1
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Walker EF, Flook M, Rodger AJ, Fielding KL, Stagg HR. Quantifying non-adherence to anti-tuberculosis treatment due to early discontinuation: a systematic literature review of timings to loss to follow-up. BMJ Open Respir Res 2024; 11:e001894. [PMID: 38359965 PMCID: PMC10875541 DOI: 10.1136/bmjresp-2023-001894] [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: 06/20/2023] [Accepted: 12/15/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND The burden of non-adherence to anti-tuberculosis (TB) treatment is poorly understood. One type is early discontinuation, that is, stopping treatment early. Given the implications of early discontinuation for treatment outcomes, we undertook a systematic review to estimate its burden, using the timing of loss to follow-up (LFU) as a proxy measure. METHODS Web of Science, Embase and Medline were searched up to 14 January 2021 using terms covering LFU, TB and treatment. Studies of adults (≥ 18 years) on the standard regimen for drug-sensitive TB reporting the timing of LFU (WHO definition) were included. A narrative synthesis was conducted and quality assessment undertaken using an adapted version of Downs and Black. Papers were grouped by the percentage of those who were ultimately LFU who were LFU by 2 months. Three groups were created: <28.3% LFU by 2 months, ≥28.3-<38.3%, ≥38.3%). The percentage of dose-months missed due to early discontinuation among (1) those LFU, and (2) all patients was calculated. RESULTS We found 40 relevant studies from 21 countries. The timing of LFU was variable within and between countries. 36/40 papers (90.0%) reported the percentage of patients LFU by the end of 2 months. 31/36 studies (86.1%) reported a higher than or as expected percentage of patients becoming LFU by 2 months. The percentage of dose-months missed by patients who became LFU ranged between 37% and 77% (equivalent to 2.2-4.6 months). Among all patients, the percentage of dose-months missed ranged between 1% and 22% (equivalent to 0.1-1.3 months). CONCLUSIONS A larger than expected percentage of patients became LFU within the first 2 months of treatment. These patients missed high percentages of dose months of treatment due to early discontinuation. Interventions to promote adherence and retain patients in care must not neglect the early months of treatment. PROSPERO REGISTRATION NUMBER CRD42021218636.
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Affiliation(s)
| | - Mary Flook
- Faculty of Life and Health Sciences, University of Liverpool, Liverpool, UK
| | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, University of the Witwatersrand- Johannesburg, Johannesburg, South Africa
| | - Helen R Stagg
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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2
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Monique OPPERMAN, Ilse DUPREEZ. FACTORS CONTRIBUTING TO PULMONARY TB TREATMENT LOST TO FOLLOW-UP IN DEVELOPING COUNTRIES: AN OVERVIEW. Afr J Infect Dis 2022; 17:60-73. [PMID: 36756489 PMCID: PMC9885020 DOI: 10.21010/ajidv17i1.6] [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: 08/16/2022] [Revised: 11/21/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
Background Despite the available treatment options, pulmonary tuberculosis (TB) remains a leading cause of disease-related deaths worldwide. Treatment non-adherence/lost to follow-up (LTFU), particularly in developing countries, is a continuous concern. LTFU prolongs TB infectiousness and contributes to TB treatment failure, relapse, and death. Furthermore, LTFU also delays global TB eradication by promoting TB spread and drug-resistant TB strain development.[1] The purpose of this paper is to give an overview of the commonly observed risk factors associated with TB treatment LTFU in developing countries. Materials and Methods A literature survey was done of studies published in the past decade, which evaluated the risk factors for LTFU in TB patients, specifically in developing countries. Furthermore, some prospective TB treatment adherence initiatives and the feasibility of these initiatives within developing countries were assessed.[3]. Results Several variables, including socio-demographic, patient-related, TB disease and other health-related-factors, healthcare and system determinants, as well as treatment-related factors, were identified to increase the risk of TB treatment LTFU. More recently applied adherence interventions in developing countries, show potential for implementation on a larger scale. Conclusion Successful TB treatment is contingent on treatment adherence, and by addressing these persisting LTFU risk factors, treatment adherence in developing countries may be improved.
