Diagnosis of childhood tuberculosis in Malawi: an audit of hospital practice.

SETTING: All 44 non-private hospitals in Malawi that register and treat children with tuberculosis (TB). OBJECTIVE: To determine 1) clinical features and diagnostic practices in children registered with TB, and 2) the use of the WHO score chart in diagnosis. DESIGN: A cross-sectional study of all children aged 14 years or below in hospital receiving anti-tuberculosis treatment, using reviews of treatment cards, case files and chest X-rays and performing a clinical assessment. RESULTS: There were 150 children, 98 with pulmonary TB (PTB) and 52 with extra-pulmonary TB (EPTB). The median duration of illness was 8 weeks. Most patients had fever, no response to anti-malarial treatment and antibiotics, and 40% had a family history of TB. Nearly 45% had weight for age <60%. Diagnosis was mainly based on clinical features and radiography, with less than 10% having tuberculin skin tests or HIV serology, and very few having other sophisticated investigations. A WHO diagnostic score chart was used in 13 (9%) patients by hospital staff. An independent assessment by the study team found that 61% of patients had a score of 7 or more; this was higher in EPTB than PTB patients. CONCLUSION: Diagnostic practices in children with TB in Malawi are poor, and improvements should be made.