Low tuberculosis case detection in Gokwe North and South, Zimbabwe in 2006.

BACKGROUND: Case detection is an important component of tuberculosis control programmes. It helps identify sources of infection, treat them, and thus break the chain of infection. OBJECTIVE: To determine the reasons of low tuberculosis case detection in Gokwe Districts, Zimbabwe. METHODS: A descriptive cross sectional study was conducted. We used interviewer administered questionnaire for nurses and patients, checklists, key informant interviews. RESULTS: Thirty-eight nurses, forty-two patients and seven key informants were interviewed and 1254 entries in tuberculosis register were reviewed. Nurses correctly defined pulmonary tuberculosis, listed signs and symptoms, preventive measures and methods of tuberculosis diagnosis. Exit interviews showed 9/42 (21%) of patients presenting with cough were asked to submit sputa for examination and asked about household contacts with tuberculosis. About 27% of patients who were sputum positive in the laboratory register were not recorded in the district tuberculosis register. This contributed to the high proportion of early defaulters among tuberculosis suspects. CONCLUSION: Low tuberculosis case detection was because nurses were not routinely requesting for sputum for examination in patients presenting with a cough or history of previous treatment for cough. Nurses should routinely request for sputum for examination in patients presenting with a cough or history of recent treatment for cough.

Low Tuberculosis Case Detection in Gokwe North and South; Zimbabwe in 2006

Background: Case detection is an important component of tuberculosis control programmes. It helps identify sources of infection; treat them; and thus break the chain of infection. Objective: To determine the reasons of low tuberculosis case detection in Gokwe Districts; Zimbabwe. Methods: A descriptive cross sectional study was conducted. We used interviewer administered questionnaire for nurses and patients; checklists; key informant interviews. Results: Thirty-eight nurses; forty-two patients and seven key informants were interviewed and 1254 entries in tuberculosis register were reviewed. Nurses correctly defined pulmonary tuberculosis; listed signs and symptoms; preventive measures and methods of tuberculosis diagnosis. Exit interviews showed 9/42 (21) of patients presenting with cough were asked to submit sputa for examination and asked about household contacts with tuberculosis. About 27of patients who were sputum positive in the laboratory register were not recorded in the district tuberculosis register. This contributed to the high proportion of early defaulters among tuberculosis suspects. Conclusion: Low tuberculosis case detection was because nurses were not routinely requesting for sputum for examination in patients presenting with a cough or history of previous treatment for cough. Nurses should routinely request for sputum for examination in patients presenting with a cough or history of recent treatment for cough

Evaluation of the Integrated Management of Childhood Illness Strategy Implementation in Bulawayo City; Zimbabwe; 2006

Introduction. Bulawayo City reported an age-specific death rate for under-5s of 5.9/1 000 in 2004; and this figure rose to 6.8/ 1 000 in 2005. Nurses were trained in implementation of the Integrated Management of Childhood Illness (IMCI) strategy in 2005. We evaluated the programme in order to establish the level of implementation and the quality of care given to children aged under 5 years. Methods. We conducted a cross-sectional study on a population of sick children aged between 2 months and 5 years; health care workers and caregivers. Data were collected using a structured observation checklist of the case management of sick children; exit interviews with caregivers; and a structured inventory checklist for equipment; drugs and supplies at each health facility. Results. Nine facilities; 17 nurses and 72 children were observed during the study. Seventeen children (24) were assessed for the three general danger signs (failure to drink or breastfeed; vomiting everything ingested; and convulsions); 31 (43) were correctly prescribed an oral antibiotic; and 11received the first dose of treatment at the health facility. Thirty-two per cent of caregivers who received a prescription for an oral medication were able to report correctly how to give the treatment. Drugs were below minimum stock levels in all 9 facilities. Only 19 (20) of the 94 nurses were trained in IMCI. Conclusion. IMCI implementation in Bulawayo failed to meet the accepted standard protocol requirements. The main deficiencies noted were the low number of IMCI-trained health workers and the lack of availability of essential drugs at health facilities. However; it was noteworthy that only two case assessment parameters differed statistically between IMCI-trained and non-trained nurses. Larger studies are needed to confirm or refute these findings

Quantitative differences in sputum smear microscopy results for acid-fast bacilli by age and sex in four countries.

