Tuberculosis Treatment Default Research Articles

Factors Associated with Tuberculosis Treatment Default in an Endemic Area of the Brazilian Amazon: A Case Control-Study

SettingTreatment default is a serious problem in tuberculosis control because it implies persistence of infection source, increased mortality, increased relapse rates and facilitates the development of resistant strains.ObjectiveThis study analyzed tuberculosis treatment default determinants in the Amazonas State to contribute in planning appropriate control interventions.DesignObservational study with a retrospective cohort using Brazilian Disease Notification System data from 2005 to 2010. A nested case control study design was used. Patients defaulting from treatment were considered as ‘cases’ and those completing treatment as ‘controls’. In the analysis, 11,312 tuberculosis patients were included, 1,584 cases and 9,728 controls.ResultsTreatment default was observed to be associated to previous default (aOR 3.20; p<0.001), HIV positivity (aOR 1.62; p<0.001), alcoholism (aOR 1.51; p<0.001), low education level (aOR 1.35; p<0.001) and other co-morbidities (aOR 1.31; p = 0.05). Older patients (aOR 0.98; p = 0.001) and DOT (aOR 0,72; p<0.01) were considered as protective factor for default.ConclusionsAssociated factors should be considered in addressing care and policy actions to tuberculosis control. Information on disease and treatment should be intensified and appropriate to the level of education of the population, in order to promote adherence to treatment and counter the spread of multidrug resistance to anti-TB drugs.

Patient- and provider-level risk factors associated with default from tuberculosis treatment, South Africa, 2002: a case-control study.

BackgroundPersons who default from tuberculosis treatment are at risk for clinical deterioration and complications including worsening drug resistance and death. Our objective was to identify risk factors associated with tuberculosis (TB) treatment default in South Africa.MethodsWe conducted a national retrospective case control study to identify factors associated with treatment default using program data from 2002 and a standardized patient questionnaire. We defined default as interrupting TB treatment for two or more consecutive months during treatment. Cases were a sample of registered TB patients receiving treatment under DOTS that defaulted from treatment. Controls were those who began therapy and were cured, completed or failed treatment. Two respective multivariable models were constructed, stratified by history of TB treatment (new and re-treatment patients), to identify independent risk factors associated with default.ResultsThe sample included 3165 TB patients from 8 provinces; 1164 were traceable and interviewed (232 cases and 932 controls). Significant risk factors associated with default among both groups included poor health care worker attitude (new: AOR 2.1, 95% CI 1.1-4.4; re-treatment: AOR 12, 95% CI 2.2-66.0) and changing residence during TB treatment (new: AOR 2.0, 95% CI 1.1-3.7; re-treatment: AOR 3.4, 95% CI 1.1-9.9). Among new patients, cases were more likely than controls to report having no formal education (AOR 2.3, 95% CI 1.2-4.2), feeling ashamed to have TB (AOR 2.0, 95% CI 1.3-3.0), not receiving adequate counseling about their treatment (AOR 1.9, 95% CI 1.2-2.8), drinking any alcohol during TB treatment (AOR 1.9, 95% CI 1.2-3.0), and seeing a traditional healer during TB treatment (AOR 1.9, 95% CI 1.1-3.4). Among re-treatment patients, risk factors included stopping TB treatment because they felt better (AOR 21, 95% CI 5.2-84), having a previous history of TB treatment default (AOR 6.4, 95% CI 2.9-14), and feeling that food provisions might have helped them finish treatment (AOR 5.0, 95% CI 1.3-19).ConclusionsRisk factors for default differ between new and re-treatment TB patients in South Africa. Addressing default in both populations with targeted interventions is critical to overall program success.

Burden of new and recurrent tuberculosis in a major South African city stratified by age and HIV-status.

