Operational research within the national tuberculosis control programme in Benin.

OBJECTIVE: To document whether the placement of operational research (OR) fellows within disease control programmes in low and middle income countries leads to the implementation of operational research and improvements in policy and practice. RESULT: In 2012, an OR fellow was placed within the National TB Programme, Benin, to strengthen the implementation of operational research. From 2012 to 2015, eight OR projects were implemented, of which three contributed to changes in programme practice and five provided information which was not previously available from quarterly/annual reports. Two of these projects-one on the burden and treatment outcomes of childhood TB and one on tracing patients who had discontinued treatment-are discussed in more detail. OR should be strongly encouraged within national TB programme settings and an OR fellow facilitates this process.

Tuberculosis Case Finding in Benin, 2000-2014 and Beyond: A Retrospective Cohort and Time Series Study.

Objective. To determine any changes in tuberculosis epidemiology in the last 15 years in Benin, seasonal variations, and forecasted numbers of tuberculosis cases in the next five years. Materials and Methods. Retrospective cohort and time series study of all tuberculosis cases notified between 2000 and 2014. The "R" software version 3.2.1 (Institute for Statistics and Mathematics Vienna Austria) and the Box-Jenkins 1976 modeling approach were used for time series analysis. Results. Of 246943 presumptive cases, 54303 (22%) were diagnosed with tuberculosis. Annual notified case numbers increased, with the highest reported in 2011. New pulmonary bacteriologically confirmed tuberculosis (NPBCT) represented 78% ± SD 2%. Retreatment cases decreased from 10% to 6% and new pulmonary clinically diagnosed cases increased from 2% to 8%. NPBCT notification rates decreased in males from 2012, in young people aged 15-34 years and in Borgou-Alibori region. There was a seasonal pattern in tuberculosis cases. Over 90% of NPBCT were HIV-tested with a stable HIV prevalence of 13%. The ARIMA best fit model predicted a decrease in tuberculosis cases finding in the next five years. Conclusion. Tuberculosis case notifications are predicted to decrease in the next five years if current passive case finding is used. Additional strategies are needed in the country.

Characteristics and Treatment Outcomes of Retreatment Tuberculosis Patients in Benin.

Objective. To determine among retreatment tuberculosis patients in Benin baseline characteristics, culture, and drug sensitivity testing (DST) results and treatment outcomes. Materials and Methods. A retrospective national cohort study of all retreatment tuberculosis patients in Benin in 2013 using registers and treatment cards. Results. Of 3957 patients with tuberculosis, 241 (6%) were retreatment cases. Compared to new pulmonary bacteriologically confirmed tuberculosis (NPBCT) patients, there were significantly higher numbers of males (P = 0.04), patients from "Atlantique-Littoral" (P = 0.006), patients aged 45-64 years (P = 0.007), and HIV-positive patients (P = 0.04) among those retreated. Overall, 171 (71%) patients submitted sputum for DST, of whom (163) 95% were positive for Mycobacterium tuberculosis on Xpert MTB/RIF and/or culture and 17 (10%) were rifampicin resistant (9 with MDR-TB and 8 monoresistant to rifampicin). For those without MDR-TB (n = 224), treatment success was 93%. Worse outcomes occurred in those with unknown HIV status (RR: 0.27; 0.05-1.45; P < 0.01) while better outcomes occurred in those who relapsed (RR: 1.06, 95 CI: 1.02-1.10, P = 0.04). Conclusion. In 2013, a high proportion of retreatment patients received DST. Treatment success was good although more needs to be done to systematically increase the final follow-up smear examination. Reasons of high losses to follow-up from "Oueme-Plateau" should be investigated.

Follow-up and tracing of tuberculosis patients who fail to attend their scheduled appointments in Cotonou, Benin: a retrospective cohort study.

BACKGROUND: In the "Centre National Hospitalier de Pneumo-Phtisiologie" of Cotonou, Benin, little is known about the characteristics of patients who have not attended their scheduled appointment, the results of tracing and the possible benefits on improving treatment outcomes. This study aimed to determine the contribution of tracing activities for those who missed scheduled appointments towards a successful treatment outcome. METHODS: A retrospective cohort study was carried out among all smear-positive pulmonary tuberculosis patients treated between January and September 2013. Data on demographic and diagnostic characteristics and treatment outcomes were accessed from tuberculosis registers and treatment cards. Information on those who missed their scheduled appointments was collected from the tracing tuberculosis register. A univariate analysis was performed to explore factors associated with missing a scheduled appointment. RESULTS: Of 457 patients (410 new smear-positive and 47 retreatment tuberculosis), 37 (8%) missed one or more of their appointments with a total of 44 episodes of missed appointments. The 3.5th (32%) and 5th (43%) month appointments were the ones most likely to be missed. Being male was associated with a higher risk of missing appointments (RR = 4.2; 95% CI = 1.5-11.8, p = 0.004) while having HIV infection was associated with a lower risk (RR = 0.3, 95% CI = 0.1-0.9, p = 0.03). Principal reasons for missed appointments were travelling outside Cotonou (34%) and feeling better (21%). In 24 (55%) of these 44 episodes of missed appointments, contact was made with the patient who returned to the programme. These follow-up activities increased the treatment success by 4%. CONCLUSION: In Cotonou, Benin, less than 10% of tuberculosis patients miss at least one of their scheduled appointments. Tracing activities increase the treatment success rate by 4% and current on-going practices in the Programme need to be endorsed and encouraged.

