Incidence of smear-positive tuberculosis in Dabat, northern Ethiopia

OBJECTIVE

To determine the incidence of smear-positive tuberculosis (TB) in Dabat District, northern Ethiopia.

METHODS

Using a population-based longitudinal design, a TB surveillance system was initiated among 46,165 residents at the Dabat Health and Demographic Surveillance System site. Trained field workers visited each household every third month and interviewed all individuals aged ≥14 years using a uniform questionnaire to detect suspected cases of TB (cough ≥15 days), at which time two sputum (spot-morning) samples were collected for smear microscopy.

RESULTS

A total of 281,820 person-months were observed during the 1-year period, which generated 74 smear-positive TB cases. The incidence of smear-positive TB was calculated at 311 per 100,000 person-years (95%CI 240-382). Higher rates were observed among females (incidence rate ratio [IRR] 2.08, 95%CI 1.24-3.52), persons with no schooling (IRR 2.74, 95%CI 1.11-6.78) and urban residents (IRR 2.39, 95%CI 1.39-4.12).

CONCLUSION

The incidence of smear-positive TB is high in Dabat District, suggesting a high risk of transmission in the communities. TB control programmes thus need to improve case-finding mechanisms at the community level in Ethiopia, with greater emphasis on risk groups.

Once-daily initiation of basal insulin as add-on to metformin: a 26-week, randomized, treat-to-target trial comparing insulin detemir with insulin glargine in patients with type 2 diabetes

AIMS

This study assessed the efficacy and safety of once-daily insulin initiation using insulin detemir (detemir) or insulin glargine (glargine) added to existing metformin in type 2 diabetes (T2D).

METHODS

This 26-week, multinational, randomized, treat-to-target trial involved 457 insulin-naïve adults with T2D (HbA1c 7-9%). Detemir or glargine was added to current metformin therapy [any second oral antidiabetic drug (OAD) discontinued] and titrated to a target fasting plasma glucose (FPG) ≤90 mg/dl (≤5.0 mmol/l). Primary efficacy endpoint was change in HbA1c.

RESULTS

Mean (s.d.) HbA1c decreased with detemir and glargine by 0.48 and 0.74%-points, respectively, to 7.48% (0.91%) and 7.13% (0.72%) [estimated between-treatment difference, 0.30 (95% CI: 0.14-0.46)]. Non-inferiority for detemir at the a priori level of 0.4%-points was not established. The proportions of patients reaching HbA1c ≤ 7% at 26 weeks were 38% and 53% (p = 0.026) with detemir and glargine, respectively. FPG decreased ∼43.2 mg/dl (∼2.4 mmol/l) in both groups [non-significant (NS)]. Treatment satisfaction was good for both insulins. Hypoglycaemia, which occurred infrequently, was observed less with detemir than glargine [rate ratio 0.73 (95% CI 0.54-0.98)]. The proportions of patients reaching HbA1c ≤ 7% without hypoglycaemia in the detemir and glargine groups were 32% and 38% (NS), respectively. Weight decreased with detemir [-0.49 (3.3) kg] and increased with glargine [+1.0 (3.1) kg] (95% CI for difference: -2.17 to -0.89 kg).

CONCLUSION

While both detemir and glargine, when added to metformin therapy, improved glycaemic control, glargine resulted in greater reductions in HbA1c, while detemir demonstrated less weight gain and hypoglycaemia.

Dexamethasone blocks the migration of the human neuroblastoma cell line SK-N-SH

Glucocorticoids (Gc) influence the differentiation of neural crest-derived cells such as those composing sympathoadrenal tumors like pheochromocytomas, as well as neuroblastomas and gangliomas. In order to obtain further information on the effects of Gc on cells evolving from the neural crest, we have used the human neuroblastoma cell line SK-N-SH to analyze: 1) the presence and the binding characteristics of Gc receptors in these cells, 2) the effect of dexamethasone (Dex) on the migration of SK-N-SH cells, and 3) the effect of Dex on the organization of the cytoskeleton of SK-N-SH cells. We show that: 1) receptors that bind [(3)H]-Dex with high affinity and high capacity (Kd of 9.6 nM, Bmax of 47 fmol/mg cytosolic protein, corresponding to 28,303 sites/cell) are present in cytosolic preparations of SK-N-SH cells, and 2) treatment with Dex (in the range of 10 nM to 1 microM) has an inhibitory effect (from 100% to 74 and 43%, respectively) on the chemotaxis of SK-N-SH cells elicited by fetal bovine serum. This inhibition is completely reversed by the Gc receptor antagonist RU486 (1 microM), and 3) as demonstrated by fluorescent phalloidin-actin detection, the effect of Dex (100 nM) on SK-N-SH cell migration is accompanied by modifications of the cytoskeleton organization that appear with stress fibers. These modifications did not take place in the presence of 1 microM RU486. The present data demonstrate for the first time that Dex affects the migration of neuroblastoma cells as well as their cytoskeleton organization by interacting with specific receptors. These findings provide new insights on the mechanism(s) of action of Gc on cells originating in the neural crest.

