Treatment outcomes of new tuberculosis patients hospitalized in Kampala, Uganda: a prospective cohort study

Tuberculosis diagnostic and treatment delays among patients in Uganda

Background

Mycobacterium tuberculosis, a bacterium that relies on its human host to achieve airborne transmission and existence, is the primary cause of tuberculosis (TB), a disease that is vital to public health.

Aim

To update the society on tuberculosis diagnostic and treatment delays among patients in Uganda.

Materials and Methods

The review paper utilized different search engines, such as Pubmed Central, Scopus, Web of Science, Google Scholar, and so forth, to conduct this review paper.

Results

Delays in diagnosis could cause diseases to spread throughout the community, progress more quickly, and increase mortality. With many populations experiencing TB diagnostic delay and less than a third of the population experiencing TB treatment delay, the rates of tuberculosis diagnosis and treatment delays are high.

Conclusion

The delay in diagnosing and treating tuberculosis in men is positively correlated with knowledge of the disease's symptoms and the regular use of a handkerchief or both hands to cover the mouth and nose while coughing or sneezing.

Treatment outcomes of Gene Xpert positive tuberculosis patients in KwaMashu Community Health Centre, KwaZulu-Natal, South Africa: A retrospective review

Background

We sought to investigate the relationship between tuberculosis (TB) treatment outcomes and its predictors in the KwaMashu region in KwaZulu-Natal (KZN). This area is currently a hotbed for TB and human immunodeficiency virus (HIV) co-infection.

Method

A retrospective study design was adopted to characterise adult patients diagnosed with Gene Expert (GXP) positive pulmonary TB from 01 January 2016 to 31 December 2017. Tuberculosis treatment outcomes were assessed after two months and five months according to the standard World Health Organization (WHO) criteria. Multiple logistic regression analysis was used to calculate the odds ratio (OR) of the possible determinants associated with unsuccessful treatment outcomes.

Results

Amongst the 596 patients diagnosed, 57.4% (95% confidence interval [CI]: 53.3–61.4; 342 of 596) had successful treatment outcomes. Of these reported cases, 88.89% (85.1–92.0; 304 of 342) were cured. For the unsuccessful treatment outcomes, 52.4% (46.0–58.6; 133 of 254) patients were lost to follow-up, 20.9% (16.0–26.4; 53 of 254) failed treatment, 1.2% (0.2–3.4; 3 of 254) died and 25.6% (20.3–31.4; 65 of 254) of the patients could not be accounted for. Patients with unknown HIV status were more likely to have unsuccessful treatment outcomes (adjusted OR [aOR] = 4.94 [1.83–13.36]). Patients who had sputum conversion at 2 months (aOR = 1.94 [1.27–2.96]) were significantly more likely to exhibit unsuccessful treatment outcomes.

Conclusion

Treatment success rate was 57.4% which was below the target set by the WHO. This underscores the urgent need to strengthen treatment adherence strategies to improve outcomes, especially in high HIV burden settings.

Trends of unsuccessful treatment outcomes and associated factors among tuberculosis patients in public hospitals of Bale Zone, Southeast Ethiopia: A 5-year retrospective study

INTRODUCTION

Tuberculosis (TB) is a curable disease caused by the tubercle bacillus and its treatment is designed to cure, interrupt transmission, and prevent drug resistance. These aims have not yet been achieved in many regions of the world, particularly in developing countries like Ethiopia. Thus, this study was designed to assess the trends of unsuccessful treatment outcomes and associated factors among patients with TB in two public hospitals in the Bale zone, southeast Ethiopia.

METHODS

A 5-year retrospective data among 1281 patients with TB who registered and started treatment (from July 2013 to June 2018/19) in two selected Bale zone hospitals was retrieved. Together with descriptive statistics, binomial and multinomial logistic regression modeling were carried out using STATA version 14 to estimate the odds ratio.

RESULTS

The overall unsuccessful TB treatment outcomes in this study was 10.4% and moderately decreased over the year of treatment (from 14.1% to 8.4%, x2 = 7.35, and p = 0.011). Approximately 34 (7.6%) of pulmonary positive and 34 (7.4%) of pulmonary negative TB patients had experienced treatment failure and death, respectively. The level of the hospital, patients with smear-negative and extrapulmonary, transferred in, aged, and human immunodeficiency virus status were found to have a statistically significant association with unsuccessful treatment outcomes of patients with TB.

CONCLUSION

In this study, approximately one-tenth of patients with TB had unsuccessful treatment outcomes that moderately declined over the year of treatment. Strengthening control efforts like counseling during the intensive and continual phases of treatment and scheduling home visits is recommended.

Current in-hospital management for patients with tuberculosis in a high-income country: a retrospective cohort study

OBJECTIVES

In Japan, most cases of tuberculosis (TB) occur among individuals aged 65 years or older. However, data on in-hospital adverse events (AEs) associated with TB management, especially in high-income nations with an ageing population, are scarce. The present study aimed to scrutinize the current TB unit practices, incidence of in-hospital AEs and predictors of in-hospital mortality.

