A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg in partial fulfilment of the requirements for the degree of Master of Public Health (Hospital Management) Johannesburg, August 2014 / Background Tuberculosis (TB) remains a major cause of disease and death worldwide. In 2008, South Africa ranked third in the world in terms of the total numbers of new TB cases. Little is known about the profile of TB deaths at individual hospital level. Hence, the aim of the study was to describe the profile of TB deaths in Charles Hurwitz TB Hospital for the period January to December 2007. Methods A descriptive study was done, based on retrospective record review of all patients who died between January and December 2007 at Charles Hurwitz TB Hospital, irrespective of the date of admission. The data was analysed using Microsoft Excel. Findings The mean age at death was 41 years (standard deviation =10.9 years). Less than half of deceased individuals were employed (43.4%), more than one third had a history of smoking (42%) and the majority had a history of alcohol consumption (60.5%). Almost three quarters of the patients (75.3%) were being treated for the first time. The majority (85.1%) of deceased patients tested for HIV were HIV positive, but only 23.3% of those referred for treatment were actually on ART, indicating missed opportunities in treatment and care at the hospital. Conclusion There is need for ongoing vigilance and training to ensure that TB hospitals and individual health care providers comply with the national quality of care and TB management standards, and that missed opportunities are eliminated to reduce avoidable TB deaths.

This research explored several adaptations to tuberculosis among the Indian population of Saskatchewan from 1926 to 1965 in order to demonstrate that this was an era in which disease played an significant role in the lives of the Indians. A broad ecological model' allowed for a variety of interactions to be explored. Within this framework, the study examined: the epidemiology and ecology of tuberculosis in the Saskatchewan Indian population; the development of health services to the Indians and the role of health services in the ecology of disease in this population; and the individual Indians' hospitalization and tuberculosis experience.<P> The epidemic of tuberculosis among the Indians of Saskatchewan began in the early 1880s. Rapidly assuming epidemic proportions, the death rate from tuberculosis among the Qu'Appelle Indians peaked in 1886 at a rate of 9,000 per 100,000. The death rate declined gradually after 1890 through the acquisition of population resistance and the elimination of the non-resistant families. The acute phase of the tuberculosis epidemic, characterized by extra-pulmonary disease in which the majority of cases terminated in a few months, lasted about two decades. Between 1907 and 1926, with gradually improving living conditions, continued acquisition of population resistance, but without application of any specific anti-tuberculosis measures, the death rate fell to 800 per 100,000.<p> Tuberculosis was endemic in the Saskatchewan Indian population by the beginning of the 1930s. Once endemic, the decline of the tuberculosis death rate continued to the end of the 1940s, without application of any specific anti-tuberculosis measures. By the time that specific measures were introduced, the death rate had declined to 417 per 100,000 in 1949. With the introduction of BCG vaccination and antimicrobial drug treatment, by 1959 the death rate declined to 39 per 100,000.<p> By the early 1960s tuberculosis mortality was successfully controlled in Saskatchewan, although death rates remained 15 times higher among the Indians. Tuberculosis morbidity continued to be a problem into the 1980s. In 1984, the incidence of tuberculosis was 21 times greater among the Indians than the corresponding rate in the non-Indian population.<p> Various environmental and cultural factors contributed to the Indian population's experiences with tuberculosis. The most important factor was the absence of population immunity. In addition, concentration of the population on reserves, the occurrence of intercurrent epidemics, sudden and dramatic dietary change, and lifestyle factors such as housing, sanitation and personal hygiene all contributed to incredibly high tuberculosis mortality in this population. The effect of medical care on the epidemiology of tuberculosis in the Saskatchewan Indians was not even considered in the preliminary analysis of the epidemic, because throughout the first several decades of the epidemic, no organized health services existed for the Indians.