Have Hand Hygiene Practices in Two Tertiary Care Hospitals, Freetown, Sierra Leone, Improved in 2023 following Operational Research in 2021?

In 2021, an operational research study in two tertiary hospitals in Freetown showed poor hand hygiene compliance. Recommended actions were taken to improve the situation. Between February-April 2023, a cross-sectional study was conducted in the same two hospitals using the World Health Organization hand hygiene tool to assess and compare hand hygiene compliance with that observed between June-August 2021. In Connaught hospital, overall hand hygiene compliance improved from 51% to 60% (p < 0.001), and this applied to both handwash actions with soap and water and alcohol-based hand rub. Significant improvements were found in all hospital departments and amongst all healthcare worker cadres. In 34 Military Hospital (34MH), overall hand hygiene compliance decreased from 40% to 32% (p < 0.001), with significant decreases observed in all departments and amongst nurses and nursing students. The improvements in Connaught Hospital were probably because of more hand hygiene reminders, better handwash infrastructure and more frequent supervision assessments, compared with 34MH where interventions were less well applied, possibly due to the extensive hospital reconstruction at the time. In conclusion, recommendations from operational research in 2021 contributed towards the improved distribution of hand hygiene reminders, better handwash infrastructure and frequent supervision assessments, which possibly led to improved hand hygiene compliance in one of the two hospitals. These actions need to be strengthened, scaled-up and guided by ongoing operational research to promote good hand hygiene practices elsewhere in the country.

Genomic insights of mcr-1 harboring Escherichia coli by geographical region and a One-Health perspective.

The importance of the One Health concept in attempting to deal with the increasing levels of multidrug-resistant bacteria in both human and animal health is a challenge for the scientific community, policymakers, and the industry. The discovery of the plasmid-borne mobile colistin resistance (mcr) in 2015 poses a significant threat because of the ability of these plasmids to move between different bacterial species through horizontal gene transfer. In light of these findings, the World Health Organization (WHO) recommends that countries implement surveillance strategies to detect the presence of plasmid-mediated colistin-resistant microorganisms and take suitable measures to control and prevent their dissemination. Seven years later, ten different variants of the mcr gene (mcr-1 to mcr-10) have been detected worldwide in bacteria isolated from humans, animals, foods, the environment, and farms. However, the possible transmission mechanisms of the mcr gene among isolates from different geographical origins and sources are largely unknown. This article presents an analysis of whole-genome sequences of Escherichia coli that harbor mcr-1 gene from different origins (human, animal, food, or environment) and geographical location, to identify specific patterns related to virulence genes, plasmid content and antibiotic resistance genes, as well as their phylogeny and their distribution with their origin. In general, E. coli isolates that harbor mcr-1 showed a wide plethora of ARGs. Regarding the plasmid content, the highest concentration of plasmids was found in animal samples. In turn, Asia was the continent that led with the largest diversity and occurrence of these plasmids. Finally, about virulence genes, terC, gad, and traT represent the most frequent virulence genes detected. These findings highlight the relevance of analyzing the environmental settings as an integrative part of the surveillance programs to understand the origins and dissemination of antimicrobial resistance.

Risk of obstructive sleep apnea and quality of sleep among adults with type 2 diabetes mellitus in a sub-Saharan Africa city.

