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SHORT COMMUNICATION
Year : 2010  |  Volume : 54  |  Issue : 1  |  Page : 21-23 Table of Contents     

A study on factors influencing treatment outcome of failure patients receiving DOTS in a district of West Bengal


1 Assistant Professor, Community Medicine, Burdwan Medical College,West Bengal, India
2 Medical Officer, District Tuberculosis Centre, Burdwan, West Bengal, India

Date of Web Publication29-Sep-2010

Correspondence Address:
Sujishnu Mukhopadhyay
Assistant Professor, Community Medicine, Burdwan Medical College, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.70541

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   Abstract 

Failure to primary treatment under RNTCP can be an enormous setback for the society. A record based retrospective cohort analysis of 212 patients failing primary treatment under Cat I or Cat III was done in Burdwan district of West Bengal to find the treatment outcome after re-registration under Cat II and its possible influencing factors. Retreatment of failed patients resulted in 24.06% chronicity. Important factors influencing the outcome of being failure were found to be Adolescence (AOR = 2.350; C.I. 0.660-8.281), Urban residence (AOR = 1.878; C.I. 0.705-5.002), primary categorization in Cat I versus Cat III (AOR = 5.036; C.I. 0.897-28.281), higher bacillary load at the beginning of retreatment regimen (AOR = 5.437; C.I. 0.787-37.562) and more than three weeks delay in instituting Cat II treatment (AOR = 3.550; C.I. 0.941- 13.393). 17.35% of such failed patients were still defaulters. Hence such factors may be looked into for more efficient control of Tuberculosis in our country.

Keywords: DOTS, Risk of failure, Cause of failure, Cohort analysis


How to cite this article:
Mukhopadhyay S, Sarkar AP, Sarkar S. A study on factors influencing treatment outcome of failure patients receiving DOTS in a district of West Bengal. Indian J Public Health 2010;54:21-3

How to cite this URL:
Mukhopadhyay S, Sarkar AP, Sarkar S. A study on factors influencing treatment outcome of failure patients receiving DOTS in a district of West Bengal. Indian J Public Health [serial online] 2010 [cited 2019 Sep 20];54:21-3. Available from: http://www.ijph.in/text.asp?2010/54/1/21/70541

India, the home of most Tuberculosis patients, accounts for one fifth of the global incidence of Tuberculosis. It causes 400,000 deaths and costs the country more than Rs. 120,000 million per year [1] . In response to this enormous problem, like many other countries, India adopted Directly Observed Chemotherapy (DOTS) in Revised National Tuberculosis Control Programme (RNTCP) in 1992 and moved into category 4 of WHO gradation (DOTS being implemented in more than 90% of population). RNTCP was set forth in the state of West Bengal during 1994. Ten years had elapsed and the state began achieving the primary objectives of 85% cure rate and 70% case finding rate from 2004 onwards [1] . Since then the state is maintaining the success. But simultaneously the public health professionals are beginning to ponder about the rest of the new and previously treated sputum positive patients who could not be declared as "cured". A sizeable proportion of these patients did not show sputum conversion despite administration of recommended regimen of drugs for legitimate duration. They are the patients in whom the drugs were inadequate to conquer the illness. Such "Failed" patients, though remained less than the predicted rate of 4% in West Bengal [2] proved to be negative canvassers of the programme itself. Another problem that is inadequately addressed is that of MDR TB, which is around 3 - 4% among new cases [3] and 12 - 18% among the re-treatment cases [4] , failed patients being a part of them. Hence it becomes imperative that such "failed" patients are managed in such a way that best possible outcome could be imparted to them within the framework of RNTCP itself. With this background, the present work was taken up with the objective of studying the outcome of the patients failed to Cat I or Cat III treatment and re-registered in Category II and the possible factors that might have influenced that outcome.

The rural district of Burdwan in West Bengal, India, is comprised of seventeen Tuberculosis Units (T.U.s). This study was conducted in half of them, that is, nine randomly selected T U-s. It was a retrospective cohort analysis of the new pulmonary or extra-pulmonary tuberculosis patients who ended up being "failed" to Cat I or Cat III treatment. All such patients, who were registered in the selected T.U.s from 1 st quarter 2004 to 4 th quarter 2006 were searched out from the Tuberculosis Registers of the respective T.U.s and followed up about their final outcome after being re-registered as Cat II patients. All of those who could not be traced on account of absence of new T.B. no. at the end of initial treatment were excluded from the study. The determinants of the outcome of the treatment were obtained from the Tuberculosis registers only. The data were analyzed with the help of software SPSS version 10.0.

The total number of patients that could be recruited for the study was 212. Among them 156 (73.6%) were males and rest 56 (26.4%) females. Mean age for females were 37.8 years and that for males were 36.7 years. There was 30 (14.15%) adolescents and 21 (9.90%) elderly people among the subjects, others 161 (75.95%) being in the productive age group of 20 to 60 years. 128 (60.38%) of the patients had rural residence and 84 (39.62%) came from urban setting. There was a Hindu preponderance (137; 64.62%) in the group, followed by 45 (21.23%) Muslims and 30 (14.15%) Santhals. Only two patients were suffering from extra-pulmonary tuberculosis and the others from pulmonary and the majority 177 (83.47%) was categorized into Cat I and the rest 35 (16.53%) into Cat III.

