Directly Observed Treatment Short Research Articles

Treatment Outcome of Tuberculosis Cases and HIV Co-infected Patients. A Retrospective Study at a Federal Medical Centre of North Central Nigeria

Background: Tuberculosis (TB) is the leading cause of death among people living with HIV/AIDS worldwide. Despite the availability of highly effective treatment for decades, Tuberculosis (TB) remains a major health problem in Nigeria due to the increasing association between HIV and TB observed over the past three decades when HIV was discovered. However, the proportion of TB and or TB/HIV co-infected patients who have successful TB treatment outcome is not well known. This study determined the treatment outcome of TB/HIV co-infected patients with HIV negative patients at Federal Medical Centre Makurdi, Benue State, Nigeria. Methods: A retrospective study that used secondary data from Directly Observed Treatment Short (DOTS) course center (APIN Unit). 268 cases were considered and the period under review covers from January, 2019 to December, 2021. Results: Out of the total 268 TB cases reviewed, the HIV prevalence rate was 28.7 %. More than two-third (78.4%) of HIV-negative patients had successful treatment compared to 68.9% of HIV positive patients that were treated successful. Out of the 77 HIV co-infected patients, 10.4% defaulted, 14.2% had died, and 6.5% failed treatment compared to HIV-negative patients amongst whom 15.2% defaulted, 4.8% died and 1.6% failed treatment. TB/HIV co-infection was significantly associated with poor treatment outcome (AOR: 1.158; 95 % CI 0.617-2.173; p = 0.648).Conclusion: The favorable treatment outcome of HIV-negative patients is more than that of HIV-positive patients and the most probable predictable factor responsible is the CD4 count of patient; indicating that TB/HIV co-infection has remained a major public health problem in Benue state. Therefore, there is the need for sustained strengthening and expansion of the national TB/HIV programmes.

Stigma associated with tuberculosis - An Indian perspective

Background: Social stigma has been identified as an important barrier that delays initiation and adherence to treatment thereby adding to the disease burden and prolong transmission in community. Stigma may limit social participation and lead to social exclusion which may result in an economic burden for the household and thus aggravate poverty. Aims and Objectives: The present study was carried out to estimate the level of perceived and enacted stigma experienced by tuberculosis (TB) patients and also their care providers. This study was planned with the following objectives: (i) To assess the prevalence of stigma among TB patients; and (ii) to assess the different factors associated with stigma. Materials and Methods: This was a prospective, observational, multi-centric study, undertaken on TB patients attending to directly observed treatment short (DOTS) course centers. Patients were interviewed about stigma associated with TB using questionnaire – Explanatory Model Interview Catalogue. Personal interview of the patients and the DOTS providers by a trained person to assess the stigma using pre-tested questionnaires after taking informed consent was arranged. Results: Around half (50.57%) of the patients perceived the social stigma. The present study has found that level of education and socioeconomic class of the patients are statistically significantly associated perception of stigma by patients but not for other socio-demographic characteristics such as age, gender, and marital status of the patients. Conclusion: Stigma associated with TB is significantly associated with patients with the lower level of education and with lower socio-economic status, which is certainly grave area of concerns as often these population are at higher risk for health disparities.

REDESIGNING THE ROLES OF TUBERCULOSIS TREATMENT SUPPORTER IN INDONESIA

Background: Indonesia is the third-highest rank country for tuberculosis. Many studies already compared the effectiveness of the Directly Observed Treatment-Short (DOTS) course with self-administered therapy (SAT) in tuberculosis treatment and pointed out that DOTS did not improve the succession rate (SR) significantly. The participation of a tuberculosis treatment supporter that has an important rule in the DOTS strategy to improve the patients’ adherence in taking treatment should be reviewed.Aims: The study aims to analyze the determination of environmental factors in the effectiveness of tuberculosis treatment which can lead to the program improvement issue.Method: This research was a cross-sectional study conducted by involving 55 of 121 tuberculosis patients. The sampling frame was tuberculosis patients who were reported under the first and third quarters in Primary Healthcare Center of Tanah Kalikedinding as it had failed to reach the succession rate during 2012-2015.Results: These findings indicated that the social environment of tuberculosis patients significantly contributed to their adherence to taking medicine. It showed that tuberculosis treatment supporters had an essential role in maintaining the patients’ adherence. Tuberculosis treatment supporters who lived in one roof with the patient tended to get 2.265 times risk to be contagious. This study also pointed out that the physical environment had the highest determination in the success rate of treatment.Conclusion: Modifying the physical environment of tuberculosis patients can be the greater alternative program to fight tuberculosis rather than the tuberculosis treatment supporters. Tuberculosis treatment supporters must be provided with universal protection due to their high-risk position to be contagious.Keywords: treatment adherence, DOTS, patient environment, treatment effectiveness.

