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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 99-103

Compliance to antituberculous drugs among patients in Erbil, Kurdistan Region of Iraq


1 Department of Medicine, Respiratory Unit, Rizgari Hospital, Erbil, Iraq
2 Kurdistan Board for Medical Specialities, Ministry of Higher Education and Research, Erbil, Iraq

Date of Web Publication17-Jun-2019

Correspondence Address:
Shapol Jalal Kokha Ubed
Department of Medical, Respiratory Unit, Rizgari Hospital, Erbil
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJBL.MJBL_1_19

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  Abstract 


Introduction: In Erbil, Kurdistan region of Iraq, some patients registered with tuberculosis (TB) diagnosis in Chest and Respiratory Diseases Center have interrupted treatment before completing their course, and many patients take their treatment irregularly due to different reasons. In this study, we try to determine the percentage of patients who are noncompliant to antituberculous drugs, to know the causes of noncompliance and to compare the outcome of patients taking drugs irregularly to those who take them regularly. Materials and Methods: Patients enrolled in this study were those who were diagnosed as having TB and registered in Erbil Chest and Respiratory Center during the years 2015 and 2016. Data were collected from patient forms and registers. For most patients, the causes of interruption in the course of treatment are not documented in the registers, and thus patients had been called by phone to know factors behind that. Results: Among 394 patients registered in this study, it was found that 57 patients (15%) registered to having TB have been registered as default from the treatment and 14 patients (3.55%) have interrupted their treatment because they had been wrongly diagnosed as TB. Fifteen patients (3.8%) have completed their treatment, but their follow-up was not documented. One (0.25%) of the patients completed his treatment outside Iraq. Another patient was originally from other governorates (Al-Anbar) and completed his treatment when he returned to his governorate. Two (0.5%) were non-Iraqi patients who returned to their countries and their outcome is unknown. Five (1.27%) of the patients stopped treatment due to side effects of drugs; three (0.8) of them were told by the referring doctor to stop treatment. Conclusion: Most TB-infected patients who were registered in Erbil Chest and Respiratory Diseases Center were compliant to the treatment but with occasional interruptions. Not all patients who were registered as default were really defaulters as many of those have completed their treatment, but their follow-up was not documented, and many were misdiagnosed as TB.

Keywords: Antituberculous drugs, compliance, Tuberculosis


How to cite this article:
Ubed SJ, Jaff HH. Compliance to antituberculous drugs among patients in Erbil, Kurdistan Region of Iraq. Med J Babylon 2019;16:99-103

How to cite this URL:
Ubed SJ, Jaff HH. Compliance to antituberculous drugs among patients in Erbil, Kurdistan Region of Iraq. Med J Babylon [serial online] 2019 [cited 2019 Jul 24];16:99-103. Available from: http://www.medjbabylon.org/text.asp?2019/16/2/99/260459




  Introduction Top


Tuberculosis (TB) is one of the oldest infective diseases that are still affecting human beings with a worldwide incidence rate of 8.8–9 million new patients annually and it causes 1.5–2 million deaths every year.[1],[2] It mainly affects lungs, but any other organ could be affected.[3] The disease spreads by inhalation route from a tuberculous patient to others.[4] In Iraq, it is estimated that 42 new cases of TB appear per every 100,000 population yearly.[5]

To help countries to eradicate this disease, in 2006, stop TB strategy has been developed.. This strategy concentrates at diagnosing TB as early as possible through qualified bacteriology whenever possible and starting treatment early with continuous observation and support to patients until they complete the treatment course for 6 months, and this course is called Directly Observed Treatment Short course.[6]

In Erbil, some who registered with TB diagnosis in Erbil Chest and Respiratory Diseases Center have interrupted treatment before completing their course, and many patients take their treatment irregularly due to different reasons.

The aim of this study was to evaluate the compliance of patients to anti-TB drugs.


  Materials and Methods Top


In Erbil Chest and Respiratory Diseases Center, pulmonary TB is diagnosed by specialist internists based on clinical, chest X-ray findings and bacteriological examination of sputum samples for acid-fast bacillus by direct microscopy, GeneXpert test, and/or bacterial culture, whereas extrapulmonary TB is diagnosed by histopathological examination of tissues or by biochemical and cytological characteristics of pleural fluid, ascitic fluid, or cerebrospinal fluid according to site of the disease.

Following diagnosis and registration, all patients were given qualified anti-TB drugs from the Global Drug Facility according to the World Health Organization (WHO) guidelines. The diagnosis and treatment outcome of patients is decided and registered by specialist internists working in Erbil Chest and Respiratory Diseases Center.

All of the 394 patients registered as TB-infected patients in Erbil Chest and Respiratory Diseases Center during the years 2015 and 2016 were included in this study. Data were collected from patient forms and registers. The cause of drug interruption is not documented in the registers for most patients who have interrupted their course of treatment, and thus, they had been called by phone to know the causes behind this interruption. As the data were taken mostly from registers, informed consent was not required for this study except for the 57 patients who were contacted by phone from whom verbal informed consent was obtained.


