Nossal Institute for Global Health - Theses
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ItemEpidemiology of pulmonary tuberculosis in Beira city, Mozambique( 2011)Objectives: The present study had the following objectives: to identify risk factors associated with diagnostic and treatment delay and with poor treatment outcomes among patients with pulmonary tuberculosis; to describe the role of health workers in the management of patients with tuberculosis; and to describe the genotypic characteristics of Mycobacterium tuberculosis strains circulating among patients with pulmonary tuberculosis. Methods: The study was carried out in Beira city, Mozambique using a mix of quantitative and qualitative methods. The quantitative component was based on a consecutive cohort of newly registered pulmonary tuberculosis patients recruited from five diagnostic and treatment centres. Patients were included in the study if they were at least 18 years of age at enrolment and lived in Beira City. The qualitative study was carried out in one TB clinic and it was based on an ethnographic study of health workers. Results: TB delay was assessed in 774 patients. Total delay, defined as the sum of patient delay and health system delay, varied from 30 to 780 days and the median total delay for new smear-positive, new smear-negative and retreatment patients was 123, 180 and 150 days, respectively. The median patient delay for new smear-positive patients, new smear-negative patients and re-treatment patients was 56 days, 68 days and 58 days, respectively. The median health system delay for new smear-positive patients, new smear-negative patients and re-treatment patients was 52 days, 73 days and 65 days, respectively. Patient delay was associated with farming, visiting first a traditional healer, low TB knowledge and presence of a concomitant chronic disease. Health system delay was associated with multiple visits to primary health care facilities, farming and presence of a concomitant chronic disease. Age, negative sputum smear result and poor access to health services also played a role in total delay. The treatment outcomes of 843 patients were assessed. The treatment success rate for new smear-positive, new smear-negative and relapse patients was 91.4 percent, 95.5 percent and 82.0 percent, respectively. Male sex and HIV infection had a strong association with a poor treatment outcome and total delay was associated with an increased rate of death. The death rate for new smear-positive, new smear-negative and retreatment patients was 30, 23 and 34 per 100 000 population, respectively. The identification and characterization of genotype families was based on samples obtained from 67 patients. A method known as mycobacterial interspersed repeat units-variable number of tandem repeats was used and the results showed that the M. tuberculosis strains circulating in Beira city are a mix of ancestral and modern strains, with a predominance of the East African-Indian and Latin American families. Ancestral strains are characterized by the presence of the TbD1 region which is absent in the modern strain. Among both the ancestral and modern strains, a high genetic diversity was observed, suggesting that these strains have been in circulation in Beira city for a long period of time. This was the first study carried out in Mozambique that used an ethnographic approach to identify enabling factors and barriers to a successful management of TB patients. The study was based on participant observation of one TB clinic and interviews with seven key informants. The high level of organization of the TB clinic; the low level of perceived TB stigma; the presence of auxiliary workers; and the appropriateness of the TB messages provided to patients found in this study were considered enabling factors. Potential barriers included the presence of misconceptions related to TB; the difficulties in the classification of retreatment patients and management of side effects; treatment interruptions; the lack of clarity in relation to infection control measures; and the lost opportunity to screen TB patients for co-morbidities other than those related to HIV & AIDS. Conclusions: The TB programme in Beira city is strong and well organized and it has been very successful in treating patients. However, there is a need to implement interventions to reduce patient delay and to improve TB diagnosis at the health facility level, especially at the primary health care level.