INTRODUCTION: diabetes mellitus (DM) and Obstructive Sleep Apnea (OSA) are two major and interconnected non-communicable diseases. Both negatively impact on sleep quality. This study aimed to determine among persons with type 2 DM, the proportions at high risk of OSA and of self-reported poor sleep quality along with their associated-factors in Parakou city, Benin. METHODS: this was a cross-sectional prospective study of 100% (n=383) outpatient adults with type 2 DM, conducted between April and August 2019 in the three top centres managing diabetic persons in Parakou city. They were interviewed, examined and investigated using capillary fasting blood glucose tests. The STOP-Bang Questionnaire (SBQ) was used to determine the risk of OSA. RESULTS: overall, their mean age was 57.37 (11.45) years. They were 61.62% (n=236) females and 38.38% (n=147) males. Sleep duration was insufficient in 26.89% (n=103). Nocturia was reported in 49.35% (n=189). The risk of OSA was high in 14.10% (n=54), intermediate in 24.80% (n=95) and low in 61.10% (n=234). Friedman Position Tongue Grade 3 (Adjusted Odds Ratio, aOR=2.48; 95%CI=1.11 - 5.55; p=0.025) and 4 (aOR=4.65; 95%CI=1.26 - 15.90; p=0.015) were independently associated with a high risk of OSA. The prevalence of reported poor sleep quality was 27.42% (n=105). Female gender (aOR=2.08; 95%CI=1.18-3.83; p=0.014), diabetic foot (aOR=5.07; 95%CI=1.15-23.63; p=0.031), nocturia (aOR=1.96; 95%CI=1.18-3.29; p=0.010), tiredness (aOR=2.77; 95%CI=1.26-6.23; p=0.012) and a high risk of OSA (aOR=3.31; 95%CI=1.28-8.93; p=0.015) were independently associated with a greater risk of reported poor sleep quality. CONCLUSION: in Parakou, the proportions of patients with type 2 DM at increased risk of OSA and with poor quality of sleep are relatively high. There is need for better systematic screening of OSA in persons with DM.

Prevention of mother-to-child transmission activities after one-off clinical mentorship training in selected health facilities, Zimbabwe: 2014-2018.

This was a cross-sectional study describing HIV testing uptake and ART initiation for pregnant women and HIV-exposed infants after one-off clinical mentorship training in 2013 for nurses in 56 peripheral health-facilities, Zimbabwe. Between 2014-2018, 92% of 106411 pregnant women were HIV tested and 98% of HIV-positive women initiated antiretroviral therapy (ART). There were 15846 HIV-exposed infants, of whom 96% had dried blood spots collected for virologic diagnosis and 51% of those diagnosed HIV-positive initiated ART. In conclusion, this one-off clinical mentorship training in 2013 was associated with consistently high HIV testing and ART initiation in pregnant women and their children.

An Opportunity to END TB: Using the Sustainable Development Goals for Action on Socio-Economic Determinants of TB in High Burden Countries in WHO South-East Asia and the Western Pacific Regions.

The progress towards ending tuberculosis (TB) by 2035 is less than expected in 11 high TB burden countries in the World Health Organization South-East Asia and Western Pacific regions. Along with enhancing measures aimed at achieving universal access to quality-assured diagnosis, treatment and prevention services, massive efforts are needed to mitigate the prevalence of health-related risk factors, preferably through broader actions on the determinants of the "exposure-infection-disease-adverse outcome" spectrum. The aim of this manuscript is to describe the major socio-economic determinants of TB and to discuss how there are opportunities to address these determinants in an englobing manner under the United Nations Sustainable Development Goals (SDGs) framework. The national TB programs must identify stakeholders working on the other SDGs, develop mechanisms to collaborate with them and facilitate action on social-economic determinants in high TB burden geographical areas. Research (to determine the optimal mechanisms and impact of such collaborations) must be an integral part of this effort. We call upon stakeholders involved in achieving the SDGs and End TB targets to recognize that all goals are highly interlinked, and they need to combine and complement each other's efforts to end TB and the determinants behind this disease.

Screening for active pulmonary tuberculosis: Development and applicability of artificial neural network models.

Tuberculosis (TB) remains a significant public health challenge, motivated by the diversity of healthcare epidemiological settings, as other factors. Cost-effective screening has substantial importance for TB control, demanding new diagnostic tools. This paper proposes a decision support tool (DST) for screening pulmonary TB (PTB) patients at a secondary clinic. The DST is composed of an adaptive resonance model (iART) for risk group identification (low, medium and high) and a multilayer perceptron (MLP) neural network for classifying patients as active or inactive PTB. Our tool attains an overall sensitivity (SE) and specificity (SP) of 92% (95% CI; 79-97) and 58% (95% CI; 47-68), respectively. SE values for smear-positive and smear-negative patients are 96% (95% CI; 80-99) and 82% (95% CI; 52-95), as well as higher than 83% (95% CI; 43-97) in low and high-risk cases. Even in scenarios with prevalence up to 20%, negative predictive values superior to 95% are obtained. The proposed DST provides a quick and low-cost pretest for presumptive PTB patients, which is useful to guide confirmatory testing and patient management, especially in settings with limited resources in low and middle-incoming countries.

