The impact of rural residence and HIV infection on poor tuberculosis treatment outcomes in a large urban hospital: a retrospective cohort analysis

Impact of HIV-AIDS on tuberculosis treatment outcome in Southern Ethiopia - A retrospective cohort study

BACKGROUND

Globally, the Tuberculosis treatment success rate was worse for HIV-positive TB patients compared with HIV- negative TB patients. This study aimed at determining the impact of HIV-AIDS and factors associated with TB treatment outcomes.

METHODS

This study was a retrospective cohort study of five years of tuberculosis data from four public health facilities in Hosanna Town. A total of 604 study participants were included using a systematic random sampling technique. Descriptive analysis of ratios, rates, and proportions was done and binary logistic regression, bivariable and multivariable, analysis was also done.

RESULT

A total of 604 TB patients were enrolled in this study. 302 (50%) were HIV co-infected. The overall treatment success rate was 90.1% (544/604). Treatment success rates are 86.4% (261/302) for TB-HIV co-infected patients and 93.7% (283/302) for non-co-infected patients. TB-HIV co-infected patients had a higher risk of an unsuccessful treatment outcome (Adjusted Relative Risk [ARR]: 2.7; 95% Confidence Interval [CI]: 1.4 - 5.2). The risk of unsuccessful treatment outcome is also higher among rural residents (ARR: 3.3; CI: 1.4 - 5.0), patients on the re-treatment category (ARR: 2.7; CI: 1.4 - 5.1), and with chronic disease (ARR: 3.3; CI: 1.3 - 8.1).

CONCLUSION

TB treatment success rate is good as compared to the WHO minimum requirement. Successful treatment outcome is lower among patients with HIV infection, rural residents, patients on re-treatment, and patients with chronic disease. Therefore, due emphasis should be given to these high-risk groups.

Impact of socio-economic factors on Tuberculosis treatment outcomes in north-eastern Uganda: a mixed methods study

BACKGROUND

Tuberculosis (TB) is a major public health problem and at 48%, Karamoja in North-Eastern Uganda has the lowest treatment success rate nationally. Addressing the social determinants of TB is crucial to ending TB. This study sought to understand the extent and ways in which socio-economic factors affect TB treatment outcomes in Karamoja.

METHODS

We conducted a convergent parallel mixed methods study in 10 TB Diagnostic and Treatment Units. The study enrolled former TB patients diagnosed with drug-susceptible TB between April 2018 and March 2019. Unit TB and laboratory registers were reviewed to identify pre-treatment losses to follow-up. Four focus group discussions with former TB patients and 18 key informant interviews with healthcare workers were conducted. Principle component analysis was used to generate wealth quintiles that were compared to treatment outcomes using the proportion test. The association between sociodemographic characteristics and TB treatment outcomes was evaluated using the chi-square test and multiple logistic regression.

RESULTS

A total of 313 participants were randomly selected from 1184 former TB patients recorded in the unit TB registers. Of these, 264 were contacted in the community and consented to join the study: 57% were male and 156 (59.1%) participants had unsuccessful treatment outcomes. The wealthiest quintile had a 58% reduction in the risk of having an unsuccessful treatment outcome (adj OR = 0.42, 95% CI 0.18-0.99, p = 0.047). People who were employed in the informal sector (adj OR = 4.71, 95% CI 1.18-18.89, p = 0.029) and children under the age of 15 years who were not in school or employed (adj OR = 2.71, 95% CI 1.11-6.62, p = 0.029) had significantly higher odds of unsuccessful treatment outcome. Analysis of the pre-treatment loss to follow-up showed that 17.2% of patients with pulmonary bacteriologically confirmed TB did not initiate treatment with a higher proportion among females (21.7%) than males (13.5%). Inadequate food, belonging to migratory communities, stigma, lack of social protection, drug stock-outs and transport challenges affected TB treatment outcomes.

CONCLUSIONS

This study confirmed that low socio-economic status is associated with poor TB treatment outcomes emphasizing the need for multi- and cross-sectoral approaches and socio-economic enablers to optimise TB care.

