Community- vs. hospital-based management of multidrug-resistant TB in Pakistan.

BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18-24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI -0.02 to 0.15; P = 0.144).CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.

Pre-treatment loss to follow-up among smear-positive TB patients in tertiary hospitals, Quetta, Pakistan.

Setting: Three public sector tertiary care hospitals in Quetta, Balochistan, Pakistan, with anecdotal evidence of gaps between the diagnosis and treatment of patients with tuberculosis (TB). Objectives: To assess the proportion of pre-treatment loss to follow-up (LTFU), defined as no documented evidence of treatment initiation or referral in TB registers, among smear-positive pulmonary TB patients diagnosed in 2015, and the associated sociodemographic factors. Design: A retrospective cohort study involving the review of laboratory and TB registers. Results: Of 1110 smear-positive TB patients diagnosed (58% female, median age 40 years, 5% from outside the province or the country), 235 (21.2%) were lost to follow-up before starting treatment. Pre-treatment LTFU was higher among males; in patients residing far away, in rural areas, outside the province or the country; and in those without a mobile phone number. Conclusion: About one fifth of the smear-positive TB patients were lost to follow-up before starting treatment. Strengthening the referral and feedback mechanisms and using information technology to improve the tracing of patients is urgently required. Further qualitative research is needed to understand the reasons for pre-treatment LTFU from the patient's perspective.

Contexte : Trois hôpitaux publics tertiaires à Quetta, Baloutchistan, Pakistan, avec des preuves empiriques d'un fossé entre le diagnostic et le traitement des patients tuberculeux (TB).Objectif : Evaluer la proportion de patients perdus de vue avant le traitement (pas de preuve documentée de mise en route du traitement ou de référence dans les registres TB) parmi les patients atteints de TB pulmonaire à frottis positif diagnostiqués en 2015, et identifier les facteurs sociodémographiques associés.Schéma : Etude rétrospective de cohorte impliquant une revue des registres de laboratoire et de TB.Résultats : Sur 1110 patients TB à frottis positif diagnostiqués (58% de femmes, d'âge médian 40 ans, 5% venant de l'extérieur de la province ou du pays), 235 (21,2%) ont été perdus de vue avant de démarrer le traitement. Cette perte de vue avant le traitement a été plus élevée parmi les hommes ; parmi les patients résidant loin, en zone rurale, hors de la province ou du pays ; et parmi ceux ne possédant pas de téléphone portable.Conclusion : Environ un cinquième des patients TB à frottis positif ont été perdus de vue avant la mise en route du traitement. Il est nécessaire de manière urgente de renforcer les mécanismes de référence et de retro-information et d'avoir une meilleure traçabilité des patients grâce aux techniques d'information. Une autre recherche qualitative est requise afin de comprendre les raisons de cette perte de vue avant le traitement selon la perspective des patients.

Marco de referencia: Tres hospitales de atención terciaria del sector público de Quetta, en la provincia de Balochistán del Pakistán, donde existen datos anecdóticos de un desfase entre el diagnóstico y el tratamiento de los pacientes con tuberculosis (TB).Objetivos: Evaluar la proporción de pérdidas durante el seguimiento antes de comenzar el tratamiento (falta de documentación de la iniciación del tratamiento o la remisión a otros centros en los registros de TB) de los pacientes con TB pulmonar y baciloscopia positiva diagnosticados en el 2015 y analizar los factores socioeconómicos determinantes.Métodos: Un estudio retrospectivo de cohortes a partir del examen de los registros de laboratorio y los registros de TB.Resultados: De los 1110 pacientes con baciloscopia positiva diagnosticados (58% de sexo femenino, mediana de la edad 40 años y 5% procedente de otra provincia o país), 235 (21,2%) se perdieron durante el seguimiento antes de iniciar el tratamiento. Estas pérdidas fueron mayores en los pacientes de sexo masculino; los pacientes que residían en zonas rurales remotas, fuera de la provincia o del país; y en las personas que no contaban con un número de teléfono celular.Conclusión: Cerca de un quinto de los pacientes con diagnóstico de TB y baciloscopia positiva se perdió durante el seguimiento antes de comenzar el tratamiento. Es urgente fortalecer el mecanismo de remisiones y de retroinformación de los resultados y mejorar la localización de los pacientes haciendo uso de la tecnología de la información. Se precisan nuevas investigaciones cualitativas que favorezcan la comprensión de las razones de esta pérdida durante el seguimiento desde la perspectiva de los pacientes.

