Genetic profile of Mycobacterium tuberculosis and treatment outcomes in human pulmonary tuberculosis in Tanzania.

Information on the different spoligotype families of Mycobacterium tuberculosis in Tanzania is limited, and where available, restricted to small geographical areas. This article describes the genetic profile of M tuberculosis across Tanzania and suggests how spoligotype families might affect drug resistance and treatment outcomes for smear positive pulmonary tuberculosis patients in Tanzania. We conducted the study from 2006 to 2008, and the isolates were obtained from samples collected under the routine drug resistance surveillance system. The isolates were from specimens collected from 2001 to 2007, and stored at the Central and Reference Tuberculosis Laboratory. A total of 487 isolates from 23 regions in the country were spoligotyped. We were able to retrieve clinical information for 446 isolates only. Out of the 487 isolates spoligotyped, 195(40.0%) belonged to the Central Asian (CAS) family, 84 (17.5%) to the Latin American Mediterranean (LAM) family, 49 (10.1%) to the East-African Indian (EAI) family, and 33 (6.8%) to the Beijing family. Other isolates included 1 (0.2%) for H37Rv, 10 (2.1%) for Haarlem, 4 (0.8%) for S family, 58 (11.9%) for T family and 52 (10.7%) for unclassified. No spoligotype patterns were consistent with M bovis. Regarding treatment outcomes, the cure rate was 80% with no significant variation among the spoligotype families. The overall level of MDR TB was 2.5% (3/12 1), with no significant difference among the spoligotype families. All Beijing strains (11.8%, 30/254) originated from the Eastern and Southern zones of the country, of which 80% were from Dar es Salaam. Isolates from the CAS and T families were reported disproportionately from the Eastern-Southern zone, and EAI and LAM families from the Northern-Lake zones but the difference was not statistically significant. Five isolates were identified as non-tuberculous Mycobacteria. In conclusion, M. tuberculosis isolates from pulmonary tuberculosis cases in Tanzania were classified mostly within the CAS, LAM, and EAI and T families, while the Beijing family comprised about 7% isolates only. Consistently good treatment outcomes were recorded across these spoligotype families. The proportion of drug resistance strains was low. The findings also suggest variation of spoligotype families with varying geographical localities within the country, and identify this area for further research to confirm this finding.

Injuries in Khartoum state, the Sudan: a household survey of incidence and risk factors.

Low- and middle-income countries have a higher burden of fatal and non-fatal injuries. The lack of evidence-based information hampers efforts for injury prevention. The aim of this study was to calculate non-fatal injury incidence rates and to investigate causes and risk factors for non-fatal injuries in Khartoum state. Information was gathered in a community-based survey using a stratified two-stage cluster sampling technique. Methods of data collection were face-to-face interviews during October and November 2010. The total number of individuals included was 5661, residing in 973 households. The overall injury incidence rate was 82.0/1000 person-years-at-risk. The three leading causes were falls, mechanical forces and road traffic crashes. Low socio-economic status was a risk factor for injuries in urban areas. Males had a significantly higher risk of being injured in both urban and rural areas. Our findings can contribute to the planning of prevention programmes.

Genetic profile of Mycobacterium Tuberculosis and Treatment Outcomes in Human Pulmonary Tuberculosis in Tanzania

