Electronic Tuberculosis Register Research Articles

COVID-19 pandemic and other factors associated with unfavorable tuberculosis treatment outcomes-Almaty, Kazakhstan, 2018-2021.

The COVID-19 pandemic negatively influenced the availability of tuberculosis (TB) services, such as detection, diagnosis and treatment, around the world, including Kazakhstan. We set out to estimate the COVID-19 pandemic influence on TB treatment outcomes by comparing outcomes among people starting treatment before the pandemic (2018-2019) and during the pandemic (2020-2021) and to determine risk factors associated with unfavorable outcomes. We conducted a retrospective cohort study among all people newly diagnosed with drug-sensitive pulmonary or extrapulmonary TB at least 18 years old who initiated treatment from 2018 to 2021 in Almaty. We abstracted data from the national electronic TB register. Unfavorable treatment outcomes were ineffective treatment, death, loss to follow-up, results not evaluated, and transferred. We used multivariable Poisson regression to calculate adjusted relative risk (aRR) and 95% confidence intervals (95%CI). Among 1548 people newly diagnosed with TB during the study period, average age was 43 years (range 18-93) and 52% were male. The number of people initiating treatment was higher before than the pandemic (935 vs. 613, respectively). There was significantly different proportions before compared to during the pandemic for people diagnosed through routine screening (39% vs. 31%, p < 0.001), 60 years and older (16% vs. 22%, p = 0.005), and with diabetes (5% vs. 8%, p = 0.017). There was no difference in the proportion of HIV (8% in both periods). Unfavorable outcomes increased from 11 to 20% during the pandemic (aRR = 1.83; 95% CI: 1.44-2.31). Case fatality rose from 6 to 9% (p = 0.038). Risk factors for unfavorable TB treatment outcomes among all participants were being male (aRR = 1.44, 95%CI = 1.12-1.85), having HIV (aRR = 2.72, 95%CI = 1.99-3.72), having alcohol use disorder (aRR = 2.58, 95%CI = 1.83-3.62) and experiencing homelessness (aRR = 2.94, 95%CI = 1.80-4.80). Protective factors were being 18-39 years old (aRR = 0.33, 95%CI = 0.24-0.44) and 40-59 years old (aRR = 0.56, 95%CI = 0.41-0.75) compared to 60 years old and up. COVID-19 pandemic was associated with unfavorable treatment outcomes for people newly diagnosed with drug-sensitive TB in Almaty, Kazakhstan. People with fewer comorbidities were at increased risk. Results point to the need to maintain continuity of care for persons on TB treatment, especially those at higher risk for poor outcomes during periods of healthcare service disruption.

Effects of Coronavirus Disease Pandemic on Tuberculosis Notifications, Malawi.

The coronavirus disease (COVID-19) pandemic might affect tuberculosis (TB) diagnosis and patient care. We analyzed a citywide electronic TB register in Blantyre, Malawi and interviewed TB officers. Malawi did not have an official COVID-19 lockdown but closed schools and borders on March 23, 2020. In an interrupted time series analysis, we noted an immediate 35.9% reduction in TB notifications in April 2020; notifications recovered to near prepandemic numbers by December 2020. However, 333 fewer cumulative TB notifications were received than anticipated. Women and girls were affected more (30.7% fewer cases) than men and boys (20.9% fewer cases). Fear of COVID-19 infection, temporary facility closures, inadequate personal protective equipment, and COVID-19 stigma because of similar symptoms to TB were mentioned as reasons for fewer people being diagnosed with TB. Public health measures could benefit control of both TB and COVID-19, but only if TB diagnostic services remain accessible and are considered safe to attend.

Transition to an in-facility electronic Tuberculosis register: Lessons from a South African pilot project.

