Tuberculosis Services and Treatment Outcomes in Private and Public Health Care Facilities in Thailand, 2004–2006

Tuberculosis services and treatment outcomes in private and public health care facilities in Thailand, 2004–2006

N. Chengsorn,* E. Bloss,† R. Anekvorapong,* A. Anuwatnonthakate,‡ W. Wattanaamornkiat,§ S. Komsakorn,¶ S. Moolphate,# P. Limsomboon,** S. Kaewsa-ard,†† S. Nateniyom,‡‡ A. Kanphukiew,‡ J. K. Varma†‡ * Department of Health, Bangkok Metropolitan Health Administration, Bangkok, Thailand; † US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA; ‡ Thailand Ministry of Public Health–US CDC Collaboration, Nonthaburi, § Offi ce of Disease Prevention and Control 7, Ubon-ratchathani, ¶ Chiang Rai Provincial Public Health Offi ce, Chiang Rai, Thailand; # Research Institute of Tuberculosis, Tokyo, Japan; ** Phuket Provincial Public Health Offi ce, Phuket, †† Bamrasnaradura Infectious Diseases Institute, Nonthaburi, ‡‡ Thailand Ministry of Public Health, Nonthaburi, Thailand

SUMMARY

BACKGROUND: The World Health Organization rec- at least two sputum smears examined, were prescribed a ommends that national tuberculosis (TB) programs en- standard anti-tuberculosis regimen and received directly courage public and private providers to follow the ‘In- observed therapy; however, public sector facilities also ternational standards for tuberculosis care’. We assessed performed suboptimally. Treatment outcomes were un- services and treatment outcomes in TB patients in pub- successful for 237 (33%) patients in private facilities, lic and private facilities to inform public-private mix and for respectively 1018 (23%) and 655 (29%) pa- scale-up in Thailand. tients in small and large public facilities. METHODS: We prospectively collected data on TB pa- CONCLUSIONS: TB diagnostic and treatment services tients in four provinces and the national infectious dis- and outcomes should be enhanced in both public and eases hospital during 2004–2006. We analyzed services private facilities in Thailand. Initiatives are needed to and outcomes among new pulmonary TB patients ac- improve treatment outcomes and increase the use of mi- cording to facility type. croscopy, standardized TB regimens, and directly ob- RESULTS: Of 7526 patients, 4539 (60%) were treated served therapy in the public and private sectors. in small public facilities, 2275 (30%) in large public fa- KEY WORDS: tuberculosis; private sector; directly ob- cilities and 712 (10%) in private facilities. Compared served therapy; Thailand; default with the private sector, more public sector patients had

IN 2006, the World Health Organization (WHO) TB. These standards can be used as benchmarks to launched the Second Global Plan to Stop TB, which assess the quality of TB services provided by the dif- called upon countries to expand and enhance the cur- ferent sectors. rent DOTS strategy for tuberculosis (TB) control.1 An Thailand is one of the 22 WHO-designated high- essential component of this plan is the engagement of burden TB countries, with an estimated 90 000 TB private sector health care providers in diagnosing, cases occurring annually (incidence 142 TB cases treating and reporting TB cases according to inter- per 100 000 population).7 In 2006, almost 600 000 national standards, a strategy known as the ‘public- persons were also living with the human immuno- private mix’ (PPM).2 In many countries, particularly defi ciency virus/acquired immune-defi ciency syndrome in Asia, private sector providers diagnose and treat a (HIV/AIDS), and approximately 15–20% of TB cases large number of TB patients.3 Initiatives in several large were HIV-infected.8,9 The private sector is a large Asian countries, such as India and the Philippines, have provider of health care services in Thailand;10 at least demonstrated that PPM is feasible and effective in in- 10% of TB patients are treated in the private sector, creasing case detection and case management.2,4,5 with even higher proportions estimated in the densely The WHO recommends that countries rely on the populated capital city, Bangkok, but systematic, large- ‘International standards for tuberculosis care’ (ISTC) scale PPM has not yet been initiated throughout to help engage the private sector.6 The ISTC describes Thailand.11,12 standards that public and private sector health care To inform the scale-up of PPM DOTS in Thailand, providers should follow when diagnosing or treating we assessed diagnostic and treatment services provided