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Affiliation(s)
- OPPERMAN, Monique
- Human Metabolomics, North-West University (Potchefstroom Campus), Private Bag x6001, Box 269, Potchefstroom, South Africa, 2531
| | - DU PREEZ, Ilse
- Human Metabolomics, North-West University (Potchefstroom Campus), Private Bag x6001, Box 269, Potchefstroom, South Africa, 2531,Corresponding Author’s E-Mail:
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3
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Navarro PDD, Haddad JPA, Rabelo JVC, Silva CHDLE, Almeida IND, Carvalho WDS, Miranda SSD. The impact of the stratification by degree of clinical severity and abandonment risk of tuberculosis treatment. J Bras Pneumol 2021; 47:e20210018. [PMID: 34495173 PMCID: PMC8979663 DOI: 10.36416/1806-3756/e20210018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/30/2021] [Indexed: 12/01/2022] Open
Abstract
Objective: Evaluate the impact of the instrument of the “Stratification by Degree of Clinical Severity and Abandonment Risk of Tuberculosis Treatment” (SRTB) on the tuberculosis outcome. Methods: This study was a pragmatic clinical trial involving patients with a confirmed diagnosis of tuberculosis treated at one of the 152 primary health care units in the city of Belo Horizonte, Brazil, between May of 2016 and April of 2017. Cluster areas for tuberculosis were identified, and the units and their respective patients were divided into intervention (use of SRTB) and nonintervention groups. Results: The total sample comprised 432 participants, 223 and 209 of whom being allocated to the nonintervention and intervention groups, respectively. The risk of treatment abandonment in the nonintervention group was significantly higher than was that in the intervention group (OR = 15.010; p < 0.001), regardless of the number of risk factors identified. Kaplan-Meier curves showed a hazard ratio of 0.0753 (p < 0.001). Conclusions: The SRTB instrument was effective in reducing abandonment of tuberculosis treatment, regardless of the number of risk factors for that. This instrument is rapid and easy to use, and can be adapted to different realities. Its application showed characteristics predisposing to a non-adherence to the treatment and established bases to mitigate its impact.
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Affiliation(s)
- Pedro Daibert de Navarro
- . Secretaria Municipal de Saúde, Prefeitura de Belo Horizonte, Belo Horizonte (MG) Brasil.,. Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil
| | - João Paulo Amaral Haddad
- . Departamento de Medicina Veterinária Preventiva, Escola de Veterinária, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil
| | | | | | - Isabela Neves de Almeida
- . Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil.,. Faculdade de Farmácia, Universidade Federal de Ouro Preto, Ouro Preto (MG) Brasil
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4
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Sharma V, Agarwal A. Making survival in TB defaulter patient: A key challenge. Indian J Tuberc 2020; 67:262-263. [PMID: 32553323 DOI: 10.1016/j.ijtb.2019.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/11/2019] [Indexed: 06/11/2023]
Affiliation(s)
- Vikas Sharma
- Department of Community Medicine, G.R.Medical College Gwalior 474009 MP India
| | - Anil Agarwal
- Department of Community Medicine, G.R.Medical College Gwalior 474009 MP India.
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5
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Aibana O, Dauria E, Kiriazova T, Makarenko O, Bachmaha M, Rybak N, Flanigan TP, Petrenko V, Becker AE, Murray MB. Patients' perspectives of tuberculosis treatment challenges and barriers to treatment adherence in Ukraine: a qualitative study. BMJ Open 2020; 10:e032027. [PMID: 32014870 PMCID: PMC7044979 DOI: 10.1136/bmjopen-2019-032027] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 11/18/2019] [Accepted: 01/14/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To understand the challenges faced by patients with tuberculosis (TB) and factors that influence TB treatment adherence in Ukraine. DESIGN Qualitative study. SETTING TB treatment facilities in Kyiv Oblast, Ukraine. PARTICIPANTS Sixty adults who had undergone treatment for drug-sensitive TB between June 2012 and August 2015. METHODS We conducted semistructured, in-depth, individual interviews among a purposively selected clinical sample of patients previously treated for drug-sensitive TB. Interview content encompassed WHO's framework for barriers to adherence to long-term therapies and included questions about patient preferences and motivators concerning treatment adherence. We examined treatment experience across strata defined by previously identified risk correlates of non-adherence. RESULTS Among 60 participants, 19 (32.8%) were HIV positive, 12 (20.3%) had substance use disorder and 9 (15.0%) had not completed TB treatment. Respondents discussed the psychological distress associated with hospital-based TB care, as well as perceived unsupportive, antagonistic interactions with TB providers as major challenges to treatment adherence. An additional barrier to successful treatment completion included the financial toll of lost income during TB treatment, which was exacerbated by the additional costs of ancillary medications and transportation to ambulatory TB clinics. The high pill burden of TB treatment also undermined adherence. These challenges were endorsed among participants with and without major risk factors for non-adherence. CONCLUSIONS Our findings highlight important barriers to TB treatment adherence in this study population and suggest specific interventions that may be beneficial in mitigating high rates of poor treatment outcomes for TB in Ukraine.
