title: Timing, rates, and causes of death in a large South African tuberculosis programme.
abstract: BACKGROUND
  Tuberculosis (TB) mortality remains high across sub-Saharan Africa despite integration of TB and HIV/ART programmes. To inform programme design and service delivery, we estimated mortality by time from starting TB treatment.
  
  
  METHODS
  Routinely collected data on TB treatment, vital status, and the timing and causes of death, were linked to cardio-respiratory autopsy data, from 1995-2008, from a cohort of male platinum miners in South Africa. Records were expanded into person-months at risk (pm).
  
  
  RESULTS
  4162 TB episodes were registered; 3170 men were treated for the first time and 833 men underwent retreatment. Overall, 509 men died, with a case fatality of 12.2% and mortality rate of 2.0/100 pm. Mortality was highest in the first month after starting TB treatment for first (2.3/100 pm) and retreatment episodes (4.8/100 pm). When stratified by HIV status, case fatality was higher in HIV positive men not on ART (first episode 14.0%; retreatment episode 26.2%) and those on ART (12.0%; 22.0%) than men of negative or unknown HIV status (2.6%; 3.6%). Mortality was also highest in the first month for each of these groups. Mortality risk factors included older age, previous TB, HIV, pulmonary TB, and diagnostic uncertainty. The proportion of deaths attributable to TB was consistently overestimated in clinical records versus cardio-respiratory autopsy.
  
  
  CONCLUSIONS
  Programme mortality was highest in those with HIV and during the first month of TB treatment in all groups, and many deaths were not caused by TB. Resource allocation should prioritise TB prevention and accurate earlier diagnosis, recognise the role of HIV, and ensure effective clinical care in the early stages of TB treatment.
authors.affiliation: Research Department of Infection and Population Health, University College London, Mortimer Market Centre (off Capper St), London, WC1E6JB, UK. nigel.field@ucl.ac.uk.
authors.forename: Nigel
authors.initials: N
authors.lastname: Field
authors.affiliation: Research Department of Infection and Population Health, University College London, Mortimer Market Centre (off Capper St), London, WC1E6JB, UK. lim@burnet.edu.au.|Centre for Population Health, Burnet Institute, Melbourne, Australia. lim@burnet.edu.au.
authors.forename: Megan S C
authors.initials: MS
authors.lastname: Lim
authors.affiliation: National Institute for Occupational Health, National Health Laboratory Service and School of Public Health, University of the Witwatersrand, Johannesburg, South Africa. Jill.murray@telkomsa.net.
authors.forename: Jill
authors.initials: J
authors.lastname: Murray
authors.affiliation: Rustenburg Platinum Mines Limited, Rustenburg, South Africa. robdowdeswell@gmail.com.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Dowdeswell
authors.affiliation: Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK. judith.glynn@lshtm.ac.uk.
authors.forename: Judith R
authors.initials: JR
authors.lastname: Glynn
authors.affiliation: Research Department of Infection and Population Health, University College London, Mortimer Market Centre (off Capper St), London, WC1E6JB, UK. p.sonnenberg@ucl.ac.uk.
authors.forename: Pam
authors.initials: P
authors.lastname: Sonnenberg
mesh_terms: D000328:Adult; D000367:Age Factors; D023241:Antiretroviral Therapy, Highly Active; D002423:Cause of Death; D060085:Coinfection / Q000453:epidemiology / Q000401:mortality; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology / Q000401:mortality*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019233:Retreatment; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D013997:Time Factors; D014376:Tuberculosis / Q000453:epidemiology / Q000401:mortality; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy / Q000453:epidemiology / Q000401:mortality*