METHODS

This retrospective cohort study was conducted at a tertiary care centre in Tokyo, Japan from 2012 to 2017. Inpatients with the diagnosis of TB and aged >18 years were included. Quality of in-hospital care and factors associated with in-hospital mortality were investigated using multivariate logistic regression analysis.

RESULTS

In total, 448 patients were enrolled. The in-hospital mortality rate was 16.7% (75/448). Miliary/disseminated TB was common (59/448, 13.2%), especially in those who died (17/75, 22.7%). Factors independently associated with in-hospital mortality were a low Karnofsky performance status score on admission (score: 40-10, adjusted odds ratio (aOR) 25.65, 95% CI 5.63-116.92 and score: 70-50, aOR 9.47, 95% CI 2.07-43.3), age over 89 years (aOR 3.68, 95% CI 1.08-12.46), Charlson Co-morbidity Index >5 (aOR 3.56, 95% CI 1.37-9.21), development of any health-care-associated infection (aOR 2.95, 95% CI 1.35-6.41), and development of any drug-related AE leading to discontinuation of anti-TB agents (seven patients were unable to resume treatment with anti-TB agents before death) (aOR 2.29, 95% CI 1.02-5.11).

CONCLUSIONS

In-hospital AEs (i.e. health-care-associated infection and drug-related AEs), as well as patient-related variables, were associated with in-hospital mortality among TB patients.

Impact of a mobile phone-based interactive voice response software on tuberculosis treatment outcomes in Uganda (CFL-TB): a protocol for a randomized controlled trial

BACKGROUND

Throughout the last decade, tuberculosis (TB) treatment success has not surpassed 90%, the global target. The impact of mobile health interventions (MHIs) on TB treatment outcomes is unknown, especially in low- and middle-income countries (LMICs). MHIs, including interactive voice response technology (IVRT), may enhance adherence and retention in the care of patients with tuberculosis and improve TB treatment outcomes. This study seeks to determine the impact of IVRT-based MHI on TB treatment success (treatment completion and cure rates) in patients with TB receiving care at five public health facilities in Uganda.

METHODS

We used a theory-based and human-centered design (HCD) to adapt an already piloted software to design "Call for life-TB" (CFL-TB), an MHI that utilizes IVRT to deliver adherence and appointment reminders and allows remote symptom reporting. This open-label, multicenter, randomized controlled trial (RCT), with nested qualitative and economic evaluation studies, will determine the impact of CFL-TB on TB treatment success in patients with drug-susceptible TB in Uganda. Participants (n = 274) at the five study sites will be randomized (1:1 ratio) to either control (standard of care) or intervention (adherence and appointment reminders, and health tips) arms. Multivariable regression models will be used to compare treatment success, adherence to treatment and clinic appointments, and treatment completion at 6 months post-enrolment. Additionally, we will determine the cost-effectiveness, acceptability, and perceptions of stakeholders. The study received national ethical approval and was conducted in accordance with the international ethical guidelines.

DISCUSSION

This randomized controlled trial aims to evaluate interactive voice response technology in the context of resource-limited settings with a high burden of TB and high illiteracy rates. The software to be evaluated was developed using HCD and the intervention was based on the IMB model. The software is tailored to the local context and is interoperable with the MHI ecosystem. The HCD approach ensures higher usability of the MHI by integrating human factors in the prototype development. This research will contribute towards the understanding of the implementation and impact of the MHI on TB treatment outcomes and the health system, especially in LMICs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04709159 . Registered on January 14, 2021.

HIV TB coinfection - perspectives from India

Introduction: HIV and tuberculosis (TB) are two of the most challenging infections faced by humanity and place immense burden on health care systems worldwide. Both HIV and TB impact one another's progression.Areas covered: HIV is the most important risk factor for progression of latent TB to active disease. TB is the most common cause of death among People Living with HIV (PLHIV). Timely detection of TB among PLHIV and screening for HIV among TB patients, early initiation of ART and ATT among coinfected persons, provision of CPT and TB Preventive therapy along with control of air-borne infection are some of the key activities to reduce morbidity and mortality among coinfected persons. Despite many challenges, the collaboration between two programs has yielded good results and globally more than 7.3 million lives of PLHIV have been saved globally through scale-up of collaborative TB/HIV activities since 2005. The review looked into key features of both programs that are the collaboration strategies and challenges that still need to be addressed.Expert opinion: The overarching principle for effective implementation of collaborative activities is integration of the TB and HIV national programs right from policy making to service delivery and monitoring.