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Affiliation(s)
- Omowunmi Aibana
- Internal Medicine, McGovern Medical School at the University of Texas Health Science Center - Houston, Houston, Texas, USA
| | - Emily Dauria
- Psychiatry, University of California San Francisco, San Francisco, California, USA
| | | | | | | | - Natasha Rybak
- Infectious Diseases, The Miriam Hospital, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Timothy Palen Flanigan
- Infectious Diseases, The Miriam Hospital, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Vasyl Petrenko
- Phthisiology (Tuberculosis), Bogomolets National Medical University, Kyiv, Ukraine
| | - Anne E Becker
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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6
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Wollenberg K, Harris M, Gabrielian A, Ciobanu N, Chesov D, Long A, Taaffe J, Hurt D, Rosenthal A, Tartakovsky M, Crudu V. A retrospective genomic analysis of drug-resistant strains of M. tuberculosis in a high-burden setting, with an emphasis on comparative diagnostics and reactivation and reinfection status. BMC Infect Dis 2020; 20:17. [PMID: 31910804 PMCID: PMC6947865 DOI: 10.1186/s12879-019-4739-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 12/27/2019] [Indexed: 12/01/2022] Open
Abstract
Background Recurrence of drug-resistant tuberculosis (DR-TB) after treatment occurs through relapse of the initial infection or reinfection by a new drug-resistant strain. Outbreaks of DR-TB in high burden regions present unique challenges in determining recurrence status for effective disease management and treatment. In the Republic of Moldova the burden of DR-TB is exceptionally high, with many cases presenting as recurrent. Methods We performed a retrospective analysis of Mycobacterium tuberculosis from Moldova to better understand the genomic basis of drug resistance and its effect on the determination of recurrence status in a high DR-burden environment. To do this we analyzed genomes from 278 isolates collected from 189 patients, including 87 patients with longitudinal samples. These pathogen genomes were sequenced using Illumina technology, and SNP panels were generated for each sample for use in phylogenetic and network analysis. Discordance between genomic resistance profiles and clinical drug-resistance test results was examined in detail to assess the possibility of mixed infection. Results There were clusters of multiple patients with 10 or fewer differences among DR-TB samples, which is evidence of person-to-person transmission of DR-TB. Analysis of longitudinally collected isolates revealed that many infections exhibited little change over time, though 35 patients demonstrated reinfection by divergent (number of differences > 10) lineages. Additionally, several same-lineage sample pairs were found to be more divergent than expected for a relapsed infection. Network analysis of the H3/4.2.1 clade found very close relationships among 61 of these samples, making differentiation of reactivation and reinfection difficult. There was discordance between genomic profile and clinical drug sensitivity test results in twelve samples, and four of these had low level (but not statistically significant) variation at DR SNPs suggesting low-level mixed infections. Conclusions Whole-genome sequencing provided a detailed view of the genealogical structure of the DR-TB epidemic in Moldova, showing that reinfection may be more prevalent than currently recognized. We also found increased evidence of mixed infection, which could be more robustly characterized with deeper levels of genomic sequencing.