Infection control in hospitals managing drug-resistant tuberculosis in Pakistan: how are we doing?

Setting: Ten hospitals managing drug-resistant tuberculosis (TB) in Pakistan. Objective: To assess the implementation of TB infection control (IC) practices and reasons for non-adherence to guidelines. Design: This was a descriptive study conducted between April and October 2016 with three components: 1) non-participant observation of service delivery areas (SDAs) (n = 82) in hospitals (n = 10) using structured checklists; 2) exit interviews with 100 patients (10 per hospital); and 3) interviews with 100 health-care workers (HCWs, 10/hospital). Results: Of the 82 SDAs, posters were displayed in 34 (41%), mechanical ventilation was implemented in 79% and functional ultraviolet germicidal irradiation (UVGI) was available in only 26%. Patient interviews showed 50-65% adherence to triage and use of personal protective measures. Key reasons for non-adherence were lack of adequate supplies, discomfort using N-95 masks, a lack of knowledge or training, perceived non-cooperation by patients, poor maintenance of mechanical ventilators and UVGI due to unstable electricity supply, a lack of clarity in roles (no-one designated in charge) and staff shortages and subsequent workloads. Adherence to natural ventilation usage was poor for reasons related to climate and privacy. Conclusion: Implementation of TBIC measures in hospitals was suboptimal. Urgent measures need to be put in place, including retraining of HCWs, addressing weaknesses in mask and poster supplies and constant supervision and monitoring.

Contexte : Dix hôpitaux prenant en charge la tuberculose (TB) pharmacorésistante au Pakistan.Objectif : Evaluer la mise en œuvre des pratiques de lutte contre l'infection TB (CITB) et les raisons de la non-adhésion aux directives.Schéma : Étude descriptive réalisée entre avril et octobre 2016 avec trois composants : 1) observation non participative des zones de prestations de service (SDA) (n = 82) dans des hôpitaux (n = 10) grâce à des checklists structurées ; 2) entretiens de sortie avec 100 patients (10 par hôpital) ; 3) entretiens avec 100 prestataires de soins de santé (HCW, 10 par hôpital).Résultats : Parmi 82 SDA, des affiches ont été déployées dans 34 (41%) d'entre elles, une ventilation mécanique a été mise en œuvre dans 79% et un système fonctionnel d'irradiation par ultraviolets germicides (UVGI) a été disponible dans seulement 26%. Les entretiens avec les patients ont mis en évidence 50­65% d'adhérence au triage et à l'utilisation de mesures de protection personnelles. Les raisons majeures de la non-adhésion ont été le manque de fournitures appropriées, l'inconfort d'utilisation des masques N-95, le manque de connaissance ou de formation, la perception d'une non-coopération par les patients, la maintenance médiocre des ventilateurs mécaniques et de l'UVGI à cause de l'instabilité de l'alimentation électrique et le manque de clarification des responsabilités (aucune personne désignée responsable), et la pénurie de personnel avec surcharge de travail du personnel présent. L'adhésion à la ventilation naturelle a été médiocre en raison du climat et pour des problèmes de confidentialité.Conclusion : La mise en œuvre de mesures de CITB dans les hôpitaux a été sous-optimale. Des mesures urgentes sont requises, notamment la formation continue des HCW, la lutte contre les problèmes de fourniture de masques et d'affiches et une supervision et un suivi constants.