Information on the different spoligotype families of Mycobacterium tuberculosis in Tanzania is limited; and where available; restricted to small geographical areas. This article describes the genetic profile of M. tuberculosis across Tanzania and suggests how spoligotype families might affect drug resistance and treatment outcomes for smear positive pulmonary tuberculosis patients in Tanzania. We conducted the study from 2006 to 2008; and the isolates were obtained from samples collected under the routine drug resistance surveillance system. The isolates were from specimens collected from 2001 to 2007; and stored at the Central and Reference Tuberculosis Laboratory. A total of 487 isolates from 23 regions in the country were spoligotyped. We were able to retrieve clinical information for 446 isolates only. Out of the 487 isolates spoligotyped; 195(40.0) belonged to the Central Asian (CAS) family; 84 (17.5) to the Latin American Mediterranean (LAM) family; 49 (10.1) to the Latin American Mediterranean (LAM) family; 49 (10.1) to the East-African Indian (EAI) family; and 33 (6.8) to the Beijing family. Other isolates included 1 (0.2) for H37Rv; 10 (2.1) for Haarlem; 4 (0.8) for S family; 58 (11.9) for T family and 52 (10.7) for unclassified. No spoligotype patterns were consistent with M. bovis. Regarding treatment outcomes; the cure rate was 80 with no significant variation among the spoligotype families. The overall level of MDR TB was 2.5 (3/121); with no significant difference among the spoligotype families. All Beijing strains (11.8; 30/254) originated from the Eastern and Southern zones of the country; of which 80 were from Dar es Salaam. Isolates from the CAS and T families were reported disproportionately from the Eastern-Southern zone; and EAI and LAM families from the Northern-Lake zones but the difference was not statistically significant. Five isolates were identified as non-tuberculous Mycobacteria. In conclusion; M. tuberculosis isolates from pulmonary tuberculosis cases in Tanzania were classified mostly within the CAS; LAM; and EAI and T families; while the Beijing family comprised about 7 isolates only. Consistently good treatment outcomes were recorded across these spoligotype families. The proportion of drug resistance strains was low. The findings also suggest variation of spoligotype families with varying geographical localities within the country; and identify this area for further research to confirm this finding

Barriers in the management of tuberculosis in rawalpindi, pakistan: a qualitative study.

BACKGROUND: Tuberculosis (TB) is a contagious, airborne disease and remains a major global public health hazard. TB is a major cause of mortality and is affecting millions of people in low-income and middle-income countries. Worldwide, one person out of three is infected with the Mycobacterium tuberculosis. Timely diagnosis and treatment are the two key factors for better outcomes. Non-adherence to TB treatment is an important barrier for TB control programs. This study was designed to understand the barriers encountered by TB patients when seeking health care. MATERIALS AND METHODS: A qualitative study was conducted during the months of August and December 2010 on 15 health facilities. In-depth interviews were conducted with 23 TB patients (13 males and 10 females) aged 15-65 years. In addition, 15 health personnel were also interviewed. RESULTS: Most patients were found to be well informed about the idea of taking TB medications under direct supervision and its overall importance. However, many of them were not convinced with either drugs or treatment protocols. We found that limited knowledge of patients, loss of employment, financial burden, social stigma and long distance from health facility were the main barriers for TB adherence. CONCLUSION: More patient-centred interventions and attention to the barriers are required to improve the treatment adherence. Direct observation of patients and regular home visits by health workers can reduce the risk of non-adherence.

Comparing HIV prevalence estimates from prevention of mother-to-child HIV transmission programme and the antenatal HIV surveillance in Addis Ababa.

BACKGROUND: In the absence of reliable data, antenatal HIV surveillance has been used to monitor the HIV epidemic since the late 1980s. Currently, routine data from Prevention of Mother-to-child HIV transmission (PMTCT) programmes are increasingly available. Evaluating whether the PMTCT programme reports provide comparable HIV prevalence estimates with the antenatal surveillance reports is important. In this study, we compared HIV prevalence estimates from routine PMTCT programme and antenatal surveillance in Addis Ababa with the aim to come up with evidence based recommendation. METHODS: Summary data were collected from PMTCT programmes and antenatal surveillance reports within the catchment of Addis Ababa. The PMTCT programme data were obtained from routine monthly reports from 2004 to 2009 and from published antenatal HIV surveillance reports from 2003 to 2009. Data were analysed using descriptive statistics. RESULTS: In Addis Ababa, PMTCT sites had increased from six in 2004 to 54 in 2009. The site expansion was accompanied by an increased number of women testing. There were marked increases in the rate of HIV testing following the introduction of routine opt-out HIV testing approach. Paralleling these increases, the HIV prevalence showed a steady decline from 10.0% in 2004 to 4.5% in 2009. There were five antenatal surveillance sites from 2003 to 2007 in Addis Ababa and they increased to seven by 2009. Four rounds of surveillance data from five sites showed a declining trend in HIV prevalence over the years. The overall antenatal surveillance data also showed that the HIV prevalence among antenatal attendees had declined from 12.4% in 2003 to 5.5% in 2009. The HIV prevalence estimates from PMTCT programme were 6.2% and 4.5% and from antenatal surveillance 6.1 and 5.5% in 2008 and 2009 respectively. CONCLUSIONS: There were consistent HIV prevalence estimates from PMTCT programme and from antenatal surveillance reports. Both data sources showed a marked decline in HIV prevalence among antenatal care attendees in Addis Ababa. This study concludes that the routine data from the PMTCT programmes in Addis Ababa provides comparable HIV prevalence estimates with antenatal HIV surveillance data and could be used for monitoring trends.

