Determinants of unsuccessful treatment outcomes and mortality among tuberculosis patients in Malaysia: A registry-based cohort study

Tuberculosis (TB) treatment challenges in TB-diabetes comorbid patients: a systematic review and meta-analysis

BACKGROUND

The Directly Observed Treatment-Short Course (DOTS) Programme was implemented by WHO and includes a combination of four anti-tuberculosis (TB) drugs (isoniazid, pyrazinamide, ethambutol and rifampicin) for a period of six months to eradicate the TB infection completely. Diabetes mellitus (DM) is recognized as one of a strong contributor of TB according to World Health Organization (WHO). The presence of diabetes mellitus type 2 (DM type 2) makes TB treatment complicated. Thus, the objective of the current meta-analysis was to identify and quantify the impact of type 2 DM on treatment outcomes of TB patients treated under the DOTS Programme.

METHODS

This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Through a systematic review of relevant literature, we focused on studies investigating treatment outcomes including extended treatment duration and recurrence for individuals with both TB and DM undergoing DOTS therapy. The extracted information included study designs, sample sizes, patient characteristics and reported treatment results.

RESULTS

In 44 studies from different parts of the world, the pooled HR for the impact of DM on extended treatment duration and reoccurrence were HR 0.72, 95% CI 0.56-0.83, p < .01 and HR 0.93, 95% CI 0.70-1.04, p = .08, respectively. The pooled HR for impact of DM on composite TB treatment outcomes was calculated as 0.76 (95% CI 0.60-0.87), p < .01 with an effect size of 41.18. The heterogeneity observed among the included studies was moderate (I2 = 55.79%).

CONCLUSIONS

A negative impact of DM was found on recurrence and extended treatment duration in TB patients treated with DOTS therapy. DM type 2 is responsible for the TB treatment prolongation and TB recurrence rates. By implementing effective management strategies and advancing research, the challenges can be mitigated, arising due to the complex interaction between DM and TB.

Prevalence, Clinical Characteristics and Determinants of Unsuccessful Treatment Outcomes Among Pulmonary Tuberculosis Patients: A 5-Year Registry-Based Retrospective Cohort Study

Purpose

Despite the existence of effective medications, pulmonary tuberculosis (PTB) remains a significant global public health concern, The evaluation and feedback of national TB control programs are crucial, requiring diligent monitoring of TB treatment outcomes and analysis of the factors influencing these outcomes. This study aims to provide valuable insights into the challenges faced by TB patients, which can inform better strategies for treatment and management in the future.

Patients and Methods

We conducted a study in King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia (KSA), from January 1, 2018 to December 31, 2023. The study was a registry-based retrospective cohort study. Patients' data were sourced from the National Tuberculosis Registry database of Saudi Arabia. Treatment outcomes were determined as either success or failure, considering clinical evaluation, changes in chest X-rays, and the results of subsequent sputum examinations during follow-up. To evaluate the data, SPSS version 28.0 was used.

Results

A total of 427 PTB patients participated in the study. The results show successful treatment outcomes among 88.5% of patients. Among the patients, males exhibited a higher likelihood of treatment failure as compared to females (aOR 1.3; 95%Cl 1.2-1.5, p < 0.001). Patients with positive sputum smear (aOR 1.3; 95%Cl 1.1-1.3 p < 0.00) and the presence of cough were associated with an increased risk of treatment failure (aOR1.5; 95%Cl 1.1-1.4, p < 0.001).

Conclusion

This study shows that the percentage of unsuccessful treatment outcomes is high, ie, 11.5%, due to patients' deaths and loss to follow-up. Enhanced supervision and treatment monitoring for tuberculosis patients at high risk of treatment failure can lead to improved treatment success rates in Saudi Arabia.

Tuberculosis treatment outcomes and associated factors at Alemgena Health Center, Sebeta, Oromia, Ethiopia

BACKGROUND

Tuberculosis (TB) is a global public health problem. Evaluation of TB treatment outcome enables health institutions to measure and improve the effectiveness of TB control programs. This study aimed to assess treatment outcomes of tuberculosis and identify associated factors among TB patients registered at Alemgena Health Center, Oromia, Ethiopia.

METHOD

A retrospective study was conducted; Secondary data were collected from medical records of 1010 TB patients treated at Alemgena Health Center between September 2012 and August 2018, inclusively. Logistic regression was used to identify factors associated with TB treatment outcomes. P-value less than 0.05 was considered statistically significant.

RESULTS

The proportion of males and females was almost equal. Among the patients 64.7% were in the age group 15-34, 98% were new cases, 31.2% were smear positive, 13% were HIV positive and 40.3% had extra-pulmonary tuberculosis. 94.2% of the patients had successful treatment outcome, with 26.9% cured and 67.3% treatment completed, whereas 5.8% had unsuccessful treatment outcomes, of whom 4.2% died and 1.5% defaulted. Death rate was higher among patients older than 44 years (10.4%) than among children (0%). In bivariate logistic regression analysis, treatment success rate was 3.582 (95% CI 1.958-6.554, p-value = .000) times higher in the age group 44 and below compared to the age group 45 and above.

CONCLUSION

Treatment success rate exceeded the one targeted by WHO. Age was found to be associated with treatment outcome. Success rate has to be improved for TB patients in the age group greater than 45 years of age.

Characteristics, predictors and consequences of tuberculosis treatment interruption: A multicentre retrospective cohort study

OBJECTIVES

Treatment interruption is associated with poor tuberculosis (TB) treatment outcomes and increased drug resistance. To address the issue, we aimed to investigate the characteristics, predictors and consequences of treatment interruption.

