RESUMEN
BACKGROUND: Tuberculosis treatment failure and death rates are low in the Western Pacific Region, including Vietnam. However, failure or death may also occur among patients who did not complete treatment, i.e. reported as default or transfer-out. We aimed to assess the proportion failures and deaths among new smear-positive pulmonary tuberculosis patients with reported default or transfer-out. Treatment outcomes rates were 1.4% default, 3.0% transfer-out, 0.4% failure and 2.6% death in northern Vietnam in 2003. METHODS: Tuberculosis patients in 32 randomly selected district tuberculosis units in northern Vietnam were followed up 1 to 3 years after treatment initiation for survival, recent treatment history and bacteriologically confirmed tuberculosis. RESULTS: Included were 85 transferred patients and 42 who defaulted. No information was available of 41 (32%), 28 (22%) had died. Fifty-eight were available for follow-up (46%); all had sputum smear results. Tuberculosis was recorded in 11 (13%), including 6 (7%) with positive sputum smears, 3 (3%) with negative smears but positive culture and 2 (2%) who had started re-treatment for bacteriologically confirmed tuberculosis. Fifteen (17%, 95%CI 10-27%) had died within 8 months after treatment initiation. Of 86 patients with known study outcomes, 39 (45%, 95%CI 35-56%) had died or had bacteriologically confirmed tuberculosis. This was recorded for 29/53 (55%, 95%CI 40-68%) transferred patients and 10/33 (30%, 95%CI 16-49%) patients who defaulted. CONCLUSION: The total failure and death rates are 0.6% and 0.8% higher than based on routine reporting in northern Vietnam. Although this was a large proportion of treatment failures and deaths, failure and death rates were low. Defaulting and transfer carry a high risk of failure and in particular death.
Asunto(s)
Antituberculosos/uso terapéutico , Cooperación del Paciente/estadística & datos numéricos , Pacientes Desistentes del Tratamiento/estadística & datos numéricos , Insuficiencia del Tratamiento , Tuberculosis Pulmonar/tratamiento farmacológico , Tuberculosis Pulmonar/mortalidad , Adolescente , Adulto , Estudios de Cohortes , Farmacorresistencia Bacteriana , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Mycobacterium tuberculosis/efectos de los fármacos , Esputo/microbiología , Tuberculosis Resistente a Múltiples Medicamentos , Tuberculosis Pulmonar/epidemiología , Vietnam/epidemiologíaRESUMEN
BACKGROUND: Treatment delay is an important indicator of access to tuberculosis diagnosis and treatment. Analyses of patient delay (i.e. time interval between onset of symptoms and first consultation of a health care provider) and health care delay (i.e. time interval between first consultation and start of treatment) can inform policies to improve access. This study assesses the patient, health care provider and total delay in diagnosis and treatment of new smear-positive pulmonary tuberculosis patients, and the risk factors for long delay, in Vietnam. METHODS: A cross-sectional survey of new patients treated by the National Tuberculosis Control Programme was conducted in 70 randomly selected districts in Vietnam. All consecutively registered patients in one quarter of 2002 were interviewed using a pre-coded structured questionnaire. RESULTS: Median (range) delay was 4 weeks (1-48) for total, 3 (1-48) weeks for patient and 1 (0-25) week for health care delay. Patients with long total delay (> or = 12 weeks, 15%) accounted for 49% of the cumulative number of delay-weeks. Independent risk factors (p < 0.05) for long total delay were female sex, middle age, remote setting, residence in the northern or central area, and initial visit to the private sector. For long patient delay (> or = 6 weeks) this was female sex, belonging to an ethnic minority, and living at > 5 km distance from a health facility or in the northern area. For long health care delay (> or = 6 weeks) this was urban setting, residence in the central area and initial visit to a communal health post, TB hospital or the private sector. CONCLUSION: Analyses of patient and treatment delays can indicate target groups and areas for health education and strengthening of the referral system, in particular between the private sector and the NTP.
Asunto(s)
Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Programas Nacionales de Salud/normas , Aceptación de la Atención de Salud/estadística & datos numéricos , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/terapia , Citas y Horarios , Áreas de Influencia de Salud , Estudios Transversales , Femenino , Humanos , Entrevistas como Asunto , Modelos Logísticos , Masculino , Programas Nacionales de Salud/estadística & datos numéricos , Derivación y Consulta , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Factores de Tiempo , Tuberculosis Pulmonar/etnología , Vietnam/epidemiologíaRESUMEN
BACKGROUND: Delay in tuberculosis diagnosis and treatment initiation may increase disease severity and mortality. In evaluations of tuberculosis control programmes high fatality rates during tuberculosis treatment, are used as an indicator of long delays in low HIV-prevalence settings. However, data for this presumed association between delay and fatality are lacking. We assessed the association between diagnostic delay and mortality of new smear-positive pulmonary tuberculosis patients in Vietnam. METHODS: Follow-up of a patient cohort included in a survey of diagnostic delay in 70 randomly selected districts. Data on diagnosis and treatment were extracted from routine registers. Patients who had died during the course of treatment were compared to those with reported cure, completed treatment or failure (survivors). RESULTS: Complete data were available for 1881/2093 (89.9%) patients, of whom 82 (4.4%) had died. Fatality was 4.5% for patients with < or = 4 weeks delay, 5.0% for 5- < or = 8 weeks delay (aOR 1.11, 95%CI 0.67-1.84) and 3.2% for > 9 weeks delay (aOR 0.69, 95%CI 0.37-1.30). Fatality tended to decline with increasing delay but this was not significant. Fatality was not associated with median diagnostic delay at district level (Spearman's rho = -0.08, P = 0.5). CONCLUSION: Diagnostic delay is not associated with treatment mortality in Vietnam at individual nor district level, suggesting that high case fatality should not be used as an indicator of long diagnostic delay in national tuberculosis programmes.
Asunto(s)
Tuberculosis/diagnóstico , Tuberculosis/mortalidad , Adolescente , Adulto , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Sistema de Registros , Esputo/microbiología , Factores de Tiempo , Insuficiencia del Tratamiento , Tuberculosis/tratamiento farmacológico , Vietnam/epidemiologíaRESUMEN
BACKGROUND: There is limited evidence that the DOTS (directly observed therapy, short course) strategy for tuberculosis (TB) control can contain the emergence and spread of drug resistance in the absence of second-line treatment. We compared drug-resistance levels between 1996 and 2001 in the south of Vietnam, an area with a well-functioning DOTS program. METHODS: Sputum specimens were collected from consecutively diagnosed patients with smear-positive TB at 40 randomly selected public TB clinics. Mycobacterium tuberculosis isolates were tested for susceptibility to first-line drugs. RESULTS: Among 888 new patients in 2001, resistance to any drug was observed in 238 (26.3%), resistance to isoniazid was observed in 154 (16.6%), resistance to rifampin was observed in 22 (2.0%), resistance to ethambutol was observed in 12 (1.1%), resistance to streptomycin was observed in 173 (19.4%), and resistance to both isoniazid and rifampicin (multidrug resistance [MDR]) was observed in 20 (1.8% [95% confidence interval, 1.0%-3.3%]). Among 136 previously treated patients in 2001, any resistance was observed in 89 (62.9%), and MDR was observed in 35 (23.2%). The prevalence of any drug resistance and of streptomycin resistance among new patients had decreased significantly (P<.01) since 1996; there was no increase in the prevalence of MDR. CONCLUSION: The prevalence of drug resistance decreased despite high initial levels of resistance to isoniazid and streptomycin and despite the absence of second-line treatment. Therefore, a DOTS program can contain drug-resistant TB in this setting.