BackgroundSouth Africa has one of the highest incidences of Tuberculosis (TB) globally. High co-morbid HIV prevalence complicates TB management and treatment outcomes. Growing evidence suggests that integrating the TB and HIV programmes will improve the overall results.ObjectivesTo describe how TB programme staff at various levels of the South African health system responded to the transition from a paper-based to an electronic register of TB data integrated with HIV programme data.MethodThree primary health service facilities in the Cape Winelands district, Western Cape province, South Africa served as pilot sites for implementation. Semi-structured interviews were conducted with 21 TB programme staff purposively selected at facility, sub-district, district and provincial levels of the health system, based on their involvement in implementing electronic TB data. An objective-driven thematic frame was used to analyse the data.ResultsFears about the transition included reductions in data quality, changes to the status quo and a lack of computer literacy. Participants acknowledged benefits of reduced workloads, speed of accessing patient-level data and click-of-a-button reporting. Three factors influenced the ease of adopting the new system: firstly, implementation challenged the vertical position of the TB programme, TB data and staff’s conventional roles and responsibilities; secondly, perceptions of the paper-based register as functional and reliable made the transition to electronic seem unnecessary; and thirdly, lack of a process of change management challenged staff’s ability to internalise the proposed change.ConclusionA process of change management is critical to facilitate the efficiency and effectiveness with which the electronic in-facility TB register is implemented.

Predictors of loss to follow-up of tuberculosis cases under the DOTS programme in Namibia.

BackgroundIn Namibia, one out of every 25 cases of tuberculosis (TB) is “lost to follow-up” (LTFU). This has impacted negatively on national efforts to end the disease by 2035. The aim of this study was to determine the trends and predictors of LTFU under the directly observed treatment short-course (DOTS) programme in Namibia.MethodsThe study involved a retrospective longitudinal analysis of a nationwide cohort of TB cases registered under the DOTS programme in Namibia from 2006 to 2015. The trends and predictors of LTFU among cases in the National Electronic TB Register of the National TB and Leprosy Program were respectively determined by interrupted time series and multivariate logistic regression analyses using R-Studio software.ResultsOut of 104 203 TB cases, 3775 (3.6%) were LTFU. A quarter (26%) of cases with poor outcomes were due to LTFU. The annual decline in cases of LTFU was significant between the first (2005–2010) and second (2010–2015) medium-term plan period for TB programme implementation (p=0.002). The independent predictors of LTFU were male sex (p=0.004), 15–24 years age group (p=0.03), provider of treatment (p<0.001), intensive phase (p=0.047) and living in border/transit regions (p<0.001). HIV co-infection and TB regimen were not significant predictors of LTFU.ConclusionsThere were declining trends in LTFU in Namibia. DOTS programmes should integrate socioeconomic interventions for young and middle-aged adult male TB cases to reduce LTFU.

Treatment outcomes among children, adolescents, and adults on treatment for tuberculosis in two metropolitan municipalities in Gauteng Province, South Africa

BackgroundGauteng Province has the second lowest tuberculosis (TB) incidence rate in South Africa but the greatest proportion of TB/HIV co-infection, with 68% of TB patients estimated to have HIV. TB treatment outcomes are well documented at the national and provincial level; however, knowledge gaps remain on how outcomes differ across detailed age groups.MethodsUsing data from South Africa’s National Electronic TB Register (ETR), we assessed all-cause mortality and loss to follow-up (LTFU) among patients initiating treatment for TB between 01/2010 and 12/2015 in the metropolitan municipalities of Ekurhuleni Metropolitan Municipality and the City of Johannesburg in Gauteng Province. We excluded patients who were missing age, had known drug-resistance, or transferred into TB care from sites outside the two metropolitan municipalities. Among patients assigned a treatment outcome, we investigated the association between age group at treatment initiation and mortality or LTFU (treatment interruption of ≥2 months) within 10 months after treatment initiation using Cox proportional hazard models and present hazard ratios and Kaplan-Meier survival curves.ResultsWe identified 182,890 children (<10 years), young adolescent (10–14), older adolescent (15–19), young adult (20–24), adult (25–49), and older adult (≥50) TB cases without known drug-resistance. ART coverage among HIV co-infected patients was highest for young adolescents (64.3%) and lowest for young adults (54.0%) compared to other age groups (all over 60%). Treatment success exceeded 80% in all age groups (n = 170,017). All-cause mortality increased with age. Compared to adults, young adults had an increased hazard of LTFU (20–24 vs 25–49 years; aHR 1.43 95% CI: 1.33, 1.54) while children, young adolescents, and older adults had lower hazard of LTFU. Patients with HIV on ART had a lower risk of LTFU, but greater risk of death when compared to patients without HIV.ConclusionsYoung adults in urban areas of Gauteng Province experience a disproportionate burden of LTFU and low coverage of ART among co-infected patients. This group should be targeted for interventions aimed at improving clinical outcomes and retention in both TB and HIV care.

