Childhood and adult tuberculosis in a rural hospital in Southeast Ethiopia: a ten-year retrospective study

<p>Abstract</p> <p>Background</p> <p>Many DOTS experiences in developing countries have been reported. However, experience in a rural hospital and information on the differences between children and adults are limited. We described the epidemiology and treatment outcome of adult and childhood tuberculosis (TB) cases, and identified risk factors associated with defaulting and dying during TB treatment in a rural hospital over a 10-year period (1998 to 2007).</p> <p>Methods</p> <p>Retrospective data collection using TB registers and treatment cards in a rural private mission hospital. Information was collected on number of cases, type of TB and treatment outcomes using standardised definitions.</p> <p>Results</p> <p>2225 patients were registered, 46.3% of whom were children. A total of 646 patients had smear-positive pulmonary TB (PTB), [132 (20.4%) children]; 816 had smear-negative PTB [556 (68.2%) children], and 763 extra-PTB (EPTB) [341 (44.8%) children]. The percentage of treatment defaulters was higher in paediatric (13.9%) than in adult patients (9.3%) (p = 0.001). The default rate declined from 16.8% to 3.5%, and was independently positively associated with TB meningitis (AOR: 2.8; 95% CI: 1.2-6.6) and negatively associated with smear-positive PTB (AOR: 0.6; 95% CI: 0.4-0.8). The mortality rate was 5.3% and the greatest mortality was associated with adult TB (AOR: 1.7; 95% CI: 1.1-2.5), TB meningitis (AOR: 3.6; 95% CI:1.2-10.9), and HIV infection (AOR: 4.3; 95% CI: 1.9-9.4). Decreased mortality was associated with TB lymphadenitis (AOR: 0.24; 95% CI: 0.11-0.57).</p> <p>Conclusion</p> <p>(1) The registration of TB cases can be useful to understand the epidemiology of TB in local health facilities. (2) The defaulter and mortality rate of childhood TB is different to that of adult TB. (3) The rate of defaulting from treatment has declined over time.</p

Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial

Background: One of the main strategies to control tuberculosis (TB) is to find and treat people with active disease. Unfortunately, the case detection rates remain low in many countries. Thus, we need interventions to find and treat sufficient number of patients to control TB. We investigated whether involving health extension workers (HEWs: trained community health workers) in TB control improved smear-positive case detection and treatment success rates in southern Ethiopia. Methodology/Principal Finding: We carried out a community-randomized trial in southern Ethiopia from September 2006 to April 2008. Fifty-one kebeles (with a total population of 296, 811) were randomly allocated to intervention and control groups. We trained HEWs in the intervention kebeles on how to identify suspects, collect sputum, and provide directly observed treatment. The HEWs in the intervention kebeles advised people with productive cough of 2 weeks or more duration to attend the health posts. Two hundred and thirty smear-positive patients were identified from the intervention and 88 patients from the control kebeles. The mean case detection rate was higher in the intervention than in the control kebeles (122.2% vs 69.4%, p,0.001). In addition, more females patients were identified in the intervention kebeles (149.0 vs 91.6, p,0.001). The mean treatment success rate was higher in the intervention than in the control kebeles (89.3% vs 83.1%, p = 0.012) and more for females patients (89.8% vs 81.3%, p = 0.05). Conclusions/Significance: The involvement of HEWs in sputum collection and treatment improved smear-positive case detection and treatment success rate, possibly because of an improved service access. This could be applied in settings with low health service coverage and a shortage of health workers

Challenges of Loss to Follow-up in Tuberculosis Research.

In studies evaluating methods for diagnosing tuberculosis (TB), follow-up to verify the presence or absence of active TB is crucial and high dropout rates may significantly affect the validity of the results. In a study assessing the diagnostic performance of the QuantiFERON®-TB Gold In-Tube test in TB suspect children in Tanzania, factors influencing patient adherence to attend follow-up examinations and reasons for not attending were examined. In 160 children who attended and 102 children who did not attend scheduled 2-month follow-up baseline health characteristics, demographic data and risk factors for not attending follow-up were determined. Qualitative interviews were used to understand patient and caretakers reasons for not returning for scheduled follow-up. Being treated for active tb in the dots program (OR: 4.14; 95% CI:1.99-8.62;p-value<0.001) and receiving money for the bus fare (OR:129; 95% CI 16->100;P-value<0.001) were positive predictors for attending follow-up at 2 months, and 21/85(25%) of children not attending scheduled follow-up had died. Interviews revealed that limited financial resources, i.e. lack of money for transportation and poor communication, were related to non-adherence. Patients lost to follow-up is a potential problem for TB research. Receiving money for transportation to the hospital and communication is crucial for adherence to follow-up conducted at a study facility. Strategies to ensure follow-up should be part of any study protocol

