- Email: [email protected]
Diagnosis of tuberculosis in Africa
CORRESPONDENCE
Diagnosis of tuberculosis in Africa Sir—The well-done and informative study about adult pneumonia in Kenya by J A G Scott and colleagues (April 18, p 1225)1 showed that patients with pulmonary tuberculosis can present with a short duration of illness. 8% of patients in the study who had had respiratory illness for less than 2 weeks were found to be smear positive for acid-fast bacilli (AFB) from sputum specimens. This result is similar to results obtained in Malawi where 6% of patients who had had a cough for less than 2 weeks had smear-positive pulmonary tuberculosis.2 In the Kenyan study, mycobacterial cultures were also done, and nearly 40% of patients with positive cultures had evidence of associated pneumococcal infection. This finding may explain reported observations that patients with pulmonary tuberculosis can improve temporarily on antibiotics,1,3,4 a factor which may lead to delays in diagnosis. The difficult question to answer in the real world of tuberculosis control in resource-poor countries in Africa, is how patients with pulmonary tuberculosis with short duration of illness are to be diagnosed. Scott and colleagues suggest that all patients with pneumonia should be screened for tuberculosis, and should have sputum cultures for Mycobacterium tuberculosis because sputum smears identified only half of the patients with tuberculosis in their study. Doing sputum cultures on all patients presenting with pnuemonia would be an impossible task for any tuberculosis control programme in sub-Saharan Africa. International guidelines recommend that sputum smears are done on those suspected as having tuberculosis who have a cough for more than 3 weeks.5 Doing sputum smears for patients with a short history of coughing would also place an intolerable burden on an already overstretched laboratory system. We suggest an alternative strategy. Patients with pneumonia should be treated with antibiotics, and those improving should be encouraged to go home. However, the development of recurrent cough should give cause for investigation for tuberculosis, usually with sputum-smear examination. Both patients and healthcare workers need to be made aware of this, and tuberculosis programmes should include this recommendation in their case-finding guidelines. There should be a lower threshold for carrying out relevant tuberculosis investigations in
2256
patients with pneumonia who are very sick, or in patients with a short duration of cough who present in closed institutions such as prisons. Early diagnosis of tuberculosis in such settings is crucual for transmission interruption, and in such situations sputum-smear examination in patients with a short history of coughing is justified. *Anthony Harries, Nicola Hargreaves, Julia Kemp, John Kwanjana, Felix Salaniponi *c/o British High Commission, PO Box 30042, Lilongwe 3, Malawi; and Programme Management Group, National TB Control Programme, Lilongwe, Malawi (e-mail: [email protected]) 1
2
3
4
5
Scott JAG, Hall AJ, Muyodi C, et al. Aetiology, outcome, and risk factors for mortality among adults with acute pneumonia in Kenya. Lancet 2000; 355: 1225–30. Banda HT, Harries AD, Welby S, et al. Prevalence of tuberculosis in TB suspects with short duration of cough. Trans Roy Soc Trop Med Hyg 1998; 92: 161–63. Wilkinson D, De Cock KM, Sturm A. Diagnosing tuberculosis in resource-poor setting: the value of a trial of antibiotics. Trans Roy Soc Trop Med Hyg 1997; 91: 422–24. Harries AD, Banda HT, Boeree MJ, et al. Management of pulmonary tuberculosis suspects with negative sputum smears and normal or minimally abnormal chest radiographs in resource-poor settings. Int J Tuberc Lung Disease 1998; 2: 999–1004. Enarson DA, Rieder HL, Arnadottir T, Trebucq A. Tuberculosis guide for low income countries, 4th end. International Union against Tuberculosis and Lung Disease: Paris, 1996.
