Factors associated with loss to follow-up and death in cases of drug-resistant tuberculosis (DR-TB) treated at a reference center in Rio de Janeiro, Brazil

Viana, Paulo Victor de Sousa; Redner, Paulo; Ramos, Jesus Pais

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ARTICLE • Cad. Saúde Pública 34 (5) • 2018 • https://doi.org/10.1590/0102-311X00048217 copy

Factors associated with loss to follow-up and death in cases of drug-resistant tuberculosis (DR-TB) treated at a reference center in Rio de Janeiro, Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract:

Drug-resistant tuberculosis (DR-TB) poses a serious threat to tuberculosis (TB) control in Brazil and worldwide. The current study investigated factors associated with loss to follow-up and death in the course of treatment for DR-TB in a tertiary reference center in the city of Rio de Janeiro, Brazil. This was a retrospective cohort study of cases reported to the Information System on Special Treatments for Tuberculosis (SITETB) from January 1, 2012, to December 31, 2013. A total of 257 patients were reported to the SITETB and initiated treatment for DR-TB. Of this total, 139 (54.1%) achieved treatment success as the outcome, 54 (21%) were lost to follow-up, and 21 (8.2%) died. Following a multiple multinomial logistic regression analysis, the age bracket older than 50 years was the only protective factor against loss to follow-up, whereas less than eight years of schooling and reentry after loss to follow-up were considered risk factors. Reentry after loss to follow-up, relapse, and treatment failure appeared as risk factors. Our data reinforce the concept that loss to follow-up in drug-resistant tuberculosis is a serious public health problem, and that adequate follow-up of treatment is necessary in patients with this history and low schooling. A social support network for patients is also indispensable for avoiding unfavorable outcomes.

Keywords:
Tuberculosis; Multidrug-Resistant Tuberculosis; Patient Dropouts

Models	Variables	AIC
Complete	Sex, age bracket, schooling, race, clinical form, year, type of entry, resistance pattern, serology, sputum smear, type of resistance, AIDS, diabetes, drug use, smoking, and alcoholism	377.22
1	Sex, age bracket, schooling, resistance pattern, alcoholism, type of entry, drug use	361.33
2	Age bracket, schooling, resistance pattern, drug use, and type of entry	357.86
3	Age bracket, schooling, and type of entry	349.04

Characteristics	Total		Loss to follow-up		Deaths		Others		p-value
Characteristics	n	%	n	%	n	%	n	%
Sex									0.364
Male	179	69.6	41	22.9	16	8.9	122	68.1
Female	78	30.4	13	16.7	5	6.4	60	76.9
Age bracket (years)									< 0.001
15-29	59	23.0	19	32.2	5	8.5	35	59.3
30-49	135	52.5	32	23.7	12	8.8	91	67.4
50 or older	63	24.5	3	4.8	4	6.3	56	88.3
Schooling (years)									0.019
Fewer than 8	149	58.0	40	26.8	12	8.1	97	65.1
More than 8	101	39.3	14	13.8	7	6.9	80	79.2
Unknown	7	2.72	0	0.0	2	28.6	5	71.4
Race/Color									0.544
White	88	34.2	15	17.1	5	5.7	68	77.3
Black	74	28.8	16	21.6	7	9.5	51	68.9
Asian-descendant	1	0.4	0	0.0	0	0.0	1	100.0
Brown	90	35.0	23	25.5	8	8.9	59	65.5
Unknown	4	1.6	0	0.0	1	25.0	3	75.0
Year									0.599
2012	142	55.3	27	19.1	13	9.1	102	71.8
2013	115	44.7	27	23.5	8	6.9	80	69.5
Total	257	100.0	54	21.0	21	8.2	182	70.8

Characteristics	Total		Loss to follow-up		Deaths		Others		p-value
Characteristics	n	%	n	%	n	%	n	%
Time in treatment in months	14.9 (9.0-20.0)		6.0 (3.2-10.7)		9.0 (3.0-15.0)		18.0 (15.0-22.0)		< 0.001
Clinical form									0.869
Pulmonary	254	98.8	54	21.3	21	8.3	179	70.5
Extrapulmonary	1	0.4	0	0.0	0	0	1	100.0
Mixed	2	0.8	0	0.0	0	0	2	100.0
Sputum smear									0.219
Positive	200	77.8	46	23.0	18	9.0	136	68.0
Negative	44	17.1	8	18.2	2	4.5	34	77.3
Not performed	13	5.1	0	0.0	1	7.7	12	92.3
Sputum culture									0.819
Positive	237	92.2	51	21.5	21	8.9	162	69.6
Negative	10	3.9	2	20.0	0	0	8	80.0
Not performed	10	3.9	1	10.0	0	0	9	90.0
HIV serology									0.231
Positive	14	5.4	0	0.0	2	14.3	12	85.7
Negative	186	72.4	40	21.5	15	8.1	131	70.4
Not performed	57	22.2	14	24.6	4	7.0	39	68.4
Resistance pattern									0.060
Monoresistance	41	16.0	6	14.6	1	2.4	34	82.9
Multi-resistance	178	69.3	41	23.0	12	6.7	125	70.2
Polyresistance	25	9.7	5	20.0	5	20.0	15	60.0
Extensive resistance	13	5.1	2	15.4	3	23.1	8	61.5
Type of resistance									0.740
Primary	33	12.8	5	15.2	3	9.1	25	75.8
Acquired	224	87.2	49	21.9	18	8.0	157	70.1
Type of entry									< 0.001
New case	180	70.0	34	18.9	8	4.4	138	76.7
Reentry	27	10.5	16	59.3	5	18.5	6	22.2
Failure	34	13.2	3	8.8	6	17.6	25	73.5
Relapse	13	5.1	1	7.7	2	15.4	10	76.9
Resistance change	2	0.8	0	0.0	0	0.0	2	100.0
Others	1	0.4	0	0.0	0	0.0	1	100.0
AIDS									0.142
Yes	12	4.7	0	0.0	1	8.3	11	91.7
No	245	95.3	54	22.0	20	8.2	171	69.8
Diabetes									0.432
Yes	27	10.5	3	11.1	2	7.4	22	81.5
No	230	89.5	51	22.2	19	8.3	160	69.6
Drug use									0.028
Yes	21	8.2	9	42.9	2	9.5	10	47.6
No	236	91.8	45	19.1	19	8.1	172	72.9
Smoking									0.601
Yes	40	15.6	10	25.0	4	10.0	26	65.0
No	217	84.4	44	20.3	17	7.8	156	71.9
Alcoholism									0.060
Yes	25	9.7	8	32.0	4	16.0	13	52.0
No	232	90.3	46	19.8	17	7.3	169	72.8
Total	257	100.0	54	21.0	21	8.2	182	70.8

Variables	Crude OR	95%CI	p-value *	Adjusted OR	95%CI	p-value **
Loss to follow-up in the course of treatment
Age bracket (years)
15-29	Ref.
30-49	0.69	0.34-1.37	0.283	0.54	0.24-1.18	0.123
50 or more	0.10	0.10-0.37	< 0.001	0.11	0.03-0.41	< 0.001
Schoolinh (years)
Fewer than 8	2.42	1.23-4.78	0.009	2.71	1.25-5.82	0.010
More than 8	Ref.
Resistence pattern
Monoresistance	Ref.
Multi-resistance	1.88	0.73-4.81	0.188
Polyresistance	1.83	0.48-6.96	0.373
Extensive resistance	1.57	0.26-9.47	0.621
Type of entry
New case	Ref.			Ref.
Reentry	10.59	3.85-29.1	< 0.001	6.50	2.29-18.46	< 0.001
Failure	0.50	0.14-1.75	0.275	0.48	0.13-1.78	0.273
Relapse	0.40	0.05-3.21	0.386	0.35	0.04-2.94	0.330
Drug use
Yes	3.69	1.38-9.84	0.009
No	Ref.
Death in the course of treatment
Age bracket (years)
15-29	Ref.
30-49	0.98	0.46-1.58	0.967	1.04	0.31-3.49	0.947
50 or more	0.52	0.13-2.06	0.351	0.33	0.06-1.94	0.220
Schoolinh (years)
Fewer than 8	1.46	0.55-3.88	0.452	1.35	0.46-3.94	0.580
More than 8	Ref.			Ref.
Resistence pattern
Monoresistance	Ref.			Ref.
Multi-resistance	3.30	0.30-19.96	0.259
Polyresistance	11.00	1.14-100.53	0.035
Extensive resistance	14.14	1.28-156.78	0.031
Type of entry
New case	Ref.			Ref.
Reentry	14.06	3.52-56.15	< 0.001	9.36	2.08-42.07	< 0.001
Failure	4.22	1.34-13.25	0.013	5.01	1.51-16.63	0.008
Relapse	3.37	0.63-18.06	0.155	3.61	0.64-20.44	0.147
Drug use
Yes	1.94	0.39-9.66	0.424
No	Ref.

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[1] * Correspondence P. V. S. Viana Centro de Referência Professor Hélio Fraga, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz. Estrada de Curicica 2000, Rio de Janeiro, RJ 22780-194, Brasil. paulovictorsviana@gmail.com