A mortality review of tuberculosis and HIV co-infected patients in Mahalapye, Botswana: Does cotrimoxazole preventive therapy and/or antiretroviral therapy protect against death?

BackgroundThe World Health Organization aims to reduce tuberculosis (TB) mortality rate from 15% in 2015 to 6.5% by 2025.AimThis 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.SettingThe study was conducted in the Mahalapye Health District in Botswana.MethodsThis 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.ResultsThe 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.ConclusionThis 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.

Predictors of tuberculosis treatment success under the DOTS program in Namibia

ABSTRACTObjectives: Optimal treatment success rates are critical to end tuberculosis in Namibia. Despite the scale-up of high quality directly observed therapy short-course strategy (DOTS) in Namibia, treatment success falls short of the global target of 90%. The objective of this study was to ascertain the predictors of treatment success rates under DOTS in Namibia to provide future direction.Methods: A nation-wide comparative analysis of predictors of treatment success was undertaken. Tuberculosis cases in the electronic tuberculosis register were retrospectively reviewed over a 10-year period, 2004–2016. The patient, programmatic, clinical, and treatment predictors of treatment success were determined by multivariate logistic regression modeling using R software.Results: 104,603 TB cases were registered at 300 DOTS sites in 37 districts. The 10-year period treatment success rate was 80%, and varied by region (77.2%–89.2%). The patient’s sex and age were not significant predictors. The independent predictors for treatment success as were: Region of DOTS implementation (p=0.001), type of directly observed treatment (DOT) supporter (p<0.001), sputum conversion at 2 months (p=0.013), DOT regimen (p<0.001), cotrimoxazole prophylaxis (p=0.002), and HIV co-infection (p=0.001).Conclusion: Targeted programmatic, clinical and treatment interventions are required to enhance DOTS treatment success in Namibia. These are now ongoing.

Improved Treatment Outcomes With Bedaquiline When Substituted for Second-line Injectable Agents in Multidrug-resistant Tuberculosis: A Retrospective Cohort Study.

Bedaquiline is used as a substitute for second-line injectable (SLI) intolerance in the treatment of multidrug-resistant (MDR) tuberculosis, but the efficacy and safety of this strategy is unknown. In this retrospective cohort study adults receiving bedaquiline substitution for MDR tuberculosis therapy, plus a matched control group who did not receive bedaquiline, were identified from the electronic tuberculosis register in the Western Cape Province, South Africa. The primary outcome measure was the proportion of patients with death, loss to follow-up, or failure to achieve sustained culture conversion at 12 months of treatment. Data from 162 patients who received bedaquiline substitution and 168 controls were analyzed; 70.6% were infected with human immunodeficiency virus. Unfavorable outcomes occurred in 35 of 146 (23.9%) patients in the bedaquiline group versus 51 of 141 (36.2%) in the control group (relative risk, 0.66; 95% confidence interval, .46 -.95). The number of patients with culture reversion was lower in those receiving bedaquiline (1 patient; 0.8%) than in controls (12 patients; 10.3%; P = .001). Delayed initiation of bedaquiline was independently associated with failure to achieve sustained culture conversion (adjusted odds ratio for every 30-day delay, 1.5; 95% confidence interval, 1.1-1.9). Mortality rates were similar at 12 months (11 deaths in each group; P = .97). Substituting bedaquiline for SLIs in MDR tuberculosis treatment resulted in improved outcomes at 12 months compared with patients who continued taking SLIs, supporting the use of bedaquiline for MDR tuberculosis treatment in programmatic settings.

The South African Tuberculosis Care Cascade: Estimated Losses and Methodological Challenges.

