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Biomedical subjects

A D Harries

Publications and source records attributed to A D Harries.

At least 109 records · Page 6Linked to original sources
PubMed1998

An approach to the problems of diagnosing and treating adult smear-negative pulmonary tuberculosis in high-HIV-prevalence settings in sub-Saharan Africa.

The overlap between the populations in sub-Saharan Africa infected with human immunodeficiency virus (HIV) and Mycobacterium tuberculosis has led to an upsurge in tuberculosis cases over the last 10 years. The relative increase in the proportion of notified sputum-smear-negative pulmonary tuberculosis (PTB) cases is greater than that of sputum-smear-positive PTB cases. This is a consequence of the following: the association between decreased host immunity and reduced sputum smear positivity; the difficulty in excluding other HIV-related diseases when making the diagnosis of smear-negative PTB; and an increase in false-negative sputum smears because of overstretched resources. This article examines problems in the diagnosis and treatment of smear-negative PTB in high-HIV-prevalence areas in sub-Saharan Africa. The main issues in diagnosis include: the criteria used to diagnose smear-negative PTB; the degree to which clinicians actually follow these criteria in practice; and the problem of how to exclude other respiratory diseases that can resemble, and be misdiagnosed as, smear-negative PTB. The most important aspect of the treatment of smear-negative PTB patients is abandoning 12-month "standard" treatment regimens in favour of short-course chemotherapy. Operational research is necessary to determine the most cost-effective approaches to the diagnosis and treatment of smear-negative PTB. Nevertheless, substantial improvement could be obtained by implementing the effective measures already available, such as improved adherence to diagnostic and treatment guidelines.

AIDS-Related Opportunistic Infections↗
PubMed1998

Traditional healers and pulmonary tuberculosis in Malawi.

SETTING: Queen Elizabeth Central Hospital (QECH) and Blantyre district, Malawi. OBJECTIVE: To investigate the use that tuberculosis (TB) patients in Malawi make of traditional healers and traditional medicine. DESIGN: A questionnaire study was carried out on 89 smear-positive pulmonary TB patients admitted to QECH. Seven traditional healers in Blantyre were also interviewed about their knowledge, attitudes and practice of patients whom they considered to have TB. RESULTS: Of the 89 patients, 33 (37%) visited a traditional healer before seeking regular medical care. Patients spent a median length of 4 weeks with the traditional healer. During this time, 24 patients did not improve or deteriorated while on traditional treatment. No patient was referred to the medical services by the traditional healer. All traditional healers claimed to know about TB. Four said they would refer a patient to hospital if their treatment was not curative. In 1995, six traditional healers claimed to have cured 116 patients with TB. CONCLUSION: It is important to involve traditional healers in the educational activities of the National TB Control Programme. These healers need to be taught to recognise and refer patients with TB, whom they should not treat, but at the same time be encouraged to administer safe treatments for conditions which are more amenable to their practice.

Adult↗
PubMed1998

Safety in laboratories carrying out sputum smear microscopy: a dilemma for resource-poor countries.

Laboratory conditions and procedures for sputum smear microscopy (acid-fast bacilli) were assessed in 38 hospitals throughout Malawi. Of these, 17 (45%) had an area of less than 25 m2, eight (21%) had a separate room for tuberculosis work, and five (13%) had a safety cabinet. All laboratory personnel wore gloves, but in several hospitals there was no white coat, face mask, protective apron or soap for washing hands. Different disinfectants were used to clean work surfaces, only one laboratory decontaminated sputum specimens before disposal, and the laboratory cleaner was usually responsible for waste disposal. Laboratory conditions and safety procedures in Malawi are poor, indicating a need for education, training and supervision of staff.

Cytodiagnosis↗
PubMed1998

District sputum smear microscopy services in Malawi.