HIV-infected presumptive tuberculosis patients without tuberculosis: How many are eligible for antiretroviral therapy in Karnataka, India?

For certain subgroups within people living with the human immunodeficiency virus (HIV) [active tuberculosis (TB), pregnant women, children <5years old, and serodiscordant couples], the World Health Organization recommends antiretroviral therapy (ART) irrespective of CD4 count. Another subgroup which has received increased attention is "HIV-infected presumptive TB patients without TB". In this study, we assess the proportion of HIV-infected presumptive TB patients eligible for ART in Karnataka State (population 60million), India. This was a cross-sectional analysis of data of HIV-infected presumptive TB patients diagnosed in May 2015 abstracted from national TB and HIV program records. Of 42,585 presumptive TB patients, 28,964 (68%) were tested for HIV and 2262 (8%) were HIV positive. Of the latter, 377 (17%) had active TB. Of 1885 "presumptive TB patients without active TB", 1100 (58%) were already receiving ART. Of the remaining 785 who were not receiving ART, 617 (79%) were assessed for ART eligibility and of those, 548 (89%) were eligible for ART. About 90% of "HIV-infected presumptive TB patients without TB" were eligible for ART. This evidence supports a public health approach of starting all "HIV-infected presumptive TB patients without TB" on ART irrespective of CD4 count in line with global thinking about 'test and treat'.

HIV Testing among Patients with Presumptive Tuberculosis: How Do We Implement in a Routine Programmatic Setting? Results of a Large Operational Research from India.

BACKGROUND: In March 2012, World Health Organization recommended that HIV testing should be offered to all patients with presumptive TB (previously called TB suspects). How this is best implemented and monitored in routine health care settings in India was not known. An operational research was conducted in Karnataka State (South India, population 64 million, accounts for 10% of India's HIV burden), to test processes and learn results and challenges of screening presumptive TB patients for HIV within routine health care settings. METHODS: In this cross-sectional study conducted between January-March 2012, all presumptive TB patients attending public sector sputum microscopy centres state-wide were offered HIV testing by the laboratory technician, and referred to the nearest public sector HIV counselling and testing services, usually within the same facility. The HIV status of the patients was recorded in the routine TB laboratory form and TB laboratory register. The laboratory register was compiled to obtain the number of presumptive TB patients whose HIV status was ascertained, and the number found HIV positive. Aggregate data on reasons for non-testing were compiled at district level. RESULTS: Overall, 115,308 patients with presumptive TB were examined for sputum smear microscopy at 645 microscopy centres state-wide. Of these, HIV status was ascertained for 62,847(55%) among whom 7,559(12%) were HIV-positive, and of these, 3,034(40%) were newly diagnosed. Reasons for non-testing were reported for 37,700(72%) of the 52,461 patients without HIV testing; non-availability of testing services at site of sputum collection was cited by health staff in 54% of respondents. Only 4% of patients opted out of HIV testing. CONCLUSION: Offering HIV testing routinely to presumptive TB patients detected large numbers of previously-undetected instances of HIV infection. Several operational challenges were noted which provide useful lessons for improving uptake of HIV testing in this important group.

Factors Associated with Ever Being HIV-Tested in Zimbabwe: An Extended Analysis of the Zimbabwe Demographic and Health Survey (2010-2011).