BackgroundWhile tuberculosis incidence and mortality are declining in South Africa, meeting the goals of the End TB Strategy requires an invigorated programmatic response informed by accurate data. Enumerating the losses at each step in the care cascade enables appropriate targeting of interventions and resources.MethodsWe estimated the tuberculosis burden; the number and proportion of individuals with tuberculosis who accessed tests, had tuberculosis diagnosed, initiated treatment, and successfully completed treatment for all tuberculosis cases, for those with drug-susceptible tuberculosis (including human immunodeficiency virus (HIV)–coinfected cases) and rifampicin-resistant tuberculosis. Estimates were derived from national electronic tuberculosis register data, laboratory data, and published studies.ResultsThe overall tuberculosis burden was estimated to be 532005 cases (range, 333760–764480 cases), with successful completion of treatment in 53% of cases. Losses occurred at multiple steps: 5% at test access, 13% at diagnosis, 12% at treatment initiation, and 17% at successful treatment completion. Overall losses were similar among all drug-susceptible cases and those with HIV coinfection (54% and 52%, respectively, successfully completed treatment). Losses were substantially higher among rifampicin- resistant cases, with only 22% successfully completing treatment.ConclusionAlthough the vast majority of individuals with tuberculosis engaged the public health system, just over half were successfully treated. Urgent efforts are required to improve implementation of existing policies and protocols to close gaps in tuberculosis diagnosis, treatment initiation, and successful treatment completion.

Tuberculosis in adolescents and young adults: epidemiology and treatment outcomes in the Western Cape.

Western Cape Province, South Africa. To characterise tuberculosis (TB) epidemiology, disease presentation and treatment outcomes among adolescents (age 10-19 years) and young adults (age 20-24 years) in the Western Cape. A retrospective, cross-sectional review of routine patient-level data from the Electronic TB Register (ETR.Net) for 2013. Site of TB disease, human immunodeficiency virus (HIV) status and TB treatment outcomes were analysed by 5-year age groups (<5, 5-9, 10-14, 15-19, 20-24 and 25 years of age). TB notification rates were calculated using census data. Adolescents and young adults comprised 18.0% of all new TB notifications in 2013. The notification rate was 141 TB cases/100 000 person-years (py) among 10-14 year olds, 418/100 000 py among 15-19 year olds and 627/100 000 py among 20-24 year olds. HIV prevalence among TB patients was 10.9% in 10-14 year olds, 8.8% in 15-19 year olds and 27.2% in 20-24 year olds. Older adolescents (age 15-19 years) and young adults (age 20-24 years) with HIV co-infection had poor treatment outcomes: 15.6% discontinued treatment prematurely and 4.0% died. Young people in the Western Cape suffer a substantial burden of TB, and those with TB-HIV co-infection are at high risk of treatment discontinuation.

Influence of HIV and other risk factors on tuberculosis.

Tuberculosis (TB) notification in South Africa has increased six-fold over the past two decades, mainly because of the HIV epidemic. To describe the sociodemographic and outcome characteristics of TB patients, and to identify risk factors associated with TB treatment outcomes stratified by HIV status. A cross-sectional study was used to analyse data from the Cape Town Metro East geographical service area (GSA) electronic TB register (ETR.Net), including adult patients aged ≥15 years who initiated TB treatment between 1 July 2011 and 30 June 2012. TB case notification in the GSA was 922 per 100 000 population. Of the 12 672 TB patients registered, 50.5% were co-infected with HIV. The death rate in co-infected patients was 5.4% v. 2.8% in HIV-negative patients, the rate of treatment success 66.6% v. 73.5%, and the rate of unfavourable treatment outcome 28.1% v. 23.7%. The Khayelitsha subdistrict had the highest proportion of TB burden (37.0%) and co-infection (47.6%). Fourteen percent of patients had extrapulmonary TB, 65.9% of whom were co-infected with HIV. In the multivariate analysis, HIV infection (relative risk (RR) 1.2), retreatment (RR 1.4) and sputum smear microscopy not done (RR 1.4) were significantly associated with unfavourable treatment outcome. The Eastern (RR 0.9) and Northern (RR 0.7) subdistricts were less likely to have unfavourable outcomes compared with Khayelitsha. In the stratified analysis, retreatment and smear not done were significant risk factors for an unfavourable treatment outcome in both co-infected and HIV-negative patients. The burdens of both TB and co-infection were high in this community, although HIV prevalence varied. Mortality was higher and treatment completion lower in co-infected patients than in those who were HIV-negative. Co-infection, previous TB treatment and smear not done were significant risk factors for an unfavourable outcome in all patients.

