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Loveday M, Gandhi NR, Khan PY, Theron G, Hlangu S, Holloway K, Chotoo S, Singh N, Marais BJ. Critical assessment of infants born to mothers with drug resistant tuberculosis. EClinicalMedicine 2024; 76:102821. [PMID: 39290633 PMCID: PMC11405821 DOI: 10.1016/j.eclinm.2024.102821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 08/22/2024] [Accepted: 08/22/2024] [Indexed: 09/19/2024] Open
Abstract
Background There have been no detailed descriptions of infants born to mothers treated for drug resistant TB in pregnancy. Critical case history assessment is important to identify risks and guide clinical practice. Methods In a cohort of pregnant women with multidrug or rifampicin resistant (MDR/RR)-TB enrolled between 1 January 2013 and 31 December 2022, we followed mother-infant pairs until the infant was 12 months old. We performed critical case history assessments to explore potential mechanisms of Mycobacterium tuberculosis transmission to the infant, and to describe the clinical presentation and disease trajectories observed in infants diagnosed with TB. Findings Among 101 mother-infant pairs, 23 (23%) included infants diagnosed with TB disease; 16 were clinically diagnosed and seven had microbiological confirmation (five MDR/RR-TB, two drug-susceptible TB). A positive maternal sputum culture at the time of delivery was significantly associated with infant TB risk (p = 0.023). Of the 12 infants diagnosed with TB in the first three months of life, seven (58%) of the mothers were culture positive at delivery; of whom four reported poor TB treatment adherence. However, health system failures, including failing to diagnose and treat maternal MDR/RR-TB, inadequate screening of newborns at birth, not providing appropriate TB preventive therapy (TPT), and M. tuberculosis transmission from non-maternal sources also contributed to TB development in infants. Interpretation Infants born to mothers with MDR/RR-TB are at greatest risk if maternal adherence to MDR/RR-TB treatment or antiretroviral therapy (ART) is sub-optimal. In a high TB incidence setting, infants are also at risk of non-maternal household and community transmission. Ensuring maternal TB diagnosis and appropriate treatment, together with adequate TB screening and prevention in all babies born to mothers or households with TB will minimise the risk of infant TB disease development. Funding South African Medical Research Council.
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Affiliation(s)
- Marian Loveday
- HIV and Other Infectious Diseases Research Unit (HIDRU), South African Medical Research Council, Durban, South Africa
- CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Centre for Health Systems Research & Development, University of the Free State, South Africa
| | - Neel R Gandhi
- Rollins School of Public Health and Emory School of Medicine, Emory University, Atlanta, USA
| | - Palwasha Y Khan
- London School of Hygiene and Tropical Medicine, London, UK
- Africa Health Research Institute, Durban, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sindisiwe Hlangu
- HIV and Other Infectious Diseases Research Unit (HIDRU), South African Medical Research Council, Durban, South Africa
| | - Kerry Holloway
- King Dinuzulu Hospital Complex, Sydenham, Durban, South Africa
| | - Sunitha Chotoo
- King Dinuzulu Hospital Complex, Sydenham, Durban, South Africa
| | - Nalini Singh
- King Dinuzulu Hospital Complex, Sydenham, Durban, South Africa
| | - Ben J Marais
- WHO Collaborating Centre for Tuberculosis, Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia
- The Children's Hospital at Westmead, Sydney, NSW, Australia
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2
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Gichuhi HW, Magumba M, Kumar M, Mayega RW. A machine learning approach to explore individual risk factors for tuberculosis treatment non-adherence in Mukono district. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001466. [PMID: 37399173 DOI: 10.1371/journal.pgph.0001466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/05/2023] [Indexed: 07/05/2023]
Abstract
Despite the availability and implementation of well-known efficacious interventions for tuberculosis treatment by the Ministry of Health, Uganda (MoH), treatment non-adherence persists. Moreover, identifying a specific tuberculosis patient at risk of treatment non-adherence is still a challenge. Thus, this retrospective study, based on a record review of 838 tuberculosis patients enrolled in six health facilities, presents, and discusses a machine learning approach to explore the individual risk factors predictive of tuberculosis treatment non-adherence in the Mukono district, Uganda. Five classification machine learning algorithms, logistic regression (LR), artificial neural networks (ANN), support vector machines (SVM), random forest (RF), and AdaBoost were trained, and evaluated by computing their accuracy, F1 score, precision, recall, and the area under the receiver operating curve (AUC) through the aid of a confusion matrix. Of the five developed and evaluated algorithms, SVM (91.28%) had the highest accuracy (AdaBoost, 91.05% performed better than SVM when AUC is considered as evaluation parameter). Looking at all five evaluation parameters globally, AdaBoost is quite on par with SVM. Individual risk factors predictive of non-adherence included tuberculosis type, GeneXpert results, sub-country, antiretroviral status, contacts below 5 years, health facility ownership, sputum test results at 2 months, treatment supporter, cotrimoxazole preventive therapy (CPT) dapsone status, risk group, patient age, gender, middle and upper arm circumference, referral, positive sputum test at 5 and 6 months. Therefore, machine learning techniques, specifically classification types, can identify patient factors predictive of treatment non-adherence and accurately differentiate between adherent and non-adherent patients. Thus, tuberculosis program management should consider adopting the classification machine learning techniques evaluated in this study as a screening tool for identifying and targeting suited interventions to these patients.
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Affiliation(s)
- Haron W Gichuhi
- Department of Biostatistics and Epidemiology, Makerere University School of Public Health, Kampala, Uganda
| | - Mark Magumba
- Department of Information Systems, Makerere University College of Computing, and Information Science, Kampala, Uganda
| | - Manish Kumar
- Public Health Leadership Program, Gilling's School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Roy William Mayega
- Department of Biostatistics and Epidemiology, Makerere University School of Public Health, Kampala, Uganda
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Hassani S, Mohammadi Shahboulagi F, Foroughan M, Nadji SA, Tabarsi P, Ghaedamini Harouni G. Factors Associated with Medication Adherence in Elderly Individuals with Tuberculosis: A Qualitative Study. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2023; 2023:4056548. [PMID: 36937803 PMCID: PMC10017217 DOI: 10.1155/2023/4056548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/17/2022] [Accepted: 02/23/2023] [Indexed: 03/11/2023]
Abstract
Methods This qualitative study was conducted in two phases, using an integrative literature review and individual interviews. Studies were gathered without time restriction from MEDLINE databases, Institute for Scientific Information (ISI), Google Scholar, Scopus, and EMBASE, as well as national databases, including Scientific Information Database and Magiran. The findings of 38 studies that met the inclusion criteria were analyzed through the conventional content analysis method based on the ecological approach. After reviewing and forming the data matrix, purposive sampling was performed among healthcare professionals, elderly tuberculosis patients aged 60 and over, and family caregivers of elderly patients to conduct individual interviews. Data obtained from 20 interviews were analyzed using the directed content analysis method. After coding, the data from individual interviews were entered based on similarity and difference in the categories of data matrix obtained from the literature review. Results In general, the aforementioned codes were placed in four main categories, including individual factors (i.e., biological factors, affective-emotional factors, behavioral factors, cognitive factors, tuberculosis-related factors, and economic factors), interpersonal factors (i.e., patient's relationship with treatment team and family-related factors), factors related to healthcare service provider centers (i.e., medical centers' facilities and capacity building in healthcare service provider), and extraorganizational factors (i.e., social factors and health policymaking). Conclusion The results of this study showed that medication adherence in elderly patients with tuberculosis was a complex and multidimensional phenomenon. Therefore, society, policymakers, and healthcare providers should scrutinize the factors affecting medication adherence in this group of patients to plan and implement more effective interventions.