Non-Medical Financial Burden in Tuberculosis Care: a Cross-Sectional Survey in Rural China

Background: Treatment of tuberculosis (TB) in China is partially covered by national programs and health insurance schemes, though TB patients often face considerable medical expenditures. For some, especially those from poorer households, non-medical costs, such as transport, accommodation, and nutritional supplementation may be a substantial additional burden. In this article we aim to evaluate these non-medical costs induced by seeking TB care using data from a large scale cross-sectional survey. Methods: A total of 797 TB cases from three cities were randomly selected using a stratified cluster sampling design. Inpatient medical costs, outpatient medical costs, and direct non-medical costs related to TB treatment were collected using in-person interviews by trained interviewers. Mean and median non-medical costs for different sub-groups were calculated and compared using Kruskal-Wallis and Mann–Whitney U tests. Regression analysis was conducted to assess the influence of different patient characteristics on total non-medical cost. Results: The median non-medical cost was RMB 1429, with interquartile range RMB 424–2793. The median non-medical costs relating to inpatient treatment, outpatient treatment, and additional nutrition supplementation were RMB 540, 91, and 900, respectively. Of the 797 cases, 20 % reported catastrophic expenditure on non-medical costs. Statistically significant differences were detected between different cities, age groups, geographical locations, inpatient/outpatient care, education levels and family income groups. Conclusions: Non-medical costs relating to TB treatment are a serious financial burden for many TB patients. Financial assistance that can limit this burden is urgently needed during the treatment period, especially for the poor

Urban Movement and Alcohol Intake Strongly Predict Defaulting from Tuberculosis Treatment: An Operational Study

BACKGROUND: High levels of defaulting from treatment challenge tuberculosis control in many African cities. We assessed defaulting from tuberculosis treatment in an African urban setting. METHODS: An observational study among adult patients with smear-positive pulmonary tuberculosis receiving treatment at urban primary care clinics in Kampala, Uganda. Defaulting was defined as having missed two consecutive monthly clinic visits while not being reported to have died or continued treatment elsewhere. Defaulting patients were actively followed-up and interviewed. We assessed proportions of patients abandoning treatment with and without the information obtained through active follow-up and we examined associated factors through multivariable logistic regression. RESULTS: Between April 2007 and April 2008, 270 adults aged ≥15 years were included; 54 patients (20%) were recorded as treatment defaulters. On active follow-up vital status was established of 28/54 (52%) patients. Of these, 19 (68%) had completely stopped treatment, one (4%) had died and eight (29%) had continued treatment elsewhere. Extrapolating this to all defaulters meant that 14% rather than 20% of all patients had truly abandoned treatment. Daily consumption of alcohol, recorded at the start of treatment, predicted defaulting (adjusted odds ratio [OR(adj)] 4.4, 95%CI 1.8-13.5), as did change of residence during treatment (OR(adj) 8.7, 95%CI 1.8-41.5); 32% of patients abandoning treatment had changed residence. CONCLUSIONS: A high proportion of tuberculosis patients in primary care clinics in Kampala abandon treatment. Assessing change of residence during scheduled clinic appointments may serve as an early warning signal that the patient may default and needs adherence counseling

Delayed treatment of tuberculosis patients in rural areas of Yogyakarta province, Indonesia