Risk factors for mortality in TB patients: a 10-year electronic record review in a South African province

BackgroundSince 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.MethodsA 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.ResultsOf 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).ConclusionsAlthough 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.

Evaluating the electronic tuberculosis register surveillance system in Eden District, Western Cape, South Africa, 2015

ABSTRACT Background: Tuberculosis (TB) surveillance data are crucial to the effectiveness of National TB Control Programs. In South Africa, few surveillance system evaluations have been undertaken to provide a rigorous assessment of the platform from which the national and district health systems draws data to inform programs and policies. Objective: Evaluate the attributes of Eden District’s TB surveillance system, Western Cape Province, South Africa. Methods: Data quality, sensitivity and positive predictive value were assessed using secondary data from 40,033 TB cases entered in Eden District’s ETR.Net from 2007 to 2013, and 79 purposively selected TB Blue Cards (TBCs), a medical patient file and source document for data entered into ETR.Net. Simplicity, flexibility, acceptability, stability and usefulness of the ETR.Net were assessed qualitatively through interviews with TB nurses, information health officers, sub-district and district coordinators involved in the TB surveillance. Results: TB surveillance system stakeholders report that Eden District’s ETR.Net system was simple, acceptable, flexible and stable, and achieves its objective of informing TB control program, policies and activities. Data were less complete in the ETR.Net (66–100%) than in the TBCs (76–100%), and concordant for most variables except pre-treatment smear results, antiretroviral therapy (ART) and treatment outcome. The sensitivity of recorded variables in ETR.Net was 98% for gender, 97% for patient category, 93% for ART, 92% for treatment outcome and 90% for pre-treatment smear grading. Conclusions: Our results reveal that the system provides useful information to guide TB control program activities in Eden District. However, urgent attention is needed to address gaps in clinical recording on the TBC and data capturing into the ETR.Net system. We recommend continuous training and support of TB personnel involved with TB care, management and surveillance on TB data recording into the TBCs and ETR.Net as well as the implementation of a well-structured quality control and assurance system.

Factors influencing treatment default among tuberculosis patients in a high burden province of South Africa

To determine and describe the factors influencing treatment default of tuberculosis (TB) patients in the Free State Province of South Africa. A retrospective records review of pulmonary TB cases captured in the ETR.Net electronic TB register between 2003 and 2012 was performed. Subjects were >15 years of age and had a recorded pre-treatment smear result. The demographic and clinical characteristics of defaulters were described. Multivariate logistic regression analysis was used to determine factors associated with treatment default. The odds ratios (OR) together with their corresponding 95% confidence intervals (CI) were estimated. Statistical significance was considered at 0.05. A total of 7980 out of 110 349 (7.2%) cases defaulted treatment. Significantly higher proportions of cases were male (8.3% vs. female: 5.8%; p<0.001), <25 years old (9.1% vs. 25-34 years: 8.7%; 35-44 years: 7.0%; 45-54 years: 5.2%; 55-64 years: 4.4%; >64 years: 3.9%; p<0.001), undergoing TB retreatment (11.0% vs. new cases: 6.3%; p<0.001), had a negative pre-treatment sputum smear result (7.8% vs. positive smear results: 7.1%; p<0.001), were in the first 2 months of treatment (95.5% vs. >2 months: 4.8%; p<0.001), and had unknown HIV status (7.8% vs. HIV-positive: 7.0% and HIV-negative: 5.7%; p<0.001). After controlling for potential confounders, multivariate analysis revealed a two-fold increased risk of defaulting treatment when being retreated compared to being treated for the first time for TB (adjusted OR (AOR) 2.0, 95% CI 1.85-2.25). Female cases were 40% less likely to default treatment compared to their male counterparts (AOR 0.6, 95% CI 0.51-0.71). Treatment default was less likely among cases >24 years old compared to younger cases (25-34 years: AOR 0.8, 95% CI 0.77-0.87; 35-44 years: AOR 0.6, 95% CI 0.50-0.64; 45-54 years: AOR 0.4, 95% CI 0.32-0.49; 55-64 years: AOR 0.3, 95% CI 0.21-0.43; >64 years: AOR 0.3, 95% CI 0.19-0.35). Co-infected cases receiving antiretroviral therapy (ART) were 40% less likely to default TB treatment relative to those whose ART status was unknown (AOR 0.6, 95% CI 0.46-0.57). Salient factors influence TB patient treatment default in the Free State Province. Therefore, the strengthening of clinical and programmatic interventions for patients at high risk of treatment default is recommended. In particular, ART provision to co-infected cases facilitates TB treatment adherence and outcomes.