Influence of Vitamin D Receptor Gene Polymorphisms on Secondary Hyperparathyroidism and Bone Density After Kidney Transplantation

Secondary hyperparathyroidism and immunosuppressive treatments are the most important pathogenetic factors for bone disease after kidney transplantation. The aim of study was to compare the influence of vitamin D receptor (VDR) genotype on the PTH level and bone mineral density (BMD) in 67 patients, including 45 immunosuppressed with cyclosporine (CsA) and 22 with tacrolimus (Tac) versus 147 healthy volunteers. Two VDR polymorphisms: BsmI and FokI were assayed with RFLP-PCR. Scantibodies were utilized to evaluate 1-84 PTH. BMD was measured by DEXA. Hormone levels were measured on the third day and sixth month after transplantation. BMD was examined at the third and ninth month. The distribution of FokI genotype differed, but the BsmI genotypes did not differ between the transplant patients and the control group. All transplanted patients showed an elevated tPTH at the first examination. The highest PTH values, which were observed in bb genotype, significantly decreased after the transplant procedure. Patients with the FF genotype who were treated with CsA showed higher levels of tPTH than those with the Ff genotype. At 6 months, a decrease in tPTH occurred in both the CsA and the Tac patients. A low BMD at the third month was more frequent among patients of the BB genotype treated with CsA. The Z-score remained low at the third month and at the ninth month. In conclusion, kidney graft recipients show overrepresentation of the Ff genotype. Our preliminary data suggest that the bb genotype exhibits a protective effect on bone loss after renal transplantation.

Dehydroepiandrosterone replacement in healthy men with age-related decline of DHEA-S: effects on fat distribution, insulin sensitivity and lipid metabolism

Many animal and human studies show that supraphysiological doses of dehydroepiandrosterone (DHEA) can influence body composition and carbohydrate and lipid metabolism. Most studies have concentrated on women and have not been randomized, thus creating controversial results. With this in mind, we designed a cross-over double-blind placebo-controlled study of 12 men aged 59.0 +/- 4.8 years, who received either 50 mg/24 h DHEA or placebo for 3 months to assess the influence of DHEA on the content and distribution of fat tissue and serum insulin, glucose, total cholesterol, low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol levels, as well as testosterone, estradiol, DHEA-sulfate (S), prostate-specific antigen (PSA) concentrations and indexes of insulin sensitivity and resistance. Patients were recruited from university employees attending for periodic health checks, with normal hepatic and renal function with endogenous DHEA-S level < 1500 ng/dl. Our results did not reveal any significant changes in study parameters, apart from a statistically significant increase in DHEA-S levels after therapy with active substance.

Influence of dietary and genetic factors on metabolic status in obese and lean postmenopausal women

