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ABSTRACT: The rapid and massive scale-up of antiretroviral drug therapy (ART) so needed in sub-Saharan Africa will not be possible using a 'medicalised' model. A more simple approach is required. DOTS has been used now for many years to provide successful anti-tuberculosis treatment to millions of patients in poor countries of the world, and many of the established concepts can be used for the delivery of ART. Malawi, a small and impoverished country in sub-Saharan Africa, is embarking on a national scale-up of ART. In this review we describe how we have adopted several of the principles of DOTS for delivering ART in Malawi: case finding and registration, treatment, monitoring, drug procurement, staffing and the issue of free drugs. We also discuss ART for HIV-infected TB patients. We hope that by using the DOTS approach we will be able to deliver ART to large numbers of HIV-infected patients under controlled conditions, and minimise the risk of developing drug resistance.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 11/2005; 9(10):1062-71. · 2.73 Impact Factor
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[show abstract]
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ABSTRACT: The rapid and massive scale-up of antiretroviral drug therapy (ART) so needed in sub-Saharan Africa will not be possible using a medicalised model. A more simple approach is required. DOTS has been used now for many years to provide successful anti-tuberculosis treatment to millions of patients in poor countries of the world, and many of the established concepts can be used for the delivery of ART. Malawi, a small and impoverished country in sub-Saharan Africa, is embarking on a national scale-up of ART. In this review we describe how we have adopted several of the principles of DOTS for delivering ART in Malawi: case finding and registration, treatment, monitoring, drug procurement, staffing and the issue of free drugs. We also discuss ART for HIV-infected TB patients. We hope that by using the DOTS approach we will be able to deliver ART to large numbers of HIV-infected patients under controlled conditions, and minimise the risk of developing drug resistance.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 09/2005; 9(6 in the series" class="no-underline contain" target="_blank">PDF 510.4kb):1062-1071. · 2.73 Impact Factor
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R Chimzizi,
A D Harries,
F Gausi,
C Golombe,
E Manda,
A Khonyongwa, F M Salaniponi,
E Libamba,
E J Schouten,
A Mwansambo,
R Mpazanje
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ABSTRACT: Two country-wide surveys were undertaken to assess progress in scaling up human immunodeficiency virus/ acquired immune-deficiency syndrome (HIV/AIDS) and HIV-tuberculosis (TB) services in the public health sector in Malawi between 2002 and 2003. In 2003, 118 sites were performing counselling and HIV testing compared with 70 in 2002. There were 215 269 HIV tests carried out in 2003 compared with 149 540 in 2002, the largest increases being in pregnant women (from 5059 to 26791), patients with TB (from 2130 to 3983) and patients/clients attending health facilities (from 35 407 to 79 584). In 2003, 3703 patients with AIDS were started on antiretroviral therapy compared with 1220 patients in 2002.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 06/2005; 9(5):582-4. · 2.73 Impact Factor
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R. Chimzizi,
A.D. Harries,
F. Gausi,
C. Golombe,
E. Manda,
A. Khonyongwa, F.M. Salaniponi,
E. Libamba,
E.J. Schouten,
A. Mwansambo,
R. Mpazanje
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ABSTRACT: Two country-wide surveys were undertaken to assess progress in scaling up human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) and HIV-tuberculosis (TB) services in the public health sector in Malawi between 2002 and 2003. In 2003, 118 sites were performing counselling and HIV testing compared with 70 in 2002. There were 215269 HIV tests carried out in 2003 compared with 149540 in 2002, the largest increases being in pregnant women (from 5059 to 26791), patients with TB (from 2130 to 3983) and patients/clients attending health facilities (from 35407 to 79584). In 2003, 3703 patients with AIDS were started on antiretroviral therapy compared with 1220 patients in 2002.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 04/2005; 9(5):582-584. · 2.73 Impact Factor
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ABSTRACT: National Tuberculosis (TB) Control Programme (NTP), Malawi.
To determine the feasibility and effectiveness of performance-related allowances for NTP personnel working at central and regional levels in Malawi. In particular, to determine 1) whether programme staff can complete 6-monthly self-assessment forms related to the tasks they are expected to perform during that period, and 2) whether the NTP can achieve four key programme targets related to case finding, treatment outcome and the sending of sputum specimens for drug resistance monitoring.
A descriptive study.