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Affiliation(s)
- Kurt Wollenberg
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
| | - Michael Harris
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Andrei Gabrielian
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Nelly Ciobanu
- Microbiology and Morphology Laboratory, Institute of Phthisiopneumology, Chisnau, Moldova
| | - Dumitru Chesov
- Department of Pneumology and Allergology, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Moldova.,Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany
| | - Alyssa Long
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jessica Taaffe
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Darrell Hurt
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Alex Rosenthal
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Michael Tartakovsky
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Valeriu Crudu
- Microbiology and Morphology Laboratory, Institute of Phthisiopneumology, Chisnau, Moldova
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7
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Stosic M, Vukovic D, Babic D, Antonijevic G, Foley KL, Vujcic I, Grujicic SS. Risk factors for multidrug-resistant tuberculosis among tuberculosis patients in Serbia: a case-control study. BMC Public Health 2018; 18:1114. [PMID: 30208864 PMCID: PMC6134722 DOI: 10.1186/s12889-018-6021-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 09/06/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Multidrug resistant (MDR) tuberculosis (TB) represents TB which is simultaneous resistant to at least rifampicin (R) and isoniazid (H). Identifying inadequate therapy as the main cause of this form of the disease and explaining the factors leading to its occurrence, numerous social determinants that affect the risk of developing resistance are highlighted. The objectives of the study was to identify independent factors of MDR-TB among tuberculosis patients. METHODS Case-control study was conducted from 1st September 2009 to 1st June 2014 in 31 healthcare institutions in Serbia where MDR-TB and TB patients were treated. TB patients infected with MDR- M. tuberculosis and non MDR- M. tuberculosis strain were considered as cases and controls, respectively. Cases and controls were matched by the date of hospitalization. The data was collected using structured questionnaire with face to face interview. Bivariate and multivariable logistic regression analysis (MLRA) were used to identify determinants associated with MDR-TB. RESULTS A total of 124 respondents, 31 cases and 93 controls were participated in the study. MLRA identified six significant independent risk factors for the occurrence of MDR-TB as follows: monthly income of the family (Odds ratio (OR) = 3.71; 95% Confidence Interval (CI) = 1.22-11.28), defaulting from treatment (OR = 3.33; 95% CI = 1.14-9.09), stigma associated with TB (OR = 2.97; 95% CI = 1.18-7.45), subjective feeling of sadness (OR = 4.05; 95% CI = 1.69-9.70), use of sedatives (OR = 2.79; 95% CI = 1.02-7.65) and chronic obstructive pulmonary disease (OR = 4.51; 95% CI = 1.07-18.96). CONCLUSION In order to reduce burden of drug resistance, strategies of controlling MDR-TB in Serbia should emphasize multi-sectorial actions, addressing health care and social needs of TB patients.
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Affiliation(s)
- Maja Stosic
- Department of HIV/AIDS, STIs, Viral Hepatitis and TB, Public Health Institute of Serbia, "Dr Milan Jovanovic Batut", Dr Subotica 5, Belgrade, 11000, Serbia
| | - Dejana Vukovic
- Institute of Social Medicine, Faculty of Medicine, Belgrade University, Dr Subotica 9, Belgrade, 11000, Serbia
| | - Dragan Babic
- Institute of Medical Statistics and Informatics, Faculty of Medicine, Belgrade University, Dr Subotica 9, Belgrade, 11000, Serbia
| | - Gordana Antonijevic
- Special Hospital for Lung Diseases, "Ozren"Ozrenska bb, Sokobanja, 18230, Serbia
| | - Kristie L Foley
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Isidora Vujcic
- Institute of Epidemiology, Faculty of Medicine, Belgrade University, Visegradska 26, Belgrade, 11000, Serbia
| | - Sandra Sipetic Grujicic
- Institute of Epidemiology, Faculty of Medicine, Belgrade University, Visegradska 26, Belgrade, 11000, Serbia.
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8
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Priedeman Skiles M, Curtis SL, Angeles G, Mullen S, Senik T. Evaluating the impact of social support services on tuberculosis treatment default in Ukraine. PLoS One 2018; 13:e0199513. [PMID: 30092037 PMCID: PMC6084809 DOI: 10.1371/journal.pone.0199513] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 06/09/2018] [Indexed: 01/10/2023] Open
Abstract
Ukraine is among the top 20 highest drug-resistant tuberculosis burden countries in the world. Driving the high drug-resistant tuberculosis rates is an unchecked treatment default rate. This evaluation measures the effect of social support provided to tuberculosis patients at risk of defaulting on treatment during outpatient treatment. Five tuberculosis patient cohorts, served in three oblasts from 2011 and 2012, were constructed from medical records to compare risk factors for default, receipt of social services, and treatment outcome. Regression analyses were used to identify risk factors predictive of treatment default and to estimate the impact of the social support program on treatment default, controlling for risk, disease status, and demographics. In 2012, tuberculosis patients receiving social support in Ukraine reduced their probability of defaulting on continuation treatment by 10 percentage points compared to high-risk patients who did not receive social support in 2012 or 2011. Treatment success rates for the high-risk patients receiving social support were comparable to the low-risk cohorts and significantly improved over the high-risk comparison cohorts. Further research is recommended to quantify the costs and benefits for scaling-up social support services, evaluate social support program fidelity, identify which populations respond best to select services, and what barriers might still exist to achieve better adherence. With that information, tailoring programs to most effectively reach and serve clients in a patient-centered approach may reap substantial rewards for Ukraine.