SETTING: Government hospitals and health centres in 23 districts in Malawi. OBJECTIVE: To determine 1) the number and smear-positivity rate of sputum samples submitted at health centres and hospitals, and 2) the time for sputum samples to get from health centres to smear examination. DESIGN: Prospective data collection on sputum specimens coming from health centres to hospital laboratories, and over the equivalent time period, retrospective data collection from laboratory sputum registers. RESULTS: Information was collected over a period of 5.6 months during 1997. Of 21 527 patients submitting sputum samples, 16995 (79%) were from within the hospital and 4532 (21%) were from health centres. Of 15 833 new TB suspects, 12 804 (81%) submitted sputum within the hospital and 3029 (19%) were from health centres. The overall smear-positivity rate was 11.9%: the proportion of new suspects who were smear-positive was significantly higher in health centres (14.1%) compared with hospital-based patients (11.4%, P < 0.05); 27% of all sputum specimens from health centres took 8 days or longer to get to smear examination. Sputum smears were positive from 1-30 days between submission and laboratory examination. CONCLUSION: Fewer sputum samples are submitted at health centres compared with hospitals, and there may be long delays between sputum submission and smear examination. The precise reasons are unclear, but health centre staff need training about the importance of timely case finding procedures.

Community Health Centers↗
PubMed1998

Management of pulmonary tuberculosis suspects with negative sputum smears and normal or minimally abnormal chest radiographs in resource-poor settings.

SETTING: Queen Elizabeth Central Hospital, Blantyre, Malawi. OBJECTIVES: 1) To determine the proportion of pulmonary tuberculosis (PTB) suspects with negative sputum smears and a normal/minimally abnormal chest radiograph (CXR) who are culture-positive for Mycobacterium tuberculosis, and 2) to determine how many develop smear or radiographic evidence of PTB (TB CXR) during follow-up. METHODS: PTB suspects with negative sputum smears and a normal/minimally abnormal CXR were given a second course of antibiotics and followed up at 3-week intervals over 3 months with repeat sputum smears and chest radiography. RESULTS: Of 79 patients (38 men and 41 women, mean age 33 years) with negative smears and a normal/minimally abnormal CXR, 16 (21%) were culture-positive for M. tuberculosis. Of 15 culture-positive patients who were alive and attended follow-up, seven (47%) developed a TB-CXR by 3 months. Of 41 culture-negative patients who were alive and attended follow-up, 13 (32%) developed a TB-CXR, including one patient who became sputum smear-positive. TB-CXRs were found only in patients with a cough. CONCLUSION: TB suspects with negative smears and normal/minimally abnormal CXRs in high human immunodeficiency virus (HIV) prevalent countries should be given a second course of antibiotics. If cough improves, patients can be advised not to return for further follow-up. If cough continues, patients should return for further follow-up with sputum smear examination and chest radiography. Approximately 50% of those who have culture-positive PTB will develop a TB-CXR by 3 months and can be identified if radiographic facilities are available.

Adult↗
PubMed1997

Tuberculosis in a prison population in Malawi.

BACKGROUND: Much concern has been expressed about the high prevalence of tuberculosis in prisons in industrialised countries. Since there is almost no information from developing countries, we investigated the rate of pulmonary tuberculosis in a large prison in Malawi. METHODS: Between May and July, 1996; we carried out an active case-finding survey in Zomba Central Prison, Malawi, through the National Tuberculosis Control Programme. We interviewed prisoners, and those with a cough of at least 1 week's duration were screened by sputum-smear microscopy. If microscopy was negative, prisoners underwent chest radiography. We offered HIV testing, with voluntary consent and counselling before and after tests, to all prisoners, whether positive or negative for pulmonary tuberculosis. FINDINGS: 914 (70%) of 1315 prisoners were screened (905 men, nine women; mean age 30 years [SD 11]). 47 (5%) screened prisoners (all men) had pulmonary tuberculosis: 14 were taking antituberculosis treatment and 33 were undiagnosed at the start of the study; 18 were sputum-smear positive and 15 were sputum-smear negative. 16 (73%) of 22 prisoners with previously undiagnosed pulmonary tuberculosis and 30 (75%) of 40 prisoners with cough but no evidence of pulmonary tuberculosis were HIV seropositive. In all prisoners, except one, symptoms of pulmonary tuberculosis had developed after they had entered prison. INTERPRETATION: We found a high rate of pulmonary tuberculosis in Zomba Central Prison, which suggests active transmission of tuberculosis. As a result of this study, the National Tuberculosis Control Programme has implemented interventions in eight prisons in Malawi to improve tuberculosis control, including collection of health data, education of prisoners and clinical staff about tuberculosis, active screening of prisoners for pulmonary tuberculosis by sputum-smear microscopy, and active case-finding in the prisons.