Satisfying birthing experiences in Japan Sir—Until the mid-1950s most Japanese women delivered at home with the help of a community-based trained midwife. A rapid shift from home delivery occurred at the end of the 1950s, and now 95% of women in Japan give birth in hospital.1 Despite this shift, there are still about 300 active small birthing houses run by midwives in Japan. Most of these birthing houses are well respected by the local community, and women who use the services choose them because they like the quality of care offered. Staff at birthing houses are known for their respect of the physiological process that women go through during labour and for avoiding unnecessary medical interventions. We studied the quality of service at a birthing house located in Kobe city, Japan. This birthing house is a simple house-type establishment with minimum medical equipment. The birthing house follows a principle of
pursuing the fulfilment and empowerment of both women and staff. At this birthing house every woman is respected as an individual, and staff midwives fully commit themselves to accepting each woman as she is. Continuous care and emotional and psychological support during pregnancy, delivery, and postpartum are the essential components. Since 1974, the house has handled 998 births of which only 14% needed to be referred to hospitals. No maternal deaths or neonatal deaths have occurred during this period. We reviewed the experience of 175 women, who did self reports. Their reports are vivid and full of spiritual joy. 95% of the respondents expressed full satisfaction with their experience, more than 60% mentioned that they felt more confidence in themselves through their experience, and almost 50% stated that they felt a strong sense of compassion and sense of unity with the universe. The results showed that women who deliver in such birthing houses may have the chance to experience a dynamic spiritual state of their body leading them to a selftransforming experience. This insight gives us the chance to reconsider what birth means to a woman. WHO is considering making their definition of health: health is a dynamic state of complete physical, mental, spiritual and social well-being not merely the absence of disease or infirmity. We must look very carefully at what exactly the quality of a health service, leading to a real state of health, means. Women’s experiences from the birthing house we studied give us an example of a dynamic state of spiritual well-being. Are we in a new era of valuing community-based primary birthing centres rather than promoting institutional delivery? *Chizuru Misago, Takusei Umenai, Makiko Noguchi, Taeko Mori, Taneko Mori *Maternal and Child Health Improvement Project (Projeto LUZ), JICA/SESA, Av Almirante Barroso 600, 60060-440, Fortaleza, Ceara, Brazil; Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, UK; Department of Health Policy and Planning, School of International Health, University of Tokyo, Tokyo, Japan; and Mori Birthing Home, Kobe, Japan (e-mail: [email protected]) 1
Health and Welfare Statistics Association (Japan). Journal of Health and Welfare Statistics. Tokyo: Health and Welfare Statistics Association, 1999.
DEPARTMENT OF ERROR The ward—The Lancet wishes to make it clear that Gul Davis’ factional account, a contribution to our mini-series on violence (May 20, p 1809), is in no way related to the Reaside Clinic, Birmingham.
THE LANCET • Vol 355 • June 24, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
Diagnosis of tuberculosis in Africa Sir—The well-done and informative study about adult pneumonia in Kenya by J A G Scott and colleagues (April 18, p 1225)1 showed that patients with pulmonary tuberculosis can present with a short duration of illness. 8% of patients in the study who had had respiratory illness for less than 2 weeks were found to be smear positive for acid-fast bacilli (AFB) from sputum specimens. This result is similar to results obtained in Malawi where 6% of patients who had had a cough for less than 2 weeks had smear-positive pulmonary tuberculosis.2 In the Kenyan study, mycobacterial cultures were also done, and nearly 40% of patients with positive cultures had evidence of associated pneumococcal infection. This finding may explain reported observations that patients with pulmonary tuberculosis can improve temporarily on antibiotics,1,3,4 a factor which may lead to delays in diagnosis. The difficult question to answer in the real world of tuberculosis control in resource-poor countries in Africa, is how patients with pulmonary tuberculosis with short duration of illness are to be diagnosed. Scott and colleagues suggest that all patients with pneumonia should be screened for tuberculosis, and should have sputum cultures for Mycobacterium tuberculosis because sputum smears identified only half of the patients with tuberculosis in their study. Doing sputum cultures on all patients presenting with pnuemonia would be an impossible task for any tuberculosis control programme in sub-Saharan Africa. International guidelines recommend that sputum smears are done on those suspected as having tuberculosis who have a cough for more than 3 weeks.5 Doing sputum smears for patients with a short history of coughing would also place an intolerable burden on an already overstretched laboratory system. We suggest an alternative strategy. Patients with pneumonia should be treated with antibiotics, and those improving should be encouraged to go home. However, the development of recurrent cough should give cause for investigation for tuberculosis, usually with sputum-smear examination. Both patients and healthcare workers need to be made aware of this, and tuberculosis programmes should include this recommendation in their case-finding guidelines. There should be a lower threshold for carrying out relevant tuberculosis investigations in
