Beneficial effect of isoniazid preventive therapy and antiretroviral therapy on the incidence of tuberculosis in people living with HIV in Ethiopia.

BACKGROUND: IPT with or without concomitant administration of ART is a proven intervention to prevent tuberculosis among PLHIV. However, there are few data on the routine implementation of this intervention and its effectiveness in settings with limited resources. OBJECTIVES: To measure the level of uptake and effectiveness of IPT in reducing tuberculosis incidence in a cohort of PLHIV enrolled into HIV care between 2007 and 2010 in five hospitals in southern Ethiopia. METHODS: A retrospective cohort analysis of electronic patient database was done. The independent effects of no intervention, "IPT-only," "IPT-before-ART," "IPT-and-ART started simultaneously," "ART-only," and "IPT-after-ART" on TB incidence were measured. Cox-proportional hazards regression was used to assess association of treatment categories with TB incidence. RESULTS: Of 7,097 patients, 867 were excluded because they were transferred-in; a further 823 (12%) were excluded from the study because they were either identified to have TB through screening (292 patients) or were on TB treatment (531). Among the remaining 5,407 patients observed, IPT had been initiated for 39% of eligible patients. Children, male sex, advanced disease, and those in Pre-ART were less likely to be initiated on IPT. The overall TB incidence was 2.6 per 100 person-years. As compared to those with no intervention, use of "IPT-only" (aHR = 0.36, 95% CI = 0.19-0.66) and "ART-only" (aHR = 0.32, 95% CI = 0.24-0.43) were associated with significant reduction in TB incidence rate. Combining ART and IPT had a more profound effect. Starting IPT-before-ART (aHR = 0.18, 95% CI = 0.08-0.42) or simultaneously with ART (aHR = 0.20, 95% CI = 0.10-0.42) provided further reduction of TB at ∼ 80%. CONCLUSIONS: IPT was found to be effective in reducing TB incidence, independently and with concomitant ART, under programme conditions in resource-limited settings. The level of IPT provision and effectiveness in reducing TB was encouraging in the study setting. Scaling up and strengthening IPT service in addition to ART can have beneficial effect in reducing TB burden among PLHIV in settings with high TB/HIV burden.

Attitudes towards involuntary incarceration for tuberculosis: a survey of Union members.

BACKGROUND: Policies involving the use of involuntary incarceration for tuberculosis (TB) are highly ethically controversial. To encourage ethical reflection within the International Union Against Tuberculosis and Lung Disease (The Union), the Ethics Advisory Group (EAG) surveyed members regarding their attitudes and values relating to involuntary incarceration for TB. METHODS: Members of the Union TB section were invited to respond to an anonymous web-based survey. The survey included both multiple choice questions describing a range of scenarios regarding involuntary incarceration, and free-text fields inviting respondents to provide general comments on ethical issues. RESULTS: The survey was completed by 194 participants, 33 (17%) of whom were opposed to involuntary incarceration on principle. The age and sex of the respondents was not associated with likelihood of principled opposition; respondents from North America were least likely to be opposed to involuntary incarceration (P = 0.02). Respondents were most likely to consider involuntary incarceration for persons with known multidrug-resistant TB or a history of previous treatment default, and least likely where people lived alone, were university-educated or the main income provider for their families. CONCLUSION: This survey found a wide range of viewpoints regarding involuntary incarceration, and highlights a number of key elements in ethical engagement with the tensions surrounding involuntary incarceration. We provide commentary on approaches to ethical policy making in the light of these findings.

Caring for patients with surgically resectable cancers: experience from a specialised centre in rural Rwanda.

SETTING: Butaro Cancer Centre of Excellence (BCCOE), Burera District, Rwanda. OBJECTIVES: To describe characteristics, management and 6-month outcome of adult patients presenting with potentially surgically resectable cancers. DESIGN: Retrospective cohort study of patients presenting between 1 July and 31 December 2012. RESULTS: Of 278 patients, 76.6% were female, 51.4% were aged 50-74 years and 75% were referred from other district or tertiary hospitals in Rwanda. For the 250 patients with treatment details, 115 (46%) underwent surgery, with or without chemotherapy/radiotherapy. Median time from admission to surgery was 21 days (IQR 2-91). Breast cancer was the most common type of cancer treated at BCCOE, while other forms of cancer (cervical, colorectal and head and neck) were mainly operated on in tertiary facilities. Ninety-nine patients had no treatment; 52% of these were referred out within 6 months, primarily for palliative care. At 6 months, 6.8% had died or were lost to follow-up. CONCLUSION: Surgical care was provided for many cancer patients referred to BCCOE. However, challenges such as inadequate surgical infrastructure and skills, and patients presenting late with advanced and unresectable disease can limit the ability to manage all cases. This study highlights opportunities and challenges in cancer care relevant to other hospitals in rural settings.