Adult↗
PubMed1997

Tuberculosis in Africa: clinical presentation and management.

In the last decade, sub-Saharan Africa has experienced an explosive increase in tuberculosis (TB) cases, largely as a result of the co-epidemic of human immunodeficiency virus (HIV) infection. This article reviews the essential background epidemiology of TB in sub-Saharan Africa. The clinical features and diagnostic problems of pulmonary/extrapulmonary TB in adults and children are discussed, particularly in relation to HIV infection. Different treatment regimens, their cost, adverse reactions, the ways in which HIV infection influences treatment response and the extent of drug resistance are reviewed. The recommended approaches to TB control in Africa, including methods used to prevent TB through Bacillus Calmette-Guerin and chemoprophylaxis are examined. The success achieved by good National TB Control Programmes in some African countries allows cautious optimism that this epidemic can be controlled.

Adult↗
PubMed1997

The scourge of HIV-related tuberculosis: a cohort study in a district general hospital in Malawi.

Malawi is similar to a number of other African countries in having an escalating, HIV-related, tuberculosis (TB) epidemic. A prospective study was carried out to determine the pattern of disease and HIV serostatus in unselected, adult, TB patients consecutively admitted to a large, district general hospital in Zomba (in the Southern region of Malawi). Clinical details were obtained, from the district TB register, for the 714, adult TB patients, aged > or = 15 years, who were registered with the district TB officer between 1 July and 31 December in 1995. Patients were counselled, and offered HIV testing using an ELISA and particle agglutination test. Concordant HIV-test results were available for 686 (96%) of the subjects: 547 (80%) of these were HIV-seropositive and 139 seronegative. The HIV-positive patients were significantly younger than the HIV-negative patients and significantly more HIV-positive patients were males (P < 0.05 for each). The proportions of HIV-positive subjects who were new patients, had been previously treated for TB, had pulmonary TB (PTB), had smear-positive PTB or had different types of extrapulmonary TB were similar to those of the HIV-negative. A high percentage of an unselected cohort of adult TB patients admitted to a district, general hospital in Malawi, particularly of the younger age groups was therefore HIV-positive. The pattern of disease was uninfluenced by the HIV serostatus. The large number of cases registered emphasises the severity of the current epidemic of TB in Malawi and its impact upon young adults.

AIDS-Related Opportunistic Infections↗
PubMed1997

The pattern of tuberculosis in Queen Elizabeth Central Hospital, Blantyre, Malawi: 1986-1995.

SETTING: Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi. OBJECTIVE: To determine the pattern of tuberculosis (TB) cases over a period of ten years. DESIGN: TB registers for QECH for the years 1986-1995 (January 1st to December 31st) were obtained and clinical information on the type of TB in each patient was recorded. Human immunodeficiency virus (HIV) test results of adults with smear-positive pulmonary TB (PTB) and children with TB between 1993 and 1996 were recorded from case notes. RESULTS: There were 19,377 TB cases, 10,982 men and 8,395 women, registered over the ten-year period. Of these, 4,691 (24%) cases were in children aged 0-14 years and 11,890 (61%) cases were in adults aged 15-44 years. The number of cases increased from 657 in 1986 to 2,734 in 1995, and the proportion of cases with extra-pulmonary TB (EPTB) rose from 11% in 1986 to 33% in 1995. The largest increase in cases was in children and in young adults aged 15-44 years. In all age groups, PTB was more common than EPTB. There were significant increases in the proportion of adult TB cases with pleural effusion. Of those who were tested, 72% of adults with smear-positive PTB and 64% of children with TB were found to be HIV-seropositive. CONCLUSION: There has been a dramatic increase in cases of TB and changes in disease pattern in QECH during the last 10 years, which is related to the HIV epidemic.

