1
|
Ross JM, Greene C, Broshkevitch CJ, Dowdy DW, van Heerden A, Heitner J, Rao DW, Roberts DA, Shapiro AE, Zabinsky ZB, Barnabas RV. Preventing tuberculosis with community-based care in an HIV-endemic setting: a modelling analysis. J Int AIDS Soc 2024; 27:e26272. [PMID: 38861426 PMCID: PMC11166187 DOI: 10.1002/jia2.26272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 04/30/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Antiretroviral therapy (ART) and tuberculosis preventive treatment (TPT) both prevent tuberculosis (TB) disease and deaths among people living with HIV. Differentiated care models, including community-based care, can increase the uptake of ART and TPT to prevent TB in settings with a high burden of HIV-associated TB, particularly among men. METHODS We developed a gender-stratified dynamic model of TB and HIV transmission and disease progression among 100,000 adults ages 15-59 in KwaZulu-Natal, South Africa. We drew model parameters from a community-based ART initiation and resupply trial in sub-Saharan Africa (Delivery Optimization for Antiretroviral Therapy, DO ART) and other scientific literature. We simulated the impacts of community-based ART and TPT care programmes during 2018-2027, assuming that community-based ART and TPT care were scaled up to similar levels as in the DO ART trial (i.e. ART coverage increasing from 49% to 82% among men and from 69% to 83% among women) and sustained for 10 years. We projected the number of TB cases, deaths and disability-adjusted life years (DALYs) averted relative to standard, clinic-based care. We calculated programme costs and incremental cost-effectiveness ratios from the provider perspective. RESULTS If community-based ART care could be implemented with similar effectiveness to the DO ART trial, increased ART coverage could reduce TB incidence by 27.0% (range 21.3%-34.1%) and TB mortality by 34.6% (range 24.8%-42.2%) after 10 years. Increasing both ART and TPT uptake through community-based ART with TPT care could reduce TB incidence by 29.7% (range 23.9%-36.0%) and TB mortality by 36.0% (range 26.9%-43.8%). Community-based ART with TPT care reduced gender disparities in TB mortality rates, with a projected 54 more deaths annually among men than women (range 11-103) after 10 years of community-based care versus 109 (range 41-182) in standard care. Over 10 years, the mean cost per DALY averted by community-based ART with TPT care was $846 USD (range $709-$1012). CONCLUSIONS By substantially increasing coverage of ART and TPT, community-based care for people living with HIV could reduce TB incidence and mortality in settings with high burdens of HIV-associated TB and reduce TB gender disparities.
Collapse
Affiliation(s)
- Jennifer M. Ross
- Division of Allergy and Infectious DiseasesDepartment of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Chelsea Greene
- Department of Industrial and Systems EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Cara J. Broshkevitch
- Department of EpidemiologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - David W. Dowdy
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Alastair van Heerden
- Centre for Community Based ResearchHuman Sciences Research CouncilPietermaritzburgSouth Africa
- SAMRC/Wits Developmental Pathways for Health Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Jesse Heitner
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
| | - Darcy W. Rao
- Bill & Melinda Gates FoundationSeattleWashingtonUSA
| | - D. Allen Roberts
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Adrienne E. Shapiro
- Division of Allergy and Infectious DiseasesDepartment of MedicineUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Zelda B. Zabinsky
- Department of Industrial and Systems EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Ruanne V. Barnabas
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| |
Collapse
|
2
|
Derseh NM, Agimas MC, Aragaw FM, Birhan TY, Nigatu SG, Alemayehu MA, Tesfie TK, Yehuala TZ, Godana TN, Merid MW. Incidence rate of mortality and its predictors among tuberculosis and human immunodeficiency virus coinfected patients on antiretroviral therapy in Ethiopia: systematic review and meta-analysis. Front Med (Lausanne) 2024; 11:1333525. [PMID: 38707189 PMCID: PMC11066242 DOI: 10.3389/fmed.2024.1333525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 03/26/2024] [Indexed: 05/07/2024] Open
Abstract
Background Tuberculosis (TB) is the leading cause of death among HIV-infected adults and children globally. Therefore, this study was aimed at determining the pooled mortality rate and its predictors among TB/HIV-coinfected patients in Ethiopia. Methods Extensive database searching was done via PubMed, EMBASE, SCOPUS, ScienceDirect, Google Scholar, and Google from the time of idea conception on March 1, 2023, to the last search via Google on March 31, 2023. A meta-analysis was performed using the random-effects model to determine the pooled mortality rate and its predictors among TB/HIV-coinfected patients. Heterogeneity was handled using subgroup analysis, meta-regression, and sensitivity analysis. Results Out of 2,100 records, 18 articles were included, with 26,291 total patients. The pooled incidence rate of mortality among TB/HIV patients was 12.49 (95% CI: 9.24-15.74) per 100 person-years observation (PYO); I2 = 96.9%. The mortality rate among children and adults was 5.10 per 100 PYO (95% CI: 2.15-8.01; I2 = 84.6%) and 15.78 per 100 PYO (95% CI: 10.84-20.73; I2 = 97.7%), respectively. Age ≥ 45 (pooled hazard ratios (PHR) 2.58, 95% CI: 2.00- 3.31), unemployed (PHR 2.17, 95% CI: 1.37-3.46), not HIV-disclosed (PHR = 2.79, 95% CI: 1.65-4.70), bedridden (PHR 5.89, 95% CI: 3.43-10.12), OI (PHR 3.5, 95% CI: 2.16-5.66), WHO stage IV (PHR 3.16, 95% CI: 2.18-4.58), BMI < 18.5 (PHR 4.11, 95% CI: 2.28-7.40), anemia (PHR 4.43, 95% CI: 2.73-7.18), EPTB 5.78, 95% CI: 2.61-12.78 significantly affected the mortality. The effect of TB on mortality was 1.95 times higher (PHR 1.95, 95% CI: 1.19-3.20; I2 = 0) than in TB-free individuals. Conclusions The mortality rate among TB/HIV-coinfected patients in Ethiopia was higher compared with many African countries. Many clinical factors were identified as significant risk factors for mortality. Therefore, TB/HIV program managers and clinicians need to design an intervention early.
Collapse
Affiliation(s)
- Nebiyu Mekonnen Derseh
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Muluken Chanie Agimas
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Fantu Mamo Aragaw
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tilahun Yemanu Birhan
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Solomon Gedlu Nigatu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Meron Asmamaw Alemayehu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tigabu Kidie Tesfie
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tirualem Zeleke Yehuala
- Department of Health Informatics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tilahun Nega Godana
- Department of Internal Medicine, School of Medicine, University of Gondar Comprehensive Specialized Hospital, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mehari Woldemariam Merid
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| |
Collapse
|
3
|
Ross JM, Greene C, Bayer CJ, Dowdy DW, van Heerden A, Heitner J, Rao DW, Roberts DA, Shapiro AE, Zabinsky ZB, Barnabas RV. Preventing tuberculosis with community-based care in an HIV-endemic setting: a modeling analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.21.23294380. [PMID: 37662260 PMCID: PMC10473784 DOI: 10.1101/2023.08.21.23294380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Introduction Antiretroviral therapy (ART) and TB preventive treatment (TPT) both prevent tuberculosis (TB) disease and deaths among people living with HIV. Differentiated care models, including community-based care, can increase uptake of ART and TPT to prevent TB in settings with a high burden of HIV-associated TB, particularly among men. Methods We developed a gender-stratified dynamic model of TB and HIV transmission and disease progression among 100,000 adults ages 15-59 in KwaZulu-Natal, South Africa. We drew model parameters from a community-based ART initiation and resupply trial in sub-Saharan Africa (Delivery Optimization for Antiretroviral Therapy, DO ART) and other scientific literature. We simulated the impacts of community-based ART and TPT care programs during 2018-2027, assuming that community-based ART and TPT care were scaled up to similar levels as in the DO ART trial (i.e., ART coverage increasing from 49% to 82% among men and from 69% to 83% among women) and sustained for ten years. We projected the number of TB cases, deaths, and disability-adjusted life years (DALYs) averted relative to standard, clinic-based care. We calculated program costs and incremental cost-effectiveness ratios from the provider perspective. Results If community-based ART care could be implemented with similar effectiveness to the DO ART trial, increased ART coverage could reduce TB incidence by 27.0% (range 21.3% - 34.1%) and TB mortality by 36.0% (range 26.9% - 43.8%) after ten years. Increasing both ART and TPT uptake through community-based ART with TPT care could reduce TB incidence by 29.7% (range 23.9% - 36.0%) and TB mortality by 36.0% (range 26.9% - 43.8%). Community-based ART with TPT care reduced gender disparities in TB mortality rates by reducing TB mortality among men by a projected 39.8% (range 32.2% - 46.3%) and by 30.9% (range 25.3% - 36.5%) among women. Over ten years, the mean cost per DALY averted by community-based ART with TPT care was $846 USD (range $709 - $1,012). Conclusions By substantially increasing coverage of ART and TPT, community-based care for people living with HIV could reduce TB incidence and mortality in settings with high burdens of HIV-associated TB and reduce TB gender disparities.