Treatment supporters and their impact on treatment outcomes in routine tuberculosis program conditions in rawalpindi district, pakistan.

BACKGROUND: Tuberculosis (TB) is a major cause of mortality affecting millions of people in third world countries. In DOTS monitoring of patients is facility-based and treatment supporter-based; by these two ways patients' compliance to treatment is monitored. The aim of this study was to evaluate the role of treatment supporters and their impact on patients' treatment outcomes. MATERIALS AND METHODS: The study was a cross-sectional survey in the routine TB control program operational context. All sputum smear positive TB patients that were diagnosed and registered by the public sector in the urban and rural diagnostic centers in 2008 with available outcomes were included in the study. Data of 451 patients were collected during August-October 2010 from 15 health facilities. RESULTS: The majority of patients (89.6%) were provided with treatment supporters. Of 404 (89.6%) cases with treatment supporters, in 203 (50.2%) the supporters were lady health workers, in 46 (11.4%) were community health workers and health facility workers, and in 155 (38.4%) were family members and community volunteers. A total of 384 (85.1%) were categorized as "treatment success", 31 (6.9%), as "transferred out", 17 (3.8%), as "expired", 16 (3.5%) as "defaulted" and three (0.7%) as "treatment failure". The treatment success rates in patients supervised by Lady health workers, community health workers and health facility workers, and family members and community volunteers were 93.1%, 89.1% and 73.5%, respectively. CONCLUSION: We found a significantly higher treatment success rate (93.1%) in patients supervised by lady health workers compared to others. The overall treatment success rate was 85.1%.

Tuberculosis: a review of current concepts and control programme in Nigeria.

BACKGROUND: The burden of tuberculosis in Nigeria is the highest in Africa. Therefore, improved knowledge of health workers on the current issues concerning the disease, including the National guideline, is important for effective disease control. METHODS: An in-depth search of relevant literature on the subject area. This includes texts and operational documents of the Nigerian national tuberculosis programme, as well as online searches using Pubmed, Africanjournal online (Ajol), and Google scholar. RESULTS: About one third of the world population is infected with tuberculous bacilli with up to 10% lifetime risk of developing the disease. Pulmonary tuberculosis (PTB) especially the reactivated latent infection is the major source of the infection in communities. In an effort to increase case detection, a single acid fast bacillus in at least one of two sputum smears is currently adequate to diagnose PTB. Furthermore, there is a global effort to eliminate the disease by the year 2050 and these efforts are coordinated in Nigeria by the National tuberculosis controlprogramme. CONCLUSION: Tuberculosis is an impediment to human development in developing countries, especially in this era of HIV pandemic. Continuing education of health professional on tuberculosis and its accessible treatment, will improve patients' education, proper management and appropriate referral.

Current status of medication adherence and infant follow up in the prevention of mother to child HIV transmission programme in Addis Ababa: a cohort study.