INTRODUCTION: Zimbabwe has a high human immunodeficiency virus (HIV) burden. It is therefore important to scale up HIV-testing and counseling (HTC) as a gateway to HIV prevention, treatment and care. OBJECTIVE: To determine factors associated with being HIV-tested among adult men and women in Zimbabwe. METHODS: Secondary analysis was done using data from 7,313 women and 6,584 men who completed interviewer-administered questionnaires and provided blood specimens for HIV testing during the Zimbabwe Demographic and Health Survey (ZDHS) 2010-11. Factors associated with ever being HIV-tested were determined using multivariate logistic regression. RESULTS: HIV-testing was higher among women compared to men (61% versus 39%). HIV-infected respondents were more likely to be tested compared to those who were HIV-negative for both men [adjusted odds ratio (AOR) = 1.53; 95% confidence interval (CI) (1.27-1.84)] and women [AOR = 1.42; 95% CI (1.20-1.69)]. However, only 55% and 74% of these HIV-infected men and women respectively had ever been tested. Among women, visiting antenatal care (ANC) [AOR = 5.48, 95% CI (4.08-7.36)] was the most significant predictor of being tested whilst a novel finding for men was higher odds of testing among those reporting a sexually transmitted infection (STI) in the past 12 months [AOR = 1.86, 95%CI (1.26-2.74)]. Among men, the odds of ever being tested increased with age ≥ 20 years, particularly those 45-49 years [AOR = 4.21; 95% CI (2.74-6.48)] whilst for women testing was highest among those aged 25-29 years [AOR = 2.01; 95% CI (1.63-2.48)]. Other significant factors for both sexes were increasing education level, higher wealth status and currently/formerly being in union. CONCLUSIONS: There remains a high proportion of undiagnosed HIV-infected persons and hence there is a need for innovative strategies aimed at increasing HIV-testing, particularly for men and in lower-income and lower-educated populations. Promotion of STI services can be an important gateway for testing more men whilst ANC still remains an important option for HIV-testing among pregnant women.

Syndromic surveillance in Vanuatu since Cyclone Pam: a descriptive study.

In 2012, Vanuatu designed and implemented a syndromic surveillance system based on the guidelines developed by the Pacific Community and the World Health Organization to provide early warning of outbreaks and other important public health events. Four core syndromes were endorsed for surveillance: acute fever and rash, prolonged fever, influenza-like illness and acute watery diarrhoea. In March 2015, Vanuatu was struck by Cyclone Pam, after which several important changes and improvements to the country's syndromic surveillance were made. To date, there has been no formal evaluation of whether regular reports are occurring or that core syndromes are being documented. We therefore carried out a descriptive study in the 11 sentinel sites in Vanuatu conducting syndromic surveillance between July and December 2015. There was a total of 53 822 consultations which were higher in the first 13 weeks (n = 29 622) compared with the last 13 weeks (n = 24 200). During the six months, there were no cases of acute fever and rash or prolonged fever. There were cases with influenza-like illness from week 27 to 35, but no case was reported after week 35. Acute watery diarrhoea occurred in one or two cases per week during the whole study period. For these two core syndromes, there were generally more females than males, and about one third were children aged under 5 years. In conclusion, Vanuatu implemented changes to its new syndromic surveillance system from July to December 2015, although laboratory components had not yet been incorporated. The laboratory components are working in 2016 and will be the subject of a further report.

Tuberculosis management practices by private practitioners in Andhra Pradesh, India.

SETTING: Private medical practitioners in Visakhapatnam district, Andhra Pradesh, India. OBJECTIVES: To evaluate self-reported TB diagnostic and treatment practices amongst private medical practitioners against benchmark practices articulated in the International Standards of Tuberculosis Care (ISTC), and factors associated with compliance with ISTC. DESIGN: Cross- sectional survey using semi-structured interviews. RESULTS: Of 296 randomly selected private practitioners, 201 (68%) were assessed for compliance to ISTC diagnostic and treatment standards in TB management. Only 11 (6%) followed a combination of 6 diagnostic standards together and only 1 followed a combination of all seven treatment standards together. There were 28 (14%) private practitioners who complied with a combination of three core ISTC (cough for tuberculosis suspects, sputum smear examination and use of standardized treatment). Higher ISTC compliance was associated with caring for more than 20 TB patients annually, prior sensitization to TB control guidelines, and practice of alternate systems of medicine. CONCLUSION: Few private practitioners in Visakhapatnam, India reported TB diagnostic and treatment practices that met ISTC. Better engagement of the private sector is urgently required to improve TB management practices and to prevent diagnostic delay and drug resistance.

Factors associated with delays in treatment initiation after tuberculosis diagnosis in two districts of India.