<p> In Saskatchewan, before World War II, medical services to the Indians were characterized by occasional surveys, the employment of part-time physicians, and health education through the distribution of circulars to Indian agents on health-related issues. Organized anti-tuberculosis programs which were developed in the years following the Second World War, in a large part, account for the dramatic decrease in the tuberculosis death rate in the province through the decade of the 1950s.<p> In the late 1940s, and throughout the 1950s and 1960s, most active Indian tuberculosis cases diagnosed in Saskatchewan were hospitalized for treatment. At least 10% of the Indian population of Saskatchewan received Indian hospital or sanatorium treatment throughout the first decade that those services were available to them.<p> Interviews conducted with fourteen Indian individuals who had been hospitalized for tuberculosis treatment provided two dichotomous perspectives on tuberculosis. Several individuals feared tuberculosis because of their familiarity with it in their families and on their reserves, however, most said that they knew tuberculosis, but they did not fear it. In terms of their knowledge about tuberculosis from a biomedical perspective, most had some idea of its symptomology although its specific etiology was not known. Most of the people interviewed appeared to understand the infectious nature of tuberculosis, however, their concern for their families may have stemmed from observations that tuberculosis was "in" particular families, not necessarily because they thought they could "give" tuberculosis to them. In terms of a perspective on the treatment of tuberculosis, most of the individuals interviewed were aware that hospital treatment was necessary. Archival sources and government annual reports, indicated that many Indians took a very active role in attending to their health needs. None of the individuals who were interviewed refused to go to the sanatorium, except for one woman who ran away several times. Most, however, planned their escape time after time. This suggests that their stay in the sanatorium and hospital may not have been of their own volition.<p> The most common and recurring theme that emerged from the interviews about life in the sanatoria or Indian hospital revolved around the structured, regimented nature of the treatment. Several individuals remembered quite vividly seeing other patients confined in strait jackets and body casts and distinctly remembered how strict the staff was with children.<p> While they were hospitalized, all of the individuals who were interviewed knew several other people who were being treated at the same time who were also their contemporaries from their own or surrounding reserves. All of the individuals also made several lasting friendships with people that they met while in the sanatorium. In addition, all, except for one young boy, were visited frequently by their families and friends. This indicates that the Indian people interviewed were not "isolated" from their families and friends for the duration of their treatment. Hospitalization, for those interviewed, was not a traumatic event because they had an extensive social network which enabled them to cope with the experience. In addition, because of the poor living conditions on many Indian reserves, a trip to the sanatorium or Indian hospital was a relief for some. Indian children in the sanatorium and hospital were given new clothes, toys, and books, and in some cases an education; things they did not get at home. One woman chose to remain in the sanatorium after her treatment regimen ended so that she could complete her education, something she could not do back at home in the north. Only one individual suggested that the experience was instrumental in determining the direction his future took.<p> In demonstrating that this was an era in which disease played a major role in the lives of the Indians, the epidemiology of tuberculosis in this population illustrated the pervasive influence that tuberculosis had on demographic and biological aspects of the population. The history of health services illustrated the role of medical intervention in the ecology of tuberculosis in this population. As a probe for behaviourial adaptations to disease on the individual level, the interviews contributed a human dimension to the study. To complete the picture of the role of disease in the lives of the Indians, the examination of the final component in adaptation, behaviourial adaptation to disease at the cultural level, is recommended.