National profile and treatment outcomes of patients with extrapulmonary tuberculosis in Bénin.

BACKGROUND: In sub-Saharan Africa, there is a dearth of published literature on extrapulmonary tuberculosis (EPTB). OBJECTIVE: To describe demographic, diagnostic and HIV-status characteristics of patients with EPTB in Bénin, their treatment outcomes, and among those who completed their treatment in the Centre National Hospitalier de Pneumo-Phtisiologie (CNHP-P), the proportion whose bodyweight increased during treatment. MATERIAL AND FINDINGS: This was a retrospective cohort study with comparisons made between EPTB and new smear-positive pulmonary tuberculosis (NPTB) patients diagnosed in the country from January to December 2011. There were 383 EPTB patients (9% of all TB cases) with a mean age of 35 years, male/female ratio of 1.3 and important regional variation. There were significantly more females (p = 0.001), children <15 years (p<0.001) and HIV-positive patients (p = 0.005) with EPTB compared with NPTB. Pleural effusion, spinal and lymph node tuberculosis accounted for 66% of all EPTB. Children <15 years represented 16% of cases, with lymph node disease being most common among them (p<0.001). Of 130 EPTB patients registered in CNHP-P, 7% had a confirmed bacteriological/histological diagnosis. There were 331 (86%) patients who successfully completed treatment. More patients with EPTB were lost-to-follow-up compared with NPTB (p<0.001) with all these patients from one region. The best treatment completion rates were in children <15 years (OR:3.5, 95%CI:1.0-14.8) while patients with pleural effusion and ascites had the worst outcomes. Of 72 HIV-coinfected patients, 88% were on antiretroviral therapy (ART). HIV-positive status was associated with poor outcomes while those on ART fared better. In the CNHP-P, more than 80% who completed their treatment showed an increase in bodyweight and this was more evident in HIV-positive compared with HIV-negative patients (p = 0.03). CONCLUSION: Patients with EPTB generally do well in Bénin, although the TB Programme would benefit through more attention to accurate diagnosis and earlier start of ART in HIV-infected patients.

National profile and treatment outcomes of adult smear-negative pulmonary TB patients in Benin.

BACKGROUND: In Benin, patients with smear-negative pulmonary TB (SNPTB) are of low priority in the National Tuberculosis Programme (NTP) and little is known about their profile or treatment outcomes. METHODS: A retrospective cohort study was carried out to determine characteristics and treatment outcomes in all adults registered with SNPTB in 2009. Findings were compared with patients with new smear-positive pulmonary tuberculosis (PTB) diagnosed in the same period. RESULTS: Of 3140 patients with PTB, 273 (8.7%) had SNPTB, with higher rates in northern and southwestern regions. SNPTB was associated with female gender, older age and HIV-positive status (p<0.01). Patients with SNPTB had a higher proportion of unsuccessful treatment outcomes compared with smear-positive PTB owing to death and loss to follow-up (LFU) (p<0.01). The region with the capital city had the highest rate of LFU. Differences in unsuccessful outcomes between SNPTB and smear-positive PTB were more apparent in persons who were HIV-negative, and among HIV-positives not on antiretroviral treatment. CONCLUSION: In Benin, treatment outcomes of SNPTB patients were inferior to those with smear-positive PTB, with LFU being a major problem. The Benin NTP needs to better address the problem of patients with SNPTB in terms of monitoring and reporting, treatment management including that associated with HIV care, and reducing LFU.

Incidence of lipodystrophy and metabolic disorders in patients starting non-nucleoside reverse transcriptase inhibitors in Benin.

BACKGROUND: The incidence and risk factors for lipodystrophy and metabolic disorders among patients in Africa on first-line combined antiretroviral treatment (cART) mostly containing non-nucleoside reverse transcriptase inhibitors is poorly documented. METHODS: This prospective cohort study recruited 88 HIV-infected patients initiating cART between October 2004 and June 2005 in Cotonou, Benin. Patients were followed for 24 months. The main outcomes were incidence of lipodystrophy and metabolic disorders. Multivariate Cox proportional hazards regression models were used to describe factors associated with progression to lipodystrophy. RESULTS: After a median follow-up of 23.2 months (interquartile range 22.3-23.7), 24 (30%) patients developed lipodystrophy (lipoatrophy 9%, lipohypertrophy 24% and mixed pattern 2.5%). The incidence rate for lipodystrophy was estimated to 1.72 per person-month (95% confidence interval [CI] 1.15-2.56) occurring after a median time of 11 months on cART. Metabolic syndrome (International Diabetes Federation definition) appeared in 10 (13%) patients after a median of 15 months with an estimated incidence rate of 0.62 per person-month (95% CI 0.33-1.16). It was more common in women (19.2% versus 3.1% in men; P=0.043). Diabetes (8%) and hypercholesterolaemia (35%) were also observed. After adjustment, gender, young age (hazard ratio [HR] 0.45 [95% CI 0.22-0.90]; P=0.025), high BMI at inclusion (HR 1.53 [95% CI 1.28-1.83]; P<0.0001) and smoking (HR 28.0 [95% CI 2.5-307.4]; P=0.006) were significantly associated with lipohypertrophy. CONCLUSIONS: Lipodystrophy and metabolic syndrome were commonly and rapidly observed in this cohort of sub-Saharan patients initiating cART.