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Operational research on tuberculosis control in Malawi
Banerjee, A.
Publication date
2003
Link to publication
Citation for published version (APA):
Banerjee, A. (2003). Operational research on tuberculosis control in Malawi.
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SUMMARY Y
Thiss thesis presents results of operational research conducted in Ntcheu, a district in thee central region of Malawi. The studies were conducted as part of a larger programmee of operational research carried out by the National Tuberculosis (TB) Controll Programme of Malawi and were all conducted during the author's tenure as thee District Health Officer of Ntcheu.
Inn Chapter 1 an overview of the extent of the TB and human immunodefiency virus (HIV)) co-epidemic is given as well as a description of some of the major problems in TBB control such as delays in diagnosis and non-adherence to treatment. Problems specificc to TB control in high-risk populations and the impact of HIV on the TB epidemicc are looked at. The strategies being implemented such as the World Health Organizationn (WHO) DOTS (directly observed therapy, short course chemotherapy) strategyy to control TB and strategies being proposed to combat the upsurge of HIV relatedd TB are described. The latter include intensified case finding, isoniazid (INH) prophylaxis,, cotrimoxazole prophylaxis, and highly active antiretroviral therapy (HAART)) for HIV-infected TB patients. Areas for further operational research are identifiedd and areas of operational research carried out in Malawi are highlighted.
Inn Chapter 2 a short background of Malawi is provided as well as some information aboutt the National TB Control Programme. Figures on TB control and the impact of HIVV on case notification are presented, followed by a short description of Ntcheu district. .
Chapterr 3 describes the acceptability of HIV testing amongst TB patients and treatment outcomee in relation to HIV-serostatus. Two hundred and five patients with new smear-positivee pulmonary TB (PTB) were diagnosed and treated at Ntcheu District Hospitall in 1995. HIV counselling and testing was accepted by 110 (54%) patients. Of patientss who were tested, 73 (66%) were HIV-seropositive, comparable to what has beenn observed in urban hospitals in Malawi. At the end of treatment, 126 (61%) patientss were cured and 56 (27%) had died. Significantly less HIV-positive patients and lesss patients with no HIV-test result were cured compared with HIV-negative patients. Thesee results show that even in a rural area of Malawi the cure rate of 85% cannot be reached,, largely because of high HIV-related mortality. In HIV-prevalent areas the WHOO cure rate targets should be reconsidered.
Chapterr 4 describes the difference in tuberculosis incidence rates of new smear-positivee cases in township and in rural populations in Ntcheu District based on data
collectedd from the district TB register for the years 1992-96. Average annual TB incidencee rates per 100,000 for semi-urban and rural populations were calculated for thiss period. There was a significantly higher incidence of TB, particularly amongst casess with smear-negative pulmonary TB (64 versus 16/100.000; RR 4.10 - 95%% confidencee interval 3.42 - 4.92) and extrapulmonary TB (54 versus 19/100.000; RR 2.788 - 95% confidence interval 2.31 - 3.36) in the semi-urban population compared withh the rural population. Possible explanations could be higher HIV seroprevalence ratess in semi-urban areas compared with rural areas, under-diagnosis at health centress or poor access to medical facilities for rural people.
Chapterr 5 describes a prospective study, carried out between June and November 1997,, to determine the prevalence of HIV infection, sexually transmitted disease (STD) andd TB amongst new inmates imprisoned in a district prison, Ntcheu district, Malawi. Thee prison has no medical staff, and clinical screening was carried out by staff at the nearbyy district hospital. Of 275 prisoners, a full history and physical examination was carriedd out in 254 and HIV counselling performed in 250. 47 prisoners underwent HIV testing,, of whom 15 (32%) were HIV-seropositive. 27 (11%) prisoners had an active STDD (based on syndromic diagnosis), which included 15 genital ulcers, 10 urethral dischargess and 3 penile warts. Sputum specimens were collected from 111 prisoners, off whom 4 were sputum positive for acid-fast bacilli. The study shows a high prevalencee of HIV, STDs and TB amongst new prisoners admitted to a small district prison,, and suggests that screening for TB, HIV and STDs is a worthwhile exercise.
Chapterr 6 presents findings about health care provided by traditional healers and locall perceptions of tuberculosis in Ntcheu district. In-depth interviews were held withh traditional healers and structured questionnaires were completed. Focus group discussionss were conducted with TB patients and their guardians. Traditional healerss recognized four main causes of disease, related to why the patient is sick ratherr than what the patient is suffering from. Two hundred and seventy-six traditionall healers saw approximately 4600 patients a week, managing a variety of diseases,, mainly of a chronic nature. Twenty-four per cent of patients seen by traditionall healers had a cough, including patients with a chronic cough. Traditional healerss believe they can cure TB. Focus group discussions with patients showed thatt the community looked upon TB and AIDS as the same disease. It is concluded thatt there is a need to address local beliefs in health education and find ways of involvingg healers in early diagnosis and supervision of treatment.
