Catastrophic costs incurred by tuberculosis affected households from Thailand's first national tuberculosis patient cost survey.

Tuberculosis (TB) causes an economic impact on the patients and their households. Although Thailand has expanded the national health benefit package for TB treatment, there was no data on out-of-pocket payments and income losses due to TB from patients and their household perspectives. This national TB patient cost survey was conducted to examine the TB-related economic burden, and assess the proportion of TB patients and their households facing catastrophic total costs because of TB disease. A cross-sectional TB patient cost survey was employed following WHO methods. Structured interviews with a paper-based questionnaire were conducted from October 2019 to July 2021. Both direct and indirect costs incurred from the patient and their household perspective were valued in 2021 and estimated throughout pre- and post-TB diagnosis episodes. We assessed the proportion of TB-affected households facing costs > 20% of household expenditure due to TB. We analyzed 1400 patients including 1382 TB (first-line treatment) and 18 drug-resistant TB patients (DR-TB). The mean total costs per TB episode for all study participants were 903 USD (95% confident interval; CI 771-1034 USD). Of these, total direct non-medical costs were the highest costs (mean, 402 USD, and 95%CI 334-470 USD) incurred per TB-affected household followed by total indirect costs (mean, 393 USD, and 95%CI 315-472 USD) and total direct medical costs (mean, 107 USD, and 95%CI 81-133 USD, respectively. The proportion of TB-affected households facing catastrophic costs was 29.5% (95%CI 25.1-34.0%) for TB (first-line), 61.1% (95%CI 29.6-88.1%) for DR-TB and 29.9% (95%CI 25.6-34.4%) overall. This first national survey highlighted the economic burden on TB-affected households. Travel, food/nutritional supplementation, and indirect costs contribute to a high proportion of catastrophic total costs. These suggest the need to enhance financial and social protection mechanisms to mitigate the financial burden of TB-affected households.

Genomic Sequencing Profiles of Mycobacterium tuberculosis in Mandalay Region, Myanmar.

This study aimed to characterize whole-genome sequencing (WGS) information of Mycobacterium tuberculosis (Mtb) in the Mandalay region of Myanmar. It was a cross-sectional study conducted with 151 Mtb isolates obtained from the fourth nationwide anti-tuberculosis (TB) drug-resistance survey. Frequency of lineages 1, 2, 3, and 4 were 55, 65, 9, and 22, respectively. The most common sublineage was L1.1.3.1 (n = 31). Respective multi-drug resistant tuberculosis (MDR-TB) frequencies were 1, 1, 0, and 0. Four clusters of 3 (L2), 2 (L4), 2 (L1), and 2 (L2) isolates defined by a 20-single-nucleotide variant (SNV) cutoff were detected. Simpson's index for sublineages was 0.0709. Such high diversity suggests that the area probably had imported Mtb from many geographical sources. Relatively few genetic clusters and MDR-TB suggest there is a chance the future control will succeed if it is carried out properly.

Association of Health Insurance and Documentation with Stigma and Social Support Among Myanmar Migrants with Tuberculosis Before and During Thailand's Policy on Border Closure Due to COVID-19: a Cross-Sectional Study.

OBJECTIVE: The objective of this study was to assess the effect of health insurance and documentation status on tuberculosis (TB)-related stigma and social support before and during Thailand's policy on border closure. METHODS: A cross-sectional study was conducted in two TB clinics in Mae Sot district, a border area of Thailand. Myanmar migrants with new TB were interviewed before (between September 2019 and March 2020) and during Thailand's policy (between April 2020 and January 2021). We used multiple linear regression models to assess the association of health insurance and documentation status with stigma and social support before and during the policy on border closure. RESULTS: Of 229 migrants diagnosed new TB recruited, 117 and 112 were interviewed before and during Thailand's policy on border closure. The relationship of stigma with health insurance and documentation status was modified by the policy. Migrants with health insurance reported significantly lower stigma during the policy compared to those without health insurance, whereas documented migrants had lower stigma before the policy compared to undocumented migrants. No significant association of health insurance and documentation status with social support was observed. Ethnicity, perceived TB severity and education level were also independently associated with TB-related stigma. CONCLUSION: The relationships between health insurance, documentation status and TB-related stigma were modified by Thailand's policy on border closure among Myanmar migrants with TB in a border area of Myanmar and Thailand. Promotion of health insurance and well-planned documentation for migrants should be more discussed and strengthened among stakeholders and policymakers.

