Patient- and provider-level risk factors associated with default from tuberculosis treatment, South Africa, 2002: a case-control study

Exploring health care providers' engagement in prevention and management of multidrug resistant Tuberculosis and its factors in Hadiya Zone health care facilities: qualitative study

BACKGROUND

Engagement of healthcare providers is one of the World Health Organization strategies devised for prevention and provision of patient centered care for multidrug resistant tuberculosis. The need for current research question rose because of the gaps in evidence on health professional's engagement and its factors in multidrug resistant tuberculosis service delivery as per the protocol in the prevention and management of multidrug resistant tuberculosis.

PURPOSE

The purpose of this study was to explore the level of health care providers' engagement in multidrug resistant tuberculosis prevention and management and influencing factors in Hadiya Zone health facilities, Southern Ethiopia.

METHODS

Descriptive phenomenological qualitative study design was employed between 02 May and 09 May, 2019. We conducted a key informant interview and focus group discussions using purposely selected healthcare experts working as directly observed treatment short course providers in multidrug resistant tuberculosis treatment initiation centers, program managers, and focal persons. Verbatim transcripts were translated to English and exported to open code 4.02 for line-by-line coding and categorization of meanings into same emergent themes. Thematic analysis was conducted based on predefined themes for multidrug resistant tuberculosis prevention and management and core findings under each theme were supported by domain summaries in our final interpretation of the results. To maintain the rigors, Lincoln and Guba's parallel quality criteria of trustworthiness was used particularly, credibility, dependability, transferability, confirmability and reflexivity.

RESULTS

Total of 26 service providers, program managers, and focal persons were participated through four focus group discussion and five key informant interviews. The study explored factors for engagement of health care providers in the prevention and management of multidrug resistant tuberculosis in five emergent themes such as patients' causes, perceived susceptibility, seeking support, professional incompetence and poor linkage of the health care facilities. Our findings also suggest that service providers require additional training, particularly in programmatic management of drug-resistant tuberculosis.

CONCLUSION

The study explored five emergent themes: patient's underlying causes, seeking support, perceived susceptibility, professionals' incompetence and health facilities poor linkage. Community awareness creation to avoid fear of discrimination through provision of support for those with multidrug resistant tuberculosis is expected from health care providers using social behavioral change communication strategies. Furthermore, program managers need to follow the recommendations of World Health Organization for engaging healthcare professionals in the prevention and management of multidrug resistant tuberculosis and cascade trainings in clinical programmatic management of the disease for healthcare professionals.

Prediction of pulmonary tuberculosis treatment outcome in a sub-Saharan African context

Failure to treat many pathogens is a concern. Identifying a priori, patients with potential failure treatment outcome of a disease could allow measures to reduce the failure rate. The objectives of this study were to use the Scoring method to identify factors associated with the tuberculosis unsuccessful treatment outcome and to predict the treatment outcome. A total of 1,529 patients with pulmonary tuberculosis were randomly selected in the city of Douala, Cameroon, this sample was randomly split into two parts: one subsample of 1,200 patients (78%) used as the Development sample, and the remaining of 329 patients (22%) used as the Validation sample. Baseline characteristics associated with unsuccessful treatment outcomes were investigated using logistic regression. The optimal score was based on the Youden's index. HIV positive status, active smoker and non-belief in healing were the factors significantly associated with unsuccessful treatment outcomes (P#x003C;0.05). A model used to estimate the risk of unsuccessful treatment outcome was derived. The threshold probability which maximize the area under the ROC curve was 18%. Patients for whom the risk was greater than this threshold were classified as unsuccessful treatment outcome and the others as successful. HIV positive and active smoking status were associated with death; the non-belief in healing, youth and male gender associated with lost-to-follow-up, TB antecedent and not having TB contact associated with therapeutic treatment failure. To increase the tuberculosis treatment success rate, targeted follow-up could be taken during the treatment for TB patients with previous characteristics.

A qualitative exploration of tuberculosis patients who were lost to follow-up in Malaysia

BACKGROUND

Loss to follow-up (LTFU) is an unsuccessful treatment outcome for tuberculosis (TB) patients. In Malaysia, LTFU affects around 1 in 20 TB patients. Integration of qualitative research methods and evidence will provide a better understanding of LTFU and its underlying issues. In this study, we qualitatively explored TB patients' experiences in receiving treatment and their reasons for leaving TB care.

METHOD

In-depth interviews of 15 patients with a history of LTFU were conducted from January to September 2020. Interview guides were developed to explore TB patients' experiences while receiving treatment, including challenges faced and reasons for treatment interruption. Data were thematically analysed using the framework method.

RESULTS

We identified 11 emerging themes that occurred at four levels of interaction with TB patients. First, at the patient personal level, TB beliefs referring to patients' perception of illness and wellness, patients' perceived role of traditional and complementary medicine, and substance abuse were important. Second, the healthcare system and treatment factors that were highlighted included the organisation of care and treatment, interaction with healthcare professionals, particularly in communication and counselling, and TB medications' side effects. Third, structural factors including financial burden, logistical and transportation issues and work-related factors were identified to be barriers to treatment continuation. Fourth, the interpersonal level interaction of patients should not be neglected; this includes family relationships and support as well as peer influence.

CONCLUSION

Study findings put forth issues and challenges faced by TB patients while receiving treatment and underscore areas where actions can be taken. This will contribute to informing the development and implementation of future TB control strategies that are responsive to TB patients' needs and concerns, to effectively address LTFU and ensure better treatment completion rates among TB patients in Malaysia.

FACTORS CONTRIBUTING TO PULMONARY TB TREATMENT LOST TO FOLLOW-UP IN DEVELOPING COUNTRIES: AN OVERVIEW

Background

Despite the available treatment options, pulmonary tuberculosis (TB) remains a leading cause of disease-related deaths worldwide. Treatment non-adherence/lost to follow-up (LTFU), particularly in developing countries, is a continuous concern. LTFU prolongs TB infectiousness and contributes to TB treatment failure, relapse, and death. Furthermore, LTFU also delays global TB eradication by promoting TB spread and drug-resistant TB strain development.[1] The purpose of this paper is to give an overview of the commonly observed risk factors associated with TB treatment LTFU in developing countries.

Materials and Methods

A literature survey was done of studies published in the past decade, which evaluated the risk factors for LTFU in TB patients, specifically in developing countries. Furthermore, some prospective TB treatment adherence initiatives and the feasibility of these initiatives within developing countries were assessed.[3].

Results

Several variables, including socio-demographic, patient-related, TB disease and other health-related-factors, healthcare and system determinants, as well as treatment-related factors, were identified to increase the risk of TB treatment LTFU. More recently applied adherence interventions in developing countries, show potential for implementation on a larger scale.

Conclusion

Successful TB treatment is contingent on treatment adherence, and by addressing these persisting LTFU risk factors, treatment adherence in developing countries may be improved.

Nonadherence Predictors to Tuberculosis Medications among TB Patients in Gambella Region of Ethiopia

Background

Global tuberculosis (TB) disease deaths rise comparable to the one seen in 2015 (by 200,000) or even in 2012 (by 400,000) as a result of the potential impact of the COVID-19 pandemic. Ethiopia's Gambella region is leading for years in terms of TB cases and its comorbidities. The TB control program effectiveness depends on in large on the patients completing the appropriate treatment regimen. Hence, the objective of this study was to determine the determinants of nonadherence to anti-TB drug treatment among patients in Gambella regional state of Ethiopia.

Methods

A case-control study was conducted on cohorts of TB patients sampled from four public health facilities in Gambella Region from January 2019 to 2020, followed by 18 months of follow-up. The total sample size was 296 patients (74 cases and 222 controls) with a response rate of 97.3% (288 : 72 nonadhered cases and 216 controls). Cases (nonadhered) were TB patients who missed 10% of the doses while controls were patients, who completed 90% or more doses.

Results

TB patients, who perceived stigma [AOR = 2.7 at 95% CI (1.1–6.6) with P value <0.05], failed to receive any counseling during the treatment course [AOR = 65.24 at 95% CI (11.69–363.95) with P value <0.01], patients who used to smoking during treatment [AOR = 15.4 at 95% CI (7.7–30) with P value <0.01], taking TB medications regularly has no benefits [AOR = 6.8 at 95% CI (1.8–24.9) with P value <0.05], and patients believing TB disease as not severe [AOR = 8.38 at 95% CI (2.0–34.6) with P value <0.05] were significantly or highly significantly associated with nonadherence to anti-TB drugs medications.

