Prevalence and factors associated with sputum smear non-conversion after two months of tuberculosis treatment among smear-positive pulmonary tuberculosis patients in Rwanda: a cross-sectional study

doi:10.21203/rs.3.rs-2350473/v1

Download PDF

Research Article

Prevalence and factors associated with sputum smear non-conversion after two months of tuberculosis treatment among smear-positive pulmonary tuberculosis patients in Rwanda: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-2350473/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 15 Jun, 2023

Read the published version in BMC Infectious Diseases →

You are reading this latest preprint version

Background

Non-conversion of sputum smear prolongs the infectivity of pulmonary tuberculosis patients and has been associated with unfavorable tuberculosis (TB) treatment outcomes. Nevertheless, there is a lack of evidence on predictors of sputum smear non-conversion among smear-positive PTB (SPPTB) patients in Rwanda. Therefore, this study aimed to determine the factors associated with sputum smear non-conversion after two months of treatment among SPPTB patients in Rwanda.

Methods

A cross-sectional study was conducted among SPPTB patients registered in the national electronic TB reporting system by all health facilities countrywide (Rwanda) from July 2019 to June 2021. The patients had completed the first two months of anti-TB treatment and with smear results at the end of the second month of treatment. Bivariate and multivariate logistic regression analyses were done to determine the factors associated with sputum smear non-conversion. Odds ratio (OR), 95% confidence interval (CI), and p-value were reported.

Results

This study included 7,211 patients. Of them, 632 (9%) patients had sputum smear non-conversion at the end of the second month of treatment. In multivariate logistic regression analysis, age groups of 20–39 years (AOR = 1.7, 95% CI: 1.04–2.86) and 40–59 years (AOR:2, 95% CI: 1.18–3.3 ), history of first-line TB treatment failure (AOR = 2, 95% CI: 1.1–3.6), follow-up by community health workers (AOR = 1.2, 95% CI: 1.04–1.5), BMI < 18.5 at TB treatment initiation (AOR = 1.5, 95% CI: 1.25–1.8), and living in Northern Province of Rwanda (AOR = 1.4, 95% CI: 1.05-2.0), were found significantly associated with sputum smear non-conversion after two months of treatment.

Conclusion

Sputum smear non-conversion among SPPTB patients remains low in Rwanda compared to countries of similar health care setting. Nevertheless, as the WHO considers sputum conversion as a useful indicator in monitoring the performance of TB control programs, rigorous follow-up of patients with identified risk factors for non-conversion is recommended.

Tuberculosis

factors

sputum non-conversion

Rwanda

Tuberculosis (TB) disease is due to an infection from Mycobacterium tuberculosis (MTB) transmitted through the airborne route, and it was the leading killer infectious diseases before the COVID-19 pandemic [1, 2]. An estimate of around one-third of the world’s population is infected with MTB [3]. Among these, in 2019, 10 million people had developed TB, 1.4 million had died from TB, and 95% of TB cases and 98% of TB deaths had occurred in developing countries [4, 5]. The majority of TB cases occurred in Asia and Africa at (44%) and (26%) respectively [6]. In Rwanda, TB is among the leading health problems with an incidence rate of 58 per 100,000 population; HIV-negative TB mortality rate of 2.5 per 100,000 population, and HIV-positive TB mortality rate of 2.5 per 100,000 population were reported in 2020 [7]. In the same year, TB associated deaths were 6% and 14.8% in bacteriologically diagnosed cases and clinically confirmed cases respectively [8].

Sputum smear conversion after two months of TB treatment is considered as a useful indicator in monitoring the performance of TB control programs and it is an important predictor for bacteriological cures [9, 10]. Non-conversion of sputum smear at the end of the intensive phase of treatment (first two months of TB treatment) is the main contributor to unfavorable TB treatment outcome [11, 12]. Studies conducted in different settings have identified numerous factors associated with sputum smear non-conversion among pulmonary TB (PTB) patients like diabetes, high bacillary load at baseline and advanced age [13–15]. In Rwanda, PTB patients treated in health facilities from rural area were found to be more likely to have low sputum conversion rate compared to those treated in health facilities from urban area [5].

Despite a good progression in fighting against TB, the World Health Organization (WHO) had highlighted that even in a good performing national TB program, there is a proportion of PTB patients who may still be smear-positive at the end of the intensive phase, regardless of a good adherence and directed medication [5]. In Rwanda, 20% of PTB patients were reported in 2007 as having sputum smear non-conversion after intensive phase [16]. However, no studies have been carried out to identify factors associated with this non-conversion after intensive phase. This study aimed to determine the prevalence and factors associated with sputum smear non-conversion after to two months of TB treatment among SPPTB patient in Rwanda.

Study design and setting

The study was cross-sectional and consisted in reviewing abstracted retrospective records of SPPTB patients registered at TB clinics in all health facilities in Rwanda using the national electronic TB reporting system (e-TB) from July 2019 to June 2021. This period was chosen because July 2019 is when the TB cases reported by health facilities shifted to reporting individual data in the e-TB.

Study Population

This study was conducted among all SPPTB patients reported in e-TB system from July 2019 to June 2021. Were included in the study patients who have completed at least the intensive phase of first line of TB treatment, and whose follow-up sputum smear results after the second month of TB treatment were recorded. Smear-positive PTB patients without records of follow-up sputum smear examination results after the second month of TB treatment and patients who had died or had interrupted treatment before the end of the intensive phase were excluded from the study.

