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ORIGINAL ARTICLE
Year : 2013  |  Volume : 2  |  Issue : 3  |  Page : 177-180

Current status of timing of treatment interruption and pattern of default among tuberculosis patients on directly observed treatment


1 Department of Community Medicine, Major S.D. Singh Medical College, Farrukhabad, UP, India
2 Department of Community Medicine, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana-Ambala, Haryana, India
3 Department of Community Medicine, Kasturba Medical College, Mangalore, Karnataka, India

Date of Web Publication29-Aug-2013

Correspondence Address:
Abhishek Singh
Department of Community Medicine, Major S.D. Singh Medical College, Farrukhabad, (UP)
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.117183

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  Abstract 

Background: Default remains an important challenge and a threat for tuberculosis (TB) control.
Aims and Objectives: Objectives of the study were to analyze timing of treatment interruption and pattern of default among TB patients on directly observed treatment, short-course under Revised National Tuberculosis Control Programme.
Materials and Methods: The present cross sectional study was conducted among the cohort of patients registered during January 2011 to September 2011 at the Tuberculosis Unit, Ambala city. Number of interruptions/doses missed, number, and timing of default were taken from TB register and treatment cards.
Results: Out of 80 defaulters, majority (50,62.5%) defaulted in the continuation phase of treatment. Out of these 50 patients, 31 were new and remaining 19 were from previously treated categories. In category I, maximum default was seen in the third month of treatment ( 2.84%). The cumulative default rate at the end of second month was 2.57%. The default rate at the end of the eighth month, when all patients were censored, was 8.18%. In category II, maximum default (3.61%) occurred in the fourth month. The cumulative default rate by the end of third month was 13.92%; and by the end of eighth month, 21.76%. The default rate by the end of the tenth month, by which time all patients were censored, was 21.76%.
Conclusions:
Patient defaulting from treatment remains a matter of concern. Factors behind higher default rate in continuation phase need to be explored. Default in intensive phase of treatment and without smear conversion at the end of intensive phase should be retrieved on a priority basis.

Keywords: Default, timing, tuberculosis treatment


How to cite this article:
Singh A, Bhardwaj A, Mukherjee AK, Arya R, Mithra P. Current status of timing of treatment interruption and pattern of default among tuberculosis patients on directly observed treatment. J NTR Univ Health Sci 2013;2:177-80

How to cite this URL:
Singh A, Bhardwaj A, Mukherjee AK, Arya R, Mithra P. Current status of timing of treatment interruption and pattern of default among tuberculosis patients on directly observed treatment. J NTR Univ Health Sci [serial online] 2013 [cited 2019 Dec 11];2:177-80. Available from: http://www.jdrntruhs.org/text.asp?2013/2/3/177/117183


  Introduction Top


World Health Organization (WHO) report on the Global Burden of Disease ranked TB as the seventh most morbidity-causing disease in the world and expected it to continue in the same position up to 2020. [1] Tuberculosis (TB) hunts one human life every 1.5 min in India. [2] The services of Revised National Tuberculosis Control Programme (RNTCP) under the directly observed treatment, short-course (DOTS) strategy has achieved improved cure rates and reduction in unfavorable outcomes.

Default is one of the unfavorable outcomes. There is limited understanding of timing of default from TB treatment in the developing world. [3] It is very important to correlate the reasons of default with time of default. This would help to focus on specific issues in different phases of treatment to prevent default. Moreover, it would help to quantify the potential contribution of new shorter duration TB drugs (a 1- to 2-month treatment regimen may become available by 2015) for global TB control. [3]

In the state of Haryana, tuberculosis units (TUs) adopted revised classification of TB patients into new (category I) and previously treated (category II) categories from January 2011. Thus, it is important to assess current status of timing of treatment interruption and pattern of default. Therefore, objectives of the study were to analyze timing of treatment interruption and pattern of default among TB patients on DOTS under RNTCP.


  Materials and Methods Top


The present cross sectional study was conducted in TU, Ambala city. TU adopted revised classification of TB patients into new (category I) and previously treated (category II) categories from January 2011. TB patients registering for treatment during period of January 2011 to September 2011 formed the study population. Any patient who has not taken anti-TB drugs for 2 months or more consecutively after starting treatment is labeled as defaulter. [4] All patients aged more than 15 years registered in TU, Ambala city in the study period were included in the study. Number of interruptions/doses missed, number and timing of default was taken from TB register and treatment cards.

The time of default was ascertained by calculating the difference between date of initiation and date of outcome. In all patients who had defaulted, date on which the patients missed the treatment for first time was considered as the date of outcome, that is, default. The difference was divided by 30 to decide the month in which the event occurred. For example, if the difference was 100 days, it was divided by 30 to get the number 3.33, which was inferred as 'outcome (default) occurred in the fourth month'. The events which were censored were death, treatment completion, cure, failure, and transfer-out. Probability of default in each month was calculated. The cumulative probability of default by end of each month was calculated by adding default rate in the particular month and cumulative default rate in the previous month.

The collected data was entered in Microsoft Excel. Coding of variables was done. Statistical Package for Social Sciences (SPSS), version 17 was used for analysis. Interpretation of the collected data was done by using descriptive statistics like percentages. Probabilities and cumulative probabilities of default were also calculated.


  Results Top


The total number of patients registered under TU during the study period was 934, out of which 644 patients were registered under "new" and remaining in "previously treated" category. Out of 80 defaulters, majority (50, 62.5%) defaulted in the continuation phase of the treatment. Out of these 50 patients, 31 were new and remaining 19 were from previously treated categories [Table 1].
Table 1: Distribution of Defaulters According to Timing of Treatment Interruption

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In category I, maximum default is seen in the third month of treatment, that is, 2.84%. The cumulative default rate at the end of second month was 2.57%. The default rate at the end of the eighth month, when all patients were censored, was 8.18%. In category II, maximum default (3.61%) occurred in the fourth month. The cumulative default rate by end of third month was 13.92%; and by the end of eighth month, 21.76%. The default rate by the end of the tenth month, by which time all patients were censored, was 21.76% [Table 2].
Table 2: Default Over Various Periods (in Months) After Treatment Initiation in Smear-Positive Patients on Dots

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  Discussion Top


A wide range of default times has been reported from other studies and reflects the differences in period of study, context, patients, and specific programs. Regarding timing of treatment interruption, it was observed that out of total 80 defaulters, 62.5% defaulted in the continuation phase and remaining 37.5% defaulters defaulted during the intensive phase of the treatment. These findings indicate that continuation phase of treatment require a closer supervision by the RNTCP team. This result is in cohort with other studies. [5],[6],[7],[8],[9] This is in contrast to the study by Hasker from Uzbekistan who reported that patients defaulted mostly during the intensive phase. [10]

On analyzing month-wise probability of default, it was observed in our study that in category I, maximum default is seen in the third month of treatment, that is, 2.84%. The cumulative default rate at the end of second month was 2.57%; and at the end of six months, 8.18%. The default rate at the end of the eighth month, when all patients were censored, was also 8.18%.

In category II, maximum default (3.61%) occurred in the fourth month, followed by first month (3.39%). The default rate by the end of tenth month, by which time all patients were censored, was 21.76%.

Findings of another study from Maharashtra [11] are consistent with observations of our study. It was observed that amongst the study subjects, cumulative default rates at the end of intensive phase were 4 and 16%; while by end of treatment period, the default rates were 6 and 31% in category I and category II, respectively. Author concluded that, the patients defaulting in intensive phase of treatment and without smear conversion at the end of intensive phase should be retrieved on a priority basis.

Another report which analyzed factors and reasons for defaulting in TB treatment in the states of West Bengal, Jharkhand, and Arunachal Pradesh; observed that default started in the third month and increased up to the fourth month and subsequently declined. [12]

The treatment under DOTS is given in two phases. The initial intensive phase of treatment kills actively growing and semi-dormant bacilli and shortens the duration of infectiousness. The continuation phase eliminates most residual bacilli and reduces failure and relapses. At start of the continuation phase, numbers of bacilli are expected to be low with less chance of selecting drug-resistant mutants. [13]

The implications of default depend on the time of default. Poor treatment compliance is also an important factor in the development of acquired drug resistance. The earlier a patient defaults, more will be the chances of persistent smear-positive status and risk of drug resistance. Bawri [14] confirmed the above fact in his study as 45 of the 48 isolates from patients with history of default showed drug resistance. In the study, treatment after default was found to be the most important factor associated with drug resistance.


  Conclusions Top


Patient defaulting from treatment remains a matter of concern. Factors behind higher default rate in continuation phase needs to be explored. Default in intensive phase of treatment and without smear conversion at the end of intensive phase should be retrieved on a priority basis.

 
  References Top

1.Murray CJ, Lopez AD. The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. 1 st ed., vol 74. Geneva: World Health Organisation; 1996.  Back to cited text no. 1
    
2.World Health Organization. Fact sheets. Available from: http://www.who.int/mediacentre/factsheets/fs104/en/ [Last accessed on 2011 Aug 23].  Back to cited text no. 2
    
3.Kruk ME, Schwalbe NR, Aguiar CA. Timing of default from tuberculosis treatment: A systematic review. Trop Med Int Health 2008;13:703-12.  Back to cited text no. 3
[PUBMED]    
4.Central TB Division, DGHS, Ministry of Health and Family Welfare, TB India, RNTCP Status Report, New Delhi; 2010.  Back to cited text no. 4
    
5.Tekle B, Mariam DH, Ali A. Defaulting from DOTS and its determinants in three districts of Arsi Zone in Ethiopia. Int J Tuberc Lung Dis 2002;6:573-9.  Back to cited text no. 5
[PUBMED]    
6.Caminero JA. Multidrug-resistant tuberculosis: Epidemiology, risk factors and case finding. Int J Tuberc Lung Dis 2010;14:382-90.  Back to cited text no. 6
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7.Daniel OJ, Oladapo OT, Alausa OK. Default from tuberculosis treatment programme in Sagamu, Nigeria. Niger J Med 2006;15:63-7.  Back to cited text no. 7
[PUBMED]    
8.Chang KC, Leung CC, Tam CM. Risk factors for defaulting from anti-tuberculosis treatment under directly observed treatment in Hong Kong. Int J Tuberc Lung Dis 2004;8:1492-8.  Back to cited text no. 8
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9.Khan A, Sterling TR, Reves R, Vernon A, Horsburgh CR. Lack of weight gain and relapse risk in a large tuberculosis treatment trial. Am J Respir Crit Care Med 2006;174:344-8.  Back to cited text no. 9
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10.Hasker E, Khodjikhanov M, Usarova S, Asamidinov U, Yuldashova U, van der Werf MJ, et al. Default from tuberculosis treatment in Tashkent, Uzbekistan; who are these defaulters and why do they default? BMC Infect Dis 2008;8:97.  Back to cited text no. 10
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11.Pardeshi GS. Time of default in tuberculosis patients on directly observed treatment. J Glob Infect Dis 2010;2:226-30.  Back to cited text no. 11
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12.Chatterjee P, Banerjee B, Dutt D, Pati R, Mullick A. A comparative evaluation of factors and reasons for defaulting in tuberculosis treatment in the states of West Bengal, Jharkhand and Arunachal Pradesh. Indian J Tuberc 2003;50:17-21.  Back to cited text no. 12
    
13.Harries A. What are the current recommendations for standard regimens? In: Frieden T, editor. Toman′s Tuberculosis Case Detection, Treatment, and Monitoring - Questions and Answers. Geneva: WHO; 2004. p. 124.  Back to cited text no. 13
    
14.Bawri S, Ali S, Phukaa C, Tayal B, Baruwa P. A study of sputum conversion in new smear positive pulmonary tuberculosis at the monthly intervals of 1, 2 and 3 month under directly observed treatment, short course regimen. Lung India 2008;25:118-23.  Back to cited text no. 14
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