Title: Improving diagnosis of presumptive TB in hospitalised patients in Malawi
Funder: The Academy of Medical Sciences

Abstract: TTuberculosis (TB) remains a leading cause for hospital admission and death in high HIV-prevalence countries in sub-Saharan Africa (SSA). Public health interventions have started to reduce community TB incidence, but TB symptoms and disease remain very common among hospital inpatients. Diagnostic capacity in health facilities in low-resource settings has been neglected, making assessment of presumptive TB challenging. There are concerns that empirical TB treatment (in the absence of positive TB tests) is increasing, driven by poor diagnostic capacity. The main aim of this study is to undertake preliminary work to inform further research to improve management and outcomes of tuberculosis patients by (a) providing high quality data on the epidemiology of presumptive TB in hospital inpatients in Malawi (HIV-positive and negative), and (b) generating pilot data to support diagnostic interventional studies. Firstly, I will conduct a cross-sectional survey of diagnostic capacity in public sector hospitals in Malawi, and compare this to the World Health Organization essential diagnostics list. Secondly, I will analyse existing data from an electronic medical record system for inpatients at a large urban hospital in Malawi, and combine this with community TB notification and surveillance data to understand trends in microbiologically-confirmed and empirical TB treatment over the last decade. Thirdly, I will generate pilot data on the prevalence of TB and other key conditions (eg heart failure) in the differential diagnosis of TB in a study of presumptive TB through testing stored samples collected from an inpatient TB screening trial done in Malawi previously.

Lay abstract: Tuberculosis (TB) is a major public health problem in countries in sub-Saharan Africa where HIV infection is common. TB remains challenging to diagnose despite recent implementation of more accurate diagnostic tests. Therefore, it is common for clinicians to start TB treatment even in absence of positive tests (empirical treatment). There are concerns that as new TB cases in the community decline, there is over treatment of TB, especially in unwell patients presenting to hospital, which can cause harm. This may be driven by limited capacity to diagnose both TB and other non-TB conditions in hospitals. However, data on available diagnostic tests and trends in TB diagnosis and treatment over the last decade are scarce. In this project, I will collaborate with stakeholders in Malawi to map the availability of diagnostic tests in public-sector hospitals, and compare this to what is recommended by the World Health Organization’s ‘essential diagnostics’ list. I will also use data from an electronic patient record system at a large urban hospital and enhanced community TB surveillance system to describe trends in confirmed and un-confirmed TB over the last decade. Finally, I will investigate what other tests may be helpful to diagnose non-TB conditions in a small pilot study of patients admitted to hospital with symptoms of TB. The information collected will lay the groundwork for future research to improve the management and outcomes of patients admitted to hospital in sub Saharan-African countries.

Research activity codes: 4.1 DISCOVERY AND PRECLINICAL TESTING OF MARKERS AND TECHNOLOGIES
Health categories: INFECTION