For January to June 2003, 25 personnel completed self-assessment forms, and in all cases individual performance was judged satisfactory. For July to December 2003, 21 personnel completed self-assessment forms, and in 20 cases individual performance was judged satisfactory. In the first quarter of 2003, only one target was achieved for the country, and NTP personnel were awarded one quarter of the performance payment. In the third quarter, two targets were achieved and NTP personnel were awarded one half of the performance payment.
It is feasible to implement performance-related payments for NTP personnel. Ways to routinely introduce such a system for NTP and other staff in the health sector urgently need to be explored.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 03/2005; 9(2):138-44. · 2.73 Impact Factor
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ABSTRACT: The global targets for tuberculosis (TB) control were postponed from 2000 to 2005, but on current evidence a further postponement may be necessary. Of the constraints preventing these targets being met, the primary one appears to be the lack of adequately trained and qualified staff. This paper outlines: 1) the human resources and skills for global TB and human immunodeficiency virus (HIV) TB control, including the human resources for implementing the DOTS strategy, the additional human resources for implementing joint HIV-TB control strategies and what is known about human resource gaps at global level; 2) the attempts to quantify human resource gaps by focusing on a small country in sub-Saharan Africa, Malawi; and 3) the main constraints to human resources and their possible solutions, under six main headings: human resource planning; production of human resources; distribution of the work-force; motivation and staff retention; quality of existing staff; and the effect of HIV/AIDS. We recommend an urgent shift in thinking about the human resource paradigm, and exhort international policy makers and the donor community to make a concerted effort to bridge the current gaps by investing for real change.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 03/2005; 9(2):128-37. · 2.73 Impact Factor
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[show abstract]
[hide abstract]
ABSTRACT: The global targets for tuberculosis (TB) control were postponed from 2000 to 2005, but on current evidence a further postponement may be necessary. Of the constraints preventing these targets being met, the primary one appears to be the lack of adequately trained and qualified staff. This paper outlines: 1) the human resources and skills for global TB and human immunodeficiency virus (HIV) TB control, including the human resources for implementing the DOTS strategy, the additional human resources for implementing joint HIV-TB control strategies and what is known about human resource gaps at global level; 2) the attempts to quantify human resource gaps by focusing on a small country in sub-Saharan Africa, Malawi; and 3) the main constraints to human resources and their possible solutions, under six main headings: human resource planning; production of human resources; distribution of the workforce; motivation and staff retention; quality of existing staff; and the effect of HIV/AIDS. We recommend an urgent shift in thinking about the human resource paradigm, and exhort international policy makers and the donor community to make a concerted effort to bridge the current gaps by investing for real change.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 01/2005; 9(2):128-137. · 2.73 Impact Factor
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ABSTRACT: All 44 non-private hospitals in Malawi treating tuberculosis (TB) cases in which oral regimens were used allowing patients during the initial phase to receive directly observed treatment (DOT) from health centres or guardians at home.
A country-wide audit of the oral regimens to determine: 1) TB ward bed occupancy rates, 2) patient DOT options, 3) patients' knowledge of treatment and 4) treatment outcomes compared to those obtained with previous treatment regimens.
Retrospective data collection using registers and treatment cards. Prospective interviews with patients. Inspections of TB wards.
There were 1513 TB beds occupied by 807 (53%) TB patients. Over 50% of 4793 patients registered with different types of TB chose guardian-based DOT. For 266 patients with pulmonary TB the correct knowledge about total duration of treatment (45%), all three DOT options (62%) and the months for giving follow-up sputum (16%), was poor. There were differences in treatment outcomes between TB patients on oral compared with previous regimens. With oral regimens, rates of unknown outcome were high.
Oral treatment regimens are associated with reduced bed occupancy rates on TB wards. However, rates of unknown outcome are increased, and TB control is therefore weakened.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 10/2004; 8(9):1089-94. · 2.73 Impact Factor
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ABSTRACT: Fifteen hospitals in Malawi that offer voluntary counselling and testing (VCT) for the human immunodeficiency virus (HIV) for tuberculosis (TB) patients and cotrimoxazole (CTX) for patients found to be HIV-positive.
1) To describe the process of developing a national TB-HIV plan, conducting a country-wide situational assessment, and producing national guidelines on VCT and CTX for TB patients, and 2) to assess the implementation of VCT and CTX for TB patients registered between July and September 2003.
A descriptive study.