BACKGROUND: Prevention of mother to child HIV transmission (PMTCT) programmes have great potential to achieve virtual elimination of perinatal HIV transmission provided that PMTCT recommendations are properly followed. This study assessed mothers and infants adherence to medication regimen for PMTCT and the proportions of exposed infants who were followed up in the PMTCT programme. METHODS: A prospective cohort study was conducted among 282 HIV-positive mothers attending 15 health facilities in Addis Ababa, Ethiopia. Descriptive statistics, bivariate and mulitivariate logistic regression analyses were done. RESULTS: Of 282 mothers enrolled in the cohort, 232 (82%, 95% CI 77-86%) initiated medication during pregnancy, 154 (64%) initiated combined zidovudine (ZDV) prophylaxis regimen while 78 (33%) were initiated lifelong antiretroviral treatment (ART). In total, 171 (60%, 95% CI 55-66%) mothers ingested medication during labour. Of the 221 live born infants (including two sets of twins), 191 (87%, 95% CI 81-90%) ingested ZDV and single-dose nevirapine (sdNVP) at birth. Of the 219 live births (twin births were counted once), 148 (68%, 95% CI 61-73%) mother-infant pairs ingested their medication at birth. Medication ingested by mother-infant pairs at birth was significantly and independently associated with place of delivery. Mother-infant pairs attended in health facilities at birth were more likely (OR 6.7 95% CI 2.90-21.65) to ingest their medication than those who were attended at home. Overall, 189 (86%, 95% CI 80-90%) infants were brought for first pentavalent vaccine and 115 (52%, 95% CI 45-58%) for early infant diagnosis at six-weeks postpartum. Among the infants brought for early diagnosis, 71 (32%, 95% CI 26-39%) had documented HIV test results and six (8.4%) were HIV positive. CONCLUSIONS: We found a progressive decline in medication adherence across the perinatal period. There is a big gap between mediation initiated during pregnancy and actually ingested by the mother-infant pairs at birth. Follow up for HIV-exposed infants seem not to be organized and is inconsistent. In order to maximize effectiveness of the PMTCT programme, the rate of institutional delivery should be increased, the quality of obstetric services should be improved and missed opportunities to exposed infant follow up should be minimized.

Childhood tuberculosis deskguide and monitoring: an intervention to improve case management in Pakistan.

BACKGROUND: Childhood tuberculosis (TB) has been a neglected area in national TB control programme (NTCP) in high burden countries. The NTP Pakistan adapted the global approaches by developing and piloting its policy guideline on childhood TB in ten districts of the country. We developed an intervention package including a deskguide and a monitoring tool and tested with the ongoing childhood TB care in a district. The objective of our study was to measure effectiveness of intervention package with deskguide and monitoring tool by comparing TB case finding and treatment outcomes among districts in 2008, and performance assessment in intervention district. METHOD: An intervention study with cohort design within a routine TB control programme comparing case findings and treatment outcomes before and after the intervention, and in districts with and without intervention. We enrolled all children below 15 years registered at all nine public sector hospitals in three districts of Pakistan. The data was collected from hospital TB records. RESULTS: In eight months during 2007 there were 164 childhood TB cases notified, and after intervention in 2008 a total of 194 cases were notified. In intervention district case finding doubled (110% increase) and correct treatment practice significantly increased in eight months. Successful outcomes were significantly higher in intervention district (37,100%) compared to control district A (18, 18%, p < 0.05) and control district B (41, 72%, p < 0.05). CONCLUSION: Childhood TB deskguide and structured monitoring was associated with improved case management and it augmented NTP policy. More development and implementation in all health services of the district are indicated.

Are children with tuberculosis in Pakistan managed according to National programme policy guidelines? A study from 3 districts in Punjab.

BACKGROUND: The adherence to policies of National TB Control Programme (NTP) to manage a case of tuberculosis (TB) is a fundamental step to have a successful programme in any country. Childhood TB services faces an unmet challenge of case management due to difficulty with diagnosis and relatively new policies. For control of childhood TB in Pakistan, NTP developed and piloted its guidelines in 2006-2007. The objective of this study was to compare the documented case management practices of pediatricians and its impact on the outcome before and after introducing NTP policy guidelines. FINDINGS: An audit of case management practices of a historical cohort study was done in children below 15 years who were put on anti-tuberculosis treatment at all nine public hospitals in three districts in province of Punjab. The study period was two years pre-intervention (2004-05) and two years post-intervention (2006-07) after implementation of new NTP policy guidelines for childhood TB. There were 920 childhood TB cases registered during four years, 189 in pre-intervention period and 731 in post-intervention period. The practices changed significantly in post-intervention period for use of tuberculin skin test (63% of pulmonary cases, 19% of extrapulmonary cases and 67% for site unknown), and for the use of chest x-ray (69% of pulmonary cases, 16% of extrapulmonary cases and 74% for site unknown). Diagnostic scores were recorded for only a minority of cases (18%). The proportion of correct drugs pre- and post-intervention remained same. There were unknown treatment outcomes in 38 out of 141 cases (27%) in pre-intervention and in 483 out of 551 cases (87%) post-intervention, all among the 692 cases without documented treatment supporter. CONCLUSIONS: The study has shown that pediatricians have started following parts of the national policy guidelines for management of childhood TB. The documented use of diagnostic tools is increased but record keeping of case management practices remained inadequate. This seems to increase case finding substantially but the treatment outcomes were poor mainly due to unknown outcomes. Development and implementation of standardized operational tools and regular monitoring system may improve the services.