Contexte : Centre anticancéreux d'excellence de Butaro (BCCOE), District de Butera, Rwanda.Objectifs : Décrire les caractéristiques, la prise en charge et les résultats à 6 mois de patients adultes se présentant avec des cancers potentiellement extirpables par chirurgie.Schema : Etude rétrospective de cohorte des patients admis entre le 1er juillet et le 31 décembre 2012.Resultats : Sur 278 patients, 76,6% étaient des femmes, 51,4% étaient âgés entre 50 et 74 ans et 75% étaient référés d'un autre district ou d'un hôpital tertiaire du Rwanda. Parmi les 250 patients dont les traitements étaient connus, 115 (46%) ont bénéficié d'une intervention chirurgicale avec ou sans chimiothérapie/radiothérapie. Le temps médian écoulé entre l'admission et la chirurgie était de 21 jours (IQR 2 à 91). Le cancer du sein était le plus fréquent des cancers traités au BCCOE, tandis que les autres cancers (col utérin, colorectal et tumeur cérébrale ou cervicale) étaient généralement opérés dans des hôpitaux tertiaires. Quatre-vingt-dix-neuf patients n'ont eu aucun traitement ; 52% ont été référés à l'extérieur dans les 6 mois, généralement pour un traitement palliatif. A 6 mois, 6,8% étaient décédés ou perdus de vue.Conclusion : De nombreux patients référés au BCCOE pour cancer ont bénéficié d'une intervention chirurgicale. Cependant la prise en charge de tous les cas est confrontée à la limite de capacité chirurgicale et au problème des patients admis tardivement avec un cancer avancé et non extirpable. Cette étude met en lumière les opportunités et les défis de la prise en charge des cancers pour les hôpitaux situés en zone rurale.

Marco de Referencia: El Centro Butaro de Excelencia en Cáncer (BCCOE) del distrito de Burera, en Ruanda.Objetivos: Describir las características, el manejo y el desenlace clínico a los 6 meses de pacientes adultos que se presentaron con cánceres cuyo tratamiento quirúrgico podía ser viable.Métodos: Fue este un estudio retrospectivo de cohortes de los pacientes que acudieron al centro entre el 1° de julio y el 31 de diciembre del 2012.Resultados: Se incluyeron en el estudio 278 pacientes, de los cuales 76,6% eran de sexo femenino, 51,4% tenían entre 50 y 74 años de edad y 75% habían sido remitidos de otro hospital distrital o de centros de atención terciaria de Ruanda. De los 250 expedientes que contaban con detalles sobre el tratamiento, en 115 casos (46%) los pacientes recibieron tratamiento quirúrgico con o sin quimioterapia o radioterapia. La mediana del lapso entre la hospitalización y la cirugía fue 21 días (intervalo intercuartil de 2 a 91). El cáncer de mama fue el tipo más frecuente de cáncer que se trató en el BCCOE y la cirugía de otras formas de cáncer (cuello uterino, colorrectal y de cara y cuello) se realizó principalmente en centros de atención terciaria. Noventa y nueve pacientes no recibieron tratamiento; el 52% de estos se remitió a otras instituciones en los primeros 6 meses, esencialmente con el propósito de recibir tratamiento paliativo. A los 6 meses, el 6,8% de los pacientes había fallecido o se habían perdido durante el seguimiento.Conclusión: Muchos de los pacientes remitidos recibieron tratamiento quirúrgico en el BCCOE. Sin embargo, la posibilidad de tratar todos los casos se ve limitada por obstáculos como una capacidad quirúrgica inadecuada y el hecho de que los pacientes acuden tarde, en una fase avanzada de la enfermedad, con un cáncer inoperable. El presente estudio pone de relieve oportunidades y dificultades en el tratamiento del cáncer que son pertinentes para otros centros hospitalarios en un entorno rural.