This preliminary study addressed the possible associations between dietary, genetic and hormonal factors that are involved in the development of menopausal obesity and its metabolic consequences. We performed anthropometrical, hormonal and biochemical measurements and used a nutritional questionnaire on 43 postmenopausal women who were non-HRT-users (14 obese and 29 non-obese subjects, mean age +/- SD of 52.8 +/- 4.6 years, mean body mass 74.6 +/- 4.6 kg). All of the women also had fat mass assessed by DPX-Lunar. From the 24-h dietary recall, the nutrient intake in daily food rations was calculated using a computer program (Nutritionist IV, San Bruno, CA, USA) based on our own database. Restriction fragment length polymorphism of the estrogen-receptor-alpha gene was determined with the PvuII restriction enzyme. Obese women widely under-reported their daily food intake. The analysis of body fat distribution showed that the total body weight and the percentage of total fat mass were significantly increased in the obese group (p = 0.001). We observed significantly higher leptin (20.56 +/- 11.9 vs. 9.02 +/- 2.8 ng/ml) and total cholesterol (but lower cholesterol HDL), triglycerides levels in the obese subjects (261.89 +/- 48.8 vs. 248.23 +/- 55.9; 52.17 +/- 13.6 vs. 60.92 +/- 13.04; 142.82 +/- 61.02 vs. 106.61 +/- 27.7 mg/dl). Except for diastolic blood pressure, clinical variables were not significantly different between subjects with and without the PvuII ERalpha polymorphism. Allele frequencies of the ERalpha polymorphism did not differ from those previously reported (P-0.48, p-0.52) in our study. In this preliminary study we failed to find dietary and genetic factors involved in the pathogenesis of menopausal obesity. However, our results provide support for the notion that the perimenopausal increase in visceral fat is a significant factor involved in the increased cardiovascular risk in postmenopausal women.

Polish consensus: procedure in case of estrogen deficiency in women after breast cancer therapy

Women surviving breast cancer in the postmenopausal period suffer from hormonal alternations with adverse effect on mental status and functioning of a number of organs and systems. Two thirds of these women had menopause before the diagnosis of breast cancer. In the remaining one-third ovarian failure is natural or induced by chemotherapy. Doctors cautiously approach the use of estrogen therapy in this group of patients. Their fears are not unsupported bearing in mind known epidemiological data exist linking breast cancer with the use of hormonal therapy. The purpose of this review is to evaluate current data on hormonal use and breast cancer risk.

Sensitivity to anti-tuberculosis drugs in HIV-positive and -negative patients in Addis Ababa

A cross-sectional survey was conducted between 1 August and 31 December, 1998 in Addis Ababa, Ethiopia to determine the rate of primary drug resistance to anti-tuberculosis drugs and to investigate its possible association with HIV infection. Sputum culture, sensitivity to first-line anti-tuberculosis drugs and HIV testing were done for 236 sputum smear-positive pulmonary tuberculosis patients. Primary drug resistance level (single or multidrug resistance) had not changed significantly since 1994. Primary resistance occurred more often among HIV-positive than among HIV-negative patients. The association between drug resistance and HIV will have a serious impact in the control of tuberculosis because in recent years the prevalence of HIV has increased dramatically in Ethiopia. Therefore, further studies on drug resistance and HIV infection and the establishment of drug resistance surveillance are recommended.

A rapid survey to determine the prevalence of smear-positive tuberculosis in Addis Ababa

SETTING

Four kebeles (lowest administrative units) in a typical district of Addis Ababa, Ethiopia.

OBJECTIVE

To determine the prevalence of smear-positive pulmonary tuberculosis (TB) in an adult population by using a screening questionnaire and sputum examination.

DESIGN

A house-to-house visit was conducted. All those 14 years of age and above were screened for the presence of symptoms. Three sputum samples were collected from persons who had symptoms for acid-fast bacilli (AFB) examination.

RESULTS

A total of 12,149 individuals were screened, of whom 173 had symptoms suggestive of TB. Twenty-three were positive for AFB (189/100,000, 95% CI 112-267). No association was observed between smear positivity and socio-demographic factors. Only two of the 23 patients were on anti-tuberculosis treatment (8.7%, 95% CI 1.5-29.5).

CONCLUSION

This simple and cost-effective method provides a fairly realistic estimate of the prevalence of TB. Thus with further development of the method it can be used to monitor the progress of TB programmes in resource-poor settings.

Menopausal obesity--myth or fact?

Obesity, particularly with central fat distribution, and mortality from all causes are directly related in middle-aged women. Many studies have shown that women in their mid-life tend to gain weight, with a shift to visceral fat distribution. The etiology of perimenopausal obesity is not fully known, and it remains unclear whether excessive weight gain and changes in fat distribution at menopausal age result from climacteric changes or are related to the process of aging of the individual and/or to changing life-style factors. Obesity may have a genetic background. It is well established that an excessive amount of energy intake and too small an energy expenditure is crucial for the development of obesity. Diet composition also plays a role in the pathogenesis of obesity. Neuropeptides appear to be one of the factors that control food intake and nutrient balance. The aging process in women is associated with progressive declines in the levels of many hormones including estrogens, dehydroepiandrosterone (DHEA) and growth hormone-insulin-like growth factor I (GH-IGF-I). These endocrine perturbations may result in altered body composition and weight gain. Obesity in postmenopausal women is accompanied by many metabolic disturbances leading to increased mortality.