Promising outcomes of a national programme for the prevention of Mother-to-Child HIV transmission in Addis Ababa: a retrospective study.

BACKGROUND: Prevention of Mother-to-Child HIV Transmission (PMTCT) is still the most effective intervention in combating new HIV infections. In 2008, revised national PMTCT guidelines that incorporated new policies on HIV counselling and testing, antiretroviral prophylaxis regimen and infant HIV diagnosis came into effect in Ethiopia. In the present study we have examined trends in PMTCT service utilization and assessed the rate of MTCT in relation to policy changes in the national PMTCT programme. METHODS: Reports from February 2004 to August 2009 were reviewed in 10 sub-cities in Addis Ababa, Ethiopia. The data was collected from May to October 2009. RESULTS: The proportion of women who received HIV counselling and testing among new antenatal care attendees increased from 50.7% (95% CI 50.2-51.2) in 2007 to 84.5% (95% CI 84.1-84.9) in 2009 following the shift to routine opt-out testing. Nevertheless, in 2009 only 53.7% of the positive women and 40.7% of their infants received antiretroviral prophylaxis. The HIV prevalence among antenatal attendees decreased significantly from 10.5% in 2004 to 4.6% in 2009 in parallel to the increased number of women being tested. The HIV positive women were over 18 times (RR 18.5, p < 0.0001) more likely to be referred for treatment, care and support in 2009 than in 2004. The proportion of partners tested for HIV decreased by 14% in 2009 compared to 2004, although the absolute number was increasing year by year. Only 10.6% (95% CI 9.9-11.2) of the HIV positive women completed their follow up to infant HIV testing. The cumulative probability of HIV infection among babies on single dose nevirapine regimen who were tested at >=18 months was 15.0% (95% CI 9.8-22.1) in 2007, whereas it was 8.2% (95% CI 5.55-11.97) among babies on Zidovudine regimen who were tested at >=45 days in 2009. CONCLUSION: The paper demonstrates trends in PMTCT service utilization in relation to changing policy. There is marked improvement in HIV counselling and testing service utilization, especially after the policy shift to routine opt-out testing. However, despite policy changes, the ARV prophylaxis uptake, the loss to follow up and the partner testing have remained unchanged across the years. This should be a matter of immediate concern and a topic for further research.

Smear microscopy and culture conversion rates among smear positive pulmonary tuberculosis patients by HIV status in Dar es Salaam, Tanzania.

BACKGROUND: Tanzania ranks 15th among the world's 22 countries with the largest tuberculosis burden and tuberculosis has continued to be among the major public health problems in the country. Limited data, especially in patients co infected with HIV, are available to predict the duration of time required for a smear positive pulmonary tuberculosis patient to achieve sputum conversion after starting effective treatment. In this study we assessed the sputum smear and culture conversion rates among HIV positive and HIV negative smear positive pulmonary tuberculosis patients in Dar es Salaam METHODS: The study was a prospective cohort study which lasted for nine months, from April to December 2008 RESULTS: A total of 502 smear positive pulmonary tuberculosis patients were recruited. HIV test results were obtained for 498 patients, of which 33.7% were HIV positive. After two weeks of treatment the conversion rate by standard sputum microscopy was higher in HIV positive(72.8%) than HIV negative(63.3%) patients by univariate analysis(P = 0.046), but not in multivariate analysis. Also after two weeks of treatment the conversion rate by fluorescence microscopy was higher in HIV positive (72.8%) than in HIV negative(63.2%) patients by univariate analysis (P = 0.043) but not in the multivariate analysis. The conversion rates by both methods during the rest of the treatment period (8, 12, and 20 weeks) were not significantly different between HIV positive and HIV negative patients.With regards to culture, the conversion rate during the whole period of the treatment (2, 8, 12 and 20 weeks) were not significantly different between HIV positive and HIV negative patients. CONCLUSION: Conversion rates of standard smear microscopy, fluorescence microscopy and culture did not differ between HIV positive and HIV negative pulmonary tuberculosis patients.