METHODS

We conducted a retrospective cohort study by retrieving 4 years (2018-2021) of TB patients' records at 10 public health clinics in Sarawak, Malaysia. Adult patients (≥18 years) with drug-susceptible TB were selected. Treatment interruption was defined as ≥2 weeks of cumulative interruption during treatment. The Chi-square test, Mann-Whitney U test, Kaplan-Meier and Cox proportional hazards regression were used to analyse the data, with p < 0.05 being considered statistically significant.

RESULTS

Out of 2953 eligible patients, 475 (16.1%) experienced TB treatment interruption. Interruptions were most frequent during the intensive phase (46.9%, n = 223), with the greatest risk within the first 4 weeks of treatment. The median time to interruption was 2 weeks in the intensive phase and the cumulative interruption probability at the end of the intensive phase was 12.9%. Notably, treatment interruption occurred during both intensive and continuation phases for 144 patients (30.3%), while the remaining 108 (22.7%) experienced interruptions only during the continuation phase with a median time to interruption of 16 weeks. Three predictors were identified to increase the risk of treatment interruption: adverse drug reaction (aHR = 8.53, 95% Cl: 6.73-10.82), smoking (aHR = 2.67, 95% Cl: 2.03-3.53) and illicit drug use (aHR = 1.88, 95% Cl: 1.03-3.45). Conversely, underlying diabetes was associated with a reduced likelihood of treatment interruption (aHR = 0.72, 95% Cl: 0.58-0.90). Treatment interruption led to significant differences in treatment restarts (62.3% vs. 0.7%), changes in medications (47.8% vs. 4.9%), prolonged treatment duration (247 days [IQR = 105] vs. 194 days [IQR = 44.3]) and lower successful outcomes (86.5% vs. 99.9%).

CONCLUSION

Understanding the temporal characteristics, predictors and negative consequences of treatment interruption can guide the development of time-relevant approaches to mitigate the problem.

Enhancing tuberculosis treatment adherence and motivation through gamified real-time mobile app utilization: a single-arm intervention study

BACKGROUND

Finding innovative methods to enhance Tuberculosis treatment adherence in Malaysia is imperative, given the rising trend of non-adhere TB patients. Direct Observed Therapy (DOTS) has been used to ensure Tuberculosis (TB) drug compliance worldwide. However, due to its inconvenience, digitalizing this system into a virtual monitoring system via a mobile app can help deliver a more efficient tuberculosis management system. A gamified video-observed therapy is developed that connects three users the patient, supervisor, and administrator, allowing drug monitoring and patient loss to follow up with the patient tracking system. Thus, the objective of this study is to determine the impact of Gamified Real-time Video Observed Therapy (GRVOTS) mobile apps on patient medication adherence rates and motivation.

METHODS

71 patients from 18 facilities participated in the 8-week single-arm intervention study. GRVOTS mobile apps were installed in their mobile apps, and patients were expected to fulfill tasks such as providing Video Direct Observe Therapy (VDOTS) daily as well as side effect reporting. At 3-time intervals of baseline,1-month, and 2-month intervals, the number of VDOT taken, the Malaysian Medication Adherence Assessment Tool (MyMAAT), and the Intrinsic Motivation Inventory (IMI) questionnaire were collected. One-sample t-test was conducted comparing the VDOT video adherence to the standard rate of 80%. RM ANOVA was used to analyze any significant differences in MyMAAT and IMI scores across three-time intervals.

RESULTS

This study involved 71 numbers of patients from 18 healthcare facilities who showed a significantly higher treatment adherence score of 90.87% than a standard score of 80% with a mean difference of 10.87(95% CI: 7.29,14.46; p < 0.001). The participants' MyMAAT and IMI scores significantly increased over 3-time intervals with the IMI Interest domain showing the highest mean difference 19.76 (95% CI: 16.37, 21.152: p < 0.001).

CONCLUSIONS

By utilizing GRVOTS, a mobile application based on gamification and real-time features, we can enhance motivation and medication adherence among TB patients, while also addressing the limitations of physical DOTS.

TRIAL REGISTRATION

IRCT20230308057657N1, Registered on (15/03/23).

Analysis of the Outcomes of Tuberculosis Treatment and Factors Associated with Successful Treatment at the Bamenda Regional Hospital: A 10-year Retrospective Study

BACKGROUND

Tuberculosis (TB) remains a global public health issue, impacting millions of people worldwide. This study determined the outcomes of TB treatment managed within a 10 year period at the Bamenda Regional Hospital in Cameroon.

METHODS

A retrospective study was carried out among 2428 patients diagnosed and treated for active TB infection from 2013 to 2022, at the Bamenda Regional Hospital. Data collection was done from March to April 2023 using a data extraction form. Bivariate and multivariate logistic regression models were used to identify factors associated with successful TB treatment outcomes. Data was analyzed using SPSS software version 26.

RESULTS

Of the 2428 patients with TB, 1380 (56.8%) were cured, 739 (30.4%) completed treatment, treatment failures were recorded in 10 (0.4%) patients, and 200 (8.2%) died during or after receiving treatment. Treatment default was the outcome in 99 (4.1%). Successful treatment outcomes were reported in 2119 (87.3%). Patients within age groups 41-50 (P = 0.010), 51-60 (P = 0.041), and >60 years (P = 0.006), male (P = 0.004), and human immunodeficiency virus-positive patients (P < 0.001) had decreased odds of successful treatment outcomes.

CONCLUSION

The outcomes of treatment within a 10 year period showed that the treatment success was 2.7% below the World Health Organizations target. Prioritizing vulnerable patient groups in TB management and implementing public health interventions such as financial assistance and nutritional support will go a long way in improving treatment outcomes.

