Journal of Community Medicine and Primary Health Care. 30 (1) 34-46 JOURNAL OF COMMUNITY MEDICINE AND PRIMARY HEALTH CARE ORIGINAL ARTICLE Profile and Treatment Outcomes of Patients with Tuberculosis: A Five- year Review of Patients on DOTS in Delta State, Nigeria Eze GU1, Aduh U2, Obiebi IP1, Obodo KT3 1Department of Community Medicine, Delta State University Teaching Hospital, Oghara, Delta State. 2State Tuberculosis and Leprosy Control Programme, Department of Public health, Asaba, Delta State. 3Sickbay, St. John of God Secondary School, Awka, Anambra State. ABSTRACT Background: Tuberculosis (TB), the second leading cause of death among infectious diseases Keywords: continues to be a major public health threat worldwide, more so in the developing world. Several strategies have been tried in the past to address its burden, including Directly Tuberculosis; Observed Therapy Short-course (DOTS), DOTS plus, and the Stop TB Strategy. Amid these DOTS; Case efforts, TB is now listed amongst the top re-emerging diseases in the world. This study Detection; identified trends in TB case detection, major type of TB, patient demographics, AFB positive rates, and treatment outcomes within the period reviewed. AFB Positive Rate; Methods: In this descriptive records review of years 2011-2015, existing data was extracted Treatment from tuberculosis central registers from all sites in Delta State, Nigeria. The data was analysed using winPEPI and EPIDATA software solutions and presented in tables and charts. Success Results: Tuberculosis case detection declined between 2011 and 2015. Patients aged 25–34 years were the largest proportion. Males outnumbered females in total but the proportion of females was higher among 5 to 34 year olds. Treatment success rate improved from 68.3% in 2011 to 88.0% in 2014. Sputum AFB positive rate was <60% for 2011 – 2014 but rose above 70% in 2015. Prevalence of extra-pulmonary TB was 2% for all the years reviewed except 2013 which had a small variation. The proportion of patients lost to follow-up declined from 2011 through 2015. Conclusion: The Delta State Tuberculosis Control Programme improved in case-holding. These gains need to be sustained to keep up with the stipulations of the National Tuberculosis Control Programme. Correspondence to: Dr. Irikefe Obiebi Department of Community Medicine Delta State University Teaching Hospital Oghara, Delta State. Email: [email protected] Telephone: 08067315468 INTRODUCTION diseases and continues to be a major public health threat worldwide. It is a debilitating Mycobacterium tuberculosis infection is a major disease with a greater prevalence and severity infectious cause of deaths globally, mostly in in a background of reduced immunity. In developing countries.1 It is still the second more recent years, it has become even more leading cause of death among the infectious 34 JOURNAL OF COMMUNITY MEDICINE AND PRIMARY HEALTH CARE VOL. 30, NO 1, MARCH 2018 complex due to a rise in its drug-resistant only became profound in the last decade when strains, amidst a range of other issues STOP TB strategy was introduced so much including human immunodeficiency virus that within a period of five years (2006-2010) (HIV) co-infection and TB (tuberculosis) co- the death rate from TB was halved.6 morbidities - diabetes, congestive heart failure, In Delta State, though the incidence was as asbestosis, sarcoidosis, etc.2 Several strategies high as 2500 new cases recorded in 2010, with for tuberculosis control were formulated intensified efforts towards elimination the through the mid-twentieth to the twenty-first figures for new TB cases have reduced centuries, namely DOTS, DOTS plus and the significantly in subsequent years. 6 The policy Stop TB strategy intended to reduce the of the national programme in Nigeria is for all burden of this disease.3, 4 Amid all efforts to patients to be treated free of charge using control TB, the tide is not abating; instead it is DOTS strategy for six months in pulmonary reappearing in almost epidemic proportions TB cases, and twelve months for TB meningitis and now listed amongst the top re-emerging and spine. In many developing countries diseases, mainly because of increasing multi- including Nigeria, Sputum Smear Microscopy drug resistance and co-infection with human (SSM) is the most widely used test for the immunodeficiency virus (HIV). Till date, no diagnosis of pulmonary tuberculosis in other disease in history matches the sheer accordance with the International Standards on magnitude of the misery inflicted by TB on the Tuberculosis Care.11, 12 The implementation of human race in terms of morbidity and DOTS, which has been long established in mortality.5 Nigeria, is practised through sites distributed in the various states of the country. Since the In Nigeria, tuberculosis is one of the top public national programme has set targets and health problems, ranking fourth among the 30 indicators for the tuberculosis control in high-burden TB countries in the world.5 There Nigeria, it is imperative that we assess the were 90,447 TB cases notified in 2010 with performance of the Delta State TB programme. 