OBJECTIVE: To examine the influence of age and sex on the grading of tuberculosis (TB) sputum smear microscopy results. SETTING: Laboratories in Moldova, Mongolia, Uganda and Zimbabwe. METHODS: Data from nationally representative samples of laboratory registers were double-entered and validated, and discordances were resolved by rechecking against the registers. RESULTS: The dataset comprised 128,808 examinees from 23 laboratories in Moldova, all 31 in Mongolia, 30 in Uganda and 23 in Zimbabwe, each covering at least one calendar year. Among all examinees, 89,362 had a diagnostic examination, 13,577 (15.2%) of whom were cases. A non-quantified positive result was recorded among 1272 (9.4%) of these. Scanty results were most frequent in Zimbabwe (8.5%) and most infrequent in Uganda (1.1%). In contrast, the highest grade, of 3+ positive, was most frequent (43.9%) in Mongolia. The lowest proportion of low-grade positivity was recorded for males aged 15-24 years and the highest among females aged >or=65 years. CONCLUSION: Differences in the frequency of low-grade positivity between the four countries were striking. Females tended to have lower bacillary counts, and low-grade positivity was more frequent at the extremes of age. These results reinforce the need for appropriate instructions on how to produce high-quality sputum to improve yield.

Making pragmatic sense of data in the tuberculosis laboratory register.

SETTING: Tuberculosis (TB) microscopy network in Moldova, Mongolia, Uganda and Zimbabwe. OBJECTIVE: To evaluate how scrutinising the information recorded in the TB Laboratory Register can assist in improving the performance of the microscopy laboratory network and TB case management. METHODS: Review of records for completeness in registration of age, sex, reason for examination, analysis of variability patterns in serial smears and provision of exemplary statistical process charts of scanty positive results over time in the four countries. RESULTS: A total of 128808 records were analysed. A large proportion of examinees in Uganda (6.9%) and Zimbabwe (3.9%) had no information on sex. The reason for examination was unknown for 7.4%. Among suspects with three smear results with at least one positive result, 56.1% had no variation in the pattern. Statistical process control charts revealed considerable fluctuation in the frequency of scanty positive smears over a calendar year. CONCLUSION: An analysis of information recorded in the TB Laboratory Register not only identifies strengths and weaknesses in the laboratory, it also reveals weaknesses on a much wider scale, in the entire case management system. TB laboratory data can thus demonstrate when, where and what action is indicated, and how performance might be monitored over time.

Treatment outcomes of patients on antiretrovirals after six months of treatment, Khami Clinic, Bulawayo, Zimbabwe.

OBJECTIVE: To describe treatment outcomes of patients on anti-retrovirals at six months of treatment. STUDY DESIGN: We conducted pre-intervention post intervention surveys using a pretest-post test design. SETTING: Khami Municipal Clinic, Bulawayo. SUBJECTS: We interviewed consecutive patients eligible to receive antiretroviral drugs (ARVs). All patients had a history of TB treatment and a CD4 count less than 200 cells/mm. MAIN OUTCOME MEASURES: Mean change in CD4 count, weight, body mass index, and Karnofsky performance measured before and at six months ofantiretroviral treatment. RESULTS: 72 subjects were interviewed at baseline, their median age was 38 years (Q1, 32 years, Q3, 43 years). Of these, 17 (24%) died before six months of treatment. Three (4%) defaulted treatment follow up. A total of 52 respondents were alive and interviewed at six months though only 50, had repeat CD4 counts at six months. Among the 50 survivors, the mean CD4 count at six months was significantly higher than at baseline (p = 0.0003). There was a 4.2 point statistical significant increase in the mean weight from baseline (p = 0.0005). Similarly, the mean Body Mass Index (BMI) significantly increased by 1.5 kg/m2 from baseline, (p = 0.001). The mean Karnofsky performance increased from 89% at baseline to 95% at six months (p = 0004). The researchers noted that patients on TB treatment were being deferred antiretroviral therapy until they completed TB treatment. CONCLUSION: The Khami project bears testimony that even in a resource poor setting; treatment of HIV/AIDS with antiretroviral drugs is feasible. We recommend early treatment initiation for those on TB treatment in line with national guidelines.