Is Tobacco Use Associated With Risk of Recurrence and Mortality Among People With TB?: A Systematic Review and Meta-Analysis

BACKGROUND

Associations between tobacco use and poor TB treatment outcomes are well documented. However, for important outcomes such as TB recurrence or relapse and mortality during treatment, as well as for associations with smokeless tobacco (ST), the evidence is not summarized systematically.

RESEARCH QUESTION

Is tobacco use associated with risk of poor treatment outcomes among people with TB?

STUDY DESIGN AND METHODS

The MEDLINE, Embase, and Cumulative Index of Nursing and Allied Health Literature databases were searched on November 22, 2021. Epidemiologic studies reporting associations between tobacco use and at least one TB treatment outcome were eligible. Independent double-screening, extractions, and quality assessments were undertaken. Random effects meta-analyses were conducted for the two primary review outcomes (TB recurrence or relapse and mortality during treatment), and heterogeneity was explored using subgroups. Other outcomes were synthesized narratively.

RESULTS

Our searches identified 1,249 records, of which 28 were included in the meta-analyses. Based on 15 studies, higher risk of TB recurrence or relapse was found with ever using tobacco vs never using tobacco (risk ratio [RR], 1.78; 95% CI, 1.31-2.43; I2 = 85%), current tobacco use vs no tobacco use (RR, 1.95; 95% CI, 1.59-2.40; I2 = 72%), and former tobacco use vs never using tobacco (RR, 1.84; 95% CI, 1.21-2.80; I2 = 4%); heterogeneity arose from differences in study quality, design, and participant characteristics. Thirty-eight studies were identified for mortality, of which 13 reported mortality during treatment. Ever tobacco use (RR, 1.55; 95% CI, 1.32-1.81; I2 = 0%) and current tobacco use (RR, 1.51; 95% CI, 1.09-2.10; I2 = 87%) significantly increased the likelihood of mortality during treatment among people with TB compared with never using tobacco and not currently using tobacco, respectively; heterogeneity was explained largely by differences in study design. Almost all studies in the meta-analyses scored high or moderate on quality assessments. Narrative synthesis showed that tobacco use was a risk factor for other unfavorable TB treatment outcomes, as previously documented. Evidence on ST was limited, but identified studies suggested an increased risk for poor outcomes with its use compared with not using it.

INTERPRETATION

Tobacco use significantly increases the risk of TB recurrence or relapse and mortality during treatment among people with TB, highlighting the need to address tobacco use to improve TB outcomes.

TRIAL REGISTRY

PROSPERO; No.: CRD42017060821; URL: https://www.crd.york.ac.uk/prospero/.

Factors associated with tuberculosis treatment outcomes among TB patients aged 15 years and older at chawama level one hospital in Lusaka, Zambia

Tuberculosis is a global health concern n impacting communities, health systems, and economies This study assessed the TB treatment outcomes among individuals aged 15+ at Chawama first level hospital in Lusaka, Zambia, using a retrospective design focussing on individuals notified in 2020. The sample was described using descriptive statistics. The Pearson Chi-square test and logistics regression were used to analyse the characteristics of the patients influencing the treatment outcomes at 5% significant level. Out of 404 participants, 83.4% of them had successful treatment outcomes. Varied outcomes were noted in sex, patient type, TB type, HIV status, and DOT plan, but lacked significance. Odds of success were lower by 72.4% for those aged 65+ compared to those aged 15-24 years (OR (95% CI): 0.276 (0.086-0.881), p = .030). Similarly, after adjusting for other variables, the odds of success were lower by 72.9% (AOR (95% CI): 0.271 (0.083-0.882), p = .030). This study yielded an encouraging 83.4% TB success rate highlighting the potential for improvement to meet WHO targets. Notably, individuals aged 65+ showed a distinct pattern with lower treatment success odds, suggesting a need for focussed interventions. Special attention to elderly patients and targeted TB program interventions are recommended.

Tuberculosis presentation and outcomes in older Hispanic adults from Tamaulipas, Mexico

Older people are at high risk of developing and dying from pulmonary infections like tuberculosis (TB), but there are few studies among them, particularly in Hispanics. To address these gaps, we sought to identify host factors associated with TB and adverse treatment outcomes in older Hispanics by conducting a cross-sectional study of TB surveillance data from Tamaulipas, Mexico (2006-2013; n = 8381). Multivariable logistic regressions were assessed for older adults (OA ≥65 years) when compared to young (YA, 18-39 years) and middle-aged adults (40-64 years). We found that the OA had features associated with a less complicated TB (e.g., lower prevalence of extra-pulmonary TB and less likely to abandon treatment or have drug resistant TB), and yet, were more likely to die during TB treatment (adj-OR 3.9, 95% 2.5, 5.25). Among the OA, excess alcohol use and low body mass index increased their odds of death during TB treatment, while a higher number of reported contacts (social support) was protective. Diabetes was not associated with adverse outcomes in OA. Although older age is a predictor of death during TB disease, OA are not prioritized by the World Health Organization for latent TB infection screening and treatment during contact investigations. With safer, short-course latent TB infection treatment available, we propose the inclusion of OA as a high-risk group in latent TB management guidelines.

A qualitative exploration of tuberculosis patients who were lost to follow-up in Malaysia

BACKGROUND

Loss to follow-up (LTFU) is an unsuccessful treatment outcome for tuberculosis (TB) patients. In Malaysia, LTFU affects around 1 in 20 TB patients. Integration of qualitative research methods and evidence will provide a better understanding of LTFU and its underlying issues. In this study, we qualitatively explored TB patients' experiences in receiving treatment and their reasons for leaving TB care.

METHOD

In-depth interviews of 15 patients with a history of LTFU were conducted from January to September 2020. Interview guides were developed to explore TB patients' experiences while receiving treatment, including challenges faced and reasons for treatment interruption. Data were thematically analysed using the framework method.