Marco de referencia: Diez hospitales que se ocupan del tratamiento de la tuberculosis (TB) multirresistente en el Pakistán.Objetivo: Evaluar la aplicación de las prácticas de control de la infección TB (CITB) y determinar las razones del incumplimiento de las normas.Método: De abril a octubre del 2016 se realizó un estudio descriptivo que comportó los siguientes elementos: 1) personas no vinculadas evaluaron las zonas de prestación de servicios (n = 82) en los hospitales (n = 10), con listas de verificación estructuradas; 2) se realizaron entrevistas de salida a 100 pacientes (10 por cada hospital) y 3) entrevistas a 100 profesionales de salud (HCW; 10 por cada hospital).Resultados: De las 82 zonas de prestación de servicios evaluadas, en 34 había afiches expuestos (41%), el 79% contaba con sistemas de ventilación mecánica y solo en el 26% existía un dispositivo funcional de radiación ultravioleta germicida (UVGI). Las entrevistas a los pacientes revelaron un cumplimiento de 50% a 65% con la selección de los pacientes y las medidas de protección personal. Las principales explicaciones del incumplimiento fueron la insuficiencia de suministros, la incomodidad de utilización de las mascarillas N-95, la carencia de conocimientos o capacitación adecuada, la percepción de una falta de cooperación por parte de los pacientes, un mantenimiento deficiente de los ventiladores mecánicos y los dispositivos de UVGI debido a la inestabilidad del suministro eléctrico y la poca claridad con respecto a las funciones (falta de designación de una persona encargada), la escasez de personal y la consecuente sobrecarga de trabajo. El cumplimiento de las normas de ventilación natural era deficiente por causa de las condiciones climáticas y aspectos relacionados con el respeto de la intimidad.Conclusión: La aplicación de las medidas de CITB en los hospitales es deficiente. Se precisa de manera urgente instaurar medidas como la actualización de la formación de los HCW, la corrección de las deficiencias en el abastecimiento de mascarillas y afiches y la práctica constante de la supervisión y la vigilancia.

Gastric specimens for diagnosing tuberculosis in adults unable to expectorate in Rawalpindi, Pakistan.

Setting: Adult pulmonary tuberculosis (TB) patients unable to expectorate quality sputum represent a diagnostic challenge. A private hospital in Pakistan routinely performs gastric aspiration in adults with difficulties expectorating. Objective: To assess the usefulness of gastric specimens (GS) in diagnosing pulmonary TB (PTB) and drug-resistant TB in adult presumptive TB patients unable to expectorate, and to compare the diagnostic yield and sensitivity of smear, culture and the Xpert® MTB/RIF assay. Design: This was a comparative cross-sectional study based on retrospective record review. Results: Of 900, 885 and 877 GS tested by smear, Xpert and culture, respectively, interpretable results were obtained for respectively 900 (100%), 859 (97.1%) and 754 (86.0%), with a diagnostic yield of respectively 23.6%, 30.3% and 24.9%. The yield was significantly higher for Xpert in previously treated patients. There were 313 patients with definite TB, defined as positive on Xpert and/or culture. The 82.8% sensitivity of Xpert was significantly higher than that of smear (61.0%) and culture (67.8%). Conclusion: GS obtained by aspiration under routine programme conditions is useful for detecting TB and drug-resistant TB in adult patients unable to expectorate. Xpert, with its rapid testing, high proportion of interpretable results and better sensitivity, can substantially improve the diagnosis of bacteriologically confirmed TB and rifampicin resistance.

Contexte: Les patients adultes atteints de tuberculose pulmonaire (TB) incapables d'expectorer des crachats de qualité posent un problème en matière de diagnostic. Un hôpital privé du Pakistan réalise en routine l'aspiration gastrique chez les adultes qui ont du mal à expectorer.Objectif: Evaluer l'utilité des échantillons gastriques (GS) chez des patients adultes présumés atteints de TB incapables d'expectorer, pour le diagnostic de la TB pulmonaire et pharmacorésistante et pour comparer le rendement diagnostique et la sensibilité du frottis, de la culture et du test Xpert® MTB/RIF.Schéma: Etude comparative transversale basée sur une revue rétrospective des dossiers.Résultats: Un total de 900, 885 et 877 GA ont été testés respectivement par frottis, Xpert et culture et des résultats interprétables ont été obtenus chez 900 (100%), 859 (97,1%) et 754 (86,0%) patients avec un rendement diagnostique respectivement de 23,6%, 30,3% et 24,9%. Le rendement a été significativement plus élevé pour l'Xpert chez les patients déjà traités. Il y avait 313 patients avec une TB, définie comme la positivité de l'Xpert et/ou de la culture. La sensibilité de l'Xpert de 82,8% a été significativement plus élevée que le frottis (61,0%) et la culture (67,8%).Conclusion: Le GS aspiré sous des conditions de routine de programme est utile pour détecter la TB et la TB pharmacorésistante chez des patients adultes incapables d'expectorer. L'Xpert avec un test rapide, la proportion élevée de résultats interprétables et une meilleure sensibilité, peuvent substantiellement améliorer le diagnostic de la TB confirmée par bactériologie et la résistance à la rifampicine.

