'Kuyendela odwala TB'--visiting TB patients: the widening role of home-based care organisations in the management of tuberculosis patients in Lusaka, Zambia.

OBJECTIVE: To explore the widening role of home-based care (HBC) organisations in the management of TB patients in Lusaka, Zambia, in 1999. DESIGN: In a purposeful sample of eight HBC organisations and 1 hospice in Lusaka, 142 TB patients under HBC, 54 care givers, 42 TB patients not under HBC and 9 managers were interviewed. RESULTS: At least 50% of TB patients in Lusaka are cared for by HBC. The role of HBC in management of TB patients included food aid, practical and emotional support through the visits of voluntary care givers and, often, medical advice and treatment. TB diagnosis is carried out within the government health facilities. Five HBC organisations supplied anti-tuberculosis drugs, and three tried to carry out direct observation of treatment. The majority of the TB patients said their situation improved under HBC. Management was undermined by poor record keeping, sporadic anti-tuberculosis drug supplies, stigmatising preventive messages, limited supervision of care givers and poor coordination with the District Health Services. CONCLUSION: HBC organisations have become a key partner in TB control, looking after half the TB patients in Lusaka from diagnosis onwards, and complementing the public system. However, the quality of their management of TB and their partnership with government need to improve.

Utility of nucleic acid amplification techniques for the diagnosis of pulmonary tuberculosis in sub-Saharan Africa.

SETTING: Lusaka, Zambia. OBJECTIVES: To investigate the utility of nucleic amplification tests for the diagnosis of pulmonary tuberculosis in a resource-poor setting with a high incidence of human immunodeficiency virus (HIV). DESIGN: Sputum specimens from suspects attending a referral chest clinic were examined by low-cost 'in-house' one-tube nested polymerase chain reaction (PCR), the enhanced Gen-Probe Amplified Mycobacterium Direct Test (AMTD), auramine smear and Lowenstein-Jensen culture. RESULTS: PCR and AMTD detected respectively 80% and 92% of smear-positive specimens and 40% and 60% of smear-negative, culture-positive specimens. AMTD was positive for 18 culture-negative suspects; subsequent investigation indicated these to be six confirmed tuberculosis patients, nine judged from radiological data and clinical follow-up studies to have pulmonary tuberculosis, and three non-tuberculosis patients. Sensitivity for smear, culture, PCR and AMTD, when compared to a gold standard incorporating both microbiological and clinical data, was respectively 29%, 69%, 55% and 81%. CONCLUSION: In this setting, the sensitivity of the low-cost PCR proved insufficient for its effective use as a tool for diagnosing pulmonary tuberculosis, while AMTD performed considerably better than the current laboratory methods for diagnosis of pulmonary tuberculosis. However, the high cost of this technology may limit its application in the public sector of low-income countries.

An incremental cost-effectiveness analysis of the first, second and third sputum examination in the diagnosis of pulmonary tuberculosis.

SETTING: St. Francis Hospital in Katete District, Eastern Province, Zambia. OBJECTIVE: To compare the incremental cost-effectiveness of examining serial sputum smears for screening suspects for pulmonary tuberculosis at a rural district hospital in Zambia. DESIGN: An incremental cost-effectiveness analysis of serial sputum smear examinations for diagnosing pulmonary tuberculosis based on laboratory results collected during 1997 and 1998 in a rural district hospital in Zambia. The cost analysis took a health service provider perspective, and used the ingredients approach. The cost-effectiveness is expressed in terms of the incremental cost per tuberculosis case diagnosed. Relevant information was obtained from various sources, including administrative records, interviews and direct observation. RESULTS: Of a total of 166 acid-fast bacilli positive suspects who had three sputum smears examined sequentially, 128 (77.1%) were found on the first smear, a further 25 (15%) on the second smear and 13 (7.9%) additional cases were identified on the third smear. The economic analysis shows that the incremental cost of performing a third test, having already done two, increases rapidly with only a small gain in terms of additional cases of tuberculosis identified. CONCLUSION: A policy of examining two samples should be considered in resource-poor settings, if the remaining steps of the national diagnostic algorithm can be adhered to with respect to smear-negative suspects.