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Affiliation(s)
- Somayeh Hassani
- 1Iranian Research Center on Aging, University of Social Welfare and Rehabilitation Sciences (USWR), Tehran, Iran
| | - Farahnaz Mohammadi Shahboulagi
- 2Iranian Research Center on Aging, Nursing Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Mahshid Foroughan
- 1Iranian Research Center on Aging, University of Social Welfare and Rehabilitation Sciences (USWR), Tehran, Iran
| | - Seyed Alireza Nadji
- 3Virology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payam Tabarsi
- 4Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Gholamreza Ghaedamini Harouni
- 5Social Welfare Management Research Center, University of Social Welfare and Rehabilitation Sciences (USWR), Tehran, Iran
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Araia ZZ, Kibreab F, Kibrom AA, Mebrahtu AH, Girmatsion MG, Teklehiwet YW, Mesfin AB. Determinants of unsuccessful tuberculosis treatment outcome in Northern Red Sea region, Eritrea. PLoS One 2022; 17:e0273069. [PMID: 35969629 PMCID: PMC9377576 DOI: 10.1371/journal.pone.0273069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
Abstract
Background Eritrea has achieved the global target (90%) for tuberculosis (TB) treatment success rate. Though, events of unsuccessful TB treatment outcomes (death, treatment failure, lost to follow up and not evaluated) could lead to further TB transmission and the development of resistant strains. Hence, factors related to these events should be explored and addressed. This study aims to fill the gap in evidence by identifying the determinants of unsuccessful TB treatment outcomes in Eritrea’s Northern Red Sea region. Methods A retrospective cohort study was conducted in Eritrea’s Northern Red Sea region. Data collected using a data extraction tool was analyzed using Stata version 13. Frequencies, proportions, median and standard deviations were used to describe the data. Furthermore, univariable and multivariable logistic regression analysis were performed to determine the risk factors for unsuccessful TB treatment outcomes. Crude odds ratio (COR) and adjusted odds ratio (AOR) with their 95% confidence interval (CI) presented and p-value < 0.05 was considered statistically significant. Results Among 1227 TB patients included in this study, 9.6% had unsuccessful TB treatment outcomes. In multivariable logistic regression analysis, TB cases 55–64 years old (AOR: 2.75[CI: 1.21–6.32], p = 0.016) and those ≥ 65 years old (AOR: 4.02[CI: 1.72–9.45], p = 0.001) had 2.7 and 4 times higher likelihood of unsuccessful TB treatment outcome respectively. In addition, HIV positive TB patients (AOR: 5.13[CI: 1.87–14.06], p = 0.002) were 5 times more likely to have unsuccessful TB treatment outcome. TB treatment in Ghindae Regional Referral Hospital (AOR: 5.01[2.61–9.61], p < 0.001), Massawa Hospital (AOR: 4.35[2.28–8.30], p< 0.001) and Nakfa Hospital (AOR: 2.53[1.15–5.53], p = 0.021) was associated with 5, 4 and 2.5 higher odds of unsuccessful TB treatment outcome respectively. Conclusion In this setting, old age, HIV co-infection and health facility were the independent predictors of unsuccessful TB treatment outcome.
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Affiliation(s)
| | - Fitsum Kibreab
- Human Resource Development, Planning and Policy, Ministry of Health, Asmara, Eritrea
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5
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OUP accepted manuscript. J Pharm Pharmacol 2022; 74:905-917. [DOI: 10.1093/jpp/rgac004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/01/2022] [Indexed: 11/13/2022]
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Ragan EJ, Gill CJ, Banos M, Bouton TC, Rooney J, Horsburgh CR, Warren RM, Myers B, Jacobson KR. Directly Observed Therapy to Measure Adherence to Tuberculosis Medication in Observational Research: Protocol for a Prospective Cohort Study. JMIR Res Protoc 2021; 10:e24510. [PMID: 34132642 PMCID: PMC8277341 DOI: 10.2196/24510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/10/2021] [Accepted: 02/24/2021] [Indexed: 11/24/2022] Open
Abstract
Background A major challenge for prospective, clinical tuberculosis (TB) research is accurately defining a metric for measuring medication adherence. Objective We aimed to design a method to capture directly observed therapy (DOT) via mobile health carried out by community workers. The program was created specifically to measure TB medication adherence for a prospective TB cohort in Western Cape Province, South Africa. Methods Community workers collect daily adherence data on mobile smartphones. Participant-level adherence, program-level adherence, and program function are systematically monitored to assess DOT program implementation. A data dashboard allows for regular visualization of indicators. Numerous design elements aim to prevent or limit data falsification and ensure study data integrity. Results The cohort study is ongoing and data collection is in progress. Enrollment began on May 16, 2017, and as of January 12, 2021, a total of 236 participants were enrolled. Adherence data will be used to analyze the study’s primary aims and to investigate adherence as a primary outcome. Conclusions The DOT program includes a mobile health application for data collection as well as a monitoring framework and dashboard. This approach has potential to be adapted for other settings to improve the capture of medication adherence in clinical TB research. Trial Registration Clinicaltrials.gov NCT02840877; https://clinicaltrials.gov/ct2/show/NCT02840877
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Affiliation(s)
- Elizabeth J Ragan
- Section of Infectious Diseases, Boston Medical Center, Boston, MA, United States
| | - Christopher J Gill
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States
| | - Matthew Banos
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States
| | - Tara C Bouton
- Section of Infectious Diseases, Boston Medical Center, Boston, MA, United States
| | - Jennifer Rooney
- Section of Infectious Diseases, Boston Medical Center, Boston, MA, United States
| | - Charles R Horsburgh
- Section of Infectious Diseases, Boston Medical Center, Boston, MA, United States.,Department of Global Health, Boston University School of Public Health, Boston, MA, United States.,Departments of Epidemiology and Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Robin M Warren
- Department of Science and Innovation-The National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research and The South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa.,Division of Addiction Psychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Karen R Jacobson
- Section of Infectious Diseases, Boston Medical Center, Boston, MA, United States
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Temporal Factors and Missed Doses of Tuberculosis Treatment. A Causal Associations Approach to Analyses of Digital Adherence Data. Ann Am Thorac Soc 2021; 17:438-449. [PMID: 31860328 PMCID: PMC7175980 DOI: 10.1513/annalsats.201905-394oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rationale: Tuberculosis treatment lasts for 6 months or more. Treatment adherence is critical; regimen length, among other factors, makes this challenging. Globally, analyses mapping common types of nonadherence are lacking. For example, is there a greater challenge resulting from early treatment cessation (discontinuation) or intermittent missed doses (suboptimal dosing implementation)? This is essential knowledge for the development of effective interventions and more “forgiving” regimens, as well as to direct national tuberculosis programs. Objectives: To granularly describe how patients take their tuberculosis medication and the temporal factors associated with missed doses. Methods: The present study included patients with pulmonary tuberculosis enrolled in the control arm of a pragmatic, cluster-randomized trial in China of electronic reminders to improve treatment adherence. Treatment was the standard 6-month course (180 d), dosed every other day (90 doses). Medication monitor boxes recorded adherence (box opening) without prompting reminders. Patterns of adherence were visualized and described. Mixed-effects logistic regression models examined the temporal factors associated with per-dose suboptimal dosing implementation, adjusting for clustering within a participant. Cox regression models were used to examine the association between early suboptimal dosing implementation and permanent discontinuation. Results: Across 780 patients, 16,794 (23.9%) of 70,200 doses were missed, 9,487 of which were from suboptimal dosing implementation (56.5%). By 60 days, 5.1% of participants had discontinued, and 14.4% had discontinued by 120 days. Most participants (95.9%) missed at least one dose. The majority of gaps were of a single dose (71.4%), although 22.6% of participants had at least one gap of 2 weeks or more. In adjusted models, the initiation–continuation phase transition (odds ratio, 3.07 [95% confidence interval, 2.68–3.51]) and national holidays (1.52 [1.39–1.65]) were associated with increased odds of suboptimal dosing implementation. Early-stage suboptimal dosing implementation was associated with increased discontinuation rates. Conclusions: Digital tools provide an unprecedented step change in describing and addressing nonadherence. In our setting, nonadherence was common; patients displayed a complex range of patterns. Dividing nonadherence into suboptimal dosing implementation and discontinuation, we found that both increased over time. Discontinuation was associated with early suboptimal dosing implementation. These apparent causal associations between temporal factors and nonadherence present opportunities for targeted interventions. Clinical trial registered with the ISRCTN Registry (ISRCTN46846388).
