A comprehensive comparison of Ziehl-Neelsen and fluorescence microscopy for the diagnosis of tuberculosis in a resource-poor urban setting.

SETTING: Nairobi City Council Chest Clinic, Kenya. OBJECTIVES: To establish the efficiency, costs and cost-effectiveness of six diagnostic strategies using Ziehl-Neelsen (ZN) and fluorescence microscopy (FM). DESIGN: A cross-sectional study of 1398 TB suspects attending a specialised chest clinic in Nairobi subjected to three sputum examinations by ZN and FM. Lowenstein-Jensen culture was used as the gold standard. Cost analysis included health service and patient costs. RESULTS: Of 1398 suspects enrolled, 993 (71%) had a complete diagnostic work-up involving three sputum specimens for ZN and FM, culture and chest X-ray (CXR). Irrespective of whether ZN or FM was used on one, two or three smears, the overall diagnostic process detected 92% culture-positive cases. Different strategies affected the ratio of smear-positive to smear-negative TB; however, FM was more sensitive than ZN (P < 0.001). FM performance was not affected by the patient's HIV status. The cost per correctly diagnosed smear-positive case, including savings, was 40.30 US dollars for FM on two specimens compared to 57.70 US dollars for ZN on three specimens. CONCLUSION: The FM method used on one or two specimens is more cost-effective and shortens the diagnostic process. Consequently, more patients can be put on a regimen for smear-positive TB, contributing to improved treatment and reducing transmission.

Respiratory tract infection in HIV-1-infected adults in Nairobi, Kenya: evaluation of risk factors and the world health organization treatment algorithm.

To evaluate the WHO (World Health Organization) algorithm for management of respiratory tract infection (RTI) in HIV-1-infected adults and determine risk factors associated with RTI, we enrolled a cohort of 380 HIV-1-seropositive adults prospectively followed for incident RTI at an outpatient clinic in Nairobi, Kenya. RTI was diagnosed when patients presented with history of worsening or persistent cough. Patients were treated with ampicillin, or antituberculosis therapy when clinically indicated, as first-line therapy and with trimethoprim/sulfamethoxazole as second-line therapy. Five hundred ninety-seven episodes of RTI were diagnosed: 177 of pneumonia and 420 of bronchitis. The WHO RTI algorithm was used for 401 (95%) episodes of bronchitis and 151 (85%) episodes of pneumonia (p <.001). Three percent of bronchitis cases versus 32% of pneumonia cases failed to respond to first-or second-line treatment (p <.0001). Being widowed (adjusted odds ratio [OR] = 2.1, 95% confidence interval [CI]: 1.0-4.4), less than 8 years of education (adjusted OR = 2.5, CI: 1.5 - 4.1), and CD4 count < 200 cells/microl (adjusted OR = 2.4, CI: 1.4-3.9) were risk factors for pneumonia. A high percentage of patients (32%) with pneumonia required a change in treatment from that recommended by the WHO guidelines. Randomized trials should be performed to determine more appropriate treatment strategies in HIV-1-infected individuals.

Efficacy and safety of inhaled Salmeterol (Serevent) as maintenance therapy for asthma in Nairobi.

An open study to assess the efficacy and safety of 50 micrograms inhaled Salmeterol (Serevent) administered twice daily as maintenance therapy for asthma was undertaken by the Respiratory Diseases Research Unit (RDRU) in Nairobi between August and October, 1992. Salmeterol (Hydroxynaphthoate) is a long acting selective beta-2-agonist. Seventy-three adult patients recruited at Kenyatta National Hospital underwent a two weeks treatment period during which they were assessed over three visits. At Visit 1, eligibility was confirmed, baseline lung function indices measured, the study drug introduced and all the previous medications withdrawn. After treatment for one week (Visit 2) and two weeks (Visit 3), lung function indices were measured again and subjective patients' and physicians' assessments of efficacy documented. Patients with obstructive ventilatory defect (OVD) at baseline had significant improvement in their lung function compared to those without at the end of the treatment period. A significant number of patients reported decreased number of nocturnal awakenings and increased tolerance to physical activity. Cough, headache and itchy throat were adverse events possibly related to the use of Salmeterol. The patients treated with Salmeterol gained improved control of their asthma symptoms. The drug offers a convenient dose schedule and we recommend its use for maintenance therapy for mild to moderate asthma.

An effective traditional medicine for bronchial asthma: clinical demonstration and preliminary toxicological evaluation.

This clinical paper reports the investigations conducted on a traditional African anti-asthmatic formulations and evaluates its toxicological and phyto-chemical effects.