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Affiliation(s)
- Martha Priedeman Skiles
- MEASURE Evaluation Project, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Siân L. Curtis
- MEASURE Evaluation Project, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Gustavo Angeles
- MEASURE Evaluation Project, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Tatyana Senik
- International Research Agency IFAK Institut, Kyiv, Ukraine
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9
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Wohlleben J, Makhmudova M, Saidova F, Azamova S, Mergenthaler C, Verver S. Risk factors associated with loss to follow-up from tuberculosis treatment in Tajikistan: a case-control study. BMC Infect Dis 2017; 17:543. [PMID: 28778187 PMCID: PMC5545046 DOI: 10.1186/s12879-017-2655-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 07/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are very few studies on reasons for loss to follow-up from TB treatment in Central Asia. This study assessed risk factors for LTFU and compared their occurrence with successfully treated (ST) patients in Tajikistan. METHODS This study took place in all TB facilities in the 19 districts with at least 5 TB patients registered as loss to follow-up (LTFU) from treatment. With a matched case control design we included all LTFU patients registered in the selected districts in 2011 and 2012 as cases, with ST patients from the same districts being controls. Data were copied from patient records and registers. Conditional logistic regressions were run to analyse associations between collected variables and LTFU as dependent variable. RESULTS Three hundred cases were compared to 592 controls. Half of the cases had migrated or moved. In multivariate analysis, risk factors associated with increased LTFU were migration to another country (OR 10.6, 95% CI 6.12-18.4), moving within country (OR 11.0, 95% CI 3.50-34.9), having side effects of treatment (OR 3.67, 95% CI 1.68-8.00) and being previously treated for TB (OR 2.03, 95% CI 1.05-3.93). Medical staff also mentioned patient refusal, stigma and family problems as risk factors. CONCLUSIONS LTFU of TB patients in Tajikistan is largely a result of migration, and to a lesser extent associated with side-effects and previous treatment. There is a need to strengthen referral between health facilities within Tajikistan and with neighbouring countries and support patients with side effects and/or previous TB to prevent loss to follow-up from treatment.
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Affiliation(s)
- Jessica Wohlleben
- KNCV Tuberculosis Foundation, Evidence team, The Hague, The Netherlands.,Department of International Health, University Maastricht, Maastricht, The Netherlands
| | | | - Firuza Saidova
- KNCV TB Foundation, country office Tajikistan, Dushanbe, Tajikistan
| | - Shahnoza Azamova
- Republican Center for protection of population from TB, Dushanbe, Tajikistan
| | - Christina Mergenthaler
- KNCV Tuberculosis Foundation, Evidence team, The Hague, The Netherlands.,Present address: Royal Tropical Institute (KIT), Amsterdam, The Netherlands
| | - Suzanne Verver
- KNCV Tuberculosis Foundation, Evidence team, The Hague, The Netherlands. .,Academic Medical Centre, AIGHD, Amsterdam, the Netherlands. .,Present address: Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
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10
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Horter S, Stringer B, Greig J, Amangeldiev A, Tillashaikhov MN, Parpieva N, Tigay Z, du Cros P. Where there is hope: a qualitative study examining patients' adherence to multi-drug resistant tuberculosis treatment in Karakalpakstan, Uzbekistan. BMC Infect Dis 2016; 16:362. [PMID: 27465783 PMCID: PMC4964095 DOI: 10.1186/s12879-016-1723-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 07/18/2016] [Indexed: 11/29/2022] Open
Abstract
Background Treatment for multi-drug resistant tuberculosis (MDR-TB) is lengthy, has severe side effects, and raises adherence challenges. In the Médecins Sans Frontières (MSF) and Ministry of Health (MoH) programme in Karakalpakstan, Uzbekistan, a region with a high burden of MDR-TB, patient loss from treatment (LFT) remains high despite adherence support strategies. While certain factors associated with LFT have been identified, there is limited understanding of why some patients are able to adhere to treatment while others are not. We conducted a qualitative study to explore patients’ experiences with MDR-TB treatment, with the aim of providing insight into the barriers and enablers to treatment-taking to inform future strategies of adherence support. Methods Participants were purposively selected. Programme data were analysed to enable stratification of patients by adherence category, gender, and age. 52 in-depth interviews were conducted with MDR-TB patients (n = 35) and health practitioners (n = 12; MSF and MoH doctors, nurses, and counsellors), including