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Tibble H, Flook M, Sheikh A, Tsanas A, Horne R, Vrijens B, De Geest S, Stagg HR. Measuring and reporting treatment adherence: What can we learn by comparing two respiratory conditions? Br J Clin Pharmacol 2020; 87:825-836. [PMID: 32639589 DOI: 10.1111/bcp.14458] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/02/2020] [Accepted: 06/24/2020] [Indexed: 01/03/2023] Open
Abstract
Medication non-adherence, defined as any deviation from the regimen recommended by their healthcare provider, can increase morbidity, mortality and side effects, while reducing effectiveness. Through studying two respiratory conditions, asthma and tuberculosis (TB), we thoroughly review the current understanding of the measurement and reporting of medication adherence. In this paper, we identify major methodological issues in the standard ways that adherence has been conceptualised, defined and studied in asthma and TB. Between and within the two diseases there are substantial variations in adherence reporting, linked to differences in dosing intervals and treatment duration. Critically, the communicable nature of TB has resulted in dose-by-dose monitoring becoming a recommended treatment standard. Through the lens of these similarities and contrasts, we highlight contemporary shortcomings in the generalised conceptualisation of medication adherence. Furthermore, we outline elements in which knowledge could be directly transferred from one condition to the other, such as the application of large-scale cost-effective monitoring methods in TB to resource-poor settings in asthma. To develop a more robust evidence-based approach, we recommend the use of standard taxonomies detailed in the ABC taxonomy when measuring and discussing adherence. Regimen and intervention development and use should be based on sufficient evidence of the commonality and type of adherence behaviours displayed by patients with the relevant condition. A systematic approach to the measurement and reporting of adherence could improve the value and generalisability of research across all health conditions.
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Affiliation(s)
- Holly Tibble
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.,Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Mary Flook
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.,Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK.,Health Data Research UK, London, UK
| | - Athanasios Tsanas
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.,Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Rob Horne
- Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK.,Centre for Behavioural Medicine, Department for Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Bernard Vrijens
- AARDEX Group, Seraing, Belgium.,Liège University, Liège, Belgium
| | - Sabina De Geest
- Institute of Nursing Science, University of Basel, Basel, Switzerland.,Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Helen R Stagg
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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Treatment Adherence Among Persons Receiving Concurrent Multidrug-Resistant Tuberculosis and HIV Treatment in KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr 2020; 82:124-130. [PMID: 31513073 DOI: 10.1097/qai.0000000000002120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Success in multidrug-resistant tuberculosis (MDR-TB) and HIV treatment requires high medication adherence despite high pill burdens, frequent adverse events, and long treatment duration, which may jeopardize adherence. We prospectively compared MDR-TB/HIV-coinfected persons to those with MDR-TB alone to determine the impact of concurrent treatment on adherence and outcomes. METHODS We assessed medication adherence monthly using 3-day recall, 30-day recall, and visual analog scale and examined adherence to monthly study visits (months 0-12). We determined the proportion of participants fully adherent (no reported missed doses) to MDR-TB vs. HIV treatment by each measure. We assessed the association of medication and clinic visit adherence with MDR-TB treatment success (cure or completion, 18-24 months) and HIV virologic suppression. RESULTS Among 200 patients with MDR-TB, 63% were women, median age was 33 years, 144 (72%) were HIV-infected, and 81% were receiving antiretroviral therapy (ART) at baseline. Adherence to medications (81%-98% fully adherent across all measures) and clinic visits (80% missed ≤1 visit) was high, irrespective of HIV status. Adherence to ART was significantly higher than to MDR-TB treatment by all self-reported measures (3-day recall: 92% vs. 84%, respectively; P = 0.003). In multivariable analysis, the adjusted risk ratio of unsuccessful MDR-TB treatment increased with every missed visit: 1.50, 2.25, and 3.37 for unsuccessful treatment, for 1, 2, and ≥3 missed visits. CONCLUSIONS Adherence to ART was higher than to MDR-TB treatment among persons with MDR-TB/HIV coinfection. Missed clinic visits may be a simple measure for identifying patients at risk of unsuccessful MDR-TB treatment outcome.
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Vo LNQ, Codlin AJ, Forse RJ, Nguyen HT, Vu TN, Van Truong V, Do GC, Nguyen LH, Le GT, Caws M. Tuberculosis among economic migrants: a cross-sectional study of the risk of poor treatment outcomes and impact of a treatment adherence intervention among temporary residents in an urban district in Ho Chi Minh City, Viet Nam. BMC Infect Dis 2020; 20:134. [PMID: 32050913 PMCID: PMC7017549 DOI: 10.1186/s12879-020-4865-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 02/10/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a major cause of avoidable deaths. Economic migrants represent a vulnerable population due to their exposure to medical and social risk factors. These factors expose them to higher risks for TB incidence and poor treatment outcomes. METHODS This cross-sectional study evaluated WHO-defined TB treatment outcomes among economic migrants in an urban district of Ho Chi Minh City, Viet Nam. We measured the association of a patient's government-defined residency status with treatment success and loss to follow-up categories at baseline and performed a comparative interrupted time series (ITS) analysis to assess the impact of community-based adherence support on treatment outcomes. Key measures of interest of the ITS were the differences in step change (β6) and post-intervention trend (β7). RESULTS Short-term, inter-province migrants experienced lower treatment success (aRR = 0.95 [95% CI: 0.92-0.99], p = 0.010) and higher loss to follow-up (aOR = 1.98 [95% CI: 1.44-2.72], p < 0.001) than permanent residents. Intra-province migrants were similarly more likely to be lost to follow-up (aOR = 1.86 [95% CI: 1.03-3.36], p = 0.041). There was evidence that patients > 55 years of age (aRR = 0.93 [95% CI: 0.89-0.96], p < 0.001), relapse patients (aRR = 0.89 [95% CI: 0.84-0.94], p < 0.001), and retreatment patients (aRR = 0.62 [95% CI: 0.52-0.75], p < 0.001) had lower treatment success rates. TB/HIV co-infection was also associated with lower treatment success (aRR = 0.77 [95% CI: 0.73-0.82], p < 0.001) and higher loss to follow-up (aOR = 2.18 [95% CI: 1.55-3.06], p < 0.001). The provision of treatment adherence support increased treatment success (IRR(β6) = 1.07 [95% CI: 1.00, 1.15], p = 0.041) and reduced loss to follow-up (IRR(β6) = 0.17 [95% CI: 0.04, 0.69], p = 0.013) in the intervention districts. Loss to follow-up continued to decline throughout the post-implementation period (IRR(β7) = 0.90 [95% CI: 0.83, 0.98], p = 0.019). CONCLUSIONS Economic migrants, particularly those crossing provincial borders, have higher risk of poor treatment outcomes and should be prioritized for tailored adherence support. In light of accelerating urbanization in many regions of Asia, implementation trials are needed to inform evidence-based design of strategies for this vulnerable population.
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Affiliation(s)
- Luan Nguyen Quang Vo
- Friends for International TB Relief, 68B Nguyen Van Troi, 8, Phu Nhuan, Ho Chi Minh City, Viet Nam. .,Interactive Research and Development, Ho Chi Minh City, Viet Nam.
| | - Andrew James Codlin
- Friends for International TB Relief, 68B Nguyen Van Troi, 8, Phu Nhuan, Ho Chi Minh City, Viet Nam
| | - Rachel Jeanette Forse
- Friends for International TB Relief, 68B Nguyen Van Troi, 8, Phu Nhuan, Ho Chi Minh City, Viet Nam
| | | | - Thanh Nguyen Vu
- Ho Chi Minh City Public Health Association, Ho Chi Minh City, Viet Nam
| | | | - Giang Chau Do
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Viet Nam
| | | | - Giang Truong Le
- Ho Chi Minh City Public Health Association, Ho Chi Minh City, Viet Nam
| | - Maxine Caws
- Liverpool School of Tropical Medicine, Department of Clinical Sciences, Liverpool, UK.,Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
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Stagg HR, Abubakar I, Campbell CN, Copas A, Darvell M, Horne R, Kielmann K, Kunst H, Mandelbaum M, Pickett E, Story A, Vidal N, Wurie FB, Lipman M. IMPACT study on intervening with a manualised package to achieve treatment adherence in people with tuberculosis: protocol paper for a mixed-methods study, including a pilot randomised controlled trial. BMJ Open 2019; 9:e032760. [PMID: 31852704 PMCID: PMC6937100 DOI: 10.1136/bmjopen-2019-032760] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Compared with the rest of the UK and Western Europe, England has high rates of the infectious disease tuberculosis (TB). TB is curable, although treatment is for at least 6 months and longer when disease is drug resistant. If patients miss too many doses (non-adherence), they may transmit infection for longer and the infecting bacteria may develop resistance to the standard drugs used for treatment. Non-adherence may therefore risk both their health and that of others. Within England, certain population groups are thought to be at higher risk of non-adherence, but the factors contributing to this have been insufficiently determined, as have the best interventions to promote adherence. The objective of this study was to develop a manualised package of interventions for use as part of routine care within National Health Services to address the social and cultural factors that lead to poor adherence to treatment for TB disease. METHODS AND ANALYSIS This study uses a mixed-methods approach, with six study components. These are (1) scoping reviews of the literature; (2) qualitative research with patients, carers and healthcare professionals; (3) development of the intervention; (4) a pilot randomised controlled trial of the manualised intervention; (5) a process evaluation to examine clinical utility; and (6) a cost analysis. ETHICS AND DISSEMINATION This study received ethics approval on 24 December 2018 from Camberwell St. Giles Ethics Committee, UK (REC reference 18/LO/1818). Findings will be published and disseminated through peer-reviewed publications and conference presentations, published in an end of study report to our funder (the National Institute for Health Research, UK) and presented to key stakeholders. TRIAL REGISTRATION NUMBER ISRCTN95243114 SECONDARY IDENTIFYING NUMBERS: University College London/University College London Hospitals Joint Research Office 17/0726.National Institute for Health Research, UK 16/88/06.