RESULTS

We identified 11 emerging themes that occurred at four levels of interaction with TB patients. First, at the patient personal level, TB beliefs referring to patients' perception of illness and wellness, patients' perceived role of traditional and complementary medicine, and substance abuse were important. Second, the healthcare system and treatment factors that were highlighted included the organisation of care and treatment, interaction with healthcare professionals, particularly in communication and counselling, and TB medications' side effects. Third, structural factors including financial burden, logistical and transportation issues and work-related factors were identified to be barriers to treatment continuation. Fourth, the interpersonal level interaction of patients should not be neglected; this includes family relationships and support as well as peer influence.

CONCLUSION

Study findings put forth issues and challenges faced by TB patients while receiving treatment and underscore areas where actions can be taken. This will contribute to informing the development and implementation of future TB control strategies that are responsive to TB patients' needs and concerns, to effectively address LTFU and ensure better treatment completion rates among TB patients in Malaysia.

T-BACCO SCORE: A predictive scoring tool for tuberculosis (TB) loss to follow-up among TB smokers

INTRODUCTION

Loss to follow-up (LTFU) and smoking during TB treatment are major challenges for TB control programs. Smoking increases the severity and prolongs TB treatment duration, which lead to a higher rate of LTFU. We aim to develop a prognostic scoring tool to predict LTFU among TB patients who smoke to improve successful TB treatment outcomes.

MATERIALS AND METHODS

The development of the prognostic model utilized prospectively collected longitudinal data of adult TB patients who smoked in the state of Selangor between 2013 until 2017, which were obtained from the Malaysian Tuberculosis Information System (MyTB) database. Data were randomly split into development and internal validation cohorts. A simple prognostic score (T-BACCO SCORE) was constructed based on the regression coefficients of predictors in the final logistic model of the development cohort. Estimated missing data was 2.8% from the development cohort and was completely at random. Model discrimination was determined using c-statistics (AUCs), and calibration was based on the Hosmer and Lemeshow goodness of fit test and calibration plot.

RESULTS

The model highlights several variables with different T-BACCO SCORE values as predictors for LTFU among TB patients who smoke (e.g., age group, ethnicity, locality, nationality, educational level, monthly income level, employment status, TB case category, TB detection methods, X-ray categories, HIV status, and sputum status). The prognostic scores were categorized into three groups that predict the risk for LTFU: low-risk (<15 points), medium-risk (15 to 25 points) and high-risk (> 25 points). The model exhibited fair discrimination with a c-statistic of 0.681 (95% CI 0.627-0.710) and good calibration with a nonsignificant chi-square Hosmer‒Lemeshow's goodness of fit test χ2 = 4.893 and accompanying p value of 0.769.

CONCLUSION

Predicting LTFU among TB patients who smoke in the early phase of TB treatment is achievable using this simple T-BACCO SCORE. The applicability of the tool in clinical settings helps health care professionals manage TB smokers based on their risk scores. Further external validation should be carried out prior to use.

Factors Associated with Tuberculosis Mortality in Manjung District, Perak, Malaysia

Background

Tuberculosis (TB) is a communicable disease which contributes to a major cause of ill health. Worldwide, it is one of the leading causes of death from a single infectious agent.

Objectives

The study aimed to describe the epidemiology and factors associated with TB mortality in Manjung district, Perak, Malaysia.

Methods

All confirmed TB cases from 2015 to 2020 registered in Manjung district under Sistem Maklumat Tibi (MyTB) were included. Factors associated with TB mortality were analysed by using simple and multiple logistic regression analysis.

Results

A total of 742 TB cases were included in the analysis, from which 121 cases (16.3%) died before completing their treatment. The highest death was reported in 2020 (25.7%) and the lowest in 2019 (12.9%). From multiple logistic regression analysis, age 45 years old-64 years old (adjusted OR = 3.62; 95% CI: 1.38, 9.54), > 65 years old (adjusted OR = 8.67; 95% CI: 3.17, 23.74), non-Malaysian (adjusted OR = 5.18; 95% CI: 2.04, 13.14), cases notified by government hospitals (adjusted OR = 6.78; 95% CI: 3.04, 15.09), HIV-positive status (adjusted OR = 8.60; 95% CI: 3.58, 20.67) and HIV testing not offered/unknown (adjusted OR = 2.58; 95% CI: 1.18, 5.62) were significantly associated with TB mortality.

Conclusion

This study found that TB patients who were 45 years old and above, positive HIV, late diagnosis and are foreigners had a higher risk for TB mortality. Early diagnosis, optimised screening and close monitoring should be practised to reduce TB mortality.

Sex Differences in TB Clinical Presentation, Drug Exposure, and Treatment Outcomes in India

BACKGROUND

The role of sex differences in clinical presentation, TB drug pharmacokinetic variables, and treatment outcomes is unclear.

RESEARCH QUESTION

What is the effect of sex on TB disease severity, drug exposure, and treatment outcome?

STUDY DESIGN AND METHODS

This study was a prospective cohort study conducted in India. It assessed TB disease severity; risk of unfavorable treatment outcomes (failure, recurrence, and death) according to sex; and risk factors for unfavorable outcomes stratified according to sex. Effects of sex on the pharmacokinetic variables (maximum concentration and area under the curve) of rifampicin, isoniazid, and pyrazinamide were estimated by using noncompartmental analyses.