CLINICAL PROFILE OF DIFFERENT TYPE OF TUBERCULOSIS IN HOSPITALIZED CHILDREN IN TERTIARY CARE CENTER

Background: Since the implementation of directly observed treatment short (DOTS) program, the prevalence, clinical profile, and risk factors of pulmonary and non-pulmonary tuberculosis (TB) necessitating hospitalization in pediatric patients are not evaluated extensively. Materials and Methods: We designed a prospective observational study to evaluate the clinical profile of different types of TB in hospitalized children <12 years old. Different types of TB in children hospitalized from 1st January 2013 to 30th June 2014 were recorded. Detailed clinical history, clinical examination findings, diagnostic methods, and treatment of these cases were analyzed by age groups and types of TB. Results: During the study period, 150 (2.8% of total admission) patientswith TB were admitted in our institute. 87 (58%) patients were <5 years old, and 92 (61.33%) children were male. 140 (93.33%) children were malnourished. The clinical profile of TB included neuro TB in 78 (37.32%), pulmonary in 67 (32.05), abdominal in 27 (12.91%), and disseminated in 27 (12.91%) patients. Less than half of children with neuro TB and disseminated TB were immunized with Bacillus calmette-guerin (BCG). Conclusion: Despite aggressive DOTS implementation, the prevalence of TB, particularly, non-pulmonary TB in children is quite alarming. All the variants of TB are prevalent in the children. The neuro TB and the pulmonary TB dominate in the hospitalized cases. Younger age, lack of protection of BCG vaccination, and malnutrition are the main risk factors in childhood TB.

Factors associated with treatment outcome in adult tuberculosis patients under directly observed treatment short course in Ludhiana city, Punjab, India: a cohort study

Background: Tuberculosis (TB) is a communicable disease requiring prolonged treatment and poor adherence to a prescribed treatment increases the risk of morbidity, mortality and spread of disease in the community. Objective was to study factors associated with treatment outcome in adult Tuberculosis patients on directly observed treatment short (DOTS) course in Ludhiana city, Punjab, India.Methods: The present study was a community based prospective cohort study. It was conducted in the two tuberculosis units (TU) of Ludhiana city, Punjab, India. A total of 221 registered DOTS patients were taken as study subjects and were followed during the course of treatment to observe their treatment outcome. The information was collected on a pre-designed semi-structured questionnaire through personal interviews.Results: Out of 221, 183 (82.8%) subjects had favorable outcome, 35 (15.8%) had unfavourable outcome and 3 (1.4%) were transferred out. The comparison between favorable and unfavourable treatment was found be statistically significant with respect to different age groups, problems faced by subjects to reach DOTS centre, diabetes, sputum smear status, site of tuberculosis involvement and side effects of treatment.Conclusions: Elderly and diabetic patients were found to have higher unfavourable outcome. There is need for special provisions for older age groups, illiterates and for lower socio-economic status (SES) in the form of counselling for old people and health insurance for those belonging to lower SES. Keeping in mind the default rate of the present study, initial counselling, periodic motivation of patients and prompt defaulter retrieval action would be beneficial.

Effect of a brief smoking cessation intervention on adult tobacco smokers with pulmonary tuberculosis: A cluster randomized controlled trial from North India.

An association between smoking and poor tuberculosis (TB) treatment outcomes has been globally established. Various smoking cessation interventions (SCIs) have been proven worldwide to curb smoking behavior. There is a need for evidence to assess if SCI increases the chance of successful treatment outcome among TB patients. To assess the effectiveness of a brief SCI; The Ask, Brief, Cessation support (ABC) package, on treatment outcomes and smoking cessation in smear-positive adult pulmonary TB patients. A cluster, randomized controlled trial was conducted wherein 17 designated microscopic centers of Chandigarh, India were randomly assigned using a computer-generated randomization sequence to receive SCI within directly observed treatment, short (DOTS) services, or existing standard of care. Eligible and consenting smokers (15 + years) registered as smear-positive pulmonary TB for DOTS (n = 156) between January and June 2013 were enrolled. Smoking cessation (self-reported) was assessed at intervals till the end of treatment. End TB treatment outcomes were extracted from patient records. Treatment success was lower in intervention arm (83.6%) as compared control arm (88.2%), but the difference was statistically insignificant (P = 0.427). Smoking cessation was higher in intervention arm (80.2%) compared to comparison arm (57.5%) (adjusted incidence risk ratio = 1.56; 95% confidence interval = 1.24-1.93; P < 0.0001). SCI is effective in inducing smoking cessation among TB patients. No association of SCI with TB treatment outcomes could be detected.

