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Survival Analysis of Patients with Tuberculosis in Erbil, Iraqi Kurdistan Region Salah Tofik Jalal Balaky1, Ahang Hasan Mawlood1 and Nazar P

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Survival Analysis of Patients with Tuberculosis in Erbil, Iraqi Kurdistan Region Salah Tofik Jalal Balaky1, Ahang Hasan Mawlood1 and Nazar P Balaky et al. BMC Infectious Diseases (2019) 19:865 https://doi.org/10.1186/s12879-019-4544-8 RESEARCH ARTICLE Open Access Survival analysis of patients with tuberculosis in Erbil, Iraqi Kurdistan region Salah Tofik Jalal Balaky1, Ahang Hasan Mawlood1 and Nazar P. Shabila2* Abstract Background: Tuberculosis is an important health concern in Iraq, but limited research has examined the quality of tuberculosis care and the survival of the patients. This study aimed to assess the 12-month survival of tuberculosis patients and evaluate the effect of the associated risk factors on patients’ survival. Methods: We reviewed the records of 728 patients with tuberculosis who were registered and treated at the Chest and Respiratory Disease Center in Erbil, Iraqi Kurdistan Region, from January 2012 to December 2017. Demographic data, the site of the disease, and treatment outcomes were retrieved from patients’ records. Data analysis included the use of the Kaplan–Meier method and the log-rank test to calculate the estimates of the survival and assess the differences in the survival among the patients. The Cox regression model was used for univariate and multivariate analysis. Results: The mean period of the follow-up of the patients was 7.6 months. Of 728 patients with tuberculosis, 50 (6.9%) had died. The 12-month survival rate of our study was 93.1%. A statistically significant difference was detected in the survival curves of different age groups (P < 0.001) and the site of the disease (P = 0.012). In multivariate analysis, lower survival rates were only observed among patients aged ≥65 years (hazard ratio = 9.36, 95% CI 2.14–40.95) and patients with extrapulmonary disease (hazard ratio = 2.61, 95% CI 1.30–5.27). Conclusion: The 12-month survival rate of tuberculosis patients managed at the Chest and Respiratory Disease Center in Erbil was similar to the international rates. The high rates of extrapulmonary tuberculosis and the low survival rate necessitate further studies and action with a possible revision to the tuberculosis management strategy. Keywords: Tuberculosis, Mortality, Survival analysis, Extrapulmonary, Iraq Background Pulmonary TB is usually associated with nonspecific Tuberculosis (TB) is a major global health problem and signs and symptoms. Systemic manifestations might in- an important cause of morbidity and mortality in the clude anorexia, fatigue, low-grade fever, night sweats, world. TB is the ninth leading cause of death in the and weight loss, in addition to cough, which is the most world despite the presence of several treatment strat- common symptom [5]. egies to manage the disease [1]. TB is a chronic disease Mycobacterium tuberculosis is typically transmitted to that mostly affects lower socioeconomic classes [2]. a human host through the respiratory tract. Therefore, TB causes a wide range of clinical infections. The around 80% of TB patients are of pulmonary TB type. pathogen usually attacks the lungs. However, other body However, some pulmonary TB patients present with parts are also exposed to the bacterium, such as the concomitant extrapulmonary TB, which is a more ser- spine, kidney, and brain [3]. The central biology of the ious disease. This suggests that the immune systems of causative bacterium of the disease, Mycobacterium tu- pulmonary TB patients who develop concomitant extra- berculosis, makes it able to persist in the form of latent pulmonary TB cannot halt Mycobacterium tuberculosis TB resulting in long-term asymptomatic infection [4]. bacilli from extending beyond the lung parenchyma [6]. Despitemanyexternalfactors,deathduetoTBisstillsig- nificantly high. According to the World Health Organization * Correspondence: [email protected] 2Department of Community Medicine, Hawler Medical University, Erbil, Iraq (WHO), an estimated 10.4 million people suffered from TB Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Balaky et al. BMC Infectious Diseases (2019) 19:865 Page 2 of 8 in 2016, while the disease resulted in about 1.3 million deaths reach locations [18]. Few studies on TB deaths have among HIV negative cases and 374,000 deaths among HIV been conducted in Erbil city, and no studies from Erbil positive cases [1]. The Middle East region accounted for 25% have assessed the quality of TB care and the effective- of the global burden of TB in 2014. The burden of TB differs ness of treatment protocols. Therefore, this