After instituting Cat II treatment to these patients, 117 (55.37%) actually could be declared as "Cured", while about one-fourth, that is, 51 (24.06%) failed again to be declared as "Chronic". These two groups were those (168) in whom treatment could be administered for recommended duration and as such were subjected to further analysis in our study. There were 37 (17.45%) patients who still defaulted after being failed to treatment under Cat I or III. Three patients died while on treatment and in four more sputum examination was not conducted at the end of the treatment causing them to be designated as "Treatment Completed".

Out of those in whom the treatment could be ended, the adolescents were seen to be declared as "failures" more frequently compared to the other two age groups, the risk being more than double as for that of the other age groups. Among the other socio-demographic characteristics, none of the differences were statistically significant that males, Hindus and urban people were more affected compared to their respective counterparts. As might be expected, the chronicity was significantly more to those who were primarily treated in Cat I compared to those in Cat III, the possibility being about five times higher. Though the sputum result at the initiation of treatment had no bearing on the outcome at the end of the treatment, in so far as chronicity is concerned, but the results of sputum examination at the beginning of Cat II treatment show a significantly increasing trend of chronicity with the bacillary load. It was observed that delaying the initiation of Cat II treatment for more than three weeks increased the chance for chronicity by more than three fold as it was associated with a very poor outcome that 61% of such patients had to be declared "chronic" [Table 1].
Table 1 :Outcome of treatment of primarily failed patients, who had been recommended re-treatment (n=168)

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The proportion of patients who did not show sputum conversion at end of intensive/extended intensive phase of Cat II was 21.1% (n=191) and from these 40 patients 32 proved to be chronic, while five defaulted and three died and none cured.

The mean age of onset of the recruited patients as well as the male preponderance among them matches the other larger studies in South India [5] ,[6] and in North India [7] . The urban-rural divide and the different religion of the respondents are in conformity with those demographic characteristics of the district. But the significant risk of males and above 45 years for being failures found in the South Indian studies [5] ,[6] is not obtained in our study. Comparable data regarding the implication of adolescent age group as a risk factor is difficult to obtain from India. But that the aged are not at any higher risk of failure is found in other studies also [8] ,[9] . Neither religion nor residence was significantly associated to development of chronicity, though the risk is more as being urban. That failed patients in Cat I would be significantly more at risk of failing further in Cat II treatment is comprehensible and is found in other studies as well [6] ,[10] and it could well be due to MDR in them [6] . The initial sputum result was not seen to be significantly associated with the final outcome. But the risk of failing the treatment increased proportionately with bacillary load at the beginning of Cat II treatment. This finding is in conformity with other studies [7] . But delay in initiating Cat II treatment was found to be a highly significant risk factor to develop chronicity. Defaulting in those who have already failed to Cat I (17.35%) may have grave consequences given the proportional possibility of MDR in them. Therefore constant vigilance on this matter should be exercised.

 
   References Top

1.Available from: http://tbcindia.org/ [last accessed on 2009 Mar 15]. .   Back to cited text no. 1      
2.Health on the March 2006-07, State Bureau of Health Intelligence, Directorate of Health Services, Govt. of West Bengal, p. 142.  Back to cited text no. 2      
3.Zignol M, Hosseini MS, Wright A, Lambregts-van Weezenbeek C, Nunn P, Watt CJ, et al. Global Incidence of Multidrug - Resistant Tuberculosis., Stop TB Department, WHO, Geneva, Switzerland. J Infect Dis 2006;194:479-85  Back to cited text no. 3      
4.Chauhan LS. Drug Resistant TB - RNTCP Response. Indian J Tuberc 2008;55:5-8  Back to cited text no. 4      
5.Sophia V, Balasangameswara VH, Jagannatha PS, Saroja VN, Kumar P. Treatment outcome and two & half years follow-up status of new smear positive patients treated under RNTCP. Indian J Tuberc 2004;51:199-208.  Back to cited text no. 5      
6.Santha T, Garg R, Frieden TR, Chandrasekaran V, Subramani R, Gopi PG, et al. Risk factors associated with default, failure and death among tuberculosis patients treated in a DOTS programme in Tiruvallur District, South India, 2000. Int J Tuberc Lung Dis 2002;6:780-8.  Back to cited text no. 6      
7.Katiyar SK, Bihari S, Arun S, Rawat T. An analysis of failure of category II DOTS therapy. Indian J Community Med 2008;33:129-30.  Back to cited text no. 7  [PUBMED]  Medknow Journal  
8.Pardeshi G, Deshmukh D. Disease characteristics and treatment outcome in elderly tuberculosis patients on DOTS. Indian J Community Med 2007;32:10-2.  Back to cited text no. 8      
9.Arora VK, Singla Neeta, Sarin R. Profile of Geriatric Patients Under DOTS in Revised National Tuberculosis Control Programme. Indian J Chest Dis Allied Sci 2003;45:231-5.  Back to cited text no. 9      
10.Mehra RK, Dhingra VK, Aggarwal N, Vasisht RP. Study of relapse and failure cases of Cat I retreated with Cat II under RNTCP -An 11 year follow-up. Indian J Tuberc 2008;55:188-91.  Back to cited text no. 10      



 
 
    Tables

  [Table 1]


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