BACKGROUND: Excessive time between diagnosis and initiation of tuberculosis (TB) treatment contributes to ongoing TB transmission and should be minimized. In India, Revised National TB Control Programme (RNTCP) focuses on indicator start of treatment within 7 days of diagnosis for patients with sputum smear-positive PTB for monitoring DOTS implementation. OBJECTIVES: To determine length of time between diagnosis and initiation of treatment and factors associated with delays of more than 7 days in smear-positive pulmonary TB. METHODS: Using existing programme records such as the TB Register, treatment cards, and the laboratory register, we conducted a retrospective cohort study of all patients with smear-positive pulmonary TB registered from July-September 2010 in two districts in India. A random sample of patients with pulmonary TB who experienced treatment delay of more than 7 days was interviewed using structured questionnaire. RESULTS: 2027 of 3411 patients registered with pulmonary TB were smear-positive. 711(35%) patients had >7 days between diagnosis and treatment and 262(13%) had delays >15 days. Mean duration between TB diagnosis and treatment initiation was 8 days (range = 0-128 days). Odds of treatment delay >7 days was 1.8 times more likely among those who had been previously treated (95% confidence interval [CI] 1.5-2.3) and 1.6 (95% CI 1.3-1.8) times more likely among those diagnosed in health facilities without microscopy centers. The main factors associated with a delay >7 days were: patient reluctance to start a re-treatment regimen, patients seeking second opinions, delay in transportation of drugs to the DOT centers and delay in initial home visits. To conclude, treatment delay >7 days was associated with a number of factors that included history of previous treatment and absence of TB diagnostic services in the local health facility. Decentralized diagnostic facilities and improved referral procedures may reduce such treatment delays.

Are tuberculosis patients in a tertiary care hospital in Hyderabad, India being managed according to national guidelines?

SETTING: A tertiary health care facility (Government General and Chest hospital) in Hyderabad, India. OBJECTIVES: To assess a) the extent of compliance of specialists to standardized national (RNTCP) tuberculosis management guidelines and b) if patients on discharge from hospital were being appropriately linked up with peripheral health facilities for continuation of anti-Tuberculosis (TB) treatment. METHODS: A descriptive study using routine programme data and involving all TB patients admitted to inpatient care from 1(st) January to 30(th) June, 2010. RESULTS AND CONCLUSIONS: There were a total of 3120 patients admitted of whom, 1218 (39%) required anti-TB treatment. Of these 1104 (98%) were treated with one of the RNTCP recommended regimens, while 28 (2%) were treated with non-RNTCP regimens. The latter included individually tailored MDR-TB treatment regimens for 19 patients and adhoc regimens for nine patients. A total of 957 (86%) patients were eventually discharged from the hospital of whom 921 (96%) had a referral form filled for continuing treatment at a peripheral health facility. Formal feedback from peripheral health facilities on continuation of TB treatment was received for 682 (74%) patients. In a tertiary health facility with specialists the great majority of TB patients are managed in line with national guidelines. However a number of short-comings were revealed and measures to rectify these are discussed.

How do patients who fail first-line TB treatment but who are not placed on an MDR-TB regimen fare in South India?

SETTING: Seven districts in Andhra Pradesh, South India. OBJECTIVES: To a) determine treatment outcomes of patients who fail first line anti-TB treatment and are not placed on an multi-drug resistant TB (MDR-TB) regimen, and b) relate the treatment outcomes to culture and drug susceptibility patterns (C&DST). DESIGN: Retrospective cohort study using routine programme data and Mycobacterium TB Culture C&DST between July 2008 and December 2009. RESULTS: There were 202 individuals given a re-treatment regimen and included in the study. Overall treatment outcomes were: 68 (34%) with treatment success, 84 (42%) failed, 36 (18%) died, 13 (6.5%) defaulted and 1 transferred out. Treatment success for category I and II failures was low at 37%. In those with positive cultures, 81 had pan-sensitive strains with 31 (38%) showing treatment success, while 61 had drug-resistance strains with 9 (15%) showing treatment success. In 58 patients with negative cultures, 28 (48%) showed treatment success. CONCLUSION: Treatment outcomes of patients who fail a first-line anti-TB treatment and who are not placed on an MDR-TB regimen are unacceptably poor. The worst outcomes are seen among category II failures and those with negative cultures or drug-resistance. There are important programmatic implications which need to be addressed.

Will adoption of the 2010 WHO ART guidelines for HIV-infected TB patients increase the demand for ART services in India?