Collapse
Affiliation(s)
- Jennifer M. Ross
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, USA
| | - Chelsea Greene
- Department of Industrial and Systems Engineering, University of Washington, Seattle, USA
| | - Cara J. Bayer
- Department of Epidemiology, University of North Carolina, Chapel Hill, USA
| | - David W. Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Alastair van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- SAMRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Jesse Heitner
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, USA
| | | | - D. Allen Roberts
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Adrienne E. Shapiro
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
| | - Zelda B. Zabinsky
- Department of Industrial and Systems Engineering, University of Washington, Seattle, USA
| | - Ruanne V. Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| |
Collapse
|
4
|
Garg D, Radhakrishnan DM, Agrawal U, Vanjare HA, Gandham EJ, Manesh A. Tuberculosis of the Spinal Cord. Ann Indian Acad Neurol 2023; 26:112-126. [PMID: 37179681 PMCID: PMC10171010 DOI: 10.4103/aian.aian_578_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/21/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022] Open
Abstract
Tuberculosis involving the spinal cord is associated with high mortality and disabling long-term sequelae. Although tuberculous radiculomyelitis is the most frequent complication, pleomorphic clinical manifestations exist. Diagnosis can be challenging among patients with isolated spinal cord tuberculosis due to diverse clinical and radiological presentations. The principles of management of tuberculosis of the spinal cord are primarily derived from, and dependent upon, trials on tuberculous meningitis (TBM). Although facilitating mycobacterial killing and controlling host inflammatory response within the nervous system remain the primary objectives, several unique features require attention. The paradoxical worsening is more frequent, often with devastating outcomes. The role of anti-inflammatory agents such as steroids in adhesive tuberculous radiculomyelitis remains unclear. Surgical interventions may benefit a small proportion of patients with spinal cord tuberculosis. Currently, the evidence base in the management of spinal cord tuberculosis is limited to uncontrolled small-scale data. Despite the gargantuan burden of tuberculosis, particularly in lower and middle-income countries, large-scale cohesive data are surprisingly sparse. In this review, we highlight the varied clinical and radiological presentations, performance of various diagnostic modalities, summarize data on the efficacy of treatment options, and propose a way forward to improve outcomes in these patients.
Collapse
Affiliation(s)
- Divyani Garg
- Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | | | - Umang Agrawal
- Department of Infectious Diseases, PD Hinduja Hospital and MRC, Mumbai, Maharashtra, India
| | | | | | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
5
|
Siamisang K, Rankgoane-Pono G, Madisa TM, Mudiayi TK, Tlhakanelo JT, Mubiri P, Kadimo K, Banda FM, Setlhare V. Pediatric tuberculosis outcomes and factors associated with unfavorable treatment outcomes in Botswana, 2008-2019: a retrospective analysis. BMC Public Health 2022; 22:2020. [PMID: 36333805 PMCID: PMC9636819 DOI: 10.1186/s12889-022-14477-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/22/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Globally, the amount of research on the outcomes of pediatric tuberculosis (TB) is disproportionately less than that of adult TB. The diagnosis of paediatric TB is also problematic in developing countries. The aim of this study was to describe the outcomes of pediatric TB in Botswana and to identify the factors associated with unfavorable outcomes. METHODS This was a retrospective analysis of pediatric TB outcomes in Botswana, over a 12-year period from January 2008 to December 2019. Treatment success (treatment completion or cured) was considered a favorable outcome, while death, loss to follow-up and treatment failure were considered unfavorable outcomes. Program data from drug-sensitive TB (DS-TB) cases under the age of 15 years were included. Sampling was exhaustive. Binary logistic regression was used to determine the factors associated with unfavorable outcomes during TB treatment. A p value of < 0.05 was considered a statistically significant association between the predictor variables and unfavorable outcomes. RESULTS The data of 6,004 paediatric TB cases were extracted from the Botswana National TB Program (BNTP) electronic registry and analyzed. Of these data, 2,948 (49.4%) were of female patients. Of the extracted data, 1,366 (22.8%) were of HIV positive patients and 2,966 (49.4%) were of HIV negative patients. The rest of the data were of patients with unknown HIV status. Pulmonary TB accounted for 4,701 (78.3%) of the cases. Overall, 5,591 (93.1%) of the paediatric TB patient data showed treatment success, 179 (3.0%) were lost to follow-up, 203 (3.4%) records were of patients who died, and 31 (0.5%) were of patients who experienced treatment failure. The factors associated with unfavorable outcomes were positive HIV status (AOR 2.71, 95% CI: 2.09-3.52), unknown HIV status (AOR 2.07, 95% CI: 1.60-2.69) and retreatment category (AOR 1.92, 95% CI: 1.30-2.85). Compared with the 0-4 years age category, the 5-9 years (AOR 0.62, 95% CI: 0.47-0.82) and 10-14 years (AOR 0.76, 95% CI: 0.60-0.98) age categories were less likely to experience the unfavorable outcomes. CONCLUSION This study shows a high treatment success rate among paediatric TB cases in Botswana. The government under the National TB Program should maintain and consolidate the gains from this program. Public health interventions should particularly target children with a positive or unknown HIV status, those under 5 years, and those who have been previously treated for TB.
Collapse
Affiliation(s)
- Keatlaretse Siamisang
- Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana.
- Department of Health Services Management, Ministry of Health, Gaborone, Botswana.
- , P O Box 40, Letlhakeng, Botswana.
| | | | | | | | - John Thato Tlhakanelo
- Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana
| | - Paul Mubiri
- Maryland Global Initiative Corporation (MGIC), University of Maryland, Baltimore (UMB), Gaborone, Botswana
| | - Khutsafalo Kadimo
- Department of Library Services, University of Botswana, Gaborone, Botswana
| | | | - Vincent Setlhare
- Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana
| |
Collapse
|
6
|
Siamisang K, Rankgoane-Pono G, Madisa TM, Mudiayi T, Tlhakanelo JT. Outcomes and predictors of tuberculosis mortality in Kweneng West District, Botswana: a retrospective cohort study. Pan Afr Med J 2022; 42:1. [PMID: 35685381 PMCID: PMC9142783 DOI: 10.11604/pamj.2022.42.1.32381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/13/2022] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Botswana is among the countries with the highest tuberculosis (TB) notification rates in the world. However, there is paucity of data on the outcomes and predictors of TB mortality at district level in Botswana. This study was aimed at describing the TB outcomes and identifying the predictors of mortality in Kweneng West district, Botswana. METHODS this was a retrospective cohort study of TB outcomes in Kweneng West, from January 2008 to December 2016. All documented drug-sensitive TB (DS-TB) patients aged 16 years and above were included. The World Health Organization (WHO) definitions of treatment outcomes for DS-TB were used. Binary logistic regression was used to identify predictors of mortality. RESULTS there were 1475 TB notifications in the study period. The median age was 36 years and 41.5% were female. A total of 728 (49.4%) were HIV positive. Pulmonary TB (PTB) accounted for 87.3% of all cases. The overall treatment success rate (TSR) was 81.9% and the mortality rate was 9.4%. Compared to the 16-25 years age group, patients aged more than 65 years had the highest risk of mortality (AOR=9.63). Other significant predictors of mortality were male sex (AOR=1.63), no sputum microscopy (AOR=1.77), positive HIV (AOR=2.13) and unknown HIV status (AOR=4.47). Positive sputum microscopy (AOR=0.50) and extra-pulmonary TB (EPTB) (AOR=0.56) were associated with less mortality. CONCLUSION while Botswana has relatively good TB treatment success rates, the mortality rates are high. Public health interventions should target the identified risk factors of mortality.