Chapterr 7 presents data collected about practices by traditional healers collected in fivee districts in Malawi, one of which was Ntcheu. They saw an average of 28
patientss a week of which 62% were adults and 38% children. Causes of diseases weree thought to be natural in 35% of cases, bewitchment in 30%, by spirits in 18% andd due to breaking sexual taboos in 17%. Sixty-five percent (942/1450) stated that theyy would refer a TB suspect to the hospital for further investigation, and 25% (359/1450)) stated they would treat the patient with herbal medicine. Nearly one third off patients seen by the healer have symptoms compatible with TB and AIDS. As traditionall healers will be an integral part of the healthcare sought by patients for a longg time to come, they should be taught to recognize disease they cannot treat and referr them for orthodox medical care.
Chapterr 8 presents the evaluation of a unified treatment regimen for all new cases of tuberculosiss using guardian-based supervision. It evaluates whether directly observedd therapy (DOT) during the initial phase of treatment supervised either in hospital,, at health centres or by guardians in the community, was associated with 1) satisfactoryy two-month and eight-month treatment outcomes, and 2) with a reduction off in-patient hospital-bed days. Prospective data collection was carried out of all TB patientss registered between 1 April 1996 and 30 June 1997, with two-month and eight-monthh treatment outcomes, sputum smear conversion in smear-positive PTB patientss and in-patient hospital-bed days. Among the 600 new patients, 302 had smear-positivee PTB, 150 smear-negative PTB and 148 extrapulmonary TB (EPTB). Eight-monthh treatment completion was 65% for smear-positive PTB patients, which wass significantly higher than in patients with smear-negative PTB (45%) and EPTB (54%),, due mainly to high eight-month mortality rates in the latter groups. The site of thee intensive phase was determined in 596 patients: 178 (30%) received DOT from guardians,, 115 (19%) from a health centre and 303 (51%) in hospital. At two months,, mortality rates were significantly higher in hospitalised patients. Two-month treatmentt outcomes (including sputum smear conversion rates in smear-positive PTBB patients) were similar between patients receiving DOT at health centres or from guardians.. Decentralised DOT resulted in a 25% reduction in hospital-bed days in patientss alive at two months compared with that predicted using the old regimens. It wass concluded that decentralising DOT to health centres and to guardians during thee intensive phase was associated with satisfactory treatment outcomes.
Chapterr 9 compares the results of the unified treatment regimen for new cases of tuberculosiss in Ntcheu district (Chapter 8) with historical data from Ntcheu when differentt regimens were used for smear-positive TB and other forms of TB. The old regimenss were 2SRHZ/6HT for patients with new smear-positive PTB and serious formss of EPTB and 1SHT/11HT for patients with smear-negative PTB and less seriouss forms of EPTB. The new regimen consisted of 2(HRZE)3/6HE for both
smear-positivee as well as smear-negative pulmonary TB and extra-pulmonary TB. Patientss were treated ambulatory whenever possible. The oral ambulatory unified treatmentt regimen was introduced in Ntcheu District, Malawi, between April 1996 andd June 1997 for al! new patients (600) with tuberculosis (TB). There was no changee in the case finding pattern compared with the previous five years; 65% of neww smear-positive pulmonary tuberculosis (PTB) patients completed treatment, not significantlyy different compared with the previous three years. Treatment completion wass significantly lower in patients with smear-negative PTB and extra-pulmonary tuberculosis,, due mainly to high mortality rates (40% and 4 1 % respectively, comparedd to 23% for smear-positive PTB). In a rural district with high human immunodeficiencyy virus sero-prevalence rates in TB patients, case finding and end off treatment outcome of the oral unified regimen were comparable to those of previouss regimens.
Chapterr 10 presents the findings on the quality of supervision by guardians during thee intensive phase for the unified regimen. Due to the fourfold increase in cases notifiedd by the NTP between 1986 and 1996, it was decided to decentralize DOT not onlyy to health centres but to the community as well together with the introduction of thee unified regimen in Ntcheu district. Adherence to the different treatment options wass measured by form checks, tablet counts, and tests for detecting isoniazid in the urine.. Adherence was measured at two, four and eight weeks after onset of TB treatment.. Overall adherence rate was 95-96%. Inpatients showed the highest adherencee rates. Patients on guardian-based DOT (GB-DOT) (n = 35) showed 94% adherence,, while patients on health centre based DOT (n = 40) showed more non-adherentt behaviour: 11% according to monitoring forms, 14% according to tablet countss and 16% according to urine tests. The results suggest that decentralised caree is a feasible option for anti-tuberculosis treatment and that guardians can supervisee TB treatment just as well as health workers during the intensive phase of TBB treatment.