Hospitalizations and Treatment Outcomes in Patients with Urogenital Tuberculosis in Tashkent, Uzbekistan, 2016-2018

Despite the global shift to ambulatory tuberculosis (TB) care, hospitalizations remain common in Uzbekistan. This study examined the duration and determinants of hospitalizations among adult patients (≥18 years) with urogenital TB (UGTB) treated with first-line anti-TB drugs during 2016–2018 in Tashkent, Uzbekistan. This was a cohort study based on the analysis of health records. Of 142 included patients, 77 (54%) were males, the mean (±standard deviation) age was 40 ± 16 years, and 68 (48%) were laboratory-confirmed. A total of 136 (96%) patients were hospitalized during the intensive phase, and 12 (8%) had hospital admissions during the continuation phase of treatment. The median length of stay (LOS) during treatment was 56 days (Interquartile range: 56–58 days). LOS was associated with history of migration (adjusted incidence rate ratio (aIRR): 0.46, 95% confidence interval (CI): 0.32–0.69, p < 0.001); UGTB-related surgery (aIRR: 1.18, 95% CI: 1.01–1.38, p = 0.045); and hepatitis B comorbidity (aIRR: 3.18, 95% CI: 1.98–5.39, p < 0.001). The treatment success was 94% and it was not associated with the LOS. Hospitalization was almost universal among patients with UGTB in Uzbekistan. Future research should focus on finding out what proportion of hospitalizations were not clinically justified and could have been avoided.

HIV infection modifies the relationship between distance to a health facility and treatment success rate for tuberculosis in rural eastern Uganda

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Distance from residence to a health facility presents a physical barrier.

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Our data show that long-distance is associated with a lower treatment success rate.

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Also, we found long-distance is insignificantly associated with high mortality.

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HIV modifies the effect of long-distance on mortality.

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People with tuberculosis who travel long distances need improved access to treatment.

Rationale

Distance from residence to a health facility especially in rural areas presents a physical barrier and may influence tuberculosis (TB) treatment outcomes.

Objectives

We examined the association between distance from residence to a health facility and TB treatment outcomes namely treatment success rate (TSR) and mortality, and whether HIV influences this relationship among people with TB in Kumi district in rural eastern Uganda.

Methods

In this cross-sectional design, we abstracted data from TB unit registers across four large health facilities. Travel of ≥5 km to a health facility was considered a long distance. The primary outcome was TSR and the secondary was mortality. We performed a generalized linear model with Poisson distribution with a log-link and robust standard errors to determine the association between distance and the study outcomes adjusting for potential confounders. We report the adjusted risk ratio (aRR) and 95% confidence interval (CI).

Measurement and results

Of 611 participants studied, 484 (79.2%) were successfully treated, 18 (2.9%) died, and 359 (58.7%) travelled a long distance to access TB treatment. Long-distance was significantly associated with lower TSR (aRR, 0.93; 95% CI, 0.89–0.96). Further analysis showed that longer distance was associated with lower TSR among HIV positive persons with TB (aRR, 0.83; 95% CI, 0.72–0.96), but not among HIV negative persons with TB (aRR, 0.94; 95% CI, 0.85–1.03). Although it was not significant, longer distance showed a tendency towards worse mortality among HIV positive people with TB (aRR, 2.78; 95% CI, 0.80–9.66), but not among HIV negative people with HIV (aRR, 0.21; 0.03–1.74).

Conclusions

A majority of people with TB travel long distances to access treatment. Long distances are associated with lower TSR and higher mortality and affect people with TB who are HIV positive but not HIV negative. Interventions should focus on improving access to treatment for people with TB who travel long distances.

Prevalence and factors associated with non-adherence to multi-drug resistant tuberculosis (MDR-TB) treatment at Mulago National Referral Hospital, Kampala, Uganda

Background

In Uganda, 12% of previously treated TB cases and 1.6% of new cases have MDR-TB and require specialized treatment and care. Adherence is crucial for improving MDR-TB treatment outcomes. There is paucity of information on the extent to which these patients adhere to treatment and what the drivers of non-adherence are.

Methods

We conducted a cohort study using retrospectively collected routine program data for patients treated for MDR-TB between January 2012 – May 2016 at Mulago Hospital. We extracted anonymized data on non-adherence (missing 10% or more of DOT), socio-economic, demographic, and treatment characteristics of the patients. All participants were sensitive to MDR-TB drugs after second line Drug Susceptible Testing (DST) at entry into the study. Factors associated with non-adherence to MDR-TB treatment were determined using generalized linear models for the binomial family with log link and robust standard errors. We considered a p- value less than 0.05 as statistically significant.

Results

The records of 227 MDR- TB patients met the inclusion criteria, 39.4% of whom were female, 32.6% aged between 25 – 34 years, and 54.6% living with HIV/AIDS. About 11.9% of the patients were non-adherent. The main driver for non-adherence was history of previous DR-TB treatment; previously treated DR-TB patients were 3.46 (Adjusted prevalence ratio: 3.46, 95 % CI: 1.68 – 7.14) times more likely to be non-adherent.

Conclusion

One in 10 MDR-TB patients treated at Mulago hospital is non-adherent to treatment. History of previous DRTB treatment was significantly associated with non-adherence in this study. MDR-TB program should strengthen adherence counselling, strengthen DST surveillance, and close monitoring for previously treated DR-TB patients.