The 3-year HIV-TB plan was finalised in 2002. Between January and March 2003, an assessment was carried out of HIV/AIDS and joint HIV-TB services in Malawi and a decision made to support 15 hospitals in implementing VCT and CTX for TB patients. Between April and June 2003, national guidelines on VCT and CTX were developed through a consultative process, and treatment units were prepared for implementation. Between July and September 2003, 2397 TB patients were registered, and 1404 (59%) accepted VCT; 956 (68%) were HIV-positive, of whom 927 (97%) started CTX. Deficiencies in the registration process and in patient understanding about VCT and CTX were identified.
The results show that it is feasible to routinely implement VCT and CTX for TB patients.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 09/2004; 8(8):938-44. · 2.73 Impact Factor
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ABSTRACT: All 44 non-private hospitals in Malawi treating pulmonary tuberculosis (PTB) patients with an oral regimen (0.5RHZE/1.5R3H3Z3E3/6HE).
In new smear-positive PTB patients, to determine whether: 1) numbers of tablets were correctly prescribed according to pre-treatment weights, and 2) medication dosages were adequate, too low or too high.
Retrospective review of TB registers and TB treatment cards for patients registered with new smear-positive PTB between 1 October and 31 December 2001.
Of 1970 patients aged > or = 15 years, 1211 (62%) had treatment cards and pre-treatment weights. Incorrect prescriptions were given to 88 (7%), and many of these received dosages of anti-tuberculosis drugs that were too high or too low. For those receiving correct prescriptions, daily treatment in the initial and continuation phases was generally associated with adequate dosages of drugs. However, in the initial intermittent phase, between 3% and 40% of patients received anti-tuberculosis drug dosages that were too low.
A small percentage of patients receive incorrect prescriptions, which can be resolved by training and supervision. In those receiving correct prescriptions, intermittent treatment provides dosages that are sometimes too low. Weight bands for intermittent treatment should be re-examined.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 06/2004; 8(6):724-9. · 2.73 Impact Factor
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R Chimzizi,
F Gausi,
A Bwanali,
D Mbalume,
R Teck,
P Gomani,
R Zachariah,
W Zuza,
R Malombe, F M Salaniponi,
A D Harries
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ABSTRACT: Two rural districts in Malawi: Thyolo, where voluntary counselling and human immunodeficiency virus (HIV) testing (VCT) is offered to all tuberculosis (TB) patients and adjunctive cotrimoxazole to HIV positives, and Mulanje, where no such interventions are offered.
For all TB patients registered in 2001: 1) to determine the uptake of VCT and cotrimoxazole in Thyolo, and 2) to compare treatment outcomes between Thyolo and Mulanje.
A cohort study using routinely collected programme data.
There were 1239 TB patients in Mulanje and 1103 in Thyolo. In Thylo, 1064 (97%) patients consented to VCT, 1006 were HIV tested (91%) and 761 (69%) were started on cotrimoxazole a median of 4 days from registration; 77% of patients tested in Thyolo were HIV-positive. For all TB patients, in Thyolo and Mulanje, treatment success was respectively 75% and 61% (P < 0.001); death was 21% and 25% (P = 0.026); and other outcomes were 4% and 14% (P < 0.001). The adjusted relative risks of treatment success (1.23), death (0.84) and other outcomes (0.26) in Thyolo were significantly different from those in Mulanje (P < 0.001).
VCT and adjunctive cotrimoxazole is well accepted by TB patients in Thyolo and, with other HIV care and support services, is associated with good treatment outcome indicators for the National Tuberculosis Programme. This intervention is being expanded to other districts in Malawi, and other African countries should consider a similar approach to the dual HIV-TB epidemic.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 06/2004; 8(5):579-85. · 2.73 Impact Factor
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ABSTRACT: Forty-four tuberculosis (TB) officers who attended the National TB Seminar were given a multiple choice questionnaire (MCQ), based on information in the TB manual. They were asked to complete the MCQ in their hospitals, using the manual, and return it within 6 weeks to the Central Unit. Thirty-one (70%) officers returned completed MCQs. There was negative marking for incorrect answers. The mean mark was 69%. Twelve (39%) officers scored 80% or higher and four (13%) scored below 50%. MCQ assessments may be a useful way of stimulating TB officers to read TB manuals and other guidelines.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 06/2004; 8(5):618-20. · 2.73 Impact Factor
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ABSTRACT: Following an operational research study in Zomba Central Prison, Malawi, in 1996, the National Tuberculosis Control Programme (NTP) and the Prison Medical Services worked together to improve the diagnosis and treatment of tuberculosis (TB) in prisoners. Prisoners are screened for TB on admission and during their prison sentences. A system was established of treating patients, according to NTP guidelines, while in prison and on discharge from prison. Monitoring and evaluation is undertaken using TB officers at district and regional level, and 6-monthly meetings are held with all stakeholders and the central unit to collate data and review prison TB control activities.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 06/2004; 8(5):614-7. · 2.73 Impact Factor
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ABSTRACT: All 44 non-private hospitals (four central, 22 district and 18 mission) in Malawi that registered and treated tuberculosis (TB) cases, October-December 2001.