RESULTS

Of 1,541 people with microbiologically confirmed TB, 567 (37%) were women. Women had a lower risk of high mycobacterial burden (smear grade ≥ 2 and/or time to detection < 7 days) with an adjusted OR of 0.70 (95% CI, 0.56-0.87). Among the 744 participants who were followed up prospectively, 261 (35%) were women. Women had a lower risk of unfavorable treatment outcomes (adjusted incidence risk ratio, 0.60; 95% CI, 0.43-0.85), mostly because recurrence was lower (adjusted incidence risk ratio, 0.45; 95% CI, 0.23-0.86). Isoniazid (but not rifampicin and pyrazinamide) maximum concentration and area under the curve were significantly higher among women (P < .01) than men. Among women, unfavorable outcomes were more likely among those with cavitary disease, but among men, increased risk of unfavorable outcomes was associated with alcohol use, higher BMI, and lower glycated hemoglobin level.

INTERPRETATION

Women present with lower mycobacterial burden, achieve higher TB drug exposure, and are less likely to have unfavorable treatment outcomes than men. Strategies to improve TB treatment success should take into account sex differences in risk factors for unfavorable outcomes.

A Gamified Real-time Video Observed Therapies (GRVOTS) Mobile App via the Modified Nominal Group Technique: Development and Validation Study

BACKGROUND

The success rate of tuberculosis (TB) treatment in Malaysia remains below the recommended World Health Organization target of 90% despite the implementation of directly observed therapy, short-course, a physical drug monitoring system, since 1994. With increasing numbers of patients with TB in Malaysia defaulting on treatment, exploring another method to improve TB treatment adherence is vital. The use of gamification and real-time elements via video-observed therapies in mobile apps is one such method expected to induce motivation toward TB treatment adherence.

OBJECTIVE

This study aimed to document the process of designing, developing, and validating the gamification, motivation, and real-time elements in the Gamified Real-time Video Observed Therapies (GRVOTS) mobile app.

METHODS

The modified nominal group technique via a panel of 11 experts was used to validate the presence of the gamification and motivation elements inside the app, which were assessed based on the percentage of agreement among the experts.

RESULTS

The GRVOTS mobile app, which can be used by patients, supervisors, and administrators, was successfully developed. For validation purposes, the gamification and motivation features of the app were validated as they achieved a total mean percentage of agreement of 97.95% (SD 2.51%), which was significantly higher than the minimum agreement score of 70% (P<.001). Further, each component of gamification, motivation, and technology was also rated at 70% or more. Among the gamification elements, fun received the lowest scores, possibly because the nature of serious games does not prioritize the fun element and because the perception of fun varies by personality. The least popular element in motivation was relatedness, as stigma and discrimination hinder interaction features, such as leaderboards and chats, in the mobile app.

CONCLUSIONS

It has been validated that the GRVOTS mobile app contains gamification and motivation elements, which are intended to encourage medication adherence to TB treatment.

A cost-effectiveness evaluation of latent tuberculosis infection screening of a migrant population in Malaysia

To estimate the costs and benefits of screening for latent tuberculosis infection (LTBI) in a migrant population in Malaysia. An economic model was developed from a Malaysian healthcare perspective to compare QuantiFERON-TB Gold Plus (QuantiFERON) with the tuberculin skin test (TST). A decision tree was used to capture outcomes relating to LTBI screening followed by a Markov model that simulated the lifetime costs and benefits of the patient cohort. The Markov model did not capture the impact of secondary infections. The model included an R shiny interactive interface to allow adaptation to other scenarios and settings. QuantiFERON is both more effective and less costly than TST (dominant). Compared with QuantiFERON, the lifetime risk of developing active TB increases by approximately 40% for TST due to missed LTBI cases during screening (i.e. a higher number of false negative cases for TST). For a migrant population in Malaysia, QuantiFERON is cost-effective when compared with TST. Further research should consider targeted LTBI screening for migrants in Malaysia based on common risk factors.

Smear grading at initial treatment association with treatment outcomes among new smear positive pulmonary tuberculosis patients: A retrospective study

Introduction

Tuberculosis (TB) is one of the most challenging diseases in diagnosis, treatment and control. We aimed to assess the association of the initial grading of Mycobacterium Sputum Smear (MSS) on the outcomes of TB treatment.

Materials and methods

In a retrospective study, data of 418 positive pulmonary smear patients were retrieved from the TB registration system in Iran during 2014 to 2021. Patients' data included demographic, laboratory and clinical information and were recorded in our checklist. The grading of Mycobacterium Sputum Smear (MSS) at the initial treatment was assessed based on World Health Organization (WHO) guidelines. Chi-square test was used to assess the relationship between tuberculosis treatment outcomes and Mycobacterium grade at initial treatment in SPSS.

Results

The mean age of cases was 51.19 ± 22.29 years old and varied between 14 and 95 years. Laboratory results showed that the rate of 1-9, 1+,2+ and 3+ Mycobacterium tuberculosis was 17.7%, 44.3%, 19.4% and 18.7%, respectively. The rate of cure, death and treatment failure in patients was 87.1%, 6.9%, and 1.2%, respectively. The highest mortality rate (11.5%) occurred in patients with 3+ and the lower rate of cure was 79.5% in this group. Moreover, by increasing the Mycobacterium grade the rate of transferred out and lost to follow up from treatment increased (p = 0.024).

Conclusion

High smear grading of sputum is inversely associated with lower curing and on-time treatment. Moreover, by increasing the Mycobacterium grade at initial treatment, treatment failure and lost to follow up increased Therefore, improvement the health system and patient-diagnosis and screening programs is necessary to on-time diagnosis and facilitate the treatment process.

Epidemiology of Pediatric Tuberculosis and Factors Associated with Unsuccessful Treatment Outcomes in the Centre Region of Cameroon: A Three-Year Retrospective Cohort Study

Background

In Cameroon, there are limited data on treatment outcomes of pediatric tuberculosis (TB). We sought to identify the factors associated with unsuccessful treatment outcomes and the risk factors for mortality among children receiving TB treatment in the Centre Region of Cameroon.