Anemia in tuberculosis cases: A biomarker of severity?

INTRODUCTION

Anemia is a common condition at tuberculosis diagnosis, and there is evidence that its prevalence is higher in patients with tuberculosis than in those infected with Mycobacterium tuberculosis and healthy controls. Information about anemia during tuberculosis diagnosis is still scarce in the Brazilian population. The aim of this study was to describe the prevalence of anemia in patients with tuberculosis cared for at a referral center and its association with clinical forms of tuberculosis and other characteristics of these patients.

MATERIALS AND METHODS

This was a retrospective cross-sectional study of tuberculosis patients diagnosed from January 2015 to December 2018 at the Clinical Research Laboratory on Mycobacteria (LAPCLIN-TB) of Evandro Chagas National Institute of Infectious Diseases (INI)/Oswaldo Cruz Foundation (Fiocruz). A database of an ongoing cohort study underway at this service since 2000 provided the baseline information on tuberculosis cases extracted from a visit template. Exploratory and logistic regression analyses were performed to verify associations between anemia and demographic characteristics, socioeconomic status, clinical conditions, and laboratory results.

RESULTS

Of the 328 cases reviewed, 70 were excluded, with258 retained. The prevalence of anemia was 61.2% (27.5% mild, 27.5% moderate and 6.2% severe). Among patients with anemia, 60.8% had normochromic normocytic anemia, and 27.8% showed hypochromic microcytic anemia. In logistic regression analysis, anemia was associated with a history of weight loss >10%, hospitalizations, coinfection with HIV, increased platelet count and microcytosis. Anemia was more frequent in the most severe clinical forms, such as meningeal and disseminated tuberculosis.

CONCLUSIONS

Anemia was highly prevalent in tuberculosis patients at diagnosis, predominantly as normochromic normocytic anemia and in mild and moderate forms. It was associated with baseline characteristics and conditions indicative of severe disease, suggesting that anemia could be a biomarker of tuberculosis severity.

Tuberculosis in Hospitalized Patients With Human Immunodeficiency Virus: Clinical Characteristics, Mortality, and Implications From the Rapid Urine-based Screening for Tuberculosis to Reduce AIDS Related Mortality in Hospitalized Patients in Africa

BACKGROUND

Tuberculosis (TB) is the major killer of people living with human immunodeficiency virus (HIV) globally, with suboptimal diagnostics and management contributing to high case-fatality rates.

METHODS

A prospective cohort of patients with confirmed TB (Xpert MTB/RIF and/or Determine TB-LAM Ag positive) identified through screening HIV-positive inpatients with sputum and urine diagnostics in Malawi and South Africa (Rapid urine-based Screening for Tuberculosis to reduce AIDS Related Mortality in hospitalized Patients in Africa [STAMP] trial). Urine was tested prospectively (intervention) or retrospectively (standard of care arm). We defined baseline clinical phenotypes using hierarchical cluster analysis, and also used Cox regression analysis to identify associations with early mortality (≤56 days).

RESULTS

Of 322 patients with TB confirmed between October 2015 and September 2018, 78.0% had ≥1 positive urine test. Antiretroviral therapy (ART) coverage was 80.2% among those not newly diagnosed, but with median CD4 count 75 cells/µL and high HIV viral loads. Early mortality was 30.7% (99/322), despite near-universal prompt TB treatment. Older age, male sex, ART before admission, poor nutritional status, lower hemoglobin, and positive urine tests (TB-LAM and/or Xpert MTB/RIF) were associated with increased mortality in multivariate analyses. Cluster analysis (on baseline variables) defined 4 patient subgroups with early mortality ranging from 9.8% to 52.5%. Although unadjusted mortality was 9.3% lower in South Africa than Malawi, in adjusted models mortality was similar in both countries (hazard ratio, 0.9; P = .729).

CONCLUSIONS

Mortality following prompt inpatient diagnosis of HIV-associated TB remained unacceptably high, even in South Africa. Intensified management strategies are urgently needed, for which prognostic indicators could potentially guide both development and subsequent use.

Improving survival with tuberculosis & HIV treatment integration: A mini-review

Tuberculosis (TB) is a leading cause of morbidity and mortality among HIV-infected patients while HIV remains a key risk factor for the development of active TB infection. Treatment integration is a key in reducing mortality in patients with HIV-TB co-infection. However, this opportunity to improve outcomes of both infections is often missed or poorly implemented. Challenges in TB-HIV treatment integration range from complexities involving clinical management of co-infected patients to obstacles in health service-organization and prioritization. This is evident in high prevalence settings such as in sub-Saharan Africa where TB-HIV co-infection rates reach up to 80 per cent. This review discusses published literature on clinical trials and cohort studies of strategies for TB-HIV treatment integration aimed at reducing co-infection mortality. Studies published since 2009, when several treatment guidelines recommended treatment integration, were included. A total of 43 articles were identified, of which a total of 23 observational studies and nine clinical trials were informative on TB-HIV treatment integration. The data show that the survival benefit of AIDS therapy in patients infected with TB can be maximized among patients with advanced immunosuppression by starting antiretroviral therapy (ART) soon after TB treatment initiation, i.e. in patients with CD4+ cell counts <50 cells/μl. However, patients with greater CD4+ cell counts should defer initiation of ART to no less than eight weeks after initiation of TB treatment to reduce the occurrence and extent of immune reconstitution disease and subsequent hospitalization. Addressing operational challenges in integrating TB-HIV care can significantly improve patient outcomes, generate substantial public health impact by decreasing morbidity and death in settings with a high burden of HIV and TB.