Conclusion

The determinants of nonadherence to anti-TB treatment among TB patients in the Gambella region during the study period were the absence of counselling services, and patients' behavior (smoking habits, undermining the severity of TB disease, lack of trust in the outcomes of regular medications, and perceived stigmatization). Accordingly, capacitating healthcare providers and workers at all TB clinics for effective counseling , preventing perceived stigma by protecting the patient's secrecy, and routine health education has paramount importance for effective TB control in Gambella.

Exploring Factors Associated with Diabetic Retinopathy Treatment Compliance Behaviour in Cape Town, South Africa

Complete patient adherence to treatment for diabetic retinopathy (DR) is critical to limit vision loss. There is a dearth of evidence regarding the reasons why South African patients referred for suspected vision-threatening DR stay compliant to or default their treatment. The current study sought to explore factors associated with treatment compliance among patients living with diabetes who have been referred for suspected vision-threatening DR in the Northern/Tygerberg sub-Structure (NTSS) public health care system of Cape Town, South Africa. A qualitative research approach was used where semi-structured in-depth interviews were conducted with 13 adult patients living with DR, and 2 key informants who are primary eye care providers. Thematic data analysis was conducted using taguette.org. Fear of going blind was the most notable patient-related factor associated with compliance. Notable patient-related barriers reported were forgetfulness and a poor state of health. Notable institution-related barriers included suboptimal information received from health care service providers, poor referral management by the organisation delivering retinal screening services, as well as the inaccessibility of the main NTSS hospital via telephone calls. All these factors were confirmed by the key informants of the current study. Finally, all patients and key informants agreed that SARS-CoV-2 negatively affected patients’ adherence to their DR treatment. Hence, scaling up of health care, referral, and appointment setting services could increase the uptake of treatment and retinal screenings among patients attending the Cape Town, NTSS public health care system.

Predictors of Drug-Resistant Tuberculosis among High-Risk Population Diagnosed under National Program Conditions in the Littoral Region, Cameroon

Multiple drug resistance TB (MDR-TB) has greatly jeopardized the effective control of tuberculosis in Africa. This study is aimed at determining the incidence and predictors of drug resistant-TB amongst bacteriologically diagnosed cases in the Littoral region of Cameroon. This was a descriptive cross-sectional survey conducted from January 2016 to December 2017. A total of 1665 participants were enrolled from 32 diagnostic and treatment centers (DTCs) in the Littoral region. Demographic, clinical, socioeconomic, and behavioral data were obtained using a pretested structured questionnaire. Drug susceptibility testing was performed using Gene Xpert MTB/RIF assay and line probe assay (LPA). Consent was obtained from participant/guidance. Data analysis was carried with SPSS version 21. Univariate and multiple logistic regression was performed at 5% significance level. The incidence of rifampicin and MDR-TB was 86 (5.2%) and 75 (4.5%), respectively. More (11.3%) cases of drug resistance were diagnosed in 2016 compared to 2017 (3.7%). Eleven (0.7%) were resistant to rifampicin only. A total of 19 (4.4%) cases of rifampicin resistance were detected from newly diagnosed cases and 67 (5.4%) from previously retreated cases. Pre-XDR-TB was detected in 2 (2.7%) of the MDR-TB cases amongst whom 1 (1.3%) was extensive drug resistance TB (XDR-TB). Age greater than 60 years old (OR = 4.98, p = 0.047), being married (OR = 1.91, p = 0.006), being currently incarcerated (OR = 1.74, p = 0.027), and having contact with known TB cases (OR = 1.88, p = 0.007) were associated to MDR-TB in a univariate analysis. This study highlights the declining rates of TB drug resistance in the region over the years probably due to the introduction of Gene Xpert that results in early detection of RR-TB. It also shows that age greater than 60 years, being married, and incarcerated are predictors of drug resistant-TB, while the year of patient enrolment and previous exposure to TB treatment were independent predictors of drug resistance in the Littoral region of Cameroon.

Treatment Interruption Among Drug-Susceptible Pulmonary Tuberculosis Patients in Southern Ethiopia

BACKGROUND

Tuberculosis treatment interruption is a failure of attending two scheduled appointments to collect the drugs in either phase of tuberculosis treatment. Even if TB treatment is crucial to achieve a cure and avoid the emergence of drug resistance, treatment interruption is the most testing and deterring factor for successful tuberculosis treatment and one of the problems leading to the development of drug-resistant tuberculosis. TB treatment interruption is the precursor for loss to follow-up and treatment failure, but the magnitude of this problem is unknown in Ethiopia. Thus, this study was intended to identify determinants of treatment interruption among drug-susceptible pulmonary tuberculosis patients in South Ari district, Southern Ethiopia.

METHODS

An institution-based unmatched case control study was conducted from February through April 2020 using 255 samples with a ratio of 2:1 (controls to cases). Data were entered into Epi data version 4.2 and exported for analysis using STATA 14.0 statistical software. The variables having a p-value of less than 0.25 in the bivariable analysis were subjected to multivariable logistic regression analysis. In multivariable logistic regression analysis, AORs, 95% CIs, and p-values of <0.05 were used to identify significant variables.

RESULTS

The median age was 34 (IQR: 18) years in cases and 29 (IQR: 16) years in control groups. Significant factors that were associated with treatment interruption were alcohol consumption (AOR = 2.99, 95% CI; 1.41-6.36); smoking habits (AOR = 2.82, 95% CI; 1.14-6.94); use of traditional medicine (AOR = 2.35, 95% CI 1.05-5.24); co-infected with HIV (AOR=1.58, 95% CI; 1.85-4.29), and waiting time at the health facility ≥30 minutes (AOR = 2.98, 95% CI; 1.31-6.80).

CONCLUSION

Alcohol consumption, waiting time at the health facility ≥30 minutes, smoking habits, used traditional medicine, and HIV co-infected were potential determinants. Enhancing public health education, designing strategies that emphasize patients with HIV co-infection, and reducing waiting times are recommended.

Quantification and correlates of tuberculosis stigma along the tuberculosis testing and treatment cascades in South Africa: a cross-sectional study

Background

South Africa has one of the world’s worst tuberculosis (TB) (520 per 100 000 population) and TB-human immunodeficiency virus (HIV) epidemics (~ 56% TB/HIV co-infected). While individual- and system-level factors influencing progression along the TB cascade have been identified, the impact of stigma is underexplored and underappreciated. We conducted an exploratory study to 1) describe differences in perceived community-level TB stigma among community members, TB presumptives, and TB patients, and 2) identify factors associated with TB stigma levels among these groups.

Methods

A cross sectional study was conducted in November 2017 at public health care facilities in Buffalo City Metro (BCM) and Zululand health districts, South Africa. Community members, TB presumptives, and TB patients were recruited. Data were collected on sociodemographic characteristics, TB knowledge, health and clinical history, social support, and both HIV and TB stigma. A validated scale assessing perceived community TB stigma was used. Univariate and multivariate linear regression models were used to describe differences in perceived community TB stigma by participant type and to identify factors associated with TB stigma.

Results

We enrolled 397 participants. On a scale of zero to 24, the mean stigma score for TB presumptives (14.7 ± 4.4) was statistically higher than community members (13.6 ± 4.8) and TB patients (13.3 ± 5.1). Community members from Zululand (β = 5.73; 95% CI 2.19, 9.72) had higher TB stigma compared to those from BCM. Previously having TB (β = − 2.19; 95% CI − 4.37, 0.0064) was associated with reduced TB stigma among community members. Understanding the relationship between HIV and TB disease (β = 2.48; 95% CI 0.020, 4.94), and having low social support (β = − 0.077; 95% CI − 0.14, 0.010) were associated with increased TB stigma among TB presumptives. Among TB Patients, identifying as Black African (β = − 2.90; 95% CI − 4.74, − 1.04) and knowing the correct causes of TB (β = − 2.93; 95% CI − 4.92, − 0.94) were associated with decreased TB stigma, while understanding the relationship between HIV and TB disease (β = 2.48; 95% CI 1.05, 3.90) and higher HIV stigma (β = 0.32; 95% CI 0.21, 0.42) were associated with increased TB stigma.

Conclusions

TB stigma interventions should be developed for TB presumptives, as stigma may increase initial-loss-to-follow up. Given that stigma may be driven by numerous factors throughout the TB cascade, adaptive stigma reduction interventions may be required.

