The burden and treatment outcomes of extra-pulmonary tuberculosis in Bhutan

Epidemiological and laboratory characteristics of multidrug-resistant tuberculosis patients in Bhutan, 2015-2019

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Multidrug-resistant tuberculosis (MDR-TB) reported in high numbers of new TB cases

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Majority of MDR-TB patients in the economically productive age group

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No major variations in mutation pattern for Line Probe Assay results across 5 years

Background

Bhutan is no exception to the rising global threat of drug resistance tuberculosis (TB), particularly multidrug-resistant (MDR) TB. Although drug resistance surveillance has been carried out in Bhutan since 2010, limited analysis reports are available. Therefore, we looked at data from 2015−2019 to understand patient characteristics.

Method

To obtain data for MDR-TB from the past 5 years, we looked at manual registers and laboratory worksheets for all samples received at National TB Reference Laboratory. Epidemiological factors and laboratory variables were analyzed using descriptive statistics.

Result

Among 304 patients with MDR-TB, 85.20% (n=259) are new cases with no previous history of treatment. Those aged 16−25 years from both genders are affected more (46.05%, n=140) than other age groups. The majority (94.62%, n=264) of rifampicin resistance was found in the MUT 3 rpoB gene. For Isoniazid, 97.13% (n=271) resistance was seen in the MUT1 band of the katG gene.

Conclusion

A high number of MDR-TB cases among new patients and little variation in the resistance band pattern over 5 years could indicate uncontrolled ongoing transmission. Whole-genome sequencing for the samples is required to further understand the epidemiology of the resistance pattern.

Cancer obscures extrapulmonary tuberculosis (EPTB) at a tertiary hospital in Northern Malawi

Data on the prevalence of extrapulmonary tuberculosis (EPTB) patients are limited in many African countries including Malawi. We conducted a retrospective review of all histology reports for cancer suspected patients at Mzuzu Central Hospital (MZCH) between 2013 and 2018 to determine the proportion of EPTB cases among cancer suspected patients and characterised them epidemiologically. All reports with inconclusive findings were excluded. In total, 2214 reports were included in the review, 47 of which reported EPTB, representing 2.1% (95% CI 1.6-2.8). The incidence of EPTB was significantly associated with sex, age and HIV status. Men were more than twice (OR 2.1; 95% CI 1.2-3.9) as likely to have EPTB as women while those with HIV were more than six times (OR 6.4; 95% CI 1.7-24.8) as likely to have EPTB compared to those who were HIV-negative. EPTB demonstrated an inverse relationship with age. The highest proportion of EPTB was found from neck lymph nodes (10.3% (5.4-17.2)). A reasonable number of EPTB cases are diagnosed late or missed in Malawi's hospitals. There is a need for concerted efforts to increase EPTB awareness and likely come up with a policy to consider EPTB as a differential diagnosis in cancer suspected patients.

Treatment outcome of tuberculosis patient of Samtse General Hospital, Bhutan

Background

Tuberculosis (TB) is one of the major public health problems in Bhutan. Evaluation of treatment outcomes of TB and identification of the risk factors are important components for the success of National TB control program. Therefore, this study was undertaken to assess the TB treatment outcome and factors associated with it in Samtse General Hospital.

Methods

This was a retrospective, cross sectional study using the TB data from Samtse General Hospital from 2008-2019. A univariate and multiple logistic regression was used to check for associations between the outcome and other independent variables.

Results

The study included a total of 634 TB patients. Of this, 44.0% (279) were smear positive TB (PTB+), 36.1% (229) were extra pulmonary TB (EPTB) and 19.9% (126) were smear negative TB (PTB-). During the study period, 56.2% (356) of them completed treatment, 33.3% (211) were declared cured, 0.2% (1) had defaulted, 5.1% (32) died and 5.4% (34) had treatment failure. The mean treatment success rate (TSR) was 89.4% (567). The TSR was highest for EPTB with 96.9% (222/229), followed by PTB- at 88.1% (111/126) and lowest for PTB+ with 83.9% (234/279). Successful treatment outcome was observed in EPTB patients (AOR: 7.3; 95% CI: 2.46-21.36), patients in age 15-28 years (AOR: 3.4; 95% CI: 1.59-7.46) and 29-42 years (AOR: 9.1; 95% CI: 2.44-33.61).

Conclusion

The treatment outcome of TB in Samtse General Hospital is satisfactory and at par with the national level. Since, smear positive TB and elderly patients are prone to develop poor treatment outcome, they need to be monitored and followed up adequately.