Small intestinal volvulus in Southern Ethiopia

BACKGROUND

Small intestinal volvulus (SIV) is a common surgical emergency encountered in many countries. It was reported as the most common cause of intestinal obstruction in the southern part of Ethiopia.

OBJECTIVE

This study was intended to evaluate the magnitude and treatment outcome of SIV in a rural hospital.

DESIGN

Retrospective study.

SETTING

A rural general hospital with 250 beds.

SUBJECTS

Ninety eight of 235 patients operated on for acute intestinal obstruction. There were 88 males and 10 females (age range of 16-65 years).

INTERVENTION

All patients who were operated on for acute intestinal obstruction during 1992-1996 were included.

MAIN OUTCOME MEASURES

Age of patients, duration of the illness and extent of the bowel involved, treatment, and complications were the main outcome measures.

RESULTS

Of the 235 patients with acute intestinal obstruction, 98 (41.7%) had SIV. The mean age was 34 years (range 16-65 years). The male to female ratio was 8.8:1.0. SIV occurred mostly among young adults most of whom were farmers. Postoperative complications occurred in 36 cases. The mortality rate was 13.3%, sepsis being the most frequent cause of death.

CONCLUSION

Small intestinal volvulus was the leading cause of intestinal obstruction in this series. Early diagnosis and prompt operative intervention minimises the morbidity and mortality rate.

Modified dexamethasone and gonadotropin-releasing hormone agonist (Dx-GnRHa) test in the evaluation of androgen source(s) in hirsute women

INTRODUCTION

Polycystic ovary syndrome (PCOS) and congenital adrenal hyperplasia (COH) are heterogeneous disorders, in which excess of androgens may be caused by improper function of ovaries and/or adrenals. In many cases an overlap between ovarian and adrenal type of functional hyperandrogenism has been observed. The relationship between adrenal and ovarian metabolism in hyperandrogenic women is not totally known and etiologic diagnosis of female hyperandrogenism is often difficult. The aim of the present study was to evaluate the usefulness of combined Dexamethasone-Triptoreline testing in distinguishing ovarian and adrenal type of functional hyperandrogenism, and checking if the test could be shortened in order to economise it.

MATERIALS AND METHODS

We have examined 57 women with androgen excess divided into two groups: ovarian (n = 42) and adrenal (n = 15) and 20 women with idiopathic hirsutism. There was also one patient suffering from Morris syndrome taken under examination just for curiosity. The blood for hormonal assay was taken in baseline conditions at 8.00 a.m. for LH, FSH, PRL, cortisol, T, DHEAS, 17OHP, E2. Dx was given for 4 days 0.5 mg p.o. every 6 hours. 8 hours after the last Dx administration, the blood was taken for 17OHP and T. Immediately after that Triptorelin 100 mg was given s.c. Then the blood was collected every 4 hours during 24 hours for 17OHP estimation.

RESULTS

Decrease in T levels (from 1.65 +/- 0.52 to 0.73 +/- 0.25 ng/ml) after Dexamethasone administration was observed in adrenal group, which indicates adrenal glands as a source of excessive androgen production. No significant differences were seen in ovarian group. But in women from ovarian group supranormal 17OHP response after Triptoreline administration was seen: (ng/ml): at 8.00 am-0.68 +/- 0.44, 12.00--1.21 +/- 0.7*, 16.00--1.71 +/- 1.19*, 20.00--2.39 +/- 1.81*, 24.00--3.41 +/- 2.64*, 4.00--3.91 +/- 2.82*, 8.00--6.06 +/- 2.43* (*p < 0.01, **p < 0.001). Such a response is typical for women with well defined PCOS and other forms of functional ovarian hyperandrogenism and indicates ovary as a source of androgens. Significant differences were also noticed in idiopathic group: 8.00--0.31 +/- 0.09, 12.00--0.38 +/- 0.17, 16.00--1.41 +/- 0.62*, 20.00--1.52 +/- 0.97*, 24.00--1.89 +/- 0.83*, 4.00--2.17 +/- 0.83*, 8.00--1.83 +/- 0.71** (*p < 0.01). 17OHP levels did not change significantly during the whole test in adrenal group: 8.00--1.83 +/- 1.24, 12.00--1.91 +/- 1.37, 16.00--1.95 +/- 0.86, 20.00--2.19 +/- 0.93, 24.00--2.63 +/- 1.58, 4.00--2.56 +/- 1.78, 8.00--237 +/- 0.94. But patients from this group had exaggerated 17OHP response to ACTH (from 4.32 +/- 1.31 to 15.34 +/- 4.1 ng/ml). In patient suffering from Morris syndrome, after Triptoreline, serum 17OHP levels reminded on the same level as they were before drug administration.