Correspondence to: Emily Bloss, Division of Tuberculosis Elimination, International Research and Programs Branch, CDC, 1600 Clifton Road, MS E-10 Atlanta, GA 30333, USA. Tel: (+1) 404 639 2658. Fax: (+1) 404 639 1566. e-mail: dpu2@ cdc.gov Article submitted 18 December 2008. Final version accepted 11 March 2009. TB services and outcomes in Thailand 889 to and treatment outcomes of TB patients treated in ful TB treatment outcomes included failure, death public and private sectors, using data collected as part and default. of a prospective, population-based surveillance system Physicians applied independent clinical judgment and, wherever possible, in line with ISTC standards. about measuring CD4+ T-lymphocyte count (CD4), This information can be used by both public and pri- and providing opportunistic infection prophylaxis or vate partners to better understand the status of TB antiretroviral therapy (ART). The Thai Ministry of diagnostic and treatment services in the different sec- Public Health guidelines recommend that HIV-infected tors and where to intensify efforts and resources. patients with CD4 <200 cells/mm3 receive cotrimoxazole (CTX) and recommend ART for HIV-infected < 3 15 METHODS persons with CD4 250 cells/mm . Patients administered at least one dose of ART or CTX were consid- Setting ered to be receiving it throughout TB treatment, re- The Thailand TB Active Surveillance Network is a gardless of adherence or interruptions.16 project implemented in 2004 to provide enhanced surveillance, monitoring, evaluation, and treatment of TB Data analysis in four provinces (all districts in Ubon-rachathani, We limited our analysis to new pulmonary TB patients Phuket, Chiang Rai; nine districts in Bangkok) and the registered for TB treatment between 1 October 2004 national infectious diseases hospital (in Nonthaburi and 30 September 2006 with a known treatment out- Province) in Thailand. In 2006, the catchment area in- come. Patients previously treated for TB or known to cluded 59 public and 26 private health care facilities. have multidrug-resistant TB (MDR-TB) were excluded Staff in participating public and private facilities from the analysis, as such patients are known to have received refresher training on national guidelines for markedly different treatment outcomes than patients TB diagnosis, treatment and case management and never treated for TB.17 Patients diagnosed with extra- on human immunodefi ciency virus (HIV) counseling, pulmonary TB were excluded, as their drug regimen, testing and care and treatment before and during proj- treatment duration and outcomes vary depending upon ect implementation. However, clinicians were not re- the site of the disease.13 We also excluded patients who quired to follow any specifi c standard of TB or HIV transferred in from a different TB program due to in- care and treatment as a part of this project. Provin- complete data on their initial TB treatment. cial TB programs were provided with additional re- Based on known differences in clinical services and sources to support staff training, program monitor- patient populations, we classifi ed treatment facilities ing and evaluation in private and public settings, but into three groups: small public facilities (e.g., public routine TB diagnostic and treatment services were health centers, district hospitals); large public facili- conducted using existing funds. ties (e.g., provincial, regional and Bangkok city hos- Public health staff in each province directly con- pitals); and private facilities. We analyzed differences tacted medical personnel working in both public and in patient characteristics by treatment facility type us- private facilities about case fi nding and management ing the χ2 test for categorical variables. Additional at least once per month to obtain information about post-hoc χ2 tests were conducted to examine relation- each newly diagnosed case of TB. Standardized data ships between each facility type and patient character- were recorded using a modifi ed version of the na- istics. Statistical signifi cance was defi ned as P < 0.05. tional TB register, and data were entered into an elec- We calculated odd ratios (ORs) and 95% confi - tronic database. A more detailed description of this dence intervals (CIs) examining the relationship be- project was published previously.11 tween patient characteristics and unsuccessful treatment, stratifi ed by type of treatment facility in bivariate Data collection and patient population and multivariate analyses. Factors were entered into Demographic, clinical and laboratory data were col- three multivariate logistic regression models based lected prospectively from routine medical and labo- on biological plausibility, previous literature and sta- ratory records for all patients with a diagnosis of TB tistical signifi cance in bivariate analysis. Forward step- in the national infectious diseases hospital or any pub- wise logistic regression was used to construct three lic or private facility in the four provinces. Patients separate models to determine covariates associated were classifi ed according to TB type, previous TB his- with unsuccessful treatment within each facility type. tory and TB treatment outcome using WHO catego- Colinearity and interactions were assessed; no vari- ries.13 According to Thai national and WHO guide- ables included in the fi nal models were found to be lines, a patient could be diagnosed with smear-positive, c olinear and no interaction terms were found to be sig- pulmonary TB based on at least two sputum smears nifi cant. We used the Hosmer-Lemeshow test to eval- positive for acid-fast bacilli (AFB) or one positive uate goodness-of-fi t and the likelihood ratio test to smear and a chest radiograph (CXR) consistent with select the best fi tting models. Data were analyzed us- pulmonary TB.13,14 Successful TB treatment outcomes ing the Statistical Package for Social Science (SPSS, comprised cure and completion outcomes; unsuccess- College Station, TX, USA) for Windows. 890 The International Journal of Tuberculosis and Lung Disease