This research explored several adaptations to tuberculosis among the Indian population of Saskatchewan from 1926 to 1965 in order to demonstrate that this was an era in which disease played an significant role in the lives of the Indians. A broad ecological model' allowed for a variety of interactions to be explored. Within this framework, the study examined: the epidemiology and ecology of tuberculosis in the Saskatchewan Indian population; the development of health services to the Indians and the role of health services in the ecology of disease in this population; and the individual Indians' hospitalization and tuberculosis experience.<P> The epidemic of tuberculosis among the Indians of Saskatchewan began in the early 1880s. Rapidly assuming epidemic proportions, the death rate from tuberculosis among the Qu'Appelle Indians peaked in 1886 at a rate of 9,000 per 100,000. The death rate declined gradually after 1890 through the acquisition of population resistance and the elimination of the non-resistant families. The acute phase of the tuberculosis epidemic, characterized by extra-pulmonary disease in which the majority of cases terminated in a few months, lasted about two decades. Between 1907 and 1926, with gradually improving living conditions, continued acquisition of population resistance, but without application of any specific anti-tuberculosis measures, the death rate fell to 800 per 100,000.<p> Tuberculosis was endemic in the Saskatchewan Indian population by the beginning of the 1930s. Once endemic, the decline of the tuberculosis death rate continued to the end of the 1940s, without application of any specific anti-tuberculosis measures. By the time that specific measures were introduced, the death rate had declined to 417 per 100,000 in 1949. With the introduction of BCG vaccination and antimicrobial drug treatment, by 1959 the death rate declined to 39 per 100,000.<p> By the early 1960s tuberculosis mortality was successfully controlled in Saskatchewan, although death rates remained 15 times higher among the Indians. Tuberculosis morbidity continued to be a problem into the 1980s. In 1984, the incidence of tuberculosis was 21 times greater among the Indians than the corresponding rate in the non-Indian population.<p> Various environmental and cultural factors contributed to the Indian population's experiences with tuberculosis. The most important factor was the absence of population immunity. In addition, concentration of the population on reserves, the occurrence of intercurrent epidemics, sudden and dramatic dietary change, and lifestyle factors such as housing, sanitation and personal hygiene all contributed to incredibly high tuberculosis mortality in this population. The effect of medical care on the epidemiology of tuberculosis in the Saskatchewan Indians was not even considered in the preliminary analysis of the epidemic, because throughout the first several decades of the epidemic, no organized health services existed for the Indians.<p> In Saskatchewan, before World War II, medical services to the Indians were characterized by occasional surveys, the employment of part-time physicians, and health education through the distribution of circulars to Indian agents on health-related issues. Organized anti-tuberculosis programs which were developed in the years following the Second World War, in a large part, account for the dramatic decrease in the tuberculosis death rate in the province through the decade of the 1950s.<p> In the late 1940s, and throughout the 1950s and 1960s, most active Indian tuberculosis cases diagnosed in Saskatchewan were hospitalized for treatment. At least 10% of the Indian population of Saskatchewan received Indian hospital or sanatorium treatment throughout the first decade that those services were available to them.<p> Interviews conducted with fourteen Indian individuals who had been hospitalized for tuberculosis treatment provided two dichotomous perspectives on tuberculosis. Several individuals feared tuberculosis because of their familiarity with it in their families and on their reserves, however, most said that they knew tuberculosis, but they did not fear it. In terms of their knowledge about tuberculosis from a biomedical perspective, most had some idea of its symptomology although its specific etiology was not known. Most of the people interviewed appeared to understand the infectious nature of tuberculosis, however, their concern for their families may have stemmed from observations that tuberculosis was "in" particular families, not necessarily because they thought they could "give" tuberculosis to them. In terms of a perspective on the treatment of tuberculosis, most of the individuals interviewed were aware that hospital treatment was necessary. Archival sources and government annual reports, indicated that many Indians took a very active role in attending to their health needs. None of the individuals who were interviewed refused to go to the sanatorium, except for one woman who ran away several times. Most, however, planned their escape time after time. This suggests that their stay in the sanatorium and hospital may not have been of their own volition.<p> The most common and recurring theme that emerged from the interviews about life in the sanatoria or Indian hospital revolved around the structured, regimented nature of the treatment. Several individuals remembered quite vividly seeing other patients confined in strait jackets and body casts and distinctly remembered how strict the staff was with children.<p> While they were hospitalized, all of the individuals who were interviewed knew several other people who were being treated at the same time who were also their contemporaries from their own or surrounding reserves. All of the individuals also made several lasting friendships with people that they met while in the sanatorium. In addition, all, except for one young boy, were visited frequently by their families and friends. This indicates that the Indian people interviewed were not "isolated" from their families and friends for the duration of their treatment. Hospitalization, for those interviewed, was not a traumatic event because they had an extensive social network which enabled them to cope with the experience. In addition, because of the poor living conditions on many Indian reserves, a trip to the sanatorium or Indian hospital was a relief for some. Indian children in the sanatorium and hospital were given new clothes, toys, and books, and in some cases an education; things they did not get at home. One woman chose to remain in the sanatorium after her treatment regimen ended so that she could complete her education, something she could not do back at home in the north. Only one individual suggested that the experience was instrumental in determining the direction his future took.<p> In demonstrating that this was an era in which disease played a major role in the lives of the Indians, the epidemiology of tuberculosis in this population illustrated the pervasive influence that tuberculosis had on demographic and biological aspects of the population. The history of health services illustrated the role of medical intervention in the ecology of tuberculosis in this population. As a probe for behaviourial adaptations to disease on the individual level, the interviews contributed a human dimension to the study. To complete the picture of the role of disease in the lives of the Indians, the examination of the final component in adaptation, behaviourial adaptation to disease at the cultural level, is recommended.