Effective communication approaches in tuberculosis control: Health workers’ perceptions and experiences

BackgroundHealth workers’ experiences and understanding of the myths, misconceptions, beliefs about TB, and patients in the community (and effective communication methods) can be useful in designing effective IEC materials and strategies. ObjectiveTo study the perceptions and experiences of health workers regarding TB disease, patients, and effective communication strategies in TB control. MethodsA survey was conducted among health workers involved in Directly Observed Treatment Short (DOTS) course. Data regarding general health beliefs, prevalent myths and misconceptions about TB in their respective localities, knowledge level among patients, and utilization of various communication strategies were collected. ResultsThere is a significant increase in knowledge about TB during DOTS among patients, as observed by about half of the health workers. TB patients are aware about how TB spreads to others and their responsibilities. Regular interaction with patients is required for treatment adherence. Two thirds of the health workers believe that media-mix strategy can be very effective in creating awareness among the patients as well as the public. Health workers realized that the video player facility on their mobile phones is useful for showing health-related videos. ConclusionA combination of mass media and interpersonal communication could be effective for TB control. Face-to-face communication with community members, patient-provider discussions, and information through television could be very effective techniques. Exclusive communication materials should be designed for family members of the patients. Smart phones can be used for effective implementation of TB control programs.

Process Evaluation of Quality in the Diagnosis and Treatment of Tuberculosis in Public Health Facilies of Southwes Ethiopia: Cross Sectional Study

Background: Even though Ethiopia has implemented the Directly Observed Treatment Short (DOTS) service for a long time, the national targets of Tuberculosis (TB) control were not achieved yet. Like the country wide, the Kersa district shares the same problem, and also TB control program have never been evaluated in this district. Methods: Process evaluation was conducted based on Donabedian’s structure-process-outcome model of health care quality. Facility based cross-sectional study design was employed. Four, tuberculosis directly observed short course therapy providing health centers were selected. Medical records of TB suspects and patients were reviewed. Ongoing laboratory practice and patient provider interaction was observed. Results: The resources recommended by national tuberculosis control program for diagnosis and treatment were available, except a shortage of paediatric dose of TB drug and Acid Fast Bacilli (AFB) reagents. Only 64.8% of TB suspects received sputum smear laboratory examination, and 52.7% of TB patients received the right doses of treatment. Conclusion: The shortage of drugs and reagents and, low uptake of microscopic AFB examination service was the main constraints of service. Adequate and continuous resource supply and regular and continuous monitoring of diagnosis and treatment process should be considered. J Microbiol Infect Dis 2016;6(4): 156-162

The tuberculosis recurrence in city of Jundiaí since 2006 to 2011: a clinical and epidemiological profile

The TB recurrence occurs when a patient presents current diagnosis of tuberculosis with positive bacteriology ( microscopy or culture) , with history of cured TB with anti -TB drugs. Evaluation of the clinical and epidemiological aspects of TB recurrence is extremely important, because this data is able to guide and clarify the effectiveness of DOTS ( Directly Observed Treatment Short), the pharmacological treatment regimen used and the predisposing factors for recurrence. Objective: Describe some characteristics of clinical and epidemiological profile of tuberculosis recurrence in Jundiaí in the period 2006-2011. Methods: This is a descriptive study, type of survey data from the Officer of the Ministry of health of Brazil named Tbweb. Results: In the period from 2006 to 2011 were reported 34 cases of recurrence, all pacients being residents in the city of Jundiaí. The median age was 51 ± 17.5 years. The serology for human immunodeficiency virus (HIV ) was performed in 34 (100 %) patients and was positive in 10 ( 29.4%) of them. For other comorbidities 6 (17.6%) cases were alcoholics, and 1 (2.9%) , drug user. The quadruple regimen ( rifampicin , isoniazid , pyrazinamide , ethambutol ) drugs was adopted since 2006. The Strategy Directly Observed Treatment ( DOTS) was held in 21 cases ( 61.7 % ) . The pulmonary type was the most common, presenting 82.3 % of cases. Tb laboratory tests were positive in 17 ( 50.0 %) cases of pulmonary involvement , and 6 ( 17.6 %) cases of extrapulmonary involvement. The duration of treatment was on average 6.5 mounths. The pharmacological treatment ended with 29 cases (85.2 %) cured , 2 ( 5.9%) with treatment neglect and 1 (2.9%) death due to tuberculosis. Conclusion: The relapse of TB was more common in HIV-positive patients. The job of the quadruple (rifampicin , isoniazid , pyrazinamide , ethambutol ) schema in the treatment showed no reduction in the number of cases of TB recurrence of this sample. The use of DOTS had no impact on the cases of relapse in the municipality of Jundiaí. However, new studies with longer historical series must be carried out to check their epidemiological significance appropriate