2256
patients with pneumonia who are very sick, or in patients with a short duration of cough who present in closed institutions such as prisons. Early diagnosis of tuberculosis in such settings is crucual for transmission interruption, and in such situations sputum-smear examination in patients with a short history of coughing is justified. *Anthony Harries, Nicola Hargreaves, Julia Kemp, John Kwanjana, Felix Salaniponi *c/o British High Commission, PO Box 30042, Lilongwe 3, Malawi; and Programme Management Group, National TB Control Programme, Lilongwe, Malawi (e-mail: [email protected]) 1
2
3
4
5
Scott JAG, Hall AJ, Muyodi C, et al. Aetiology, outcome, and risk factors for mortality among adults with acute pneumonia in Kenya. Lancet 2000; 355: 1225–30. Banda HT, Harries AD, Welby S, et al. Prevalence of tuberculosis in TB suspects with short duration of cough. Trans Roy Soc Trop Med Hyg 1998; 92: 161–63. Wilkinson D, De Cock KM, Sturm A. Diagnosing tuberculosis in resource-poor setting: the value of a trial of antibiotics. Trans Roy Soc Trop Med Hyg 1997; 91: 422–24. Harries AD, Banda HT, Boeree MJ, et al. Management of pulmonary tuberculosis suspects with negative sputum smears and normal or minimally abnormal chest radiographs in resource-poor settings. Int J Tuberc Lung Disease 1998; 2: 999–1004. Enarson DA, Rieder HL, Arnadottir T, Trebucq A. Tuberculosis guide for low income countries, 4th end. International Union against Tuberculosis and Lung Disease: Paris, 1996.
Satisfying birthing experiences in Japan Sir—Until the mid-1950s most Japanese women delivered at home with the help of a community-based trained midwife. A rapid shift from home delivery occurred at the end of the 1950s, and now 95% of women in Japan give birth in hospital.1 Despite this shift, there are still about 300 active small birthing houses run by midwives in Japan. Most of these birthing houses are well respected by the local community, and women who use the services choose them because they like the quality of care offered. Staff at birthing houses are known for their respect of the physiological process that women go through during labour and for avoiding unnecessary medical interventions. We studied the quality of service at a birthing house located in Kobe city, Japan. This birthing house is a simple house-type establishment with minimum medical equipment. The birthing house follows a principle of
pursuing the fulfilment and empowerment of both women and staff. At this birthing house every woman is respected as an individual, and staff midwives fully commit themselves to accepting each woman as she is. Continuous care and emotional and psychological support during pregnancy, delivery, and postpartum are the essential components. Since 1974, the house has handled 998 births of which only 14% needed to be referred to hospitals. No maternal deaths or neonatal deaths have occurred during this period. We reviewed the experience of 175 women, who did self reports. Their reports are vivid and full of spiritual joy. 95% of the respondents expressed full satisfaction with their experience, more than 60% mentioned that they felt more confidence in themselves through their experience, and almost 50% stated that they felt a strong sense of compassion and sense of unity with the universe. The results showed that women who deliver in such birthing houses may have the chance to experience a dynamic spiritual state of their body leading them to a selftransforming experience. This insight gives us the chance to reconsider what birth means to a woman. WHO is considering making their definition of health: health is a dynamic state of complete physical, mental, spiritual and social well-being not merely the absence of disease or infirmity. We must look very carefully at what exactly the quality of a health service, leading to a real state of health, means. Women’s experiences from the birthing house we studied give us an example of a dynamic state of spiritual well-being. Are we in a new era of valuing community-based primary birthing centres rather than promoting institutional delivery? *Chizuru Misago, Takusei Umenai, Makiko Noguchi, Taeko Mori, Taneko Mori *Maternal and Child Health Improvement Project (Projeto LUZ), JICA/SESA, Av Almirante Barroso 600, 60060-440, Fortaleza, Ceara, Brazil; Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, UK; Department of Health Policy and Planning, School of International Health, University of Tokyo, Tokyo, Japan; and Mori Birthing Home, Kobe, Japan (e-mail: [email protected]) 1
Health and Welfare Statistics Association (Japan). Journal of Health and Welfare Statistics. Tokyo: Health and Welfare Statistics Association, 1999.
DEPARTMENT OF ERROR The ward—The Lancet wishes to make it clear that Gul Davis’ factional account, a contribution to our mini-series on violence (May 20, p 1809), is in no way related to the Reaside Clinic, Birmingham.
THE LANCET • Vol 355 • June 24, 2000
For personal use only. Not to be reproduced without permission of The Lancet.