<p>Abstract</p> <p>Background</p> <p>In year 2000, the entire population in Indonesia was 201 million and 57.6 percent of that was living in rural areas. This paper reports analyses that address to what extent the rural structure influence the way TB patients seek care prior to diagnosis by a DOTS facility.</p> <p>Methods</p> <p>We documented healthcare utilization pattern of smear positive TB patients prior to diagnosis and treatment by DOTS services (health centre, chest clinic, public and private hospital) in Yogyakarta province. We calculated the delay in treatment as the number of weeks between the onset of symptoms and the start of DOTS treatment. Statistical analysis was carried out with Epi Info version 3.3 (October 5, 2004).</p> <p>Results</p> <p>The only factor which was significantly associated with total delay was urban-rural setting (p = < 0.0001). The median total delay for TB patients in urban districts was 8 (1^stQuartile = 4; 3^rdQuartile = 12) weeks compared to 12 (1^stQuartile = 7; 3^rdQuartile = 23) weeks for patients in rural districts. Multivariate analysis suggested no confounding between individual factors and urban-rural setting remained as the main factor for total delay (p = < 0.0001). Primary health centre was the first choice provider for most (38.7%) of these TB patients. Urban-rural setting was also the only factor which was significantly associated with choice of first provider (p = 0.03).</p> <p>Conclusion</p> <p>Improving access to DOTS services in rural areas is an area of vital importance in aiming to make progress toward achieving TB control targets in Indonesia.</p

Barriers and facilitators of adherence to TB treatment in patients on concomitant TB and HIV treatment: a qualitative study

<p>Abstract</p> <p>Background</p> <p>Tuberculosis is a major public health problem in Ethiopia, and a high number of TB patients are co-infected with HIV. There is a need for more knowledge about factors influencing treatment adherence in co-infected patients on concomitant treatment. The aim of the present study is to explore patients' and health care professionals' views about barriers and facilitators to TB treatment adherence in TB/HIV co-infected patients on concomitant treatment for TB and HIV.</p> <p>Methods</p> <p>Qualitative study using in-depth interviews with 15 TB/HIV co-infected patients and 9 health professionals and focus group discussions with 14 co-infected patients.</p> <p>Results</p> <p>We found that interplay of factors is involved in the decision making about medication intake. Factors that influenced adherence to TB treatment positively were beliefs in the curability of TB, beliefs in the severity of TB in the presence of HIV infection and support from families and health professionals. Barriers to treatment adherence were experiencing side effects, pill burden, economic constraints, lack of food, stigma with lack of disclosure, and lack of adequate communication with health professionals.</p> <p>Conclusion</p> <p>Health professionals and policy makers should be aware of factors influencing TB treatment in TB/HIV co-infected patients on concomitant treatment for TB and HIV. Our results suggest that provision of food and minimal financial support might facilitate adherence. Counseling might also facilitate adherence, in particular for those who start ART in the early phases of TB treatment, and beliefs related to side-effects and pill burden should be addressed. Information to the public may reduce TB and HIV related stigma.</p

Investigation Outcomes of Tuberculosis Suspects in the Health Centers of Addis Ababa, Ethiopia

BACKGROUND: Little is known about the prevalence of tuberculosis (TB) and HIV among TB suspects in primary health care units in Ethiopia. METHODS: In the period of February to March, 2009, a cross sectional survey was done in 27 health centers of Addis Ababa to assess the prevalence of TB and HIV among TB suspects who have > = 2 weeks symptoms of TB such as cough, fever and weight loss. Diagnosis of TB and HIV was based on the national guidelines. Information concerning socio-demographic variables and knowledge of the respondents about TB was collected using pretested questionnaire. RESULTS: Of the 545 TB suspects, 506 (92.7%) of them participated in the study. The prevalence of both pulmonary and extra pulmonary TB was 46.0% (233/506). The smear positivity rate among pulmonary TB suspect was 21.3%. Of the TB suspects, 298 (58.9%) of them were tested for HIV and 27.2% (81/298) were HIV seropositive. Fifty percent of the HIV positive TB suspects had TB. TB suspects who had a contact history with a TB patient in the family were 9 times more likely to have TB than those who did not have a contact history, [OR = 9.1, (95%CI:4.0, 20.5)]. Individuals who had poor [OR = 5.2, (95%CI: 2.3, 11.2)] and fair knowledge [OR = 3.7, (95%CI: 1.3, 10.4)] about TB were more likely to have TB than individuals who had good knowledge. CONCLUSION: In conclusion, the prevalence of TB among TB suspects with duration of 2 or more weeks is high. Fifty percent of the HIV positive TB suspects had TB. Case finding among TB suspects with duration of 2 or more weeks should be intensified particularly among those who have a contact history with a TB patient

