Relapse and recurrent tuberculosis in the context of a National Tuberculosis Control Programme

The proportion of patients with recurrent tuberculosis (TB) is reported to be increased in TB patients with human immunodeficiency virus (HIV) infecti on after they have completed treatment. Despite rising HIV seroprevalence a mongst TB patients in Malawi, notifications of patients with relapse smear- positive pulmonary TB (PTB) and recurrent smear-negative TB have remained s table during the past 12 years. We suspected that patients with recurrent o r relapse TB were being missed under routine programme conditions. Forty-th ree hospitals in Malawi were visited in 1999, and TB inpatients who had bee n registered as 'new' cases in the TB register and treatment card were inte rviewed about previous episodes of TB. A previous history of TB was elicite d in 94 (7.5%) of 1254 patients who were being treated as new cases. Compar ed with patients with smear-positive PTB, a previous episode of TB was sign ificantly more common in patients with smear-negative PTB (OR 3.5, [95% CI 2.1-5.7], P < 0.001) and patients with extrapulmonary TB (OR 2.0, [95% CI 1 .1-3.7], P < 0.05). Of 94 patients with a previous episode of TB, 76 had co mpleted treatment and 18 had defaulted from treatment during this episode. Patients with recurrent or relapse TB are being incorrectly registered with in the Malawi TB Control Programme, and in the case of smear-positive PTB p atients this is associated with administration of incorrect treatment. Meas ures have been put in place to rectify the situation, and further operation al research is planned to monitor treatment outcomes of patients with recur rent smear-negative TB.