Methods

This was a multicentre facility-based retrospective cohort study using routinely collected programmatic data. All children <15 years old treated for TB between 2018 and 2020 in 21 health facilities were included. We assessed risk factors for experiencing an unsuccessful treatment outcome and mortality through multivariable logistic regression analysis.

Results

Of the 610 children with TB, 307 (50.3%) were females and the median age was 6 years (IQR = 2–12). One hundred and fifty-three (25.1%) of the children were TB/HIV co-infected patients. TB treatment success (cases categorized as cured and completed treatment) was observed in 488 (80.0%) of the patients. Unsuccessful treatment outcomes were experienced by 122 (20.0%) children. Of these, 73 (12.0%) died, 4 (0.6%) had treatment failure, 25 (4.1%) were lost to follow-up, and the outcomes of 20 (3.3%) children were not evaluated. In multivariable analysis, HIV-positive status (adjusted odds ratio [AOR] = 2.43; 95% CI, 1.55–3.80, p < 0.001) and clinical method of TB diagnosis (AOR = 2.46; 95% CI, 1.55–3.91, p < 0.001] were associated with unsuccessful treatment outcomes. HIV-positive status (AOR = 4.23; 95% CI, 2.44–7.33, p < 0.001) and clinical method of TB diagnosis (AOR = 2.22; 95% CI, 1.25–3.91, p=0.006) were the risk factors for mortality among children on TB treatment.

Conclusion

The study found that HIV-TB co-infected children and those clinically diagnosed with TB were significantly more likely to have had unsuccessful TB treatment outcomes and mortality. Our findings underscore the need for healthcare workers to closely monitor and support HIV-TB co-infected children on TB treatment. TB/HIV collaborative activities should be strengthened by implementing TB preventive interventions among HIV-infected children.

Determinants of unsuccessful tuberculosis treatment outcome in Northern Red Sea region, Eritrea

Background

Eritrea has achieved the global target (90%) for tuberculosis (TB) treatment success rate. Though, events of unsuccessful TB treatment outcomes (death, treatment failure, lost to follow up and not evaluated) could lead to further TB transmission and the development of resistant strains. Hence, factors related to these events should be explored and addressed. This study aims to fill the gap in evidence by identifying the determinants of unsuccessful TB treatment outcomes in Eritrea’s Northern Red Sea region.

Methods

A retrospective cohort study was conducted in Eritrea’s Northern Red Sea region. Data collected using a data extraction tool was analyzed using Stata version 13. Frequencies, proportions, median and standard deviations were used to describe the data. Furthermore, univariable and multivariable logistic regression analysis were performed to determine the risk factors for unsuccessful TB treatment outcomes. Crude odds ratio (COR) and adjusted odds ratio (AOR) with their 95% confidence interval (CI) presented and p-value < 0.05 was considered statistically significant.

Results

Among 1227 TB patients included in this study, 9.6% had unsuccessful TB treatment outcomes. In multivariable logistic regression analysis, TB cases 55–64 years old (AOR: 2.75[CI: 1.21–6.32], p = 0.016) and those ≥ 65 years old (AOR: 4.02[CI: 1.72–9.45], p = 0.001) had 2.7 and 4 times higher likelihood of unsuccessful TB treatment outcome respectively. In addition, HIV positive TB patients (AOR: 5.13[CI: 1.87–14.06], p = 0.002) were 5 times more likely to have unsuccessful TB treatment outcome. TB treatment in Ghindae Regional Referral Hospital (AOR: 5.01[2.61–9.61], p < 0.001), Massawa Hospital (AOR: 4.35[2.28–8.30], p< 0.001) and Nakfa Hospital (AOR: 2.53[1.15–5.53], p = 0.021) was associated with 5, 4 and 2.5 higher odds of unsuccessful TB treatment outcome respectively.

Conclusion

In this setting, old age, HIV co-infection and health facility were the independent predictors of unsuccessful TB treatment outcome.

Tuberculosis mortality: quantifying agreement in clinical cause of death assessments

OBJECTIVES

Mortality is a key statistic for public health globally, and mortality reduction is a key target of 'End TB' strategy. However, cause of death in relation to tuberculosis (TB) may be controversial, and we aimed to evaluate classification in Australia.

METHODS

We surveyed Australian clinicians and public health officers, presenting a variety of scenarios. Respondents were asked to classify each scenario with regards to whether TB was considered causative, contributory or not related to death.

RESULTS

Fifty-nine individuals completed the survey. Respondents were experienced TB clinicians and public health officers (median 14 years of TB care experience), with a majority having recently been involved in death certification/classification. In most scenarios, there was substantial variation, particularly where death was related to TB medications, or if an alternative contributing process was recognised, such as cardiovascular complications. Variation in classification was not evidently associated with classification experience.

CONCLUSION

We found significant variation in cause of death classification among experienced TB clinicians and public health officers, using representative TB death scenarios.

IMPLICATIONS FOR PUBLIC HEALTH

Consensus and transparency with regards to classification would assist in more uniform cause of death classification across jurisdictions and allow for better tracking of this critical performance measure.

Characteristics and determinants of loss to follow-up among tuberculosis (TB) patients who smoke in an industrial state of Malaysia: a registry-based study of the years 2013-2017

Background

The increased risk of loss to follow-up among TB smokers raises concern over the secondary spread within the community. This study aimed to determine the factors associated with loss to follow-up among TB patients who smoke.

