Surveillance of tuberculosis in Malawian prisons.

SETTING: The Malawi National Tuberculosis Programme (NTP) has collaborated with the Prison Health Services (PHS) on tuberculosis (TB) control in prisons since 1996. Information on case finding and treatment outcomes is routinely collected, but there has not been any recent countrywide review of these prison data. OBJECTIVES: To determine 1) the number of prisoners registered for TB in 2007, 2) TB treatment outcomes in 2006 and 3) training of prison health care staff in all Malawian prisons. DESIGN: Descriptive study involving a review of 2006 and 2007 data collected by the NTP during surveillance in 2008. RESULTS: In 2007, 278 TB patients were registered in Malawian prisons, representing a TB case notification rate of 835 per 100 000 (higher than that in the general population, at 346/100 000). The treatment success rate for new smear-positive TB cases for 2006 was 73%, lower than the national average of 78%. In all, 52 prison health care staff had received 1 week of training in TB management, usually just after starting work in the prison. CONCLUSIONS: TB case notifications in Malawian prisons were higher than in the general population and treatment outcomes less favourable. The NTP and PHS need better collaboration to improve TB control in Malawian prisons.

Reduced tuberculosis case notification associated with scaling up antiretroviral treatment in rural Malawi.

OBJECTIVE: To report on the trends in new and recurrent tuberculosis (TB) case notifications in a rural district of Malawi that has embarked on large-scale roll-out of antiretroviral treatment (ART). METHODS: Descriptive study analysing TB case notification and ART enrolment data between 2002 and 2009. RESULTS: There were a total of 10,070 new and 755 recurrent TB cases. ART scale-up started in 2003, and by 2007 an estimated 80% ART coverage had been achieved and was sustained thereafter. For new TB cases, an initial increase in case notifications in the first years after starting ART (2002-2005) was followed by a highly significant and sustained decline from 259 to 173 TB cases per 100,000 population (χ(2) for trend 261, P < 0.001, cumulative reduction for 2005-2009 = 33%, 95%CI 27-39). For recurrent TB, the initial increase was followed by a significant drop, from 20 to 15 cases/100,000 (χ(2) for linear trend = 8.3, P = 0.004, constituting a 25% (95%CI 9-49) cumulative reduction between 2006 and 2009. From 2005 to 2009, ART averted an estimated 1164 (95%CI 847-1480) new TB cases and 78 (95%CI 23-151) recurrent TB cases. CONCLUSIONS: High ART implementation coverage is associated with a very significant declining trend in new and recurrent TB case notifications at population level.

Prevalence of smear-positive pulmonary tuberculosis among prisoners in Malawi: a national survey.

A cross-sectional cell-to-cell survey was conducted in 18 of 22 prisons in Malawi to determine the period prevalence of smear-positive pulmonary tuberculosis (PTB). In each prison, prisoners were interviewed using a structured questionnaire. Prisoners with cough of >1 week's duration were investigated by sputum smear examination. Of 7661 prisoners, 3887 had cough of > or =1 week, of whom 3794 submitted three sputum specimens: 54 (0.7%) had smear-positive PTB. The prevalence of PTB was higher in large urban prisons (1.1%) than in district prisons (0.3%, P < 0.001). More needs to be done to improve TB control in urban prisons.

Scaling up HIV/AIDS and joint HIV-TB services in Malawi.

Two country-wide surveys were undertaken to assess progress in scaling up human immunodeficiency virus/ acquired immune-deficiency syndrome (HIV/AIDS) and HIV-tuberculosis (TB) services in the public health sector in Malawi between 2002 and 2003. In 2003, 118 sites were performing counselling and HIV testing compared with 70 in 2002. There were 215 269 HIV tests carried out in 2003 compared with 149 540 in 2002, the largest increases being in pregnant women (from 5059 to 26791), patients with TB (from 2130 to 3983) and patients/clients attending health facilities (from 35 407 to 79 584). In 2003, 3703 patients with AIDS were started on antiretroviral therapy compared with 1220 patients in 2002.

Auditing the new decentralised oral treatment regimens in Malawi.

