| BACKGROUNDTuberculosis (TB) has remained a major global public health problem since antiquity. It is estimated that over 90% of global TB cases and TB deaths occur in developing countries, and affects mainly people within the economically productive age group (15-54 years). Tuberculosis control has evolved over the centuries. The TB control evolution includes the identification of tubercles; the sanitoria era; identification of Mycobacterium tuberculosis; artificial pneumothorax as an active therapy; the discovery of x-ray; development of BCG vaccine; tuberculin testing; the discovery of streptomycin, p-aminosalicylic acid, isoniazid, pyrazinamide, cycloserine, ethambutol, and rifampicin; the development of vertical national control programmes; development of integrated control programmes using directly observed therapy (DOT); the setting of World Health Assembly (WHA) targets in 1991 to achieve a cure rate of 85% of infectious TB cases and detecting 70% of estimated cases by the year 2000; creation of the stop TB department within WHO to provide specialized managerial approach to TB control; deferral of the 2000 WHA target to 2005; and the millennium development goal of reversing the global incidence of TB by 2015. The problem of TB has been aggravated by co-infections with the human immunodeficiency virus (HIV) and the emergence and spread of multi-drug resistance. China is listed among the 22 high-burden countries in the world. However, the nation by the end of 2005 had attained a treatment success rate of 94%(above the global target of 85%) whilst Ghana, not among the high-burden countries, had attained a lower treatment success rate of 72%.AIMS AND OBJECTIVESThis study aimed at using the 2005-2006 national surveillance data to comprehensively analyze TB treatment outcomes within the Hunan province, and compare treatment success between the Province and Eastern Ghana with the view of providing useful information for TB control. The specific objectives of the study were to elucidate factors associated with TB treatment outcomes in Hunan; to assess prediction models for TB treatment outcomes in Hunan; and to assess TB treatment success differences between Hunan and Eastern Ghana.METHODSTreatment outcomes selected for analyzing the Hunan data were successfully treated, defaulted, TB deaths, and general deaths. These were analyzed by demographic characteristics of patient (gender, age group, and per capita GDP of city of residence); classification of patient (new or old case); treatment regimen (categoryâ… , categoryâ…¡, and categoryâ…¢); mode of payment for treatment (free or payment made); and mode of treatment (DOT, modified DOT, Case management, and self-treatment). Univariate analyses (Chi-square and fisher's exact tests) were used to determine significant associations between treatment outcome and the explanatory variables. Multivariate logistic regression analyses were used to determine the independent effects of all the significant explanatory variables on each selected treatment outcome, and to establish prediction models for the outcomes.For the comparative analyses of treatment success differences between Hunan and Eastern Ghana,2 cities were selected from both areas. These were the Provincial/Regional capital and a randomly selected city of lower economic status. Explanatory variables common to the 2 national registers were used to assess treatment success differences. The variables were gender, age group, patient classification, type of city of residence, and treatment regimen. Treatment outcomes for the different treatment regimens (categoryâ… ,â…¡, andâ…¢) were compared with each other. Furthermore, multivariate logistic regression was used to analyze the independent effect of explanatory variables on treatment success. To confirm the role of country in determining treatment success, country was added to the explanatory variables in a combined data from the 2 study areas and used in the multivariate logistic regression.RESULTSA total of 68430 registered patients in Hunan were evaluated. The majority of these were males (72.9%); aged 15-44 years (48.8%); new TB patients (93.3%); residents of cities with per capita GDP of 1,000-1,999 US$ (50.7%); and received categoryâ… treatment (93.4%). Nearly all patients (97.3%) received free treatment, and DOT was the main mode of treatment used (85.9%). The majorities of patients were smear positive (67%) prior to treatment, and were successfully treated (96.2%). Males showed a lower odds ratio for treatment success compared with females (OR=0.87; 95% CI=0.79,0.95), and were at a higher risk of treatment default (OR=1.25; 95% CI=1.08,1.44). The odds ratios for treatment success were highest among patients aged 0-14 years compared with those aged 65 years or above (OR=6.46; 95% CI=2.40,17.35), and decreased with increasing age. The risk of default was lowest among patients aged 15-44 years (OR=0.67; 95% CI=0.57,0.78), and increased with increasing age. The risk of death (both TB-related and general) increased with increasing age, with no reported deaths among patients aged 0-14 years. New TB cases showed higher odds ratios for treatment success (OR=1.40; 95% CI=1.03,1.89) and lower risk of death (OR=0.50; 95% CI=0.33,0.76), compared with old cases. Patients living in cities with per capita GDP of less than 1,000 US$ showed the lowest risk of default (OR=0.60; 95% CI=0.49,0.72) and the highest risk of TB-related death (OR=2.35; 95% CI=1.81, 3.05), compared with patients living in cities with per capita GDP of 2,000 US$ and above. Patients receiving categoryâ…¡treatment regimen were at a higher risk of default compared with those receiving categoryâ… treatment regimen (OR=1.99; 95% CI=1.22,3.23). The odds ratios for general deaths were higher among patients who received free treatment compared with those who paid for their treatment (OR=12.54; 95% CI=3.92,40.15). Patients treated under DOT and MDOT showed lower odds ratios for treatment success compared with patients treated under case management (OR=0.78; 95% CI=0.65,0.94 and OR=0.65,95% CI=0.51,0.82, respectively) whilst patients who treated themselves showed the highest risk of death compared with those treated under case management (OR=3.47; 95% CI=1.27,9.46).Selection of the Provincial/Regional capital and another city of lower economic status yielded 7384 cases for Hunan and 483 cases for Eastern Ghana. Generally, TB treatment success rate was significantly higher in Hunan than Eastern Ghana (93.1% vs.60.7%). Stratified analyses also showed a similar pattern for all the group-specific rates. Key factors associated with treatment success in Hunan were gender, age group, and type of city of residence whilst in Eastern Ghana treatment success associated with only age group. The odds ratio for treatment success in Hunan was significantly lower for males (OR=0.78; 95% CI=0.63,0.97). The odds ratio of treatment success were also higher for patients resident in the provincial capital (OR=1.35; 95% CI=1.12,1.62). In both Hunan and Eastern Ghana treatment success rates decreased with increasing age. Analysis of combined data from the 2 study areas further showed that Hunan had a significantly higher treatment success rate than Eastern Ghana (OR=9.84,95%CI=7.89-12.18).CONCLUSIONIn conclusion, the study has shown that TB treatment outcomes in the Hunan province are associated with key variables in the national surveillance dataset. These variables are gender, age group, patient classification, per capita GDP of city of residence, treatment regimen, mode of payment of treatment, and mode of treatment. Furthermore, the study suggests that TB control in China is comparatively better than that of Ghana. Useful lessons from China, in the area of health financing, internet-based reporting system, and training and retaining of health personnel, among others, would help improve the situation in Ghana.
|
PDF Full Text Request