A mortality review of adult inpatients with tuberculosis in Mendi, Papua New Guinea

SETTING

Mendi Provincial Hospital, Southern Highlands Province, Papua New Guinea (PNG).

BACKGROUND

PNG is a high burden country for tuberculosis (TB) and TB-human immunodeficiency virus (HIV). TB is the second most common cause of death in PNG.

OBJECTIVE

To identify the number of adult inpatients with TB who died between 1 January 2015 and 30 August 2017; describe these patients' characteristics and identify contributing factors that could be modified.

DESIGN

This was a retrospective case series review.

RESULTS

Among 905 inpatients with TB during the study period, there were 90 deaths. The patients who died were older than those who survived (median age 40 years vs. 32 years, P = 0.011). The majority of patients who died lived less than 3 hours from the hospital (71%), were diagnosed after admission (79%) and were clinically diagnosed (77%). HIV status was not known in 50% of the deaths. Of patients with a known status, 27% (12/45) were HIV-positive. The median symptom duration prior to presentation was 28 days, with females presenting later than males (84 vs. 28 days, P = 0.008).

CONCLUSION

This study highlights areas where community and hospital-based management of TB could be improved to potentially reduce TB mortality, including earlier detection and treatment, improved bacteriological diagnosis and increased HIV testing.

Treatment success rate among adult pulmonary tuberculosis patients in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVES

To summarise treatment success rate (TSR) among adult bacteriologically confirmed pulmonary tuberculosis (BC-PTB) patients in sub-Saharan Africa (SSA).

DESIGN

We searched MEDLINE, EMBASE, Google Scholar and Web of Science electronic databases for eligible studies published in the decade between 1 July 2008 and 30 June 2018. Two independent reviewers extracted data and disagreements were resolved by consensus with a third reviewer. We used random-effects model to pool TSR in Stata V.15, and presented results in a forest plot with 95% CIs and predictive intervals. We assessed heterogeneity with Cochrane's (Q) test and quantified with I-squared values. We checked publication bias with funnel plots and Egger's test. We performed subgroup, meta-regression, sensitivity and cumulative meta-analyses.

SETTING

SSA.

PARTICIPANTS

Adults 15 years and older, new and retreatment BC-PTB patients.

OUTCOMES

TSR measured as the proportion of smear-positive TB cases registered under directly observed therapy in a given year that successfully completed treatment, either with bacteriologic evidence of success (cured) or without (treatment completed).

RESULTS

31 studies (2 cross-sectional, 1 case-control, 17 retrospective cohort, 6 prospective cohort and 5 randomised controlled trials) involving 18 194 participants were meta-analysed. 28 of the studies had good quality data. Egger's test indicated no publication bias, rather small study effect. The pooled TSR was 76.2% (95% CI 72.5% to 79.8%; 95% prediction interval, 50.0% to 90.0%, I² statistics=96.9%). No single study influenced the meta-analytical results or conclusions. Between 2008 and 2018, a gradual but steady decline in TSR occurred in SSA but without statistically significant time trend variation (p=0.444). The optimum TSR of 90% was not achieved.

CONCLUSION

Over the past decade, TSR was heterogeneous and suboptimal in SSA, suggesting context and country-specific strategies are needed to end the TB epidemic.

PROSPERO REGISTRATION NUMBER

CRD42018099151.

Risk score for predicting mortality including urine lipoarabinomannan detection in hospital inpatients with HIV-associated tuberculosis in sub-Saharan Africa: Derivation and external validation cohort study

BACKGROUND

The prevalence of and mortality from HIV-associated tuberculosis (HIV/TB) in hospital inpatients in Africa remains unacceptably high. Currently, there is a lack of tools to identify those at high risk of early mortality who may benefit from adjunctive interventions. We therefore aimed to develop and validate a simple clinical risk score to predict mortality in high-burden, low-resource settings.