Initial loss to follow up of tuberculosis patients in South Africa: perspectives of program managers

Background

Tuberculosis (TB) remains a serious public health problem in South Africa. Initial loss to follow up (LTFU) rates among TB patients are high, varying between 14.9 and 22.5%. From the perspective of patients, documented reasons for this include poor communication between patient and staff after testing, not being aware that results are ready and other competing priorities such as preference to go to work as opposed to seeking healthcare. Ward-based Outreach Teams (WBOTs) routinely conduct home visits to ensure adherence to medication for various conditions including TB. We explored reasons for TB initial loss to follow up from the perspectives of TB program managers and WBOT program managers, with a focus on the WBOT’s (potential) role in reducing initial LTFU, in particular.

Methods

Key informant interviews with five WBOT program managers and four TB program managers were conducted. The interviews were audio-recorded, then transcribed and exported to NVivo 11 software for coding. A hybrid analytic approach consisting of both inductive and deductive coding was used to identify themes.

Results

The age of the nine managers ranged between 28 and 52 years old, of which two were male. They had been in their current position for between 2 to 12 years. Prior to treatment initiation, WBOTs screen household members for TB and refer them for TB testing if need be, but integration of the two programs is emphasized only after TB treatment has been initiated. Counseling of patients testing for TB is not guaranteed due to frequent staff rotations and staff shortages. Participants reported that possible dissatisfaction with services as well as stigma associated with the TB diagnosis could explain loss to follow up prior to treatment initiation.

Conclusion

Program managers view health system related factors such as staff rotations, poor communication with patients and lack of counseling as contributing to the problem of initial LTFU among TB patients. The integration of the WBOT and TB programs is limited to referring suspected cases for testing and patients already on treatment.

'They are inconveniencing us' - exploring how gaps in patient education and patient centred approaches interfere with TB treatment adherence: perspectives from patients and clinicians in the Free State Province, South Africa

BACKGROUND

Tuberculosis (TB) treatment loss to follow up (LTFU) plays an important contributory role to the staggering TB epidemic in South Africa. Reasons for treatment interruption are poorly understood. Treatment interruption appears to be the culmination of poor health literacy of patients and inadequate health education provided by clinicians. We explored clinician and patient perspectives of the gaps in TB messaging that influence TB treatment LTFU.

METHODS

We conducted semi-structured in-depth interviews between January and May 2018 with a sample of 15 clinicians managing TB and 7 patients identified as LTFU in public clinics in the Free State Province, South Africa. Thematic analysis using a mixed deductive/inductive thematic approach was used.

RESULTS

Limited occupational opportunities, fear of disclosure and stigmatization all contributed to treatment LTFU. Patients felt that the TB messaging received was inadequate. Many of the clinicians interviewed felt that improving patient's TB knowledge would reinforce adherence to treatment and thus focused on sharing information on treatment completion, side effects and infection control. However, the inability of clinicians to establish rapport with patients or to identify social support challenged TB treatment adherence by patients. Clinicians perceived this as patients not following their instructions despite what they considered lengthy TB education. Having said this, clinicians concurred that their medical management of TB lacked the psycho-social dimension to treat a social disease of this magnitude.

CONCLUSIONS

Limited occupational opportunities, fear of disclosure and stigmatization all contributed to treatment LTFU. Clinicians concurred that poor patient understanding of TB and that biomedical management lacking a psycho-social dimension further exacerbated the poor treatment outcome. TB remains a social disease, the successful management of which hinges on patient-centred care.

User experience and patient satisfaction with tuberculosis care in low- and middle-income countries: A systematic review

Background

Patient-centered care is at the forefront of the End TB strategy, yet little is known about user (patient's) experience and patient satisfaction with TB services. Our study aims to systematically review quantitative studies evaluating user experience and TB patient satisfaction within the health care system.

Methods

Five medical databases were systematically searched between January 1st, 2009 and December 31st, 2018. English studies assessing user experience and patient satisfaction within the healthcare system from a TB patient's perspective in low and middle-income countries, were included.

Results

Thirty-five studies from 16 low and middle-income countries evaluated three major themes; facilities and patient centeredness (n = 23), patient-provider relationship (n = 22) and overall satisfaction (n = 19). Overall study quality was low as they used varying tools to measure user experience and patient satisfaction.

Conclusion

Our study shows large variability in measurement of user experiences and patient satisfaction. Studies reported that patients were mostly satisfied with TB care services, and those that were dissatisfied were substantially more likely to be lost to follow-up. The high satisfaction rates could have been due to lack of education on good quality patient care or fear of losing access to health care. A standardized patient centered tool could be designed to help assess user experience and patient satisfaction to allow comparisons among health systems and countries.

Comorbidities between tuberculosis and common mental disorders: a scoping review of epidemiological patterns and person-centred care interventions from low-to-middle income and BRICS countries

Background

There is increasing evidence that the substantial global burden of disease for tuberculosis unfolds in concert with dimensions of common mental disorders. Person-centred care holds much promise to ameliorate these comorbidities in low-to-middle income countries (LMICs) and emerging economies. Towards this end, this paper aims to review 1) the nature and extent of tuberculosis and common mental disorder comorbidity and 2) person-centred tuberculosis care in low-to-middle income countries and emerging economies.

Main text

A scoping review of 100 articles was conducted of English-language studies published from 2000 to 2019 in peer-reviewed and grey literature, using established guidelines, for each of the study objectives. Four broad tuberculosis/mental disorder comorbidities were described in the literature, namely alcohol use and tuberculosis, depression and tuberculosis, anxiety and tuberculosis, and general mental health and tuberculosis. Rates of comorbidity varied widely across countries for depression, anxiety, alcohol use and general mental health. Alcohol use and tuberculosis were significantly related, especially in the context of poverty. The initial tuberculosis diagnostic episode had substantial socio-psychological effects on service users. While men tended to report higher rates of alcohol use and treatment default, women in general had worse mental health outcomes. Older age and a history of mental illness were also associated with pronounced tuberculosis and mental disorder comorbidity. Person-centred tuberculosis care interventions were almost absent, with only one study from Nepal identified.

Conclusions

There is an emerging body of evidence describing the nature and extent of tuberculosis and mental disorders comorbidity in low-to-middle income countries. Despite the potential of person-centred interventions, evidence is limited. This review highlights a pronounced need to address psychosocial comorbidities with tuberculosis in LMICs, where models of person-centred tuberculosis care in routine care platforms may yield promising outcomes.

Adherence to Anti-Tuberculosis Treatment Among Pediatric Patients at Nekemte Specialized Hospital, Western Ethiopia

BACKGROUND

Non-adherence to tuberculosis treatment is the most challenging and hindering factor for successful tuberculosis therapy. The long duration of tuberculosis treatment and the undesirable effects of anti-tuberculosis drugs result in non-adherence to treatment among pediatric patients. Hence, this study was aimed to evaluate pediatrics adherence status among tuberculosis pediatric patients on anti-tuberculosis treatment at Nekemte Specialized Hospital.

METHODS

A health facility-based cross-sectional study design was used to recruit pediatric TB patients who were receiving their treatment between February 15 and March 15, 2019. Adherence to tuberculosis therapy was evaluated using data obtained from face-to-face interviews of their respective caregivers. The collected data were entered into EPI-manager 4.0.2 software and analyzed using SPSS version 24. Logistic regression was used to analyze the variables and variables with p-value <0.05 had a statistically significant association with the adherence to anti TB treatment.

RESULTS

Among 202 participants involved in the study, 120 (59.4%) of them were males and 119 (58.9%) were in the age category of 11-15 years. A total of 166 (82.2%) of the patients had extra-pulmonary tuberculosis and 174 (86.1%) of them were in the intensive phase. Of the pediatric tuberculosis patients, 48 (73.3%) of them have adhered to the treatment regimen. Female gender [AOR: 3.3, 95% CI: 1.52-7.2], younger age (0-5 years) [AOR: 5.96 95% CI: 1.81-19.6], living in urban area [AOR: 3.73, 95% CI: 1.67-8.36], and patients who did not experience side effect [AOR: 2.87, 95% CI: 1.41-5.81] were predictors of good adherence to tuberculosis treatment up on multivariable logistic regression analysis.

CONCLUSION

The level of adherence observed in our study area was low. Age, sex, residence, and side effect experience showed an association with tuberculosis treatment adherence. Therefore, health care providers should educate all patients with tuberculosis before the initiation of anti-tuberculosis treatment.

