title: Performance of the new WHO diagnostic algorithm for smear-negative pulmonary tuberculosis in HIV prevalent settings: a multisite study in Uganda.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Reach Out Mbuya Parish HIV/AIDS Initiative, Kampala, Uganda.
authors.forename: Stella-Talisuna
authors.initials: ST
authors.lastname: Alamo
authors.forename: Setor
authors.initials: S
authors.lastname: Kunutsor
authors.forename: John
authors.initials: J
authors.lastname: Walley
authors.forename: Janine
authors.initials: J
authors.lastname: Thoulass
authors.forename: Morgan
authors.initials: M
authors.lastname: Evans
authors.forename: Simon
authors.initials: S
authors.lastname: Muchuro
authors.forename: Ahmed
authors.initials: A
authors.lastname: Matovu
authors.forename: Elly
authors.initials: E
authors.lastname: Katabira
mesh_terms: D000328:Adult; D000465:Algorithms; D015331:Cohort Studies; D005188:False Negative Reactions; D005260:Female; D015658:HIV Infections / Q000175:diagnosis*; D006801:Humans; D008297:Male; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D012423:Rural Health / Q000706:statistics & numerical data; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013183:Sputum / Q000382:microbiology; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis*; D014454:Uganda; D014504:Urban Health / Q000706:statistics & numerical data; D014944:World Health Organization