Laboratory and clinico-demographic profile of patients investigated for tuberculosis in the National Referral Hospital of Bhutan

Tuberculosis (TB), caused by the bacterium Mycobacterium tuberculosis, is an important public health problem in Bhutan. Microscopy is the primary method of diagnosis of TB in developing countries including Bhutan. Performance of microscopy in the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), has never been assessed. A retrospective review of laboratory records for three years (2014-2016) was performed to determine the laboratory profile of patients investigated for different types of TB at the JDWNRH. A total of 10,821 sputum and 3,495 non-sputum samples were examined for pulmonary TB (PTB) and extrapulmonary TB (EPTB) respectively. The commonest EPTB samples were Fine Needle Aspiration Cytology (FNAC), urine and sterile fluids. About 6% (127/2163), 5 % (130/2390) and 5% (289/5310) were positive for PTB in 2014, 2015 and 2016 respectively and EPTB positivity was about 7% in all years. During follow-up a significant number of patients remained sputum positive. Sputum sample satisfactory rate (quality) varied between 51 % to 79% in the primary samples. Sample completeness (number) ranged between 62.3% to 94.6% but dropped sequentially in the follow-up cases. Sample completeness of urine samples for EPTB ranged between 75-90%. EPTB positivity rate was highest in FNAC, followed by urine, pleural fluid and ascitic fluid samples. Higher number of patients were investigated for TB in subsequent years from 2014 to 2016. TB positivity rates for PTB and EPTB remained consistent over three years at about 5-6% and 7% respectively. There was a significant variation in sputum sample adequateness (by quality and number). Sputum conversion in the follow-up cases was lower than other countries. Educating the patients on the importance of providing adequate samples can improve TB diagnosis, enhance early treatment, reduce transmission and contribute significantly towards TB elimination.

Treatment outcomes of extrapulmonary tuberculosis in Bahawalpur, Pakistan; a record review

Background

There is limited published data form Pakistan on treatment success rate among extrapulmonary tuberculosis (EPTB) patients. The aim of this study was to assess clinical form, treatment outcomes, and identify the factors associated with unfavorable treatment outcome among EPTB patients.

Methods

A retrospective study was conducted at the Chest Disease Unit of the Bahawal Victoria Hospital, Pakistan. Medical records of EPTB patients, registered at the study site from January 1, 2015 to September 30, 2017, were reviewed to obtain the data. Final treatment outcomes among EPTB patients were evaluated in accordance with the standard Word Health Organization (WHO) criteria. Multivariate binary logistic regression analysis was used to identify the factors associated with unfavorable treatment outcome.

Results

A total of 651 EPTB patients were included in the study. Highest proportion of patients had pleural TB (n = 217, 33.3%). Out of the total 651 patients, 463 (71.1%) successfully completed the treatment. Among 177 (27.2%) patients with unfavorable treatment outcome, 10 (1.5%) died, while 165 (25.4%) lost to follow-up the treatment. Lymph node TB (AOR 0.65, 95% CI 0.422, 0.989) and meningeal TB (AOR 2.1, 95% CI 1.065, 4.144) were significantly associated with unfavorable treatment outcome.

Conclusion

The treatment success (favorable outcome) rate among EPTB patients was less than the target (i.e., ≥ 90%) set by the WHO. Highest proportion of patients lost to follow-up during the treatment.

Childhood tuberculosis and treatment outcomes in Accra: a retrospective analysis

BACKGROUND

Tuberculosis (TB) is a leading cause of death in children and adults. Unlike for adults, there is paucity of data on childhood TB in several countries in Africa. The study objective was to assess the characteristics and treatment outcomes of children with TB from multiple health facilities in Accra, Ghana.

METHODS

A retrospective analyses was conducted using secondary data on children less than 15 years collected from 11 facilities during a TB case finding initiative in Accra from June 2010 to December 2013. Demographic and clinical characteristics as well as treatment outcomes were assessed. Multivariable logistic regression was conducted to assess predictors of mortality.

RESULTS

Out of the total 3704 TB cases reported, 5.9% (219) consisted of children with a female: male ratio of 1:1.1. Children less than 5 years made up 56.2% of the patients while 44.2% were HIV positive. The distribution of TB type were as follows: smear positive pulmonary TB (SPPTB), 46.5%, clinically diagnosed pulmonary TB 36.4%.%, extra-pulmonary TB 17.4%. Among the 214 children (97.7%) for whom treatment outcome was documented, 194 (90.7%) were successfully treated consisting of 81.3% who completed treatment and 9.4% who were cured. Eighteen children (8.4%) died. Mortality was significantly higher among the 1-4 year group (p < 0.001), those with SPPTB (p < 0.001) and HIV positive children (p < 0.001). In logistic regression, SPPTB and HIV positivity were predictors of mortality.