CONCLUSIONS

Combined Dx-Triptorelin test can be very useful to distinguish ovarian and adrenal type of functional hyperandrogenism. The number of times of blood collection for 17OHP can be reduced to 4 times a day (during 24 hours): at 8.00, 20.00, 24.00, 8.00.

Cold chain status at immunisation centres in Ethiopia

BACKGROUND

Child immunisation is among the most cost-effective ways of preventing premature child deaths, and the potency of vaccines, crucial for vaccine efficacy, is dependent on effective management of the cold chain at all levels of vaccine handling.

OBJECTIVE

To assess the status of the cold chain at peripheral vaccine stores in Ethiopia.

DESIGN

Institution based cross-sectional survey in two rural and one urban administrative areas were included in the study. Sixty seven health institutions providing static vaccination services were included in the study but cold chain system was assessed fully in only sixty four. Data were collected by interviewing health workers and by directly observing the cold chain equipment and records using structured forms.

RESULTS

Conditions of the cold chain system were described based on 64 of the 67 centres visited, three were excluded because of non-functioning cold chain. Complete temperature record was observed in 37 (57.8%) of the centres. Thermometer was not available in four (6.3%) and thermometer reading was found to be outside the optimal range in another seven (10.9%) centres. Vaccine storage in the refrigerator was not proper in 47 (73.4%) centres. Majority of the centres had neither trained personnel nor budget for maintenance of the cold chain.

CONCLUSION

There is a real danger of vaccines losing their potency at these centres even if they were potent on arrival. Relevant training for those handling the cold chain, improving the maintenance conditions of refrigerators and introduction of cold chain monitoring devises are recommended.

Influence of obesity and menopausal status on serum leptin, cholecystokinin, galanin and neuropeptide Y levels

Obesity occurs in 60% of women after menopause and is characterized by an excess of adipose tissue that depends on several orexigenic (neuropeptide Y (NPY) stimulates carbohydrate ingestion, galanin stimulates fat intake) and anorectic (leptin, cholecystokinin (CCK)) factors. Both leptin and insulin can reduce hypothalamic NPY production and secretion. Behavior related to the consumption of food is probably attributed to the NPY-galanin signalling route. We investigated basal levels of serum leptin, CCK, galanin and NPY in 16 non-obese premenopausal women, in 15 obese premenopausal women (body mass index (BMI) 34.6 +/- 1.3 SD) and in ten obese postmenopausal women (BMI 34.7 +/- 1.5 SD) to determine the relationship between obesity, menopause and these neuropeptides. Obese premenopausal women had three-fold elevations of serum leptin (32.1 +/- 3.2 ng/ml) in comparison to non-obese premenopausal women (10.3 +/- 1.5 ng/ml), but similar levels to those in obese postmenopausal women (35.3 +/- 4.1 ng/ml). In all 44 patients and in both sub-groups of premenopausal and postmenopausal women, serum leptin exhibited a strong positive correlation with BMI (r = 0.8692, p < 0.0001; r = 0.8803, p = 0.0001; r = 0.8184, p = 0.0001, respectively). Serum galanin values showed a statistically significant increment in the obese postmenopausal group (51.1 +/- 8.1 pg/ml) compared to both premenopausal groups: the non-obese (34.9 +/- 5.8 pg/ml) and the obese (36.0 +/- 5.5 pg/ml). Non-obese menstruating women demonstrated NPY levels (175.0 +/- 12.8 pg/ml) significantly higher than those of obese premenopausal women (126.0 +/- 12.1 pg/ml) and obese postmenopausal women (138.1 +/- 15.4 pg/ml). CCK values showed no differences between non-obese and obese pre- and postmenopausal groups. Basal insulin values were elevated in both obese groups compared to non-obese premenopausal women. Significantly increased leptin and galanin levels in postmenopausal obese women coupled with decreased NPY levels revealed some changes in the neuropeptides regulating eating behavior, which may be the reason for the onset of postmenopausal obesity.