Collapse
Affiliation(s)
- Keatlaretse Siamisang
- Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana,,Department of Health Services Management, Ministry of Health and Wellness, Gaborone, Botswana,Corresponding author: Keatlaretse Siamisang, Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana.
| | | | - Tumisang Malebo Madisa
- Department of Health Services Management, Ministry of Health and Wellness, Gaborone, Botswana
| | - Tantamika Mudiayi
- Department of Health Services Management, Ministry of Health and Wellness, Gaborone, Botswana
| | - John Thato Tlhakanelo
- Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana
| |
Collapse
|
7
|
Naidoo K, Gengiah S, Yende-Zuma N, Mlobeli R, Ngozo J, Memela N, Padayatchi N, Barker P, Nunn A, Karim SSA. Mortality in HIV and tuberculosis patients following implementation of integrated HIV-TB treatment: Results from an open-label cluster-randomized trial. EClinicalMedicine 2022; 44:101298. [PMID: 35198922 PMCID: PMC8850328 DOI: 10.1016/j.eclinm.2022.101298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND HIV-TB treatment integration reduces mortality. Operational implementation of integrated services is challenging. This study assessed the impact of quality improvement (QI) for HIV-TB integration on mortality within primary healthcare (PHC) clinics in South Africa. METHODS An open-label cluster randomized controlled study was conducted between 2016 and 2018 in 40 rural clinics in South Africa. The study statistician randomized PHC nurse-supervisors 1:1 into 16 clusters (eight nurse-supervisors supporting 20 clinics per arm) to receive QI, supported HIV-TB integration intervention or standard of care (control). Nurse supervisors and clinics under their supervision, based in the study health districts were eligible for inclusion in this study. Nurse supervisors were excluded if their clinics were managed by municipal health (different resource allocation), did not offer co-located antiretroviral therapy (ART) and TB services, services were performed by a single nurse, did not receive non-governmental organisation (NGO) support, patient data was not available for > 50% of attendees. The analysis population consists of all patients newly diagnosed with (i) both TB and HIV (ii) HIV only (among patients previously treated for TB or those who never had TB before) and (iii) TB only (among patients already diagnosed with HIV or those who were never diagnosed with HIV) after QI implementation in the intervention arm, or enrolment in the control arm. Mortality rates was assessed 12 months post enrolment, using unpaired t-tests and cox-proportional hazards model. (Clinicaltrials.gov, NCT02654613, registered 01 June 2015, trial closed). FINDINGS Overall, 21 379 participants were enrolled between December 2016 and December 2018 in intervention and control arm clinics: 1329 and 841 HIV-TB co-infected (10·2%); 10 799 and 6 611 people living with Human Immunodeficiency Virus (HIV)/ acquired immunodeficiency syndrome (AIDS) (PLWHA) only (81·4%); 1 131 and 668 patients with TB only (8·4%), respectively. Average cluster sizes were 1657 (range 170-5782) and 1015 (range 33-2027) in intervention and control arms. By 12 months, 6529 (68·7%) and 4074 (70·4%) were alive and in care, 568 (6·0%) and 321 (5·6%) had completed TB treatment, 1078 (11·3%) and 694 (12·0%) were lost to follow-up, with 245 and 156 deaths occurring in intervention and control arms, respectively. Mortality rates overall [95% confidence interval (CI)] was 4·5 (3·4-5·9) in intervention arm, and 3·8 (2·6-5·4) per 100 person-years in control arm clusters [mortality rate ratio (MRR): 1·19 (95% CI 0·79-1·80)]. Mortality rates among HIV-TB co-infected patients was 10·1 (6·7-15·3) and 9·8 (5·0-18·9) per 100 person-years, [MRR: 1·04 (95% CI 0·51-2·10)], in intervention and control arm clusters, respectively. INTERPRETATION HIV-TB integration supported by a QI intervention did not reduce mortality in HIV-TB co-infected patients. Demonstrating mortality benefit from health systems process improvements in real-world operational settings remains challenging. Despite the study being potentially underpowered to demonstrate the effect size, integration interventions were implemented using existing facility staff and infrastructure reflecting the real-world context where most patients in similar settings access care, thereby improving generalizability and scalability of study findings. FUNDING Research reported in this publication was supported by South African Medical Research Council (SAMRC), and UK Government's Newton Fund through United Kingdom Medical Research Council (UKMRC).
Collapse
Affiliation(s)
- Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
- South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
- Corresponding author at: Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa.
| | - Santhanalakshmi Gengiah
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
- South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | - Regina Mlobeli
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
| | | | - Nhlakanipho Memela
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
- South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | - Pierre Barker
- Institute for Healthcare Improvement, Gilling's School of Global Public Health, UNC Chapel Hill, Chapel Hill, Cambridge, MA, USA
| | - Andrew Nunn
- Medical Research Council Clinical Trials Unit at University College, London, UK
| | - Salim S. Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
- South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| |
Collapse
|
8
|
Baluku JB, Mukasa D, Bongomin F, Stadelmann A, Nuwagira E, Haller S, Ntabadde K, Turyahabwe S. Gender differences among patients with drug resistant tuberculosis and HIV co-infection in Uganda: a countrywide retrospective cohort study. BMC Infect Dis 2021; 21:1093. [PMID: 34689736 PMCID: PMC8542192 DOI: 10.1186/s12879-021-06801-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 10/18/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Gender differences among patients with drug resistant tuberculosis (DRTB) and HIV co-infection could affect treatment outcomes. We compared characteristics and treatment outcomes of DRTB/HIV co-infected men and women in Uganda. METHODS We conducted a retrospective chart review of patients with DRTB from 16 treatment sites in Uganda. Eligible patients were aged ≥ 18 years, had confirmed DRTB, HIV co-infection and a treatment outcome registered between 2013 and 2019. We compared socio-demographic and clinical characteristics and tuberculosis treatment outcomes between men and women. Potential predictors of mortality were determined by cox proportional hazard regression analysis that controlled for gender. Statistical significance was set at p < 0.05. RESULTS Of 666 DRTB/HIV co-infected patients, 401 (60.2%) were men. The median (IQR) age of men and women was 37.0 (13.0) and 34.0 (13.0) years respectively (p < 0.001). Men were significantly more likely to be on tenofovir-based antiretroviral therapy (ART), high-dose isoniazid-containing DRTB regimen and to have history of cigarette or alcohol use. They were also more likely to have multi-drug resistant TB, isoniazid and streptomycin resistance and had higher creatinine, aspartate and gamma-glutamyl aminotransferase and total bilirubin levels. Conversely, women were more likely to be unemployed, unmarried, receive treatment from the national referral hospital and to have anemia, a capreomycin-containing DRTB regimen and zidovudine-based ART. Treatment success was observed among 437 (65.6%) and did not differ between the genders. However, mortality was higher among men than women (25.7% vs. 18.5%, p = 0.030) and men had a shorter mean (standard error) survival time (16.8 (0.42) vs. 19.0 (0.46) months), Log Rank test (p = 0.046). Predictors of mortality, after adjusting for gender, were cigarette smoking (aHR = 4.87, 95% CI 1.28-18.58, p = 0.020), an increase in alanine aminotransferase levels (aHR = 1.05, 95% CI 1.02-1.07, p < 0.001), and history of ART default (aHR = 3.86, 95% CI 1.31-11.37, p = 0.014) while a higher baseline CD4 count was associated with lower mortality (aHR = 0.94, 95% CI 0.89-0.99, p = 0.013 for every 10 cells/mm3 increment). CONCLUSION Mortality was higher among men than women with DRTB/HIV co-infection which could be explained by several sociodemographic and clinical differences.
Collapse
Affiliation(s)
- Joseph Baruch Baluku
- Division of Pulmonology, Kiruddu National Referral Hospital, Kampala, Uganda ,grid.11194.3c0000 0004 0620 0548Makerere University Lung Institute, PO Box 26343, Kampala, Uganda
| | - David Mukasa
- grid.31501.360000 0004 0470 5905Complex Diseases and Genome Epidemiology, Graduate School of Public Health, Seoul National University, Seoul, South Korea
| | - Felix Bongomin
- grid.442626.00000 0001 0750 0866Department of Medical Microbiology & Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Anna Stadelmann
- grid.17635.360000000419368657Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN USA
| | - Edwin Nuwagira
- grid.33440.300000 0001 0232 6272Infectious Diseases Unit, Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Sabine Haller
- grid.7400.30000 0004 1937 0650Department of Public and Global Health, Epidemiology, Biostatistics, & Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Kauthrah Ntabadde
- grid.415861.f0000 0004 1790 6116MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Stavia Turyahabwe
- grid.415705.2National Tuberculosis and Leprosy Control Program, Ministry of Health, Kampala, Uganda
| |
Collapse
|
9
|
Bukundi EM, Mhimbira F, Kishimba R, Kondo Z, Moshiro C. Mortality and associated factors among adult patients on tuberculosis treatment in Tanzania: A retrospective cohort study. J Clin Tuberc Other Mycobact Dis 2021; 24:100263. [PMID: 34355068 PMCID: PMC8322306 DOI: 10.1016/j.jctube.2021.100263] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Tuberculosis (TB) is the global leading cause of death from an infectious agent. Tanzania is among the 30 high TB burden countries with a mortality rate of 47 per 100,000 population and a case fatality of 4%. This study assessed mortality rate, survival probabilities, and factors associated with death among adult TB patients on TB treatment in Tanzania. METHODS A retrospective cohort study was conducted utilizing case-based national TB program data of adult (≥15 years) TB cases enrolled on TB treatment from January 2017 to December 2017. We determined survival probabilities using the Kaplan-Meier estimator and a Cox proportional hazard model was used to identify independent risk factors of TB mortality. Hazard ratios and their respective 95% confidence intervals were reported. RESULTS Of 53,753 adult TB patients, 1927 (3.6%) died during TB treatment and the crude mortality rate was 6.31 per 1000 person-months. Male accounted for 33,297 (61.9%) of the study population and the median (interquartile range [IQR]) age was 40 (30-53) years. More than half 1027 (56.7%) of deaths occurred in first two months of treatment. Overall survival probabilities were 96%, and 92% at 6th and 12th month respectively. The independent risk factors for TB mortality among TB patients included: advanced age ≥ 45 years (adjusted hazard ratio (aHR) = 1.74, 95% confidence interval (CI) = 1.45-2.08); receiving service at the hospital level (aHR = 1.22, 95% CI = 1.09-1.36); TB/HIV co-infection (aHR = 2.51, 95% CI = 2.26-2.79); facility-based direct observed therapy (DOT) option (aHR = 2.23, 95% CI = 1.95-2.72); having bacteriological unconfirmed TB results (aHR = 1.58, 95% CI = 1.42-1.76); and other referral type (aHR = 1.44, 95% CI = 1.16-1.78). CONCLUSION Advanced age, TB/HIV co-infection, bacteriological unconfirmed TB results, other referral types, receiving service at facility-based DOT option and obtaining service at the hospital level were significant contributors to TB death in Tanzania. Appropriate targeted intervention to improve TB referral systems, improve diagnostic capacity in the primary health facilities, minimize delay and misdiagnosis of TB patients might reduce TB mortality.
