Evaluation of Treatment Outcome of DOTS in Patients Attending Urban Health Centre in Southern India: A 15 Years Retrospective Study

Introduction

Tuberculosis is among the leading cause of death due to an infectious etiology in the world. Every year, about 10 million people are infected with Tuberculosis around the world. Although Tuberculosis is curable, 1.5 million Tuberculosis patients succumb to death per year.The majority of Tuberculosis cases are concentrated in low and middle-income countries. There are 30 high burden countries that account for 87% of the new cases and India is one amongst them.¹

Realizing the gravity of burden due to Tuberculosis, in 1993, the World health organization (WHO) recommended directly observed treatmentshort course (DOTS) as a strategy to control Tuberculosis. DOTS is based on principles likepolitical commitment, good quality diagnosis, uninterrupted supply of quality drugs, directly observed treatment, and systematic monitoring and accountability. Directly observed treatment ensures treatmentadherence by supervised drug intake.² Experiences from countries like Tanzania and China, who implemented the strategy early on, showed increased cure rates.^3,4 India adopted DOTS in the mid-90s under the revised national tuberculosis control program (RNTCP) and was expanded to the entire country by 2005.⁵

This study aimed to evaluate the treatment outcome of DOTS in patients attending the Urban Heath Centre area of a medical college.

Materials and Methods

This was a cross-sectional study to evaluate the treatment outcome of 143 Tuberculosis patients who were registered and treated in the urban health centre area of JSS Medical College, Mysuru from 2003 to 2018. Institutional ethical committee clearance was obtained at the start of the study.

The treatment cards of registered patients are maintained in the urban health centre and contain information regarding age, sex, initial body weight, sputum smear microscopy result, site of Tuberculosis, X-ray and other investigation details, weight gain during treatment, treatment outcome, number of missed doses, details of retrieval actions taken for patients missing the doses, details of children below 6 years who are contacts and prescribed chemoprophylaxis and details of DOTS provider. The designated staff from the urban health centre (DOTS provider) marks the appropriateboxes in the treatmentcard with a tick after administering the drugs under observation in the intensive phase. In the continuation phase, the patient collects drugs on a specific day in a week and the first dose is taken under supervision, which is marked by an ‘X’ in the box and the rest of the week is marked by a line, to indicate that drugs for the remaining of the week has been given. If the patient doesn’t visit for a scheduled dose, the DOTS provider tries to reach the patient through phone calls/ house visits. Despite this, if the dose is missed, it is marked ‘O’ in the appropriate box.

Data regarding age, sex, initial and final body weight, type of Tuberculosis, and treatment outcome was collected and entered in Microsoft Excel and analyzed using SPSS Version 23(licensed to JSS AHER). Descriptive statistics like percentages, mean and standard deviation, and inferential statistical tests like paired t-test was used.

Definitions of treatment outcome ⁶

Cured: Initially, sputum smear-positive patient who completed treatment and had negative smears, on two occasions, one of which at the end of treatment.

Treatment completed: Sputum smear-positive patient who has completed treatment, with negative smears at the end of the intensive phase but none at the end of treatment or Sputum smear-negative TB patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment or Extra-pulmonary TB patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment

Failure: A patient whose sputum smear is positive at 5 months or later after starting the treatment.

Death: A Tuberculosis patient who died during the course of treatment regardless of the cause.

Defaulted: A TB patient who has not taken treatment for two months or more consecutively after starting treatment.

Transferred out: A patient who has been transferred to another area register and treatment results are not known.

Results

Among the 143 patients who received treatment, 67% were males and 33% were females. The mean age of the participants was 34 + 16. Figure 1, represents the distribution of the participants by age. 18% belonged to the 0-14 year category, 67% were between the age group of 15-54 years and 15% were above 55 years. Out of the 143 patients, 77% had pulmonary Tuberculosis and 23% has extra pulmonary Tuberculosis. At the end of the treatment period, 47% were cured, 36% completed the treatment, 2% were treatment failures, 7% defaulted, 5% died and 3% migrated to other places and their data was not available. The treatment outcome of the patients is represented in Figure 2. Comparison of the weight before and after treatment among the cured and the course completed patients are given in Table 1.The mean weight before treatment was 40.2 + 15.6 Kg and after treatment was 44.8 + 16.2 Kg. There was a significant improvement in weight, post-treatment.

Discussion

DOTS is an internationally recommended strategy to treat Tuberculosis.Tanzania and China were a few countries that implemented DOTS early, and literature from these countries report an increased cure rate of 80% and 90% respectively.3,4 India adopted DOTS in the year 1997 and encompassed the entire country by 2005.5 In the present study, the majority of the patients were males and 67% of the total patients belonged to the age group of 15 to 54 years. These findings were consistent with the findings of Kashyap et al in Himachal Pradesh and Mohandas et al in Kerala who reported a higher prevalence in males and the productive age group.^7,8 Reports suggest that the higher prevalence in males may be due to biological differences, more exposure in males, and underreporting among females.⁹ 77% of the patients in this study had pulmonary Tuberculosis which was consistent with the findings of Sunday et al in Nigeria and Kashyap et al in India. ^8,10 In this study among 143 Tuberculosis patients, 83% were treated successfully (cured and treatment completed), 2% showed treatment failure and 5% died during treatment. Gebrezgabiher et al in Ethiopia reported a treatment success rate of 85.3%, 0.3% failure, and 3.4% deaths. Mohandas et al in Kerala reported similar findings of the treatment success rate of 88.6%, the death rate of 3.4 %, and the failure rate of 2.1%.^7,11 We found significant improvement in the weight of the successfully treated tuberculosis patients. Bernabe-Ortiz et al and Vasantha et al report that positive treatment outcome is associated with improvement in the weight of the patients.^12,13

In this study among 143 Tuberculosis patients who were treated under the DOTS strategy the treatment success rate was 83% and also positive treatment outcome was associated with significant improvement in the weight of the patients.

Conflict of interest

None

Funding

None