METHODS AND FINDINGS

A cohort of HIV-positive adults with laboratory-confirmed TB from the STAMP TB screening trial (Malawi and South Africa) was used to derive a clinical risk score using multivariable predictive modelling, considering factors at hospital admission (including urine lipoarabinomannan [LAM] detection) thought to be associated with 2-month mortality. Performance was evaluated internally and then externally validated using independent cohorts from 2 other studies (LAM-RCT and a Médecins Sans Frontières [MSF] cohort) from South Africa, Zambia, Zimbabwe, Tanzania, and Kenya. The derivation cohort included 315 patients enrolled from October 2015 and September 2017. Their median age was 36 years (IQR 30-43), 45.4% were female, median CD4 cell count at admission was 76 cells/μl (IQR 23-206), and 80.2% (210/262) of those who knew they were HIV-positive at hospital admission were taking antiretroviral therapy (ART). Two-month mortality was 30% (94/315), and mortality was associated with the following factors included in the score: age 55 years or older, male sex, being ART experienced, having severe anaemia (haemoglobin < 80 g/l), being unable to walk unaided, and having a positive urinary Determine TB LAM Ag test (Alere). The score identified patients with a 46.4% (95% CI 37.8%-55.2%) mortality risk in the high-risk group compared to 12.5% (95% CI 5.7%-25.4%) in the low-risk group (p < 0.001). The odds ratio (OR) for mortality was 6.1 (95% CI 2.4-15.2) in high-risk patients compared to low-risk patients (p < 0.001). Discrimination (c-statistic 0.70, 95% CI 0.63-0.76) and calibration (Hosmer-Lemeshow statistic, p = 0.78) were good in the derivation cohort, and similar in the external validation cohort (complete cases n = 372, c-statistic 0.68 [95% CI 0.61-0.74]). The validation cohort included 644 patients between January 2013 and August 2015. Median age was 36 years, 48.9% were female, and median CD4 count at admission was 61 (IQR 21-145). OR for mortality was 5.3 (95% CI 2.2-9.5) for high compared to low-risk patients (complete cases n = 372, p < 0.001). The score also predicted patients at higher risk of death both pre- and post-discharge. A simplified score (any 3 or more of the predictors) performed equally well. The main limitations of the scores were their imperfect accuracy, the need for access to urine LAM testing, modest study size, and not measuring all potential predictors of mortality (e.g., tuberculosis drug resistance).

CONCLUSIONS

This risk score is capable of identifying patients who could benefit from enhanced clinical care, follow-up, and/or adjunctive interventions, although further prospective validation studies are necessary. Given the scale of HIV/TB morbidity and mortality in African hospitals, better prognostic tools along with interventions could contribute towards global targets to reduce tuberculosis mortality.

Treatment outcomes and factors affecting unsuccessful outcome among new pulmonary smear positive and negative tuberculosis patients in Anqing, China: a retrospective study

Background

Monitoring the treatment outcomes of tuberculosis and determining the specific factors associated with unsuccessful treatment outcome are essential to evaluate the effectiveness of tuberculosis control program. This study aimed to assess treatment outcomes and explore the factors associated with unsuccessful outcomes among new pulmonary smear positive and negative tuberculosis patients in Anqing, China.

Methods

A nine-year retrospective study was conducted using data from Anqing Center for Diseases Prevention and Control. New pulmonary tuberculosis patients treated with two six-month regimens were investigated. Non-conditional logistic regression was performed to calculate odds ratios and 95% confidence intervals for factors associated with unsuccessful outcomes.

Results

Among 22,998 registered patients (16,939 males, 6059 females), 64.54% were smear-positive patients. The treatment success rates was 95.02% for smear-positive patients and 95.00% for smear-negative patients. Characteristics associated with an higher risk of unsuccessful treatment among smear-positive patients included aged above 35 years, treatment management model of self-medication, full-course management and supervision in intensive phase, unchecked chest X-ray, cavity in chest X-ray, and miliary shadow in chest X-ray, while normal X-ray was negative factor. Unsuccessful treatment among smear-negative patients was significantly associated with age over 45 years, treatment management model of full-course management, unchecked chest X-ray, presence of miliary shadow in chest X-ray and delay over 51 days.

Conclusions

Tuberculosis treatment in Anqing area was successful and independent of treatment regimens. Special efforts are required for patients with unsuccessful outcomes.

Poor tuberculosis treatment outcomes in Southern Mozambique (2011-2012)

BACKGROUND

In Mozambique, there is limited data regarding the monitoring of Tuberculosis (TB) treatment results and determinants of adverse outcomes under routine surveillance conditions. The objectives of this study were to evaluate treatment outcomes among TB patients, analyze factors associated with a fatal outcome and determine the proportion of deaths attributable to TB in the district of Manhiça, Southern Mozambique.

METHODS

This is a retrospective observational study based on TB patients diagnosed in the period 2011-2012. We used three different data sources: a) TB related variables collected by the National TB Control Program in the district of Manhiça for all TB cases starting treatment in the period 2011-2012. b) Population estimates for the district were obtained through the Mozambican National Statistics Institute. c) Deaths and other relevant demographic variables were collected from the Health and Demographic Surveillance System at Manhiça Health Research Center. WHO guidelines were used to define TB cases and treatment outcomes.