AimTo describe the burden of tuberculosis (TB) in Cape Town by calculating TB incidence rates stratified by age and HIV-status, assessing the contribution of retreatment disease and estimating the cumulative lifetime TB risk in HIV-negative individuals.MethodsDetails of TB cases were abstracted from the 2009 electronic TB register. Population denominators were estimated from census data and actuarial estimates of HIV prevalence, allowing calculation of age-specific and HIV-stratified TB notification rates.ResultsThe 2009 mid-year population was 3,443,010 (3,241,508 HIV-negative and 201,502 HIV-positive individuals). There were 29,478 newly notified TB cases of which 56% were laboratory confirmed. HIV status was recorded for 87% of cases and of those with known HIV-status 49% were HIV-negative and 51% were positive. Discrete peaks in the incidence of non-HIV-associated TB occurred at three ages: 511/100,000 at 0–4 years of age, 553/100,000 at 20–24 years and 628/100,000 at 45–49 years with 1.5%, 19% and 45% being due to retreatment TB, respectively. Only 15.5% of recurrent cases had a history of TB treatment failure or default. The cumulative lifetime risks in the HIV-negative population of all new TB episodes and new smear-positive TB episodes were 24% and 12%, respectively; the lifetime risk of retreatment disease was 9%. The HIV-positive notification rate was 6,567/100,000 (HIV-associated TB rate ratio = 17). Although retreatment cases comprised 30% of the HIV-associated TB burden, 88% of these patients had no history of prior treatment failure or default.ConclusionsThe annual burden of TB in this city is huge. TB in the HIV-negative population contributed almost half of the overall disease burden and cumulative lifetime risks were similar to those reported in the pre-chemotherapy era. Retreatment TB contributed significantly to both HIV-associated and non-HIV-associated TB but infrequently followed prior inadequate treatment. This likely reflects ongoing TB transmission to both HIV-negative and positive individuals.

Tuberculosis treatment default among HIV‐TB co‐infected patients in urban Uganda

To identify health facility and patient-specific factors associated with TB treatment default in HIV-infected patients, in a TB clinic on the campus of Mulago National Referral Hospital in Kampala, Uganda. Unmatched case-control study between March and May 2009. Cases were TB patients known to have defaulted on their anti-TB treatment, defined as a TB patient who had documented discontinuation of TB medication for two or more consecutive months due to reasons other than physician's advice and who did not access care at another facility. Controls were TB patients who completed 8 months of anti-TB treatment without interruption of two or more months. Data on health facility-specific factors and individual characteristics were collected using semi-structured questionnaires. Factors associated with defaulting from TB treatment were: distance from home to clinic (OR 2.22; 1.21-4.06); long waiting time at the clinic (OR 4.18; 2.18-8.02); poor drug availability (OR 4.75; 2.29-9.84); conduct of staff (OR 2.72; 1.02-7.25); lack of opportunity to express feelings (OR 3.47; 1.67-7.21). Other patient-related factors were lack of health education, i.e. not being aware of the duration of treatment or the risk of discontinuing it (OR 5.31; 1.94-14.57); not knowing that TB can be cured (OR 44.11; 13.66-142.41); length of TB treatment (OR 10.77; 5.18-22.41), and side effects of treatment OR 5.53 (2.25-13.61). Defaulting is influenced by health systems, staff factors, and patient misinformation. Health education on TB directed at patients combined with staff sensitization could help to improve adherence to TB treatment.

Risk factors for tuberculosis treatment failure, default, or relapse and outcomes of retreatment in Morocco

BackgroundPatients with tuberculosis require retreatment if they fail or default from initial treatment or if they relapse following initial treatment success. Outcomes among patients receiving a standard World Health Organization Category II retreatment regimen are suboptimal, resulting in increased risk of morbidity, drug resistance, and transmission.. In this study, we evaluated the risk factors for initial treatment failure, default, or early relapse leading to the need for tuberculosis retreatment in Morocco. We also assessed retreatment outcomes and drug susceptibility testing use for retreatment patients in urban centers in Morocco, where tuberculosis incidence is stubbornly high.MethodsPatients with smear- or culture-positive pulmonary tuberculosis presenting for retreatment were identified using clinic registries in nine urban public clinics in Morocco. Demographic and outcomes data were collected from clinical charts and reference laboratories. To identify factors that had put these individuals at risk for failure, default, or early relapse in the first place, initial treatment records were also abstracted (if retreatment began within two years of initial treatment), and patient characteristics were compared with controls who successfully completed initial treatment without early relapse.Results291 patients presenting for retreatment were included; 93% received a standard Category II regimen. Retreatment was successful in 74% of relapse patients, 48% of failure patients, and 41% of default patients. 25% of retreatment patients defaulted, higher than previous estimates. Retreatment failure was most common among patients who had failed initial treatment (24%), and default from retreatment was most frequent among patients with initial treatment default (57%). Drug susceptibility testing was performed in only 10% of retreatment patients. Independent risk factors for failure, default, or early relapse after initial treatment included male gender (aOR = 2.29, 95% CI 1.10-4.77), positive sputum smear after 3 months of treatment (OR 7.14, 95% CI 4.04-13.2), and hospitalization (OR 2.09, 95% CI 1.01-4.34). Higher weight at treatment initiation was protective. Male sex, substance use, missed doses, and hospitalization appeared to be risk factors for default, but subgroup analyses were limited by small numbers.ConclusionsOutcomes of retreatment with a Category II regimen are suboptimal and vary by subgroup. Default among patients receiving tuberculosis retreatment is unacceptably high in urban areas in Morocco, and patients who fail initial tuberculosis treatment are at especially high risk of retreatment failure. Strategies to address risk factors for initial treatment default and to identify patients at risk for failure (including expanded use of drug susceptibility testing) are important given suboptimal retreatment outcomes in these groups.

