Local problems, local solutions: improving tuberculosis control at the district level in Malawi.
OBJECTIVE
To examine the causes of a low cure rate at the district level of a tuberculosis (TB) control programme and to formulate, implement, and evaluate an intervention to improve the situation.


METHODS
The study setting was Mzuzu (population 60,000), where the annual smear-positive pulmonary TB incidence was 160 per 100,000 and the human immunodeficiency virus (HIV) seroprevalence was 67% among TB patients. There is one TB treatment unit, but several other organizations are involved with TB control. An examination of case-holding activities was carried out, potential areas for improvement were identified, and interventions performed.


RESULTS
In 1990-91, the cure rate was 24% among smear-positive cases (29% among survivors to end of treatment). Problems identified included a fragmented TB control programme; inadequate training and supervision; suboptimal recording of patients' addresses; and nonadherence to national TB control programme protocols. These problems were addressed, and in 1992-93 the cure rate rose to 68% (relative risk (RR) = 2.85 (95% confidence interval (CI) = 1.63, 4.96)) and to 92% among survivors to the end of treatment (RR = 3.12 (95% CI = 1.84, 5.29)). High cure rates are therefore achievable despite high HIV prevalence.


CONCLUSIONS
Simple, inexpensive, local programmatic interventions can dramatically improve TB case holding. This study demonstrates the need for evaluation, training, and supervision at all levels of the programme.
Menzies School of Health Research Darwin, Australia, and St John's Hospital, PO Box 18, Mzuzu, Malawi. paulk@menzies.edu.au
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Kelly
D000995:Antitubercular Agents / Q000008:administration & dosage*; D015331:Cohort Studies; D003153:Community Health Services / Q000458:organization & administration*; D003150:Community Health Workers; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D015995:Prevalence; D015996:Survival Rate; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000453:epidemiology / Q000517:prevention & control; D014397:Tuberculosis, Pulmonary / Q000453:epidemiology / Q000517:prevention & control*
D000995:Antitubercular Agents