The Isoniazid Paradigm of Killing, Resistance, and Persistence in Mycobacterium tuberculosis

Isoniazid (INH) was the first synthesized drug that mediated bactericidal killing of the bacterium Mycobacterium tuberculosis, a major clinical breakthrough. To this day, INH remains a cornerstone of modern tuberculosis (TB) chemotherapy. This review describes the serendipitous discovery of INH, its effectiveness on TB patients, and early studies to discover its mechanisms of bacteriocidal activity. Forty years after its introduction as a TB drug, the development of gene transfer in mycobacteria enabled the discovery of the genes encoding INH resistance, namely, the activator (katG) and the target (inhA) of INH. Further biochemical and x-ray crystallography studies on KatG and InhA proteins and mutants provided comprehensive understanding of INH mode of action and resistance mechanisms. Bacterial cultures can harbor subpopulations that are genetically or phenotypically resistant cells, the latter known as persisters. Treatment of exponentially growing cultures of M. tuberculosis with INH reproducibly kills 99% to 99.9% of cells in 3 days. Importantly, the surviving cells are slowly replicating or non-replicating cells expressing a unique stress response signature: these are the persisters. These persisters can be visualized using dual-reporter mycobacteriophages and their formation prevented using reducing compounds, such as N-acetylcysteine or vitamin C, that enhance M. tuberculosis' respiration. Altogether, this review portrays a detailed molecular analysis of INH killing and resistance mechanisms including persistence. The phenomenon of persistence is clearly the single greatest impediment to TB control, and research aimed at understanding persistence will provide new strategies to improve TB chemotherapy.

ImPROving TB outcomes by modifying LIFE-style behaviours through a brief motivational intervention followed by short text messages (ProLife): study protocol for a randomised controlled trial

Background

South Africa is among the seven highest tuberculosis (TB) burden countries. Harmful lifestyle behaviours, such as smoking and alcohol, and poor adherence to medication can affect clinical outcomes. Modification of these behaviours is likely to improve TB treatment outcomes and has proven possible using motivational interviewing (MI) techniques or use of short message service (SMS) text messaging. There have been no studies assessing the effect of combined MI and SMS interventions on multiple lifestyle factors and TB treatment outcomes.

Methods

This is a prospective, multicentre, two-arm individual randomised controlled trial looking at the effectiveness and cost-effectiveness of a complex behavioural intervention (the ProLife programme) on improving TB and lifestyle-related outcomes in three provinces of South Africa. The ProLife programme consists of an MI counselling strategy, delivered by lay health workers, augmented with subsequent SMS. We aim to recruit 696 adult participants (aged 18 years and over) with drug-sensitive pulmonary TB who are current smokers and/or report harmful or hazardous alcohol use. Patients will be consecutively enrolled at 27 clinics in three different health districts in South Africa. Participants randomised individually to the intervention arm will receive three MI counselling sessions one month apart. Each MI session will be followed by twice-weekly SMS messages targeting treatment adherence, alcohol use and tobacco smoking, as appropriate. We will assess the effect on TB treatment success, using standard World Health Organization (WHO) treatment outcome definitions (primary outcome), as well as on a range of secondary outcomes including smoking cessation, reduction in alcohol use, and TB medication and anti-retroviral therapy adherence. Secondary outcomes will be measured at the three-month and six-month follow-ups.

Discussion

This trial aligns with the WHO agenda of integrating TB care with the care for chronic diseases of lifestyle, such as provision of smoking cessation treatments, and with the use of digital technologies. If the ProLife programme is found to be effective and cost-effective, the programme could have significant implications for TB treatment globally and could be successfully implemented in a wide range of TB treatment settings.

Trial registration

ISRCTN Registry, ISRCTN62728852. Registered on 13 April 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3551-9) contains supplementary material, which is available to authorized users.

Factors associated with non-adherence during tuberculosis treatment among patients treated with DOTS strategy in Jayapura, Papua Province, Indonesia

BACKGROUND

Despite the implementation of Directly Observed Treatment Short-course (DOTS) strategy in all public health centers in Papua Province, Indonesia, since 1998, the rate of loss to follow-up (LTFU) during tuberculosis (TB) treatment remains high (above 16%).

OBJECTIVES

We aimed to identify factors associated with non-adherence during TB treatment among patients treated at public health centers (PHCs) in Jayapura, Papua.

METHOD

We conducted a case-control study including new TB patients registered at eight PHCs from 2007 to 2009. Non-adherent cases were TB patients with a history of not taking anti-TB drugs for >2 consecutive weeks or >30 days cumulatively. Controls were randomly selected from patients who completed all doses of TB drugs in time. Data were collected by face-to-face interview using a pre-structured questionnaire and analyzed with logistic regression models.

RESULTS

Data were available for 81 of 103 eligible cases and 183 of 206 eligible controls. Difficult access to healthcare (i.e. reported to have a problem with distance/travel cost and history of moving residence in the past year), lack of TB knowledge (i.e. lack of knowledge about TB transmission and the cause of TB and unawareness of the consequences of stopping TB treatment), and treatment experience (i.e. lack of TB education provided by TB nurse and the use of loose vs. fixed-dose combinations) were associated with non-adherence during TB treatment in the adjusted model, as were being aged under 35 years and having a history of TB in the family.

CONCLUSION

Our results suggest the need to improve TB treatment delivery especially to those who have difficult access to healthcare, and to routinely provide education to increase patients' knowledge about TB and TB treatment. In addition, more attention to younger patients and those with a history of TB in their family is also needed.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

The impact of social conditions on patient adherence to pulmonary tuberculosis treatment

SETTING

Tuberculosis (TB) remains one of the main concerns in global health. One of the main threats to treatment success is patient non-adherence to anti-tuberculosis treatment.

OBJECTIVE

To identify the relation between social conditions and treatment adherence in a prospective cohort setting in an intermediate TB burden country.

DESIGN

To identify associations between poor adherence and social conditions, including educational level, type of residence and occupation, we constructed hierarchical logistic regression models.

RESULTS

A total of 551 participants were included in the study. Low educational levels, poor housing and occupations in the construction and manufacturing industries and service sectors were associated with poor adherence; this association was likely to be differentiated by previous history of anti-tuberculosis treatment.

CONCLUSION

Policy making should focus on improving the social conditions of patients by working towards better housing conditions and providing health promoting working conditions to enable treatment adherence.

Factors associated with interruption of tuberculosis treatment among patients in Nandi County, Kenya 2015

Introduction

Kenya is ranked 15th on the list of 22 high-tuberculosis (TB) burden countries with a case notification rate of 440 cases per 100,000 persons. Interruption of TB treatment is one of the major obstacles to effective TB treatment and control. Since 2009, emphasis has been on direct observation treatment short-course (DOTS) to ensure adherence. This study assessed the factors associated with interruption of treatment among patients on DOTS in Nandi County, Kenya.

Methods

we reviewed medical records and interviewed randomly selected persons from the County TB register, among those initiated on TB treatment between 1st January 2013 and 30th June 2014. Data on socio-demographics, clinical characteristics, behavioral factors, family support, health system factors, income, and lifestyle and treatment interruption (i.e., therapy discontinuation ≥ 2 weeks) were collected. We calculated odds ratios (OR) and 95% confidence intervals (CI) to evaluate factors associated with TB interruption and performed multivariable logistic regression to examine independent risk factors.

Results

from a total of 1,287 records in the TB register, we randomly selected 280 patients for interview, out of whom 252 were traced. Of the 252 participants interviewed, 149 (59.1%) were males and the mean age was 40.0 (SD ± 15.3) years. Seventy-eight (31.0%) interrupted treatment. Treatment interruption was associated with personal monthly income ≤ 10,000 Kenya shillings ($100) (AOR 4.3, CI = 2.13-8.62) compared to income > 10,000 Kenya shillings, daily alcohol consumption of > 3 days per week (AOR 3.3, CI = 1.72-6.23) compared to consumption of ≤ 3 days per week and average waiting time at the health facility ≥ 1 hour (AOR 3.5 CI = 1.86-6.78) compared to waiting time < 1 hour.

Conclusion

we suggest expanding DOTS services to increase the number of service points for patients. This will probably reduce the waiting time by distributing the work load across many facilities. Intensifying patient counseling and education prior to initiation of treatment could also be adopted to cover effects of alcohol use during treatment and teach patients to take up some income generating activities.

