Performance of the new WHO diagnostic algorithm for smear-negative pulmonary tuberculosis in HIV prevalent settings: A multisite study in Uganda
Tropical Medicine and International Health
Reach Out Mbuya Parish HIV/AIDS Initiative, Kampala, Uganda; Nuffield Centre for International Health and Development, Institute of Health Sciences, Leeds University, Leeds, United Kingdom; Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom; Section of Population Health, College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, United Kingdom; Department of Infectious Diseases, Ninewells Hospital and Medical School, Dundee, United Kingdom; USAID/SUSTAIN Project/Intergrated Community Based Initiatives, Naguru, Kampala, Uganda; Kayunga District Hospital, Kayunga, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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. 28.5days, 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. © 2012 Blackwell Publishing Ltd.
accuracy assessment; algorithm; disease prevalence; guideline; hospital sector; human immunodeficiency virus; performance assessment; questionnaire survey; resource availability; respiratory disease; rural area; tuberculosis; urban area; World Health Organization; acquired immune deficiency syndrome; adult; algorithm; article; community care; diagnostic accuracy; female; follow up; health care personnel; human; Human immunodeficiency virus infection; Human immunodeficiency virus prevalence; intermethod comparison; interview; lung tuberculosis; major clinical study; male; observational study; practice guideline; prospective study; public hospital; rural area; sensitivity and specificity; sputum smear; Uganda; urban area; world health organization; world health organization diagnostic algorithm; Adult; Algorithms; Cohort Studies; False Negative Reactions; Female; HIV Infections; Humans; Male; Mycobacterium tuberculosis; Predictive Value of Tests; Prospective Studies; Reproducibility of Results; Rural Health; Sensitivity and Specificity; Severity of Illness Index; Sputum; Tuberculosis, Pulmonary; Uganda; Urban Health; World Health Organization; Uganda