Many countries in the world record annual summary statistics such as economic indicators like Gross Domestic Product (GDP) and vital statistics for example the number of births and deaths. In this thesis we focus on mortality data from various causes including Tuberculosis (TB) and HIV. TB is an infectious disease caused by bacteria called Mycobacterium tuberculosis. It is the main cause of death in the world among all infectious diseases. An additional complexity is that HIV/AIDS acts as a catalyst to the occurrence of TB. Vaidyanathan and Singh revealed that people infected with mycobacterium tuberculosis alone have an approximately 10% life time risk of developing active TB, compared to 60% or more in persons co-infected with HIV and mycobacterium tuberculosis. South Africa was ranked seventh highest by the World Health Organization among the 22 TB high burden countries in the world and fourth highest in Africa. The research work in this thesis uses the 2007 Statistics South Africa (STATSSA) data on TB and HIV as the primary cause of death to build statistical models that can be used to investigate factors associated with death due to TB. Logistic regression, Survey Logistic regression and generalized linear models (GLM) will be used to assess the effect of risk factors or predictors to the probability of deaths associated with TB and HIV. This study will be guided by a theoretical approach to understanding factors associated with TB and HIV deaths. Bayesian modeling using WINBUGS will be used to assess spatial modeling of relative risk and spatial prior distributions for disease mapping models. Of the 615312 deceased, 546917 (89%) died from natural death, 14179 (2%) were stillborn and 54216 (9%) from non-natural death possibly accidents, murder, suicide. Among those who died from natural death and disease, 65052 (12%) died of TB and 13718 (2%) died of HIV. The results of the analysis revealed risk factors associated with TB and HIV mortality. / Thesis (M.Sc.)-University of KwaZulu-Natal, Pietermaritzburg, 2012.

Made available in DSpace on 2016-06-02T19:48:16Z (GMT). No. of bitstreams: 1 3355.pdf: 2544166 bytes, checksum: 3997021b81781769b20b68ba6a04ee9f (MD5) Previous issue date: 2010-10-22 / The area of the Regional Department of Health (DRS) III has been demonstrating that it possesses good indicators of life quality, besides a number of establishments of health that you/they overcome the average of the state. However, studies demonstrate that the reality of control of TB is far away from the established rates for the organs of health. The death for TB should be a rare event, some authorities of health have been recommending the establishment of a surveillance that qualifies the information through the verification of the death, using methods that identify diagnosis mistakes, what really appears not just for the characteristics of the lethality as a quality indicator and of the treatment opportunity, but it goes much beyond, with the observation of deaths non included previously. It was aimed at to characterize the epidemic profile of the cases of TB that you/they developed for death registered in DRS III of the state of São Paulo, in the period from 2006 to 2008. It was treated of a quantitative and descriptive exploratory study, in which the information of the database were used TBWeb and YES. In the YES, it was used CID regarding the definition of TB, that you/they are the classifications of A15.0 to A19.9. After the individual collection of each bank, the information were confronted for the possible identification of cases subnotificados or sub detected. The characterization of the profile epidemic of the cases of TBWeb identified that, of the 640 cases notified in the period, 22 developed for death, being these 82% of the masculine sex; the predominant age group was of 30-59 years, but with occurrences also among the ends of age, only that in smaller frequency; education from 4 to 7 years of studies; defined occupation as others e not specified in the system; it forms lung clinic in 95% of the cases; in discovery type, 45% happened in the service of Emergency, and the comorbidade alcoholism appeared in 45% of the cases. In the YES, they were identified 34 death declarations that contained as basic cause one of CID with definition of TB and similar occurrence was observed: the masculine sex presents larger acometimento (73,5%), with