Ethical review parisons). Sputum examination results were missing This demonstration project underwent ethical review for 190 (27%) private facility patients. Among all TB by the Thailand Ministry of Public Health and the patients treated in private facilities, 96 (14%) had a United States Centers for Disease Prevention and Con- positive mycobacterial culture, compared with 2437 trol; it was determined to be surveillance and public (54%) in small public and 1104 (49%) in large pub- health program implementation, and not human sub- lic health facilities (P < 0.01, both comparisons). jects research needing to be overseen by an institu- A WHO-recommended anti-tuberculosis regimen tional review board. was not prescribed for 144 (20%) private facility patients, compared with 264 (6%) and 98 (4%) patients in small and large public facilities (P < 0.01, both RESULTS comparisons). Overall, 45 patients were prescribed a Study population treatment regimen containing at least one fl uoroqui- Between 1 October 2004 and 30 September 2006, nolone (FQ): 11 (2%) patients were from private fa- 8392 new pulmonary TB patients were treated in pub- cilities, 15 (0.3%) from small public facilities and 19 lic and private facilities in the Active Surveillance Net- (0.8%) from large public facilities. Self-administered work. We excluded 73 patients with MDR-TB, 461 therapy (i.e., no directly observed therapy [DOT]) who transferred in, 161 for whom the diagnosis was was provided for 542 (77%) patients treated at pri- changed and 171 with unknown outcomes, leaving vate facilities compared with 372 (8%) at small and 7526 patients eligible for analysis. Of these, 4539 501 (22%) at large public facilities (P < 0.01, both (60%) were treated in small public facilities, 2275 comparisons). (30%) in large public facilities and 712 (10%) in pri- Treatment outcomes were unsuccessful for 237 vate facilities. (33%) private sector patients and for 1018 (23%) and 655 (29%) patients in small and large public facili- Patient characteristics associated with ties, respectively (P < 0.01, small vs. private; P < 0.05, treatment facility large vs. private). Default rates were highest in pri- Table 1 presents patient characteristics signifi cantly vate facilities. Among patients with poor outcomes, associated with facility type. Most small public facili- 218 (92%) private patients defaulted compared with ties were located outside Bangkok, and a greater pro- 412 (41%) in small and 261 (40%) in large public fa- portion of patients treated at these facilities were cilities (P < 0.01, both comparisons). older (⩾65 years) and married compared with other facility types. Patients from private facilities more of- Factors associated with unsuccessful ten lived in urban areas and were the most mobile, treatment outcomes defi ned as not living in the surveillance area for 3 of In small public facilities, factors signifi cantly associ- the past 6 months. Large public facilities treated the ated with unsuccessful treatment outcome included age, largest proportion of male and Thai patients. marital status, nationality, municipality, mobility, HIV Overall, 1552 (21%) TB patients were known to and ART status, and treatment observer (Table 2). Pa- be HIV-infected. HIV infection accounted for 714 tients with poor treatment outcomes were signifi cantly (31%) patients in large public facilities, 767 (17%) in more likely to be aged >44 years (age 45–64 years, small public facilities and 71 (10%) in private facili- adjusted OR [aOR] 1.9, 95%CI 1.5–2.3) (age ⩾65, ties (P < 0.001, both comparisons). HIV test results aOR 3.2, 95%CI 2.5–4.1), divorced or widowed (aOR were missing for 509 (72%) private facility patients. 1.6, 95%CI 1.3–2.0), have non-Thai nationality (aOR Overall, 647 (42%) and 1196 (77%) of the 1552 3.5, 95%CI 2.6–4.7) and mobile (aOR 1.4, 95%CI HIV-infected patients received ART and CTX, respec- 1.1–1.9). Unsuccessful treatment outcomes were less tively, during TB treatment. ART was prescribed for likely among patients living in an urban area (aOR 289 (38%) patients from small public facilities, 344 0.8, 95%CI 0.6–0.9). Patients with unsuccessful treat- (48%) from large public facilities, and 14 (20%) from ment outcomes were over six times more likely to be private facilities; and the total numbers and propor- HIV-infected and not taking ART (aOR 6.4, 95%CI tions that received CTX were respectively 585 (76%), 5.0–8.1) and twice as likely to be HIV-infected and 595 (83%), and 16 (23%). receiving ART (aOR 2.1, 95%CI 1.5–2.9) than pa- The ISTC recommend that at least two sputum tients without HIV infection. Patients with treatment specimens be examined for diagnosis of pulmonary observers (i.e., DOT) were less likely to have unsuc- TB. We found that 128 (18%) private sector patients cessful outcomes compared with patients with no had two or more smears recorded, compared with treatment observer (aOR 0.6, 95%CI 0.5–0.8). 1095 (48%) from large public facilities and 1831 Similar to small public facilities, older age, being (40%) from small public facilities (P < 0.01, both widowed or divorced and being mobile were found to comparisons). A smear-positive diagnosis was made be associated with unsuccessful treatment outcomes for 2974 (66%) and 1516 (67%) patients from small in large public facilities in multivariate analysis. Pa- and large public facilities, respectively, compared with tients with unsuccessful outcomes were less likely to 330 (46%) from private facilities (P < 0.01, both com- live in an urban area (aOR 0.8, 95%CI 0.6–0.9), more TB services and outcomes in Thailand 891