RESULTS

Of the 1957 cases starting TB treatment in the period 2011-2012, 294 patients (15.1 %) died during anti-tuberculous treatment. Ten per cent of patients defaulted treatment. The proportion of patients considered to have treatment failure was 1.1 %. HIV infection (OR 2.73; 95 % CI: 1.70-4.38), being male (OR: 1.39; 95 % CI 1.01-1.91) and lack of laboratory confirmation (OR: 1.54; 95 % CI 1.12-2.13) were associated with dying during the course of TB treatment (p value <0.05). The contribution of TB to the overall death burden of the district for natural reasons was 6.5 % (95 % CI: 5.5-7.6), higher for males than for females (7.8 %; 95 % CI: 6.1-9.5 versus 5.4 %; 95 % CI: 4.1-6.8 respectively). The age group within which TB was responsible for the highest proportion of deaths was 30-34 among males and 20-24 among females (20 % of all deaths in both cases).

CONCLUSION

This study shows a very high proportion of fatal outcomes among TB cases starting treatment. There is a high contribution of TB to the overall causes of mortality. These results call for action in order to improve TB (and TB/HIV) management and thus treatment outcomes of TB patients.

Spatial analysis of avoidable hospitalizations due to tuberculosis in Ribeirao Preto, SP, Brazil (2006-2012)

OBJECTIVE

To describe the spatial distribution of avoidable hospitalizations due to tuberculosis in the municipality of Ribeirao Preto, SP, Brazil, and to identify spatial and space-time clusters for the risk of occurrence of these events.

METHODS

This is a descriptive, ecological study that considered the hospitalizations records of the Hospital Information System of residents of Ribeirao Preto, SP, Southeastern Brazil, from 2006 to 2012. Only the cases with recorded addresses were considered for the spatial analyses, and they were also geocoded. We resorted to Kernel density estimation to identify the densest areas, local empirical Bayes rate as the method for smoothing the incidence rates of hospital admissions, and scan statistic for identifying clusters of risk. Softwares ArcGis 10.2, TerraView 4.2.2, and SaTScan™ were used in the analysis.

RESULTS

We identified 169 hospitalizations due to tuberculosis. Most were of men (n = 134; 79.2%), averagely aged 48 years (SD = 16.2). The predominant clinical form was the pulmonary one, which was confirmed through a microscopic examination of expectorated sputum (n = 66; 39.0%). We geocoded 159 cases (94.0%). We observed a non-random spatial distribution of avoidable hospitalizations due to tuberculosis concentrated in the northern and western regions of the municipality. Through the scan statistic, three spatial clusters for risk of hospitalizations due to tuberculosis were identified, one of them in the northern region of the municipality (relative risk [RR] = 3.4; 95%CI 2.7-4,4); the second in the central region, where there is a prison unit (RR = 28.6; 95%CI 22.4-36.6); and the last one in the southern region, and area of protection for hospitalizations (RR = 0.2; 95%CI 0.2-0.3). We did not identify any space-time clusters.

CONCLUSIONS

The investigation showed priority areas for the control and surveillance of tuberculosis, as well as the profile of the affected population, which shows important aspects to be considered in terms of management and organization of health care services targeting effectiveness in primary health care.

Economic loss due to traumatic injury in Uganda: The patient's perspective

INTRODUCTION

Traumatic injury is a growing public health concern globally, and is a major cause of death and disability worldwide. The purpose of this study was to quantify the socioeconomic impact of lower extremity fractures in Uganda.

METHODS

All adult patients presenting acutely to Uganda's national referral hospital with a single long bone lower extremity fracture in October 2013 were recruited. Consenting patients were surveyed at admission and again at six-months and 12-months post-injury. The primary outcome was the cumulative 12-month post-injury loss in income. Secondary outcome measures included the change in health-related quality of life (HRQoL) and the injury's effect on school attendance for the patients' dependents.

RESULTS

Seventy-four patients were recruited during the study period. Sixty-four (86%) of the patients were available for 12-months of follow-up. Compared to pre-injury earnings, patients lost 88.4% ($1822 USD) of their annual income in the 12-months following their injury. To offset this loss in income, patients borrowed an average of 28% of their pre-injury annual income. Using the EuroQol-5D instrument, the mean HRQoL decreased from 0.91 prior to the injury to 0.39 (p<0.0001) at 12-months post-injury. Ninety-three percent of school-aged dependents missed at least one month of school during their guardian's recovery and only 61% had returned to school by 12-months post-injury.

CONCLUSION

This study demonstrates that lower extremity fractures in Uganda had a profound impact on the socioeconomic status of the individuals in our sample population, as well as the socioeconomic health of the family unit.

Factors associated with death during tuberculosis treatment of patients co-infected with HIV at the Yaoundé Central Hospital, Cameroon: an 8-year hospital-based retrospective cohort study (2006-2013)

Background

Contributors to fatal outcomes in TB/HIV co-infected patients actively undergoing TB treatment are poorly characterized. The aim was to assess factors associated with death in TB/HIV co-infected patients during the initial 6 months of TB treatment.