Tuberculosis burden in an urban population: a cross sectional tuberculosis survey from Guinea Bissau

<p>Abstract</p> <p>Background</p> <p>Little is known about the prevalence of pulmonary tuberculosis (TB) in low income countries. We conducted a cross sectional survey for pulmonary TB and TB symptoms in Bissau, Guinea-Bissau, in an urban cohort with known HIV prevalence. TB surveillance in the area is routinely based on passive case finding.</p> <p>Methods</p> <p>Two cohorts were selected based on a previous HIV survey, but only 52.5% of those enrolled in the adult cohort had participated in the HIV survey. One cohort included all adults living in 384 randomly selected houses; in this cohort 8% (135/1687) were HIV infected. The other included individuals 50 years or older from all other houses in the study area; of these 11% (62/571) were HIV infected. Symptom screening was done through household visits using a standardised questionnaire. TB suspects were investigated with sputum smear microscopy and X-ray.</p> <p>Results</p> <p>In the adult cohort, we found 4 cases among 2989 individuals screened, giving a total TB prevalence of 134/100,000 (95% CI 36-342/100,000). In the >50 years cohort, we found 4 cases among 571 individuals screened, giving a total prevalence of 701/100,000 (191-1784/100.000). Two of the eight detected TB cases were unknown by the TB program. Of the total TB cases five were HIV uninfected while three had unknown HIV status. The prevalence of TB symptoms was 2.1% (63/2989) and 10.3% (59/571) in the two cohorts respectively.</p> <p>Conclusions</p> <p>In conclusion we found a moderately high prevalence of pulmonary TB and TB symptoms in the general population, higher among elderly individuals. By active case finding unknown cases were detected. Better awareness of TB and its symptoms needs to be promoted in low income settings.</p

The effect of household heads training on long-lasting insecticide-treated bed nets utilization: a cluster randomized controlled trial in Ethiopia

<p>Abstract</p> <p>Background</p> <p>Long-lasting insecticide-treated bed nets (LLITN) have demonstrated significant impact in reducing malaria-related childhood morbidity and mortality. However, utilization of LLITN by under-five children is not satisfactory in many sub-Saharan African countries due to behavioural barriers. Previous studies had focused on the coverage and ownership of LLITN. The effect of skill-based training for household heads on LLITN utilization had not yet been investigated. A cluster-randomized trial on the effect of training of household heads on the use of LLITN was done in Ethiopia to fill this knowledge gap.</p> <p>Methods</p> <p>The study included 22 (11 intervention and 11 control) villages in southwest Ethiopia. The intervention consisted of tailored training of household heads about the proper use of LLITN and community network system. All households in each group received free LLITN. Data were collected at baseline, six and 12 months of the follow up periods. Utilization of LLITN in the control and intervention villages was compared at baseline and follow up periods.</p> <p>Results</p> <p>A total of 21,673; 14,735 and 13,758 individuals were included at baseline, sixth and twelfth months of the project period. At the baseline survey, 47.9% of individuals in the intervention villages and 68.4% in the control villages reported that they had utilized LLITN the night before the survey. At the six month, 81.0% of individuals in the intervention villages and 79.3% in the control villages had utilized LLITN. The utilization of LLITN in all age groups in the intervention villages was increased by 17.7 percentage point (95% CI 9.7-25.6) at sixth month and by 31.0 percentage point (95% CI 16.9-45.1) at the twelfth month. Among under-five children, the LLITN utilization increased by 31.6 percentage point (95% CI 17.3-45.8) at the sixth month and 38.4 percentage point (95% CI 12.1-64.7) at the twelfth months of the project period.</p> <p>Conclusion</p> <p>Household level skill-based training has demonstrated a marked positive effect in the utilization of LLITN. The effect of the intervention steadily increased overtime. Therefore, distribution of LLITN should be accompanied by a skill-based training of household heads to improve its utilization.</p> <p>Trail registration</p> <p>Australian New Zealand Clinical Trials Registry (ACTR number: <a href="http://www.anzctr.org.au/ACTRN12610000035022.aspx">ACTRN12610000035022</a>).</p