Determinants of sputum conversion at two months of treatment under National Tuberculosis Programme, South India

Background: In India, Revised National Tuberculosis (TB) control programme (RNTCP) offers free diagnosis and treatment for TB, based on the Directly Observed Treatment Short (DOTS) course strategy. Under RNTCP, sputum conversion rate (SCR), at the end of 2 months of treatment is an important operational indicator, which is ideally expected to be 90%. Objectives: The objective of the present work was to investigate the factors associated with low SCR at the end of 2 months of treatment in Sira TB unit, Tumkur District, India. Material and Methods: It is a retrospective cohort study of all new sputum smear-positive patients registered in RNTCP in 2011. Data were retrieved from the TB register maintained at the District TB center. Chi-square and Student’s t-test were used for analysis of the study variables between patients who were sputum positive and sputum negative at the end of 2 months of treatment. Multivariate logistic regression was applied to determine the risk contributed by the variables towards non-conversion of sputum. Results: Of the 268 included patients, 66.7% patients were sputum negative. Patients aged ≥ 45 years were twice prone to be sputum positive (OR = 2.14) (P = 0.007). The odds of being sputum positive after 2 months of treatment was observed to be significantly high (OR = 7.12; 95% C.I. = 1.52–33.22; P = 0.01) for sputum grade 3+ at the time of diagnosis, respectively. Conclusion: Elderly patients with a high bacilli load should be advised and counselled well regarding adherence to treatment. Further, advice should be given on preventing spread of the disease by practising cough hygiene, as they are more infectious than other patients with less sputum-positive grade.

Evaluation of Tuberculosis Treatment Outcome of TB/HIV Co-Infection: A Four-Year Retrospective Cohort Study in HIV-Prevalent Setting of North Central Nigeria

Background: Despite the availability of highly effective treatment for decades, Tuberculosis (TB) remains a major health problem in Nigeria due to the increasing association between HIV and TB observed over the past three decades when HIV was discovered. However, the proportion of TB and or TB/HIV co-infected patients who have successful TB treatment outcome is not well known. This study determined the treatment outcome of TB/HIV co-infected patients with HIV negative patients in two states in Nigeria. Materials and Methods: A retrospective study of secondary data from eight Directly Observed Treatment Short (DOTS) course and Anti- Retroviral Therapy (ART) service providers in Benue and Federal Capital Territory (FCT), Nigeria, was carried out. The period under review covers January, 2010 to December, 2013. Results: Out of the total 5266 TB cases reviewed, the HIV prevalence rate was 52%. They were predominantly (53.3%) male with mean age of 34.4 years (SD = 15.1 years). More than two-third (72.5%) of HIV-negative patients had successful treatment compared to 1718 (62.7%) HIV-positive patients. Of the 2334 HIV co-infected patients, 19.5% defaulted, 11.5% had died, 5.6% were transferred out and 0.7% failed treatment compared to HIV-negative patients amongst whom 18.3% defaulted, 3.6% died, 3.9% were transferred out and 1.6% failed treatment (p < 0.05). TB/HIV co-infected patients with baseline CD4 of ≥300 cell/mm3 are more likely to have successful treatment outcome {OR-1.541 (95% CI = 1.030 - 2.305) p = 0.035}. Patients ≥45 years old and those not on Co-trimoxazole Preventive Therapy (CPT) are more likely to have unsuccessful treatment outcome {OR-1.022 (95% CI = 0.643 - 1.488) p = 0.918 and OR-1.306 (95% CI = 0.956 - 1.555) respectively. Conclusion: The favourable treatment outcome of HIV-negative patients is more than that of HIV-positive patients and the most probable predictable factor responsible is the CD4 count of patient; indicating that TB/HIV co-infection has remained a major public health problem in Benue state and FCT. Hence there is the need for sustained strengthening and expansion of the national TB/HIV programmes.