SETTING: All 44 non-private hospitals in Malawi treating tuberculosis (TB) cases in which oral regimens were used allowing patients during the initial phase to receive directly observed treatment (DOT) from health centres or guardians at home. OBJECTIVES: A country-wide audit of the oral regimens to determine: 1) TB ward bed occupancy rates, 2) patient DOT options, 3) patients' knowledge of treatment and 4) treatment outcomes compared to those obtained with previous treatment regimens. DESIGN: Retrospective data collection using registers and treatment cards. Prospective interviews with patients. Inspections of TB wards. RESULTS: There were 1513 TB beds occupied by 807 (53%) TB patients. Over 50% of 4793 patients registered with different types of TB chose guardian-based DOT. For 266 patients with pulmonary TB the correct knowledge about total duration of treatment (45%), all three DOT options (62%) and the months for giving follow-up sputum (16%), was poor. There were differences in treatment outcomes between TB patients on oral compared with previous regimens. With oral regimens, rates of unknown outcome were high. CONCLUSION: Oral treatment regimens are associated with reduced bed occupancy rates on TB wards. However, rates of unknown outcome are increased, and TB control is therefore weakened.

Prescriptions and dosages of anti-tuberculosis drugs in the National Tuberculosis Control Programme of Malawi.

SETTING: All 44 non-private hospitals in Malawi treating pulmonary tuberculosis (PTB) patients with an oral regimen (0.5RHZE/1.5R3H3Z3E3/6HE). OBJECTIVES: In new smear-positive PTB patients, to determine whether: 1) numbers of tablets were correctly prescribed according to pre-treatment weights, and 2) medication dosages were adequate, too low or too high. DESIGN: Retrospective review of TB registers and TB treatment cards for patients registered with new smear-positive PTB between 1 October and 31 December 2001. RESULTS: Of 1970 patients aged > or = 15 years, 1211 (62%) had treatment cards and pre-treatment weights. Incorrect prescriptions were given to 88 (7%), and many of these received dosages of anti-tuberculosis drugs that were too high or too low. For those receiving correct prescriptions, daily treatment in the initial and continuation phases was generally associated with adequate dosages of drugs. However, in the initial intermittent phase, between 3% and 40% of patients received anti-tuberculosis drug dosages that were too low. CONCLUSION: A small percentage of patients receive incorrect prescriptions, which can be resolved by training and supervision. In those receiving correct prescriptions, intermittent treatment provides dosages that are sometimes too low. Weight bands for intermittent treatment should be re-examined.

When are follow-up sputum smears actually examined in patients treated for new smear-positive pulmonary tuberculosis?

SETTING: All 44 non-private hospitals (four central, 22 district and 18 mission) in Malawi that registered and treated tuberculosis (TB) cases, October-December 2001. OBJECTIVES: To determine, in new smear-positive pulmonary tuberculosis (PTB) patients, for the 2-, 5- and 7-month smear examinations, 1) the proportion with smears examined and 2) the actual timing of smear examination. STUDY DESIGN: Retrospective data collection using TB registers, TB treatment cards and laboratory sputum registers. Timing of smear examinations was judged acceptable if 2-month smears were examined at 2 or 3 months, 5-month smears at 4, 5 or 6 months and 7-month smears at 6, 7, 8 or 9 months. RESULTS: Of 1994 patients, for those alive and on treatment, 78% had smears definitely examined at 2 months, 75% at 5 months and 74% at 7 months. Of these, 82% had smears examined at an acceptable time for the 2-month smear, 71% for the 5-month smear and 78% for the 7-month smear. Smears were examined after the 8-month treatment regimen for the 2- and 5-month smear in respectively 2% and 9% of patients. Smears were done more frequently in female than male patients, and in district/mission hospitals than central hospitals. Smears were done at acceptable times more frequently in younger than older patients and in mission/central hospitals than district hospitals. CONCLUSION: During supervision, the actual time of follow-up sputum smear examinations needs to be monitored more closely.

Characteristics and outcome of tuberculosis patients whose sputum smears are positive at or after 5 months of treatment.

A country-wide survey was carried out to assess the management of new smear-positive pulmonary TB (PTB) patients whose sputum smears were recorded as positive 5 months or later during treatment. During 2000 and 2001, there were 250 patients, of whom 161 (64%) had positive smears at 5 months and 89 at 7 months. Several inconsistencies and inadequacies in management were identified which need to be remedied: 7% of patients were assessed on one sputum specimen instead of two, and 17% on the basis of one positive smear result; 47% of patients with 5-month positive smears and 52% with 7-month positive smears had sputum smears examined too early or too late; 14% of patients with 5-month positive smears continued treatment, and over 60% of these were recorded as 'cured'.

Voluntary counselling, HIV testing and adjunctive cotrimoxazole are associated with improved TB treatment outcomes under routine conditions in Thyolo District, Malawi.