Marco de referencia: El diagnóstico de la tuberculosis (TB) pulmonar se dificulta en los pacientes adultos que no pueden suministrar muestras de esputo de buena calidad. En un hospital privado del Pakistán se practica de manera sistemática la aspiración gástrica en los adultos con dificultad para expectorar.Objetivo: Evaluar la utilidad del aspirado gástrico (GS) para el diagnóstico de la TB pulmonar farmacorresistente, en los pacientes con presunción de TB que tienen dificultad para expectorar y comparar el rendimiento diagnóstico y la sensibilidad de la baciloscopia, el cultivo y la prueba Xpert® MTB/RIF.Método: Un estudio transversal comparativo a partir del examen retrospectivo de las historias clínicas.Resultados: Se examinaron 900 muestras de GS mediante baciloscopia, 885 con la prueba Xpert y 877 por cultivo; se obtuvieron resultados interpretables en 900 (100%), 859 (97,1%) y 754 muestras (86,0%), con un rendimiento diagnóstico de 23,6%, 30,3% y 24,9%, respectivamente. El rendimiento fue significativamente superior con la prueba Xpert en los pacientes con antecedente de tratamiento. El diagnóstico definitivo de TB, definido como un resultado positivo de la prueba Xpert, el cultivo o ambos, se estableció en 313 pacientes. La prueba Xpert exhibió una sensibilidad de 82,8%, que fue significativamente más alta que la sensibilidad de la baciloscopia (61,0%) y la del cultivo (67,8%).Conclusión: El examen de las muestras de GS en el marco del programa corriente es útil para detectar la TB y la TB farmacorresistente en los pacientes adultos que no pueden expectorar. La prueba Xpert que ofrece un diagnóstico rápido, alta proporción de resultados interpretables y mejor sensibilidad puede mejorar notablemente el diagnóstico con confirmación bacteriológica de la TB y la resistencia a rifampicina.

Pattern of first- and second-line drug resistance among pulmonary tuberculosis retreatment cases in Pakistan.

BACKGROUND: Drug resistance in general, and multidrug-resistant tuberculosis (MDR-TB) in particular, threatens global tuberculosis (TB) control efforts. Population-based estimates of drug resistance are needed to develop strategies for controlling drug-resistant TB in Pakistan. OBJECTIVE: To obtain population-based data on Mycobacterium tuberculosis drug resistance in Pakistan. METHODS: To obtain drug resistance data, we conducted a population-based study of TB cases in all provinces of Pakistan. We performed culture and drug susceptibility testing on M. tuberculosis isolates from patients with a prior history of anti-tuberculosis treatment (retreatment cases) from all over the country. RESULTS: Of 544 isolates from previously treated cases, 289 (53.1%) were susceptible to all first-line drugs, 255 (46.9%) were resistant to at least one anti-tuberculosis drug and 132 (24.3%) were MDR-TB. Among MDR-TB isolates, 47.0% were ofloxacin (OFX) resistant. Extensively drug-resistant TB was found in two (0.4%) isolates. CONCLUSION: Prevalence of drug resistance in retreatment isolates was high. The alarmingly high prevalence of OFX resistance among MDR-TB isolates may threaten the success of efforts to control and treat MDR-TB.

Use of Xpert(®) MTB/RIF assay in the first national anti-tuberculosis drug resistance survey in Pakistan.

SETTING: The first national anti-tuberculosis drug resistance survey in Pakistan, a high tuberculosis (TB) and low human immunodeficiency virus (HIV) burden country. OBJECTIVE: To determine the proportion of patients with multidrug-resistant TB (MDR-TB) and to compare the performance of Xpert(®) MTB/RIF with conventional phenotypic drug susceptibility testing (DST). METHODS: Sputum samples were collected from 1972 consecutively enrolled pulmonary TB patients from 40 clusters. Phenotypic DST was performed in parallel with Xpert. RESULTS: The proportion of MDR-TB patients was 3.7% (95%CI 2.5-5.0) among new and 18.1% (95%CI 13.0-23.4) among previously treated cases. A valid rifampicin (RMP) testing result was available from substantially more cases with Xpert (n = 1809) than with phenotypic DST (n = 1592). Among strains with discordant results, rpoB sequencing revealed only one false-resistant result (new TB case) with Xpert and 7.7% (8/104) of RMP-resistant cases missed with Xpert against 3.8% (4/14) by phenotypic DST. This difference was not significant. CONCLUSIONS: This survey provides the first representative data for Pakistan on its MDR-TB burden. The Xpert assay had nearly 100% specificity, even in a low MDR-TB prevalence setting. The use of this assay greatly simplifies survey logistics, making it a feasible option for survey implementation, especially in resource-constrained settings.