Whole-genome analysis of drug-resistant Mycobacterium tuberculosis reveals novel mutations associated with fluoroquinolone resistance.

Multidrug-resistant and extensively drug-resistant tuberculosis (M/XDR-TB) remains a global public-health challenge. Known mutations in quinolone resistance-determination regions cannot fully explain phenotypic fluoroquinolone (FQ) resistance in Mycobacterium tuberculosis (Mtb). The aim of this study was to look for novel mutations in Mtb associated with resistance to FQ drugs using whole-genome sequencing analysis. Whole-genome sequences of 659 Mtb strains, including 214 with phenotypic FQ resistance and 445 pan-susceptible isolates, were explored for mutations associated with FQ resistance overall and with resistance to individual FQ drugs (ofloxacin, levofloxacin, moxifloxacin and gatifloxacin). Three novel genes (recC, Rv2005c and PPE59) associated with FQ resistance were identified (P < 0.00001 based on screening analysis and absence of relevant mutations in a pan-susceptible validation set of 360 strains). Nine novel single nucleotide polymorphisms (SNPs), including in gyrB (G5383A and G6773A), gyrA (G7892A), recC (G725900C and G726857T/C), Rv2005c (C2251373G, G2251420C and C2251725T) and PPE59 (C3847269T), were used for diagnostic performance analysis. Enhancing the known SNP set with five of these novel SNPs, including gyrA [G7892A (Leu247Leu)], recC [G725900C (Leu893Leu) and G726857T/C (Arg484Arg)], Rv2005c [G2251420C (Pro205Arg)] and PPE59 [C3847269T (Asn35Asn)] increased the sensitivity of detection of FQ-resistant Mtb from 83.2% (178/214) to 86.9% (186/214) while maintaining 100% specificity (360/360). No specific mutation associated with resistance to only a single drug (ofloxacin, levofloxacin, moxifloxacin or gatifloxacin) was found. In conclusion, this study reports possible additional mutations associated with FQ resistance in Mtb.

Changes in health-related quality of life and the associated factors among Myanmar migrants with tuberculosis: a cohort study.

BACKGROUND: Migrants are known to be predominantly poor population which are predisposing to social and health problems, particularly infectious diseases including tuberculosis (TB). TB itself and effect of treatment may further result in substantial morbidity and lowering the quality of life. This study aimed to assess the changes in health-related quality of life (HRQOL) within six months of anti-TB treatment initiation, and the associated factors in Myanmar migrants under anti-TB treatment within this border area. METHODS: This was a prospective cohort study of adult Myanmar migrants with new TB who were within two months of treatment initiation in two TB clinics in Mae Sot, a Thai-Myanmar border area between September 2019 and July 2020. Eight individual domain scores of the HRQOL and Physical and Mental Component Summary (PCS and MCS) scores measured by SF-36 were calculated at month-2 (T1) as baseline, and at the month-4 (T2) and month-6 follow-up visits (T3). Generalized estimation equation models were used to assess the longitudinal changes in PCS and MCS scores of HRQOL. RESULTS: Of the 155 patients recruited, 93 (60.0%) and 65 (69.9%) completed the month-4 and month-6 follow-ups, respectively. Both the PCS (+ 6.1) and MCS (+ 6.3) scores significantly improved between T1 and T3, with the lowest scores being general health, with the least improvement in social function (+ 1.5) compared with the other domains. Migrants with ethnic origin of Burmese or other were associated with higher PCS and MCS. Those living with family and having higher numbers of initial TB symptoms were associated with lower PCS and MCS scores. Those diagnosed during routine medical checkup were positively associated with PCS scores, whereas patients diagnosed during active case findings were negatively associated with MCS scores. Patients who received residential TB care had higher PCS scores than those with OPD-based TB care. CONCLUSIONS: Continuous improvement in quality of life was found among Myanmar migrants with TB during treatment but their quality of life is still low. Patients with low mental health, especially in the social domain, requires further attention. Active screening policy and supportive strategies during treatment are essential to TB migrants.

Clusters of Drug-Resistant Mycobacterium tuberculosis Detected by Whole-Genome Sequence Analysis of Nationwide Sample, Thailand, 2014-2017.