BACKGROUND: In 2010, WHO expanded previously-recommended indications for anti-retroviral treatment to include all HIV-infected TB patients irrespective of CD4 count. India, however, still limits ART to those TB patients with CD4 counts <350/mm(3) or with extrapulmonary TB manifestations. We sought to evaluate the additional number of patients that would be initiated on ART if India adopted the current 2010 WHO ART guidelines for HIV-infected TB patients. METHODS: We evaluated all TB patients recorded in treatment registers of the Revised National TB Control Programme in June 2010 in the high-HIV prevalence state of Karnataka, and cross-matched HIV-infected TB patients with ART programme records. RESULTS: Of 6182 TB patients registered, HIV status was ascertained for 5761(93%) and 710(12%) were HIV-infected. 146(21%) HIV-infected TB patients were on ART prior to TB diagnosis. Of the remaining 564, 497(88%) were assessed for ART eligibility; of these, 436(88%) were eligible for ART according to 2006 WHO ART guidelines. Altogether, 487(69%) HIV-infected TB patients received ART during TB treatment. About 80% started ART within 8 weeks of TB treatment and 95% received an efavirenz based regimen. CONCLUSION: In Karnataka, India, about nine out of ten HIV-infected TB patients were eligible for ART according to 2006 WHO ART guidelines. The efficiency of HIV case finding, ART evaluation, and ART initiation was relatively high, with 78% of eligible HIV-infected patients actually initiated on ART, and 80% within 8 weeks of diagnosis. ART could be extended to all HIV-infected TB patients irrespective of CD4 count with relatively little additional burden on the national ART programme.

From where are tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts.

BACKGROUND: Tuberculosis (TB) notification in India by the Revised National TB Control Programme (RNTCP) provides information on TB patients registered for treatment from the programme. There is limited information about the proportion of patients treated for TB outside RNTCP and where these patients access their treatment. OBJECTIVES: To estimate the proportion of patients accessing TB treatment outside the RNTCP and to identify their basic demographic characteristics. METHODS: A cross sectional community-based survey in 30 districts. Patients were identified through a door-to-door survey and interviewed using a semi-structured questionnaire. RESULTS: Of the estimated 75,000 households enumerated, 73,249 households (97.6%) were visited. Of the 371,174 household members, 761 TB patients were identified (∼205 cases per 100,000 populations). Data were collected from 609 (80%) TB patients of which 331 [54% (95% CI: 42-66%)] were determined to be taking treatment 'under DOTS/RNTCP'. The remaining 278 [46% (95% CI: 34-57%)] were on treatment from 'outside DOTS/RNTCP' sources and hence were unlikely to be part of the TB notification system. Patients who were accessing treatment from 'outside DOTS/RNTCP' were more likely to be patients from rural areas [adjusted Odds Ratio (aOR) 2.5, 95% CI (1.2-5.3)] and whose TB was diagnosed in a non-government health facility (aOR 14.0, 95% CI 7.9-24.9). CONCLUSIONS: This community-based survey found that nearly half of self-reported TB patients were missed by TB notification system in these districts. The study highlights the need for 1) Reviewing and revising the scope of the TB notification system, 2) Strengthening and monitoring health care delivery systems with periodic assessment of the reach and utilisation of the RNTCP services especially among rural communities, 3) Advocacy, communication and social mobilisation activities focused at rural communities with low household incomes and 4) Inclusive involvement of all health-care providers, especially providers of poor rural communities.

Characteristics and programme-defined treatment outcomes among childhood tuberculosis (TB) patients under the national TB programme in Delhi.