Diagnosis and follow-up of treatment of latent tuberculosis; the utility of the QuantiFERON-TB Gold In-tube assay in outpatients from a tuberculosis low-endemic country.

BACKGROUND: Interferon-gamma (IFN-gamma) Release Assays (IGRA) are more specific than the tuberculosis skin test (TST) in the diagnosis of latent tuberculosis (TB) infection (LTBI). We present the performance of the QuantiFERON-TB Gold In-tube (QFT-TB) assay as diagnostic test and during follow-up of preventive TB therapy in outpatients from a TB low-endemic country. METHODS: 481 persons with suspected TB infection were tested with QFT-TB. Thoracic X-ray and sputum samples were performed and a questionnaire concerning risk factors for TB was filled. Three months of isoniazid and rifampicin were given to patients with LTBI and QFT-TB tests were performed after three and 15 months. RESULTS: The QFT-TB test was positive in 30.8% (148/481) of the total, in 66.9% (111/166) of persons with origin from a TB endemic country, in 71.4% (20/28) previously treated for TB and in 100% (15/15) of those diagnosed with active TB with no inconclusive results. The QFT-TB test was more frequently positive in those with TST > or = 15 mm (47.5%) compared to TST 11-14 mm (21.3%) and TST 6-10 mm (10.5%), (p < 0.001). Origin from a TB endemic country (OR 6.82, 95% CI 1.73-26.82), recent stay in a TB endemic country (OR 1.32, 95% CI 1.09-1.59), duration of TB exposure (OR 1.59, 95% CI 1.14-2.22) and previous TB disease (OR 11.60, 95% CI 2.02-66.73) were all independently associated with a positive QFT-TB test. After preventive therapy, 35/40 (87.5%) and 22/26 (84.6%) were still QFT-TB positive after three and 15 months, respectively. IFN-gamma responses were comparable at start (mean 6.13 IU/ml +/- SD 3.99) and after three months (mean 5.65 IU/ml +/- SD 3.66) and 15 months (mean 5.65 IU/ml +/- SD 4.14), (p > 0.05). CONCLUSION: Only one third of those with suspected TB infection had a positive QFT-TB test. Recent immigration from TB endemic countries and long duration of exposure are risk factors for a positive QFT-TB test and these groups should be targeted through screening. Since most patients remained QFT-TB positive after therapy, the test should not be used to monitor the effect of preventive therapy. Prospective studies are needed in order to determine the usefulness of IGRA tests during therapy.

Delay in tuberculosis case detection in Pwani region, Tanzania. A cross sectional study.

BACKGROUND: Delay in Tuberculosis (TB) case detection may worsen the disease and increase TB transmission. It is also a challenge to the National TB and Leprosy control Program (NTLP). METHODS: We conducted a cross sectional study in four out of six districts in Pwani region to estimate the extent and factors responsible for delay in TB case detection in Pwani region. Delays were divided into patient, health facility and total delay. RESULTS: We enrolled a total of 226 smear positive TB patients. Out of 226 patient's results were available for 206. The majority (66.5%) of the patients were males. Mean age for males and females were 37.3 and 33.7 years respectively. Mean (SD) total delay was 125.5 (98.5) days (median 90). Out of 206 patients, 79 (38.35%) delayed to seek TB health care. Health facility delay was observed among 121 (58.7%) patients.Risk factors for delay was poor knowledge that chest pain may be a TB symptom (OR = 2.9; 95%CI 1.20- 7.03) and the belief that TB is always associated with HIV/AIDS (OR = 2.7; 95%CI 1.39-5.23). Risk for delay was low among patients who first presented to a government health facility (OR = 0.3; 95%CI 0.12- 0.71) and those presenting with chest pain (OR = 0.2; 95%CI 0.10-0.61). CONCLUSION: There is a considerable delay in TB case detection in Pwani mainly contributed by patients. Risk factors for delay include misconception about TB/HIV and poor knowledge of TB symptoms.

Pulmonary tuberculosis among women with cough attending clinics for family planning and maternal and child health in Dar Es Salaam, Tanzania.