Tuberculosis Treatment Outcome and Predictors in Africa: A Systematic Review and Meta-Analysis

This review aimed to summarize and estimate the TB treatment success rate and factors associated with unsuccessful TB treatment outcomes in Africa. Potentially eligible primary studies were retrieved from PubMed and Google Scholar. The risk of bias and quality of studies was assessed using The Joanna Briggs Institute's (JBI) appraisal criteria, while heterogeneity across studies was assessed using Cochran's Q test and I2 statistic. Publication bias was checked using the funnel plot and egger's test. The protocol was registered in PROSPERO, numbered CRD42019136986. A total of 26 eligible studies were considered. The overall pooled estimate of TB treatment success rate was found to be 79.0% (95% CI: 76-82%), ranging from 53% (95% CI: 47-58%) in Nigeria to 92% (95% CI: 90-93%) in Ethiopia. The majority of unsuccessful outcomes were attributed to 48% (95% CI: 40-57%) death and 47% (95% CI: 39-55%) of defaulter rate. HIV co-infection and retreatment were significantly associated with an increased risk of unsuccessful treatment outcomes compared to HIV negative and newly diagnosed TB patients with RR of 1.53 (95% CI: 1.36-1.71) and 1.48 (95% CI: 1.14-1.94), respectively. TB treatment success rate was 79% below the WHO defined threshold of 85% with significant variation across countries. Countries need to explore contextual underlining factors and more effort is required in providing TB preventive treatment, improve case screening and linkage for TB treatment among HIV high-risk groups and use confirmatory TB diagnostic modality. Countries in Africa need to strengthen counseling and follow-up, socio-economic support for patients at high risk of loss to follow-up and poor treatment success is also crucial for successful TB control programs.

One dollar incentive improves tuberculosis treatment outcomes in programmatic settings in rural Uganda

The study aim was to determine the association of a one United States dollar (USD) dollar incentive and tuberculosis (TB) treatment outcomes among people with TB receiving treatment at a rural hospital in Uganda under programmatic settings. We conducted a quasi-experiment in which people with TB were randomised (1:1 ratio) to receive either a one USD incentive at months 0, 2, 5 and 6 (Dollar arm) or routine care (Routine arm). A second control group (Retrospective controls) consisted of participants who had a treatment outcome in the preceding 6 months. Treatment outcomes were compared between the intervention and control groups using Pearson’s chi-square and Fisher’s exact tests. The association between the incentive and treatment outcomes was determined using Poisson regression analysis with robust variances. Between November 2018 and October 2019, we enrolled 180 participants (60 in the Dollar arm and 120 in the Control group). TB cure (33.3% vs. 20.8%, p = 0.068) and treatment success (70.0% vs. 59.2% p = 0.156) were higher in the Dollar arm than the Control group, while loss-to-follow-up was lower in the Dollar arm (10.0% vs. 20.8% p = 0.070). Participants in the Dollar arm were more likely to be cured (adjusted incidence rate ratio (aIRR): 1.59, 95% CI 1.04–2.44, p = 0.032) and less likely to be lost to follow-up (aIRR: 0.44, 95% CI 0.20–0.96, p = 0.040). A one-dollar incentive was associated with higher TB cure and lower loss-to-follow-up among people with TB in rural Uganda.

Prevalence and associated factors of tuberculosis treatment abandonment

OBJECTIVE

To estimate the prevalence of tuberculosis treatment abandonment and its associated factors.

METHOD

Cross-sectional study which used cases of tuberculosis in the System of Information on Notification Aggravations (Sistema de Informação de Agravos de Notificação) from 2001 to 2017 in Ceará state. This study included 74,006 cases and the outcome was the closing situation "treatment abandonment". A multivariate analysis was performed to estimate the association between the variables with abandonment.