Risk factors for tuberculosis smear non-conversion in Eden district, Western Cape, South Africa, 2007-2013: a retrospective cohort study.

BackgroundTuberculosis (TB) continues to be a major global health problem. While progress has been made to improve TB cure rates, South Africa’s 76 % smear-positive pulmonary TB (PTB) case cure rate remains below the WHO target of 85 %. We report on the trends of TB smear non-conversion and their predictors at the end of an intensive phase of treatment, and how this impacted on treatment outcomes of smear-positive PTB cases in Eden District, Western Cape Province, South Africa.MethodsRoutinely collected, retrospective data of smear-positive PTB cases from the electronic TB register in Eden District between 2007 and 2013 was extracted. Non-conversion was defined as persistent sputum smear-positive PTB cases at the end of the two or three month intensive phase of treatment. Chi-square test for linear trend and simple linear regression analysis were used to analyse the change in percentages and slope of TB smear non-conversion rates over time. Risk factors for TB non-conversion, and their impact on treatment outcomes, were evaluated using logistic regression models.ResultsOf 12,742 total smear-positive PTB cases included in our study, 12.8 % (n = 1627) did not sputum smear convert; 13.3 % (1411 of 10,574) of new cases and 9.9 % (216 of 2168) of re-treatment cases. Although not statistically significant in either new or re-treatment cases, between 2007 and 2013, smear non-conversion decreased from 16.4 to 12.7 % (slope = −0.60; 95 % CI: −1.49 to 0.29; p = 0.142) in new cases, and from 11.3 to 10.8 % in re-treatment cases (slope = −0.29; 95 % CI: −1.06 to 0.48; p = 0.376). Male gender, HIV co-infection and a >2+ acid fast bacilli (AFB) smear grading at the start of TB treatment were independent risk factors for non-conversion (p < 0.001). Age was a risk factor for non-conversion in new cases, but not for re-treatment cases. Non-conversion was also associated with unsuccessful treatment outcomes (p < 0.01), including treatment default and treatment failure.ConclusionsSmear-positive PTB cases, especially men and those with identified risk factors for non-conversion, should be closely monitored throughout their treatment period. The South African TB control program should invest in patient adherence counselling and education to mitigate TB non-conversion risk factors, and to improve conversion and TB cure rates.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1712-y) contains supplementary material, which is available to authorized users.

Seasonality and Trend Forecasting of Tuberculosis Prevalence Data in Eastern Cape, South Africa, Using a Hybrid Model.