study aimed by country in the region. The country with the highest inci- to assess the 12-month survival of TB patients and dence in the region is Pakistan (268/100,000 population), evaluate the effect of the associated unfavorable risk fac- while the United Arab Emirates is the country with the low- tors on patients’ survival. Knowledge about the survival est value (0.79/100,000 population) [7]. of TB patients in Erbil city can provide some awareness TB is an important public health concern in Iraq. Iraq is about the TB situation in the city. It can also direct ac- a middle burden country with TB, and is ranked 108th tion toward control programs and improving the quality globally and 7th in the Eastern Mediterranean region of TB services by the regional health authorities, includ- among countries with TB burden size [8]. An estimated ing the provision of training and support to TB screen- 20,000 TB patients were present in Iraq, and around 4000 ing programs as well as early detection and diagnosis of died from the disease in 2014 [1, 9]. The estimated inci- TB cases. dence of TB in Iraq was 43/100000 population with nearly 8268 new and relapse cases reported for 2014 [9]. The Methods prevalence of TB in Iraq is estimated at 74/100000 popu- This retrospective cohort study was carried out at the lation, and the mortality is estimated at 3/100000 popula- Chest and Respiratory Disease Center in Erbil city, Kur- tion [1]. In Sulaimaniyah city, the incidence of all distan Region of Iraq. This center was established in registered TB cases in 2011 was 31/100000 population 1978 and has widely expanded with the growth of Erbil with around 89% of patients either recovered or com- population to extend its services to the different districts. pleted treatment successfully, and the death rate was The center is primarily an outpatient specialized and about 7% [10]. consultation clinic. Different types of services are pro- A major challenge facing most TB programs is a pa- vided in the center, including the diagnosis of TB. Any tient that does not complete TB treatment for one rea- patient with suspected TB can visit or be referred to the son or another [11], which contributes to the emergence center, and all necessary investigations will be carried of multidrug-resistant (MDR) TB [12]. The application out after being seen by a specialist physician. All kinds of the directly observed treatment (DOT) has been re- of medications to treat TB are available, and patients get lated to a worldwide reduction in treatment failure, drug the course of treatment with monitoring and continuous resistance, and relapse [13]. However, the impact of follow-up. DOT on reducing TB incidence has been inadequate The records of 728 patients with TB who were regis- due to non-compliance [14]. tered and treated at Erbil Chest and Respiratory Disease Monitoring TB chemotherapy outcome is essential for Center from January 2012 to December 2017 were TB elimination. Even under treatment, more than 10% reviewed. The included patients were fully anonymized of patients might die if adherence to treatment is low or before accessing their files. The study was approved by if the rates of MDR-TB and HIV infection are high [15]. the research ethics committee of the College of Health A study from Cuba reported a death rate of 7% with a Sciences, Hawler Medical University. significantly higher rate among older patients, men, Demographic data, dates of diagnosis and outcome, those coinfected with HIV, and those without a history the site of the disease (pulmonary or extrapulmonary), of incarceration [15]. In a study performed on 202 TB and treatment outcome were retrieved from patients’ re- patients, 190 (94.1) had survived through the entire cords. For demographic data, only information about the follow-up period, and the mortality rate was 5.9% [16]. age, gender, and residence of the patients was available Studying the survival patterns of TB patients might assist on the records. The residence was classified according to in determining the risk factors associated with mortality the four zones of Erbil city. Zone I includes the area in TB patients. Determining the risk factors associated from the center of the city to the 60 m circular street. with death following the diagnosis of TB is crucial to Zone II includes the area from 60 m circular street to predict prognosis in TB patients and adopt effective in- 100 m circular street. Zone III includes the area from terventions to reduce death rates [17]. 100 m circular street to 120 m circular street. Zone IV The national TB program has confirmed a significant includes the area outside 120 m circular street. Thus, rise in TB cases in Iraq over the last few years.
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