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Affiliation(s)
- Helen R Stagg
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
| | | | - Andrew Copas
- Centre for Pragmatic Global Health Trials, Institute of Global Health, University College London, London, UK
| | | | - Robert Horne
- UCL School of Pharmacy, University College London, London, UK
| | - Karina Kielmann
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Edinburgh, UK
| | - Heinke Kunst
- Department of Respiratory Medicine, Queen Mary University of London, London, UK
| | | | - Elisha Pickett
- Department of Respiratory Medicine, Royal Free London NHS Foundation Trust, London, UK
| | - Alistair Story
- Find&Treat, University College Hospitals NHS Foundation Trust, London, UK
| | - Nicole Vidal
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Edinburgh, UK
| | - Fatima B Wurie
- Institute for Global Health, University College London, London, UK
| | - Marc Lipman
- UCL Respiratory, University College London, London, UK
- Department of Respiratory Medicine, Royal Free London NHS Foundation Trust, London, UK
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12
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Drabarek D, Anh NT, Nhung NV, Hoa NB, Fox GJ, Bernays S. Implementation of Medication Event Reminder Monitors among patients diagnosed with drug susceptible tuberculosis in rural Viet Nam: A qualitative study. PLoS One 2019; 14:e0219891. [PMID: 31329610 PMCID: PMC6645511 DOI: 10.1371/journal.pone.0219891] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 07/04/2019] [Indexed: 12/18/2022] Open
Abstract
Background Despite the criticality of adherence to tuberculosis treatment, there is paucity of rigorous experimental research exploring the efficacy of interventions to promote adherence and a greater lack of inquiry addressing the integral role of adherence behaviour. The aim of this formative study was to examine the way in which the Wisepill evriMED Medication Event Reminder Monitor (MERM) was used among outpatients with drug susceptible pulmonary tuberculosis. Methods In depth interviews were conducted with 20 outpatients receiving treatment from two public healthcare facilities in Thanh Hoa, a rural province in northern Viet Nam. Patients had been enrolled in a randomized controlled trial evaluating the effect of using the MERM device upon adherence for between 1–3 months. The control group used the device without an alert, while the intervention group used the device with a daily alert and scheduled dosing history review. Findings All 20 patients interviewed were supportive of using the MERM device. Those able to be at home at the time that their treatment was due (50%) used the device as intended. Patients who worked all reported separating the time when the box was opened from the time at which they ingested their medication. Patients expressed fidelity to the prescribed medication taking time and concerns regarding the portability of the device. Limitations of the study surround the inclusion of a small sample population that did not experience factors that further compromise adherence. Conclusions Data recorded by the box did not always accurately reflect usage patterns. The alert in the intervention arm was able to support adherence only in patients who did not work while completing their treatment. MERM implementation can be improved by better aligning prescriber instructions with patients’ daily routines, and increasing the use of adherence data to guide adherence support practices. Healthcare staff need to be aware of potential barriers to optimal use of MERM devices. A rigorous qualitative approach to formative assessment is essential to inform the scale up of new digital technologies.
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Affiliation(s)
- Dorothy Drabarek
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- * E-mail:
| | - Nguyen T. Anh
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | | | | - Greg J. Fox
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Sarah Bernays
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Sumari-de Boer M, Pima FM, Ngowi KM, Chelangwa GM, Mtesha BA, Minja LM, Semvua HH, Mpagama S, Mmbaga BT, Nieuwkerk PT, Aarnoutse RE. Implementation and effectiveness of evriMED with short messages service (SMS) reminders and tailored feedback compared to standard care on adherence to treatment among tuberculosis patients in Kilimanjaro, Tanzania: proposal for a cluster randomized controlled trial. Trials 2019; 20:426. [PMID: 31300028 PMCID: PMC6626331 DOI: 10.1186/s13063-019-3483-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adherence to tuberculosis (TB) treatment is challenging because of many factors. The World Health Organization has recommended the use of digital adherence monitoring technologies in its End TB Strategy. However, evidence on improving adherence is limited. EvriMED is a real-time medication-monitoring device which was found to be feasible and acceptable in a few studies in Asia. In Tanzania, however, there may be challenges in implementing evriMED due to stigmatization, network and power access, accuracy, and cost effectiveness, which may have implications for treatment outcome. We propose a pragmatic cluster randomized trial to investigate the effectiveness of evriMED with reminder cues and tailored feedback on adherence to TB treatment in Kilimanjaro, Tanzania. METHODS/DESIGN We will create clusters in Kilimanjaro based on level of health care facility. Clusters will be randomized in an intervention arm, where evriMED will be implemented, or a control arm, where standard practice directly observed treatment will be followed. TB patients in intervention clusters will take their medication from the evriMED pillbox and receive tailored feedback. We will use the 'Stages of Change' model, which assumes that a person has to go through the stages of pre-contemplation, contemplation, preparation, action, and evaluation to change behavior for tailored feedback on adherence reports from the device. DISCUSSION If the intervention shows a significant effect on adherence and the devices are accepted, accurate, and sustainable, the intervention can be scaled up within the National Tuberculosis Programmes. TRIAL REGISTRATION Pan African Clinical Trials Registry, PACTR201811755733759 . Registered on 8 November 2018.
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Affiliation(s)
- Marion Sumari-de Boer
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania. .,Department of International Health, RadboudUMC, Nijmegen, the Netherlands.
| | - Francis M Pima
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Kennedy M Ngowi
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania.,Department of Medical Psychology, Amsterdam UMC, Amsterdam, the Netherlands.,Medical psychologypsychology, AMC, AZ, 9 1105, Meibergdreef, Amsterdam, Netherlands
| | | | - Benson A Mtesha
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Linda M Minja
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Hadija H Semvua
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Stella Mpagama
- Kibong'oto Infectious Diseases Hospital, Sanya Juu, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Rob E Aarnoutse
- Department of Clinical Pharmacology, RadboudUMC, Nijmegen, the Netherlands
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14
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Watermeyer J, Penn C. Community perspectives on tuberculosis care in rural South Africa. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:182-190. [PMID: 30159955 DOI: 10.1111/hsc.12637] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/22/2018] [Accepted: 07/29/2018] [Indexed: 06/08/2023]
Abstract
Patient nonadherence to tuberculosis (TB) treatment is an ongoing challenge, particularly since the advent of drug-resistant TB and complications posed by HIV/AIDS. Some solutions may lie in understanding patient and community perspectives about barriers to TB care and treatment adherence. Using a qualitative framework, we explored community perceptions and beliefs about TB and perceived facilitators and barriers to care in a rural South African community affected by TB. We were particularly interested in capturing cross-cutting themes and the "merged voices" of participants. Interviews were conducted in 2013 and 2014 with 43 participants, including home-based care workers, clinic staff, patients living with TB and community members in and around a primary healthcare clinic. The data were analysed using principles of thematic analysis. The study reveals the complex interplay between contextual factors and community understandings of the disease. Cultural beliefs about causality and treatment-seeking paths were often mentioned in conjunction with biomedical views. There was a strong interface between TB and HIV in this community, and knowledge of TB was often confused with HIV. HIV-related stigma has been extended to those living with TB. The impact of poverty on treatment adherence was a particularly important theme. Other themes related to the role of the clinic in the community. Our study highlights the socioeconomic vulnerability of this community and the fragility of existing care systems. The findings reinforce the need for a community-centred approach to TB care that takes cognisance of lifeworld issues. We discuss some implications of this study for practice and policy.