Patient attitudes towards community-based tuberculosis DOT and adherence to treatment in an urban setting; Kampala, Uganda

INTRODUCTION

High Tuberculosis treatment default rate (17%) and sub-optimal treatment completion rates (45%) has burdened Kampala. Nevertheless, there are observable increase in the number of patients on TB DOT; from 6% to 29% in two consecutive annual reports. The main objective was to determine the association of TB patient attitudes towards community-based observers on the TB drug adherence on directly observed treatment for TB in Kampala.

METHODS

A cross-sectional study was carried out in Lubaga division, Kampala. A total of 201 patients in continuation phase of treatment for Pulmonary TB (i.e. 8 to 20 weeks of TB treatment) were included in the study. Patient attitudes were measured using a 4-point Likert scale aggregated into a binary outcome with ''agree'' and ''disagree'' responses. Poisson regression model using a forward fitting approach in STATA v12 was used to determine the association between patient attitude towards CB-DOTs observers and adherence to TB treatment.

RESULTS

Among the 201 patients, 66% reported their treatment was being observed by someone. Relatives were the commonest (82%) treatment observers, 26% were non adherent to their TB treatment. Perceiving ''no need for a treatment observer'' and ''people rejecting TB patients'' were predictors of non-adherence to TB treatment (IRR=1.6,95%CI 1.00-2.57;p=0.048) and (IRR=0.6, 95%CI 0.35-0.95; p=0.019) respectively.

CONCLUSION

Patient's perceived attitude and stigma towards treatment observers contribute to non-adherence on TB treatment. For improved local TB control, more emphasis is needed to build a friendly environment between treatment supporters and patients during the course of TB treatment.

Magnitude and determinants of adverse treatment outcomes among tuberculosis patients registered under Revised National Tuberculosis Control Program in a Tuberculosis Unit, Wardha, Central India: A record-based cohort study

INTRODUCTION

Deaths, defaults, relapses, and treatment failures have made the control of TB difficult across the globe.

METHODOLOGY

This study is a record-based follow-up of a cohort of patients registered under Revised National Tuberculosis Control Program in the year 2014 in Wardha Tuberculosis Unit, India. Data was collected from the records available at the District Tuberculosis Office.

RESULTS

Data of 510 patients was analyzed. The sputum conversion rate was 88%. The overall treatment success rate was 81.9%, and rates of any adverse outcome, deaths, defaults, failure, and shift to Category IV regimen were 32.60/100 person years at risk (PYAR), 16.88/100 PYAR, 11.12/100 PYAR, 3.45/100 PYAR, and 1.15/100 PYAR, respectively. The median times for the above outcomes were 81days, 110days, 66days, 118days, and 237days, respectively. The cumulative probability of occurrence at 6months of any adverse outcome, deaths, default, failure, and shift to Category IV regimen was 0.145, 0.056, 0.088, 0.002, and 0.004, respectively. On multivariate analysis, the determinant of any adverse outcome was age >45years, whereas extrapulmonary disease was protective. The hazard of defaulting was also significantly higher in male patients and those aged >45years.

CONCLUSION

Appropriate interventions and program implementation to reduce the adverse treatment outcomes and interruptions will help in improving program performance.

Assessment of Directly Observed Treatment in Revised National Tuberculosis Control Programme: A Study from North India

Introduction:

Directly observed treatment short-course (DOTS) strategy is one of the vital components of Revised National Tuberculosis Control Programme (RNTCP) came into existence in 1997. Directly observed treatment providers (DOT providers) are the grass root level link between program and clients.

Aims:

This study was undertaken to assess the quality of DOTS and facilities available at DOT centers and association between program input and outcome.

Materials and Methods:

This prospective study was carried out to evaluate RNTCP in a North Indian District. Totally, 42 DOT providers providing treatment to registered RNTCP patients in four designated microscopy centers were included in this study. Program input was assessed based on a ten-point questionnaire regarding processes and facilities followed DOT center. Treatment outcome of 302 patients receiving DOTS under these providers was also assessed.

Statistical Analysis:

Data were analyzed using SPSS version 20. Categorical variables such as age group, sex, religion, location, work experience of DOT providers are measured in frequency and percentage. Chi-square was used to find association between quality of DOTS and outcome of treatment. P < 0.05 was considered statistically significant.

Results:

The basic principle of DOTS was followed only in half (47.6%) of the DOT centers, counseling was not being done by 40.5% of the providers. Formal training of DOTS was given to two-thirds of the providers. The treatment outcome of patients was significantly associated with program input at DOT center level (Chi-square = 4.02, P < 0.05).

Conclusions:

There are few gaps in DOT practices such as administration of DOTS, patient counseling, and tracing of follow-up. This study also concluded that improved program input can enable to get a better outcome.

Patient non adherence to tuberculosis treatment in Sudan: socio demographic factors influencing non adherence to tuberculosis therapy in Khartoum State

INTRODUCTION

Despite the Treatment pulmonary TB patients, defaulting from treatment may remain the major challenge to control TB. In addition, it increases the risk of drug resistance, relapse, and death and may prolong infectiousness. Our objective was to identify determinants of treatment defaulting among TB patients in Khartoum State, Sudan.

METHODS

We conducted a case-control study where the patients defaulting from treatment were considered as 'cases' and those completing treatment as 'controls'. Between May 2010 to May 2011.

RESULTS

There were 2727 TB patients who attended TB treatment clinics during study period. Out of these 2399 patients (86%) had continued their treatment while 328 patients (14%) had interrupted it. 105 cases were traced and interviewed. In addition 210 patients who had continued their treatment were included (controls). In the multivariate analysis the variables that remained in the model were: residential locality (rural area) (OR 2.58; 95% CI 1.4 -4.67), patients moving or changing address (OR 5.47; 95% CI 2,90- 10-35), absence of family support (OR 2.14; 95% CI 1.12 - 4.11), and occupation (blue collar work) (OR 2.38; 95% CI 1.39 -4.10).

CONCLUSION

The results of this study conclude some socio-demographic factors influence defaulting of TB treatment. We believe that the findings are applicable to current situation of TB management and control in Sudan and other developing countries.

Using Survival Analysis to Identify Risk Factors for Treatment Interruption among New and Retreatment Tuberculosis Patients in Kenya

Despite high tuberculosis (TB) treatment success rate, treatment adherence is one of the major obstacles to tuberculosis control in Kenya. Our objective was to identify patient-related factors that were associated with time to TB treatment interruption and the geographic distribution of the risk of treatment interruption by county. Data of new and retreatment patients registered in TIBU, a Kenyan national case-based electronic data recording system, between 2013 and 2014 was obtained. Kaplan-Meier curves and log rank tests were used to assess the adherence patterns. Mixed-effects Cox proportional hazards modeling was used for multivariate analysis. Records from 90,170 patients were included in the study. The cumulative incidence of treatment interruption was 4.5% for new patients, and 8.5% for retreatment patients. The risk of treatment interruption was highest during the intensive phase of treatment. Having previously been lost to follow-up was the greatest independent risk factor for treatment interruption (HR: 4.79 [3.99, 5.75]), followed by being HIV-positive not on ART (HR: 1.96 [1.70, 2.26]) and TB relapse (HR: 1.70 [1.44, 2.00]). Male and underweight patients had high risks of treatment interruption (HR: 1.46 [1.35, 1.58]; 1.11 [1.03, 1.20], respectively). High rates of treatment interruption were observed in counties in the central part of Kenya while counties in the northeast had the lowest risk of treatment interruption. A better understanding of treatment interruption risk factors is necessary to improve adherence to treatment. Interventions should focus on patients during the intensive phase, patients who have previously been lost to follow-up, and promotion of integrated TB and HIV services among public and private facilities.

[Factors related to treatment adherence in patients with tuberculosis in Pereira, Colombia, 2012-2013]

INTRODUCTION

According to the World Health Organization, the adherence to the tuberculosis treatment is the extent to which a patient's medication taking coincides with the prescribed treatment. The sum of cured patients and those who have completed treatment (directly observed therapy strategy, DOTS) are pragmatic indicators of the adherence. The patients who do not complete treatment correspond to non-adherents. Objective: To determine the relationship between anti-tuberculosis treatment adherence and socio-demographic, economic, clinical, and drug-related objective and subjective factors in patients over 18 years of age. Materials and methods: This was a descriptive, cross-sectional study of 174 patient records of the tuberculosis control program and 15 semi-structured interviews to non-adherent patients during the period between June, 2012, and June, 2013. Results: The adherence in patients with pulmonary tuberculosis was 94.8%. It was higher in patients in the social security contributory regime (p=0.035). Non-adherence was 5.2%. Drug intolerance was higher in the group of non-adherent patients. The lack of family support, absenteeism in the workplace, economic impact and dissatisfaction with the timeliness and the care of the health institution, were important in the decision of non-adherence.

