How can detection of infectious tuberculosis be improved? Experience in the Somali region of Ethiopia.

In early 1999, 48% of pulmonary tuberculosis (PTB) cases detected in the Somali region of Ethiopia were smear-positive. Actions at the laboratory level and peer-review of smear-negative PTB diagnoses were proposed. Clinicians knew, but did not adhere to, the algorithm recommended by the National Tuberculosis Programme for these diagnoses, partly due to the costs involved to patients. Challenging clinicians, in a non-threatening way, to become more clinically rigorous proved successful, and the proportion of smear-positive PTB increased to 65%. Operational research is needed to assess the feasibility of these widely-recommended smear-negative PTB diagnosis guidelines.