BACKGROUND: Tuberculosis (TB) case detection in women has remained low in developing world. This study was conducted to determine the proportion of smear positive TB among women with cough regardless of the duration attending family Planning (FP) and Maternal and child health (MCH) clinics in Dar es Salaam. METHODS: We conducted a cross sectional study in all three municipal hospitals of Dar es Salaam, between October 2007 and June 2008. All women with cough attending FP and MCH clinics were screened for TB by smear microscopy. Pearson chi-square was used to compare group difference for categorical variables. Risk factors for smear positive were estimated by logistics regression with 95% confidence intervals (CI) given for odds ratios indicating statistically significant relationship if the CI did not include one. RESULTS: We enrolled a total of 749 TB suspects. Five hundred and twenty nine patients (70.6%) were from MCH clinics. Mean (SD) age was 27.6 (5.2) years. A total of 616 (82.2%) patients were coughing for less than two weeks as compared to 133 (17.8%), who coughed for two or more weeks. Among 616 TB suspects, 14 (2.3%) were smear positive TB patients, and of the 133 who had coughed for two or more weeks, 13 (9.8%) were smear positive TB patients. Risk factors associated with smear positive results were having attended more than one visit to any facility prior to diagnosis (OR = 6.8; 95%CI 2.57-18.0) and having HIV/AIDS (OR = 4.4; 95%CI 1.65-11.96). Long duration of cough was not a risk factor for being smear positive (OR = 1.6; 95%CI 0.59-4.49). CONCLUSION: The proportion of smear positive TB patients among women with cough attending MCH and FP was 3.8%. Visits to any health facility prior to Diagnosis and HIV infection were risk for having a smear positive TB.

Delay in the diagnosis of tuberculosis in Nepal.

BACKGROUND: Identifying reasons for delay in diagnosis and treatment of tuberculosis is important for the health system to find ways to treat patients as early as possible, and hence reduce the suffering of patients and transmission of the disease. The objectives of this study was to assess the duration of delay in the diagnosis of tuberculosis and to investigate its determinants. METHODS: A cross-sectional survey was conducted using a structured questionnaire in 307 new tuberculosis patients registered by the National Tuberculosis Programme (NTP) in all DOTS centres in Banke district of Nepal. RESULTS: The median patient delay was 50 days, the median health system delay was 18 days, and the median total delay was 60 days. Sputum smear negative participants had significantly lower risk of patient delay. Smokers using >5 cigarettes per day had higher risk of patient delay and health system delay. CONCLUSION: Total delay in the diagnosis of tuberculosis in Banke district is shorter compared to other places in Nepal and neighbouring countries. The shorter delay for smear negative pulmonary tuberculosis raises suspicion that many of these patients are not examined according to the NTP manual before being diagnosed. Increasing public awareness of the disease and expansion of the facilities with assured quality could be helpful to reduce the delay in the diagnosis of tuberculosis.

Detection of pulmonary tuberculosis among patients with cough attending outpatient departments in Dar Es Salaam, Tanzania: does duration of cough matter?

BACKGROUND: According to WHO estimates, tuberculosis case detection rate in Tanzania is less than 50% and this poses a major challenge to control tuberculosis in the country. Currently, one of the defining criteria for suspecting tuberculosis is cough for two weeks or more. We wanted to find out whether the prevalence of tuberculosis was different in patients who reported cough for two weeks or more, compared to patients with cough for less than two weeks. METHODS: We conducted a cross sectional study in six health facilities in Dar es Salaam, between September and October 2007. All patients aged five years and above with cough were screened for pulmonary tuberculosis (PTB) by smear microscopy. Patients were divided into two groups, those who coughed for less than two weeks (<2 wks) and those who coughed for two weeks or more (> or = 2 wks). RESULTS: A total of 65,530 patients attended outpatients department (OPD). Out of these, 2274 (3.5%) patients reported cough. Among patients who reported cough, 2214 (97.4%) remembered their cough duration. One thousand nine hundred and seventy three patients (89.1%) coughed for >/= 2 wks as compared to 241 (10.9%) patients who coughed for <2 wks. Of those who coughed for two weeks or more, 250 (12.7%) had smear positive PTB, and of those who had coughed for less than two weeks, 21 (8.7%) had smear positive PTB. There was no statistically significant difference in prevalence of smear positive tuberculosis among the two groups (Pearson Chi-Square 3.2; p = 0.074). CONCLUSION: Detection of smear positive PTB among patients who coughed for less than two weeks was as high as for those who coughed for two weeks or more.