Childhood immunisation in Bungoma County, Kenya, from 2008 to 2011: need for improved uptake.

Uptake of immunisations in children aged 1-2 years in Bungoma County, Kenya, was determined as part of the 6-monthly Health and Demographic Surveillance System surveys. A total of 2699 children were assessed between 2008 and 2011. During this time period, full immunisation declined significantly from 84% to 58%, and measles vaccine declined uptake from 89% to 60% (P < 0.001). Each year there was a significant fall-off for the third doses of the oral polio and pentavalent vaccines (P < 0.001). These findings are of concern, as low immunisation coverage may lead to vaccine-preventable disease outbreaks. Further investigations into the reasons for declining immunisation trends are required.

La couverture vaccinale des enfants de âgés de 1 à 2 ans dans la conté de Bungoma au Kenya a été déterminée dans le cadre d'un enquête du Système de surveillance sanitaire et démographique. Au total 2699 enfants ont été évalués de 2008 à 2011. Au cours de cette période, le taux de vaccination complète a diminué de façon significative, de 84% à 58%, et celui de la vaccination contre la rougeole de 89% à 60% (P < 0,001). Chaque année, on a constaté une chute de l'administration de la 3e dose du vaccin polio oral et du vaccin pentavalent (P < 0,001). Ces résultats sont préoccupants car cette faible couverture vaccinale pourrait conduire à des épidémies de maladies évitables. Il est nécessaire de faire d'autres investigations à la recherche des causes de ce déclin de la vaccination.

La vacunación de los niños de 1 a 2 años de edad en el condado de Bungoma, en Kenia, se investigó como parte de las encuestas semestrales del Sistema de Vigilancia Sanitaria y Demográfica. Se evaluaron 2699 niños del 2008 al 2011. Durante este período se observó una disminución considerable de la administración de un esquema completo de vacunación, de 84% a 58%, y la aplicación de la vacuna antisarampionosa disminuyó de 89% a 60% (P < 0,001). En cada año, se redujo de manera notable la administración de la tercera dosis de la vacuna antipoliomielítica oral y la vacuna pentavalente (P < 0,001). Estas observaciones son fuente de preocupación, pues una baja cobertura de vacunación puede dar origen a brotes epidémicos de enfermedades prevenibles. Se justifica la realización de nuevas investigaciones que aclaren las razones de esta tendencia decreciente de las vacunaciones.

Xpert(®) MTB/RIF under routine conditions in diagnosing pulmonary tuberculosis: a study in two hospitals in Pakistan.

Xpert(®) MTB/RIF testing was offered to consecutive patients with presumptive tuberculosis (TB) attending two hospitals in Pakistan during April-May 2012, in addition to routine diagnostic protocol (smear microscopy, chest radiography and clinical judgement). We assessed the relative contribution of each tool in detecting pulmonary TB under routine conditions. Of 606 participants, 121 (20%) were detected as pulmonary TB: 46 (38%) by microscopy, 38 (31%) by Xpert alone and 37 (31%) on clinical and radiological grounds; 41 (65%) were detected by both Xpert and microscopy. One patient had rifampicin resistance. Although Xpert detected approximately twice as many TB cases as microscopy (n = 79, 65%), clinical judgement remained favoured by clinicians even when smear and Xpert were negative.

En plus d'un protocole de diagnostic de routine (examen microscopique des frottis, cliché thoracique et évaluation clinique), on a offert Xpert® MTB/RIF à des patients consécutifs suspects de tuberculose (TB) qui présentaient à deux hôpitaux du Pakistan au cours de la période avril­mai 2012. Nous avons évalué la contribution relative de chaque outil à la détection de la TB pulmonaire dans les conditions de routine. Sur 606 participants, 121 (20%) ont été diagnostiqués comme TB pulmonaire : 46 (38%) par l'examen microscopique, 38 (31%) par Xpert seul, et 37 (31%) sur une base clinique et radiologique ; 41 (65%) ont été détectés par l'examen microscopique et Xpert. Chez un patient, on a trouvé une résistance à la rifampicine. Quoique l'Xpert ait détecté approximativement deux fois le nombre de cas de TB détectés par l'examen microscopique (n = 79, 65%), le jugement clinique reste favorisé par les cliniciens, même lorsque le résultat du frottis et de l'Xpert est négatif.

