Second nationwide anti-tuberculosis drug resistance survey in Namibia.

SETTING: Namibia ranks among the 30 high TB burden countries worldwide. Here, we report results of the second nationwide anti-TB drug resistance survey.OBJECTIVE: To assess the prevalence and trends of multidrug-resistant TB (MDR-TB) in Namibia.METHODS: From 2014 to 2015, patients with presumptive TB in all regions of Namibia had sputum subjected to mycobacterial culture and phenotypic drug susceptibility testing (DST) for rifampicin, isoniazid, ethambutol and streptomycin if positive on smear microscopy and/or Xpert MTB/RIF.RESULTS: Of the 4124 eligible for culture, 3279 (79.5%) had Mycobacterium tuberculosis isolated. 3126 (95%) had a first-line DST completed (2392 new patients, 699 previously treated patients, 35 with unknown treatment history). MDR-TB was detected in 4.5% (95%CI 3.7-5.4) of new patients, and 7.9% (95%CI 6.0-10.1) of individuals treated previously. MDR-TB was significantly associated with previous treatment (OR 1.8, 95%CI 1.3-2.5) but not with HIV infection, sex, age or other demographic factors. Prior treatment failure demonstrated the strongest association with MDR-TB (OR 17.6, 95%CI 5.3-58.7).CONCLUSION: The prevalence of MDR-TB among new TB patients in Namibia is high and, compared with the first drug resistance survey, has decreased significantly among those treated previously. Namibia should implement routine screening of drug resistance among all TB patients.

Caesarean section rate as a process indicator of safe motherhood programmes: the case of Midlands Province.

OBJECTIVE: To evaluate the Safe Motherhood Programme of Midlands Province by means of process indicators, in particular Caesarean Section Rates (CSR), in comparison with the commonly used outcome indicator Maternal Mortality Ratio (MMR). DESIGN: A cross sectional descriptive study. SETTING: Midlands Province, Zimbabwe. MAIN OUTCOME MEASURES: Process indicators of the Safe Motherhood Programme of Midlands Province, and Maternal Mortality Ratio as an outcome indicator for the nation and the province. RESULTS: For Midlands province, a population based CSR of 3.1% was calculated for 1999, which is well below the internationally recommended 5%. The figures for the eight districts ranged considerably from 0.18 to 7.1%. The provincial institutional CSR for the same year was 8.7% (range: 0.53 to 34.5) with a significantly higher rate in private institutions (24%) as compared to government run hospitals (8%), (Chi-square 398.26, p << 0.05). The Ante Natal Care (ANC) coverage ranged from 43.9 to 75.4% with a provincial average of 62.8%. The provincial institutional delivery coverage figure was 55% (range: 49.9 to 63.6%). These findings differed from the figures obtained in the Demographic and Health Survey for the same year: ANC and institutional delivery coverages for the Midlands province were 95.2% and 73% respectively. The availability of obstetric services was well above the minimum acceptable level as defined by the World Health Organisation (WHO) guidelines. CONCLUSION: MMR is not a very useful indicator to monitor progress in Safe Motherhood Programmes. The figures are unreliable, difficult to obtain if population based, and they show a wide range, even within one given year. Process indicators, especially CSR are easily accessible and give insight in the degree of unmet obstetric need and in referral patterns within one district and the province.

Risk factors for mortality in smear-negative tuberculosis suspects: a cohort study in Harare, Zimbabwe.

OBJECTIVE: To investigate mortality rates and risk factors for death among smear-negative tuberculosis (TB) suspects. DESIGN: Cohort study nested within a cluster-randomised trial of community-based active case finding. Smear-negative TB suspects were followed for 12 months, with home tracing where necessary. We calculated mortality rates and used regression analysis to investigate the relationship between clinical characteristics and death. RESULTS: Between February 2006 and June 2007, 1195 smear-negative TB suspects were followed for 1136.8 person-years. Human immunodeficiency virus (HIV) prevalence was 63.3%. During follow-up, 139 participants died (11.6%) and mortality rates remained high throughout; 119 (16.5%) HIV-positive individuals and 13 (3.1%) HIV-negative individuals died (HR = 5.8, 95%CI 3.3-10.4, P < 0.001). Advanced immunosuppression was the main risk factor for death among HIV-positive participants, with CD4 count < 50 cells/µ l associated with a 13-fold increased risk of death. Antiretroviral treatment (ART) was initiated by only 106 (14.7%), with long delays in accessing care. CONCLUSION: HIV-positive smear-negative TB suspects are at high and sustained risk of death. Current guidelines for the management of HIV-infected TB suspects are limited, and this study adds to evidence that specific policies are required to promote earlier HIV and TB diagnosis and reduce delays in ART initiation.