CONCLUSIONS

Affiliation to the health system regime and drug tolerance were objective factors related to adherence to treatment. The social and economic burden of disease is a subjective factor associated with the decision of not adhering to treatment.

Adherence to Concurrent Tuberculosis Treatment and Antiretroviral Treatment among Co-Infected Persons in South Africa, 2008-2010

Background

Adherence to tuberculosis (TB) treatment and antiretroviral therapy (ART) reduces morbidity and mortality among persons co-infected with TB/HIV. We measured adherence and determined factors associated with non-adherence to concurrent TB treatment and ART among co-infected persons in two provinces in South Africa.

Methods

A convenience sample of 35 clinics providing integrated TB/HIV care was included due to financial and logistic considerations. Retrospective chart reviews were conducted among persons who received concurrent TB treatment and ART and who had a TB treatment outcome recorded during 1 January 2008–31 December 2010. Adherence to concurrent TB and HIV treatment was defined as: (1) taking ≥80% of TB prescribed doses by directly observed therapy (DOT) as noted in the patient card; and (2) taking >90% ART doses as documented in the ART medical record during the concurrent treatment period (period of time when the patient was prescribed both TB treatment and ART). Risk ratios (RRs) and 95% confidence intervals (CIs) were used to identify factors associated with non-adherence.

Results

Of the 1,252 persons receiving concurrent treatment, 138 (11.0%) were not adherent. Non-adherent persons were more likely to have extrapulmonary TB (RR: 1.71, 95% CI: 1.12 to 2.60) and had not disclosed their HIV status (RR: 1.96, 95% CI: 1.96 to 3.76).

Conclusions

The majority of persons with TB/HIV were adherent to concurrent treatment. Close monitoring and support of persons with extrapulmonary TB and for persons who have not disclosed their HIV status may further improve adherence to concurrent TB and antiretroviral treatment.

The Effects of Psycho-Emotional and Socio-Economic Support for Tuberculosis Patients on Treatment Adherence and Treatment Outcomes - A Systematic Review and Meta-Analysis

BACKGROUND

There is uncertainty about the contribution that social support interventions (SSI) can have in mitigating the personal, social and economic costs of tuberculosis (TB) treatment on patients, and improving treatment outcomes.

OBJECTIVE

To identify psycho-emotional (PE) and socio-economic (SE) interventions provided to TB patients and to assess the effects of these interventions on treatment adherence and treatment outcomes.

SEARCH STRATEGY

We searched PubMed and Embase from 1 January 1990-15 March 2015 and abstracts of the Union World Conference on Lung Health from 2010-2014 for studies reporting TB treatment adherence and treatment outcomes following SSI.

SELECTION CRITERIA

Studies measuring the effects of PE or SE interventions on TB treatment adherence, treatment outcomes, and/or financial burden.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed titles and abstracts for inclusion of articles. One reviewer reviewed full text articles and the reference list of selected studies. A second reviewer double checked all extracted information against the articles.

MAIN RESULTS

Twenty-five studies were included in the qualitative analysis; of which eighteen were included in the meta-analysis. Effects were pooled from 11 Randomized Controlled Trials (RCTs), including 9,655 participants with active TB. Meta-analysis showed that PE support (RR 1.37; CI 1.08-1.73), SE support (RR 1.08; CI 1.03-1.13) and combined PE and SE support (RR 1.17; CI 1.12-1.22) were associated with a significant improvement of successful treatment outcomes. Also PE support, SE support and a combination of these types of support were associated with reductions in unsuccessful treatment outcomes (PE: RR 0.46; CI 0.22-0.96, SE: RR 0.78; CI 0.69-0.88 and Combined PE and SE: RR 0.42; CI 0.23-0.75). Evidence on the effect of PE and SE interventions on treatment adherence were not meta-analysed because the interventions were too heterogeneous to pool. No evidence was found to show whether SE reduced the financial burden for TB patients.

DISCUSSION AND CONCLUSIONS

Our review and meta-analysis concluded that PE and SE interventions are associated with beneficial effects on TB treatment outcomes. However, the quality of evidence is very low and future well-designed evaluation studies are needed.

Risk Factors for DOTS Treatment Default Among New HIV-TB Coinfected Patients in Nalgonda (Dist.) Telangana (State): A Case Control Study

Background:

The therapeutic regimens as recommended by the Revised National TB Control Programme (RNTCP) have been shown to be highly effective for both preventing and treating tuberculosis, but poor adherence to medication is a major barrier to its global control.

Aim and Objectives:

The study was conducted to assess the influence of patient related factors for DOTS Treatment Default among HIV-TB Co-infected cases.

Setting and Design:

This was a case control study conducted in Nalgond, Telangana.

Materials and Methods:

All new HIV-TB coinfected and DOTS-defaulted patients registered under RNTCP for the period from January 2010 to December 2012 were selected. Of the 154 patients, 23 had died and 11 could not be traced, and these were excluded. Thus the total number of available cases were 120 for those age- and sex-matched controls (HIV-TB coinfected patients and those who had completed the DOTS regimen successfully) were selected.

Results:

The mean age was 36.5 ± 9 years; the majority (23.3%) of patients defaulted during the second month of treatment. Significant risk factors associated with defaulting included unskilled occupation [adjusted odds ratio (AOR: 3.56; 95% confidence interval (CI): 1.1-11.56], lower middle class socioeconomic status (AOR: 17.16; 95% CI: 3.93-74.82), small family size (AOR: 21.3; 95% CI: 6.4-70.91), marital disharmony (AOR: 6.78; 95% CI: 1.93-23.76), not being satisfied with the conduct of health personnel (AOR: 7.38; 95% CI: 2.32-23.39), smoking (AOR: 8.5; 95% CI: 2.31-31.21), and side effects of drugs (AOR: 4.18; 95% CI: 1.35-12.9).

Conclusion:

Unskilled occupation, marital disharmony, small family size, lower middle class socioeconomic status, not being satisfied with the conduct of health personnel, smoking, and drug side effects were significantly associated with defaulting. Information on the pattern of tuberculosis (TB), the outcome of anti-tuberculosis treatment (ATT), and the factors associated with it will help in planning interventions to improve adherence to DOTS treatment.

Direct Observation of Treatment Provided by a Family Member as Compared to Non-Family Member among Children with New Tuberculosis: A Pragmatic, Non-Inferiority, Cluster-Randomized Trial in Gujarat, India

Background

The World Health Organization recommends direct observation of treatment (DOT) to support patients with tuberculosis (TB) and to ensure treatment completion. As per national programme guidelines in India, a DOT provider can be anyone who is acceptable and accessible to the patient and accountable to the health system, except a family member. This poses challenges among children with TB who may be more comfortable receiving medicines from their parents or family members than from unfamiliar DOT providers. We conducted a non-inferiority trial to assess the effect of family DOT on treatment success rates among children with newly diagnosed TB registered for treatment during June–September 2012.

Methods

We randomly assigned all districts (n = 30) in Gujarat to the intervention (n = 15) or usual-practice group (n = 15). Adult family members in the intervention districts were given the choice to become their child’s DOT provider. DOT was provided by a non-family member in the usual-practice districts. Using routinely collected clinic-based TB treatment cards, we compared treatment success rates (cured and treatment completed) between the two groups and the non-inferiority limit was kept at 5%.

Results

Of 624 children with newly diagnosed TB, 359 (58%) were from intervention districts and 265 (42%) were from usual-practice districts. The two groups were similar with respect to baseline characteristics including age, sex, type of TB, and initial body weight. The treatment success rates were 344 (95.8%) and 247 (93.2%) (p = 0.11) among the intervention and usual-practice groups respectively.

Conclusion

DOT provided by a family member is not inferior to DOT provided by a non-family member among new TB cases in children and can attain international targets for treatment success.