RESULTS

Throughout the period, the abandonment rate was 12.54%. A higher abandonment prevalence was verified among people who live in the urban zone (PR = 2.45; 95%CI: 2.20-2.74), who are readmitted after abandonment (PR = 2.84; 95%CI: 2.68-3.01), among those notified as recurrent (PR = 1.22; 95%CI: 1.10-1.35) and among drinkers (PR = 1.50; 95%CI: 1.42-1.58). Those who were sputum smear-positive (PR = 1.11; 95%CI: 1.03-1.19) or for whom sputum smear was unperformed (PR = 1.30; 95%CI: 1.20-1.40), coinfection (PR = 2.04; CI95%: 1.89-2.21) and who were not submitted to serology (PR = 1.62; 95%CI: 1.53-1.71) have also a higher prevalence of tuberculosis treatment abandonment.

CONCLUSION

Tuberculosis treatment abandonment is associated to biological and social factors, habits, and health service structure.

Factors predictive of the success of tuberculosis treatment: A systematic review with meta-analysis

OBJECTIVE

To produce pooled estimates of the global results of tuberculosis (TB) treatment and analyze the predictive factors of successful TB treatment.

METHODS

Studies published between 2014 and 2019 that reported the results of the treatment of pulmonary TB and the factors that influenced these results. The quality of the studies was evaluated according to the Newcastle-Ottawa quality assessment scale. A random effects model was used to calculate the pooled odds ratio (OR) and 95% confidence interval (CI). This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) in February 2019 under number CRD42019121512.

RESULTS

A total of 151 studies met the criteria for inclusion in this review. The success rate for the treatment of drug-sensitive TB in adults was 80.1% (95% CI: 78.4-81.7). America had the lowest treatment success rate, 75.9% (95% CI: 73.8-77.9), and Oceania had the highest, 83.9% (95% CI: 75.2-91.0). In children, the success rate was 84.8% (95% CI: 77.7-90.7); in patients coinfected with HIV, it was 71.0% (95% CI: 63.7-77.8), in patients with multidrug-resistant TB, it was 58.4% (95% CI: 51.4-64.6), in patients with and extensively drug-resistant TB it was 27.1% (12.7-44.5). Patients with negative sputum smears two months after treatment were almost three times more likely to be successfully treated (OR 2.7; 1.5-4.8), whereas patients younger than 65 years (OR 2.0; 1.7-2.4), nondrinkers (OR 2.0; 1.6-2.4) and HIV-negative patients (OR 1.9; 1.6-2.5 3) were two times more likely to be successfully treated.

CONCLUSION

The success of TB treatment at the global level was good, but was still below the defined threshold of 85%. Factors such as age, sex, alcohol consumption, smoking, lack of sputum conversion at two months of treatment and HIV affected the success of TB treatment.

Treatment success rate among adult pulmonary tuberculosis patients in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVES

To summarise treatment success rate (TSR) among adult bacteriologically confirmed pulmonary tuberculosis (BC-PTB) patients in sub-Saharan Africa (SSA).

DESIGN

We searched MEDLINE, EMBASE, Google Scholar and Web of Science electronic databases for eligible studies published in the decade between 1 July 2008 and 30 June 2018. Two independent reviewers extracted data and disagreements were resolved by consensus with a third reviewer. We used random-effects model to pool TSR in Stata V.15, and presented results in a forest plot with 95% CIs and predictive intervals. We assessed heterogeneity with Cochrane's (Q) test and quantified with I-squared values. We checked publication bias with funnel plots and Egger's test. We performed subgroup, meta-regression, sensitivity and cumulative meta-analyses.

SETTING

SSA.

PARTICIPANTS

Adults 15 years and older, new and retreatment BC-PTB patients.

OUTCOMES

TSR measured as the proportion of smear-positive TB cases registered under directly observed therapy in a given year that successfully completed treatment, either with bacteriologic evidence of success (cured) or without (treatment completed).