BACKGROUND: Childhood tuberculosis (TB) patients under India's Revised National TB Control Programme (RNTCP) are managed using diagnostic algorithms and directly observed treatment with intermittent thrice-weekly short-course treatment regimens for 6-8 months. The assignment into pre-treatment weight bands leads to drug doses (milligram per kilogram) that are lower than current World Health Organization (WHO) guidelines for some patients. OBJECTIVES: The main aim of our study was to describe the baseline characteristics and treatment outcomes reported under RNTCP for registered childhood (age <15 years) TB patients in Delhi. Additionally, we compared the reported programmatic treatment completion rates between children treated as per WHO recommended anti-TB drug doses with those children treated with anti-TB drug doses below that recommended in WHO guidelines. METHODS: For this cross-sectional retrospective study, we reviewed programme records of all 1089 TB patients aged <15 years registered for TB treatment from January to June, 2008 in 6 randomly selected districts of Delhi. WHO disease classification and treatment outcome definitions are used by RNTCP, and these were extracted as reported in programme records. RESULTS AND CONCLUSIONS: Among 1074 patients with records available, 651 (61%) were females, 122 (11%) were <5 years of age, 1000 (93%) were new cases, and 680 (63%) had extra-pulmonary TB (EP-TB)--most commonly peripheral lymph node disease [310 (46%)]. Among 394 pulmonary TB (PTB) cases, 165 (42%) were sputum smear-positive. The overall reported treatment completion rate was 95%. Similar reported treatment completion rates were found in all subgroups assessed, including those patients whose drug dosages were lower than that currently recommended by WHO. Further studies are needed to assess the reasons for the low proportion of under-5 years of age TB case notifications, address challenges in reaching all childhood TB patients by RNTCP, the accuracy of diagnosis, and the clinical validity of reported programme defined treatment completion.

Increased mortality of male adults with AIDS related to poor compliance to antiretroviral therapy in Malawi.

OBJECTIVE: To investigate the effect of gender on mortality of HIV-infected adults receiving antiretroviral therapy (ART) and its possible reasons. METHODS: A retrospective study to review the records for outcomes of adult cases receiving ART at Mzuzu Central Hospital, Malawi, between July 2004 and December 2006. RESULTS: Over the study period, 2838 adult AIDS patients received ART. Of these, 2029 (71.5%) were alive and still on ART, 376 (13.2%) were dead and 433 (15.3%) were lost to follow-up. Survival analysis with Kaplan-Meier estimator showed significantly higher survival rates among females than males in WHO stage 1, 2 and 3 (both P < 0.0001) and borderline in stage 4 (P = 0.076). The Cox model revealed a death hazard ratio (males vs. females) of 1.70 (95% confidence interval 1.35-2.15) after controlling for WHO clinical stages, body mass index and age. More men than women were lost to follow-up in all occupations except health workers. CONCLUSIONS: The most important reasons for a higher mortality in male patients starting ART may relate to their seeking medical care at a more advanced stage of immunodeficiency and poorer compliance with therapy. The issue needs to be addressed in scaling up ART programmes in Africa.

Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport.

BACKGROUND: A study was conducted among newly registered HIV-positive tuberculosis (TB) patients systematically offered anti-retroviral treatment (ART) in a district hospital in rural Malawi in order to a) determine the acceptance of ART b) conduct a geographic mapping of those placed on ART and c) examine the association between "cost of transport" and ART acceptance. METHODOLOGY/PRINCIPAL FINDINGS: A retrospective cross-sectional analysis was performed on routine program data for the period of February 2003 to July 2004. Standardized registers and patient cards were used to gather data. The place of residence was used to determine road distances to the Thyolo district hospital. Cost of transport from different parts of the district was based on the known cost for public transport to the road-stop closest to the patient's residence. Of 1,290 newly registered TB patients, 1,003(78%) underwent HIV-testing of whom 770 (77%) were HIV-positive. 742 of these individuals (pulmonary TB = 607; extra-pulmonary TB = 135) were considered eligible for ART of whom only 101(13.6%) accepted ART. Cost of transport to the hospital ART site was significantly associated with ART acceptance and there was a linear trend in association between cost and ART acceptance (chi(2) for trend = 25.4, P<0.001). Individuals who had to pay 50 Malawi Kwacha (1 United States Dollar = 100 Malawi Kwacha, MW) or less for a one-way trip to the Thyolo hospital were four times more likely to accept ART than those who had to pay over 100 MW (Adjusted Odds ratio = 4.0, 95% confidence interval: 2.0-8.1, P<0.001). CONCLUSIONS/SIGNIFICANCE: ART acceptance among TB patients in a rural district in Malawi is low and associated with cost of transport to the centralized hospital based ART site. Decentralizing the ART offer from the hospital to health centers that are closer to home communities would be an essential step towards reducing the overall cost and burden of travel.