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Affiliation(s)
- Jennifer Watermeyer
- Health Communication Research Unit, School of Human and Community Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Claire Penn
- Health Communication Research Unit, School of Human and Community Development, University of the Witwatersrand, Johannesburg, South Africa
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Tola HH, Karimi M, Yekaninejad MS. Effects of sociodemographic characteristics and patients' health beliefs on tuberculosis treatment adherence in Ethiopia: a structural equation modelling approach. Infect Dis Poverty 2017; 6:167. [PMID: 29241454 PMCID: PMC5731079 DOI: 10.1186/s40249-017-0380-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 11/30/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Patients' beliefs are a major factor affecting tuberculosis (TB) treatment adherence. However, there has been little use of Health Belief Model (HBM) in determining the pathway effect of patients' sociodemographic characteristics and beliefs on TB treatment adherence. Therefore, this study was aimed at determining the effect of sociodemographic characteristics and patients' health beliefs on TB treatment adherence based on the HBM concept in Ethiopia. METHODS A cross-sectional study was conducted in Addis Ababa, Ethiopia among TB patients undertaking treatment. Thirty health centres were randomly selected and one hospital was purposely chosen. Six hundred and ninety-eight TB patients who had been on treatment for 1-2 month, were aged 18 years or above, and had the mental capability to provide consent were enrolled consecutively with non-probability sampling technique from the TB registration book until required sample size achieved. Structured questionnaires were used to collect data. Structural equation modelling was employed to assess the pathway relationship between sociodemographic characteristics, patients' beliefs, and treatment adherence. RESULTS Of the 698 enrolled participants, 401 (57.4%) were male and 490 (70.2%) were aged 35 years and below. The mean age of participants was 32 (± 11.7) and the age range was 18-90 years. Perceived barrier/benefit was shown to be a significant direct negative effect on TB treatment adherence (ß = -0.124, P = 0.032). In addition, cue to action (ß = -0.68, P ≤ 0.001) and psychological distress (ß = 0.08, P < 0.001) were shown significant indirect effects on TB treatment adherence through perceived barrier/benefit. CONCLUSIONS Interventions intended to decrease perceived barriers and maximize perceived benefits should be implemented to enhance TB treatment adherence. In addition, it is crucial that counselling is incorporated with the regular directly observed therapy program. Motivators (cue to actions) such as friends, family, healthcare workers, and the media could be used to promote TB treatment adherence.
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Affiliation(s)
- Habteyes Hailu Tola
- Department of Epidemiology and Biostatics, School of Public Health, Tehran University of Medical Sciences, International Campus, Tehran, Iran
- Tuberculosis/HIV Research Directorate, Ethiopian Public Health Institute, P.O. Box 1242, /5654 Addis Ababa, Ethiopia
| | - Mehrdad Karimi
- Department of Epidemiology and Biostatics, School of Public Health, Tehran University of Medical Sciences, International Campus, Tehran, Iran
| | - Mir Saeed Yekaninejad
- Department of Epidemiology and Biostatics, School of Public Health, Tehran University of Medical Sciences, International Campus, Tehran, Iran
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16
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Tola HH, Garmaroudi G, Shojaeizadeh D, Tol A, Yekaninejad MS, Ejeta LT, Kebede A, Kassa D. The Effect of Psychosocial Factors and Patients' Perception of Tuberculosis Treatment Non-Adherence in Addis Ababa, Ethiopia. Ethiop J Health Sci 2017; 27:447-458. [PMID: 29217949 PMCID: PMC5615005 DOI: 10.4314/ejhs.v27i5.2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Although there are several studies reported on factors affecting tuberculosis (TB) treatment non-adherence, there is information gap on psychosocial and patients' perceptions aspects. Therefore, this study was aimed to investigate the effect of psychosocial factors and patients' perceptions on TB treatment non-adherence in Ethiopia. METHODS A cross sectional study was conducted in Addis Ababa from May to December, 2014. Thirty one health facilities were randomly selected and 698 TB patients, who had been on treatment, were enrolled consecutively using patient registration number. Structured questionnaire was used to collect data on demographics, knowledge, psychological distress, alcohol use, tobacco smoking and six HBM domains. Treatment adherence level was the main outcome variable, and it measured using visual analog scale. Statistical Package for Social Sciences version 20 was used for data analysis. RESULTS Non-adherence level within last one month prior to the study was 19.5%. After controlling for all potential confounding variables, Antiretroviral Therapy (ART) status (Adjusted Odds Ratio (AOR) = 1.79, 95% Confidence interval (CI) (1.09 -2.95)), alcohol use (AOR = 2.11, 95% CI (1.33-3.37)), economic status (AOR = 0.53, 95% CI (0.33-0.82)), perceived barriers (AOR = 1.21, 95% CI (1.10-1.47)) and psychological distress (AOR = 1.83, 95% CI (1.47-2.29)) were independently associated with TB treatment non-adherence. CONCLUSION ART status, economic status, alcohol use, perceived barrier and psychological distress are the major areas that need to be targeted with health promotion intervention to enhance TB treatment adherence.
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Affiliation(s)
- Habteyes Hailu Tola
- Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences-International Campus, Tehran, Iran
- TB/HIV Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Gholamreza Garmaroudi
- Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences-International Campus, Tehran, Iran
| | - Davoud Shojaeizadeh
- Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences-International Campus, Tehran, Iran
| | - Azar Tol
- Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences-International Campus, Tehran, Iran
| | - Mir Saeed Yekaninejad
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Luche Tadesse Ejeta
- Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences-International Campus, Tehran, Iran
| | - Abebaw Kebede
- TB/HIV Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Desta Kassa
- TB/HIV Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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17
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O'Donnell MR, Daftary A, Frick M, Hirsch-Moverman Y, Amico KR, Senthilingam M, Wolf A, Metcalfe JZ, Isaakidis P, Davis JL, Zelnick JR, Brust JCM, Naidu N, Garretson M, Bangsberg DR, Padayatchi N, Friedland G. Re-inventing adherence: toward a patient-centered model of care for drug-resistant tuberculosis and HIV. Int J Tuberc Lung Dis 2017; 20:430-4. [PMID: 26970149 DOI: 10.5588/ijtld.15.0360] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite renewed focus on molecular tuberculosis (TB) diagnostics and new antimycobacterial agents, treatment outcomes for patients co-infected with drug-resistant TB and human immunodeficiency virus (HIV) remain dismal, in part due to lack of focus on medication adherence as part of a patient-centered continuum of care. OBJECTIVE To review current barriers to drug-resistant TB-HIV treatment and propose an alternative model to conventional approaches to treatment support. DISCUSSION Current national TB control programs rely heavily on directly observed therapy (DOT) as the centerpiece of treatment delivery and adherence support. Medication adherence and care for drug-resistant TB-HIV could be improved by fully implementing team-based patient-centered care, empowering patients through counseling and support, maintaining a rights-based approach while acknowledging the responsibility of health care systems in providing comprehensive care, and prioritizing critical research gaps. CONCLUSION It is time to re-invent our understanding of adherence in drug-resistant TB and HIV by focusing attention on the complex clinical, behavioral, social, and structural needs of affected patients and communities.