  Results Top


The present study found that the number of patients who were registered in Erbil Chest and Respiratory Diseases Center between the years 2015 and 2016 was 394, and their characteristics are illustrated in [Table 1].
Table 1: Characteristics of patients in the study population

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[Table 2] classifies patients into six categories according to the outcomes of treatment.
Table 2: Treatment outcome of patients treated for tuberculosis

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[Table 3] gives information about the number of days different patients interrupted their treatment. [Table 4] shows the maximum numbers of days where patients were off treatment consecutively. The relation between number of days off treatment and treatment outcomes is shown in [Table 5].
Table 3: Number and frequency of days of treatment interruption

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Table 4: Number and frequency of days off treatment consecutively

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Table 5: Outcome of treatment according to duration of treatment interruption

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Using paired sample t-test, it was found that there is a significant correlation between number of days of drug interruption and treatment outcome categories of good outcome (complete treatment and cure) and bad output (default, fail, death, and transferred out) with a P value of 0.000 at a confidence interval of 99%.

[Table 6] details the response of patients registered as defaults to our phone calls and the cause they provided for stopping their treatment.
Table 6: Response of defaulted patients to our phone call

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[Table 7] divides the patients wrongly diagnosed as TB according to the site of the disease.
Table 7: Site of disease for patients wrongly diagnosed as tuberculosis

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  Discussion Top


The present study found that most patients among those (394) who registered in Erbil Chest and Respiratory Diseases Center completed their treatment successfully with 73.6% rate of success although it is below the WHO recommended rate (85%);[2] this may be due to high number of defaults and deaths [Table 2].

The present study also found that more than half of patients (57.6%) completed their course of treatment without interruption, and for the remaining patients, the treatment was interrupted by a range of 1–103 days with a mean of 20 days, and most of these interruptions were <2 weeks [Table 3]. Comparable result was found by Jakubowiak et al. study on Russian patients which reported 1–127 days of treatment interruption.[7]

The number of days that patients were off treatment consecutively was ranging from 1 to 55 days with a mean of 19 days [Table 4]; this result is comparable to that found by Jakubowiak et al. which was 58 days.[7] Most of patients were off their treatment for <2 weeks continuously.

Although there are conflicting data regarding the effect of drug interruptions on treatment outcome with some studies showing association between drug interruption and bad outcomes [8] while others showing no association between drug interruption and mortality,[9],[10] the present study shows a significant association between the number of days the patients interrupted their treatment and bad outcomes including death.

In the present study, 16 patients (28%) among those who were registered as defaults could not be reached either because the phone numbers provided were wrong or the numbers were no more used [Table 6]. This may be either patient did not want to reveal their numbers or they changed their numbers due to stigma, or the registering staff registered the number wrongly.

The present study found that 15 patients (3.8%) among those who were registered as defaults had actually completed their treatment courses but their treatment follow-up was not documented in the registers, which indicate poor program performance and this observation is less than 7.6% as a nondocumentation of treatment outcome by TB program which was reported by de Oliveira et al.,[11] but it is more than 1.9% which was reported by Mfungwe et al. (2016) as a wrong documentation by TB program in Lusaka, Zambia 2012–2013.[12]

Fourteen patients (3.6%) had been wrongly diagnosed as TB. Although this percentage is less than 10.8% which was reported by Pedrazzoli et al.,[13] and this can be explained by that the patients were registered as defaults by Erbil TB program. This may be attributed to the diagnosis of TB depending on clinical, cytological, and histopathological grounds rather than bacteriological confirmation. Moreover, many doctors still use therapeutic trial to exclude TB.

One patient (0.25%) completed his treatment outside Iraq, and another patient was originally from other governorates (Al-Anbar) and completed his treatment when he returned to his governorate. Thus, the TB program has failed to follow-up or to contact these patients to document their treatment outcome correctly in the registry.

In the present study, the treatment had been stopped by five (1.27%) patients due to side effects of drugs; this percentage is much lower than 13% which has been reported by Breen et al.[14] Three (0.8%) of the five patients were told by the referring doctor to stop treatment, which is due to noncooperation of some of private and public doctors with TB program. All of these five patients have restarted a new treatment course after the study period.

Regarding the causes of default, the present study did not find causes that are similar to those found by other studies such as early improvements and high cost of drugs as the drugs are given free of charge in Iraq [15],[16],[17] or distance from health facility as the population of the present study was limited to residents of Erbil city center.

The present study found that more patients with extrapulmonary disease (78.6%) were wrongly diagnosed as TB than pulmonary disease (21.4%) in the ratio of 11:3. Pedrazzoli et al. reported that more patients were misdiagnosed as pulmonary than extrapulmonary TB in the United Kingdom between 2001 and 2011.[13] In the present study, pleural disease is the most frequent extrapulmonary disease that was misdiagnosed as TB, followed by meningitis [Table 7]. This may be due to the fact that these patients were diagnosed depending on fluid cytology alone.


