First national survey of Mycobacterium tuberculosis drug resistance, Madagascar, 2005-2006.

SETTING: A national survey of Mycobacterium tuberculosis resistance was conducted for the first time in Madagascar between October 2005 and July 2007. OBJECTIVE: To determine resistance rates among new and previously treated cases of pulmonary tuberculosis. METHODS: In a cluster sampling representative of the general population of the country, 1275 smear-positive tuberculosis patients recruited at 34 sites, 926 new patients and 87 previously treated patients underwent drug susceptibility testing against rifampicin (RMP), isoniazid (INH), streptomycin and ethambutol on Löwenstein-Jensen medium using the indirect proportion method. RESULTS: Resistance among new cases was 6.5% (95%CI 4.9-8) and among previously treated cases it was 11.5% (95%CI 4.8-18.2). Monoresistance among new cases was 5.8% (95%CI 4.2-7.3), mainly to INH (3.7%). Multiresistance to INH and RMP was 0.2% (95%CI 0-0.5) among new cases and 3.4% (95%CI 0-7.2) among previously treated cases. No significant difference was noted with regard to sex or age. CONCLUSION: The rates of resistance among new and previously treated cases remain relatively low in Madagascar.

Controle de qualite inter-laboratoires centraux pour le diagnostic microscopique de la tuberculose a Madagascar en 2000

"Tuberculosis diagnosis by microscopy in Madagascar : quality control comparison of the two central laboratories"" : Since June 1997; a quarterly quality control of sputum smear exam for the tubercle diagnosis; depending on double reading of slides; was implemented between both central laboratories of the Mycobacteria National Reference Centre in Madagascar (mycobactoria laboratories of Institut Pasteur Madagascar [IPM] and Institut Hygiene Sociale [IHS] - Health Ministry). In 2000; four controls were done; in the course of which 240 slides were coloured by auramine; coming both from IPM and IHS; and another 80 slides from IHS were coloured by Ziehl-Neelsen. All the results were in agreement for the samples stained with auramine; while two false negatives were found for the samples stained with Ziehl-Neelsen. The maintenance of this quality control between the two laboratories is necessary to insure the reliability of their results and the controls that they make for the peripheral laboratories."

Bacteriological follow-up of tuberculosis treatment: a comparative study of smear microscopy and culture results at the second month of treatment.

SETTING: Significance of a positive bacillary examination of sputum at 2 months of treatment in relation to the viability of the bacilli and the final treatment result. OBJECTIVE: To compare the results of smear microscopy and sputum culture at the second month of tuberculosis treatment and to follow the progress of the patients. METHODS: Follow-up of 297 patients with smear-positive pulmonary tuberculosis in Madagascar, 152 of whom were smear-positive at 2 months of treatment and 145 smear-negative. The number of bacilli was recorded, as were the culture results and the final outcome of treatment. RESULTS: Among the 152 patients who were smear-positive at the second month, 77 (51%) were culture-negative; there were 12 (8%) treatment failures and four relapses (4.6%). Among the 145 smear-negative patients, 22 (15%) were culture-positive, of which one was a treatment failure (1%). CONCLUSION: The majority of failures and relapses were observed in the group of smear-positive patients. It is important to reinforce the surveillance of these patients in order to reduce the number lost to follow-up. Furthermore, a positive smear microscopy at the end of the second month is not sufficiently specific for early identification of treatment failures. It is preferable to wait until the fifth month, as the great majority of patients who are positive at 2 months achieve cure. The treatment strategy currently recommended in Madagascar is satisfactory.

[Central inter-laboratory quality control for microscopic diagnosis of tuberculosis in Madagascar in 2000]. / Contrôle de qualité inter-laboratoires centraux pour le diagnostic microscopique de la tuberculose à Madagascar en 2000.

Since June 1997, a quarterly quality control of sputum smear exam for the tubercle diagnosis, depending on double reading of slides, was implemented between both central laboratories of the Mycobacteria National Reference Centre in Madagascar (mycobactoria laboratories of Institut Pasteur Madagascar [IPM] and Institut Hygiène Sociale [IHS]--Health Ministry). In 2000, four controls were done, in the course of which 240 slides were coloured by auramine, coming both from IPM and IHS, and another 80 slides from IHS were coloured by Ziehl-Neelsen. All the results were in agreement for the samples stained with auramine, while two false negatives were found for the samples stained with Ziehl-Neelsen. The maintenance of this quality control between the two laboratories is necessary to insure the reliability of their results and the controls that they make for the peripheral laboratories.