RESULTS

31 studies (2 cross-sectional, 1 case-control, 17 retrospective cohort, 6 prospective cohort and 5 randomised controlled trials) involving 18 194 participants were meta-analysed. 28 of the studies had good quality data. Egger's test indicated no publication bias, rather small study effect. The pooled TSR was 76.2% (95% CI 72.5% to 79.8%; 95% prediction interval, 50.0% to 90.0%, I² statistics=96.9%). No single study influenced the meta-analytical results or conclusions. Between 2008 and 2018, a gradual but steady decline in TSR occurred in SSA but without statistically significant time trend variation (p=0.444). The optimum TSR of 90% was not achieved.

CONCLUSION

Over the past decade, TSR was heterogeneous and suboptimal in SSA, suggesting context and country-specific strategies are needed to end the TB epidemic.

PROSPERO REGISTRATION NUMBER

CRD42018099151.

Patient predictors of poor drug sensitive tuberculosis treatment outcomes in Kyiv Oblast, Ukraine

Background: Ukraine has high rates of poor treatment outcomes among drug sensitive tuberculosis (DSTB) patients, while global treatment success rates for DSTB remain high.     We evaluated baseline patient factors as predictors of poor DSTB treatment outcomes. Methods: We conducted a retrospective analysis of new drug sensitive pulmonary TB patients treated in Kyiv Oblast, Ukraine between November 2012 and October 2014. We defined good treatment outcomes as cure or completion and poor outcomes as death, default or treatment failure. We performed logistic regression analyses, using routine program data, to identify baseline patient factors associated with poor outcomes. Results: Among 302 patients, 193 (63.9%) experienced good treatment outcomes while 39 (12.9%) failed treatment, 34 (11.3%) died, and 30 (9.9%) defaulted. In the multivariate analysis, HIV positive patients on anti-retroviral therapy (ART) [OR 3.50; 95% CI 1.46 - 8.42; p 0.005] or without ART (OR 4.12; 95% CI 1.36 - 12.43; p 0.01) were at increased risk of poor outcomes. Alcohol abuse (OR 1.81; 95% CI 0.93 - 3.55; p 0.08) and smear positivity (OR 1.75; 95% CI 1.03 - 2.97; p 0.04) were also associated with poor treatment outcomes. Conclusions: High rates of poor outcomes among patients with newly diagnosed drug sensitive TB in Kyiv Oblast, Ukraine highlight the urgent need for programmatic interventions, especially aimed at patients with the highest risk of poor outcomes.

Patient predictors of poor drug sensitive tuberculosis treatment outcomes in Kyiv Oblast, Ukraine

Background: Ukraine has high rates of poor treatment outcomes among drug sensitive tuberculosis (DSTB) patients, while global treatment success rates for DSTB remain high.     We evaluated baseline patient factors as predictors of poor DSTB treatment outcomes. Methods: We conducted a retrospective analysis of new drug sensitive pulmonary TB patients treated in Kyiv Oblast, Ukraine between November 2012 and October 2014. We defined good treatment outcomes as cure or completion and poor outcomes as death, default or treatment failure. We performed logistic regression analyses, using routine program data, to identify baseline patient factors associated with poor outcomes. Results: Among 302 patients, 193 (63.9%) experienced good treatment outcomes while 39 (12.9%) failed treatment, 34 (11.3%) died, and 30 (9.9%) defaulted. In the multivariate analysis, HIV positive patients on anti-retroviral therapy (ART) [OR 3.50; 95% CI 1.46 - 8.42; p 0.005] or without ART (OR 4.12; 95% CI 1.36 - 12.43; p 0.01) were at increased risk of poor outcomes. Alcohol abuse (OR 1.81; 95% CI 0.93 - 3.55; p 0.08) and smear positivity (OR 1.75; 95% CI 1.03 - 2.97; p 0.04) were also associated with poor treatment outcomes. Conclusions: High rates of poor outcomes among patients with newly diagnosed drug sensitive TB in Kyiv Oblast, Ukraine highlight the urgent need for programmatic interventions, especially aimed at patients with the highest risk of poor outcomes.