five follow-up interviews. Interview notes, then transcripts, were analysed using coding to identify emerging patterns and themes. Manual analysis drew upon principles of grounded theory with constant comparison of codes and categories within and between cases to actively seek discrepancies and generate concepts from participant accounts. Ethics approval was received from the MoH of the Republic of Uzbekistan Ethics Committee and MSF Ethics Review Board. Results Several factors influenced adherence. Hope and high quality knowledge supported adherence; autonomy and control enabled optimal engagement with treatment-taking; and perceptions of the body, self, treatment, and disease influenced drug tolerance. As far as we are aware, the influence of patient autonomy and control on MDR-TB treatment-taking has not previously been described. In particular, the autonomy of married women around treatment-taking was potentially undermined through their societal position as daughter-in-law, compromising their ability to adhere to treatment. Patients’ engagement with and adherence to treatment could be hindered by hierarchical practitioner-patient relationships that displaced authority, ownership, and responsibility from the patient. Conclusions Our findings reinforce the need for an individualised and holistic approach to adherence support with engagement of patients as active participants in their care who feel ownership and responsibility for their treatment.
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Affiliation(s)
- Shona Horter
- Médecins Sans Frontières (UK), Lower Ground Floor, Chancery Exchange, 10 Furnival Street, London, EC4A 1AB, UK.
| | - Beverley Stringer
- Médecins Sans Frontières (UK), Lower Ground Floor, Chancery Exchange, 10 Furnival Street, London, EC4A 1AB, UK
| | - Jane Greig
- Médecins Sans Frontières (UK), Lower Ground Floor, Chancery Exchange, 10 Furnival Street, London, EC4A 1AB, UK
| | | | | | - Nargiza Parpieva
- Ministry of Health of the Republic of Uzbekistan, Tashkent, Uzbekistan
| | | | - Philipp du Cros
- Médecins Sans Frontières (UK), Lower Ground Floor, Chancery Exchange, 10 Furnival Street, London, EC4A 1AB, UK
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11
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Alobu I, Oshi SN, Oshi DC, Ukwaja KN. Risk factors of treatment default and death among tuberculosis patients in a resource-limited setting. ASIAN PAC J TROP MED 2014; 7:977-84. [DOI: 10.1016/s1995-7645(14)60172-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 10/15/2014] [Accepted: 11/15/2014] [Indexed: 10/24/2022] Open
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Intensive-phase treatment outcomes among hospitalized multidrug-resistant tuberculosis patients: results from a nationwide cohort in Nigeria. PLoS One 2014; 9:e94393. [PMID: 24722139 PMCID: PMC3983205 DOI: 10.1371/journal.pone.0094393] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/14/2014] [Indexed: 11/19/2022] Open
Abstract
Background Nigeria is faced with a high burden of Human Immunodeficiency Virus (HIV) infection and multidrug-resistant tuberculosis (MDR-TB). Treatment outcomes among MDR-TB patients registered across the globe have been poor, partly due to high loss-to-follow-up. To address this challenge, MDR-TB patients in Nigeria are hospitalized during the intensive-phase(IP) of treatment (first 6–8 months) and are provided with a package of care including standardized MDR-TB treatment regimen, antiretroviral therapy (ART) and cotrimoxazole prophylaxis (CPT) for HIV-infected patients, nutritional and psychosocial support. In this study, we report the end-IP treatment outcomes among them. Methods In this retrospective cohort study, we reviewed the patient records of all bacteriologically-confirmed MDR-TB patients admitted for treatment between July 2010 and October 2012. Results Of 162 patients, 105(65%) were male, median age was 34 years and 28(17%) were HIV-infected; all 28 received ART and CPT. Overall, 138(85%) were alive and culture negative at the end of IP, 24(15%) died and there was no loss-to-follow-up. Mortality was related to low CD4-counts at baseline among HIV-positive patients. The median increase in body mass index among those documented to be underweight was 2.6 kg/m2 (p<0.01) and CD4-counts improved by a median of 52 cells/microL among the HIV-infected patients (p<0.01). Conclusions End-IP treatment outcomes were exceptional compared to previously published data from international cohorts, thus confirming the usefulness of a hospitalized model of care. However, less than five percent of all estimated 3600 MDR-TB patients in Nigeria were initiated on treatment during the study period. Given the expected scale-up of MDR-TB care, the hospitalized model is challenging to sustain and the national TB programme is contemplating to move to ambulatory care. Hence, we recommend using both ambulatory and hospitalized approaches, with the latter being reserved for selected high-risk groups.
