Childhood tuberculosis in Malawi: caseload, diagnostic practices and treatment outcomes.

There were 22,982 cases of TB registered in Malawi in 1998, of which 2739 (11.9%) were children. Children accounted for 11.3% of all case notifications with smear-positive pulmonary TB (PTB), 21.3% with smear-negative PTB and 15.9% with extrapulmonary TB (EPTB). A significantly higher proportion of TB cases were diagnosed in central hospitals. Only 45% of children completed treatment. There were high rates of death (17%), default (13%) and unknown treatment outcomes (21%). Treatment outcomes were worse in younger children and in children with smear-negative PTB. In 2001, all 44 non-private hospitals in Malawi that register and treat children with tuberculosis (TB) were surveyed to determine actual diagnostic practice. This cross sectional study identified 150 children aged 14 years or below in hospital receiving anti-TB treatment, 98 with pulmonary TB (PTB) and 52 with extrapulmonary TB (EPTB). Median duration of illness was 8 weeks. Most patients had fever, no response to anti-malarial treatment and antibiotics, and 40% had a positive family history of TB. Nearly 45% had weight for age < 60%. Diagnosis was mainly based on clinical features and radiography, with less than 10% having tuberculin skin tests or HIV serology, and very few having other sophisticated investigations. Diagnostic difficulties make it difficult to accurately define the actual burden of childhood TB in Malawi. Diagnostic practices are poor and treatment outcomes unsatisfactory.

Outcome of patients with tuberculosis who transfer between reporting units in Malawi.

SETTING: All 43 non-private hospitals in Malawi which in 1999 registered and treated patients with tuberculosis (TB). OBJECTIVE: To determine the proportion of TB patients who transferred from one reporting unit to another and their treatment outcome, and to compare outcome results between the main TB register and the transfer-in register. DESIGN: Retrospective data collection, using the main TB register and transfer-in register, on all patients registered in Malawi in 1999. RESULTS: There were 24,908 patients, of whom 3249 (13%) in total were transfers. Significantly more patients transferred from mission hospitals (23%) compared with central (8%) or district (5%) hospitals (P < 0.001). The date of transfer was recorded for 1406 patients, of whom 1170 (83%) transferred in the first 10 weeks. Respectively 45% and 58% of transfer patients had unknown outcomes in the main TB register and transfer-in register; these rates were significantly lower in smear-positive pulmonary TB (PTB) patients. A total of 1357 patients were entered into transfer-in registers; 694 patients had matched names and/or registration numbers in both registers. Of the matched patients, 373 (54%) had similar treatment outcomes. CONCLUSION: It is common for patients to transfer between treatment units, but the quality of the data for patients who transfer is poor, and needs to be improved.

Diagnosis of childhood tuberculosis in Malawi: an audit of hospital practice.

SETTING: All 44 non-private hospitals in Malawi that register and treat children with tuberculosis (TB). OBJECTIVE: To determine 1) clinical features and diagnostic practices in children registered with TB, and 2) the use of the WHO score chart in diagnosis. DESIGN: A cross-sectional study of all children aged 14 years or below in hospital receiving anti-tuberculosis treatment, using reviews of treatment cards, case files and chest X-rays and performing a clinical assessment. RESULTS: There were 150 children, 98 with pulmonary TB (PTB) and 52 with extra-pulmonary TB (EPTB). The median duration of illness was 8 weeks. Most patients had fever, no response to anti-malarial treatment and antibiotics, and 40% had a family history of TB. Nearly 45% had weight for age <60%. Diagnosis was mainly based on clinical features and radiography, with less than 10% having tuberculin skin tests or HIV serology, and very few having other sophisticated investigations. A WHO diagnostic score chart was used in 13 (9%) patients by hospital staff. An independent assessment by the study team found that 61% of patients had a score of 7 or more; this was higher in EPTB than PTB patients. CONCLUSION: Diagnostic practices in children with TB in Malawi are poor, and improvements should be made.

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 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.