Multidrug-resistant tuberculosis (MDR TB), pre-extensively drug-resistant tuberculosis (pre-XDR TB), and extensively drug-resistant tuberculosis (XDR TB) complicate disease control. We analyzed whole-genome sequence data for 579 phenotypically drug-resistant M. tuberculosis isolates (28% of available MDR/pre-XDR and all culturable XDR TB isolates collected in Thailand during 2014-2017). Most isolates were from lineage 2 (n = 482; 83.2%). Cluster analysis revealed that 281/579 isolates (48.5%) formed 89 clusters, including 205 MDR TB, 46 pre-XDR TB, 19 XDR TB, and 11 poly-drug-resistant TB isolates based on genotypic drug resistance. Members of most clusters had the same subset of drug resistance-associated mutations, supporting potential primary resistance in MDR TB (n = 176/205; 85.9%), pre-XDR TB (n = 29/46; 63.0%), and XDR TB (n = 14/19; 73.7%). Thirteen major clades were significantly associated with geography (p<0.001). Clusters of clonal origin contribute greatly to the high prevalence of drug-resistant TB in Thailand.

Contact tracing for tuberculosis, Thailand.

PROBLEM: Despite implementation of universal health coverage in Thailand, gaps remain in the system for screening contacts of tuberculosis patients. APPROACH: We designed broader criteria for contact investigation and new screening practices and assessed the approach in a programme-based operational research study in 2017-2018. Clinic staff interviewed 100 index patients and asked them to give household and non-household contacts an invitation for a free screening and chest X-ray. Contact persons who attended received 250 Thai baht (about 8 United States dollars) allowance for transport. LOCAL SETTING: Chiang Rai province, Thailand, has high rates of tuberculosis notification and a high number of people living in poverty. The coverage of contact investigation in under 5-year-olds was only 33.2% (222 screened out of 668 contacts) over 2011-2015. RELEVANT CHANGES: Index patients identified 440 contacts in total and gave invitation cards to 227 of them. The contact investigation coverage was 81.1% (184/227) and tuberculosis detection among contacts screened was 6.0% (11/184). Of the 11 contacts with active tuberculosis, three did not have tuberculosis symptoms, three were non-household contacts and three were contacts of non-smear-positive tuberculosis patients. The contact investigation coverage of the contacts younger than 5 years was 100% (14/14) and the yield of tuberculosis detection in this age group was 21.4% (3/14). LESSONS LEARNT: High coverage of contact investigation with a high yield of tuberculosis detection among contacts can be achieved by applying broader criteria for contact investigation and providing financial support for transportation.

Evaluation of Proinflammatory Cytokines and Adverse Events in Healthy Volunteers upon Inhalation of Antituberculosis Drugs.

Inhalation therapy is a promising drug delivery approach for tuberculosis treatment. However, there is always concern about the safety of the dosage form by inhalation as it may induce inflammation. Developing a new dosage form for inhalation must include tests for its safety especially for the tumor necrosis factor (TNF)-α and interleukine (IL)-1ß. The safety of four anti-tuberculosis (anti-TB) drugs administered via inhalation was assessed in healthy volunteers. Four anti-TB drugs; isoniazid, rifampicin, pyrazinamide and levofloxacin were prepared as dry powder and evaluated for uniformity of delivered dose and in vitro drug deposition. These four anti-TB dry powder formulations for inhalation met the criteria of uniformity of delivered dose and exhibited suitable size for lung delivery. Forty healthy volunteers were recruited and each was sequentially challenged with isoniazid, rifampicin, pyrazinamide and levofloxacin in different orders. Safety was monitored by measuring the pro-inflammatory cytokines in their sputum, lung function test, blood chemistry and adverse events. This study proves that all four anti-TB dry powders did not provoke inflammatory cytokines and are safe to healthy volunteers.

Hospital tuberculosis control activities and treatment success in Thailand during the implementation year of the admission policy for new smear positive pulmonary tuberculosis patients.

