Performance of the new WHO diagnostic algorithm for smear‐negative pulmonary tuberculosis in HIV prevalent settings: a multisite study in Uganda

• Published in: Tropical medicine & international health 2012-07, Vol.17 (7), p.884-895
• Main Authors: Alamo, Stella‐Talisuna, Kunutsor, Setor, Walley, John, Thoulass, Janine, Evans, Morgan, Muchuro, Simon, Matovu, Ahmed, Katabira, Elly
• Format: Article
• Language: English
• Subjects: Adult; Algorithms; baciloscopia negativa; Bacterial diseases; Bacterial diseases of the respiratory system; Biological and medical sciences; Cohort Studies; diagnostic; diagnóstico; False Negative Reactions; Female; frottis négatif; General aspects; HIV Infections - diagnosis; HIV prevalent; Human bacterial diseases; Humans; Infectious diseases; Male; Medical sciences; Mycobacterium tuberculosis - isolation & purification; Predictive Value of Tests; prevalencia VIH; Prospective Studies; pulmonary tuberculosis; recursos limitados; Reproducibility of Results; resource limited; ressources limitées; Rural Health - statistics & numerical data; Sensitivity and Specificity; Severity of Illness Index; smear negative; Sputum - microbiology; tuberculose pulmonaire; Tuberculosis and atypical mycobacterial infections; tuberculosis pulmonar; Tuberculosis, Pulmonary - diagnosis; Uganda; Urban Health - statistics & numerical data; VIH répandue; World Health Organization
• ISSN: 1360-2276; 1365-3156
• DOI: 10.1111/j.1365-3156.2012.03003.x

Objective  To compare the performance of the new WHO (2007) diagnostic algorithm for pulmonary tuberculosis (PTB) in high HIV prevalent settings (WHO07) to the WHO 2003 guidelines used by the Ugandan National Tuberculosis Program (UgWHO03). Methods  A prospective observational cohort design was used at Reach Out Mbuya Parish HIV/AIDS Initiative, an urban slum community‐based AIDS Service Organisation (ASO) and Kayunga Rural District Government Hospital. Newly diagnosed and enrolled HIV‐infected patients were assessed for PTB. Research staff interviewed patients and staff and observed operational constraints. Results  WHO07 reduced the time to diagnosis of smear‐negative PTB with increased sensitivity compared with the UgWHO03 at both sites. Time to diagnosis of smear‐negative PTB was significantly shorter at the urban ASO than at the rural ASO (12.4 vs. 28.5 days, P = 0.003). Diagnostic specificity and sensitivity [95% confidence intervals (CIs)] for smear‐negative PTB were higher at the rural hospital compared with the urban ASO: [98% (93–100%) vs. 86% (77–92%), P = 0.001] and [95% (72–100%) vs. 90% (54–99%), P > 0.05], respectively. Common barriers to implementation of algorithms included failure by patients to attend follow‐up appointments and poor adherence by healthcare workers to algorithms. Conclusion  At both sites, WHO07 expedited diagnosis of smear‐negative PTB with increased diagnostic accuracy compared with the UgWHO03. The WHO07 expedited diagnosis more at the urban ASO but with more diagnostic accuracy at the rural hospital. Barriers to implementation should be taken into account when operationalising these guidelines for TB diagnosis in resource‐limited settings. Objectif:  Comparer les performances de nouvel algorithme de l’OMS (2007) pour le diagnostic de la tuberculose pulmonaire (TBP) dans les zones à forte prévalence du VIH (WHO07) aux directives de l’OMS 2003 utilisées par le Programme National Ougandais de la Tuberculose (UgWHO03). Méthodes:  Une étude de cohorte observationnelle prospective a été utilisée dans l’Initiative Reach Out VIH/SIDA de la paroisse de Mbuya, un Service d’Organisation contre le SIDA (ASO) en milieu urbain communautaire de bidonville et à l’Hôpital Rural Gouvernemental du District de Kayunga. Les personnes nouvellement diagnostiquées avec le VIH et inscrites, ont étéévaluées pour la TBP. Le personnel de recherche a interviewé les patients et le personnel, et a observé les contraintes opérationnelles. Résultats: