|FULL LENGTH ARTICLE
|Year : 2016 | Volume
| Issue : 2 | Page : 164-169
Determining treatment outcome of smear-positive pulmonary tuberculosis cases in Afar Regional State, Ethiopia: A retrospective facility based study
Ketema Tafess1, Belete Mengistu2, Desalegn Woldeyohannes3, Solomon Sisay4
1 Department of Medical Laboratory Sciences, College of Health Sciences, Arsi University, Asella, Ethiopia
2 Directorate of Pastoralist Health Promotion and Disease Prevention, Federal Ministry of Health, Addis Ababa, Ethiopia
3 Department of Zoonoses, Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
4 Federal Ministry of Health, Addis Ababa, Ethiopia
|Date of Web Publication||9-Feb-2017|
Department of Medical Laboratory Sciences, College of Health Sciences, Arsi University, P.O.Box 193, Asella
Source of Support: None, Conflict of Interest: None
Objective/background: The World Health Organization (WHO) declared tuberculosis (TB) as a global public health emergency and recommended directly observed treatment, short-course (DOTS) as a standard strategy to control the disease. In Ethiopia the strategy was started in 1992 as a pilot in the Arsi and Bale zone, Oromia Region. The DOTS strategy has been subsequently scaled up in the country and implemented at a national level reaching better coverage, although there are recognizable variations from region to region and district to district. The aim of this study was to assess the impact of the DOTS strategy on smear-positive pulmonary TB case findings and their treatment outcomes in the Afar Regional State, Ethiopia, from 2003 to 2012 and from 2002 to 2011, respectively.
Methods: A health facility-based retrospective study was conducted. Data were collected and reported on a quarterly basis using the WHO reporting format for TB case findings and their treatment outcomes from all DOTS-implementing health facilities in all zones of the region to the Federal Ministry of Health.
Results: A total of 34,894 of TB cases had been registered in the period from 2003 to 2012. Out of these, 11,595 (33.2%) were smear-positive pulmonary TB, 13,859 (39.7%) smear-negative pulmonary TB, and 9838 (28.2%) extrapulmonary TB. The case detection rate (CDR) of smear-positive pulmonary TB had increased from 18.3% to 37.2%, with the average value being 32% (standard deviation = 6.8) from the total TB cases to its peak of 39% in 2008. The treatment success rate (TSR) had an average value of 86.2% from 2002 to 2011 with its peak value being 96.5% in 2007. Moreover, the average values of treatment defaulter and treatment failure rate were 2.9% and 2.7%, respectively.
Conclusion: The implementation for the DOTS strategy in the area improved the CDR of smear-positive TB, although it is unacceptably lower than the recommended WHO target of 70%. Additionally, the WHO target of 85% for TSR had already been achieved in the region. However, continued efforts should be in place to increase the CDR and maintain the high TSR registered.
Keywords: Afar Regional State, Case detection rate, Directly observed treatment short-course, Treatment success rate, Tuberculosis
|How to cite this article:|
Tafess K, Mengistu B, Woldeyohannes D, Sisay S. Determining treatment outcome of smear-positive pulmonary tuberculosis cases in Afar Regional State, Ethiopia: A retrospective facility based study. Int J Mycobacteriol 2016;5:164-9
|How to cite this URL:|
Tafess K, Mengistu B, Woldeyohannes D, Sisay S. Determining treatment outcome of smear-positive pulmonary tuberculosis cases in Afar Regional State, Ethiopia: A retrospective facility based study. Int J Mycobacteriol [serial online] 2016 [cited 2019 Sep 15];5:164-9. Available from: http://www.ijmyco.org/text.asp?2016/5/2/164/199925
| Introduction|| |
Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, which is a rod-shaped bacillus called “acid-fast” due to its staining characteristics in the laboratory. Globally, in 2012, an estimated 8.6 million people developed TB. At the same time, there were 1.3 million deaths from the disease (including an estimated 1.1 million cases and 320,000 deaths among human immunodeficiency virus [HIV] infected people). About 58% of the 8.6 million people who developed TB in 2012 were from Asian and African Regions, respectively .
In 1993, the World Health Organization (WHO) declared TB as a global public health emergency and recommended directly observed treatment, short-course (DOTS) as a standard strategy to control TB. The multidimensional DOTS framework was being implemented in 184 countries and over 132 million patients had been treated with DOTS which resulted in more than 125 million people being cured . The specific targets of DOTS were detailed in the updated global plan of TB from 2011 to 2015 for achieving a case detection rate (CDR) of 84% (for all forms of TB) and a treatment success rate (TSR) of 87% for smear-positive TB by 2015 .
The DOTS strategy was piloted in Ethiopia in 2000 at the Arsi and Bale zones of Oromia Regional State . In 2010, it was gradually scaled up to the entire country and came to have 100% district- and 90% health-facility coverage . Evaluating treatment outcome of TB is essential in order to assess the effectiveness of DOTS strategy in different regions of a given country . Additionally, understanding the specific reasons for unsuccessful treatment outcomes is helpful for improving the quality and accessibility of treatment service . The aim of this study was to assess the impact of the DOTS strategy on smear positive-pulmonary TB case findings and their treatment outcomes in the Afar Regional State, Ethiopia from 2003 to 2012 and from 2002 to 2011, respectively.
| Materials and methods|| |
The Afar Regional State consists of five administrative zones and 30 districts. The size of the population in the region according to the 2007 National Census was about 1,390,273, out of which 775,117 (55.75%) were men and 615,156 (44.25%) women .
Health facility-based retrospective data were collected for TB cases that were registered during the study period from 2003 to 2012 and for their treatment outcomes from 2002 to 2012 in the Afar Regional State.
Inclusion and exclusion criteria
All forms of TB cases that were registered during the study period were included in the study. Treatment outcomes of extrapulmonary TB and smear-negative pulmonary TB cases were excluded as treatment outcomes mainly focus on smear-positive pulmonary TB cases due to their infectiousness compared to other forms of TB and the scope of study.
Data collection procedures
Data were collected by WHO standardized reporting formats for case detection and treatment outcomes. Reports from all zones in the region were collected by trained data collectors and investigators. Data were first collected from health facilities where TB focal persons compiled the data and reported it on a quarterly basis about all TB patients entered into the TB clinic, assigned a unique TB registration number for each TB patient, and submitted the report to zonal TB focal persons who were responsible for compiling a zonal summary, and in turn, the zonal TB focal persons submitted the report to the regional TB Program Officer. The regional TB Program Officer checked the completeness, quality, and accuracy of the reports. Then, data were analyzed and interpreted, and sent as a compiled report to the Office of National Tuberculosis and Leprosy Control Program Office, Federal Ministry of Health.
Data that were collected and reported from standardized WHO formats were analyzed and interpreted using excel spread sheets and SPSS version 20 (SPSS Inc., Chicago, Il, USA). Data were summarized using frequencies, percentages, and standard deviations including for mean values of variables like CDR, TSR, death rate, and defaulter rate.
Federal Ministry of Health (FMOH), Ethiopia used the Health Management Information System for all health program recording and reporting, which consisted of its own unique data collection book and reporting format. Data that were obtained by WHO reporting formats were crosschecked for the data which were obtained in the Health Management Information System for maintaining consistency of information within the study period.
Percentage of smear-positive TB cases detected among the total number of TB cases estimated to occur.
Smear-positive pulmonary TB
A patient with at least two initial sputum smear positive for acid-fast bacilli (AFB) with direct microscopy or a patient with only one sputum smear positive for AFB and with chest radiographic abnormalities consistent with active pulmonary TB followed by the clinician's decision.
Smear-negative pulmonary TB
A patient with at least three initial sputum smear negative for AFB with direct microscopy and with chest radiographic abnormalities consistent with active pulmonary TB and no clinical response to 2weeks of broad spectrum antibiotic therapy followed by the clinician's decision.
TB involving organs other than the lungs, such as skin, abdomen, joints and bones, lymph nodes, pleura, genitourinary tract, and meninges.
Treatment success rate
A sum of smear-positive TB cases who completed treatment and who were declared cured divided by the total smear-positive TB cases in the same period.
A patient who has been on treatment for at least 4weeks and whose treatment was interrupted for ≥8 consecutive weeks.
A patient who has started treatment and has been transferred to another health facility and for whom treatment outcome is not known at the time of evaluation.
A patient who is sputum-smear negative 1month prior to the completion of treatment and on at least one previous occasion (usually at the end of the 2nd month or 5th month).
A patient who has completed treatment but in whom smear results are not available at or 1month prior to the completion of treatment.
A patient who remained smear positive or became smear positive again at the end of ≥5months after commencing treatment.
The study secured ethical clearance from institutional review board of afar regional stat health bureau.
| Results|| |
A total of 34,894 cases were registered with all forms of TB for the past 10years (from 2003 to 2012; [Table 1). Out of these, 11,595 (33.2%) were smear-positive pulmonary TB, 13,859 (39.7%) smear-negative pulmonary TB, and 9838 (28.2%) extrapulmonary TB ([Table 1]). Trends of case finding for all forms of TB cases were shown for the decade ([Figure 1]). CDR of smear-positive TB had increased from 18.3% to 37.2% with an average value of 32% (standard deviation = 6.8) from the total TB cases to its peak of 39% in 2008 ([Figure 3]).
|Table 1: Case notification rate of all forms of tuberculosis in the Afar Regional State from 2003 to 2012.|
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|Figure 1: Trend of case finding for all forms of tuberculosis cases in the Afar Regional State from 2003 to 2012. Note: EPTB = extrapulmonary tuberculosis; PTB = pulmonary tuberculosis; Y = years; +ve = positive; -ve = negative.|
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|Figure 3: Trends of case detection rate (CDR) and treatment success rate (TSR) of smear-positive pulmonary tuberculosis in the Afar Regional State from 2002 to 2011. Note: mov. avg. = moving average; Y = years.|
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Out of 7345 smear-positive cases, the highest number of cases (1233 [23.1%]) were reported among age group ranges from 25years to 34years followed by 374 (7%) in the age group of 15–24years, while the lowest number of cases (25 [0.5%]) were reported among the age group ≥65years ([Table 2]).
|Table 2: Smear-positive pulmonary tuberculosis cases by sex and age groups in the Afar Regional State from 2005 to 2010.|
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A total of 12,162 smear-positive TB patients were considered as a cohort for treatment outcome. Eleven thousand five hundred and eighty-three (95.2%) of them were evaluated for their treatment outcome from the period of 2002–2012 ([Table 3]). Among the total evaluated smear-positive TB cases, 4245 (34.9%) were cured and 5781 (47.5%) completed their treatment which give a total value of TSR of 86.2%.
|Table 3: Treatment outcomes of smear-positive pulmonary tuberculosis cases in the Afar Regional State from 2002 to 2011.|
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TSR had an average value of 86.2% from 2002 to 2011 with its peak value being 96.5% in 2007 and then it significantly declined in 2004 by 34.2% ([Figure 3]). The targets by WHO for TSR had already been achieved, as the TSR was >85% from 2006 onwards in the region. Among the total 12,162 smear-positive TB patients who registered during 2002–2011, the cure rate, death rate, failure rate, default rate, and transfer out were found to be 4245 (34.9%), 272 (2.2%), 330 (2.7%), 353 (2.9%), and 381 (3.1%), respectively ([Table 3] and [Figure 2]).
|Figure 2: Number of smear-positive retreatment case findings of the Afar Regional State from 2003 to 2012. Note: Y = years.|
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| Discussion|| |
A total of 34,894 cases were registered with all forms of TB for treatment. Of these, 11,595 (33.2%), 13,859 (39.7%), and 9838 (28.2%) were smear-positive TB, smear-negative TB, and extrapulmonary TB, respectively. Smear-positive TB CDR had increased from 18.3% to 37.2% from the total TB cases registered for the study period. Similarly, trends of increments were recorded in the study done in the Gambella region  and Addis Ababa City Administration . The increment in the case detection of smear-positive pulmonary TB cases might be linked to the decentralization and expansion of the DOTS program in the country. It might also be explained by the influence of improvement of diagnostic settings of health facilities in the region as per the National Tuberculosis Control Program recommendation. However, the total average value of CDR was 33.2% for the study period which was by far less than the WHO target of 70%. The possible explanation might be because the CDR relies on an estimate for the incidence of TB; therefore, it is difficult to measure accurately in most settings, especially in the context of a high prevalence of HIV . Additionally, the national average CDR for the year 2008 was 34% . This might be linked to inadequate decentralization of DOTS program, shortage of trained personnel, and low sensitivity of smear microscopy.
The highest number of cases (2310 [12.6%]) were observed for smear-positive TB among the age group of 25–34years followed by 1245 (6.7%) in the age group of 15–24years. This indicates that a high proportion of smear-positive TB is available in those age groups who are the economically productive segment of the population. This might be due to the fact that these age groups are active physiologically, socially, behaviorally, and biologically and may interact with other infectious individuals, thereby enhancing the chance for acquiring TB compared with the other age groups. Besides, there is an agreement in findings that these age groups are sexually active and the possibility of being infected with HIV is higher which fuels the susceptibility of TB infection . The highest numbers of smear-positive TB cases among similar age groups were also observed by previous studies ,.
The study showed that the average value of TSR (86.5%) was higher than the average of 72% of other African countries  and slightly higher than the 85% WHO target and the national average of 84% . TSR was lower than the 85% WHO target from the years 2003 to 2005 and higher than the WHO target from 2006 to 2011. The lower TSR in the earlier years might be related to the poor observation of patients during the course of treatment, poor patient treatment compliance, poor standardized and improper recording and reporting systems, inadequate treatment regimens, and an increase in the incidence of drug-resistant strains. Similar trends in TSR were reported by Woldeyohannes et al.  in the Gambella region. The possible explanations for the increase in TSR (>85%) from 2006 to 2011 might be due to adequate treatment regimens, good adherence to treatment, or government commitment to ensure comprehensive TB control activities in the region .
The average treatment failure rate was about 2.7% for smear-positive TB cases who were treated with the DOTS program for the same study period. The result is higher than a previous report (0.3%) from the Gambella Region . The current 2.7% failure rate might be related to the gradual increasing rate of MDR-TB in the country .
Limitations of the study
As the data sources were secondary, the existence of poor records and reporting at each level of the health system might have its own effect in the findings and conclusions of the study. Furthermore, in this study we could not include data before the implementation of the DOTS strategy, which might have supported our study results by clearly indicating the before and after type of analysis.
| Conclusions|| |
The implementation for the DOTS strategy in the area improved the CDR of smear-positive TB, although it is unacceptably lower than the recommended WHO target of 70%. Additionally, the WHO target of 85% for TSR had already been achieved in the region. However, continued efforts should be in place to increase the CDR and maintain the high TSR registered.
| Conflicts of interest|| |
The authors declare that they have no any conflict of interests.
| Acknowledgements|| |
XSThe authors would like to thank staff members of Tuberculosis and Leprosy Control Office of both the Afar Regional Health Bureau and the Federal Ministry of Health for facilitating the data collection process.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]
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