41,416 (58%) new smear positive cases, and a This would enable us identify its achievements case detection rate of 40% in Nigeria.6 and opportunity areas and enlighten Although targets were set to reverse the stakeholders on the way forward. This study incidence, half the prevalence and mortality, therefore aimed to provide a summary diagnose 70 percent of new smear-positive description of patients who received DOTS for cases and cure 85 percent of tuberculosis cases tuberculosis in Delta State, Nigeria. The by 2015, for many countries, these targets were prevalence of tuberculosis, age/sex not achieved despite the current existence of distribution, new smear positive cases, the interventions.7, 8 New TB cases were estimated major type of TB seen, and treatment outcomes to be 10.6 million globally in 2016, with 1.4 including cure rates, failure, loss to follow up million deaths and an additional 0.4 million (LTFU) and death rates among tuberculosis deaths among persons co-infected with patients managed at DOTS centres over a five– human immunodeficiency virus; 95% of these year period were reported. occurred in developing countries.9 With the setting up of the national tuberculosis control METHODOLOGY programme in 1989 several strategies, including DOTS, have been adopted to combat This descriptive study involving the use of the persistently high burden of TB in Nigeria. pre-existing data (from January, 2011 through 10 However, the gains of such interventions December, 2015) from all ninety-eight TB- 35 JOURNAL OF COMMUNITY MEDICINE AND PRIMARY HEALTH CARE VOL. 30, NO 1, MARCH 2018 DOTS sites in the three senatorial zones of 1.2%). Although the proportion of females was Delta State was conducted in a period from higher than the males, for age groups 5-14 March - June, 2017. (males: 2.1%, Females: 3.7%), 15-24 (males: 13.4%, females: 18.5%) and 25-34 (males: Brief description of TB-DOTS in Delta state: 24.7%, females: 29.8%) years, the relative There are 98 DOTS centres spread across all 25 number of males was consistently higher than LGAs in the state and a TB referral centre in that of females for all the years reviewed. Ethiope-East LGA. Each centre is manned by (Table 1) Each year, age-group 25–34 years health workers who report to the Local made up the modal age group of new sputum Government TB Programme Control Officer smear positive TB cases presenting at DOTS who is accountable to the State TB Control clinics. The next highest frequencies were seen Programme Coordinator. in age groups 35-44 years and 15-24 years. Data collection: Data was extracted from a There was less than an average of 1 (0.1%) case standardized and updated State Tuberculosis of sputum smear positive TB among 0–4 year Central Registry using a proforma. The State olds in the 5 years reviewed. Sputum smear Tuberculosis Central Registry from which data positive TB was more common among males extracted was up-to-date at the time of this for all age groups except among 5–34 years study and the challenge with missing data was olds where the proportions were higher circumvented. among females. (Table 2) Ethical consideration: Ethical clearance was There was a consistent decline in the total obtained from the Ethical Review Board of number of TB cases seen each year: from 3076 Delta State Ministry of Health, Asaba before in 2011 to 2349 in 2015; but the proportion of conducting this study. Patient confidentiality AFB positive cases fluctuated during the years was maintained throughout the study as no reviewed. AFB+/N ratio were as follows: information that could personally identify 2011: 51.8%, 2012: 56.4%, 2013: 54.0%, 2014: them was used. 56.1%, and 2015: 70.6%. (Figure 1) Although Data analysis: Data was analysed to identify total number of TB patients on DOTS care was trends using Microsoft Excel, winPEPI and on the decline, the proportion of new patients Epidata software solutions. The results were registering into the program each year was on represented using frequency tables and charts. the increase from 2011 through 2015. The newly registered cases were 85.5% in 2011 and RESULTS gradually rose to 97.8% in 2015 except for 2012 The total number of TB patients seen at DOTS when newly registered cases constituted 93.9% clinics in Delta State in the five years reviewed which was higher than the newly registered was 13,635. There was a steady yearly decline cases in 2013. (Figure 2) The relative in the number of TB cases from 2011 to 2015: proportion of pulmonary tuberculosis (PTB) the count in 2011 was 3076 while that in 2015 and extra-pulmonary tuberculosis (EPTB) was 2349.