CONCLUSION

The proportion of children in Accra successfully treated for TB met the target of END TB Strategy treatment success indicator. HIV positivity was a risk factor for death. Reducing mortality in TB-HIV co-infected children will further improve treatment outcomes of children with TB in Accra.

Extra-pulmonary tuberculosis: A retrospective study of patients in Accra, Ghana

Background

Information on extrapulmonary TB (EPTB) patients is limited in many African countries including Ghana. The study objective was to describe the epidemiology of EPTB patients diagnosed from different categories of health facilities in Accra, Ghana compared to pulmonary TB (PTB) patients and identify risk factors for mortality among EPTB patients.

Method

We conducted retrospective analyses of demographic and clinical data accessed from medical records of EPTB and PTB patients from different types of health facilities from June 2010 to December 2013. Factors at diagnosis associated with EPTB compared to pulmonary TB (PTB) and factors associated with treatment outcome death among EPTB patients were assessed using logistic regression.

Results

Out of 3,342 new TB patients ≥15 years diagnosed, 728 (21.8%) had EPTB with a male: female ratio of 1.17. The EPTB sites commonly affected were disseminated 32.8%, pleura 21%, spine 13%, and Central Nervous System (CNS) 11%. Treatment success rate for EPTB was 70.1% compared to 84.2% for PTB (p<0.001). In logistic regression, HIV positivity (adjusted Odds Ratio [aOR] 3.19; 95% confidence interval [CI] 2.69–3.79) and female gender (aOR 1.59; 95% CI 1.35–1.88) were found to be significantly associated with EPTB compared with PTB. Older age, being HIV positive (aOR 3.15; 95% CI 1.20–8.25) and having CNS TB (aOR 3.88; 95% CI 1.14–13.23) were associated with mortality among EPTB patients. While more EPTB patients were diagnosed in the tertiary hospital, health facility type was not associated with mortality.

Conclusion

EPTB patients in Accra have a worse treatment outcome compared to PTB patients with mortality of EPTB being associated with HIV, older age and CNS TB. Being HIV positive and female gender were found to be significantly associated with EPTB. Increased awareness of these factors may facilitate early case finding and better management outcomes for these patients.

National profile and treatment outcomes of patients with extrapulmonary tuberculosis in Bénin

BACKGROUND

In sub-Saharan Africa, there is a dearth of published literature on extrapulmonary tuberculosis (EPTB).

OBJECTIVE

To describe demographic, diagnostic and HIV-status characteristics of patients with EPTB in Bénin, their treatment outcomes, and among those who completed their treatment in the Centre National Hospitalier de Pneumo-Phtisiologie (CNHP-P), the proportion whose bodyweight increased during treatment.

MATERIAL AND FINDINGS

This was a retrospective cohort study with comparisons made between EPTB and new smear-positive pulmonary tuberculosis (NPTB) patients diagnosed in the country from January to December 2011. There were 383 EPTB patients (9% of all TB cases) with a mean age of 35 years, male/female ratio of 1.3 and important regional variation. There were significantly more females (p = 0.001), children <15 years (p<0.001) and HIV-positive patients (p = 0.005) with EPTB compared with NPTB. Pleural effusion, spinal and lymph node tuberculosis accounted for 66% of all EPTB. Children <15 years represented 16% of cases, with lymph node disease being most common among them (p<0.001). Of 130 EPTB patients registered in CNHP-P, 7% had a confirmed bacteriological/histological diagnosis. There were 331 (86%) patients who successfully completed treatment. More patients with EPTB were lost-to-follow-up compared with NPTB (p<0.001) with all these patients from one region. The best treatment completion rates were in children <15 years (OR:3.5, 95%CI:1.0-14.8) while patients with pleural effusion and ascites had the worst outcomes. Of 72 HIV-coinfected patients, 88% were on antiretroviral therapy (ART). HIV-positive status was associated with poor outcomes while those on ART fared better. In the CNHP-P, more than 80% who completed their treatment showed an increase in bodyweight and this was more evident in HIV-positive compared with HIV-negative patients (p = 0.03).

CONCLUSION

Patients with EPTB generally do well in Bénin, although the TB Programme would benefit through more attention to accurate diagnosis and earlier start of ART in HIV-infected patients.