Can the number of patients with presumptive tuberculosis lost in the general health services in Pakistan be reduced?

The frequency of patients with presumptive tuberculosis (TB) who are not investigated by sputum smear microscopy is unknown in Pakistan. Using a simple intervention comparing patient and laboratory registers, patients with presumptive TB were identified in two districts from July to December 2013, a list of missing patients was prepared and the patients traced. The intervention significantly reduced the number of patients with presumptive TB lost, from 8.5% before the intervention to 6.9% after. A systematic comparison of out-patient and laboratory registers, followed by tracing missing persons, can reduce the proportion of patients with presumptive TB lost before diagnosis.

Success of active tuberculosis case detection among high-risk groups in urban slums in Pakistan.

BACKGROUND: In Pakistan, patients with symptoms suggestive of tuberculosis (TB) seek care from a wide array of health care providers, many of whom do not notify cases to the National TB Programme (NTP). SETTING: We evaluated an active case detection intervention in five randomly selected districts in urban slums of Sindh Province, Pakistan. OBJECTIVE: To evaluate the increase in case notification of smear-positive TB by active case finding at community-based chest camps by engaging the private providers. DESIGN: A cross-sectional study of TB case detection associated with a project using integrated intervention and chest camps. RESULTS: From April 2011 to September 2012, the total number of clients seen in the camps was 165 280. Of all the attendees, 13 481 (12.7%) were examined by sputum smear microscopy. The proportion of smear-positive results was significantly higher among those from engaged private providers than among those referred from camps (OR 1.54, 95%CI 1.42-1.66). During the project, the total number of smear-positive TB notifications increased over the intervention period from 5158 to 8275. CONCLUSION: Active case detection by engaging private providers and chest camps can significantly increase the number of smear-positive TB case notifications.

Estimating tuberculosis burden and case detection in Pakistan.

BACKGROUND: The National Tuberculosis Control Programme (NTP) in Pakistan has officially achieved a tuberculosis (TB) case detection rate of 64% in 2011, with an estimated incidence rate of 230 per 100 000 population, but is likely to be missing an unknown number of patients, particularly in the private sector. SETTING: All public and private sector providers in 12 randomly selected districts of Pakistan were included. OBJECTIVE: To estimate TB incidence and TB notification rates in Pakistan in 2012. DESIGN: A surveillance system was established among all eligible non-NTP providers in selected districts from January to March 2012. Record linkage and capture-recapture analysis was conducted. RESULTS: Of 8346 TB cases identified after record linkage, 6061 were registered with the NTP. The estimated number of unobserved TB cases was 10 030 (95%CI 7800-12 910), which meant that the proportion of notified cases was 32% (95%CI 17-49). The calculated annual incidence was 878 000 cases (95%CI 573 000-1 675 000), corresponding to a rate of 497/100 000 (95%CI 324-948) annually in the population. CONCLUSION: The study estimated that the proportion of cases notified to the NTP was low, with actual incidence rates being higher than official estimates. TB surveillance should be strengthened to reduce under-reporting.

Investigation of presumptive tuberculosis cases by private health providers: lessons learnt from a survey in Pakistan.

Pakistan's National Tuberculosis Control Programme (NTP) is missing data on many tuberculosis (TB) cases who visit private providers. A survey on the incidence and under-reporting of TB in Pakistan provided a database for exploring the investigation and referral of presumptive TB cases by private health providers. The survey showed that private health providers requested both sputum smear and X-ray for diagnostic investigations. Of 2161 presumptive TB cases referred, 1189 (55%) were sent for investigations to a district NTP TB centre, of whom only 314 (26.4%) were registered. This indicates an urgent need to strengthen the link between private health providers and NTP to enhance TB notification.

Le Programme national de lutte contre la tuberculose (PNT) du Pakistan manque de nombreux cas de tuberculose (TB) soignés par des prestataires de soins privés. Une enquête sur l'incidence et la sous-déclaration de la TB au Pakistan a fourni une base de données afin d'explorer les investigations réalisées en cas de présomption de TB et leur référence par les prestataires de soins privés. L'enquête a montré que les prestataires privés demandaient à la fois un frottis de crachats et une radiographie pour le diagnostic. Sur 2161 cas suspects de TB référés, 1189 (55%) ont été envoyés pour investigations à un centre anti-tuberculeux de district (PNT), parmi lesquels seulement 314 (26,4%) ont été enregistrés. Ceci met en évidence le besoin urgent de renforcer les liens entre les prestataires privés et les PNT afin d'améliorer la déclaration de la TB.