En dos hospitales de Paquistán se propuso a un grupo de pacientes con presunción de tuberculosis (TB) que acudieron de manera consecutiva entre abril y mayo del 2012 la prueba Xpert® MTB/RIF, además del protocolo diagnóstico corriente (que comportaba la baciloscopia, la radiografía de tórax y la evaluación clínica). Se analizó la contribución relativa de cada instrumento en el diagnóstico de la TB pulmonar en las condiciones corrientes. De los 606 participantes, en 121 (20%) se estableció el diagnóstico de TB pulmonar de la siguiente manera: en 46 casos (38%) por microscopia, en 38 (31%) mediante la prueba Xpert sola y en 37 casos (31%) con base en las características clínicas y radiográficas; 41 (65%) fueron detectados por microscopia y Xpert. Un paciente exhibió resistencia a rifampicina. Si bien la prueba Xpert permitió el diagnóstico de cerca del doble de casos de tuberculosis que la baciloscopia (n = 79, 65%), el juicio clínico predomina aun en la decisión de los médicos, incluso frente a un resultado negativo de la baciloscopia y la prueba Xpert.

Oops, what about ethics?

Ethics approval of research studies is essential for the protection and rights of study subjects, whether this is for prospective research or record reviews. This article shares a painful lesson learned from a field experience where the appropriate steps for obtaining ethics approval were not followed by a young researcher. This researcher had embarked on an operational research project, but had omitted to seek ethics approval from a local ethics committee. Young researchers, particularly from low- and middle-income countries, need to learn about the importance and value of ethics.

L'approbation éthique des études de recherche est essentielle pour la protection et les droits des sujets de l'étude, que celle-ci soit destinée à une recherche prospective ou qu'elle consiste en une révision de dossiers. Cet article partage une pénible leçon provenant d'une expérience sur le terrain dans laquelle les étapes appropriées d'obtention des accords éthiques n'ont pas été suivies par un jeune chercheur. Ce chercheur s'est embarqué dans un projet de recherche opérationnelle, mais a omis de solliciter l'approbation éthique du comité local d'éthique. Il y a lieu de veiller à ce que les jeunes chercheurs, principalement ceux provenant de pays à revenus faibles ou moyens, s'informent au sujet de l'importance et de la valeur des données éthiques.

La aprobación de los estudios científicos por parte del comité de ética es primordial para la protección de las personas que participan y el respeto de sus derechos, ya sea en las investigaciones prospectivas o en los análisis de las historias clínicas. Por conducto del presente artículo se comparte una dolorosa enseñanza extraída de una experiencia en el terreno, en la cual un joven investigador no cumplió con las etapas necesarias en materia de aprobación por el comité de ética. El investigador se lanzó en un proyecto de investigación operativa, pero omitió buscar la aprobación del comité local de ética. Los jóvenes investigadores, sobre todo en los países de ingresos bajos e intermedios, deben aprender la importancia y la utilidad de los aspectos éticos de su trabajo.

Tuberculosis treatment outcomes among hospital workers at a public teaching and national referral hospital in Kenya.

SETTING: Kenyatta National Hospital (KNH), Nairobi, Ken-ya, a large referral and teaching hospital. OBJECTIVE: 1) To document tuberculosis (TB) case notification rates and trends; 2) to describe demographic, clinical and workplace characteristics and treatment outcomes; and 3) to examine associations between demographic and clinical characteristics, HIV/AIDS (human immunodeficiency virus/acquired immune-deficiency syndrome) treatment and anti-tuberculosis treatment outcomes among hospital workers with TB at KNH during the period 2006-2011. DESIGN: A retrospective cohort study involving a review of medical records. RESULTS: The TB case notification rate among hospital staff ranged between 413 and 901 per 100 000 staff members per year; 51% of all cases were extra-pulmonary TB; 74% of all cases were among medical, paramedical and support staff. The TB-HIV coinfection rate was 60%. Only 75% had a successful treatment outcome. Patients in the retreatment category, those with unknown HIV status and those who were support staff had a higher risk of poor treatment outcomes. CONCLUSION: The TB case rate among hospital workers was unacceptably high compared to that of the general population, and treatment outcomes were poor. Infection control in the hospital and management of staff with TB requires urgent attention.