Table 1 Characteristics of TB patients (n = 7526) by type of treatment facility*†

Small public Large public Private Small public Large public Private facilities facilities facilities facilities facilities facilities (n = 4539) (n = 2275) (n = 712) (n = 4539) (n = 2275) (n = 712) Characteristic n (%) n (%) n (%) Characteristic n (%) n (%) n (%) Socio-demographic Risk factors for TB (continued) Facility location CTX treatment status Bangkok area 498 (11.0) 801 (35.2) 547 (76.8) HIV-infected and not Outside Bangkok 4041 (89.0) 1474 (64.8) 165 (23.2) known to have Age at diagnosis, years received CTX 182 (4.0) 119 (5.2) 55 (7.7) 0–14 51 (1.1) 63 (2.8) 3 (0.4) HIV-infected and known 15–44 2064 (45.5) 1332 (58.5) 506 (71.5) to have received CTX 585 (12.9) 595 (26.2) 16 (2.2) 45–64 1435 (31.6) 585 (25.7) 154 (21.8) Not HIV-infected 3123 (68.8) 1157 (50.9) 132 (18.5) ⩾65 988 (21.8) 294 (12.9) 45 (6.4) HIV infection status Sex missing 649 (14.3) 404 (17.8)509 (71.5) Male 3003 (66.2) 1561 (68.6) 434 (61.0) Diagnosis and treatment Female 1535 (33.8) 714 (31.4) 278 (39.0) At least 2 sputum smears Marital status examined for diagnosis Single 830 (18.3) 694 (30.5) 287 (40.3) pulmonary TB Divorced/widow 720 (15.9) 308 (13.5) 12 (1.7) ⩾2 smears 1831 (40.3) 1095 (48.1) 128 (18.0) Married 2969 (65.4) 1225 (53.8) 229 (32.2) 1 smear 2522 (55.6) 1115 (49.0) 389 (54.6) Data missing 20 (0.4) 48 (2.1) 184 (25.8) Data missing 186 (4.1) 65 (2.9) 195 (27.4) Nationality Type of pulmonary TB Thai 4116 (90.8) 2140 (94.1) 654 (92.2) Smear-positive 2974 (65.5) 1516 (66.6) 330 (46.3) Non-Thai 419 (9.2) 133 (5.9) 55 (7.8) Smear-negative 1562 (34.4) 726 (31.9) 192 (27.0) Living in an urban district Data missing 3 (0.1) 33 (1.5) 190 (26.7) Yes 1402 (30.9) 1152 (50.6) 462 (64.9) Cavitary disease No 3036 (66.9) 1080 (47.5) 174 (24.4) Abnormal radiograph Data missing 101 (2.2) 43 (1.9) 76 (10.7) and cavity present 1289 (28.4) 381 (16.7) 159 (22.3) Mobility‡ Abnormal