Methods

All registered TB patients who smoke in the state of Selangor between 2013 and 2017 via the Malaysian Tuberculosis Information System (MyTB) database were included for analysis. TB patients who smoke were considered those who are “current smoker” during the notification, while loss to follow-up was defined as a TB patient who had interrupted treatment for 2 months or longer. There were 3 main variable domains included for analysis: sociodemographic profiles, disease profiles, and comorbidities. Logistic regression analysis was used to identify determinants of loss to follow-up among TB patients who smoke.

Results

A total of 14.1% (N = 813) of TB patients who smoke loss to follow-up. The determinants of loss to follow-up among TB smokers were working age population aged 32-41 and 42-53 years old (AOR 1.08; 95%CI 1.23,2.08) and (AOR 1.44; 95%CI 1.11,1.87) respectively, Malaysian nationality (AOR 2.34; 95%CI 1.66,3.30), patients staying in urban area (AOR 1.55; 95% CI 1.23,1.97), income level less than RM2160 (AOR 1.59; 95% CI 1.14,2.20), un-employed (AOR 1.30; 95%CI 1.09-1.55), have low education level i.e., secondary school education, primary school education and no formal education (AOR 1.60; 95%CI 1.22,2.10), (AOR 1.73; 95%CI 1.16,2.57) and (AOR 2.29; 95% CI 1.57,3.33) respectively, previously treated TB cases (AOR 2.19; 95% CI 1.71,2.81), active TB case detection methods (AOR 2.06; 95%CI 1.40,3.02), moderate lesion x-ray (AOR 1.60; 95%CI 1.13,2.27) and HIV positive (AOR 1.36; 95%CI 1.02,1.82). All the significant factors gave rise to the final model of determinants, with a predictability of 67.2% (95% CI 65.0,69.3).

Conclusions

The high proportion of loss to follow-up among TB patients who smoke highlight the importance of providing early risk detection that examines the three main domains of risk factors such as socioeconomic, disease profiles and comorbidities. Potential integrated intervention should aim to reduce the proportion of smoking among TB patients through the stop smoking programme together with directly observed therapy (DOT).

Prediction of tuberculosis cases based on sociodemographic and environmental factors in gombak, Selangor, Malaysia: A comparative assessment of multiple linear regression and artificial neural network models

Background

Early prediction of tuberculosis (TB) cases is very crucial for its prevention and control. This study aims to predict the number of TB cases in Gombak based on sociodemographic and environmental factors.

Methods

The sociodemographic data of 3325 TB cases from January 2013 to December 2017 in Gombak district were collected from the MyTB web and TB Information System database. Environmental data were obtained from the Department of Environment, Malaysia; Department of Irrigation and Drainage, Malaysia; and Malaysian Metrological Department from July 2012 to December 2017. Multiple linear regression (MLR) and artificial neural network (ANN) were used to develop the prediction model of TB cases. The models that used sociodemographic variables as the input datasets were referred as MLR1 and ANN1, whereas environmental variables were represented as MLR2 and ANN2 and both sociodemographic and environmental variables together were indicated as MLR3 and ANN3.

Results

The ANN was found to be superior to MLR with higher adjusted coefficient of determination (R²) values in predicting TB cases; the ranges were from 0.35 to 0.47 compared to 0.07 to 0.14, respectively. The best TB prediction model, that is, ANN3 was derived from nationality, residency, income status, CO, NO₂, SO₂, PM₁₀, rainfall, temperature, and atmospheric pressure, with the highest adjusted R² value of 0.47, errors below 6, and accuracies above 96%.

Conclusions

It is envisaged that the application of the ANN algorithm based on both sociodemographic and environmental factors may enable a more accurate modeling for predicting TB cases.

Tuberculosis Death Epidemiology and Its Associated Risk Factors in Sabah, Malaysia

Tuberculosis (TB) is a leading killer from a single infectious agent globally. In 2019, Malaysia's TB incidence rate was 92 per 100,000 population, and the TB mortality rate was estimated at 4 cases per 100,000 population per year. However, the state of Sabah had a higher burden of TB with a notification rate of 128 per 100,000 population and a TB case fatality rate of 8% compared to the national figure. This study aims to provide a comprehensive report on TB deaths epidemiology and its associated factors at a sub-national level. This nested case-control study used Sabah State Health Department TB surveillance data from the Malaysia national case-based TB registry (MyTB) between 2014 and 2018. Cases were defined as all-cause TB deaths that occurred before anti-TB treatment completion from the time of TB diagnosis. Controls were randomly selected from TB patients who completed anti-TB treatment. The TB mortality rate had increased significantly from 9.0/100,000 population in 2014 to 11.4/100,000 population in 2018. The majority of TB deaths occurred in the first two months of treatment. TB-related deaths were primarily due to advanced disease or disseminated TB, whereas non-TB-related deaths were primarily due to existing comorbidities. Many important independent risk factors for TB deaths were identified which are useful to address the increasing TB mortality rate.

Community health workers augment the cascade of TB detection to care in urban slums of two metro cities in India

Background

Tuberculosis Health Action Learning Initiative (THALI) funded by USAID is a person-centered initiative, supporting vulnerable urban populations to gain access to TB services. THALI trained and placed 112 Community health workers (CHWs) to detect and support individuals with TB symptoms or disease within urban slums in two cities, Hyderabad and Bengaluru, covering a population of about 3 million.

Methods

CHWs visited the slums once in a fortnight. They conducted TB awareness activities. They referred individuals with TB symptoms for sputum testing to nearest public sector laboratories. They visited those testing TB positive, once a fortnight in the intensive phase, and once a month thereafter. They supported TB patients and families with counselling, contact screening and social scheme linkages. They complemented the shortfall in urban TB government field staff numbers and their capacity to engage with TB patients. Data on CHWs’ patient referral for TB diagnosis and treatment support activities was entered into a database and analyzed to examine CHWs’ role in the cascade of TB care. We compared achievements of six monthly referral cohorts from September 2016 to February 2019.