Research ethics in The Union: an 8-year review of the Ethics Advisory Group.

SETTING: The Ethics Advisory Group (EAG) of the International Union Against Tuberculosis and Lung Disease (The Union) was established in 2004 to provide ethical guidance and promote ethical standards within The Union, including reviews of proposed research projects associated with The Union. OBJECTIVES: To describe research proposal reviews conducted by the EAG in the period 2005-2012 in terms of 1) annual numbers, 2) the Union departments in which the proposals originated, 3) study designs, 4) regions and countries where studies were to be conducted, 5) study topics, 6) problems encountered by the EAG, and 7) review outcomes. DESIGN: Descriptive study of application records of the EAG. RESULTS: A total of 292 applications were reviewed; 79% were proposals for operational research; 85% were from Africa and Asia, with 64% from India, South Africa, Malawi, Kenya and Zimbabwe. Tuberculosis was the topic in 68%; only three studies in the 8 years were on other lung diseases. Several problems encountered are highlighted. All applications were approved except six, either immediately or after modification. CONCLUSION: The proposal review process of the EAG serves to maintain ethical standards of research within The Union. Ideas for expanding the scope of the EAG are discussed.

Language in tuberculosis services: can we change to patient-centred terminology and stop the paradigm of blaming the patients?

The words 'defaulter', 'suspect' and 'control' have been part of the language of tuberculosis (TB) services for many decades, and they continue to be used in international guidelines and in published literature. From a patient perspective, it is our opinion that these terms are at best inappropriate, coercive and disempowering, and at worst they could be perceived as judgmental and criminalising, tending to place the blame of the disease or responsibility for adverse treatment outcomes on one side-that of the patients. In this article, which brings together a wide range of authors and institutions from Africa, Asia, Latin America, Europe and the Pacific, we discuss the use of the words 'defaulter', 'suspect' and 'control' and argue why it is detrimental to continue using them in the context of TB. We propose that 'defaulter' be replaced with 'person lost to follow-up'; that 'TB suspect' be replaced by 'person with presumptive TB' or 'person to be evaluated for TB'; and that the term 'control' be replaced with 'prevention and care' or simply deleted. These terms are non-judgmental and patient-centred. We appeal to the global Stop TB Partnership to lead discussions on this issue and to make concrete steps towards changing the current paradigm.

Tuberculosis treatment outcomes among retreatment patients registered by private practitioners in Myanmar.

The objectives of this retrospective cohort study were to report treatment outcomes and identify factors associated with treatment failure among all retreatment tuberculosis (TB) patients registered in the public-private mix DOTS programme of Populations Services International-Myanmar over 6 years. Among 3643 retreatment patients, 2657 (73%) were successfully treated and 309 (8.5%) failed. This study shows that retreatment patients who have failed treatment for their first TB episode are almost twice as likely to fail a second time (13.5%). We have identified some key programmatic challenges associated with retreatment TB in the private sector, and steps are being taken to address this issue.

Les objectifs de cette étude rétrospective de cohorte ont été de rapporter les résultats du traitement et d'identifier les facteurs en association avec les échecs de traitement chez tous les patients TB en retraitement dans un programme PPM-DOTS du programme Population Services International­Myanmar au cours d'une période de 6 années. Parmi 3643 patients en retraitement, 2657 (73%) ont été traités avec succès et 309 (8,5%) ont échoué. Cette étude montre que les patients en retraitement par suite d'un échec du traitement de leur premier épisode de TB sont presque deux fois plus susceptibles d'échouer une deuxième fois (13,5%). Nous avons identifié un certain nombre de défis-clé du programme en rapport avec le retraitement de la TB dans le secteur privé ainsi que les étapes à parcourir pour résoudre ce problème.