Incidence, time and determinants of tuberculosis treatment default in Yaounde, Cameroon: a retrospective hospital register-based cohort study

ObjectivesHigh rates of antituberculosis treatment discontinuation have been reported in some areas of Africa. The aim of this study was to determine the rate, time to and determinants of antituberculosis...

Treatment default and death among tuberculosis patients in Hunan, China

We used the 2005 and 2006 national surveillance data to elucidate some of the risk factors for treatment default and death among tuberculosis (TB) patients in Hunan, China. Risk of default was higher in males (odds ratio (OR) 1.25; 95% confidence interval (CI) 1.08, 1.44); lowest in patients aged 15-24 y (OR 0.60; 95% CI 0.49, 0.75), and generally increased with increasing age; lower in patients living in cities with per capita gross domestic product (GDP) of less than 1000 US$ (OR 0.60, 95% CI 0.49, 0.72), and increased with increasing per capita GDP of city of residence; and higher in patients with previously treated smear-positive pulmonary TB (diagnostic category II according to the World Health Organization definition; OR 1.99; 95% CI 1.22, 3.23). Risk of death was lowest in patients aged 15-24 y (OR 0.07; 95% CI 0.05, 0.10), and increased with increasing age; lower in new cases (OR 0.50; 95% CI 0.33, 0.76); and highest in patients who treated themselves (OR 3.47; 95% CI 1.27, 9.46). We conclude that male TB patients, elderly TB patients, patients resident in cities with higher per capita GDP, and patients receiving category II treatment need special attention to reduce TB treatment default in the province. Furthermore, elderly TB patients and patients with a long history of TB need special attention to reduce mortality. Self-treatment also needs to be discouraged to reduce mortality.

Quality of tuberculosis care and its association with patient adherence to treatment in eight Ethiopian districts

Little is known about the quality of tuberculosis (TB) service delivery in public health facilities in Ethiopia and its association with patients' non-adherence to TB treatment. This study assessed the organization, management and processes of TB care delivery, and their effects on patients' adherence to TB treatment. The quality of TB care was investigated in 44 public health facilities from three perspectives: structure, processes of TB care delivery and patient treatment outcome. Quality of care was determined by adherence to national TB guidelines. On-site observations of TB service delivery and interviews with health providers were conducted to evaluate structural factors. Patients (n = 237) in the health facilities were interviewed prospectively at completion of their treatment to determine the quality of tuberculosis care delivered. Three measures of treatment adherence [treatment interruption (>or=2 weeks), availability of unused TB drugs and treatment default] were quantified from a review of patient treatment registers and an audit of unused TB drugs at patients' homes. Effects were identified of poor quality structures and processes of service delivery on these three measures of adherence. TB care providers were untrained in 18 (44%) of 44 facilities and daily outpatient TB care was not given in 13 of 44 (25%). Among the 237 patients, 43% interrupted treatment for >or=15 days and 30% had at least 1 day's dose of TB drugs unused. Patients tended to interrupt and default from treatment when their care provider had been inadequately supervised by district TB control experts and was incapable of dealing with patients' minor illnesses. Unavailability of daily TB care in health facilities was associated with missing daily doses. Better training of TB care providers and district supervisory support could be important interventions to improve the quality of care delivery and patient adherence to treatment.

Facteurs associés à l'abandon du traitement anti-tuberculeux dans la ville d'Antananarivo, Madagascar

A retrospective epidemiological study of patients' medical records (n = 442) was conducted in one of the tuberculosis (TB) treatment centers in the city of Antananarivo, to identify risk factors of treatment default. Results show that males give up treatment more than women (OR=1,81 [1,13; 3,03]). Among those living farthest away from the center, patients younger than 30 years old tend to be more irregular in the follow-up of their treatment (OR=3,43 [1,16; 10,15]). There is no statistically significant relationship between TB treatment default and the patient's age, the clinical form, the therapeutic regime or the place of residence. Managers of treatment centers should be more aware and vigilant regarding male and young TB patients presenting these characteristics and should adapt methods and means for follow-up according to these risk factors.