Collapse
Affiliation(s)
- Elias M. Bukundi
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Tanzania
- Tanzania Field Epidemiology and Laboratory Training Programme, Tanzania
| | - Francis Mhimbira
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Tanzania
- Ifakara Health Institute, Tanzania
| | - Rogath Kishimba
- Tanzania Field Epidemiology and Laboratory Training Programme, Tanzania
| | - Zuweina Kondo
- National Tuberculosis and Leprosy Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Tanzania
| | - Candida Moshiro
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Tanzania
| |
Collapse
|
10
|
Baluku JB, Kabamooli RA, Kajumba N, Nabwana M, Kateete D, Kiguli S, Andia-Biraro I. Contact tracing is associated with treatment success of index tuberculosis cases in Uganda. Int J Infect Dis 2021; 109:129-136. [PMID: 34174434 PMCID: PMC9395259 DOI: 10.1016/j.ijid.2021.06.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE: To determine the effect of contact tracing on the treatment outcomes of index tuberculosis (TB) cases in Uganda. METHODS: We evaluated TB cases registered at an urban public health facility in Uganda in 2015–2020. We extracted data from the unit’s TB and contact tracing registers. Treatment outcomes were classified as cure, loss to follow-up, death and treatment failure. Treatment success was the sum of cure and treatment completion. RESULTS: Among 778 TB cases, contact tracing was conducted for 455 (58.5%). Compared with cases without contract tracing (n=323), cases with contract tracing (n=455) had higher treatment success (92.5% vs 79.3%) and cure rates (57.1% vs 39.9%) and lower loss to follow-up (3.5% vs 9.3%), treatment failure (0.4% vs 1.6%) and death (3.5% vs 9.9%) (P<0.001). Contact tracing was associated with higher odds of treatment success (adjusted odds ratio (aOR) 3.00, 95% CI 1.92–4.70, P<0.001) and cure (aOR 3.11, 95% CI 1.97–4.90, P<0.001), and lower odds of loss to follow-up (aOR 0.33, (0.13–0.83), P=0.018) and death (aOR 0.38, (0.20–0.72), P=0.003). CONCLUSION: TB contact tracing should be conducted consistently not only for the benefit of identifying new TB cases but also to promote treatment success of index cases.
Collapse
Affiliation(s)
- Joseph Baruch Baluku
- Kiruddu National Referral Hospital, Kampala, Uganda; Makerere University Lung Institute, Kampala, Uganda.
| | | | | | - Martin Nabwana
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - David Kateete
- Department of Microbiology and Immunology, Makerere University College of Health Sciences
| | - Sarah Kiguli
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences
| | - Irene Andia-Biraro
- Department of Internal Medicine, Makerere University College of Health Sciences
| |
Collapse
|
11
|
Ballayira Y, Yanogo PK, Konaté B, Diallo F, Sawadogo B, Antara S, Méda N. Time and risk factors for death among smear-positive pulmonary tuberculosis patients in the Health District of commune VI of Bamako, Mali, 2016. BMC Public Health 2021; 21:942. [PMID: 34006238 PMCID: PMC8132441 DOI: 10.1186/s12889-021-10986-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023] Open
Abstract
Background The End Tuberculosis (TB) Strategy aims to achieve 90% reduction of deaths due to TB by 2030, compared with 2015. Mortality due to tuberculosis in Mali was 13 per 100,000 inhabitants in 2014 and 11 per 100,000 inhabitants in 2017. Risk factors for death are not known. The objective of this study was to determine the time and risk factors for death in pulmonary TB patients with positive microscopy. Methods We conducted a retrospective cohort study from October to December 2016 in Commune VI of Bamako. Smear positive cases pulmonary tuberculosis from 2011 to 2015 were included. We reviewed the treatment registers and collected sociodemographic, clinical, biological and therapeutic data. Median time to death and hazard ratio (HR) were estimated by the Kaplan-Meier method and a Cox regression model, respectively. Results In total, we analysed 1362 smear positive cases of pulmonary TB including 104 (8%) HIV positive and 90 (7%) deaths. The mean age was 36 ± 13 years, the sex ratio of males to females was 2:1. Among the deaths, 48 (53%) occurred during the first 2 months of treatment. Age ≥ 45 years (HR 2.09 95% CI [1.35–3.23]), weight < 40 kg (HR 2.20 95% CI [1.89–5.42]), HIV unknown status (HR 1.96, 95% CI [1.04–3.67]) and HIV-positive (HR 7.10 95% CI [3.53–14.26]) were significantly associated with death. Conclusions The median time to death was 2 months from the start of treatment. Independent risk factors for death were age ≥ 45 years, weight < 40 kg, unknown and positive HIV status. We recommend close monitoring of patients over 45 years, HIV testing in those with unknown status, an adequate care for positive HIV status, as well as a nutritional support for those with weight below 40 kg during the intensive phase of TB treatment.
Collapse
Affiliation(s)
- Yaya Ballayira
- Burkina Field Epidemiology Training Program, University Joseph KI-ZERBO, Ouagadougou, Burkina Faso
| | - Pauline Kiswendsida Yanogo
- Burkina Field Epidemiology Training Program, University Joseph KI-ZERBO, Ouagadougou, Burkina Faso. .,Department of Public Health, Faculty of medicine, University Joseph KI-ZERBO, Ouagadougou, Burkina Faso.
| | - Bakary Konaté
- National Directorate of Health, Ministry of Health, Bamako, Mali
| | - Fadima Diallo
- Burkina Field Epidemiology Training Program, University Joseph KI-ZERBO, Ouagadougou, Burkina Faso
| | | | - Simon Antara
- African Field Epidemiology Network, Kampala, Uganda
| | - Nicolas Méda
- Burkina Field Epidemiology Training Program, University Joseph KI-ZERBO, Ouagadougou, Burkina Faso.,Department of Public Health, Faculty of medicine, University Joseph KI-ZERBO, Ouagadougou, Burkina Faso
| |
Collapse
|
12
|
Ngari MM, Schmitz S, Maronga C, Mramba LK, Vaillant M. A systematic review of the quality of conduct and reporting of survival analyses of tuberculosis outcomes in Africa. BMC Med Res Methodol 2021; 21:89. [PMID: 33906605 PMCID: PMC8080365 DOI: 10.1186/s12874-021-01280-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/12/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Survival analyses methods (SAMs) are central to analysing time-to-event outcomes. Appropriate application and reporting of such methods are important to ensure correct interpretation of the data. In this study, we systematically review the application and reporting of SAMs in studies of tuberculosis (TB) patients in Africa. It is the first review to assess the application and reporting of SAMs in this context. METHODS Systematic review of studies involving TB patients from Africa published between January 2010 and April 2020 in English language. Studies were eligible if they reported use of SAMs. Application and reporting of SAMs were evaluated based on seven author-defined criteria. RESULTS Seventy-six studies were included with patient numbers ranging from 56 to 182,890. Forty-three (57%) studies involved a statistician/epidemiologist. The number of published papers per year applying SAMs increased from two in 2010 to 18 in 2019 (P = 0.004). Sample size estimation was not reported by 67 (88%) studies. A total of 22 (29%) studies did not report summary follow-up time. The survival function was commonly presented using Kaplan-Meier survival curves (n = 51, (67%) studies) and group comparisons were performed using log-rank tests (n = 44, (58%) studies). Sixty seven (91%), 3 (4.1%) and 4 (5.4%) studies reported Cox proportional hazard, competing risk and parametric survival regression models, respectively. A total of 37 (49%) studies had hierarchical clustering, of which 28 (76%) did not adjust for the clustering in the analysis. Reporting was adequate among 4.0, 1.3 and 6.6% studies for sample size estimation, plotting of survival curves and test of survival regression underlying assumptions, respectively. Forty-five (59%), 52 (68%) and 73 (96%) studies adequately reported comparison of survival curves, follow-up time and measures of effect, respectively. CONCLUSION The quality of reporting survival analyses remains inadequate despite its increasing application. Because similar reporting deficiencies may be common in other diseases in low- and middle-income countries, reporting guidelines, additional training, and more capacity building are needed along with more vigilance by reviewers and journal editors.
