARTI) in urban and rural areas of Cambodia in 1995, and to document the decreasing trend since 1955. To compare tuberculosis (TB) estimates based on ARTI with active case finding activities and tuberculosis notification data. METHODS: Two national representative samples of 3524 and 4407 schoolchildren were tested with 1 TU of tuberculin, PPD RT23/Tween 80. Estimates based on ARTI were compared with the results of both active TB case finding and case notification, using WHO/IUATLD-recommended quarterly reports available country-wide since 1994. FINDINGS: ARTI was estimated to be 0.75% (0.56-0.96%) in Cambodia in 1995 using a 10 mm induration cut-off point. The average ARTI annual decrease was 4.2% per year in Phnom Penh and 4.9% per year in the provincial areas from 1955 to 1995. The estimated TB incidence based on urban ARTI is 2.4 times lower than the TB notification rate in 1995, and 4.3 times lower than the incidence estimated from the screening survey. CONCLUSION: The ARTI has regularly declined over time. Predicting the TB incidence from ARTI should be complemented in Cambodia by ongoing prevalence surveys. More accurate estimates are needed to maintain political support for the National Tuberculosis Programme.

Estimate of the global market for rifampicin-containing fixed-dose combination tablets.

SETTING: Despite WHO and IUATLD recommendations to use fixed-dose combination (FDC) tablets for treatment of tuberculosis, more than 75% of all rifampicin used in the public sector globally is administered as single drug tablets. OBJECTIVE: To estimate the potential global market for rifampicin-containing FDCs in the public and private sectors. DESIGN: The public sector market for FDCs was calculated from the number of tuberculosis cases notified to WHO for 1996 and from information on treatment regimens currently used in each country. The private sector market was calculated from the estimated number of treated tuberculosis cases and the treatment regimens presumed to be used in the private sector. RESULTS: The potential global market for the four-drug FDC tablet (rifampicin 150 mg, isoniazid 75 mg, pyrazinamide 400 mg and ethambutol 275 mg) is 305 (90%CI 145-505) million tablets per year, 105 (90%CI 50-160) and 200 (90%CI 95-345) million of which would be distributed in the public and private sectors, respectively. The uncertainty of the estimate remains considerable, as shown by the 90% confidence intervals. CONCLUSION: The study demonstrated a large potential global market for FDCs that should encourage pharmaceutical manufacturers to produce WHO-recommended dosages of FDCs at affordable prices.

Availability of quality fixed-dose combinations for the treatment of tuberculosis: what can we learn from studying the World Health Organization's vaccine model?

SETTING: In efforts to promote the use of fixed-dose combinations (FDCs) for the treatment of tuberculosis (TB), the World Health Organization (WHO) and partners address the issue of quality assurance. OBJECTIVE: To provide guidance for the development of strategies for quality assurance of FDCs. DESIGN: This review examines the WHO strategies for and experience with quality assurance and supply of vaccines. RESULTS: Several elements in the strategies for quality assurance and supply of vaccines may be applicable for FDCs. At national level, the important strategies are to strengthen National Regulatory Authorities (NRA) and procurement systems and develop planning activities. Stressing quality assurance of FDCs in training activities for regulatory personnel and recommending that aid agencies require adherence to quality assurance policies as conditions for support would promote the implementation of quality assurance of FDCs at country level. At the global level, pre-qualification of manufacturers of FDCs should be explored as a mechanism to assure quality. The pre-qualification process should include evaluation of product files, initial testing for compliance and consistency of specifications, and site visits to producers and NRAs. The vaccine model defines criteria for reassessment that can be used for FDCs.

DOTS (Directly Observed Treatment Strategy) project in Mongolia, 1995.

OBJECTIVE: To establish a tuberculosis (TB) control programme consistent with recommendations made by the WHO and the International Union Against Tuberculosis and Lung Disease (IUATLD) in a country where, as in control programmes of the former USSR, TB management previously relied on active case-finding with radiology and long-term monitoring and treatment of patients. DESIGN AND METHODS: A pilot DOTS strategy (directly observed treatment, short course) project was implemented in Dornod Aimak, Eastern Mongolia During a 6-week period, individuals with chronic cough of > or =3 weeks were screened with sputum smear microscopy. Smear-positive patients received a supervised 6-month regimen (2SRHZ/4RH). Outcome was assessed with smear examination 2, 5, and 6 months after the initiation of treatment. RESULTS: Screening of 1241 symptomatic individuals identified 169 smear-positive TB cases (14%). Most of them (92%) were cured as demonstrated by documented sputum conversion. Five patients completed treatment, but were not available for follow-up smear examination, four patients died and four defaulted. CONCLUSION: The DOTS strategy was successfully introduced in a former socialist model country, paving the way to national DOTS implementation in Mongolia. It may serve as an example for countries with a health care tradition similar to that of the Commonwealth of Independent States.

DOTS in Cambodia. Directly observed treatment with short-course chemotherapy.

SETTING: Since the 1970s, Cambodia, a country of 10 million people in South East Asia, has experienced war, genocide and the virtual dismantling of the health system. It has a severe tuberculosis (TB) problem, with a new tuberculosis case notification rate, all forms, of about 150 per 100000 population and a tuberculosis programme, established in the early 1980s, achieving cure rates of only 40-50% in the last decade. OBJECTIVE: To describe the implementation of a DOTS programme (directly observed treatment with short-course chemotherapy) under difficult conditions and its rapid success on a nation-wide scale. DESIGN: The World Health Organisation's recommended strategy was implemented in a phased manner throughout the country from 1994. The resources for TB drugs and running costs came from 13 sources. The DOTS strategy was gradually introduced after training and with regular supervision into 120 TB units inside general public hospitals at provincial and district level, after a mapping exercise; 75% of tuberculosis cases, all forms, are hospitalized during the entire initial phase and 85% of the total number of tuberculosis cases received free food from the World Food Programme. RESULTS: Two and a half years after the start of the new programme, DOTS was implemented in 85% of all public hospitals. In 1996, case-detection rates had reached 127 smear-positive PTB (pulmonary tuberculosis) and 149 PTB all forms per 100000 inhabitants; 90% of all tuberculosis patients received DOTS. From January 1994 to June 1995, 4164 new cases started category 1 treatment (2ERHZ/6EH). Of these, 89% were cured or completed treatment, 5% defaulted, 3% died, 1% were treatment failures and 2% transferred out. CONCLUSION: The DOTS strategy can be successfully implemented in even very difficult conditions such as those found in Cambodia.