[Mycobacterium tuberculosis resistance to antitubercular agents in Antananarivo in 2000]. / Résistance de Mycobacterium tuberculosis aux antituberculeux à Antananarivo en 2000.

In 1991, the National Tuberculosis control Program (NTP) of Madagascar adopted the short treatment course and the Directly Observed Treatment Strategy (DOTS), according to the recommendations of the OMS/UICTMR. Development of M. tuberculosis primary resistance to the four antituberculosis drugs (streptomycin [S], rifampicine [R], isoniazid [H], ethambutol [E]) is an indicator of the NTP efficiency. We report results from a five-year survey among patients with new smear positive pulmonary tuberculosis. Acquired resistance is assessed among recurrent cases. During the first survey, carried out in 1994-1995 in four large cities, multidrug resistance (MDR) rate to the major antituberculosis drug H and R was low, 0.25% for primary MDR and 5% for acquired MDR. No primary MDR was found in Antananarivo; on the other hand, acquired resistance rate was the highest there (22%). Because of logistical reasons, the second survey (1999-2000) was only carried out in the capital, Antananarivo. Results obtained among 789 new patients with smear positive pulmonary tuberculosis and 79 recurrents cases in 9 diagnostic centres showed low primary and acquired resistance of 11.1% to any drug. Primary resistance to one drug was 10.6%, mainly due to streptomycin 8.5%. MDR rates are comparable with those observed in 1994-1995: 0.1% for primary MDR and 4% for acquired MDR. These results show that ten years after the new NTP implementation, only a few MDR strains are circulating in Antananarivo, which suggests that NTP has been effective.

[Laboratory network for the microscopic diagnosis of tuberculosis in Madagascar: quality control of slides]. / Réseau des laboratoires de microscopie pour le diagnostic de la tuberculose à Madagascar: contrôle de qualité des lames en 1999.

As part of the National Tuberculosis Program (NTP), a quality control of the slides (search of acido-fast bacilli in the sputa) of the Treatment and Diagnosis Centers (TDC) forming the National Laboratory Network is carried out each year. In 1999, 76 TDC out of the 174 (44%) had been controlled using the method of double reading of the smears. The global concordance of the results in the 76 TDC is satisfactory (98%). Reability was 91% for the positive smears and 92% for the negative smears. A good quality of smears was observed in 53% of the centers. The TDC reliable at 100% for both positive and negative smears were 51 (67%) of which 36 (47%) had also a good quality of smears. Those later were mainly found in Toamasina, Fianarantsoa, Antananarivo and Mahajanga.

[Microscopy laboratories for the diagnosis of tuberculosis in Madagascar: quality control]. / Réseau des laboratoires de microscopie pour le diagnostic de la tuberculose à Madagascar: contrôle de qualité.

As part of the National Tuberculosis Program (NTP), a quality control of the slides (search of acido-fast-bacilli in the sputa) of the Treatment and Diagnosis Centers (TDC) forming the National Laboratory Network was carried out in 1996. 60 TDC of the 165 TDC (36%) had been controlled according to the system of double reading of the smears. The global concordance of the results in the 60 TDC is satisfactory since it was of 94%. Reliability of smears positive was of 83%. For the negative smears reliability, 14% of the TDC had a low or insufficient level. A good quality of smears was observed in 40% of the centers. The TDC that had both positive and negative reliability at 100% were 23 (38%) of which 13 had good quality of smears. Those were especially found in Antananarivo, Toliara, Fianarantsoa and Mahajanga.

[National Laboratory for Mycobacterias. Evolution, missions and activities from 1991 to 1994]. / Laboratoire National des Mycobactéries. Evolution, missions et activitiés de 1991 à 1994.

The setting up of a new nationwide tuberculosis control programme allowed the creation of a National Mycobacteria Reference Laboratory. This latter originated from the small bacteriology laboratory of the antitubercular dispensary of the Institut d'Hygiène Sociale (IHS) and its activities increased tenfold within three years. Extension of rooms, a more numerous staff and the acquisition of a modern equipment explained those results. However, to carry out the tasks of such a laboratory a rapid modification of structures and a new job distribution facilitated by a cooperation with the Institut Pasteur de Madagascar are necessary.