Los objetivos del presente estudio retrospectivo de cohortes fueron notificar los desenlaces terapéuticos y definir los factores asociados con el fracaso del tratamiento, en los pacientes con tuberculosis (TB) que iniciaron un esquema de retratamiento en el marco de una colaboración publicoprivada de suministro de DOTS del programa Population Services International de Myanmar durante 6 años. De los 3643 pacientes inscritos en retratamiento, 2657 (73%) lograron un tratamiento exitoso y en 309 (8,5%) ocurrió un fracaso. Los resultados del estudio indican que los pacientes que se encuentran en retratamiento por causa del fracaso terapéutico de su primer episodio de TB tienen una probabilidad casi dos veces mayor de sufrir un segundo fracaso (13,5%). El trabajo permitió definir algunos obstáculos programáticos relacionados con el retratamiento de la TB en el sector privado y se están adoptando las medidas encaminadas a resolver el problema.

What proportion of patients diagnosed with TB and started on treatment in Manicaland Province, Zimbabwe, are registered?

A retrospective record review was carried out in selected districts in Manicaland Province, Zimbabwe, to compare the number of patients diagnosed and started on anti-TB treatment with the number listed in the TB register. There were 574 patients (290 females) diagnosed and treated for TB during the first 6 months of 2010, of whom 248 (43%) were not registered. Not being registered was associated with attending a rural hospital. An unacceptably high proportion of patients diagnosed and treated for TB were not being registered and were therefore not reported to national authorities or the WHO. The registration process in Zimbabwe requires review.

Diagnostic management and outcomes of pulmonary tuberculosis suspects admitted to a central hospital in Malawi.

SETTING: Zomba Central Hospital, Malawi. OBJECTIVE: To determine diagnostic management and outcomes of pulmonary tuberculosis (PTB) suspects admitted to adult wards. DESIGN: A retrospective, cross-sectional review of medical records of patients admitted to hospital between July and September 2010. RESULTS: There were 141 PTB suspects. Sputum examination was requested and performed in 67 (48%) suspects, but none were smear-positive. Chest X-ray (CXR) was requested and performed in 26 (39%) suspects whose sputum smears were negative. Eleven suspects had a CXR suggestive of PTB: two were started on TB treatment and eight died before treatment started. Human immunodeficiency virus (HIV) status was known for 50 patients (35% of all suspects) on admission, all of whom were HIV-positive. HIV testing was requested for 37 patients, but was only performed in 12, five of whom were HIV-positive. Only one patient was referred for antiretroviral treatment. There were 41 (29%) deaths, eight of whom had probable TB and were not treated. In the remaining 33 patients who died, only nine (27%) had sputum smears examined and four (12%) had a CXR. CONCLUSION: The study shows inadequacies in the diagnostic management of PTB suspects in the Zomba Central Hospital, but suggests opportunities for improvement.

Symptom screen: diagnostic usefulness in detecting pulmonary tuberculosis in HIV-infected pregnant women in Kenya.

OBJECTIVE: To determine the diagnostic usefulness of tuberculosis (TB) symptom screening to detect active pulmonary TB among human immunodeficiency virus (HIV) infected pregnant women in two PMTCT (prevention of mother-to-child transmission) clinics in western Kenya that are supported by the United States Agency for International Development-Academic Model Providing Access to Healthcare partnership. DESIGN: Cross-sectional study. Participants were interviewed for TB symptoms with a standardized questionnaire (cough >2 weeks, fever, night sweats, weight loss or failure to gain weight). Those with cough submitted sputum specimens for smear microscopy for acid-fast bacilli and mycobacterial culture. Women at >14 weeks gestation underwent shielded chest radiography (CXR). RESULTS: Of 187 HIV-infected women, 38 (20%) were symptom screen-positive. Of these, 21 had a cough for >2 weeks, but all had negative sputum smears and mycobacterial cultures. CXRs were performed in 26 symptomatic women: three were suggestive of TB (1 miliary, 1 infiltrates and 1 cavitary). Of 149 women with a negative symptom screen, 100 had a CXR and seven had a CXR suggestive of TB (1 cavitary, 2 miliary and 4 infiltrates). CONCLUSION: This study did not support the utility of isolated symptom screening in identification of TB disease in our PMTCT setting. CXR was useful in identification of TB suspects in both symptomatic and asymptomatic women.

Surveillance for MDR-TB: is there an obligation to ensure treatment for individuals identified with MDR-TB?