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Affiliation(s)
- M R O'Donnell
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA; Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - A Daftary
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - M Frick
- Treatment Action Group, New York, USA
| | - Y Hirsch-Moverman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA; International Center for AIDS Care and Treatment Programs, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - K R Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | | | - A Wolf
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - J Z Metcalfe
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA
| | | | - J L Davis
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - J R Zelnick
- Touro College Graduate School of Social Work, New York, New York, USA
| | - J C M Brust
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, New York, USA
| | - N Naidu
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - M Garretson
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | | | - N Padayatchi
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - G Friedland
- Yale University School of Public Health, New Haven, Connecticut, USA; Yale University School of Medicine, New Haven, Connecticut, USA
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18
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Tola HH, Shojaeizadeh D, Tol A, Garmaroudi G, Yekaninejad MS, Kebede A, Ejeta LT, Kassa D, Klinkenberg E. Psychological and Educational Intervention to Improve Tuberculosis Treatment Adherence in Ethiopia Based on Health Belief Model: A Cluster Randomized Control Trial. PLoS One 2016; 11:e0155147. [PMID: 27167378 PMCID: PMC4864292 DOI: 10.1371/journal.pone.0155147] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 04/25/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Treatment non-adherence results in treatment failure, prolonged transmission of disease and emergence of drug resistance. Although the problem widely investigated, there remains an information gap on the effectiveness of different methods to improve treatment adherence and the predictors of non-adherence in resource limited countries based on theoretical models. This study aimed to evaluate the impact of psychological counseling and educational intervention on tuberculosis (TB) treatment adherence based on Health Belief Model (HBM). METHODOLOGY A cluster randomized control trial was conducted in Addis Ababa from May to December, 2014. Patients were enrolled into study consecutively from 30 randomly selected Health Centers (HCs) (14 HCs intervention and 16 HCs control groups). A total of 698 TB patients, who were on treatment for one month to two months were enrolled. A structured questionnaire was administered to both groups of patients at baseline and endpoint of study. Control participants received routine directly-observed anti-TB therapy and the intervention group additionally received combined psychological counseling and adherence education. Treatment non-adherence level was the main outcome of the study, and multilevel logistic regression was employed to assess the impact of intervention on treatment adherence. RESULTS At enrollment, the level of non-adherence among intervention (19.4%) and control (19.6%) groups was almost the same. However, after intervention, non-adherence level decreased among intervention group from 19.4 (at baseline) to 9.5% (at endpoint), while it increased among control group from 19.4% (baseline) to 25.4% (endpoint). Psychological counseling and educational interventions resulted in significant difference with regard to non-adherence level between intervention and control groups (Adjusted OR = 0.31, 95% Confidence Interval (CI) (0.18-0.53), p < 0.001)). CONCLUSION Psychological counseling and educational interventions, which were guided by HBM, significantly decreased treatment non-adherence level among intervention group. Provision of psychological counseling and health education to TB patients who are on regular treatment is recommended. This could be best achieved if these interventions are guided by behavioral theories and incorporated into the routine TB treatment strategy. TRIAL REGISTRATION Pan African Clinical Trials Registry PACTR201506001175423.
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Affiliation(s)
- Habteyes Hailu Tola
- Tehran University of Medical Sciences-International Campus, School of Public Health, Department of Health Education and Promotion, Tehran, Iran
- Ethiopian Public Health Institute, TB/HIV Research Directorate, Addis Ababa, Ethiopia
| | - Davoud Shojaeizadeh
- Tehran University of Medical Sciences-International Campus, School of Public Health, Department of Health Education and Promotion, Tehran, Iran
| | - Azar Tol
- Tehran University of Medical Sciences-International Campus, School of Public Health, Department of Health Education and Promotion, Tehran, Iran
| | - Gholamreza Garmaroudi
- Tehran University of Medical Sciences-International Campus, School of Public Health, Department of Health Education and Promotion, Tehran, Iran
| | - Mir Saeed Yekaninejad
- Tehran University of Medical Sciences International Campus, School of Public Health, Department of Epidemiology and Biostatistics, Tehran, Iran
| | - Abebaw Kebede
- Ethiopian Public Health Institute, TB/HIV Research Directorate, Addis Ababa, Ethiopia
| | - Luche Tadesse Ejeta
- Tehran University of Medical Sciences-International Campus, School of Public Health, Department of Health Education and Promotion, Tehran, Iran
| | - Desta Kassa
- Ethiopian Public Health Institute, TB/HIV Research Directorate, Addis Ababa, Ethiopia
| | - Eveline Klinkenberg
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
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de Sumari-de Boer IM, van den Boogaard J, Ngowi KM, Semvua HH, Kiwango KW, Aarnoutse RE, Nieuwkerk PT, Kibiki GS. Feasibility of Real Time Medication Monitoring Among HIV Infected and TB Patients in a Resource-Limited Setting. AIDS Behav 2016; 20:1097-107. [PMID: 26604004 DOI: 10.1007/s10461-015-1254-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HIV infected and tuberculosis (TB) patients need high levels of treatment adherence to achieve optimal treatment outcomes. We conducted a pilot-study on real time medication monitoring (RTMM) in a resource-limited setting. We enrolled five HIV infected and five TB patients from Kilimanjaro, Tanzania. They took their medication using RTMM. When the device was not opened on time, patients received a reminder SMS. After 3 months, we interviewed patients. Six patients (60 %) reached adherence of >95 %. Nine-hundred-twenty-two of 1104 intakes (84 %) were on time. Five-hundred reminders (45 %) were sent, of which 202 (40 %) were incorrect, because of an unstable mobile network. Nine patients found the device helpful and nine mentioned it keeps medication safe. Six patients reported that the size was too big. Five patients mentioned they received incorrect reminders. The device is considered useful in Kilimanjaro. Optimization of the device should consider network connectivity and the size of the device.
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Affiliation(s)
- I Marion de Sumari-de Boer
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania.
| | - Jossy van den Boogaard
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania
| | - Kennedy M Ngowi
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania
| | - Hadija H Semvua
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania
| | - Krisanta W Kiwango
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Amsterdam Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Gibson S Kibiki
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania
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Mohd Shariff N, Shah SA, Kamaludin F. Previous treatment, sputum-smear nonconversion, and suburban living: The risk factors of multidrug-resistant tuberculosis among Malaysians. Int J Mycobacteriol 2015; 5:51-8. [PMID: 26927990 DOI: 10.1016/j.ijmyco.2015.11.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 11/09/2015] [Accepted: 11/12/2015] [Indexed: 10/22/2022] Open
Abstract
The number of multidrug-resistant tuberculosis patients is increasing each year in many countries all around the globe. Malaysia has no exception in facing this burdensome health problem. We aimed to investigate the factors that contribute to the occurrence of multidrug-resistant tuberculosis among Malaysian tuberculosis patients. An unmatched case-control study was conducted among tuberculosis patients who received antituberculosis treatments from April 2013 until April 2014. Cases are those diagnosed as pulmonary tuberculosis patients clinically, radiologically, and/or bacteriologically, and who were confirmed to be resistant to both isoniazid and rifampicin through drug-sensitivity testing. On the other hand, pulmonary tuberculosis patients who were sensitive to all first-line antituberculosis drugs and were treated during the same time period served as controls. A total of 150 tuberculosis patients were studied, of which the susceptible cases were 120. Factors found to be significantly associated with the occurrence of multidrug-resistant tuberculosis are being Indian or Chinese (odds ratio 3.17, 95% confidence interval 1.04-9.68; and odds ratio 6.23, 95% confidence interval 2.24-17.35, respectively), unmarried (odds ratio 2.58, 95% confidence interval 1.09-6.09), living in suburban areas (odds ratio 2.58, 95% confidence interval 1.08-6.19), are noncompliant (odds ratio 4.50, 95% confidence interval 1.71-11.82), were treated previously (odds ratio 8.91, 95% confidence interval 3.66-21.67), and showed positive sputum smears at the 2nd (odds ratio 7.00, 95% confidence interval 2.46-19.89) and 6th months of treatment (odds ratio 17.96, 95% confidence interval 3.51-91.99). Living in suburban areas, positive sputum smears in the 2nd month of treatment, and was treated previously are factors that independently contribute to the occurrence of multidrug-resistant tuberculosis. Those with positive smears in the second month of treatment, have a history of previous treatment, and live in suburban areas are found to have a higher probability of becoming multidrug resistant. The results presented here may facilitate improvements in the screening and detection process of drug-resistant patients in Malaysia in the future.
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Affiliation(s)
- Noorsuzana Mohd Shariff
- Community Health Department, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia; Advanced Medical and Dental Institute, Universiti Sains Malaysia, Pulau Pinang, Malaysia.
