Glynn J R, Warndorff D K, Fine P E, Munthali M M, Sichone W, Pönnighaus J M
London School of Hygiene and Tropical Medicine, England.
Bull World Health Organ. 1998;76(3):295-305.
Evaluation of disease outcome is central to the assessment of tuberculosis (TB) control programmes. In the study reported in this article we examined the factors influencing the measurement of outcome, survival rates during and after treatment, smear conversion rates, and relapse rates for patients diagnosed with TB in a rural area of Malawi between 1986 and mid-1994. Patients with less certain diagnoses of TB were more likely to die than those with confirmed TB, both among those who were seropositive and those who were seronegative to human immunodeficiency virus (HIV). The mortality rate among smear-positive patients with a separate culture-positive specimen was half that of patients with no such diagnostic confirmation. Patients not registered by the Ministry of Health had much higher mortality and default rates than did registered patients. Among smear-positive patients, HIV serostatus was the most important influence on mortality both during and after treatment (crude hazard ratios (95% confidence intervals) = 5.6 (3.0-10) and 7.7 (3.4-17), resp.), but HIV serostatus did not influence smear conversion rates. The initial degree of smear positivity influenced smear conversion rates, but not mortality rates. No significant predictors of relapse were identified. Unless considerable care is taken to include all TB patients, and to exclude nontuberculous patients, recorded TB outcome statistics are difficult to interpret and may be misleading. In populations with high rates of HIV infection, TB target cure rates of 85% are unrealistic. When new interventions are assessed it cannot be assumed that factors which influence the smear conversion rate will also influence the mortality rate.
疾病转归评估是结核病（TB）控制项目评估的核心。在本文报道的研究中，我们考察了1986年至1994年年中马拉维农村地区确诊为结核病的患者中，影响转归测量、治疗期间及治疗后的生存率、涂片转阴率和复发率的因素。在人类免疫缺陷病毒（HIV）血清学阳性和血清学阴性的患者中，结核病诊断不明确的患者比确诊为结核病的患者更易死亡。有单独培养阳性标本的涂片阳性患者的死亡率是没有此类诊断确认患者的一半。未在卫生部登记的患者的死亡率和失访率比登记患者高得多。在涂片阳性患者中，HIV血清学状态是治疗期间及治疗后死亡率的最重要影响因素（粗危险比（95%可信区间）分别为5.6（3.0 - 10）和7.7（3.4 - 17）），但HIV血清学状态不影响涂片转阴率。涂片阳性的初始程度影响涂片转阴率，但不影响死亡率。未发现复发的显著预测因素。除非格外小心地纳入所有结核病患者并排除非结核患者，否则记录的结核病转归统计数据难以解释且可能产生误导。在HIV感染率高的人群中，结核病目标治愈率达85%是不现实的。在评估新的干预措施时，不能假定影响涂片转阴率的因素也会影响死亡率。