OBJECTIVE: To demonstrate the tuberculosis (TB) control activities in hospital and treatment success rate during the implementation year of the admission policy. MATERIAL AND METHOD: The hospital-based survey was conducted in 12 provinces, five hospitals of each province. The medical records of hospitalized patients, with new sputum smear positive (NSS+) pulmonary tuberculosis (PTB), registered between October 2008 and September 2009 were reviewed, as well as the TB control activities. RESULTS: Fifty-one hospitals with complete hospital information were included Of 2,290 patients, less than half(46.1%) were hospitalized, while the treatment success rate was 83.8% (1,921 patients). This is slightly lower than World Health Organization target of 85%. In 2009, the six main control activities implemented in the studied hospital as part of the National Tuberculosis Program guideline of 15 items were 1) annual plan project for TB control program (51/51 hospitals, 100%), 2) protective equipment to prevent TB infection for personnel (50/51 hospitals, 98.0%), 3) appointment of committee in hospital for TB control program (49/51, 96.0%), 4) surveillance TB infection system in hospital for personnel (49/51, 96.0%), 5) protective equipment protection TB infection (mask) for patients and relatives (48/51 hospitals, 94.1%), and 6) intensive health education for NSS+ PTB patients with admission (48/51 hospitals, 94.1%). CONCLUSION: During the implementation year of admission policy, the hospitalization rate was low and treatment success rate was not as high as expected. However the enhanced effect of program activities on admission and treatment success was not fully supported by the present study.

Barriers to and motivations for the implementation of a treatment programme for latent tuberculosis infection using isoniazid for people living with HIV, in upper northern Thailand.

BACKGROUND: Isoniazid Preventive Therapy (IPT) has been recommended by WHO/UNAIDS for people living with HIV (PLWH) since 1993; however the uptake of IPT implementation has been very low globally. This study aims to assess the barriers to and motivations for the implementation of IPT for PLWH in upper northern Thailand, an area with a high tuberculosis (TB) and human immunodeficiency virus (HIV) burden. METHODS: A survey was carried out via self-administered questionnaires mailed to healthcare workers (HCW) in all 95 public hospitals in the upper northern region of Thailand. A reminding phone call, one month after sending the mail, was made. RESULTS: The response rate from the hospitals was 94% and from the HCW's, 70%. IPT programme was being implemented at only 18 (20%) out of the 89 public hospitals. The main barriers as reported by 144 HCWs working in hospitals without IPT programme, were: (1) unclear direction of national policy (60%), (2) fear of emerging Isoniazid resistant tuberculosis (52%), and (3) fear of poor adherence (30%). The 38 HCWs from hospitals implementing IPT programme, were motivated by (1) knowledge that IPT can prevent TB (63%), (2) the following of national guideline (34%), (3) concern for TB prevention even after the expansion of access to antiretroviral therapy (ART) (32%). CONCLUSION AND RECOMMENDATION: To implement an IPT programme for PLWH, giving a clear national policy and straightforward direction are necessary. Furthermore, provision of public health information and updated evidences may enhance HCW's comprehension of benefits and risks of IPT, thus it may increase the IPT programme implementation.

Migrant workers' occupation and healthcare-seeking preferences for TB-suspicious symptoms and other health problems: a survey among immigrant workers in Songkhla province, southern Thailand.

BACKGROUND: Much of the unskilled and semi-skilled workforce in Thailand comprises migrant workers from neighbouring countries. While, in principle, healthcare facilities in the host country are open to those migrants registered with the Ministry of Labour, their actual healthcare-seeking preferences and practices, as well as those of unregistered migrants, are not well documented. This study aimed to describe the patterns of healthcare-seeking behaviours of immigrant workers in Thailand, emphasizing healthcare practices for TB-suspicious symptoms, and to identify the role of occupation and other factors influencing these behaviours. METHODS: A survey was conducted among 614 immigrant factory workers (FW), rubber tappers (RT) and construction workers (CW), in which information was sought on socio-demography, history of illness and related healthcare-seeking behaviour. Mixed effects logistic regression modeling was employed in data analysis. RESULTS: Among all three occupations, self-medication was the most common way of dealing with illnesses, including the development of TB-suspicious symptoms, for which inappropriate drugs were used. Only for GI symptoms and obstetric problems did migrant workers commonly seek healthcare at modern healthcare facilities. For GI illness, FW preferred to attend the in-factory clinic and RT a private facility over government facilities owing to the quicker service and greater convenience. For RT, who were generally wealthier, the higher cost of private treatment was not a deterrent. CW preferentially chose a government healthcare facility for their GI problems. For obstetric problems, including delivery, government facilities were utilized by RT and CW, but most FW returned to their home country. After adjusting for confounding, having legal status in the country was associated with overall greater use of government facilities and being female and being married with use of both types of modern healthcare facility. One-year estimated period prevalence of TB-suspicious symptoms was around 6% among FW but around 27% and 30% in RT and CW respectively. However, CW were the least likely to visit a modern healthcare facility for these symptoms. CONCLUSIONS: Self medication is the predominant mode of healthcare seeking among these migrant workers. When accessing a modern healthcare facility the choice is influenced by occupation and its attendant lifestyle and socioeconomic conditions. Utilization of modern facilities could be improved by reducing the current barriers by more complete registration coverage and better provision of healthcare information, in which local vendors of the same ethnicity could play a useful role. Active surveillance for TB among migrant workers, especially CW, may lead to better TB control.