| | - Shamsul Azhar Shah
- Community Health Department, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Fadzilah Kamaludin
- Office of Deputy Director General of Health Malaysia, Ministry of Health Malaysia, Putrajaya, Malaysia
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21
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Affiliation(s)
- John Z. Metcalfe
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Max R. O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York, United States of America
| | - David R. Bangsberg
- Massachusetts General Hospital, Harvard Medical School, Harvard School of Public Health, Boston, Massachusetts, United States of America
- Mbarara University of Science and Technology, Mbarara, Uganda
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22
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Makharia GK, Ghoshal UC, Ramakrishna BS, Agnihotri A, Ahuja V, Chowdhury SD, Gupta SD, Mechenro J, Mishra A, Mishra A, Pathak MK, Pandey RM, Sharma R, Sharma SK. Intermittent Directly Observed Therapy for Abdominal Tuberculosis: A Multicenter Randomized Controlled Trial Comparing 6 Months Versus 9 Months of Therapy. Clin Infect Dis 2015; 61:750-757. [PMID: 25969531 DOI: 10.1093/cid/civ376] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 04/29/2015] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The duration of treatment of gastrointestinal tuberculosis continues to be a matter of debate. The World Health Organization advocates intermittent directly observed short-course therapy (DOTs), but there is a lack of data of its efficacy in abdominal tuberculosis. We therefore conducted a multicenter randomized controlled trial to compare 6 months and 9 months of antituberculosis therapy using DOTs. METHODS One hundred ninety-seven patients with abdominal tuberculosis (gastrointestinal, 154; peritoneal, 40; mixed, 3) were randomized to receive 6 months (n = 104) or 9 months (n = 93) of antituberculosis therapy using intermittent directly observed therapy. Patients were followed up 1 year after completion of treatment to assess recurrence. Patients were evaluated for primary endpoint (complete clinical response, partial response, and no response) and secondary endpoint (recurrence of the disease at the end of 1 year of follow-up). RESULTS Baseline characteristics were similar between the 2 randomized groups. There was no difference between the 6-month group and 9-month group in the complete clinical response rate on per-protocol analysis (91.5% vs 90.8%; P = .88) or intent-to-treat analysis (75% vs 75.8%; P = .89). Only 1 patient in the 9-month group and no patients in the 6-month group had recurrence of disease. Side effects occurred in 21 (21.3%) and 16 (18.2%) patients in the 6-month and 9-month groups, respectively. CONCLUSIONS There was no difference in efficacy of antituberculosis therapy delivered for either 6 months or 9 months in either gastrointestinal or peritoneal tuberculosis, confirming the efficacy of intermittent directly observed therapy. CLINICAL TRIALS REGISTRATION NCT01124929.
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Affiliation(s)
- Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow
| | - Balakrishnan S Ramakrishna
- Department of Gastroenterology, SRM Institute of Medical Sciences, Chennai Department of Gastroenterology, Christian Medical College, Vellore
| | - Abhishek Agnihotri
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi
| | | | | | - John Mechenro
- Department of Gastroenterology, SRM Institute of Medical Sciences, Chennai Department of Gastroenterology, Christian Medical College, Vellore
| | - Asha Mishra
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi
| | - Asha Mishra
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow
| | - Manish K Pathak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi
| | | | | | - Surendra K Sharma
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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23
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Kouyos RD, Metcalf CJE, Birger R, Klein EY, Abel zur Wiesch P, Ankomah P, Arinaminpathy N, Bogich TL, Bonhoeffer S, Brower C, Chi-Johnston G, Cohen T, Day T, Greenhouse B, Huijben S, Metlay J, Mideo N, Pollitt LC, Read AF, Smith DL, Standley C, Wale N, Grenfell B. The path of least resistance: aggressive or moderate treatment? Proc Biol Sci 2015; 281:20140566. [PMID: 25253451 DOI: 10.1098/rspb.2014.0566] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The evolution of resistance to antimicrobial chemotherapy is a major and growing cause of human mortality and morbidity. Comparatively little attention has been paid to how different patient treatment strategies shape the evolution of resistance. In particular, it is not clear whether treating individual patients aggressively with high drug dosages and long treatment durations, or moderately with low dosages and short durations can better prevent the evolution and spread of drug resistance. Here, we summarize the very limited available empirical evidence across different pathogens and provide a conceptual framework describing the information required to effectively manage drug pressure to minimize resistance evolution.
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Affiliation(s)
- Roger D Kouyos
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - C Jessica E Metcalf
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA Department of Zoology, Oxford University, Oxford, UK
| | - Ruthie Birger
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA
| | - Eili Y Klein
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA Center for Advanced Modeling, Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Pia Abel zur Wiesch
- Division of Global Health Equity, Brigham and Women's Hospital and Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Peter Ankomah
- Department of Biology, Emory University, Atlanta, GA, USA
| | - Nimalan Arinaminpathy
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Tiffany L Bogich
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | | | - Charles Brower
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Geoffrey Chi-Johnston
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ted Cohen
- Division of Global Health Equity, Brigham and Women's Hospital and Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Troy Day
- Departments of Mathematics and Biology, Queen's University, Kingston, Ontario, Canada
| | - Bryan Greenhouse
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, VA, USA
| | - Silvie Huijben
- Barcelona Centre for International Health Research, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Joshua Metlay
- General Medicine Division, Massachusetts General Hospital, Boston, MA, USA
| | - Nicole Mideo
- Department of Ecology and Evolutionary Biology, University of Toronto, Toronto, Ontario, Canada
| | - Laura C Pollitt
- Centre for Infectious Disease Dynamics, The Pennsylvania State University, University Park, State College, PA, USA Departments of Biology and Entomology, The Pennsylvania State University, University Park, State College, PA, USA Centre for Immunology, Infection and Evolution, University of Edinburgh, Edinburgh, UK
| | - Andrew F Read
- Centre for Infectious Disease Dynamics, The Pennsylvania State University, University Park, State College, PA, USA Departments of Biology and Entomology, The Pennsylvania State University, University Park, State College, PA, USA Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - David L Smith
- Department of Zoology, Oxford University, Oxford, UK
| | - Claire Standley
- Department of Health Policy, George Washington University, Washington, DC, USA
| | - Nina Wale
- Centre for Infectious Disease Dynamics, The Pennsylvania State University, University Park, State College, PA, USA Departments of Biology and Entomology, The Pennsylvania State University, University Park, State College, PA, USA
| | - Bryan Grenfell
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
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24
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Magis-Escurra C, Later-Nijland HMJ, Alffenaar JWC, Broeders J, Burger DM, van Crevel R, Boeree MJ, Donders ART, van Altena R, van der Werf TS, Aarnoutse RE. Population pharmacokinetics and limited sampling strategy for first-line tuberculosis drugs and moxifloxacin. Int J Antimicrob Agents 2014; 44:229-34. [PMID: 24985091 DOI: 10.1016/j.ijantimicag.2014.04.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 04/17/2014] [Accepted: 04/23/2014] [Indexed: 10/25/2022]
Abstract
Therapeutic drug monitoring (TDM) of tuberculosis (TB) drugs currently focuses on peak plasma concentrations, yet total exposure [area under the 24-h concentration-time curve (AUC₀₋₂₄)] is probably most relevant to the efficacy of these drugs. We therefore assessed population AUC₀₋₂₄ data for all four first-line TB drugs (rifampicin, isoniazid, pyrazinamide and ethambutol) as well as moxifloxacin and developed limited sampling strategies to estimate AUC₀₋₂₄ values conveniently. AUC₀₋₂₄ and other pharmacokinetic (PK) parameters were determined following intensive PK sampling in two Dutch TB referral centres. Best subset selection multiple linear regression was performed to derive limited sampling equations. Median percentage prediction error and median absolute percentage prediction error were calculated via jackknife analysis to evaluate bias and imprecision of the predictions. Geometric mean AUC₀₋₂₄ values for rifampicin, isoniazid, pyrazinamide, ethambutol and moxifloxacin were 41.1, 15.2, 380, 25.5 and 33.6 hmg/L, respectively. Limited sampling at various fixed sampling points enabled an accurate and precise prediction of AUC₀₋₂₄ values of all drugs separately and simultaneously. In the absence of clinically validated target values for AUC₀₋₂₄, average AUC₀₋₂₄ values can be used as reference values in TDM. Limited sampling of AUC₀₋₂₄ is feasible in many settings and allows for TDM to be performed at a larger scale.