age group between 30 and 59 years and 91% of the deaths for TB happened in the hospitalar. In the confrontment of the data, he/she identified only 22 cases in common, and 11 were notified in TBWeb, but they were not in the YES and 12 were in the YES, but they consisted in TBWeb. This way, the total of deaths for TB of the area was of 45 cases. The analysis of the systems of information YES and TBWeb identified inconsistency of data pointing flaws in the completion of the same ones. The information disponibilizeds indicate the need of better qualification of the same ones, what can feel through the involved professionals' larger training, as well as for the establishment of periodic confrontments of data in search of possible mistakes. Although they are clear the limitations of the research, imposed partially by the quality of the data, the study made possible to know the profile of the population more reached by the disease and your possible tendencies. It is done necessary also to detach that these information cannot be considered in real time, because although the systems are on-line, it is observed that there is still delay in the flow of the information. / A região do Departamento Regional de Saúde (DRS) III tem demonstrado bons indicadores de qualidade de vida, além de um número de estabelecimentos de saúde que superam a média do estado. No entanto, estudos demonstram que a realidade de controle da tuberculose (TB) está longe das taxas estabelecidas pelos órgãos de saúde. E o óbito por TB que deveria ser um evento raro, vem sendo alvo de algumas autoridades de saúde que recomendam o estabelecimento de uma vigilância que qualifique a informação através da verificação desta ocorrência, baseando-se em métodos que identifiquem erros de diagnóstico, que aponte características da letalidade como um indicador de qualidade e da oportunidade de tratamento, além de possibilitar através da observação, identificar óbitos não inclusos anteriormente. Objetivou-se caracterizar o perfil epidemiológico dos casos de TB que evoluíram para óbito registrado no DRS III do estado de São Paulo, no período de 2006 a 2008. Tratou-se de um estudo exploratório quantitativo e descritivo, no qual foram utilizadas as informações do banco de dados TBWeb e SIM. No SIM, utilizou-se a CID referente à definição de TB, que são as classificações de A15.0 até A19.9. Após a coleta individual de cada banco, as informações foram confrontadas para a possível identificação de casos subnotificados. A caracterização do perfil epidemológico dos casos do TBWeb identificou que, dos 640 casos notificados no período, 22 evoluíram para óbito, sendo estes 82% do sexo masculino; a faixa etária predominante foi de 30-59 anos, mas com ocorrências também entre os extremos de idade, só que em menor frequência; escolaridade de 4 a 7 anos de estudos; ocupação definida como outras e não especificadas no sistema; forma clínica pulmonar em 95% dos casos; em tipo de descoberta, 45% ocorreram no serviço de Urgência/Emergência, e a comorbidade alcoolismo apareceu em 45% dos casos. No SIM, foram identificadas 34 declarações de óbito que continham como causa básica um das CID com definição de TB e observou-se ocorrência semelhante ao do TBWeb: o sexo masculino apresenta maior acometimento (73,5%), com faixa etária entre 30 e 59 anos e 91% dos óbitos por TB ocorreram no hospitalar. No confrontamento dos dados, identificou-se apenas 22 casos em comum, sendo que 11 estavam notificados no TBWeb, mas não estavam no SIM e 12 estavam no SIM, mas constavam no TBWeb. Desta forma, o total de óbitos por TB da região foi de 45 casos. A análise dos sistemas de informação SIM e TBWeb possibilitou identificar inconsistência de dados apontando falhas no preenchimento dos mesmos. As informações disponibilizadas indicam a necessidade de melhor qualificação das mesmas, o que pode se dar por meio de maior capacitação dos profissionais envolvidos, bem como pelo estabelecimento de confrontamentos periódicos de dados em busca de possíveis erros. Embora fiquem claras as limitações da pesquisa, impostas parcialmente pela qualidade dos dados, o estudo possibilitou conhecer o perfil da população mais atingida pela doença e suas possíveis tendências. Faz-se necessário também destacar que estas informações não podem ser consideradas em tempo real, pois embora os sistemas sejam on-line, observa-se que há ainda atraso no fluxo da informação.