To determine, in new smear-positive pulmonary tuberculosis (PTB) patients, for the 2-, 5- and 7-month smear examinations, 1) the proportion with smears examined and 2) the actual timing of smear examination.
Retrospective data collection using TB registers, TB treatment cards and laboratory sputum registers. Timing of smear examinations was judged acceptable if 2-month smears were examined at 2 or 3 months, 5-month smears at 4, 5 or 6 months and 7-month smears at 6, 7, 8 or 9 months.
Of 1994 patients, for those alive and on treatment, 78% had smears definitely examined at 2 months, 75% at 5 months and 74% at 7 months. Of these, 82% had smears examined at an acceptable time for the 2-month smear, 71% for the 5-month smear and 78% for the 7-month smear. Smears were examined after the 8-month treatment regimen for the 2- and 5-month smear in respectively 2% and 9% of patients. Smears were done more frequently in female than male patients, and in district/mission hospitals than central hospitals. Smears were done at acceptable times more frequently in younger than older patients and in mission/central hospitals than district hospitals.
During supervision, the actual time of follow-up sputum smear examinations needs to be monitored more closely.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 05/2004; 8(4):440-4. · 2.73 Impact Factor
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ABSTRACT: A country-wide survey was carried out to assess the management of new smear-positive pulmonary TB (PTB) patients whose sputum smears were recorded as positive 5 months or later during treatment. During 2000 and 2001, there were 250 patients, of whom 161 (64%) had positive smears at 5 months and 89 at 7 months. Several inconsistencies and inadequacies in management were identified which need to be remedied: 7% of patients were assessed on one sputum specimen instead of two, and 17% on the basis of one positive smear result; 47% of patients with 5-month positive smears and 52% with 7-month positive smears had sputum smears examined too early or too late; 14% of patients with 5-month positive smears continued treatment, and over 60% of these were recorded as 'cured'.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 04/2004; 8(3):384-7. · 2.73 Impact Factor
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ABSTRACT: All non-private hospitals in Malawi that registered TB cases in 2001, during which there was a bus service for transporting sputum specimens to the Central Reference Laboratory (CRL) for mycobacterial culture and drug sensitivity testing (CDST).
To determine the performance of the system of collecting and processing sputum specimens from patients with recurrent smear-positive pulmonary TB through to CDST.
Structured interviews with TB Officers, and retrospective data collection using TB and laboratory registers.
There were 964 patients with recurrent smear-positive PTB. TB Officers took responsibility for collecting and transporting sputum to the CRL, and 73% reported using the bus service. Sputum specimens from 384 (40%) patients arrived at the CRL. Of these, 40% were found to have negative concentrated smears at the CRL, and 36% of specimen sets arriving at CRL were successfully cultured for DST. Most specimens had been collected after the start of anti-tuberculosis treatment. Although delays in collection adversely affected culture, only 43% of specimen sets collected on or before the first day of treatment yielded Mycobacterium tuberculosis.
Problems were identified at all stages of the system and strategies to remedy these are being put in place.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 03/2004; 8(2):204-10. · 2.73 Impact Factor
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ABSTRACT: All 43 non-private hospitals in Malawi, which registered TB cases between 1 July 1999 and 30 June 2000.
To determine 1) the characteristics, management and treatment outcome, 2) timing of the previous episode of TB, and 3) pattern of drug resistance in patients registered with recurrent smear-positive pulmonary TB.
Retrospective data collection using TB registers and laboratory culture and drug sensitivity registers.
There were 748 recurrent patients; data were available for 747. Of these, 487 (65%) successfully completed a re-treatment regimen, 185 (25%) died and the remainder had another outcome. Information about previous TB was recorded for 491 (66%) patients. In 286 (58%) there were 2 years or less between completing and re-starting treatment. Only 307 (41%) patients had sputum sent for culture and drug sensitivity tests. In 164 patients with cultures of Mycobacterium tuberculosis, 122 (81%) were fully sensitive, 25 (15%) had resistance to isoniazid and/or streptomycin, and 6 (4%) had resistance to isoniazid and rifampicin (MDR-TB).