This article raises ethical issues that result if individuals, during the course of research to measure the prevalence of drug-resistant tuberculosis, are identified with the disease but are not provided with or referred for appropriate treatment. It draws attention to and applauds recently published World Health Organization guidelines on the subject. Questions posed are: 1) Should treatment be provided for individuals identified through surveillance projects for MDR-TB, whatever their purpose (specific research or 'routine' national prevalence studies)? 2) If treatment availability is a problem, who is responsible for assuring this?

Tuberculosis culture testing at a tertiary care hospital: options for improved management and use for treatment decisions.

SETTING: Chris Hani Baragwanath Hospital, a tertiary care hospital in Johannesburg, South Africa. OBJECTIVES: To determine the proportion of patients with positive Mycobacterium tuberculosis cultures and whether those who were positive were on treatment. DESIGN: Tuberculosis (TB) culture results were obtained from the laboratory for a 3-month period. Positive results were checked against registrations at the hospital TB Care Centre (TBCC). The treatment status of non-registered patients was obtained from various records at the hospital, district clinics and from home visits. RESULTS: Overall, 3909 patients had 5404 samples sent for culture. Of these, 708 patients (18%) had at least one positive culture. The positive yield from 2749 adult sputum samples was 33% and ranged from 6% to 40% for different extra-pulmonary specimens. Among 1160 children, the yield varied from 0% to 12%, with 12% in sputum and gastric washing specimens. Of the 708 culture-positive patients, 429 (61%) patients were registered at the TBCC and were known to have started TB treatment. Of the 279 subjects not registered (39% overall), 100 (36%) died. Only 67 of the 179 survivors were confirmed on treatment, 40 were not on treatment and 72 could not be traced. CONCLUSIONS: Large numbers of TB culture tests were performed, some inappropriately. Study findings highlight inadequacies in the management of culture-confirmed TB at this hospital.

Tuberculosis at Chris Hani Baragwanath Hospital: an intervention to improve patient referrals to district clinics.

SETTING: A study in 2001 described the process of managing tuberculosis (TB) at Chris Hani Baragwanath hospital, the numbers of patients diagnosed and poor outcomes of referring patients to clinics in the adjacent sub-districts. The present study describes and evaluates an intervention to address the problems. OBJECTIVES: To describe the intervention process (education and referral of TB patients) and the subsequent results over a 2-year period from 2003 to 2005. METHODS: The process of establishing the system and how it was evaluated at district clinics in Johannesburg are described. RESULTS: In the first 2 years of operation, August 2003 to July 2005, 13,138 patients were registered. Extra-pulmonary tuberculosis (EPTB) was diagnosed in 34%. Of the 46% tested for human immunodeficiency virus (HIV), 93% were positive. Successful referral to clinics was achieved for 94% of patients. CONCLUSIONS: Very large numbers of patients are diagnosed with TB at Chris Hani Baragwanath Hospital. A TB care centre has successfully addressed important referral, education and registration requirements for the comprehensive management of TB with links to clinics. It is suggested that this model be applied at other hospitals.

Tuberculosis at Chris Hani Baragwanath Hospital: numbers of patients diagnosed and outcomes of referrals to district clinics.

SETTING: Chris Hani Baragwanath Hospital, in Johannesburg. South Africa is experiencing a serious epidemic of tuberculosis (TB), with a measured rate of 500 cases per 100,000 population. Patients in public hospitals are referred for treatment to district clinics or to specific TB hospitals. OBJECTIVES: To measure numbers of patients diagnosed with TB, and to describe the type of disease and referral outcomes. METHODS: A descriptive study of patients diagnosed with TB in a tertiary hospital. Data in patient files were collected for medical and paediatric patients, and patients were interviewed by researchers who visited clinics to check if referred patients had attended. RESULTS: In the 8-week study period, 1291 patients were diagnosed with TB: 74% had pulmonary disease and 80% of those tested for HIV were positive; 19% died in hospital, and 21% required transfer to a TB hospital. Only half of the patients referred to clinics attended within 2 weeks. CONCLUSIONS: Patients with advanced TB are commonly seen at this hospital. Notifications were an inadequate record and an unacceptable proportion of patients were lost between hospital and clinics. This study has recommended that opportunities for education and discussion must be provided if patients are to reach clinics successfully.