Original ResearchDuration of treatment in pulmonary tuberculosis: are international guidelines on the management of tuberculosis missing something?
Introduction
Tuberculosis (TB) is a public health challenge. In 2012, approximately 8.6 million people developed TB. With an estimated 1.3 million deaths every year, TB is the second highest cause of adult mortality from an infectious disease, after human immunodeficiency virus (HIV).1 Malaysia is situated in the Western Pacific region of the World Health Organization (WHO), and is considered to have an intermediate burden of TB.1 According to a recent report, over the past few years, the incidence of TB in Malaysia has been 80–82 cases per 100,000. However, the absolute number of new cases increased from 15,057 in 2000 to 21,851 in 2012.1 These pointers reflect a slowly increasing burden of TB in Malaysia.
Provision of standardized treatment regimens, under supervision, is one of the five components of directly observed therapy (DOT). According to the current TB management guidelines, the treatment regimen for new smear-positive pulmonary tuberculosis (PTB) patients should be six months. Standardized TB treatment is divided into two phases: the intensive phase (IP) and the continuation phase (CP). For the IP of treatment, patients are prescribed isoniazid, rifampicin, pyrazinamide and ethambutol for two months, while during the CP of treatment, isoniazid and rifampicin are prescribed for four months. Patients living in isoniazid-resistant areas or diagnosed with isoniazid-resistant TB are prescribed isoniazid, rifampicin and ethambutol for four months during the CP of treatment.2, 3 In some situations [e.g. if a TB patient is immunocompromised (e.g. HIV, diabetes mellitus), a smoker and/or exhibits extensive lung involvement (e.g. lung cavities) at the start of the treatment], clinicians may decide to treat patients for a longer duration.
In spite of the evidence of an association between TB treatment outcomes and the performance of national tuberculosis programmes (NTP),4, 5, 6 no studies to date have rigorously and extensively documented the durations of the IP and CP of treatment among PTB patients. As such, this study was conducted to determine the duration of TB treatment and its predictors among new smear-positive PTB patients.
Section snippets
Study setting
This study was conducted at the Chest Clinic of Penang General Hospital. In addition to the committed paramedic staff, the Chest Clinic has a minimum of five to six medical officers and three chest consultants. A fully equipped quality assured TB laboratory, situated adjacent to the Chest Clinic, provides routine TB-specific investigation services to patients and suspected TB cases. The Radiology and Pathology Departments of Penang General Hospital also provide routine investigation services to
Results
Three hundred and thirty-six new smear-positive PTB patients were enrolled in the study. The mean age of the patients was 49.1 years [standard deviation (SD) 16.6]. More than 60% of the patients were aged 18–54 years. The Chinese ethnic group constituted the greatest proportion of the patients (53.3%), whilst the Tamils were least represented (9.8%). Table 1 shows the sociodemographic characteristics of the patients.
Only 72 patients exhibited five or more TB-related symptoms at the start of
Discussion
The intricacy and cost of TB treatment have risen in recent years. The emergence of multidrugresistant TB (MDR-TB), longer duration of TB treatment in HIV-seropositive patients, higher treatment failure rates in difficult-to-reach patients (i.e. drug abusers, immigrants, etc.) and increasing demands of DOT programmes contribute to higher costs of TB treatment.12, 13 This has put additional pressure on healthcare budgets. Due to the complexity of treatment regimens, it is difficult to reduce the
Acknowledgements
The authors would like to thank the Director General of Health Malaysia for granting permission to publish this paper.
Ethical approval
This study was registered at National Medical Research Register, Malaysia. The study design and conduct were approved by the National Institute of Health and by the Medical Research Ethics Committee, Ministry of Health, Malaysia (Registration ID: NMRR-10-77-5099; MERC Ref.: dim. KKM/NIHSEC/08/08/04P10-69).
Funding
Institute of Postgraduate Studies at Universiti Sains Malaysia
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