Factors associated with tuberculosis treatment default among HIV-infected tuberculosis patients in Thailand

Ensuring completion of tuberculosis (TB) treatment remains a major public health problem. In HIV-infected patients, TB is the most common severe opportunistic infection. Few studies have evaluated risk factors for TB treatment default in HIV-infected patients. We conducted a prospective, observational study of HIV-infected TB patients in Thailand. Patients underwent standardised evaluations at the beginning of TB treatment, at the end of the intensive phase and at the end of TB treatment. TB treatment outcomes were assessed according to WHO guidelines. The analysis was limited to patients who defaulted or who had treatment success. Of the 554 patients analysed, 61 (11%) defaulted. In multivariate analysis, factors associated with TB treatment default included incarceration history [adjusted odds ratio (AOR) 2.0, 95% CI 1.1-3.7), smoking (AOR 2.3, 95% CI 1.3-4.1) and having a symptom complaint score >15 (AOR 3.4, 95% CI 1.4-8.0); one marker of wealth, namely owning a refrigerator, was protective (AOR 0.4, 95% CI 0.2-0.8). Default during TB treatment was a significant problem in HIV-infected patients. Reducing default may require enhancing services for patients with a history of incarceration or smoking and designing patient-centred systems to address poverty and patient wellness.

Meta-analysis of factors related to health services that predict treatment default by tuberculosis patients

The identification of factors that predict tuberculosis (TB) treatment default can help control this problem. The current study used a systematic review to investigate associations between TB treatment default and previously studied factors related to health services. Abstracts were searched in the MEDLINE and LILACS databases and in the bibliography of the full texts under evaluation. Studies were included if TB treatment default was evaluated by comparing two or more groups and data could be extracted. A total of 41 studies were included for combining data. It was possible to combine five exposures: "difficult access to health services"; "need for hospitalization"; "training or support for adherence"; "delay in initiating treatment"; "long wait before medical attendance". "Difficult access to health services", "training or support for adherence", and "need for hospitalization" were associated with TB treatment default. All exposures demonstrated heterogeneity, which was only explained in one. Publication bias was only detected for one exposure.

Treatment default among urban tuberculosis patients, Thailand

Tuberculosis treatment default, missing medical appointments for two consecutive months or more, is a serious problem not only for individuals but also for societies and health-care systems. Most research focuses only on patient factors without considering health-care system factors' effects on treatment default. The study purpose was to examine the influence of process of care on treatment default. Structured interviews and medical chart reviews were conducted in 160 tuberculosis patients receiving care at a tertiary hospital in Thailand. The samples included 54 patients with treatment default and 106 patients with treatment completion. Hierarchical logistic regression was used to examine relationships among the variables. After adjusting for patient factors, having severe medication side-effect and travel time to clinic increased treatment default. The patient factor of being paid on a daily basis was also significantly associated with treatment default. Evidence indicates that some process of care factors influence treatment default. Findings can be applied to practice levels to maintain patients until treatment completion.

Factors associated with tuberculosis treatment default and completion at the Effia-Nkwanta Regional Hospital in Ghana

The level of defaulting from treatment among tuberculosis (TB) patients at the Effia-Nkwanta Regional Hospital between January 2000 and December 2001 was 13.9%. This study was therefore designed to assess factors associated with TB treatment default and completion at the hospital. The initial part of the study consisted of three separate focus group discussions for health workers, defaulters and non-defaulters. The information collected was used to design a questionnaire that was administered to defaulters and non-defaulters selected from the Institutional TB Register. Univariate logistic regression analysis was performed to identify significant factors associated with treatment default. Statistical significance was taken as P < 0.05. Default from treatment was significantly associated with income per month (P = 0.03), ability to afford supplementary drugs (P = 0.008), availability of social support (P = 0.005) and problems relating with others while on treatment (P = 0.01). A cordial relationship between patients and health staff was the main motivating factor for completion of treatment, whilst financial difficulty was the main reason for defaulting from treatment. Determination of the characteristics found to be associated with defaulting in this study among TB patients at the start of treatment may be helpful in improving compliance among patients registered for treatment at the hospital.