Collapse
Affiliation(s)
- Moses M Ngari
- KEMRI/Wellcome Trust Research Programme, P.O Box 230, Kilifi, 80108, Kenya.
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya.
- Competence Center for Methodology and Statistics, Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg.
| | - Susanne Schmitz
- Competence Center for Methodology and Statistics, Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Christopher Maronga
- KEMRI/Wellcome Trust Research Programme, P.O Box 230, Kilifi, 80108, Kenya
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Lazarus K Mramba
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas, USA
| | - Michel Vaillant
- Competence Center for Methodology and Statistics, Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg
| |
Collapse
|
13
|
Wu Y, Yang Y, Wei H, Jia L, Jiang T, Tian Y, Guo C, Zhang Y. Mortality predictors among patients with HIV-associated pulmonary tuberculosis in Northeast China: A retrospective cohort analysis. J Med Virol 2021; 93:4901-4907. [PMID: 33788289 DOI: 10.1002/jmv.26977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/31/2021] [Accepted: 03/18/2021] [Indexed: 11/07/2022]
Abstract
The coexistence of pulmonary tuberculosis (PTB) and human immunodeficiency virus (HIV) infection leads to high morbidity and mortality in these populations. Although antiretroviral therapy (ART) has decreased TB incidence in HIV-infected patients, this coexistence still prevails in China. Patients with HIV-PTB admitted to Beijing You An Hospital from 2014 to 2018 were retrospectively enrolled, and information on demographics, clinical characteristics, and laboratory findings were extracted from medical records. Predictors of death, including age (adjusted hazard ratio [AHR]: 1.03; 95% confidence interval [CI]: 1.00-1.05), tobacco use (AHR: 2.76; 95% CI: 1.54-4.94), history of tuberculosis (AHR: 3.53; 95% CI: 1.82-6.85), not being on ART (AHR: 2.94; 95% CI: 1.31-6.63), extrapulmonary tuberculosis (AHR: 2.391; 95% CI: 1.37-4.18), sputum smear positivity (AHR: 2.84; 95% CI: 1.61-4.99), CD4+ T cell count ≤ 50 cells/µl (AHR: 3.45; 95% CI: 1.95-6.10), and initiating ART ≥ 8 weeks after the initiation of antituberculous therapy (odds ratio: 3.30; 95% CI: 1.09-10.04). By contrast, there were no deaths among the six patients who began ART within 8 weeks after the initiation of antituberculous therapy. Age, tobacco use, not being on ART, extrapulmonary tuberculosis, sputum smear positivity, and CD4+ T cell count ≤50 cells/µl predict those patients at high risk of death among HIV-infected patients with PTB, and the time of initiating ART after the initiation of antituberculous therapy is also important for prognosis.
Collapse
Affiliation(s)
- Yongfeng Wu
- Department of Infectious Diseases, Beijing You An Hospital, Capital Medical University, Beijing Institute of Hepatology, Beijing, China
| | - Yang Yang
- Department of Infectious Diseases, Beijing You An Hospital, Capital Medical University, Beijing Institute of Hepatology, Beijing, China
| | - Huaying Wei
- Department of Infectious Diseases, Beijing You An Hospital, Capital Medical University, Beijing Institute of Hepatology, Beijing, China
| | - Lin Jia
- Department of Infectious Diseases, Beijing You An Hospital, Capital Medical University, Beijing Institute of Hepatology, Beijing, China
| | - Taiyi Jiang
- Department of Infectious Diseases, Beijing You An Hospital, Capital Medical University, Beijing Institute of Hepatology, Beijing, China
| | - Yakun Tian
- Department of Infectious Diseases, Beijing You An Hospital, Capital Medical University, Beijing Institute of Hepatology, Beijing, China
| | - Caiping Guo
- Department of Infectious Diseases, Beijing You An Hospital, Capital Medical University, Beijing Institute of Hepatology, Beijing, China
| | - Yulin Zhang
- Department of Respiratory and Infectious Diseases, Beijing You An Hospital, Capital Medical University, Beijing Institute of Hepatology, Beijing, China
| |
Collapse
|
14
|
Osei E, Oppong S, Der J. Trends of tuberculosis case detection, mortality and co-infection with HIV in Ghana: A retrospective cohort study. PLoS One 2020; 15:e0234878. [PMID: 32579568 PMCID: PMC7313972 DOI: 10.1371/journal.pone.0234878] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/03/2020] [Indexed: 12/23/2022] Open
Abstract
Background In an era of renewed commitment to accelerate the declines in Tuberculosis (TB) incidence and mortality, there is the need for National Tuberculosis Programmes (NTPs) to monitor trends in key indicators across a geographical location and to provide reliable data for direct measurement of TB incidence and mortality. In this context, we explored the trends of TB case detection, mortality and HIV co-infection, and examined the predictors of TB deaths in Ten districts of the Volta region of Ghana. Methods We conducted a retrospective cohort study of all TB cases registered from 2013 to 2017 in 10 districts of the Volta Region of Ghana. Case detection rate (CDR) was computed as the ratio of the number of new and relapse TB case notified to NTP to the number of estimated incident TB cases in a given year. Case fatality rates were estimated using data from 2012–2016 cohort of TB patients. Simple and multiple logistic regression were used to identify predictors of TB deaths with odds ratios and 95% confidence intervals estimated. Results Overall, there were 3,735 new and relapse TB patients who commenced anti-TB treatment during the period, representing the case detection rate of 40.1% with district variations. The CDR remained stable during the 5 years. Of the total cases, HIV status was documented for 3,144 (84.2%), among whom, 712 (22.6%) were HIV positive. The TB/HIV co-infection was more prevalent among children under 15 years of age (30.1%), males (30.6%), treatment after lost to follow-up patients (33.3%), and smear-negative pulmonary TB patients (29.1%). The prevalence of TB/HIV co-infection did not significantly change over the years. The overall case fatality rate was 13% (n = 486), with considerable variation among HIV-positives and HIV-negative TB patients (21.8% and 11% respectively) (p<0.001) and among districts. TB/HIV co-infection, sputum smear-negative pulmonary TB and district of anti-TB treatment predicted TB mortality. Conclusion TB case detection rate was low and remained stable during the study period, whereas co-infection with HIV and mortality rates were quite high, indicating the need for feasible strategies such as active case finding to improve case detection, and improved case management to reduce mortality.
Collapse
Affiliation(s)
- Eric Osei
- Department of Population and Behavioural Sciences, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
- Department of Public Health Graduate School, Yonsei University, Seoul, Republic of Korea
- * E-mail:
| | - Samuel Oppong
- Department of Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Joyce Der
- Department of Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| |
Collapse
|
15
|
Francisco C, Lansang MA, Salvana EM, Leyritana K. Multidrug-resistant tuberculosis (MDR-TB) and multidrug-resistant HIV (MDR-HIV) syndemic: challenges in resource limited setting. BMJ Case Rep 2019; 12:e230628. [PMID: 31471363 PMCID: PMC6720699 DOI: 10.1136/bcr-2019-230628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2019] [Indexed: 11/03/2022] Open
Abstract
Tuberculosis (TB) is common among persons living with HIV. This public health concern is aggravated by infection with multidrug-resistant organisms and adverse effects of polypharmacy. There are few published cases of multidrug-resistant tuberculosis (MDR-TB) in multidrug-resistant HIV (MDR-HIV) infected patients. We report a case of a 29-year-old Filipino man with HIV on zidovudine (AZT)-containing antiretroviral therapy (ART) but was eventually shifted to tenofovir due to anaemia. He presented with left flank tenderness, which was found to be due to an MDR-TB psoas abscess, and for which second-line anti-TB treatment was started. HIV genotyping showed MDR-HIV infection susceptible only to AZT, protease inhibitors and integrase inhibitors. Subsequently, he developed neck abscess that grew Mycobacterium avium complex and was treated with ethambutol and azithromycin. ART regimen was revised to AZT plus lamivudine and lopinavir/ritonavir. Erythropoietin was administered for recurrent AZT-induced anaemia. Both abscesses resolved and no recurrence of anaemia was noted.