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Affiliation(s)
- C Magis-Escurra
- Radboud University Medical Centre, Department of Pulmonary diseases, Nijmegen and University Centre for Chronic Diseases Dekkerswald, Groesbeek, The Netherlands.
| | - H M J Later-Nijland
- Radboud University Medical Centre, Department of Pharmacy, Nijmegen, The Netherlands
| | - J W C Alffenaar
- University Medical Centre Groningen, Department of Hospital and Clinical Pharmacy, Groningen, The Netherlands
| | - J Broeders
- Radboud University Medical Centre, Department of Pharmacy, Nijmegen, The Netherlands
| | - D M Burger
- Radboud University Medical Centre, Department of Pharmacy, Nijmegen, The Netherlands
| | - R van Crevel
- Radboud University Medical Centre, Department of Internal Medicine, Nijmegen, The Netherlands
| | - M J Boeree
- Radboud University Medical Centre, Department of Pulmonary diseases, Nijmegen and University Centre for Chronic Diseases Dekkerswald, Groesbeek, The Netherlands
| | - A R T Donders
- Radboud University Medical Centre, Department for Epidemiology, Biostatistics and HTA, Nijmegen, The Netherlands
| | - R van Altena
- University Medical Centre Groningen, Tuberculosis Centre Beatrixoord, Haren, The Netherlands
| | - T S van der Werf
- University Medical Centre Groningen, Tuberculosis Centre Beatrixoord, Haren, The Netherlands; University Medical Centre Groningen, Department of Internal Medicine, Groningen, The Netherlands
| | - R E Aarnoutse
- Radboud University Medical Centre, Department of Pharmacy, Nijmegen, The Netherlands
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25
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de Steenwinkel JEM, Aarnoutse RE, de Knegt GJ, ten Kate MT, Teulen M, Verbrugh HA, Boeree MJ, van Soolingen D, Bakker-Woudenberg IAJM. Optimization of the rifampin dosage to improve the therapeutic efficacy in tuberculosis treatment using a murine model. Am J Respir Crit Care Med 2013; 187:1127-34. [PMID: 23525933 DOI: 10.1164/rccm.201207-1210oc] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The dosage of 10 mg/kg/d rifampin, as currently used in the treatment of tuberculosis (TB), is not an optimal dose. Shortening of treatment duration might be achievable using an increased rifampin dose. OBJECTIVES Determination of optimal rifampin dosage in mice, resulting in maximum therapeutic effect and without adverse effects. Assessment of associated pharmacokinetic parameters and pharmacokinetic/pharmacodynamic indices. METHODS A murine TB infection using a Beijing genotype Mycobacterium tuberculosis strain was established by intratracheal bacterial instillation followed by proper inhalation, while keeping mice in a vertical position. We assessed dose-dependent activity of rifampin in single-drug treatment during 3 weeks. The maximum tolerated dosage, pharmacokinetic parameters, and pharmacokinetic/pharmacodynamic index were determined. Therapeutic efficacy of a range of rifampin (R) dosages added to a regimen of isoniazid (H) and pyrazinamide (Z) was assessed. MEASUREMENTS AND MAIN RESULTS Maximum tolerated dosage of rifampin in the murine TB was 160 mg/kg/d. Pharmacokinetic measurement in HR(10)Z and HR(160)Z therapy regimens showed for rifampin a C(max) of 16.2 and 157.3 mg/L, an AUC(0-24h) of 132 and 1,782 h·mg/L, and AUC(0-24h)/minimum inhibitory concentration ratios of 528 and 7129, respectively. A clear dose-effect correlation was observed for rifampin after 3-week single-drug treatment. Administration of HR(80)Z allowed 9-week treatment duration to be effective without relapse of infection. CONCLUSIONS Our findings indicate that the currently used rifampin dosage in the therapy of TB is too low. In our murine TB model a rifampin dosage of 80 mg/kg/d enabled a significant reduction in therapy duration without adverse effects.
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Affiliation(s)
- Jurriaan E M de Steenwinkel
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
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26
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Mkopi A, Range N, Lwilla F, Egwaga S, Schulze A, Geubbels E, van Leth F. Adherence to tuberculosis therapy among patients receiving home-based directly observed treatment: evidence from the United Republic of Tanzania. PLoS One 2012; 7:e51828. [PMID: 23284782 PMCID: PMC3526644 DOI: 10.1371/journal.pone.0051828] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 11/06/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Non-adherence to tuberculosis (TB) treatment is the leading contributor to the selection of drug-resistant strains of Mycobacterium tuberculosis and subsequent treatment failure. Tanzania introduced a TB Patient Centred Treatment (PCT) approach which gives new TB patients the choice between home-based treatment supervised by a treatment supporter of their own choice, and health facility-based treatment observed by a medical professional. The aim of this study was to assess the extent and determinants of adherence to anti-TB therapy in patients opting for home-based treatment under the novel PCT approach. METHODS In this cross-sectional study, the primary outcome was the percentage of patients adherent to TB therapy as detected by the presence of isoniazid in urine (IsoScreen assay). The primary analysis followed a non-inferiority approach in which adherence could not be lower than 75%. Logistic regression was used to examine the influence of potentially predictive factors. RESULTS A total of 651 new TB patients were included. Of these, 645 (99.1%) provided urine for testing and 617 patients (95.7%; 90%CI 94.3-96.9) showed a positive result. This result was statistically non-inferior to the postulated adherence level of 75% (p<0.001). CONCLUSIONS Adherence to TB therapy under home-based Directly Observed Treatment can be ensured in programmatic settings. A reliable supply of medication and the careful selection of treatment supporters, who preferably live very close to the patient, are crucial success factors. Finally, we recommend a cohort study to assess the rate of adherence throughout the full course of TB treatment.
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27
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de Steenwinkel JEM, ten Kate MT, de Knegt GJ, Verbrugh HA, Aarnoutse RE, Boeree MJ, den Bakker MA, van Soolingen D, Bakker-Woudenberg IAJM. Consequences of noncompliance for therapy efficacy and emergence of resistance in murine tuberculosis caused by the Beijing genotype of Mycobacterium tuberculosis. Antimicrob Agents Chemother 2012; 56:4937-44. [PMID: 22802244 PMCID: PMC3421871 DOI: 10.1128/aac.00124-12] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 07/02/2012] [Indexed: 01/30/2023] Open
Abstract
Despite great effort by health organizations worldwide in fighting tuberculosis (TB), morbidity and mortality are not declining as expected. One of the reasons is related to the evolutionary development of Mycobacterium tuberculosis, in particular the Beijing genotype strains. In a previous study, we showed the association between the Beijing genotype and an increased mutation frequency for rifampin resistance. In this study, we use a Beijing genotype strain and an East-African/Indian genotype strain to investigate with our mouse TB model whether the higher mutation frequency observed in a Beijing genotype strain is associated with treatment failure particularly during noncompliance therapy. Both genotype strains showed high virulence in comparison to that of M. tuberculosis strain H37Rv, resulting in a highly progressive infection with a rapid lethal outcome in untreated mice. Compliance treatment was effective without relapse of TB irrespective of the infecting strain, showing similar decreases in the mycobacterial load in infected organs and similar histopathological changes. Noncompliance treatment, simulated by a reduced duration and dosing frequency, resulted in a relapse of infection. Relapse rates were correlated with the level of noncompliance and were identical for Beijing infection and East African/Indian infection. However, only in Beijing-infected mice, isoniazid-resistant mutants were selected at the highest level of noncompliance. This is in line with the substantial selection of isoniazid-resistant mutants in vitro in a wide isoniazid concentration window observed for the Beijing strain and not for the EAI strain. These results suggest that genotype diversity of M. tuberculosis may be involved in emergence of resistance and indicates that genotype-tailor-made treatment should be investigated.
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Affiliation(s)
- Jurriaan E. M. de Steenwinkel
- Erasmus MC, University Medical Centre Rotterdam, Department of Medical Microbiology & Infectious Diseases, Rotterdam, the Netherlands
| | - Marian T. ten Kate
- Erasmus MC, University Medical Centre Rotterdam, Department of Medical Microbiology & Infectious Diseases, Rotterdam, the Netherlands
| | - Gerjo J. de Knegt
- Erasmus MC, University Medical Centre Rotterdam, Department of Medical Microbiology & Infectious Diseases, Rotterdam, the Netherlands
| | - Henri A. Verbrugh
- Erasmus MC, University Medical Centre Rotterdam, Department of Medical Microbiology & Infectious Diseases, Rotterdam, the Netherlands
| | - Rob E. Aarnoutse
- Radboud University Nijmegen Medical Centre, Department of Pharmacy, Nijmegen, the Netherlands
| | - Martin J. Boeree
- Radboud University Nijmegen Medical Centre, Department of Pulmonary Diseases, Nijmegen, the Netherlands
| | - Michael A. den Bakker
- Erasmus MC, University Medical Centre Rotterdam, Department of Pathology, Rotterdam, the Netherlands
| | - Dick van Soolingen
- National Tuberculosis Reference Laboratory, National Institute of Public Health and the Environment Centre for Infectious Disease Control (CIb/LIS), Bilthoven, the Netherlands
- Radboud University Nijmegen Medical Centre, Department of Clinical Microbiology, Nijmegen, the Netherlands
| | - Irma A. J. M. Bakker-Woudenberg
- Erasmus MC, University Medical Centre Rotterdam, Department of Medical Microbiology & Infectious Diseases, Rotterdam, the Netherlands
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