Physicians' practices regarding management of antituberculosis drug-induced hepatotoxicity.

To investigate the practices of physicians regarding the diagnosis and management of antituberculosis drug-induced hepatotoxicity (ATH), a cross sectional descriptive survey using a self-administered questionnaire with multiple choice questions was conducted among physicians who treated adult tuberculosis (TB) patients at 74 public hospitals in southern Thailand. Of the 272 questionnaires mailed, 204 (75%) were returned. Sixty-two physicians (31.0%) said they used alanine aminotransferase (ALT), aspartate aminotransferase (AST) and bilirubin concurrently to diagnose ATH. Only 9.0% of physicians adhered to the American Thoracic Society (ATS) guidelines of using either an ALT or AST level. Nearly all physicians (96.6%) withheld suspected antituberculosis (anti-TB) drugs in their management of ATH patients. While waiting for normalization of liver enzyme, the alternative combination regimen of ethambutol, ofloxacin, and streptomycin (EOS) was used by most physicians (99/197). Of the 197 physicians who withheld anti-TB drugs, 175 (88.8%) decided to reintroduce them. Among these, 169 (96.6%) used a sequential rechallenge method (16.6% prescribed a full dosage, 71.4% prescribed an increasing dosage) and 1 (0.6%) used a simultaneous rechallenge method. Isoniazid was prescribed as the first drug for rechallenge in 77.5% of physicians. Only 6.5% of physicians complied with the ATS guidelines by prescribing rifampicin as the first agent. The reported practices of physicians in the diagnosis and management of ATH noticeably diverged from ATS guidelines. However, alternative regimen selection and rechallenge method complied with ATS guidelines.

Socio-demographic and AIDS-related factors associated with tuberculosis stigma in southern Thailand: a quantitative, cross-sectional study of stigma among patients with TB and healthy community members.

BACKGROUND: Tuberculosis (TB) remains one of the most important infectious diseases worldwide. A comprehensive approach towards disease control that addresses social factors including stigma is now advocated. Patients with TB report fears of isolation and rejection that may lead to delays in seeking care and could affect treatment adherence. Qualitative studies have identified socio-demographic, TB knowledge, and clinical determinants of TB stigma, but only one prior study has quantified these associations using formally developed and validated stigma scales. The purpose of this study was to measure TB stigma and identify factors associated with TB stigma among patients and healthy community members. METHODS: A cross-sectional study was performed in southern Thailand among two different groups of participants: 480 patients with TB and 300 healthy community members. Data were collected on socio-demographic characteristics, TB knowledge, and clinical factors. Scales measuring perceived TB stigma, experienced/felt TB stigma, and perceived AIDS stigma were administered to patients with TB. Community members responded to a community TB stigma and community AIDS stigma scale, which contained the same items as the perceived stigma scales given to patients. Stigma scores could range from zero to 30, 33, or 36 depending on the scale. Three separate multivariable linear regressions were performed among patients with TB (perceived and experience/felt stigma) and community members (community stigma) to determine which factors were associated with higher mean TB stigma scores. RESULTS: Only low level of education, belief that TB increases the chance of getting AIDS, and AIDS stigma were associated with higher TB stigma scores in all three analyses. Co-infection with HIV was associated with higher TB stigma among patients. All differences in mean stigma scores between index and referent levels of each factor were less than two points, except for incorrectly believing that TB increases the chance of getting AIDS (mean difference of 2.16; 95% CI: 1.38, 2.94) and knowing someone who died from TB (mean difference of 2.59; 95% CI: 0.96, 4.22). CONCLUSION: These results suggest that approaches addressing the dual TB/HIV epidemic may be needed to combat TB stigma and that simply correcting misconceptions about TB may have limited effects.

Village health volunteer participation in tuberculosis control in southern thailand.