AIDS-Related Opportunistic Infections↗
PubMed1997

Tuberculous pericardial effusion: a prospective clinical study in a low-resource setting--Blantyre, Malawi.

SETTING: Queen Elizabeth Central Hospital, Blantyre, Malawi. OBJECTIVE: Review of clinical and investigation findings and outcome, using a standard management protocol, in human immunodeficiency virus (HIV)-positive and HIV-negative patients with tuberculous pericardial effusion, in a low-resource setting in sub-Saharan Africa. DESIGN: A prospective study under field conditions of adult patients with tuberculous pericardial effusion admitted to Queen Elizabeth Central Hospital between May 1993 and December 1994. RESULTS: In total 77 patients fulfilled the diagnostic criteria for tuberculous pericardial effusion. Of 74 patients sero-tested, 68 (92%) were HIV seropositive. Classical clinical features of pericardial effusion were often absent. Many patients had no other clinical features of HIV infection. Outcome compared favourably with quoted survival rates from the pre-HIV era. CONCLUSION: Tuberculous pericardial effusion is a common problem in Blantyre and is strongly associated with HIV infection. Successful management using a standard protocol is possible in a low-resource setting.

AIDS-Related Opportunistic Infections↗
PubMed1997

Practical and affordable measures for the protection of health care workers from tuberculosis in low-income countries.

With the global upsurge in tuberculosis (TB), fueled by the human immunodeficiency virus (HIV) pandemic, and the increase in multidrug-resistant TB, the condition has become a serious occupational hazard for health care workers worldwide. Much of the current understanding about nosocomial TB transmission stems from the USA; however, little is known about the risk of such transmission in low-income countries. The focus of this review is on sub-Saharan Africa, since this is the region with the highest TB incidence, the highest HIV incidence, the worst epidemic of HIV-related TB, and where the risk to health care workers is probably greatest. Measures used in industralized countries to control nosocomial TB transmission (ventilation systems, isolation rooms, personal protective equipment) are beyond the resources of low-income countries. Protecting health care workers in these settings involves practical measures relating to diagnosis and treatment of infectious cases; appropriate environmental control; and relevant personal protection and surveillance of health care workers. Research needs to be carried out to examine the feasibility and cost-effectiveness of measures such as voluntary HIV-testing of health care workers (to enable known HIV-positive health care workers to avoid high-risk settings) and isoniazid preventive therapy for workers in high-risk settings. More resources are also needed to ensure full implementation of currently recommended measures to decrease the risk of nosocomial and laboratory-acquired TB.

AIDS-Related Opportunistic Infections↗
PubMed1997

Case finding for pulmonary tuberculosis, Queen Elizabeth Central Hospital, Blantyre, Malawi.

SETTING: Queen Elizabeth Central Hospital, Malawi. OBJECTIVE: To evaluate the investigation of patients with cough who attend out-patient services and the adherence to recommended diagnostic protocols. DESIGN: Two operational studies in 1995: 1) an audit of management of patients presenting to non-fee-paying out-patient services (OPD) with cough, and 2) an audit of the laboratory sputum register and the OPD cough register. The annual number of out-patient attendances was also recorded. RESULTS: Of 2381 patients seen by OPD medical assistants, 438 (18.4%) complained of cough: 303 for < 3 weeks and 135 for > or = 3 weeks. Sputum smear examinations were requested in 97 patients, 79 (58.5%) with long duration and 18 (5.9%) with short duration of cough. Between May and December 1995, of the 1668 OPD patients who had sputum results in the laboratory register, 1392 (83%) had sputum results in the cough register. Of patients listed in the cough register, 98% collected their sputum smear results. In 1995, there were 395,439 OPD attendances; data extrapolation suggests that about 15,000 patients should have had sputum examined instead of the 2337 listed in the laboratory register. CONCLUSION: A large burden is imposed on out-patient services by patients with cough. Despite recommended protocols, this investigation suggests deficiencies in case detection which require further study.

Adult↗