Results

Overall, 31 617 (approximately 1%) of slum population were identified as TB symptomatic and referred for diagnosis. Among the referred persons, 23 976 (76%) underwent testing of which 3841 (16%) were TB positive. Overall, 3812 (99%) were initiated on treatment and 2760 (72%) agreed for regular follow up by the CHWs. Fifty-seven percent of 2952 referred were tested in the first cohort, against 86% of 8315 in the last cohort. The annualized case detection rate through CHW referrals in Bengaluru increased from 5.5 to 52.0 per 100 000 during the period, while in Hyderabad it was 35.4 initially and increased up to 118.9 per 100 000 persons. The treatment success rate was 87.1% among 193 in the first cohort vs 91.3% among 677 in the last cohort.

Conclusions

CHWs in urban slums augment TB detection to care cascade. Their performance and TB treatment outcomes improve over time. It would be important to examine the cost per TB case detected and successfully treated.

Association of sociodemographic and environmental factors with spatial distribution of tuberculosis cases in Gombak, Selangor, Malaysia

Tuberculosis (TB) cases have increased drastically over the last two decades and it remains as one of the deadliest infectious diseases in Malaysia. This cross-sectional study aimed to establish the spatial distribution of TB cases and its association with the sociodemographic and environmental factors in the Gombak district. The sociodemographic data of 3325 TB cases such as age, gender, race, nationality, country of origin, educational level, employment status, health care worker status, income status, residency, and smoking status from 1st January 2013 to 31st December 2017 in Gombak district were collected from the MyTB web and Tuberculosis Information System (TBIS) database at the Gombak District Health Office and Rawang Health Clinic. Environmental data consisting of air pollution such as air quality index (AQI), carbon monoxide (CO), nitrogen dioxide (NO₂), sulphur dioxide (SO₂), and particulate matter 10 (PM₁₀,) were obtained from the Department of Environment Malaysia from 1st July 2012 to 31st December 2017; whereas weather data such as rainfall were obtained from the Department of Irrigation and Drainage Malaysia and relative humidity, temperature, wind speed, and atmospheric pressure were obtained from the Malaysia Meteorological Department in the same period. Global Moran’s I, kernel density estimation, Getis-Ord Gi* statistics, and heat maps were applied to identify the spatial pattern of TB cases. Ordinary least squares (OLS) and geographically weighted regression (GWR) models were used to determine the spatial association of sociodemographic and environmental factors with the TB cases. Spatial autocorrelation analysis indicated that the cases was clustered (p<0.05) over the five-year period and year 2016 and 2017 while random pattern (p>0.05) was observed from year 2013 to 2015. Kernel density estimation identified the high-density regions while Getis-Ord Gi* statistics observed hotspot locations, whereby consistently located in the southwestern part of the study area. This could be attributed to the overcrowding of inmates in the Sungai Buloh prison located there. Sociodemographic factors such as gender, nationality, employment status, health care worker status, income status, residency, and smoking status as well as; environmental factors such as AQI (lag 1), CO (lag 2), NO₂ (lag 2), SO₂ (lag 1), PM₁₀ (lag 5), rainfall (lag 2), relative humidity (lag 4), temperature (lag 2), wind speed (lag 4), and atmospheric pressure (lag 6) were associated with TB cases (p<0.05). The GWR model based on the environmental factors i.e. GWR2 was the best model to determine the spatial distribution of TB cases based on the highest R² value i.e. 0.98. The maps of estimated local coefficients in GWR models confirmed that the effects of sociodemographic and environmental factors on TB cases spatially varied. This study highlighted the importance of spatial analysis to identify areas with a high TB burden based on its associated factors, which further helps in improving targeted surveillance.

Characteristics of paediatric patients with tuberculosis and associated determinants of treatment success in Malaysia using the MyTB version 2.1 database over five years

Background

Tuberculosis (TB) among children remains a significant public health problem in many parts of the world. The objective of this study was to describe the characteristics of TB patients and to determine the predictors of treatment success among children in Malaysia.

Methods

Secondary data from MyTB version 2.1, a national database, were analysed using R version 3.6.1. Descriptive analysis and multivariable logistic regression were conducted to identify treatment success and its determinants.

Results

In total, 3630 cases of TB cases were registered among children in Malaysia between 2013 and 2017. The overall treatment success rate was 87.1% in 2013 and plateaued between 90.1 and 91.4% from 2014 to 2017. TB treatment success was positively associated with being a Malaysian citizen (aOR = 3.43; 95% CI = 2.47, 4.75), being a child with BCG scars (aOR = 1.93; 95% CI = 1.39, 2.68), and being in the older age group (aOR = 1.06; 95% CI = 1.03, 1.09). Having HIV co-infection (aOR = 0.31; 95% CI = 0.16, 0.63), undergoing treatment in public hospitals (aOR = 0.38; 95% CI =0.25, 0.58), having chest X-ray findings of advanced lesion (aOR = 0.48; 95% CI = 0.33, 0.69), having EPTB (aOR = 0.58; 95% CI = 0.41, 0.82) and having sputum-positive PTB (aOR = 0.58; 95% CI = 0.43, 0.79) were negatively associated with TB treatment success among children.

Conclusions

The overall success rate of treatment among children with TB in Malaysia has achieved the target of 90% since 2014 and remained plateaued until 2017. The socio-demographic characteristics of children, place of treatment, and TB disease profile were associated with the likelihood of TB treatment success among children. The treatment success rate can be increased by strengthening contact tracing activities and promoting early identification targeting the youngest children and non-Malaysian children.