Profile and Outcome of Childhood Tuberculosis Treated with DOTS—An Observational Study

To study the clinical profile and outcome of childhood tuberculosis treated with Directly Observed Treatment Short (DOTS) course regimen. Also to study the side effects of anti-tubercular treatment (ATT). This prospective hospital based observational study was conducted at Department of Pediatrics, Karnataka Institute of Medical Sciences (KIMS), Hubli. Inclusion criteria were i) All newly diagnosed cases of tuberculosis from 0 to 12y of age. ii) Children with relapse, treatment failure or defaulters. Exclusion criteria was children with tuberculosis on anti-tubercular treatment (ATT) other than DOTS regimen. A detailed history including demographic profile and clinical examination were carried out for each case. Diagnosis, categorization, treatment (DOTS regimen) and outcome measures were defined according to WHO/RNTCP guidelines. Data was analyzed using SPSS 17. Total number of children enrolled in the study were 93. Mean age was 6y. Male to female ratio was 0.9:1. Extra pulmonary tuberculosis (EPTB) was common 58 (62.4%) than pulmonary tuberculosis 35 (37.6%). The common symptoms/signs were fever (83.8%), cough (46.2%), convulsion (17.2%), loss of appetite (11.8%) and pallor (75.3%), lymphadenopathy (18.3%), hepatomegaly (9.7%) and splenomegaly (6.5%). Mantoux test was positive in 59 (63.4%) children. Acid fast bacilli (AFB) was isolated in 13 (14%) children in various fluid/histological specimens. The prevalence of HIV infection was 7.5%. Among 93 children, 88(94.6%) completed treatment and were declared cured; four children were lost to follow up and one child died. Compliance of DOTS was good and there were no side effects due to ATT. EPTB was common than pulmonary TB. Efficacy of DOTS in index study was 94.6%. No adverse effects of ATT were observed.

Why Did the Scale-up of HIV Treatment Work?: A Case Example From Malawi

The national scale-up of antiretroviral therapy (ART) in Malawi is based on a public health approach, with principles and practices borrowed from the successful DOTS (directly observed treatment short course-the system used to successfully deliver antituberculosis treatment to people in some of the poorest countries of the world) tuberculosis control framework. During the first 6 years, the number of patients registered on treatment increased from 3000 to >350,000 in both the public and private sectors. The most important reasons for this success have been strong international and national leadership combined with adequate funds, a standardized approach to ART with practical guidelines, an approved national scale-up plan with clear, time-bound milestones; investment in an intensive program of training and accreditation of ART sites, quarterly supervision and monitoring of ART and operational research, rational drug forecasting and no stock-outs of drugs during the first few years, and involvement of the private sector. The looming challenges of human resources, guaranteed financial support, better but also more expensive ART regimens, use of electronic medical records to monitor response to therapy, and attention to HIV prevention need to be met head-on and solved if the momentum of the earlier years is to be maintained.

Multiple drug resistance: a threat for tuberculosis control

Drug-resistant tuberculosis (TB) was reported soon after the introduction of streptomycin, although it did not receive major attention until recently. It was not considered a major issue in the industrialized world until outbreaks of multidrug-resistant TB (MDR-TB) were reported among HIV infected people. Administration of standard short-course chemotherapy (SSCC) with first-line drugs under directly observed therapy (DOT) is the cornerstone of modern TB control. Unfortunately, data available on the treatment outcome of MDR-TB cases under routine programmatic conditions suggest that patients with MDR-TB respond poorly to SSCC with first-line drugs. Since 1994, the World Health Organization and the International Union Against Tuberculosis and Lung Disease (IU-ATLD) have conducted anti-TB drug resistance surveys through a network of subregional laboratories and researchers. Drug resistance was present in almost all settings surveyed, and prevalence varied widely across regions. High prevalence of MDR-TB is widespread in the Russian Federation and areas of the former Soviet Union (Estonia, Kazakhstan, Latvia, and Lithuania) as well as Israel, Liaoning and Henan Provinces in China, and Ecuador. The Global Project has surveyed areas representing over one third of notified TB cases. However, enormous gaps still exist in the most crucial areas. The most effective strategy to prevent the emergence of drug resistance is through implementation of the directly observed treatment short (DOTS) strategy. Effective implementation of the DOTS strategy saves lives through decreased TB transmission, decreased risk of emergence of drug-resistance, and decreased risk for individual TB patients of treatment failure, TB relapse, and death. The World Bank recognizes the DOTS strategy as one of the most cost-effective health interventions, and recommends that effective TB treatment be a part of the essential clinical services package available in primary health care settings. Governments are responsible for ensuring the provision of effective TB control through the DOTS strategy. WHO and its international partners have formed the DOTS-Plus Working Group, which is attempting to determine the best possible strategy to manage MDR-TB. One of the goals of DOTS-Plus is to increase access to expensive second-line anti-TB drugs for WHO-approved TB control programmes in low- and middle-income countries.