Patients with recurrent TB had acceptable treatment outcomes, and most had fully sensitive organisms. Over half had recurrent TB 2 years or less after completing treatment. Ways to prevent recurrence need to be investigated and implemented in the field.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 11/2003; 7(10):948-52. · 2.73 Impact Factor
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ABSTRACT: All non-private hospitals in Malawi.
To determine 1) how many patients with pulmonary tuberculosis (PTB) exceed the maximum number of visits needed for registration as defined by the National Tuberculosis Control Programme, and 2) the factors associated with this delay.
Cross-sectional study interviewing hospitalised patients with new smear-positive and smear-negative PTB.
Of 380 patients with PTB admitted to the 44 hospitals visited between April and June 2002, 329 (212 smear-positive and 117 smear-negative PTB) were interviewed: 64 (30%) smear-positive PTB patients needed more than five visits, and 44 (37%) smear-negative PTB patients needed more than six visits before being registered and started on treatment. Factors associated with exceeding the maximum number of visits were the first visit being to a health centre, submission of > 1 set of sputum specimens, and > 1 course of antibiotics. The main consequence of exceeding the maximum number of visits was increased duration of cough and increased time spent at health facilities.
One third of patients exceed the maximum number of visits for registration of PTB. The main consequence of this is an increased duration of cough and an increased time spent at health facilities. Ways to reduce this delay need to be found.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 10/2003; 7(10):953-8. · 2.73 Impact Factor
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ABSTRACT: National Tuberculosis (TB) Control Programme (NTP) and College of Medicine (COM), Malawi.
To develop a TB/HIV module, incorporating TB control and the DOTS strategy, for 4th year medical undergraduates. To describe 1) the way in which the module was developed, 2) the contents and structure of the module, 3) the experience of teaching the module from 2000-2002, and d) the financial costs to the NTP.
A descriptive study.
The TB/HIV module, including the teaching manual, resource materials and undergraduate assessments, was developed between June and December 1999 by NTP, College of Medicine, interested stakeholders and an external consultant. The module was well received by medical undergraduates. Student knowledge, based on pre-module and post-module assessments, increased to satisfactory levels. Novel aspects of teaching, which included reading chapters in class followed by student-led knowledge reviews, modular assessments and using NTP staff as facilitators, were highly rated. The cost of developing the module was 14,070 US dollars, and the recurrent annual cost of teaching the module was 900 US dollars.
The results show that a national tuberculosis control programme can work effectively with an academic medical institution in teaching medical undergraduates the important principles of country-wide TB control.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 10/2003; 7(9):842-7. · 2.73 Impact Factor
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ABSTRACT: Five districts in Malawi.
A new oral anti-tuberculosis treatment regimen with different directly observed treatment (DOT) choices in the initial phase of treatment was introduced for new patients in the five districts. The objectives were to determine 1) the site of DOT during the initial phase of treatment, and 2) the effectiveness of the new regimen.
Prospective data collection on all tuberculosis (TB) patients registered in a phased approach between 1 July 1997 and 31 December 1998, including site of DOT option in initial phase of treatment, 2-month and 8-month treatment outcomes, 2-month sputum smear conversion in smear-positive pulmonary tuberculosis (PTB) patients and in-patient hospital bed days.
There were 6335 new patients: 2671 (42%) with smear-positive PTB, 2211 (35%) with smear-negative PTB and 1453 (23%) with extra-pulmonary TB. The site of the initial phase of treatment was determined in 5790 patients: 1759 (30%) received DOT from guardians, 1465 (25%) from a health centre, 753 (13%) as out-patients from the hospital TB ward and 1813 (32%) remained in hospital. Eight-month treatment completion was 67% for smear-positive PTB patients, 51% for smear-negative PTB patients and 56% for extra-pulmonary TB patients. Two-month outcomes and 8-month treatment outcomes for all out-patient sites of supervision were satisfactory, except that a higher proportion of smear-positive PTB patients under guardian DOT failed to smear convert at 2 months. Over two-thirds of patients received ambulatory treatment out of hospital during the initial phase.
The new treatment strategy, tested in five districts, was associated with a reduction in hospital bed days and satisfactory treatment outcomes. The results of these studies were vital in helping the National TB Control Programme make an informed decision about phased expansion of the strategy countrywide.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 10/2003; 7(9 Suppl 1):S38-47. · 2.73 Impact Factor