Collapse
Affiliation(s)
- Christian Francisco
- Section of Infectious Diseases, Department of Medicine, Philippine General Hospital, Manila, Philippines
| | - Mary Ann Lansang
- Section of Infectious Diseases, Department of Medicine, Philippine General Hospital, Manila, Philippines
| | - Edsel Maurice Salvana
- Section of Infectious Diseases, Department of Medicine, Philippine General Hospital, Manila, Philippines
| | - Katerina Leyritana
- Sustained Health Initiatives of the Philippines, Mandaluyong, Philippines
| |
Collapse
|
16
|
Tweed CD, Crook AM, Dawson R, Diacon AH, McHugh TD, Mendel CM, Meredith SK, Mohapi L, Murphy ME, Nunn AJ, Phillips PPJ, Singh KP, Spigelman M, Gillespie SH. Toxicity related to standard TB therapy for pulmonary tuberculosis and treatment outcomes in the REMoxTB study according to HIV status. BMC Pulm Med 2019; 19:152. [PMID: 31412895 PMCID: PMC6694514 DOI: 10.1186/s12890-019-0907-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 07/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The phase III REMoxTB study prospectively enrolled HIV-positive (with CD4+ count > 250 cells, not on anti-retroviral therapy) and HIV-negative patients. We investigated the incidence of adverse events and cure rates according to HIV status for patients receiving standard TB therapy in the trial. METHODS Forty-two HIV-positive cases were matched to 220 HIV-negative controls by age, gender, ethnicity, and trial site using coarsened exact matching. Grade 3 and 4 adverse events (AEs) were summarised by MedDRA System Organ Class. Kaplan-Meier curves for time to first grade 3 or 4 AE were constructed according to HIV status with hazard ratios calculated. Patients were considered cured if they were culture negative 18 months after commencing therapy with ≥2 consecutive negative culture results. RESULTS Twenty of 42 (47.6%) HIV-positive and 34 of 220 (15.5%) HIV-negative patients experienced ≥1 grade 3 or 4 AE, respectively. The majority of these were hepatobiliary disorders that accounted for 12 of 40 (30.0%) events occurring in 6 of 42 (14.3%) HIV-positive patients and for 15 of 60 (25.0%) events occurring in 9 of 220 (4.1%) HIV-negative patients. The median time to first grade 3 or 4 AE was 54 days (IQR 15.5-59.0) for HIV-positive and 29.5 days (IQR 9.0-119.0) for HIV-negative patients, respectively. The hazard ratio for experiencing a grade 3 or 4 AE among HIV-positive patients was 3.25 (95% CI 1.87-5.66, p < 0.01). Cure rates were similar, with 38 of 42 (90.5%) HIV-positive and 195 of 220 (88.6%) HIV-negative patients (p = 0.73) cured at 18 months. CONCLUSIONS HIV-positive patients receiving standard TB therapy in the REMoxTB study were at greater risk of adverse events during treatment but cure rates were similar when compared to a matched sample of HIV-negative patients.
Collapse
Affiliation(s)
- Conor D Tweed
- MRC Clinical Trials Unit at University College London, London, UK.
| | - Angela M Crook
- MRC Clinical Trials Unit at University College London, London, UK
| | - Rodney Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | | | - Timothy D McHugh
- Division of Infection and Immunity, University College London, London, UK
| | | | - Sarah K Meredith
- MRC Clinical Trials Unit at University College London, London, UK
| | - Lerato Mohapi
- Perinatal HIV Research Unit, Johannesburg, South Africa
| | - Michael E Murphy
- Division of Infection and Immunity, University College London, London, UK
| | - Andrew J Nunn
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Kasha P Singh
- The Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Parkville, Australia
| | | | | |
Collapse
|
17
|
Tshitenge S, Ogunbanjo GA, Citeya A. A mortality review of tuberculosis and HIV co-infected patients in Mahalapye, Botswana: Does cotrimoxazole preventive therapy and/or antiretroviral therapy protect against death? Afr J Prim Health Care Fam Med 2018; 10:e1-e5. [PMID: 30456967 PMCID: PMC6244457 DOI: 10.4102/phcfm.v10i1.1765] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 07/31/2018] [Accepted: 08/22/2018] [Indexed: 11/14/2022] Open
Abstract
Background The World Health Organization aims to reduce tuberculosis (TB) mortality rate from 15% in 2015 to 6.5% by 2025. Aim This study determined the profile of TB and human immunodeficiency virus (HIV) co-infected patients who died in Mahalapye District, Botswana, while on anti-TB medication and the factors that contributed to such outcome. Setting The study was conducted in the Mahalapye Health District in Botswana. Methods This was a cross-sectional study that reviewed patient records from the Mahalapye District Health Management Team Electronic Tuberculosis Register from January 2013 to December 2015. Results The majority of the TB and HIV co-infected patients were on antiretroviral therapy (ART) (486 [81.63%]) or were initiated cotrimoxazole preventive therapy (CPT) (518 [87.2%]) while taking anti-TB treatment. Seventy-three (13.6%) TB and HIV co-infected patients died before completing anti-TB treatment. Three-quarters (54 [74.4%]) of patients who died before completing anti-TB treatment were on ART, among them two patients who were on ART at least 3 months prior to commencing anti-TB. Also, the majority (64 [87.7%]) of TB and HIV co-infected patients were commenced on CPT prior to death. There was a bimodal density curve of death occurrence in those who did not commence ART and in those who did not commence CPT. Conclusion This study established that TB and HIV co-infected patients had a TB mortality of 13.6%. A high mortality rate was observed during the first 3 months in those who did not take ART and during the second and the fifth month in those who did not commence CPT. Further study is needed to clarify this matter.
Collapse
Affiliation(s)
- Stephane Tshitenge
- Department of Family Medicine and Public Health, University of Botswana.
| | | | | |
Collapse
|
18
|
Predictors of In-Hospital Mortality among Patients with Pulmonary Tuberculosis: A Systematic Review and Meta-analysis. Sci Rep 2018; 8:7230. [PMID: 29740001 PMCID: PMC5940698 DOI: 10.1038/s41598-018-25409-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 04/13/2018] [Indexed: 11/08/2022] Open
Abstract
Background: There is uncertainty regarding which factors are associated with in-hospital mortality among patients with pulmonary TB (PTB). The aim of this systematic review and meta-analysis is to identify predictors of in-hospital mortality among patients with PTB. Methods: We searched MEDLINE, EMBASE, and Global Health, for cohort and case-control studies that reported risk factors for in-hospital mortality in PTB. We pooled all factors that were assessed for an association, and presented relative associations as pooled odds ratios (ORs). Results: We identified 2,969 records, of which we retrieved 51 in full text; 11 cohort studies that evaluated 5,468 patients proved eligible. Moderate quality evidence suggested an association with co-morbid malignancy and in-hospital mortality (OR 1.85; 95% CI 1.01–3.40). Low quality evidence showed no association with positive sputum smear (OR 0.99; 95% CI 0.40–2.48), or male sex (OR 1.09, 95% CI 0.84–1.41), and very low quality evidence showed no association with diabetes mellitus (OR 1.31, 95% IC 0.38–4.46), and previous TB infection (OR 2.66, 95% CI 0.48–14.87). Conclusion: Co-morbid malignancy was associated with increased risk of in-hospital death among pulmonary TB patients. There is insufficient evidence to confirm positive sputum smear, male sex, diabetes mellitus, and previous TB infection as predictors of in-hospital mortality in TB patients.
Collapse
|
19
|
Griesel R, Stewart A, van der Plas H, Sikhondze W, Mendelson M, Maartens G. Prognostic indicators in the World Health Organization's algorithm for seriously ill HIV-infected inpatients with suspected tuberculosis. AIDS Res Ther 2018; 15:5. [PMID: 29433509 PMCID: PMC5808414 DOI: 10.1186/s12981-018-0192-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/31/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Criteria for the 2007 WHO algorithm for diagnosing tuberculosis among HIV-infected seriously ill patients are the presence of one or more danger signs (respiratory rate > 30/min, heart rate > 120/min, temperature > 39 °C, and being unable to walk unaided) and cough ≥ 14 days. Determining predictors of poor outcomes among HIV-infected inpatients presenting with WHO danger signs could result in improved treatment and diagnostic algorithms. METHODS We conducted a prospective cohort study of inpatients presenting with any duration of cough and WHO danger signs to two regional hospitals in Cape Town, South Africa. The primary outcome was all-cause mortality up to 56 days post-discharge, and the secondary outcome a composite of any one of: hospital admission for > 7 days, died in hospital, transfer to a tertiary level or tuberculosis hospital. We first assessed the WHO danger signs as predictors of poor outcomes, then assessed the added value of other variables selected a priori for their ability to predict mortality in common respiratory opportunistic infections (CD4 count, body mass index (BMI), being on antiretroviral therapy (ART), hypotension, and confusion) by comparing the receiver operating characteristic (ROC) area under the curve (AUC) of the two multivariate models. RESULTS 484 participants were enrolled, median age 36, 66% women, 53% had tuberculosis confirmed on culture. The 56-day mortality was 13.2%. Inability to walk unaided, low BMI, low CD4 count, and being on ART were independently associated with poor outcomes. The multivariate model of the WHO danger signs showed a ROC AUC of 0.649 (95% CI 0.582-0.717) for predicting 56-day mortality, which improved to ROC AUC of 0.740 (95% CI 0.681-0.800; p = 0.004 for comparison between the two ROC AUCs) with the multivariate model including the a priori selected variables. Findings were similar in sub-analyses of participants with culture-positive tuberculosis and with cough duration ≥ 14 days. CONCLUSION The study design prevented a rigorous evaluation of the prognostic value of the WHO danger signs. Our prognostic model could result in improved algorithms, but needs to be validated.
