title: Inaccuracy of death certificate diagnosis of tuberculosis and potential underdiagnosis of TB in a region of high HIV prevalence.
abstract: Despite the South African antiretroviral therapy rollout, which should reduce the incidence of HIV-associated tuberculosis (TB), the number of TB-attributable deaths in KwaZuluNatal (KZN) remains high. TB is often diagnosed clinically, without microbiologic confirmation, leading to inaccurate estimates of TB-attributed deaths. This may contribute to avoidable deaths, and impact population-based TB mortality estimates.
  
  
  OBJECTIVE
  (1) To measure the number of cases with microbiologically confirmed TB in a retrospective cohort of deceased inpatients with TB-attributed hospital deaths. (2) To estimate the rates of multi-drug resistant (MDR) and extensively drug resistant (XDR) TB in this cohort.
  
  
  RESULTS
  Of 2752 deaths at EDH between September 2006 and March 2007, 403 (15%) were attributed to TB on the death certificate. 176 of the TB-attributed deaths (44%) had a specimen sent for smear or culture; only 64 (36%) had a TB diagnosis confirmed by either test. Of the 39 culture-confirmed cases, 27/39 (69%) had fully susceptible TB and 27/39 (69%) had smear-negative culture-positive TB (SNTB). Two patients had drug monoresistance, three patients had MDR-TB, and one had XDR-TB.
  
  
  CONCLUSIONS
  Most TB-attributed deaths in this cohort were not microbiologically confirmed. Of confirmed cases, most were smear-negative, culture positive and were susceptible to all first line drugs.
authors.affiliation: Division of Infectious Diseases, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada K1H 8L6. heresa.liu@queensu.ca
authors.forename: Theresa T
authors.initials: TT
authors.lastname: Liu
authors.forename: Douglas
authors.initials: D
authors.lastname: Wilson
authors.forename: Halima
authors.initials: H
authors.lastname: Dawood
authors.forename: D William
authors.initials: DW
authors.lastname: Cameron
authors.forename: Gonzalo G
authors.initials: GG
authors.lastname: Alvarez
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000008:administration & dosage / Q000627:therapeutic use; D058491:Bacterial Load; D018791:CD4 Lymphocyte Count; D060085:Coinfection; D003644:Death Certificates; D003951:Diagnostic Errors; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality; D015497:HIV-1; D006801:Humans; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012189:Retrospective Studies; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents