|Year : 2006 | Volume
| Issue : 3 | Page : 103-105
Profile of treatment failure in tuberculosis - Experience from as tertiary care hospital
D Behera, T Balamugesh
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh., India
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh -160012.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Behera D, Balamugesh T. Profile of treatment failure in tuberculosis - Experience from as tertiary care hospital. Lung India 2006;23:103-5
| Introduction|| |
The persistence of TB has been due chiefly to the neglect of TB control by governments, poorly managed TB control programmes, poverty, population growth and migration, and a significant rise of TB cases in HIV endemic areas. To help address the situation, the global strategy called DOTS was introduced. Tuberculosis kills close to 500,000 people in India per year, which is more than any other infectious disease  . Modern Anti-tubercular treatment can cure virtually all patients provided correct combination treatment is taken in amount and duration.
WHO category II patients are those who have received anti-tuberculosis treatment for more than one month in the past. They are therefore at an increased risk of having multi-drug resistant disease. These include smear positive relapses, smear-positive failure cases, and smear positive patients being treated after default.
WHO recommends retreatment with category II ATT regimen (2HRZES + 1HREZ + 5HRE) for patients with relapse, treatment failure or treatment after interruption. There are various postulated factors, which lead on to failure of treatment or relapse of cases of tuberculosis. To name a few are poverty, intolerance to drugs, ignorance about duration of treatment, poor prescription practices, co-morbid illness such as diabetes mellitus etc.
In the present study we have attempted to characterize the factors responsible for relapse or treatment failure of tuberculosis.
| Material and Methods|| |
Forty-seven cases of tuberculosis on retreatment (WHO-category II regimen) attending the chest clinic of PGIMER, Chandigarh, were interviewed with a questionnaire, which contained questions on the following factors: demography, socioeconomic status (number of family members, type of family, average family income), smoking status, alcohol consumption, co-morbid illnesses, previous episodes of tuberculous disease, how and where the diagnosis was made, weight at the time of diagnosis, name/duration/combination/side effects of drugs received, compliance/cost of therapy and cause(s) for noncompliance.
Relapse is defined as previously treated cases of pulmonary tuberculosis and been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) tuberculosis. Treatment failure is defined as a patient who, while on treatment, is sputum smear positive at 5 months or later during the course of treatment.
| Results|| |
Out of 47 patients who underwent retreatment with WHO category II, 34 (74.34%) were males. All were positive for sputum AFB smear examination. The mean age±SD was 35.87±14.5 years (males 37.24±13.6; females 32.31±16.6 years). 14 patients were manual labourers, 10 were housewives, 7 government employees, 4 students and 8 miscellaneous jobs. 4 patients were unemployed. Retreatment with category II was administered in 31 cases (65.61%) for relapse. In such cases patient had received antitubercular therapy for a mean of 7.6±6.4 yrs (Range 2-23 yr) back. In 14(29.8%) cases category II drugs were given for treatment failure and two (4.26%) cases for treatment after interruption. Patients received treatment with ATT for an average of 5.3 months (Range: 2-10 months) before being labeled as treatment failure.
Average monthly income was Rs.1,819. The type of family was joint family in 44 cases and nuclear in 3 cases. Average number of family members per case was 6.4. Six of the cases were current smokers and 13 cases were ex-smokers. 17 cases had history of regular alcohol consumption. Co-morbid illnesses were found in 7 cases (chronic obstructive airway disease-4, diabetes mellitus-2, nutritional anemia-1, alcoholic liver disease-1).
Initial diagnosis of tuberculosis was made on basis of CXR alone in 15 cases, sputum investigation in 2 cases, both CXR and sputum investigation in 21 cases. No investigation was available in 9 cases.
Diagnosis was made by MBBS doctors in 8 cases, MD physician in 11, chest specialist in 26 cases and not known in 2 cases. The place of diagnosis was private clinic in 16 cases, T.B clinic in 12, Government hospital in 6, Medical College in 3 and PGIMER, in 10 (Government set up in 31). Weight was recorded at diagnosis in 22 cases (46.8%). The average initial weight was 43.95 kg. The names of the prescribed drugs were known in 29 cases and unknown in 18 cases. Seven different regimens were used as follows: -
RHEZ - 11
RHZES - 7
RHSE - 1
RHZ - 5
RHE - 2
HE+THIO - 1
HS+PAS - 2
Duration of ATT was made known to the patient in 20 of the 47 cases. Average duration of taking ATT was 12.62 months (range 3-24 months). Only 31 of the cases the side effects of the drugs or the method of taking the drugs were explained.
Drugs were procured from Government hospitals/ dispensaries by only 10 patients (21.7%) despite the diagnosis being made at Government set up in 31 [Table 1]. Private clinics provided the drugs in 37 patients. The cost of the drugs per day was Rs. 21.05. Follow up visit was done every 28.04 days.
The number of physicians visited before diagnosis of tuberculosis was made was 2.83 (range1-6). The reasons for the doctor shopping were :
Not satisfied with treatment in 8
Lack of immediate improvement in symptoms in 29
Relapse of symptoms after a period of remission in 4 No reason in 13.
In 10 cases the treating physician did not enquire about the compliance or side effects of ATT on follow up visits.
The causes for poor compliance were
Symptoms improved after some time in 16
Cannot afford drugs in 5
Intolerance to drugs in 5
Persistent symptoms in 3
Not aware of duration of treatment in 1
The compliance was good in only 17 cases (36.2%).
There were no side effects in 17 cases. 30 patients had side effects (nausea in 16, vomiting in 3, abdominal fullness in 5, jaundice in 5, arthralgia in 2, others in 10).
| Discussion|| |
This study indicates that tuberculosis relapses and treatment failures affect the most productive age group who are the bread earners of the family. 26 to 49% of cases occur in the age group 15 to 44. It puts enormous burden on the family. Treatment interruption was found to be higher in males in some studies , . Relapse is the commonest cause of administering retreatment regimen with Category II in up to 65.61 % of cases.
Patients were labeled as treatment failure an average of 5.3 months that is in accordance with the WHO guidelines. The number of family members per retreatment case was relatively high. Default has been found to be common in joint family system, perhaps, due to lack of individual care when many members shared a common economy  . Also family events like births, deaths, marriages, which cause treatment interruption, will be more common in large families. Co-morbid illnesses were not an important cause of relapse or treatment failure and were found only in 7 cases. We have not done HIV serology for all the patients.
In spite of the WHO guidelines, which stress the importance of sputum microscopy, chest X-ray is the commonest modality used to diagnose tuberculosis. Sputum was examined for AFB in only 23 (48.3%) cases, which is little alarming.
Initial diagnosis of tuberculosis was made in private clinic in 16 (34%) cases. Private practitioners are perceived more sympathetic, more conveniently located, more effective and more trusted for privacy than government run services as having condescending doctors, substandard drugs, inconvenient timing and long waiting times. Uplekar et al examined the practices of private doctors in managing lung tuberculosis , . Over reliance on chest X-ray rather than sputum examination is common among private practitioners. They are not well versed with the inexpensive standard regimens for treating tuberculosis and few of regimens used by them conformed to the ones recommended under the RNTCP. In the study by Uplekar 90 different treatment regimes were prescribed by 113 doctors which were either inappropriate in combination of drugs used or in duration. Half of them make no attempt to contact patients who defaulted from follow up visits. This contributes significantly to treatment interruption. Private doctors are usually aware of but skeptical about tuberculosis treatment available public health facilities  .
Weight of the cases was recorded in less than half of the patients. This is of concern since dosages of drugs depends on the weight of patient. Giving higher dosages will cause increased incidence of side effects and thereby decreasing the compliance with therapy. Similarly, lower dosages will cause emergence of bacterial resistance and then treatment failure.
Symptomatic treatment after starting ATT was the commonest cause of poor compliance. This is because the duration of ATT was explained to the patient at diagnosis in only 20 of the 47 cases. The most important cause of failure of anti-TB therapy is that the patient does not take the medication as prescribed which has been shown is other studies , . Clinical improvement before completion of therapy was found as the commonest cause of treatment default  . Inability to afford drugs, intolerance to drugs and persistent symptoms were other causes for default.
From this preliminary observation, the commonest cause of treatment default was symptomatic improvement with anti-tubercular therapy. Suggestions to overcome poor compliance include improving the general standard of living, improving patient's awareness of the gravity of the disease, the need to take regular treatment, the expected duration of treatment, and knowledge about side effects of drugs. DOT may be the most effective way to ensure compliance with ATT and hence cure. Effective involvement of private health care providers is imperative in order to achieve total geographical and patient coverage for DOTS implementation since a good percentage of patients get treated by them. The private health sector comprising private practitioners, voluntary and for-profit organizations, professional societies, private hospitals and corporate health providers offers major opportunities to further DOTS implementation.
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