Sputum smear-positive tuberculosis: empiric evidence challenges the need for confirmatory smears.

OBJECTIVE: To determine the frequency of single scanty or positive sputum smear results and its impact on the surveillance definition of sputum smear-positive tuberculosis (TB). SETTING: Moldova, Mongolia, Uganda and Zimbabwe. METHODS: A representative sample of laboratories was selected in each country. Data were double-entered and discordances resolved by rechecking the register. RESULTS: The dataset comprised 128808 examinees with valid information from 23 laboratories in Moldova, all 31 in Mongolia, 30 in Uganda and 23 in Zimbabwe, each covering at least one calendar year. The reason for the examination was diagnostic for 89362, of which 15.2% (n = 13577) were defined as laboratory cases with at least one bacillus on at least one examination. Cases were confirmed by another examination in 72.6% (n = 9861). Of the 9014 cases who had a full set of three examinations, confirmation was obtained in 92.4% (n = 8325). CONCLUSION: One quarter of laboratory cases had no confirmatory result, almost entirely attributable to not examining another specimen. The current definition of sputum smear-positive TB requires two positive smears or one positive smear result plus more complex confirmatory evidence. Accepting a single positive examination as sufficient for the definition would greatly increase the sensitivity of the surveillance definition without sacrificing its specificity.

Schistosomiasis infection among school children in the Zhaugwe resettlement area, Zimbabwe April 2005.

OBJECTIVES: To investigate the prevalence and factors associated with contracting schistosomiasis in Zhaugwe resettlement area of Shurugwi district. DESIGN: Cross sectional study. STUDY SETTING: The community in the Zhaugwe resettlement area of Shurugwi district, Midlands Province, Zimbabwe. SUBJECTS: School children in primary and secondary levels. MAIN OUTCOME MEASURES: Prevalence of schistosomiasis infection, risk factors for contracting schistosomiasis. RESULTS: Prevalence of S. haematobium and S. mansoni was 68% and 0.2%, respectively. Participating in watering the respondents' household garden (O.R = 8.1, 95% CI 1.65 to 40.2), fetching water for the home garden (O.R=3,96 95% CI 1.38 to 11.32), fishing with their legs in the water (O.R = 3.1 95% CI 1.6 to 5.8), bathing in the river or stream (O.R = 3.1 95% CI 1.68 to 5.8) were found to be statistically significantly associated with contracting schistosomiasis infection. Fishing with legs immersed in water, having a garden at home, and swimming in the river were positively associated with infection. Those who reported blood in their urine were 16 times more like to be positive for S. haematobium than those without. Vector snails were present at all water contact sites. CONCLUSION: Schistosomiasis is a major public health problem in the area. We recommend mass treatment of all school children in all other schools in the area. The community should be encouraged to cultivate Phytoloca dedocandra for snail control.

Efficiency of serial smear examinations in excluding sputum smear-positive tuberculosis.

SETTING: This study determined the number of slides required to identify one additional case of sputum smear-positive tuberculosis (TB) from the third smear. The study hypothesis was that not more than 100 and 75 slides, respectively, in Mongolia and Zimbabwe, need to be examined to find one additional case of TB with a third serial diagnostic sputum smear examination. METHODS: In a retrospective, record-based study, data were abstracted from TB laboratory registers from all 31 laboratories in Mongolia and 23 randomly selected laboratories in Zimbabwe using a uniform EpiData collection instrument. RESULTS: A total of 52,909 records of examinees were available. In Mongolia, of 15 103 suspects, 1717 (11.4%) were positive. Of these, 0.7% were positive for the first time on the third smear examination. In Zimbabwe, of 25 693 suspects, 3452 (13.4%) were positive and 4.5% were positive only on the third smear examination. The expected number of slides required to detect one additional case on the third examination was 1153.3 for Mongolia and 132.6 for Zimbabwe. CONCLUSIONS: The requirement of routine examination of three serial smears before declaring a suspect as a 'non-case' (of sputum smear-positive TB) will need to be reviewed in both Mongolia and Zimbabwe.