radiograph Non-mobile 3863 (85.1) 1462 (64.3) 275 (38.6) and no cavity present 2686 (59.2) 1568 (68.9) 406 (57.0) Mobile 587 (12.9) 728 (32.0) 328 (46.1) Normal radiograph 55 (1.2) 25 (1.1) 25 (3.5) Data missing 89 (2.0) 85 (3.7) 109 (15.3) Data missing 509 (11.2) 301 (13.2) 122 (17.1) § Risk factors for TB Sputum culture result Cough lasting >2 weeks Growth of M. tuberculosis 2437 (53.7) 1104 (48.5) 96 (13.5) at diagnosis No growth 786 (17.3) 292 (12.8) 59 (8.3)

Yes 3295 (72.6) 1481 (65.1) 422 (59.3) Data missing 1316 (29.0) 879 (38.6) 557 (78.2) No 1237 (27.3) 634 (27.9) 178 (25.0) Initial treatment prescribed Data missing 7 (0.2) 160 (7.0) 112 (15.7) Category I 4275 (94.2) 2177 (95.7) 568 (79.8) Ever treated with isoniazid Other regimens 264 (5.8) 98 (4.3) 144 (20.2) preventive therapy Fluoroquinolones used Yes 36 (0.8) 17 (0.7) 3 (0.4) during treatment No 4495 (99.0) 2256 (99.2) 659 (92.6) Yes 15 (0.3) 19 (0.8) 11 (1.5) Data missing 8 (0.2) 2 (0.1) 50 (7.0) No 4524 (99.7) 2256 (99.2) 701 (98.5) Ever used injection drugs DOT observer Yes 95 (2.1) 81 (3.6) 6 (0.8) Health care worker 1166 (25.9) 551 (24.3) 5 (0.7) No 4391 (96.7) 1966 (86.4) 382 (53.7) Family 2969 (65.9) 1219 (53.7) 157 (22.3) Data missing 53 (1.2) 228 (10.0) 324 (45.5) Self-administered/other 372 (8.3) 501 (22.1) 542 (77.0) HIV status Final treatment outcome HIV-infected 767 (16.9) 714 (31.4) 71 (10.0) Cured 2256 (49.7) 894 (39.3) 60 (8.4) Not HIV-infected 3123 (68.8) 1157 (50.9) 132 (18.5) Completed 1265 (27.9) 726 (31.9) 415 (58.3) Data missing 649 (14.3) 404 (17.8) 509 (71.5) Failure 76 (1.7) 30 (1.3) 7 (1.0) ART treatment status Died 530 (11.7) 364 (16.0) 12 (1.7) HIV-infected and not Default 412 (9.1) 261 (11.5) 218 (30.6) known to have received ART 478 (10.5) 370 (16.3) 57 (8.0) HIV-infected and known to have received ART 289 (6.4) 344 (15.1) 14 (2.0) Not HIV-infected 3123 (68.8) 1157 (50.9) 132 (18.5) HIV infection status missing 649 (14.3) 404 (17.8)509 (71.5)

