Outcomes and Diagnostic Processes in Outpatients with Presumptive Tuberculosis in Zomba District, Malawi

In Malawi, outpatients who have presumptive tuberculosis (TB), i.e. fever, night sweats, weight loss and/or any-duration cough (HIV-infected) or cough of at least 2 weeks (HIV-uninfected), are registered in chronic cough registers. They should receive a diagnostic work-up with first-step provider-initiated HIV testing and sputum testing which includes XpertMTB/RIF, following a national algorithm introduced in 2012.

An operational study, in which we prospectively studied 6-month outcomes of adult outpatients who were registered in chronic cough registers in Zomba Central Hospital and Matawale peri-urban Health Center, between February and September 2013. We recorded implementation of the diagnostic protocol and outcomes at 6 months from registration.

Of 348 patients enrolled, 165 (47%) were male, median age was 40 years, 72 (21%) had previous TB. At registration 154 (44%) were known HIV-positive, 34 (10%) HIV-negative (26 unconfirmed) and 160(46%) had unknown HIV status; 104 (56%) patients with unknown/unconfirmed HIV status underwent HIV testing. At 6 months 191 (55%) were HIV-positive, 87(25%) HIV-negative (26 unconfirmed) and 70 (20%) still had unknown HIV status. Higher age and registration in Matawale were independently associated with remaining unknown HIV status after 6 months. 62% of patients had sputum tested, including XpertMTB/RIF, according to the algorithm. TB was diagnosed in 54 (15%) patients. This was based on XpertMTB/RIF results in 8 (15%) diagnosed cases. In 26 (48%) TB was diagnosed on clinical grounds. Coverage of ART in HIV-positive patients was 89%. At 6 months, 236(68%) were asymptomatic, 48 (14%) symptomatic, 25 (7%) had been lost-to-follow-up and 39(11%) had died. Mortality among those HIV-positive, HIV-negative and with unknown HIV-status was 15%, 2% and 10%, respectively. Male gender, being HIV-positive-not-on-ART and not receiving antibiotics were independent risk factors for mortality.

HIV prevalence among patients with presumptive TB was high (55%). One quarter was not HIV tested and mortality in this group was substantial (10%). The impact of XpertMTB/RIF on TB diagnosis was limited.

Full article at: http://goo.gl/CTgdcQ

By: 

Monique van Lettow, Richard Bedell, Sonia Maosa, Kenneth Phiri, Adrienne K. Chan, Edson Mwinjiwa, Aunex Kwekwesa, Harry Kawonga, Joep J. van Oosterhout

Dignitas International, Zomba, Malawi

Monique van Lettow, Adrienne K. Chan

Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

Adrienne K. Chan

Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada

Martias Joshua

Zomba Central Hospital, Ministry of Health, Zomba, Malawi

Anthony D. Harries

The International Union against Tuberculosis and Lung Disease, Paris, France

Anthony D. Harries

London School of Hygiene and Tropical Medicine, London, United Kingdom

Joep J. van Oosterhout

Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi

 

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