Pattern of histopathologic diagnosis of lymph node biopsies in a teaching hospital in Addis Ababa, 1981-1990 G.C

To determine the pattern of diseases that are responsible for lymph node biopsy, a retrospective study was carried out by reviewing daily register and pathologic reports for surgical biopsy specimens for the year 1981-1990 in the Department of Pathology, Medical Faculty, Addis Ababa University. Among 33,924 biopsy specimens 3,396 (10%) were lymph node biopsies (1,378 females, 2018 males). The results showed that 57% were cervical, 15.17% axillary and 8.7% inguinal lymph nodes. The three main causes of lymphadenopathy were tuberculosis (47.8%), reactive lymphadenopathy (26.3%) and malignant lesions (19.8%). In general this study has shown that the majority of lymphadenopathies in patients under 40 years of age are mainly due to tuberculosis and non specific (reactive) lesions and we think this may serve as a basic information for clinicians in their daily activities.

Primary resistance to anti-tuberculosis drugs in Addis Ababa, Ethiopia

OBJECTIVE

To obtain current, representative information on current drug resistance patterns in Addis Ababa, Ethiopia.

DESIGN

A cross-sectional study whereby 167 isolates were tested for susceptibility to the anti-tuberculosis drugs commonly used in the country (isoniazid, thiacetazone, rifampicin, streptomycin and ethambutol). All hospitals, health centres and 6 of the 9 clinics in Addis Ababa were included in the study.

RESULT

Overall primary drug resistance was found to be 15.6% (26/167). Primary resistance to two or more drugs was 7.2% (12/167). The highest rate of primary resistance was to streptomycin (10.2%) followed by isoniazid (8.4%). Resistance to rifampicin was low (1.8%, 3/167) and to ethambutol nil. Multiple drug resistance in combinations with rifampicin was low.

CONCLUSION

To prevent further development and spread of resistance, universal use of standard treatment protocol, control of the circulation of anti-tuberculosis drugs, training of health workers, expansion of strictly supervised short-course treatment and establishing a nation-wide and regular surveillance system are recommended.

Kaposi's sarcoma diagnosed in the Department of Pathology, Addis Ababa University Medical Faculty: a 15 years retrospective review of biopsy results 1981-1994

This is a fifteen years' retrospective analysis of 37 kaposi's sarcoma cases diagnosed in the Department of Pathology, Addis Ababa University Medical Faculty between 1981-1994 G.C.. There were 12 female (32%) and 25 male (66%) patients. The median age was 35 years. There was a marked increase in 1994 when 14 cases (38%) were diagnosed. The most frequent site of the lesion is the lower extremeties followed by lymph nodes. The predominant histologic findings were spindle cell proliferation, vascular proliferation, extravasation and slit spaces. The authors believe that the finding of this study may serve as a base-line data for future studies.

Defaulting from tuberculosis treatment at the Addis Abeba Tuberculosis Centre and factors associated with it

A case control study among patients registered at the Addis Abeba Tuberculosis Centre was carried out from 1 September 1989 to 31 August 1990 to determine the rate of defaulting from treatment and to identify factors associated with it. The medical records of 1,206 new tuberculosis patients registered over the 12 month period were reviewed. A high rate of defaulting, 82%, was found. The rates of defaulting were higher in males, in the older age groups and in those living near to the TB centre. Most of the defaulting occurred in the third and fourth months of treatment. Social problems and feeling of improvement were the top two reasons for patients to default. A sample of the defaulters (cases) and the non-defaulters (controls) were then traced and interviewed. The two groups were compared by social, demographic and health variables. Inadequate knowledge, low educational level, nearer distance and negative attitude toward the TB Centre were found to be statistically significant predictors for defaulting p < 0.0001, p < 0.001, p < 0.001, and p < 0.05 respectively). These high rates of defaulting suggest important programme inadequacies and an urgent need for change. Therefore the introduction of an alternative national tuberculosis control programme with new strategies is recommended.