* The χ2 test was used to examine the association between type of facility and each patient characteristic; all associations in the Table are signifi cant at least at the P < 0.01 level. † Cell counts do not always sum to column total due to missing data. ‡ Mobile defi ned as not living in the same district for at least 3 of the past 6 months. §I ncludes cultures that were not done, were contaminated or developed non-tuberculous mycobacteria. TB = tuberculosis; HIV = human immunodefi ciency virus; ART = antiretroviral therapy; CTX = cotrimoxazole; DOT = directly observed therapy. likely to be male (aOR 1.3, 95%CI 1.1–1.7), and comes occurred more frequently in patients who were more likely to be HIV-infected and not receiving ART male (aOR 1.8, 95%CI 1.3–2.5), treated in Bangkok (aOR 7.5, 95%CI 5.7–10.0). (aOR 1.9, 95%CI 1.3–2.9) and not of Thai national- In private facilities, we found that unsuccessful out- ity (aOR 2.5, 95%CI 1.4–4.3). 892 The International Journal of Tuberculosis and Lung Disease

Table 2 Multivariate analysis of factors associated with unsuccessful treatment outcomes stratiﬁ ed by type of treatment facility*

Small public facilities Large public facilities Private facilities (n = 4539) (n = 2275) (n = 712) Not successful Adjusted OR Not successful Adjusted OR Not successful Adjusted OR n/N (%) (95%CI) n/N (%) (95%CI) n/N (%) (95%CI) Socio-demographic Facility location Bangkok area 67/498 (13.5) 245/801 (30.6) 200/547 (36.6) 1.9 (1.3–2.9) Outside Bangkok 951/4041 (23.5) 410/1474 (27.8) 37/165 (22.4) Referent Age, years 0–14 8/51 (15.7) 0.5 (0.2–1.2) 17/63 (27.0) 1.3 (0.7–2.5) 2/3 (66.7) 15–44 409/2064 (19.8) Referent 347/1332 (26.1) Referent 163/506 (32.2) 45–64 298/1438 (20.8) 1.9 (1.5–2.3) 178/585 (30.4) 1.7 (1.3–2.2) 50/154 (32.5) ⩾65 302/988 (30.6) 3.2 (2.5–4.1) 113/294 (38.4) 2.8 (2.0–3.9) 21/45 (46.7) Sex Male 684/3003 (22.8) 473/1561 (30.3) 1.4 (1.1–1.7) 165/434 (38.0) 1.8 (1.3–2.5) Female 333/1535 (21.7) 182/714 (25.5) Referent 72/278 (25.9) Referent Marital status Single 162/830 (19.5) 1.1 (0.9–1.4) 184/694 (26.5) 0.9 (0.7–1.2) 93/287 (32.4) Divorced/widow 229/720 (31.8) 1.6 (1.3–2.0) 131/308 (42.5) 1.7 (1.3–2.2) 4/12 (33.3) Data missing 5/20 (25.0) 0.7 (0.2–2.7) 14/48 (29.2) 1.2 (0.6–2.3) 68/184 (37.0) Married 622/2969 (20.9) Referent 326/1225 (26.6) Referent 72/229 (31.4) Thai nationality Thai 820/4116 (19.9) Referent 626/2140 (29.3) 205/654 (31.3) Referent Non-Thai 196/419 (46.8) 3.5 (2.6–4.7) 29/133 (21.8) 31/55 (56.4) 2.5 (1.4–4.3) Living in an urban district Yes 248/1402 (17.7) 0.8 (0.6–0.9) 303/1152 (26.2) 0.6 (0.5–0.8) 159/462 (34.4) Data missing 19/101 (18.8) 0.9 (0.5–1.5) 7/43 (16.3) 0.4 (0.1–1.0) 35/76 (46.1) No 751/3036 (24.7) Referent 345/1080 (31.9) Referent 43/174 (24.7) Mobile† Mobile 793/3863 (20.5) 1.4 (1.1–1.9) 380/1462 (26.0) 1.8 (1.4–2.2) 80/275 (29.1) Data missing 13/89 (14.6) 0.7 (0.4–1.3) 19/85 (22.4) 1.3 (0.7–2.4) 37/109 (33.9) Non-mobile 212/587 (36.1) Referent 256/728 (35.2) Referent 120/328 (36.6) Risk factors for TB HIV-ART treatment status HIV infected and not known to have received ART 215/478 (45.0) 6.4 (5.0–8.1) 228/370 (61.6) 7.5 (5.7–10.0) 19/57 (33.3) HIV infected and known to have received ART 57/289 (19.7) 2.1 (1.5–2.9) 72/344 (20.9) 1.2 (0.8–1.6) 6/14 (42.9) HIV infection status missing 233/649 (35.9) 2.2 (1.8–2.7) 108/404 (26.7) 1.3 (1.0–1.7) 170/509 (33.4) Not HIV-infected 513/3123 (16.4) Referent 247/1157 (21.3) Referent 42/132 (31.8) Diagnosis and treatment DOT observer Health care worker 218/1166 (18.7) 0.6 (0.5–0.8) 128/551 (23.2) 1/5 (20.0) Family 647/2969 (21.8) 0.6 (0.5–0.8) 383/1219 (31.4) 47/157 (29.9) Self-administered/other 147/372 (39.5) Referent 141/501 (28.1) 186/542 (34.3)