Trial Registration

Clinical Trials Registry–India, National Institute of Medical Statistics (Indian Council of Medical Research) CTRI/2015/09/006229

Predictors of Default from Treatment for Tuberculosis: a Single Center Case-Control Study in Korea

Default from tuberculosis (TB) treatment could exacerbate the disease and result in the emergence of drug resistance. This study identified the risk factors for default from TB treatment in Korea. This single-center case-control study analyzed 46 default cases and 100 controls. Default was defined as interrupting treatment for 2 or more consecutive months. The reasons for default were mainly incorrect perception or information about TB (41.3%) and experience of adverse events due to TB drugs (41.3%). In univariate analysis, low income (< 2,000 US dollars/month, 88.1% vs. 68.4%, P = 0.015), absence of TB stigma (4.3% vs. 61.3%, P < 0.001), treatment by a non-pulmonologist (74.1% vs. 25.9%, P < 0.001), history of previous treatment (37.0% vs. 19.0%, P = 0.019), former defaulter (15.2% vs. 2.0%, P = 0.005), and combined extrapulmonary TB (54.3% vs. 34.0%, P = 0.020) were significant risk factors for default. In multivariate analysis, the absence of TB stigma (adjusted odd ratio [aOR]: 46.299, 95% confidence interval [CI]: 8.078-265.365, P < 0.001), treatment by a non-pulmonologist (aOR: 14.567, 95% CI: 3.260-65.089, P < 0.001), former defaulters (aOR: 33.226, 95% CI: 2.658-415.309, P = 0.007), and low income (aOR: 5.246, 95% CI: 1.249-22.029, P = 0.024) were independent predictors of default from TB treatment. In conclusion, patients with absence of disease stigma, treated by a non-pulmonologist, who were former defaulters, and with low income should be carefully monitored during TB treatment in Korea to avoid treatment default.

Nationwide and regional incidence of microbiologically confirmed pulmonary tuberculosis in South Africa, 2004-12: a time series analysis

BACKGROUND

South Africa has the highest incidence of tuberculosis in the world, largely resulting from a high population prevalence of HIV infection. We investigated the incidence of microbiologically confirmed pulmonary tuberculosis, and new cases of pulmonary tuberculosis registered for treatment, nationally and provincially in South Africa from 2004 to 2012, during which time there were changes in antiretroviral therapy (ART) coverage among individuals with HIV infection.

METHODS

We identified cases of microbiologically confirmed pulmonary tuberculosis from 2004 to 2012 from the National Health Laboratory Service Corporate Data Warehouse. New cases registered for treatment were identified from National Department of Health electronic registries. A time series analysis, using autoregressive models, was undertaken on incidence of microbiologically confirmed pulmonary disease nationally and provincially; this trend was also examined relative to ART coverage of adults with HIV infection.

FINDINGS

During the 9-year period, 3 523 371 cases of microbiologically confirmed pulmonary tuberculosis were recorded nationally. Annual incidence (per 100 000 population) increased from 650 (95% CI 648-652) in 2004 to 848 (845-850) in 2008, declining to 774 (771-776) by 2012 (9% decrease from 2008 to 2012). Incidence varied by age-group, sex, and province. There was an inverse association between incidence of microbiologically confirmed disease and ART coverage among HIV-infected individuals nationally and provincially. Trends in incidence of tuberculosis cases registered for treatment mirrored those of microbiologically confirmed cases nationally and provincially; however, incidence of microbiologically confirmed cases was consistently higher than cases registered for treatment nationally and in seven of nine provinces.

INTERPRETATION

Since its peak in 2008, the incidence of microbiologically confirmed pulmonary tuberculosis in South Africa had declined by 2012; this decline is associated with an increase in ART coverage. Future integration of registries for microbiologically confirmed cases and new cases registered for treatment would improve the assessment of the burden of pulmonary tuberculosis in South Africa.

FUNDING

National Institute for Communicable Diseases: Division of the National Health Laboratory Service, South Africa.

Patient Characteristics Associated with Tuberculosis Treatment Default: A Cohort Study in a High-Incidence Area of Lima, Peru

Background

Although tuberculosis (TB) is usually curable with antibiotics, poor adherence to medication can lead to increased transmission, drug resistance, and death. Prior research has shown several factors to be associated with poor adherence, but this problem remains a substantial barrier to global TB control. We studied patients in a high-incidence district of Lima, Peru to identify factors associated with premature termination of treatment (treatment default).

Methods

We conducted a prospective cohort study of adult smear-positive TB patients enrolled between January 2010 and December 2011 with no history of TB disease. Descriptive statistics and multivariable logistic regression analyses were performed to determine risk factors associated with treatment default.

Results

Of the 1233 patients studied, 127 (10%) defaulted from treatment. Patients who defaulted were more likely to have used illegal drugs (OR = 4.78, 95% CI: 3.05-7.49), have multidrug-resistant TB (OR = 3.04, 95% CI: 1.58-5.85), not have been tested for HIV (OR = 2.30, 95% CI: 1.50-3.54), drink alcohol at least weekly (OR = 2.22, 95% CI: 1.40-3.52), be underweight (OR = 2.08, 95% CI: 1.21-3.56), or not have completed secondary education (OR = 1.55, 95% CI: 1.03-2.33).

Conclusions

Our study identified several factors associated with defaulting from treatment, suggesting a complex set of causes that might lead to default. Addressing these factors individually would be difficult, but they might help to identify certain high-risk patients for supplemental intervention prior to treatment interruption. Treatment adherence remains a barrier to successful TB care and reducing the frequency of default is important for both the patients’ health and the health of the community.

Adherence in the treatment of patients with extensively drug-resistant tuberculosis and HIV in South Africa: a prospective cohort study

OBJECTIVE

Extensively drug-resistant tuberculosis (XDR-TB)/HIV coinfection is difficult to treat with frequent adverse drug reactions and associated with high mortality. Adherence to antiretroviral therapy (ARV) and second-line TB medications may reduce mortality, prevent amplification of drug resistance, and improve outcomes.

METHODS

Prospective cohort study of XDR-TB patients on treatment in KwaZulu-Natal, South Africa. Adherence to ARV and TB medications was assessed separately at baseline and monthly. Knowledge, attitudes, and beliefs were assessed at baseline. Optimal adherence was defined as self-report of taking all pills in the previous 7 days; missing any pills was defined as suboptimal adherence. Primary outcome was optimal adherence 6 months after initiation of XDR-TB treatment to TB medications, ARV, and both ("dual adherence").

RESULTS

One hundred four XDR-TB patients (79.8% HIV coinfected, 84.3% on ARV at enrollment) were enrolled and followed monthly (median 8 visits; interquartile range: 4-12). Six-month optimal adherence was higher for ARV (88.2%) than TB medications (67.7%) (P < 0.001). Low educational attainment, male gender, and year of enrollment were independently associated with dual suboptimal adherence. At baseline, participants indicated that XDR-TB was curable (76.0%), HIV and TB were linked (81.7%), and ARV improves TB outcomes (72.1%). Baseline knowledge, attitudes, and beliefs did not predict subsequent adherence.

CONCLUSIONS

Medication adherence was significantly higher for ARV than for TB medications in this cohort. Short-course treatment regimens for drug-resistant TB with lower pill burden may increase adherence and improve outcomes in XDR-TB/HIV. Programmatic support for dual adherence is critical in the treatment of drug-resistant TB and HIV.

Tuberculosis Treatment Non-Adherence and Lost to Follow Up among TB Patients with or without HIV in Developing Countries: A Systematic Review

This systematic review intended to combine factors associated with tuberculosis treatment non-adherence and lost to follow up among TB patients with/without HIV in developing countries. Comprehensive remote electronic databases (MEDLINE, (PMC, Pub Med Central), Google scholar and Web of science) search was conducted using the following keywords: Tuberculosis, treatment, compliance, adherence, default, behavioural factors and socioeconomic factors. All types of studies intended to assess TB treatment non-adherence and lost to follow up in developing countries among adult TB patient from 2008 to data extraction date were included. Twenty-six original and one-reviewed articles, which meet inclusion criteria, were reviewed. TB treatment non-adherence and lost to follow up were continued across developing countries. The main factors associated with TB treatment non-adherence and lost to follow up were socioeconomic factors: lack of transportation cost, lack of social support, and patients-health care worker poor communication. Behavioural factors were Feeling better after few weeks of treatments, tobacco and alcohol use, knowledge deficit about duration of treatment and consequences of non-adherence and lost to follow up. TB treatment non-adherence and lost to follow up were continued across developing countries throughout the publication years of reviewed articles. Numerous, socioeconomic and behavioural factors were influencing TB treatment adherence and lost to follow up. Therefore, well understanding and minimizing of the effect of these associated factors is very important to enhance treatment adherence and follow up completion in developing countries.