Collapse
Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, UCT Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Annemie Stewart
- Division of Clinical Pharmacology, Department of Medicine, UCT Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Helen van der Plas
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Welile Sikhondze
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, UCT Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925 South Africa
| |
Collapse
|
20
|
Teklu AM, Nega A, Mamuye AT, Sitotaw Y, Kassa D, Mesfin G, Belayihun B, Medhin G, Yirdaw K. Factors Associated with Mortality of TB/HIV Co-infected Patients in Ethiopia. Ethiop J Health Sci 2018; 27:29-38. [PMID: 28465651 PMCID: PMC5402803 DOI: 10.4314/ejhs.v27i1.4s] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Despite the large number of TB patients on ART in Ethiopia, their mortality remains high. This study reports the effect of TB on HIV related mortality and determinants of TB/HIV co-infection related mortality. METHODS A longitudinal study design was employed as part of the Advanced Clinical Monitoring of ART (ACM) in Ethiopia. All patients started on ART at or after January 1, 2005 were included. Survival analysis was done to compare survival patterns of HIV patients with TB against HIV patients without TB. In addition, determinants of survival among TB/HIV co-infected patients were analyzed. Adjusted effects of the different factors on time to death were generated using Cox-proportional hazards regression. RESULTS A total of 3,889 patients were enrolled in the ACM study, of which 355 TB cases were identified, making the crude prevalence 9% (95% CI 8.3 - 10.2). Overall, incidence of TB was 2.2 (95% CI 1.9-2.4) per 100 person-years. TB was highest in the first 2 months and declined with time on ART to reach 1 per 100 person years after 24 months on ART. TB was significantly associated with mortality among HIV patients on HAART (AHR 2.0, 95% CI 1.47-2.75). Male gender was associated with mortality among TB/HIV co-infected patients. CONCLUSION Tuberculosis plays a key role in HIV associated mortality. Targeted interventions which can keep patients free of TB in the early stages of their treatment are required to reduce TB related mortality.
Collapse
Affiliation(s)
- Alula M Teklu
- Alula M. Teklu: MERQ Consultancy Services, Addis Ababa, Ethiopa
| | - Abiy Nega
- Abiy Nega: MERQ Consultancy Services, Addis Ababa, Ethiopia
| | - Admasu Tenna Mamuye
- Admasu Tenna Mamuye: Addis Ababa University, Medical Faculty, Addis Ababa, Ethiopia
| | - Yohannes Sitotaw
- Yohannes Sitotaw: Ministry of Science and Technology, Addis Ababa, Ethiopia
| | - Desta Kassa
- Desta Kassa: Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Getnet Mesfin
- Getnet Mesfin: Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Bekele Belayihun
- Mekele Belayhiun: Ethiopian Public Health Association, Addis Ababa, Ethiopia
| | - Girmay Medhin
- Girmay Medhin: Aklilu Lemma Institute of Pathobiology, Addis Ababa
| | | |
Collapse
|
21
|
Feleke BE, Alene GD, Feleke TE, Motebaynore Y, Biadglegne F. Clinical response of tuberculosis patients, a prospective cohort study. PLoS One 2018; 13:e0190207. [PMID: 29293580 PMCID: PMC5749762 DOI: 10.1371/journal.pone.0190207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/11/2017] [Indexed: 11/18/2022] Open
Abstract
Clinical response means a response to drug intake that can be detected and appreciated by a change in signs and symptoms. The objectives of this study were to assess time to clinical response, the incidence density for clinical response and determinants of clinical response of tuberculosis (TB) patients in the intensive phases of TB treatment. Prospective cohort study design was implemented. The target population for this study was all patients following the directly observed therapy. Baseline data has been collected during the start of the directly observed TB treatment strategy. We have been collected updated data after the seven days of the baseline data collection, then after every seven days updated data has been collected from each pulmonary and extra pulmonary TB patients. Kaplan Meier curve was used to estimate time to clinical response. Incidence density using person days was used to estimate incidence of clinical response. Cox proportional hazard model was used to identify the predictors of clinical responses. A total of 1608 TB patients were included with a response rate at 99.5%. The mean age of the respondents was 24.5 years [standard deviation (SD) 14.34 years]. The incidence density for clinical response was 1429/38529 person days. One fourth of the TB patients showed clinical response at day 14, 25% of at day 21 and 75% o at day 31. Predictors of clinical response for TB patients includes: age (AHR 1.007 [95% CI 1.003-1.011]), type of TB (AOR 2.3[95% CI 2.04-2.59]), Previous history of TB (AHR 0.18 [95% CI 0.11-0 .30]), Intestinal parasitic infection (AOR 0.22[95% CI 0.19-0.26]), hemoglobin (AOR 2.35 [95% CI 2.18-2.54]), weight gain (AOR 1.11 [95% CI 1.05-1.17]), Micronutrient supplementation (AOR 9.71 [95% CI 8.28-11.38]), male sex (AOR 0.87 [95% CI 0.79-0.97]).The clinical responses for extra-pulmonary TB patients were slower than pulmonary TB. Deworming and micronutrient supplementation should be considered as the additional TB treatment strategy for TB patients.
Collapse
Affiliation(s)
- Berhanu Elfu Feleke
- Department of Epidemiology and Biostatistics, University of Bahir Dar, Bahir Dar, Ethiopian
- * E-mail:
| | - Getu Degu Alene
- Department of Epidemiology and Biostatistics, University of Bahir Dar, Bahir Dar, Ethiopian
| | - Teferi Elfu Feleke
- Department of Pediatrics, University of St. Paul, Addis Ababa, Ethiopian
| | | | | |
Collapse
|
22
|
Abedi S, Moosazadeh M, Afshari M, Charati JY, Nezammahalleh A. Determinant factors for mortality during treatment among tuberculosis patients: Cox proportional hazards model. Indian J Tuberc 2017; 66:39-43. [PMID: 30797281 DOI: 10.1016/j.ijtb.2017.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/20/2017] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Investigating the survival of tuberculosis (TB) patients is one of the main parts of the TB control program. It can be related to many factors. This study aimed to estimate the survival experience and its associated factors among these patients. METHODOLOGY All TB patients detected during March 2005 to 31 September 2014 were entered into this prospective cohort. Each patient was investigated from the diagnosis date and followed until the last available information during treatment. Data analysis was performed using Kaplan Meier and multivariate Cox regression models. RESULTS The survival experience of 2493 TB patients was investigated 73.7% of which were pulmonary type. Mean and median survival time were 6.5 and 6.2 months respectively. The incidence rate of death among patients during the treatment courses was 0.99 (95% confidence interval: 0.84-1.1) per 100 person-months. Controlling the confounders, the incidence (95% confidence interval) of death was significantly higher among men (HR=1.8; 1.2-2.6), diabetic patients (HR=1.7; 1.2-2.6), cancerous patients (HR=4.8; 2.6-8.8) and HIV positive patients (HR=22.1; 7.3-66.4). CONCLUSION This study showed that male gender, TB/HIV co-infection and concurrent development of TB and cancer were determinant factors of death during the treatment period of TB.
Collapse
Affiliation(s)
- Siavosh Abedi
- Department of Internal Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahmood Moosazadeh
- Health Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Mahdi Afshari
- Department of Community Medicine, Zabol University of Medical Sciences, Zabol, Iran
| | | | - Asghar Nezammahalleh
- Student Research Committee, Faculty of Health, Mazandaran University of Medical Sciences, Sari, Iran
| |
Collapse
|
23
|
Adamu AL, Gadanya MA, Abubakar IS, Jibo AM, Bello MM, Gajida AU, Babashani MM, Abubakar I. High mortality among tuberculosis patients on treatment in Nigeria: a retrospective cohort study. BMC Infect Dis 2017; 17:170. [PMID: 28231851 PMCID: PMC5324260 DOI: 10.1186/s12879-017-2249-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 02/07/2017] [Indexed: 12/02/2022] Open
Abstract
Background Tuberculosis (TB) remains a leading cause of death in much of sub-Saharan Africa despite available effective treatment. Prompt initiation of TB treatment and access to antiretroviral therapy (ART) remains vital to the success of TB control. We assessed time to mortality after treatment onset using data from a large treatment centre in Nigeria. Methods We analysed a retrospective cohort of TB patients that commenced treatment between January 2010 and December 2014 in Aminu Kano Teaching Hospital. We estimated mortality rates per person-months at risk (pm). Cox proportional hazards model was used to determine risk factors for mortality. Results Among 1,424 patients with a median age of 36.6 years, 237 patients (16.6%) died after commencing TB treatment giving a mortality rate of 3.68 per 100 pm of treatment in this cohort. Most deaths occurred soon after treatment onset with a mortality rate of 37.6 per 100 pm in the 1st week of treatment. Risk factors for death were being HIV-positive but not on anti-retroviral treatment (ART) (aHR 1.39(1 · 04–1 · 85)), residence outside the city (aHR 3 · 18(2.28–4.45)), previous TB treatment (aHR 3.48(2.54–4.77)), no microbiological confirmation (aHR 4.96(2.69–9.17)), having both pulmonary and extra-pulmonary TB (aHR 1.45(1.03–2.02), and referral from a non-programme linked clinic/centre (aHR 3.02(2.01–4.53)). Conclusions We attribute early deaths in this relatively young cohort to delay in diagnosis and treatment of TB, inadequate treatment of drug-resistant TB, and poor ART access. Considerable expansion and improvement in quality of diagnosis and treatment services for TB and HIV are needed to achieve the sustainable development goal of reducing TB deaths by 95% by 2035.