* Multivariate logistic regression models were run separately for each type of facility. † Defi ned as not living in the same district for at least 3 of the past 6 months. OR = odds ratio; CI = confi dence interval; TB = tuberculosis; HIV = human immunodefi ciency virus; ART = antiretroviral therapy.

DISCUSSION regimens has important implications for TB control by prolonging infectiousness, reducing the likelihood The ISTC describes a widely accepted level of care of cure and selecting for drug resistance.18 Use of FQs that all public and private practitioners should seek to is of concern because this class of medications is con- achieve. Using the ISTC, we found that TB diagnostic sidered a reserve medication exclusively for use in pa- and treatment services and outcomes can be enhanced tients with drug-resistant TB.19 Widespread use of in both public and private facilities in Thailand. Spe- such drugs could select for resistant strains.20 It is un- cifi c areas where efforts should be intensifi ed include clear why non-standard regimens were used in Thailand. the use of standard TB regimens, DOT, microscopy- In Vietnam, the most commonly reported reasons for based diagnosis, and HIV testing and treatment. not using recommended regimens included lack of The ISTC recommends that patients receive an in- con fi dence in regimen effectiveness (36%) and per- ternationally accepted fi rst-line anti-tuberculosis regi- ceived inconvenience and/or risk involved in strepto- men. In this project, both public and private sector pa- mycin injections (27%).21 Thai public health offi cials tients were occasionally prescribed non-standard TB should consider approaches such as ‘academic detail- treatment regimens and FQs; however, this was more ing’ (university-based educational outreach), which frequent in the private sector. Use of non-standardized have been shown in the United States to improve drug TB services and outcomes in Thailand 893 prescribing practices.22 Such provider-targeted strat- pulmonary TB cases. For example, standards related egies may help ensure that treatment is consistent to management of TB suspects or retreatment and with medical evidence in both the public and private extra-pulmonary cases were not addressed. A strength sectors. of the study is that it included comparable data about Patient-centered strategies to promote treatment ad- diagnostic practices and treatment services and out- herence, such as DOT, are recommended by the ISTC. comes from both public and private sectors across a In Thailand, approximately one quarter of patients in large, diverse patient population in a country with a private settings, three quarters in large public facili- high burden of TB and a generalized HIV epidemic. ties and almost all patients in small public facilities received DOT. DOT was strongly associated with suc- Acknowledgements cessful treatment outcomes in small public facilities. This project was supported by the US Centers for Disease Control A study from India found that treatment outcomes for and Prevention and the United States Agency for International De- private sector patients receiving DOT were similar to velopment (USAID). Some authors from this publication are em- those achieved in patients receiving DOT in the pub- ployed by the CDC. USAID was not involved in the design, analy- 23 sis or writing of this manuscript. The fi ndings and conclusions in lic sector. Authors attributed the similar outcomes this report are those of the authors and do not necessarily repre- to ongoing supervision of private DOT providers by sent the offi cial position of the CDC. the public sector TB program staff. Similar creative PPM approaches may be useful to facilitate DOT up- take in private facilities in Thailand. 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RÉSUMÉ