Methods

We conducted a hospital-based retrospective cohort study from January 2006 to December 2013 at the Yaoundé Central Hospital, Cameroon. We reviewed medical records to identify hospitalized co-infected TB/HIV patients aged 15 years and older. Death was defined as any death occurring during TB treatment, as per the World Health Organization's recommendations. We conducted logistic regression analysis to identify factors associated with a fatal outcome. Magnitudes of associations were expressed by adjusted odds ratio (aOR) with 95% confidence interval.

Results

The 337 patients enrolled had a mean age of 39.3 (standard deviation 10.3) years and 54.3% were female. TB treatment outcomes were distributed as follows: 205 (60.8%) treatment success, 99 (29.4%) deaths, 18 (5.3%) not evaluated, 14 (4.2%) lost to follow-up, and 1 (0.3%) failed. After exclusion of patients lost to follow-up and not evaluated, death in TB/HIV co-infected patients during TB treatment was associated with a TB diagnosis made before 2010 (aOR = 2.50 [1.31–4.78]; p = 0.006), the presence of other AIDS-defining diseases (aOR = 2.73 [1.27–5.86]; p = 0.010), non-AIDS comorbidities (aOR = 3.35 [1.37–8.21]; p = 0.008), not receiving cotrimoxazole prophylaxis (aOR = 3.61 [1.71–7.63]; p = 0.001), not receiving antiretroviral therapy (aOR = 2.45 [1.18–5.08]; p = 0.016), and CD4 cells count <50 cells/mm³ (aOR = 16.43 [1.05–258.04]; p = 0.047).

Conclusions

The TB treatment success rate among TB/HIV co-infected patients in our setting is low. Mortality was high among TB/HIV co-infected patients during TB treatment and is strongly associated with clinical and biological factors, highlighting the urgent need for specific interventions focused on enhancing patient outcomes.

Impact of HIV-1, HIV-2, and HIV-1+2 dual infection on the outcome of tuberculosis

BACKGROUND

HIV-1 infection has been shown to impact the outcome of patients with tuberculosis (TB), but data regarding the impact of HIV-2 on TB outcomes are limited. The aim of this study was to assess the impact of HIV types on mortality among TB patients in Guinea-Bissau and to examine the predictive ability of the TBscoreII, a clinical score used to assess disease severity.

METHODS

In a prospective follow-up study, we examined the prevalence of HIV-1, HIV-2, and HIV-1+2 co-infection in TB patients in Guinea-Bissau, and the impact on outcomes at 12 months of follow-up. We included all adult TB patients in an observational TB cohort at the Bandim Health Project (BHP) in Guinea-Bissau between 2003 and 2013 and assessed survival status at 12 months after the start of treatment.

RESULTS

A total 1312 patients were included; 499 (38%) were female (male/female ratio 1.6). Three hundred and seventy-nine patients were HIV-infected: 241 had HIV-1, 93 had HIV-2, and 45 were HIV-1+2 dual infected. The HIV type-associated risk of TB was 6-fold higher for HIV-1, 7-fold higher for HIV-1+2 dual infection, and 2-fold higher for HIV-2 compared with the HIV-uninfected. Of the patients included, 144 (11%) died, 62 (12%) among females and 82 (9%) among males (hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.64-1.30; p=0.596). Compared to male patients, female patients were younger (1 year younger, 95% CI 0.5-2; p=0.04), reported a longer duration of symptoms (14 days longer, 95% CI 4-25; p=0.003), and had a higher TBscoreII (0.5 points more, 95% CI 0.3-0.7; p<0.001). More females than males were HIV-infected (36% vs. 25%; p<0.001) and more females had a body mass index (BMI) <15 kg/m(2) (11% vs. 6%; p<0.001) and a mid upper arm circumference (MUAC) <200 mm (13% vs. 7%; p < 0.001). HIV infection increased the mortality risk, with HIV-1 infection displaying the highest HR (5.0, 95% CI 3.5-7.1), followed by HIV-1+2 (HR 4.2, 95% CI 2.2-7.8) and HIV-2 (HR 2.1, 95% CI 1.2-3.8). A TBscoreII ≥4 was associated with increased mortality (HR 2.2, 95% CI 1.5-3.1). Significantly increased HRs were found for signs of wasting; a BMI <18 kg/m(2) was associated with a HR of 1.8 (95% CI 1.3-2.6) and a MUAC <220 mm with a HR of 3.8 (95% CI 2.7-5.2).

CONCLUSION

The HIV type-associated risk of TB was much higher for HIV-1 patients and higher but less so for HIV-2 patients, compared with the HIV-uninfected. Clinical severity at presentation was also higher for HIV-infected patients, although less so for HIV-2-infected patients, and all HIV-infected patients had a poorer outcome than the uninfected; mortality was 4-5-fold higher for HIV-1 and dually infected patients and two-fold higher for HIV-2-infected patients. These differences between HIV types did not disappear after adjusting for CD4 count.