Background: Tuberculosis (TB) is a deadly infectious disease caused by Mycobacteria tuberculosis. Tuberculosis as a chronic and highly infectious disease is prevalent in almost every part of the globe. More than 95% of TB mortality occurs in low/middle income countries. In 2014, approximately 10 million people were diagnosed with active TB and two million died from the disease. In this study, our aim is to compare the predictive powers of the seasonal autoregressive integrated moving average (SARIMA) and neural network auto-regression (SARIMA-NNAR) models of TB incidence and analyse its seasonality in South Africa. Methods: TB incidence cases data from January 2010 to December 2015 were extracted from the Eastern Cape Health facility report of the electronic Tuberculosis Register (ERT.Net). A SARIMA model and a combined model of SARIMA model and a neural network auto-regression (SARIMA-NNAR) model were used in analysing and predicting the TB data from 2010 to 2015. Simulation performance parameters of mean square error (MSE), root mean square error (RMSE), mean absolute error (MAE), mean percent error (MPE), mean absolute scaled error (MASE) and mean absolute percentage error (MAPE) were applied to assess the better performance of prediction between the models. Results: Though practically, both models could predict TB incidence, the combined model displayed better performance. For the combined model, the Akaike information criterion (AIC), second-order AIC (AICc) and Bayesian information criterion (BIC) are 288.56, 308.31 and 299.09 respectively, which were lower than the SARIMA model with corresponding values of 329.02, 327.20 and 341.99, respectively. The seasonality trend of TB incidence was forecast to have a slightly increased seasonal TB incidence trend from the SARIMA-NNAR model compared to the single model. Conclusions: The combined model indicated a better TB incidence forecasting with a lower AICc. The model also indicates the need for resolute intervention to reduce infectious disease transmission with co-infection with HIV and other concomitant diseases, and also at festival peak periods.

Independent predictors of tuberculosis mortality in a high HIV prevalence setting: a retrospective cohort study.

BackgroundIdentifying those at increased risk of death during TB treatment is a priority in resource-constrained settings. We performed this study to determine predictors of mortality during TB treatment.MethodsWe performed a retrospective analysis of a TB surveillance population in a high HIV prevalence area that was recorded in ETR.net (Electronic Tuberculosis Register). Adult TB cases initiated TB treatment from 2007 through 2009 in Khayelitsha, South Africa. Cox proportional hazards models were used to identify risk factors for death (after multiple imputations for missing data). Model selection was performed using Akaike’s Information Criterion to obtain the most relevant predictors of death.ResultsOf 16,209 adult TB cases, 851 (5.3 %) died during TB treatment. In all TB cases, advancing age, co-infection with HIV, a prior history of TB and the presence of both pulmonary and extra-pulmonary TB were independently associated with an increasing hazard of death. In HIV-infected TB cases, advancing age and female gender were independently associated with an increasing hazard of death. Increasing CD4 counts and antiretroviral treatment during TB treatment were protective against death. In HIV-uninfected TB cases, advancing age was independently associated with death, whereas smear-positive disease was protective.ConclusionWe identified several independent predictors of death during TB treatment in resource-constrained settings. Our findings inform resource-constrained settings about certain subgroups of TB patients that should be targeted to improve mortality during TB treatment.

Completeness and Reliability of the Republic of South Africa National Tuberculosis (TB) Surveillance System.

BackgroundAccurate surveillance data are paramount to effective TB control. The Republic of South Africa’s National TB Control Program (NTP) has conducted TB surveillance since 1995 and adopted the Electronic TB Register (ETR) in 2005. This evaluation aimed to determine the completeness and reliability of data in the Republic of South Africa’s TB Surveillance System.MethodsThree of nine provinces, three subdistricts per province, and 54 health facilities were selected by stratified random sampling. At each facility, 30 (or all if <30) patients diagnosed in Quarter 1 2009 were randomly selected for review. Patient information was evaluated across two paper and four electronic sources. Completeness of program indicators between paper and electronic sources was compared with chi-square tests. The kappa statistic was used to evaluate agreement of values.ResultsOver one-third (33.7 %) of all persons with presumptive TB recorded as smear positive in the TB Suspect Register did not have any records documenting notification, treatment, or management for TB disease. Of 1339 persons with a record as a TB patient at the facility, 1077 (80 %) were recorded in all data sources. Over 98 % of records contained complete age and sex data. Completeness varied for HIV status (53-86 %; p < 0.001) and DOT during the intensive phase of treatment (17-54 %; p < 0.001). Agreement for sex was excellent across sources (kappa 0.94); moderate for patient type (0.78), treatment regimen (0.79), treatment outcome (0.71); and poor for HIV status (0.33).ConclusionsThe current evaluation revealed that one-third of persons diagnosed with TB disease may not have been notified of their disease or initiated on treatment (‘initial defaulters’). The ETR is not capturing all TB patients. Further, among patients with a TB record, completeness and reliability of information in the TB Surveillance System is inconsistent across data sources. Actions are urgently needed to ensure that all diagnosed patients are treated and managed and improve the integrity of surveillance information.

