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Towards the WHO target of zero childhood tuberculosis deaths: an analysis of mortality in 13 locations in Africa and Asia.
International Journal of Tuberculosis and Lung Disease. 2013 Dec; 17(12):1518-23.SETTING: Achieving the World Health Organization (WHO) target of zero paediatric tuberculosis (TB) deaths will require an understanding of the underlying risk factors for mortality. OBJECTIVE: To identify risk factors for mortality and assess the impact of human immunodeficiency virus (HIV) testing during anti-tuberculosis treatment in children in 13 TB-HIV programmes run by Medecins Sans Frontieres. DESIGN: In a retrospective cohort study, we recorded mortality and analysed risk factors using descriptive statistics and logistic regression. Diagnosis was based on WHO algorithm and smear microscopy. RESULTS: A total of 2451 children (mean age 5.2 years, SD 3.9) were treated for TB. Half (51.0%) lived in Asia, the remainder in sub-Saharan Africa; 56.0% had pulmonary TB; 6.4% were diagnosed using smear microscopy; 211 (8.6%) died. Of 1513 children tested for HIV, 935 (61.8%) were positive; 120 (12.8%) died compared with 30/578 (5.2%) HIV-negative children. Risk factors included being HIV-positive (OR 2.6, 95%CI 1.6-4.2), age <5 years (1.7, 95%CI 1.2-2.5) and having tuberculous meningitis (2.6, 95%CI 1.0-6.8). Risk was higher in African children of unknown HIV status than in those who were confirmed HIV-negative (1.9, 95%CI 1.1-3.3). CONCLUSIONS: Strategies to eliminate childhood TB deaths should include addressing the high-risk groups identified in this study, enhanced TB prevention, universal HIV testing and the development of a rapid diagnostic test.
Tuberculosis retreatment category predicts resistance in hospitalized retreatment patients in a high HIV prevalence area.
International Journal of Tuberculosis and Lung Disease. 2009 Oct; 13(10):1274-80.SETTING: Rates of multidrug-resistant tuberculosis (MDR-TB) are currently as high as 7.7% in retreatment cases in KwaZulu-Natal, South Africa. MDR-TB prevalence is known to be high in patients categorized as treatment failures. Recent reports have questioned the effectiveness of the World Health Organization (WHO) Category II regimen in retreatment TB cases. OBJECTIVE: To determine whether treatment category predicts susceptibility patterns and outcomes in a hospitalized population of retreatment TB cases. DESIGN: Retrospective cohort of 197 pulmonary retreatment cases. RESULTS: Retreatment cases treated with the standard retreatment regimen had a high in-hospital mortality (19.8%), or poor outcome (26.4%) and a high rate of MDR-TB (16.2%). The 'treatment failure' category predicted resistance, with 57.1% of patients exhibiting any resistance compared to other treatment categories (P = 0.02); 53.8% of patients with any resistance experienced poor outcomes, compared to 16.6% of pan-susceptible cases (P = 0.02). There was a trend towards poor outcome in the treatment failure category (42.9%, P = 0.13). CONCLUSION: The retreatment category 'treatment failure' is associated with a high prevalence of resistance in an area of high human immunodeficiency virus (HIV) prevalence. The 'treatment failure' category should be used to identify patients who may benefit from alternative regimens using directed, intensified therapy or second-line agents instead of the current standard retreatment regimen.
The evolving cost of HIV in South Africa: Changes in health care cost with duration on antiretroviral therapy for public sector patients.
Journal of Acquired Immune Deficiency Syndromes. 2007 Jul; 45(3):348-354.A retrospective costing study of 212 patients enrolled in a nongovernmental organization-supported public sector antiretroviral treatment (ART) program near Cape Town, South Africa was performed from a health care system perspective. t-Regression was used to analyze total costs in 3 periods: Pre-ART (median length = 30 days), first 48 weeks on ART (Year One), and 49 to 112 weeks on ART (Year Two). Average cost per patient Pre-ART was $404. Average cost per patient-year of observation was $2502 in Year One and $1372 in Year Two. The proportion of costs attributable to hospital care fell from 70% Pre-ART to 24% by Year Two; the proportion attributable to ART rose from 31% in Year One to 55% in Year Two. In multivariate analysis, Pre-ART and Year One costs were significantly lower for asymptomatic patients compared with those with AIDS. Costs were significantly higher for those who died Pre-ART or in Year One. In Year Two, only week 48 CD4 cell count and being male were significantly associated with lower costs. This analysis suggests that the total cost of treatment for patients on ART falls by almost half after 1 year, largely attributable to a reduction in hospital costs. (author's)
INTERNATIONAL JOURNAL OF TUBERCULOSIS AND LUNG DISEASE. 1998 Mar; 2(3):225-30.In 1995, Pakistan adopted the guidelines published by the World Health Organization (WHO) for the treatment of tuberculosis in developing countries. The present study, conducted at a tertiary care teaching hospital (Aga Khan University Hospital) in Karachi, assessed physician compliance with the WHO guidelines through a retrospective review of the records of all 229 patients admitted with tuberculosis in 1995. 191 of these patients were classified into WHO Category 1 (new cases of pulmonary tuberculosis and severe cases of extrapulmonary tuberculosis), 9 were Category 2 (relapses and treatment failures), and 29 were Category 3 (children and non-severely ill cases). A total of 53 Category 1 patients (23%) had a diagnostic bacteriologic sputum smear examination, of which 38% were smear-positive and 47% were culture-positive. 12% of the 25 cerebrospinal fluid cultures performed were positive. No sputum smear tests were conducted. Of the 58 Category 1 patients who completed treatment, 43 (74%) received a 2-month intensive protocol consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol, while 24 (41%) underwent a 6-month continuation phase with isoniazid and ethambutol. Most patients received these medications as part of a course that exceeded the 8-month regimen recommended by WHO. Over 70% of patients were lost to follow up, primarily during the intensive phase of treatment. Only 52% of patients who completed treatment showed complete recovery. Overall, these findings reveal poor awareness of and low physician compliance with the WHO guidelines. Recommended are physician education programs and development of a standard tool to monitor physician compliance with these guidelines.