Herbal drugs have been used since ancient times as medicines for the treatment of a wide range of diseases, for both human and livestock. A study conducted in the Lake Victoria Basin Kenya revealed vast knowledge and reliance on traditional medicine as a source of healthcare. The study documented 34 medicinal plant species distributed among 21 botanical families and 34 genera, used in the management of human ailments. The highest numbers of species were from the families Asteraceae and Leguminosae. The most commonly harvested plant parts were leaves (46.51%) and roots (34.88%). The most common growth forms utilised were herbs (40.54%) followed by shrubs (27.03%). The major methods of herbal drug preparation were concoction (31.03%) and decoction (24.14%) administered mainly through oral and dermal routes, (64.29%) and (32.14%) respectively. The use of herbal drugs as mixtures was reported to be a common practice by the herbal practitioners; 57.14% of the preparations were dispensed as mixtures while 42.86% of the preparations composed of single plants. A rich knowledge of medicinal plants was recognized and phytochemical and bioactivity analyses of these herbal plants are recommended to determine their safety and efficacy.

Background

The objective of this study was to establish 1) the performance of chest X-ray (CXR) in all suspects of tuberculosis (TB), as well as smear-negative TB suspects and 2) to compare the cost-effectiveness of the routine diagnostic pathway using Ziehl-Neelsen (ZN) sputum microscopy followed by CXR if case of negative sputum result (ZN followed by CXR) with an alternative pathway using CXR as a screening tool (CXR followed by ZN).

Methods

From TB suspects attending a chest clinic in Nairobi, Kenya, three sputum specimens were examined for ZN and culture (Lowenstein Jensen). Culture was used as gold standard. From each suspect a CXR was made using a four point scoring system: i: no pathology, ii: pathology not consistent for TB, iii: pathology consistent for TB and iv: pathology highly consistent for TB. The combined score i + ii was labeled as "no TB" and the combined score iii + iv was labeled as "TB". Films were re-read by a reference radiologist. HIV test was performed on those who consented. Laboratory and CXR costs were used to compare for cost-effectiveness.

Results

Of the 1,389 suspects enrolled, for 998 (72%) data on smear, culture and CXR was complete. 714 films were re-read, showing a 89% agreement (kappa value = 0.75 s.e.0.037) for the combined scores "TB" or "no-TB". The sensitivity/specificity of the CXR score "TB" among smear-negative suspects was 80%/67%. Using chest CXR as a screening tool in all suspects, sensitivity/specificity of the score "any pathology" was 92%, respectively 63%. The cost per correctly diagnosed case was for the routine process $8.72, compared to $9.27 using CXR as screening tool. When costs of treatment were included, CXR followed by ZN became more cost-effective.

Conclusion

The diagnostic pathway ZN followed by CXR was more cost-effective as compared to CXR followed by ZN. When cost of treatment was also considered CXR followed by ZN became more cost-effective. The low specificity of chest X-ray remains a subject of concern. Depending whether CXR was performed on all suspects or on smear-negative suspects only, 22%–45% of patients labeled as "TB" had a negative culture. The introduction of a well-defined scoring system, clinical conferences and a system of CXR quality control can contribute to improved diagnostic performance.