SETTING: Two rural districts in Malawi: Thyolo, where voluntary counselling and human immunodeficiency virus (HIV) testing (VCT) is offered to all tuberculosis (TB) patients and adjunctive cotrimoxazole to HIV positives, and Mulanje, where no such interventions are offered. OBJECTIVES: For all TB patients registered in 2001: 1) to determine the uptake of VCT and cotrimoxazole in Thyolo, and 2) to compare treatment outcomes between Thyolo and Mulanje. DESIGN: A cohort study using routinely collected programme data. RESULTS: There were 1239 TB patients in Mulanje and 1103 in Thyolo. In Thylo, 1064 (97%) patients consented to VCT, 1006 were HIV tested (91%) and 761 (69%) were started on cotrimoxazole a median of 4 days from registration; 77% of patients tested in Thyolo were HIV-positive. For all TB patients, in Thyolo and Mulanje, treatment success was respectively 75% and 61% (P < 0.001); death was 21% and 25% (P = 0.026); and other outcomes were 4% and 14% (P < 0.001). The adjusted relative risks of treatment success (1.23), death (0.84) and other outcomes (0.26) in Thyolo were significantly different from those in Mulanje (P < 0.001). CONCLUSION: VCT and adjunctive cotrimoxazole is well accepted by TB patients in Thyolo and, with other HIV care and support services, is associated with good treatment outcome indicators for the National Tuberculosis Programme. This intervention is being expanded to other districts in Malawi, and other African countries should consider a similar approach to the dual HIV-TB epidemic.

Decentralisation of tuberculosis services in an urban setting, Lilongwe, Malawi.

SETTING: Lilongwe, the capital of Malawi, one of the countries in the world badly affected by the human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) epidemic. OBJECTIVE: In the face of a rising burden of tuberculosis (TB) fuelled by HIV, to evaluate the impact on the Lilongwe district tuberculosis programme performance of decentralisation of TB services, including extending the range of options for supervision of directly observed treatment (DOT) during the initial phase of treatment, and using a fully oral, intermittent regimen. DESIGN: Prospective assessment under programme conditions of 1) duration of hospital stay, 2) bed occupancy and 3) 8-month treatment outcomes in a cohort of patients registered before (1997) and after (1998) the introduction of decentralisation of TB services. RESULTS: The number of new patients (all forms) registered in Lilongwe district was 3144 in 1997 and 3761 in 1998. There were significant differences (P < 0.05) between all outcomes that were compared. In 1998, bed occupancy dropped by 38%; among smear-positive patients, the average length of hospital stay fell from 58 days in 1997 to 16, the cure rate was higher (64% vs. 56%), default rate was lower (5% vs. 19%), and treatment completion rate was lower (2% vs. 4%); among smear-negative patients, the treatment completion rate was higher (50% vs. 33%), default rate was lower (23% vs. 55%), and death rate was higher (17% vs. 4%). This death rate is attributable to improved follow-up and reporting of outcomes, rather than to increased deaths. CONCLUSION: Programme implementation of decentralised TB services in Lilongwe, including an extended range of supervision options for DOT and the use of an ambulatory treatment regimen, achieved reduced hospital stay and bed occupancy and good treatment outcomes.

Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Lilongwe District, Malawi.

SETTING: Lilongwe District, Malawi. OBJECTIVE: To assess the cost and cost-effectiveness of new treatment strategies for new pulmonary tuberculosis patients, introduced in 1997. METHODS: For new smear-positive pulmonary patients, two strategies were compared: 1) the strategy used until the end of October 1997, involving 2 months of hospitalisation at the beginning of treatment, and 2) a new decentralised strategy introduced in November 1997, in which patients were given the choice of in- or outpatient care during the first 2 months of treatment. For new smear-negative pulmonary patients, the two strategies compared were 1) the strategy used until the end of October 1997, which did not require any direct observation of treatment (DOT) and 2) a new community-based strategy introduced in November 1997, which required DOT by a community member 'guardian' or a health worker for the first 2 months of treatment. Costs were analysed from the perspective of health services, patients, and the community in 1998 US dollars, using standard methods. Cost-effectiveness was calculated as the cost per patient cured (smear-positive cases) and as the cost per patient completing treatment (new smear-negative cases). FINDINGS: For new smear-positive patients, the cost per patient treated was dollars 456 with the conventional hospital-based strategy, and dollars 106 with the new decentralised strategy. Costs fell by 54% for health services and 58% for patients. The cost per patient cured was dollars 787 for the conventional hospital-based strategy, and dollars 296 for decentralised treatment. For smear-negative patients, the cost per patient treated was dollars 67 with the conventional unsupervised strategy, and dollars 101 with the community-based DOT strategy. Costs increased for health services, patients and guardians. Cost-effectiveness was similar with both strategies, at around dollars 200 per patient completing treatment. When new smear-positive and new smear-negative patients were considered together, the new strategies were associated with a 50% reduction in total annual costs. CONCLUSION: There is a strong economic case for expansion of decentralisation and community-based DOT in Malawi. Further investment in training and programme supervision may help to increase effectiveness.