En el Programa Nacional contra la Tuberculosis (PNT) del Pakistán se están pasando por alto muchos casos de tuberculosis (TB) que acuden a los profesionales del sector privado. A partir de una encuesta sobre la incidencia de TB y la tasa de subnotificación en el país, se examinó la investigación de los casos y la remisión de las personas con presunción diagnóstica de TB por parte de los profesionales del sector privado. Se puso en evidencia que en el sector privado, los profesionales investigan la TB mediante la solicitud de la baciloscopia del esputo y además la radiografía de tórax. De los 2161 casos referidos por presunción diagnóstica, 1189 (55%) se remitieron para estudio al centro distrital PNT de TB y de ellos solo se registraron 314 (26,4%). Estos resultados indican la urgencia que existe de fortalecer los vínculos entre los profesionales del sector privado y el PNT, con el fin de mejorar la notificación de los casos de TB.

Estimation of the contribution of private providers in tuberculosis case notification and treatment outcome in Pakistan.

To improve involvement of the private sector in the national tuberculosis (TB) programme in Pakistan various public-private mix projects were set up between 2004 and 2009. A retrospective analysis of data was made to study 6 different public-private mix models for TB control in Pakistan and estimate the contribution of the various private providers to TB case notification and treatment outcome. The number of TB cases notified through the private sector increased significantly from 77 cases in 2004 to 37,656 in 2009. Among the models, the nongovernmental organization model made the greatest contribution to case notification (58.3%), followed by the hospital-based model (18.9%). Treatment success was highest for the district-led model (94.1%) and lowest for the hospital-based model (74.2%). The private sector made an important contribution to the national data through the various public-private mix projects. Issues of sustainability and the lack of treatment supporters are discussed as reasons for lack of success of some projects.

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.

Estimation of the contribution of private providers in tuberculosis case notification and treatment outcome in Pakistan

To improve involvement of the private sector in the national tuberculosis [TB] programme in Pakistan various public-private mix projects were set up between 2004 and 2009. A retrospective analysis of data was made to study 6 different public-private mix models for TB control in Pakistan and estimate the contribution of the various private providers to TB case notification and treatment outcome. The number of TB cases notified through the private sector increased significantly from 77 cases in 2004 to 37 656 in 2009. Among the models, the nongovernmental organization model made the greatest contribution to case notification [58.3%], followed by the hospital-based model [18.9%]. Treatment success was highest for the district-led model [94.1%] and lowest for the hospital-based model [74.2%]. The private sector made an important contribution to the national data through the various public-private mix projects. Issues of sustainability and the lack of treatment supporters are discussed as reasons for lack of success of some projects

An improved record system for tracing outcome of "transferred-out" DOTS patients.

This study in Pakistan aimed to develop an improved record-keeping mechanism for the DOTS programme to establish the final treatment status of patients recorded as "transferred-out". In an intervention study in 40 DOTS diagnostics centres in Punjab province, a modification was made to the existing TB03 register. DOTS facilitators were trained to keep proper records of patients who transferred-out and transferred-in. Among 4442 registered cases, 104 patients (2.3%) transferred out of reporting centres. Correct matching of "-out and -in" patients was achieved for 74 (71.2%) patients; the remaining 30 (28.8%) were untraced. By tracing transferred-out cases, the adjusted outcome success rate increased in the intervention period from 89.6% to 90.9%.

An improved record system for tracing outcome of [transferred-out] DOTS patients

This study in Pakistan aimed to develop an improved record-keeping mechanism for the DOTS programme to establish the final treatment status of patients recorded as [transferred -out]. In an intervention study in 40 DOTS diagnostics centres in Punjab province, a modification was made to the existing TB03 register. DOTS facilitators were trained to keep proper records of patients who transferred-out and transferred-in. Among 4442 registered cases, 104 patients [2.3%] transferred out of reporting centres. Correct matching of [-out and -in] patients was achieved for 74 [71.2%] patients; the remaining 30 [28.8%] were untraced. By tracing transferred-out cases, the adjusted outcome success rate increased in the intervention period from 89.6% to 90.9%