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Jenkins HE, Crudu V, Soltan V, Ciobanu A, Domente L, Cohen T. High risk and rapid appearance of multidrug resistance during tuberculosis treatment in Moldova. Eur Respir J 2014; 43:1132-41. [PMID: 24558181 PMCID: PMC4005038 DOI: 10.1183/09031936.00203613] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is a serious problem in the former Soviet Union and may appear during TB treatment. We aimed to estimate the prevalence of, timing of and factors associated with MDR-TB diagnosis during TB treatment in Moldova, which was part of the former Soviet Union. We analysed data on 3 754 confirmed non-MDR-TB cases (between January 1, 2007 and December 31, 2010) in the Moldovan TB surveillance database, where patients provided sputum specimens for drug-susceptibility testing, multiple times, during treatment. We estimated the percentage of individuals with confirmed baseline non-MDR-TB that were diagnosed with MDR-TB during treatment, documented the time at which MDR-TB was diagnosed, and used a failure-time model to identify factors associated with MDR-TB diagnosis. Between 7.2% and 9.2% of initially non-MDR-TB cases were diagnosed with MDR-TB during treatment. Half of these MDR-TB diagnoses occurred with 3 months of the initial diagnosis. An increased MDR-TB risk during treatment was associated with baseline resistance to first-line TB drugs (linear increase in risk per additional drug), previous incarceration and HIV co-infection. MDR can appear rapidly during TB treatment. Policy considerations should emphasise management during early treatment by increasing ambulatory TB treatment to prevent nosocomial transmission, and ensuring universal rapid diagnostics access to prevent acquisition and transmission of drug resistance.
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Alcohol, hospital discharge, and socioeconomic risk factors for default from multidrug resistant tuberculosis treatment in rural South Africa: a retrospective cohort study. PLoS One 2013; 8:e83480. [PMID: 24349518 PMCID: PMC3862731 DOI: 10.1371/journal.pone.0083480] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Accepted: 11/11/2013] [Indexed: 11/21/2022] Open
Abstract
Background Default from multidrug-resistant tuberculosis (MDR-TB) treatment remains a major barrier to cure and epidemic control. We sought to identify patient risk factors for default from MDR-TB treatment and high-risk time periods for default in relation to hospitalization and transition to outpatient care. Methods We retrospectively analyzed a cohort of 225 patients who initiated MDR-TB treatment between 2007 through 2010 at a rural TB hospital in the Western Cape Province, South Africa. Results Fifty percent of patients were cured or completed treatment, 27% defaulted, 14% died, 4% failed treatment, and 5% transferred out. Recent alcohol use was common (63% of patients). In multivariable proportional hazards regression, older age (hazard ratio [HR]= 0.97 [95% confidence interval 0.94-0.99] per year of greater age), formal housing (HR=0.38 [0.19-0.78]), and steady employment (HR=0.41 [0.19-0.90]) were associated with decreased risk of default, while recent alcohol use (HR=2.1 [1.1-4.0]), recent drug use (HR=2.0 [1.0-3.6]), and Coloured (mixed ancestry) ethnicity (HR=2.3 [1.1-5.0]) were associated with increased risk of default (P<0.05). Defaults occurred throughout the first 18 months of the two-year treatment course but were especially frequent among alcohol users after discharge from the initial four-to-five-month in-hospital phase of treatment, with the highest default rates occurring among alcohol users within two months of discharge. Default rates during the first two months after discharge were also elevated for patients who received care from mobile clinics. Conclusions Among patients who were not cured or did not complete MDR-TB treatment, the majority defaulted from treatment. Younger, economically-unstable patients and alcohol and drug users were particularly at risk. For alcohol users as well as mobile-clinic patients, the early outpatient treatment phase is a high-risk period for default that could be targeted in efforts to increase treatment completion rates.
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