Immunohaematological reference values in human immunodeficiency virus-negative adolescent and adults in rural northern Tanzania.

BACKGROUND: The amount of CD4 T cells is used for monitoring HIV progression and improvement, and to make decisions to start antiretroviral therapy and prophylactic drugs for opportunistic infections. The aim of this study was to determine normal reference values for CD4 T cells, lymphocytes, leucocytes and haemoglobin level in healthy, HIV negative adolescents and adults in rural northern Tanzania. METHODS: A cross sectional study was conducted from September 2006 to March 2007 in rural northern Tanzania. Participants were recruited from voluntary HIV counselling and testing clinics. Patients were counselled for HIV test and those who consented were tested for HIV. Clinical screening was done, and blood samples were collected for CD4 T cell counts and complete blood cell counts. RESULTS: We enrolled 102 participants, forty two (41.2%) males and 60 (58.8%) females. The mean age was 32.6 +/- 95% CI 30.2-35.0. The mean absolute CD4 T cell count was 745.8 +/- 95% CI 695.5-796.3, absolute CD8 T cells 504.6 +/- 95% CI 461.7-547.5, absolute leukocyte count 5.1 +/- 95% CI 4.8-5.4, absolute lymphocyte count 1.8 +/- 95% CI 1.7-1.9, and haemoglobin level 13.2 +/- 95% CI 12.7-13.7. Females had significantly higher mean absolute CD4 T cell count (p = 0.008), mean absolute CD8 T cell count (p = 0.009) and significantly lower mean haemoglobin level than males (p = 0.003) CONCLUSION: Immunohaematological values found in this study were different from standard values for western countries. Females had significantly higher mean CD4 T cell counts and lower mean haemoglobin levels than males. This raises the issue of the appropriateness of the present reference values and guidelines for monitoring HIV/AIDS patients in Tanzania.

Gender differences in the clinical diagnosis of tuberculous lymphadenitis--a hospital-based study from Central India.

OBJECTIVE: Tuberculous lymphadenitis can be difficult to diagnose clinically, and as it is thought to be more common in females, we describe here the clinical characteristics of cervical tuberculous lymphadenitis in men and women and compare this with cytology to assess their diagnostic value. METHODS: Two hundred and nineteen patients with tuberculous lymphadenitis, aged 14 years or more, who presented with a neck mass to the Department of Pathology, Ujjain Hospital, Ujjain, India were included in the study. The presenting clinical symptoms and signs were compared between men and women and with the cytology of fine needle aspirates from the lymph nodes. RESULTS: Seventy-five percent of the patients were aged between 14 and 35 years, with a male to female ratio of 1:2.1. One or more constitutional symptoms were present in 56.6% of patients on presentation. There were more men with clinical symptoms than women. Fever was the most common manifestation in both gender groups. Fever for more than 30 days, cough, weight loss, and night sweats were significantly more common in men. On cytology, necrotic granulomas were found to be associated with constitutional symptoms. CONCLUSIONS: Constitutional symptoms were more frequently reported by men than by women and showed a correlation with necrotic granulomas on cytology.

Patient and health system delays: health-care seeking behaviour among pulmonary tuberculosis patients in Pakistan.

OBJECTIVE: To determine the time taken for diagnosis and treatment of pulmonary TB and the factors responsible for delay, by studying the level of awareness regarding TB in the patients, and the extent of social stigmatization associated with TB in Punjab (Multan and Sialkot), Pakistan. METHODS: It was a hospital based cross-sectional study using a pre-structured questionnaire. The study was done in two areas Multan (Nishtar Hospital) and Sialkot (Bethania Hospital) in the province of Punjab, Pakistan from May - July 2006. The sample (n = 301) consisted of all the TB patients coming to the hospitals during the study period. The data was analyzed using SPSS version 14.0. RESULTS: The median patient delay was 33 days (range 2-90). The median health system delay was 60 days (range 4-365). The median total delay was 90 days (range 23-365). The percentage of patients aware about TB was 37%. The number of patients who perceived stigmatization was 27%. CONCLUSION: The major portion of the delay is contributed by the health system, rather than the patient. The awareness about TB is low and emphasis should be given to increasing the awareness of TB among the community.