CONTEXTE : L’Organisation mondiale de la santé re- vices privés. Par comparaison avec le secteur privé, un commande que les programmes nationaux de tubercu- plus grand nombre de patients du secteur public ont bé- lose (TB) encouragent les pourvoyeurs de soins publics néfi cié de l’examen d’au moins deux frottis de crachats et privés à respecter les Standards internationaux pour et se sont vu prescrire un régime standard de la TB ad- la prise en charge de la TB. Nous avons évalué les ser- ministré sous forme directement observée ; toutefois, les vices et les résultats du traitement chez les patients tu- performances des services du secteur public sont subopti- berculeux dans les services publics et privés pour fournir males. Le traitement n’a pas été couronné de succès chez des informations au sujet de l’extension de l’approche 237 patients (33%) des services privés et respectivement mixte publique-privée en Thaïlande. chez 1018 (23%) et 655 (29%) patients dans les ser- MÉTHODES : Nous avons colligé de façon prospective vices publics petits ou grands. des données sur les patients TB dans quatre provinces et CONCLUSIONS : Les services de diagnostic et de traite- à l’hôpital national des maladies infectieuses au cours ment de la TB et leurs résultats devraient être renforcés des années 2004–2006. Nous avons analysé les services à la fois dans les services publics et privés de Thaïlande. et les résultats chez les nouveaux patients atteints de TB Des initiatives s’imposent pour améliorer les résultats pulmonaire en fonction du type de service. du traitement et pour accentuer l’utilisation de l’examen RÉSULTATS : Sur 7526 patients, 4539 (60%) ont été microscopique et celle des régimes standardisés de TB et traités dans de petits services publics, 2275 (30%) dans du traitement directement observé dans les secteurs tant de grands services publics et 712 (10%) dans des ser- publics que privés.

RESUMEN

MARCO DE REFERENCIA : La Organización Mundial atención del sector público y 2275 (30%) en grandes cen- de la Salud recomienda que los programas nacionales de tros y 712 (10%) en los centros privados. Los pacientes lucha contra la tuberculosis (TB) inciten a los provee- que contaron como mínimo con dos muestras de esputo dores de atención sanitaria del sector público y del sec- examinadas, recibieron una pauta antituberculosa es- tor privado a cumplir con las Normas Internacionales de tándar y un tratamiento directamente observado, fueron Tratamiento de la Tuberculosis. En el presente estudio más numerosos en el sector público que en el privado, se evaluaron los servicios de diagnóstico y tratamiento y pero los establecimientos del sector público exhibieron los desenlaces clínicos de los pacientes con TB atendi- también prestaciones defi cientes. Se observó fracaso tera- dos en centros públicos y privados, con el fi n de funda- péutico en 237 pacientes (33%) tratados en el sector pri- mentar una ampliación de la cooperación entre ambos vado, en 1018 (23%) de los pacientes atendidos en pe- sectores en Tailandia. queños centros y en 655 (29%) de los tratados en grandes MÉTODOS : Se recogieron en forma prospectiva los da- centros del sector público. tos de los pacientes con TB en cuatro provincias y el hos- CONCLUSIONES : Es preciso fortalecer los servicios de pital nacional de enfermedades infecciosas entre 2004 y diagnóstico y tratamiento de la TB en los centros sani- 2006. Se analizaron los servicios y los desenlaces clínicos tarios del sector público y del sector privado en Tailandia. de los casos nuevos de TB pulmonar en función del tipo En ambos sectores se requieren iniciativas que mejoren de centro de atención. los desenlaces terapéuticos, aumenten el recurso a la mi- RESULTADOS : De los 7526 pacientes estudiados, 4539 croscopia, las pautas normalizadas y las estrategias de (60%) recibieron tratamiento en pequeños centros de tratamiento directamente observado.