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An epidemic of tuberculosis in association with HIV, malnutrition and hyperinflation in Zimbabwe
Presented by Michael Silverman (Canada).
M. Silverman1, P. Thistle2, A. Jetha3, M. Sutter4, C. Norman3, A. Simor3, S. Bolotin5, L. Corbett6, L. Katumbe2
1University of Toronto, Infectious Diseases, Ajax, Canada, 2Howard Hospital, Glendale, Zimbabwe, 3University of Toronto, Toronto, Canada, 4University of Basel, Basel, Switzerland, 5Ontario Ministry of Health, Toronto, Canada, 6London School Hygiene and Tropical Medicine, Harare, Zimbabwe
Background: Zimbabwe is experiencing an economic crisis with resultant rapid decline in medical infrastructure. This is associated with a cholera epidemic, but the impact on tuberculosis (TB) and HIV prevalence is unknown.
Methods: Diagnoses of all outpatient visits to a rural Zimbabwean mission hospital have been prospectively recorded since Jan 1995. Data on all cases of tuberculosis (8,185), all outpatient diagnoses of nutritional diseases and national economic data between Jan 1995 and Dec 2008 were reviewed. All antenatal HIV test results between Aug 1999 and Dec 2008 (18,746, with 3,636 HIV positive) were reviewed.
Results: TB incidence rose gradually from 176/100,000 to 281/100,000 between 1995 and 2001 (p< 0.05), correlating with the rising HIV epidemic in Zimbabwe. There was a further rise in TB incidence to 426/100,000 with the onset of hyperinflation in 2001-2003 (p< 0.05). At the same time there were increased diagnoses of pellagra, kwashiorkor, and diarrheal illnesses (p< 0.01). TB incidence remained stable between 2003 and 2007, but rose a further 35% in 2008 (to 556/100,000, p< 0.01) even though there were no changes in TB testing or diagnostics. The TB incidence was seasonal, with lowest rates seen when food was plentiful (harvest time and for 3 months thereafter) and highest when food was scarce (P< 0.05). HIV prevalence in antenatal clinic patients fell between March 2001 (28.0%) and Dec 2008 (12.4%) (p< 0.01) despite stable high testing rates (>90%). 81.8% of TB cases tested in 2008 were HIV positive. TB drug sensitivity testing was not generally available but a single isolate sent for testing in 2008 was found to be MDR TB.
Conclusions: An ongoing epidemic of TB is occurring in this region of Zimbabwe. It is associated with hyperinflation, malnutrition and HIV. TB drug resistance may be a component of the problem. TB control programs must be urgently implemented.
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