Decentralisation of treatment for patients with tuberculosis in Malawi: moving from research to policy and practice.

SETTING: Five districts in Malawi. OBJECTIVE: A new oral anti-tuberculosis treatment regimen with different directly observed treatment (DOT) choices in the initial phase of treatment was introduced for new patients in the five districts. The objectives were to determine 1) the site of DOT during the initial phase of treatment, and 2) the effectiveness of the new regimen. DESIGN: Prospective data collection on all tuberculosis (TB) patients registered in a phased approach between 1 July 1997 and 31 December 1998, including site of DOT option in initial phase of treatment, 2-month and 8-month treatment outcomes, 2-month sputum smear conversion in smear-positive pulmonary tuberculosis (PTB) patients and in-patient hospital bed days. RESULTS: There were 6335 new patients: 2671 (42%) with smear-positive PTB, 2211 (35%) with smear-negative PTB and 1453 (23%) with extra-pulmonary TB. The site of the initial phase of treatment was determined in 5790 patients: 1759 (30%) received DOT from guardians, 1465 (25%) from a health centre, 753 (13%) as out-patients from the hospital TB ward and 1813 (32%) remained in hospital. Eight-month treatment completion was 67% for smear-positive PTB patients, 51% for smear-negative PTB patients and 56% for extra-pulmonary TB patients. Two-month outcomes and 8-month treatment outcomes for all out-patient sites of supervision were satisfactory, except that a higher proportion of smear-positive PTB patients under guardian DOT failed to smear convert at 2 months. Over two-thirds of patients received ambulatory treatment out of hospital during the initial phase. CONCLUSION: The new treatment strategy, tested in five districts, was associated with a reduction in hospital bed days and satisfactory treatment outcomes. The results of these studies were vital in helping the National TB Control Programme make an informed decision about phased expansion of the strategy countrywide.

Preventing tuberculosis among health workers in Malawi.

OBJECTIVE: Following the introduction of guidelines for the control of tuberculosis (TB) infection in all hospitals in Malawi, a study was carried out to determine whether the guidelines were being implemented, the time between admission to hospital and the diagnosis of pulmonary TB had been reduced, and the annual case notification rates among health workers had fallen and were comparable to those of primary-school teachers. METHODS: The study involved 40 district and mission hospitals. Staff and patients were interviewed in order to determine whether the guidelines had been adopted. In four hospitals the diagnostic process in patients with smear-positive pulmonary TB was evaluated before and after the introduction of the guidelines, with the aid of case notes and TB registers. In all hospitals the proportion of health workers registered with TB before and after the guidelines were introduced, in 1996 and 1999, respectively, was determined by conducting interviews and consulting staff lists and TB registers. A similar method was used to determine the proportion of primary-school teachers who were registered with TB in 1999. FINDINGS: The guidelines were not uniformly implemented. Only one hospital introduced voluntary counselling and testing for its staff. Most hospitals stated that they used rapid systems to diagnose pulmonary TB. However, there was no significant change in the interval between admission and diagnosis or between admission and treatment of patients with smear-positive pulmonary TB. The TB case notification rate for 2979 health workers in 1999 was 3.2%; this did not differ significantly from the value of 3.7% for 2697 health workers in 1996 but was significantly higher than that of 1.8% for 4367 primary-school teachers in 1999. CONCLUSION: The introduction of guidelines for the control of TB infection is an important intervention for reducing nosocomial transmission of the disease, but rigorous monitoring and follow-up are needed in order to ensure that they are implemented.

High frequency of tuberculosis in households of index TB patients.

A case-control study was carried out in 44 non-private hospitals in Malawi which register and treat patients with tuberculosis (TB), to determine whether households of index TB patients had an increased frequency of TB compared with households where no TB had been diagnosed. Interviews were conducted in 770 smear-positive PTB patients and 918 control patients from antenatal, orthopaedic or surgical wards. TB patients and controls came from households which were similar in terms of type of house, household cash income and family size. In the previous 12 months, 52 (7%) TB patients had household members who developed TB compared with 11 (1%) control patients (OR 5.97, 95%CI 2.99-12.21). Of 2766 household members of TB patients, 56 had developed TB in the previous 12 months (frequency = 2024/100,000), which was significantly higher than the 11/4121 household members of control patients (frequency = 343/100,000, P < 0.001). There is a higher frequency of TB in households of index TB patients.