Prognostic factors in tuberculosis related mortalities in hospitalized patients

Setting. The study was undertaken at the Department of Pulmonology at a public, tertiary care centre in Karachi, Pakistan. Objectives. To evaluate factors concerned with in-hospital deaths in patients admitted with pulmonary tuberculosis (TB). Design. A retrospective case-control audit was performed for 120 patients hospitalised with pulmonary TB. Sixty of those discharged after treatment were compared to sixty who did not survive. Radiological findings, clinical indicators, and laboratory values were compared between the two groups to identify factors related to poor prognosis. Results. Factors concerned with in-hospital mortality listed late presentation of disease (P < 0.01), noncompliance to antituberculosis therapy (P < 0.01), smoking (P < 0.01), longer duration of illness prior to treatment (P < 0.01), and low body weight (P < 0.01). Most deaths occurred during the first week of admission (P < 0.01) indicating late referrals as significant. Immunocompromised status and multi-drug resistance were not implicated in higher mortality. Conclusions. Poor prognosis was associated with noncompliance to therapy resulting in longer duration of illness, late patient referrals to care centres, and development of complications. Early diagnosis, timely referrals, and monitored compliance may help reduce mortality. Adherence to a more radically effective treatment regimen is required to eliminate TB early during disease onset.

Treatment default amongst patients with tuberculosis in urban Morocco: predicting and explaining default and post-default sputum smear and drug susceptibility results

Setting

Public tuberculosis (TB) clinics in urban Morocco.

Objective

Explore risk factors for TB treatment default and develop a prediction tool. Assess consequences of default, specifically risk for transmission or development of drug resistance.

Design

Case-control study comparing patients who defaulted from TB treatment and patients who completed it using quantitative methods and open-ended questions. Results were interpreted in light of health professionals’ perspectives from a parallel study. A predictive model and simple tool to identify patients at high risk of default were developed. Sputum from cases with pulmonary TB was collected for smear and drug susceptibility testing.

Results

91 cases and 186 controls enrolled. Independent risk factors for default included current smoking, retreatment, work interference with adherence, daily directly observed therapy, side effects, quick symptom resolution, and not knowing one’s treatment duration. Age >50 years, never smoking, and having friends who knew one’s diagnosis were protective. A simple scoring tool incorporating these factors was 82.4% sensitive and 87.6% specific for predicting default in this population. Clinicians and patients described additional contributors to default and suggested locally-relevant intervention targets. Among 89 cases with pulmonary TB, 71% had sputum that was smear positive for TB. Drug resistance was rare.

Conclusion

The causes of default from TB treatment were explored through synthesis of qualitative and quantitative data from patients and health professionals. A scoring tool with high sensitivity and specificity to predict default was developed. Prospective evaluation of this tool coupled with targeted interventions based on our findings is warranted. Of note, the risk of TB transmission from patients who default treatment to others is likely to be high. The commonly-feared risk of drug resistance, though, may be low; a larger study is required to confirm these findings.

Prevalence and factors associated with tuberculosis treatment outcome among hazardous or harmful alcohol users in public primary health care in South Africa

BACKGROUND

Tuberculosis (TB) remains a chronic infectious disease with high morbidity and mortality.

OBJECTIVE

The aim of this study was to assess the prevalence and associated factors of tuberculosis treatment failure, death and default among hazardous or harmful alcohol users.

METHOD

We conducted a prospective study with TB patients in 40 public health clinics in three districts in South Africa. All consecutively new tuberculosis and retreatment patients presenting at the 40 primary health care facilities with hazardous or harmful alcohol use were included in this study. Logistic regression was used to assess determinants of TB treatment failure, death and default.

RESULTS

The findings of our study showed that 70% of TB patients were either cured or had completed their TB treatment by the end of 6 months. In multivariate analysis participants living in a shack or traditional housing (Odds Ratio=OR: 0.63, Confidence Interval=CI: 0.45-0.89), being a TB retreatment patient (OR: 1.61, CI: 1.15-2.26) and residing in the eThekwini district (OR: 1.82, CI: 1.27-2.58) were significant predictors of treatment failure, death and default.

CONCLUSION

A high rate of treatment failure, death and default were found in the TB patients. Several factors were identified that can guide interventions for the prevention of treatment failure, death and default.

A registry-based cohort study of pulmonary tuberculosis treatment outcomes in Istanbul, Turkey

The aim of this study is to evaluate the treatment outcomes and identify factors associated with adverse tuberculosis treatment outcomes for bacteriologically confirmed pulmonary tuberculosis. Treatment outcomes of pulmonary tuberculosis were evaluated retrospectively among 11,186 smear- and/or culture-positive patients treated between 2006 and 2009 in Istanbul, Turkey. Adverse treatment outcomes were identified in 1,010 (9.0%) patients including death (1.8%), treatment default (6.1%), and treatment failure (1.1%). Factors associated with adverse treatment outcomes included being born abroad (odds ratios [OR], 5.38; 95% confidence intervals [CI], 3.67-7.91), history of tuberculosis treatment (OR, 3.77; 95% CI, 3.26-4.36), age > 65 years (OR, 2.79; 95% CI, 2.21-3.53), and male gender (OR, 1.91; 95% CI, 1.59-2.27). Death was most strongly associated with age > 65 years (OR, 45.1; 95% CI, 27.0-75.6), followed by treatment default with history of interrupted treatment (OR, 11.6; 95% CI, 8.94-15.1), and treatment failure with prior history of treatment failure (OR, 17.1; 95% CI, 6.97-41.6). Multidrug resistance was strongly associated with adverse treatment outcomes (OR, 10.8; 95% CI, 8.02-14.6). Age > 65 years, male sex, being born abroad, and history of treatment failure were found to be risk factors for adverse treatment outcomes. Hence, patients with any of these characteristics should be carefully monitored and treated aggressively.

Hazardous and harmful alcohol use and associated factors in tuberculosis public primary care patients in South Africa

The aim of this study was to assess the prevalence of hazardous and harmful alcohol use and associated factors among patients with tuberculosis in South Africa. In a cross-sectional survey new tuberculosis (TB) and TB retreatment patients were consecutively screened using the Alcohol Use Disorder Identification Test (AUDIT) within one month of anti-tuberculosis treatment. The sample included 4,900 (54.5% men and women 45.5%) tuberculosis patients from 42 primary care clinics in three districts. Results indicate that, overall 23.2% of the patients were hazardous or harmful alcohol drinkers, 31.8% of men and 13.0% of women were found to be hazardous drinkers, and 9.3% of men and 3.4% of women meet criteria for probable alcohol dependence (harmful drinking) as defined by the AUDIT. Men had significantly higher AUDIT scores than women. In multivariable analyses it was found that among men poor perceived health status, tobacco use, psychological distress, being a TB retreatment patient and not being on antiretroviral therapy (ART), and among women lower education, tobacco use and being a TB retreatment patient were associated with hazardous or harmful alcohol use. The study found a high prevalence of hazardous or harmful alcohol use among tuberculosis primary care patients. This calls for screening and brief intervention and a comprehensive alcohol treatment programme as a key component of TB management in South Africa.

A predictive scoring instrument for tuberculosis lost to follow-up outcome

BACKGROUND

Adherence to tuberculosis (TB) treatment is troublesome, due to long therapy duration, quick therapeutic response which allows the patient to disregard about the rest of their treatment and the lack of motivation on behalf of the patient for improved. The objective of this study was to develop and validate a scoring system to predict the probability of lost to follow-up outcome in TB patients as a way to identify patients suitable for directly observed treatments (DOT) and other interventions to improve adherence.

METHODS

Two prospective cohorts, were used to develop and validate a logistic regression model. A scoring system was constructed, based on the coefficients of factors associated with a lost to follow-up outcome. The probability of lost to follow-up outcome associated with each score was calculated. Predictions in both cohorts were tested using receiver operating characteristic curves (ROC).

RESULTS

The best model to predict lost to follow-up outcome included the following characteristics: immigration (1 point value), living alone (1 point) or in an institution (2 points), previous anti-TB treatment (2 points), poor patient understanding (2 points), intravenous drugs use (IDU) (4 points) or unknown IDU status (1 point). Scores of 0, 1, 2, 3, 4 and 5 points were associated with a lost to follow-up probability of 2,2% 5,4% 9,9%, 16,4%, 15%, and 28%, respectively. The ROC curve for the validation group demonstrated a good fit (AUC: 0,67 [95% CI; 0,65-0,70]).

CONCLUSION

This model has a good capacity to predict a lost to follow-up outcome. Its use could help TB Programs to determine which patients are good candidates for DOT and other strategies to improve TB treatment adherence.