Comparing early treatment outcomes of MDR-TB in decentralised and centralised settings in KwaZulu-Natal, South Africa

Self Cite

103

Setting KwaZulu-Natal, South Africa a predominantly rural province with high burdens of TB, MDR-TB and HIV infection. Objective To determine the most effective model of care by comparing MDR-TB treatment outcomes at community-based sites with traditional care at a central, specialised hospital. Design A non-randomised observational prospective cohort study comparing community-based and centralised care. Patients at community-based sites were closer to home, had easier access to care and home-based care was available from treatment initiation. Results Four community-based sites treated 736 patients, while 813 were treated at the centralised hospital (a total of 1549 patients). Overall, 75% were HIV co-infected (community: 76% vs. hospitalised: 73%, p=0.45) and 86% received antiretroviral therapy (community: 91% vs. hospitalised: 82%, p=0.22). In multivariate analysis MDR-TB patients were more likely to have a successful treatment outcome if they were treated at a community-based site (adjusted OR=1.43, p=0.01). However, there was heterogeneity in outcomes at the four community-based sites, with Site 1 demonstrating that home-based care was associated with increased treatment success of 72% compared with success of between 52 - 60% at the other three sites. Conclusion Community-based care for patients with MDR-TB was more effective than care in a central, specialised hospital. Home-based care further increased treatment success.

Section: Methodsmentioning

confidence: 99%

Community-based care vs. centralised hospitalisation for MDR-TB patients, KwaZulu-Natal, South Africa

Loveday

Wallengren²,

Brust

et al. 2015

Self Cite

103

“…In the group of studies with low default rates, a prospective cohort study based in Thailand used a comparative cohort design to assess the use of mobile phone reminders to improve adherence to treatment. 68 Both groups provided DOT at home by a family member throughout the standardised treatment regimen, and medication education provided by a pharmacist. Default rates for both groups were low, at 1.3% (95%CI 1.13-10.62).…”

Section: Comparison Of the 10 Studies With The Lowest And Highest Defmentioning

confidence: 99%

“…Among the studies with low default rates, three provided interim outcomes before the end of treatment: two reported outcomes after 12 months, resulting in default rates of 0.7% (95%CI 0.03-2.30) 62 and 1.27% (95%CI 1.13-10.62), 80 and a third calculated default after 17 months of treatment (proportion defaulting 1.69%, 95%CI 0.70-6.44). 68 However, when these studies were dropped from the overall analysis, the overall default rate remain unchanged (15.7%, Reducing default in drug-resistant TB 5 95%CI 13.0-18.5). In the group of studies with low default rates, a prospective cohort study based in Thailand used a comparative cohort design to assess the use of mobile phone reminders to improve adherence to treatment.…”

Section: Comparison Of the 10 Studies With The Lowest And Highest Defmentioning

confidence: 99%

Strategies for reducing treatment default in drug-resistant tuberculosis: systematic review and meta-analysis [Review article]

Toczek

Cox

Cros

et al. 2013

125

114

B A C K G R O U N D :Scaling up treatment for multidrugr esistant tuberculosis is a global health priority. However, current treatment regimens are long and associated with side effects, and default rates are consequently high. This systematic review aimed to identify strategies for reducing treatment default. M E T H O D S :We conducted a systematic search up to May 2012 to identify studies describing interventions to support patients receiving treatment for multidrugr esistant tuberculosis (MDR-TB). The potential influence of study interventions were explored through subgroup analyses. R E S U LT S : A total of 75 studies provided outcomes for 18 294 patients across 31 countries. Default rates ranged from 0.5% to 56%, with a pooled proportion of 14.8% (95%CI 12.4-17.4). Strategies identified to be associated with lower default rates included the engagement of community health workers as directly observed treatment (DOT) providers, the provision of DOT throughout treatment, smaller cohort sizes and the provision of patient education. C O N C L U S I O N : Current interventions to support adherence and retention are poorly described and based on weak evidence. This review was able to identify a number of promising, inexpensive interventions feasible for implementation and scale-up in MDR-TB programmes. The high default rates reported from many programmes underscore the pressing need to further refine and evaluate simple intervention packages to support patients. K E Y W O R D S : default; retention; MDR-TB THE MULTIDRUG-RESISTANT tuberculosis (MDR-TB) pandemic is rising in prevalence and global importance. There were an estimated 650 000 cases of MDR-TB cases worldwide in 2010, with <5% of all TB patients tested for multidrug resistance. 1 Historically, proportions of MDR-TB among TB cases have been highest in Eastern European countries, although in absolute numbers China and India now contribute 50% of all new MDR-TB cases. 2 Furthermore, in sub-Saharan Africa, the human immunodefi ciency virus (HIV) epidemic and limited resources for comprehensive MDR-TB programmes have aided the spread of MDR-TB and the emergence of extensively drugresistant TB (XDR-TB). 3 MDR-TB, defi ned as Mycobacterium tuberculosis resistant to isoniazid and rifampicin, is more costly and complex to treat than fully susceptible disease, with treatment typically lasting at least 18 months. XDR-TB is defi ned as MDR-TB with additional resistance to a fl uoroquinolone and a second-line injectable agent. 2 Current approaches to treating MDR-TB rely on lengthy treatment durations (typically a minimum of 20 months) using drugs associated with substantial toxicities, often resulting in high default rates. Other reported factors infl uencing treatment default include high costs of treatment for patients in settings where patients must pay, 4 indirect costs such as loss of wages, 5 increased poverty and sex discrimination, 6 dissatisfaction with health care worker attitudes, 7 limited knowledge and negative beliefs and attitudes to treatment, 8 ch...

“…Another study in the same province showed that only 67% of patients diagnosed between 1994 and 2004 had successful treatment outcomes. 15 Results from these settings The aim of this study was to determine treatment uptake among a full year's cohort of newly diagnosed MDR-TB patients in the Gauteng province of South Africa and to determine the proportion of the patients who maintained treatment up to the fourth month after treatment initiation. The study also examined the reasons for loss of MDR-TB patients along the treatment initiation pathway and risk markers for noninitiation of treatment.…”

mentioning

confidence: 99%

Low treatment initiation rates among multidrug-resistant tuberculosis patients in Gauteng, South Africa, 2011

Ebonwu

Tint²,

Ihekweazu³

2013

SUMMARY Setting: Gauteng, South AfricaObjective: To determine treatment uptake among newly diagnosed multi-drug resistant tuberculosis (MDR-TB) patients and risk markers for non-initiation of treatment. Design:A cross-sectional study was conducted including all newly diagnosed MDR-TB patients in Gauteng province of South Africa in 2011. Socio-demographic and clinical characteristics of those that attended Sizwe hospital, the designated MDR-TB hospital, were extracted from their medical records. District health offices provided data on patients not seen at Sizwe hospital. Univariate and multivariate analysis were used to determine risk markers for non-initiation of treatment.Results: Of the 942 newly diagnosed MDR-TB patients in Gauteng, only 593 (63%) initiated treatment. Of these, 70 (11.8%) did not maintain treatment up to the fourth month. Among the 349 (37%) who did not initiate treatment, 31.2% died and 46.4% 2 could not be accounted for. Referral for laboratory diagnosis from hospitals, health district of laboratory diagnosis, HIV infection and place of residence were independently associated with non-initiation of MDR-TB treatment. Conclusion:Untreated patients continue the transmission of MDR-TB in communities. The study findings highlight the need to identify and target the causes of non-initiation of treatment in specific settings.