Factors influencing treatment outcomes in tuberculosis patients in Limpopo Province, South Africa, from 2006 to 2010: A retrospective study.

South Africa has a high burden of tuberculosis (TB), with high human immunodeficiency virus (HIV)-TB co-infection rates and the emergence of multidrugresistant TB. To describe treatment outcomes and factors influencing outcomes amongst pulmonary TB (PTB) patients in the Limpopo Province. A retrospective review was conducted of data on the provincial electronic TB register (ETR.net) for the years 2006 to 2010 (inclusive), and a random sample of 1200 records was selected for further analysis. The Chi square test was used to examine the influence of age, gender, health facility level, diagnostic category and treatment regimen on treatment outcomes. Overall 90 617 (54.6% male) PTB patients were registered between 2006 and 2010. Of the sampled 1200 TB cases, 72.6% were in persons aged 22 to 55 years and 86.2% were new cases. The TB mortality rate was 13.6% (much higher than the World Health Organization target of 3%), whilst the default rate was 9.8%. There was a strong association between age (P < 0.001), diagnostic category (P < 0.001), treatment regimen (P < 0.001), and health facility level (P < 0.001) and treatment outcome. Those aged 22–55, and 56–74 years were more likely to die (P < 0.05). Poor treatment outcomes were also associated with initial treatment failure, receiving treatment at hospital and treatment regimen II. The poor TB treatment outcomes in Limpopo, characterised by a high mortality and default rates, call for strengthening of the TB control programme, which should include integration of HIV and/or AIDS and TB services.

Predictors of tuberculosis treatment defaulting in informal dwellers within the eThekwini municipality, Kwazulu-Natal

Globally, tuberculosis causes more than 2-million deaths annually. Despite the implementation of the directly observed treatment strategy (DOTS) in South Africa, cure and defaulter rates have not reached World Health Organization (WHO) target rates. This causes concern as it may increase the risks of the development of multiple drug-resistant tuberculosis. Prior to commencement of this study, the eThekwini Municipality reported a defaulter rate of 18.9% in 2007 and 29% in 2009, which is higher than the WHO guideline of 5%. In 2011, eThekwini reported a defaulter rate of 24.3%. Given these statistics and the impact that these high rates may have on susceptible populations and an already overburdened health system, this study aimed to investigate predictors of defaulting in informal dwellers of eThekwini Municipality, KwaZulu-Natal. The study population comprised 102 defaulters and 102 non-defaulters from informal settlements within eThekwini. It was a cross-sectional descriptive study. The Prince Cyril Zulu Communicable Disease Centre electronic tuberculosis register was used to trace defaulters who were interviewed from informal settlements. Demographic data for non-defaulters were matched from the Prince Cyril Zulu Communicable Disease Centre electronic tuberculosis register, but were not physically traced. A questionnaire was administered to all defaulters and retrospective data were obtained from the Prince Cyril Zulu Communicable Disease Centre register for non-defaulters. Multivariate logistic analysis found smoking, alcohol use and having a family member with tuberculosis to be statistically significant predictors of defaulting. Smoking [odds ratio (OR): 2.79, 95% confidence interval (CI): 1.15, 6.77, p-value ≤ 0.005], alcohol consumption (OR: 7.04, 95% CI: 2.96, 16.71, p-value ≤ 0.005), and having a family history of tuberculosis (OR: 4.60, 95% CI: 2.34, 9.04, p-value = 0.01), were all significantly associated with defaulting in informal dwellers. Smoking, alcohol use and having a family member with tuberculosis were predictors that informal dwellers would default from their treatment. These factors should be included in tuberculosis management programmes.