The study objectives were to compare the proportions of tuberculosis (TB) cases detected under a project launched in lower part of southern Thailand 1) by screener type [village health volunteer (VHV), health center staff, and hospital staff]; and 2) by region. Among 688 people with suspected TB symptoms referred to have sputum examination with or without chest radiograph, 55 (8%) were diagnosed of TB, including 44 (6%) smear-positive cases. The proportions of smear-positive cases among those screened by VHV, health center and hospital staff were 6.7%, 3.4% and 12.9%; respectively. The corresponding proportions for TB cases were 8.4%, 5.1%, and 12.9%. The proportions of smear-positive cases were 2.5%, 21.7%, and 14.6% for those from the Region A, B and C, respectively. The corresponding proportions of TB cases were 3.5%, 26.5%, and 16.7%. The differences by screener type were not statistically significant. VHV performances in TB case detection were comparable to health center and hospital staff, even under conditions of unrest in one province in Region B and three provinces in Region C.

Measuring stigma associated with tuberculosis and HIV/AIDS in southern Thailand: exploratory and confirmatory factor analyses of two new scales.

OBJECTIVE: To develop scales to measure tuberculosis and HIV/AIDS stigma in a developing world context. METHODS: Cross-sectional study of tuberculosis patients in southern Thailand, who were asked to rate their agreement with items measuring TB and HIV/AIDS stigma. Developing the scales involved exploratory and confirmatory factor analyses, internal consistency, construct validity, test-retest reliability and standardized summary scores. RESULTS: Factor analyses identified two sub-scales associated with both tuberculosis and HIV/AIDS stigma: community and patient perspectives. Goodness-of-fit was good (TLI = 94, LFI = 0.88 and RMSEA = 0.11), internal consistency was excellent (Cronbach's alphas 0.82-0.91), test-retest reliability was moderate, and construct validity showed an inverse correlation with social support. CONCLUSION: Our scales have good psychometric properties that measure stigma associated with tuberculosis and HIV/AIDS and allow assessment of stigma from community and patient perspectives. Their use will help document the burden of stigma, guide the development of interventions and evaluate stigma reduction programmes in areas with a high HIV/AIDS and tuberculosis burden.

Has directly observed treatment improved outcomes for patients with tuberculosis in southern Thailand?

OBJECTIVE: To validate the practice of directly observed treatment (DOT) and evaluate its effect on treatment outcomes. METHODS: This follow-up study conducted in 24 districts in southern Thailand included 411 new, smear-positive, pulmonary tuberculosis (TB) patients who started treatment between February and September 1999. Patients and/or their observers were interviewed about their actual DOT practice during the first 2 months of treatment. Treatment outcomes were evaluated at the end of the second month and at the end of treatment. RESULTS: Of 411 patients, 379 were assigned to DOT but only 68 practised strict DOT for every dose during the first 2 months. Adjusted odds ratios (ORs) for 'no sputum conversion' and 'unsuccessful treatment' were 1.1 (95% CI 0.6-2.1) and 1.3 (95% CI 0.6-2.8), respectively, for those who practised strict DOT vs. the rest. CONCLUSIONS: Actual practice of DOT was quite different from what was intended at the assignment. Practice of strict DOT during the first 2 months was not associated with sputum conversion or treatment success in this study area.

Are health personnel the best choice for directly observed treatment in southern Thailand? A comparison of treatment outcomes among different types of observers.

A prospective study was conducted in 24 districts in southern Thailand in 1999 with directly observed treatment, short-course strategy (DOTS) implemented to determine treatment outcomes in relation to the practical observer among 455 enrolled patients with tuberculosis. Health personnel (HP), community members (CM), family members (FM) and self-administration (SA) were initially assigned to be DOT observers in 43%, 5%, 44% and 8% of 411 analysed patients, respectively. In practice, 56% of the 379 patients with assigned observers changed their observers. The practical observer was the assigned observer among 17% of patients assigned to HP, 57% to CM, 75% to FM, and 34% to SA, respectively. There were no significant differences in treatment success between different types of main observers. Adjusted odds ratios (95% confidence interval) of treatment non-success were 1.1 (0.3-4.7), 0.7 (0.2-3.3), and 0.5 (0.2-1.1) for HP, CM, and FM, over SA groups, respectively. HP may not be the best choice in our setting due to poor sustainability and the availability of another promising choice (CM).