  Conclusion Top


Most TB patients who registered in Erbil Chest and Respiratory Diseases Center were compliant with treatment but with occasional interruptions. Not all patients registered as default are real defaulters as many of them have completed their treatment but not registered and many are misdiagnosed as TB.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mario CR. Tuberculosis. In: Loscalzo J. Harrison's Pulmonary and Critical Care Medicine. 3rd ed., Vol. 12. New York, USA: McGraw Hill 2017. p. 121-51.  Back to cited text no. 1
    
2.
World Health Organization. Treatment of Tuberculosis. Guidelines for National Programs. World Health Organization; 2003. Available from: http://www.who.int/tb/publications/cds_tb_2003_313/en/index.html. [Last accessed on 2009 Jul 15].  Back to cited text no. 2
    
3.
Sreeramareddy CT, Panduru KV, Verma SC, Joshi HS, Bates MN. Comparison of pulmonary and extrapulmonary tuberculosis in Nepal-a hospital-based retrospective study. BMC Infect Dis 2008;8:8.  Back to cited text no. 3
    
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Hopewell PC, Kato-Maeda M, Ernst JD. Tuberculosis. In: Broaddus VC, Mason Rj, Ernst JD, King TE, Lazarus SC, Murray JF, et al., editors. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. Vol. 35. Philadelphia, USA Elsevier Saunders; 2016. p. 596-628.  Back to cited text no. 4
    
5.
World Health Organization. Global Tuberculosis Control, WHO Report. World Health Organization; 2018. Available from: https://www.who.int/tb/publications/global_report/en/. [Last accessed on 2018 Nov 18].  Back to cited text no. 5
    
6.
Zumla A, Mullan Z. Turning the tide against tuberculosis. Lancet 2006;367:877-8.  Back to cited text no. 6
    
7.
Jakubowiak W, Bogorodskaya E, Borisov S, Danilova I, Kourbatova E. Treatment interruptions and duration associated with default among new patients with tuberculosis in six regions of Russia. Int J Infect Dis 2009;13:362-8.  Back to cited text no. 7
    
8.
Datta M, Radhamani MP, Selvaraj R, Paramasivan CN, Gopalan BN, Sudeendra CR, et al. Critical assessment of smear-positive pulmonary tuberculosis patients after chemotherapy under the district tuberculosis programme. Tuber Lung Dis 1993;74:180-6.  Back to cited text no. 8
    
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Santha T, Garg R, Frieden TR, Chandrasekaran V, Subramani R, Gopi PG, et al. Risk factors associated with default, failure and death among tuberculosis patients treated in a DOTS programme in Tiruvallur district, South India, 2000. Int J Tuberc Lung Dis 2002;6:780-8.  Back to cited text no. 9
    
10.
Pablos-Méndez A, Knirsch CA, Barr RG, Lerner BH, Frieden TR. Nonadherence in tuberculosis treatment: Predictors and consequences in New York city. Am J Med 1997;102:164-70.  Back to cited text no. 10
    
11.
de Oliveira HB, Marin-León L, Gardinali J. Analysis of treatment outcomes related to the tuberculosis control program in the city of Campinas, in the state of São Paulo, Brazil. J Braz Pneumol 2005;31:133-8.  Back to cited text no. 11
    
12.
Mfungwe V, Ota M, Koyama K, Samungole GK, Takemura Y, Hirao S, et al. 'Transfer out' tuberculosis patients: Treatment outcomes after cross-checking registers, 2012-2013, Lusaka, Zambia. Public Health Action 2016;6:118-21.  Back to cited text no. 12
    
13.
Pedrazzoli D, Abubakar I, Potts H, Hunter PR, Kruijshaar ME, Kon OM, et al. Risk factors for the misdiagnosis of tuberculosis in the UK, 2001-2011. Eur Respir J 2015;46:564-7.  Back to cited text no. 13
    
14.
Breen RA, Miller RF, Gorsuch T, Smith CJ, Schwenk A, Holmes W, et al. Adverse events and treatment interruption in tuberculosis patients with and without HIV co-infection. Thorax 2006;61:791-4.  Back to cited text no. 14
    
15.
Gupta S, Gupta S, Behera D. Reasons for interruption of anti-tubercular treatment as reported by patients with tuberculosis admitted in a tertiary care institute. Indian J Tuberc 2011;58:11-7.  Back to cited text no. 15
    
16.
Ibrahim LM, Hadejia IS, Nguku P, Dankoli R, Waziri NE, Akhimien MO, et al. Factors associated with interruption of treatment among pulmonary tuberculosis patients in Plateau state, Nigeria 2011. Pan Afr Med J 2014;17:78.  Back to cited text no. 16
    
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Gorityala SB, Mateti UV, Konuru V, Martha S. Assessment of treatment interruption among pulmonary tuberculosis patients: A cross-sectional study. J Pharm Bioallied Sci 2015;7:226-9.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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