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Longer hospital stay is associated with higher rates of tuberculosis-related morbidity and mortality within 12 months after discharge in a referral hospital in Sub-Saharan Africa

Nicola M Zetola123*, Nenad Macesic4, Chawangwa Modongo13, Sanghuk Shin5, Ronald Ncube6 and Ronald G Collman7

Author Affiliations

1 Division of Infectious Disease, University of Pennsylvania, Philadelphia, Pennsylvania, USA

2 University of Botswana Medical School, University of Botswana, Gaborone, Botswana

3 Botswana-UPenn Partnership, Gaborone, Botswana

4 Division of Infectious Diseases, University of Melbourne, Melbourne, Australia

5 School of Medicine, University of California, Los Angeles, USA

6 Botswana National TB Program, Gaborone, Botswana

7 Division of Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA

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BMC Infectious Diseases 2014, 14:409  doi:10.1186/1471-2334-14-409

An erratum was published for this article. It is available at the following link;

Published: 22 July 2014



Nosocomial transmission of pulmonary tuberculosis (PTB) is a problem in resource-limited settings. However, the degree of TB exposure and the intermediate- and long-term morbidity and mortality of hospital-associated TB is unclear. In this study we determined: 1) the nature, patterns and intensity of TB exposure occurring in the context of current TB cohorting practices in medical centre with a high prevalence of TB and HIV; 2) the one-year TB incidence after discharge; and 3) one-year TB-related mortality after hospital discharge.


Factors leading to nosocomial TB exposure were collected daily over a 3-month period. Patients were followed for 1-year after discharge. TB incidence and mortality were calculated and logistic regression was used to determine the factors associated with TB incidence and mortality during follow up.


1,094 patients were admitted to the medical wards between May 01 and July 31, 2010. HIV was confirmed in 690/1,094 (63.1%) of them. A total of 215/1,094 (19.7%) patients were diagnosed with PTB and 178/1,094 (16.3%) patients died during the course of their hospitalization; 12/178 (6.7%) patients died from TB-related complications. Eventually, 916 (83.7%) patients were discharged and followed for one year after it. Of these, 51 (5.6%) were diagnosed with PTB during the year of follow up (annual TB rate of 3,712 cases per 100,000 person per year). Overall, 57/916 (6.2%) patients died during the follow up period, of whom 26/57 (45.6%) died from confirmed TB. One-year TB incidence rate and TB-associated mortality were associated with the number of days that the patient remained hospitalized, the number of days spent in the cohorting bay (regardless of whether the patient was eventually diagnosed with TB or not), and the number and proximity to TB index cases. There was no difference in the performance of each of these 3 measurements of nosocomial TB exposure for the prediction of one-year TB incidence.


Substantial TB exposure, particularly among HIV-infected patients, occurs in nosocomial settings despite implementation of cohorting measures. Nosocomial TB exposure is strongly associated with one-year TB incidence and TB-related mortality. Further studies are needed to identify strategies to reduce such exposure among susceptible patients.

Tuberculosis; Transmission; Nosocomial; Infection control; HIV; Morbidity; Mortality