Collapse
Affiliation(s)
- Aishatu L Adamu
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Muktar A Gadanya
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Isa S Abubakar
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Abubakar M Jibo
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Musa M Bello
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Auwalu U Gajida
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Musa M Babashani
- Department of Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK.
| |
Collapse
|
24
|
Heunis JC, Kigozi NG, Chikobvu P, Botha S, van Rensburg HD. Risk factors for mortality in TB patients: a 10-year electronic record review in a South African province. BMC Public Health 2017; 17:38. [PMID: 28061839 PMCID: PMC5217308 DOI: 10.1186/s12889-016-3972-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 12/20/2016] [Indexed: 11/29/2022] Open
Abstract
Background Since 1990, reduction of tuberculosis (TB) mortality has been lower in South Africa than in other high-burden countries in Africa. This research investigated the influence of routinely captured demographic and clinical or programme variables on death in TB patients in the Free State Province. Methods A retrospective review of case information captured in the Electronic TB register (ETR.net) over the years 2003 to 2012 was conducted. Extracted data were subjected to descriptive and logistic regression analyses. The outcome variable was defined as all registered TB cases with ‘died’ as the recorded outcome. The variables associated with increased or decreased odds of dying in TB patients were established. The univariate and adjusted odds ratios (OR and AOR) together with their corresponding 95% confidence intervals (CI) were estimated, taking the clustering effect of the districts into account. Results Of the 190,472 TB cases included in the analysis, 30,991 (16.3%) had ‘died’ as the recorded treatment outcome. The proportion of TB patients that died increased from 15.1% in 2003 to 17.8% in 2009, before declining to 15.4% in 2012. The odds of dying was incrementally higher in the older age groups: 8–17 years (AOR: 2.0; CI: 1.5–2.7), 18–49 years (AOR: 5.8; CI: 4.0–8.4), 50–64 years (AOR: 7.7; CI: 4.6–12.7), and ≥65 years (AOR: 14.4; CI: 10.3–20.2). Other factors associated with increased odds of mortality included: HIV co-infection (males – AOR: 2.4; CI: 2.1–2.8; females – AOR: 1.9; CI: 1.7–2.1) or unknown HIV status (males – AOR: 2.8; CI: 2.5–3.1; females – AOR: 2.4; CI: 2.2–2.6), having a negative (AOR: 1.4; CI: 1.3–1.6) or a missing (AOR: 2.1; CI: 1.4–3.2) pre-treatment sputum smear result, and being a retreatment case (AOR: 1.3; CI: 1.2–1.4). Conclusions Although mortality in TB patients in the Free State has been falling since 2009, it remained high at more than 15% in 2012. Appropriately targeted treatment and care for the identified high-risk groups could be considered.
Collapse
Affiliation(s)
- J Christo Heunis
- Centre for Health Systems Research and Development, University of the Free State, P.O. Box 399, Bloemfontein, 9300, South Africa.
| | - N Gladys Kigozi
- Centre for Health Systems Research and Development, University of the Free State, P.O. Box 399, Bloemfontein, 9300, South Africa
| | - Perpetual Chikobvu
- Free State Department of Health, P.O. Box 277, Bloemfontein, 9300, South Africa.,Department of Community Health, University of the Free State, P.O. Box 399, Bloemfontein, 9300, South Africa
| | - Sonja Botha
- JPS Africa, Postnet Suite 132, Private Bag X14, Brooklyn, Pretoria, 0011, South Africa
| | - Hcj Dingie van Rensburg
- Centre for Health Systems Research and Development, University of the Free State, P.O. Box 399, Bloemfontein, 9300, South Africa
| |
Collapse
|
25
|
Mhimbira F, Hella J, Maroa T, Kisandu S, Chiryamkubi M, Said K, Mhalu G, Mkopi A, Mutayoba B, Reither K, Gagneux S, Fenner L. Home-Based and Facility-Based Directly Observed Therapy of Tuberculosis Treatment under Programmatic Conditions in Urban Tanzania. PLoS One 2016; 11:e0161171. [PMID: 27513331 PMCID: PMC4981322 DOI: 10.1371/journal.pone.0161171] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 08/01/2016] [Indexed: 12/28/2022] Open
Abstract
Introduction Decentralization of Directly Observed Treatment (DOT) for tuberculosis (TB) to the community (home-based DOT) has improved the coverage of TB treatment and reduced the burden to the health care facilities (facility-based DOT). We aimed to compare TB treatment outcomes in home-based and facility-based DOT under programmatic conditions in an urban setting with a high TB burden. Methodology A retrospective analysis of a cohort of adult TB patients (≥15 years) routinely notified between 2010 and 2013 in two representative TB sub-districts in the Temeke district, Dar es Salaam, Tanzania. We assessed differences in treatment outcomes by calculating Risk Ratios (RRs). We used logistic regression to assess the association between DOT and treatment outcomes. Results Data of 4,835 adult TB patients were analyzed, with a median age of 35 years, 2,943 (60.9%) were men and TB/HIV co-infection prevalence of 39.9%. A total of 3,593 (74.3%) patients were treated under home-based DOT. Patients on home-based DOT were more likely to die compared to patients on facility-based DOT (RR 2.04, 95% Confidence Interval [95% CI]: 1.52–2.73), and more likely to complete TB treatment (RR 1.14, 95% CI: 1.06–1.23), but less likely to have a successful treatment outcome (RR 0.94, 95% CI: 0.92–0.97). Home-based DOT was preferred by women (adjusted Odds Ratio [aOR] 1.55, 95% CI: 1.34–1.80, p<0.001), older people (aOR 1.01 for each year increase, 95% CI: 1.00–1.02, p = 0.001) and patients with extra-pulmonary TB (aOR 1.45, 95% CI: 1.16–1.81, p = 0.001), but less frequently by patients on a retreatment regimen (aOR 0.12, 95% CI: 0.08–0.19, p<0.001). Conclusions/significance TB patients under home-based DOT had more frequently risk factors of death such as older age, HIV infection and sputum smear-negative TB, and had higher mortality compared to patients under facility-based DOT. Further operational research is needed to monitor the implementation of DOT under programmatic conditions.
Collapse
Affiliation(s)
- Francis Mhimbira
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- * E-mail: (FM); (LF)
| | - Jerry Hella
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Thomas Maroa
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Magreth Chiryamkubi
- National TB and Leprosy Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Khadija Said
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Grace Mhalu
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Beatrice Mutayoba
- National TB and Leprosy Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Klaus Reither
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Sébastien Gagneux
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Lukas Fenner
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- * E-mail: (FM); (LF)
| |
Collapse
|
26
|
Pontali E, Centis R, D'Ambrosio L, Migliori GB. Monitoring predictors of mortality: A necessary action to reach TB elimination. REVISTA PORTUGUESA DE PNEUMOLOGIA 2015; 21:S2173-5115(15)00187-6. [PMID: 26590095 DOI: 10.1016/j.rppnen.2015.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Indexed: 06/05/2023] Open
Affiliation(s)
- E Pontali
- Department of Infectious Diseases - Galliera Hospital, Genoa, Italy
| | - R Centis
- WHO Collaborating Centre for Tuberculosis & Lung Diseases, Fondazione S. Maugeri, IRCCS, Tradate, Italy
| | - L D'Ambrosio
- WHO Collaborating Centre for Tuberculosis & Lung Diseases, Fondazione S. Maugeri, IRCCS, Tradate, Italy; Public Health Consulting Group, Lugano, Switzerland
| | - G B Migliori
- WHO Collaborating Centre for Tuberculosis & Lung Diseases, Fondazione S. Maugeri, IRCCS, Tradate, Italy.
| |
Collapse
|