Screening childhood contacts of patients with smear-positive pulmonary tuberculosis in Malawi.

A survey was conducted by the National Tuberculosis Programme in 44 Malawian hospitals on screening young children aged 5 years or less in households of adults diagnosed with smear-positive pulmonary tuberculosis. Of 659 hospitalised adult patients, 267 (41%) had a total of 365 young children; 56 (21%) adult patients had been informed about childhood screening, and in 31 (12%) some of their children were screened. Of the 365 young children, 33 (9%) were screened for TB--23 received isoniazid preventive therapy, six received anti-tuberculosis treatment, and in four no action was taken. Steps are needed to improve childhood screening procedures.

High death rates in health care workers and teachers in Malawi.

High death rates are reported in health care workers (HCWs) and teachers in urban areas of Malawi. The present study was carried out to determine the annual death rate in HCWs and primary school teachers working in semi-urban and rural areas of Malawi, and to try to ascertain the main causes of death. Forty district and mission hospitals in Malawi were visited. A record was made of the number of clinical and nursing-based HCWs in each hospital in 1999, the number of deaths in that calendar year and reported causes of death. A record was also made of the number of teachers working in 4 primary schools nearest to each hospital in 1999, the number of deaths in that calendar year and reported causes of death. There were 2979 HCWs, of whom 60 (2.0%) died. There were 4367 teachers of whom 101 (2.3%) died. Annual death rates, calculated per 100,000 people, were significantly higher in male HCWs compared with female HCWs (2495 versus 1770, RR 1.17, 95% CI 1.14-1.20, P < 0.001), and significantly higher in female teachers compared with male teachers (2521 versus 1934, RR 1.14, 95% CI 1.11-1.17, P < 0.001). In male HCWs and teachers the highest death rates were in those aged 35-44 years. In female HCWs and teachers, the highest death rates were in those aged 25-34 years and 35-44 years, respectively. Reported causes of death in HCWs were tuberculosis (TB) in 47%, chronic illness in 45% and acute illness in the remainder, while in teachers the causes were TB in 27%, chronic illness in 49% and acute illness in 25%. Chronic illness, thought to be due to AIDS, and TB were the common causes of death. The current high death rates from AIDS and TB will have a crippling toll on the health and education sectors, and effective ways of reducing these death rates must be found.

High early death rate in tuberculosis patients in Malawi.

SETTING: Thirty-eight district and mission hospitals in Malawi. OBJECTIVES: In patients registered with all types of tuberculosis (TB) in 1997 to determine 1) treatment outcomes, and 2) when in the course of anti-tuberculosis treatment TB deaths occurred. DESIGN: A retrospective study using information from TB registers, health centre registers, TB treatment cards and TB ward admission books. RESULTS: A total of 16,004 patients were registered with all types of TB, 6471 with smear-positive pulmonary tuberculosis (PTB), 5305 with smear-negative PTB and 4228 with extra-pulmonary tuberculosis (EPTB). Of patients with all types of TB, 3720 (23%) died: death rates were 22% in smear-positive PTB, 26% in smear-negative PTB and 22% in EPTB. Month of death was known in 3371 patients (91% of those who died) and day of death in 3326 patients (89% of those who died). In patients who died, 19% of deaths occurred by day 7 and 41% by the end of the first month of treatment. A higher proportion of early deaths occurred in patients with smear-negative PTB and EPTB and in relation to increasing age. CONCLUSIONS: There was a high overall death rate in TB patients registered in 1997, with 40% of deaths occurring in the first month of treatment. Strategies to combat this problem are needed.

Is oral intermittent initial phase anti-tuberculosis treatment associated with higher mortality in high HIV-prevalent areas in sub-Saharan Africa?

The Malawi Tuberculosis Programme has evaluated an oral ambulatory treatment regimen (2R3H3Z3E3/6HE) in five districts, and observed a mortality rate of 23% in 2671 new patients with smear-positive pulmonary tuberculosis (PTB). Three studies were performed comparing treatment outcomes between patients treated with 2R3H3Z3E3/6HE and 2SRHZ/6HE using historical data in the same districts and concurrent data in different districts. Using historical comparisons, mortality was significantly higher with 2R3H3Z3E3/6HE than 2SRHZ/6HE. Using concurrent comparisons, mortality was similar, although there was a higher death rate in the first month with the intermittent regimen. The intermittent regimen may be inferior to the established regimen.