Author Affiliations: Projecto de Saúde, Bandim (Drs Gustafson and Seng and Messrs Jensen and Aaby), and Hospital Raoul Follereau (Drs Gomes and Vieira), Bissau, Guinea-Bissau; Department of Epidemiology Research, Danish Epidemiology Science Centre, Statens Serum Institut, Copenhagen (Messrs Jensen and Aaby); IMEA/INSERM U88, Paris, France (Drs Seng and Samb); Swedish Institute for Infectious Disease Control, Karolinska Institute, Stockholm (Dr Norberg); and Department of Infectious Diseases, Malmö University Hospital, Malmö, Sweden (Drs Gustafson and Nauclér).
Section Editor: Annette Flanagin, RN, MA,
Managing Senior Editor.
Context Tuberculosis (TB) is an increasing global problem, despite effective
drug therapies. Access to TB therapy during conflict situations has not been
Objective To determine the effect of irregular TB treatment due to an armed conflict
in Guinea-Bissau, West Africa.
Design, Setting, and Patients Ongoing retrospective cohort study conducted in the capital city of
Bissau among 101 patients with TB who received irregular or no treatment during
the civil war (war cohort; June 7–December 6, 1998) and 108 patients
with TB who received treatment 12 months earlier (peace cohort; June 7–December
6, 1997) and comparison of an additional 42 patients who had completed treatment
before June 6, 1998, and 69 patients who had completed treatment before June
Main Outcome Measure Mortality rates, compared by irregular (war cohort) vs regular (peace
cohort) access to treatment, by intensive vs continuation phase of treatment,
and by those who had previously completed treatment for TB.
Results Irregular treatment was associated with an increased mortality rate
among patients with TB. The mortality rate ratio (MR) was 3.12 (95% confidence
interval [CI], 1.20-8.12) in the war cohort, adjusting for age, sex, human
immunodeficiency virus (HIV) infection, residence, and length of treatment.
Each additional week of treatment before the war started increased probability
of survival by 5% (95% CI, 0%-10%). In the intensive phase of treatment, the
adjusted MR was 3.30 (95% CI, 1.04-10.50) and in the continuation phase it
was 2.26 (95% CI, 0.33-15.34). Increased mortality among the war cohort was
most marked in HIV-positive patients, who had an adjusted MR of 8.19 (95%
CI, 1.62-41.25). Mortality was not increased in HIV-positive or HIV-negative
patients who had completed TB treatment when the war started.
Conclusions Interruption of treatment had a profound impact on mortality among patients
with TB during the war in Guinea-Bissau. Regular treatment for TB was associated
with significantly improved survival for HIV-infected individuals. In emergencies,
it is crucial to ensure availability of TB drugs.
Gustafson P, Gomes VF, Vieira CS, Jensen H, Seng R, Norberg R, Samb B, Nauclér A, Aaby P. Tuberculosis Mortality During a Civil War in Guinea-Bissau. JAMA. 2001;286(5):599-603. doi:10.1001/jama.286.5.599