Sampling

All SPPTB patients reported in the e-TB from July 2019 to June 2021 and who met the inclusion criteria were considered for the study. During the study period, 11,207 TB cases were reported in e-TB. Of this figure, 1824 (16.3%) were extra-pulmonary TB (EPTB) cases, and 1103 (9.8%) were smear-negative pulmonary TB (SNPTB). EPTB and SNPTB cases were excluded from the analysis. Of the total 8279 (73.8%) SPPTB cases, follow-up sputum smear examination after the 2nd month of TB treatment was not done for 844 cases (10.2%) and two cases (0.02%) had Multidrug-Resistant Tuberculosis (MDR-TB), while 222 cases (2%) did not have documented follow-up sputum smear result after the second month of TB treatment, so they were also excluded from our study. The final cases that were included in this study were 7211 (87%) who had recorded a follow-up sputum smear result after the 2nd month of TB treatment (Fig. 1).

Study variables

Dependent variable

Sputum smear conversion at the end of the second month was dichotomized into converted and not converted for patients with a negative follow up sputum smear results and for patients with a positive follow up sputum smear results respectively.

Independent variables

Age was categorized in four groups: <20 years, 20-39 years, 40-59 years, and 60 years and above.

Sex: is male or female.

Residence: was categorized in four provinces - Kigali city, Eastern, Western, Northern and Southern province.

HIV status: was dichotomized into positive or negative.

History of HIV: was categorized in three statuses - newly tested positive, people living with HIV and HIV negative for people who not having HIV.

On ART: was put into three treatment categories - Yes for patients taking ART, No for patients not taking ART and Not applicable for those not having HIV.

On cotrimoxazole: was categorized as - Yes for patients receiving cotrimoxazole, No for patients not taking cotrimoxazole, and Not applicable for not eligible patients to cotrimoxazole

BMI at the initiation of TB treatment was divided into two group: BMI less than 18.5, and BMI equal and greater than18.5

Previous treatment history: was categorized into patients who took TB treatments for the first time were categorized as new, those who had been diagnosed with TB for the second or several times were categorized as relapse, patients who had history of first-line treatment failure were categorized as treatment after failure of first-line treatment, and those who had history of TB infections but did not remember if they had failed their treatments were categorized as other previously treated, and finally those who had been lost while taking their treatment were categorized as treatment after lost to follow up.

Contact of index TB: dichotomized as Yes or No,

Contact of MDR-TB: dichotomized as Yes or No

Diabetes: was categorized in three entities - Yes, No and unknown for those who did not know their diabetic status

TB-nutrition support provided: was dichotomized as Yes or No

Follow up by a community health worker (CHWs): was dichotomized as Yes or No

Data collection and analysis methods

Sociodemographic and clinical characteristics of patients were described with frequencies and proportions. A binary logistic regression was computed between each independent variable and the dependent variable (Sputum smear conversion at the end of the second month). A collinearity test was performed for all independent variables and significant variables from the bivariate analysis with (r=) were considered for the multivariate logistic regression to determine factors statistically associated with sputum smear conversion at the end of the second month. Odds ratio (OR), confidence interval, and p-value were considered statistically significant at 95% confidence level.

Ethical considerations

The study was approved by the University of Rwanda, College of Medicine and Health Sciences, Institutional Review Board (IRB) with Reference number 280/CMHS IRB. In addition, a confidentiality agreement about handling patients’ information was made between the investigator and Rwanda Biomedical Center (RBC). During the data analysis, encryption was performed for patients’ identifiers like names and Tracnet numbers for HIV-positive patients. The full dataset was locked with a password known only by the principal investigator.

Characteristics of the study participants

From July 2019 to June 2021, 7211 SPPTB cases were reported in e-TB countrywide. Of these around three quarters of the patients (73.2%) were males and 26.7% were females, while 53.31% of participants were aged between 20 and 39 years old, and 28.3% lived in Kigali city. Of the total participants 18.2% were living with HIV, 9.6% were previously treated with TB, and 63.5% PTB had a BMI < 18.5 at TB treatment initiation. The prevalence of sputum smear non-conversion among SPPTB was 9% and the majority (12.2%) of those who did not convert their sputum were living in northern province. The prevalence of non-conversion was high (10%) among patient aged 40–59 years compared to other age groups (Table 1 and Table 2).

Table 1

Socio-demographic characteristics of study participants
Socio-demographic characteristics	Frequency (n)	Percentage (%)
n = 7211
Age-groups
< 20years	322	4.47
20–39 years	3844	53.31
40–59 years	2245	31.13
60 years and above	800	11.09
Gender
Male	5281	73.24
Female	1930	26.76
Residence (Province)
East	1774	24.6
Kigali city	2041	28.3
North	657	9.11
South	1630	22.6
West	1109	15.38

Table 2

Clinical characteristics of study participants
Clinical characteristics	Frequency (n)	Percentage (%)
HIV status
Negative	5897	81.78
Positive	1314	18.22
History of HIV
HIV negative	5897	81.78
Newly tested Positive	362	5.02
People living with HIV	952	13.20
TB treatment History
New	6521	90.43
Relapse	575	7.97
Treatment after failure of the first line	78	1.08
Treatment after lost to follow-up	27	0.37
Other previously treated	10	0.14
Currently on ART
Yes	1239	17.18
No	75	1.04
Not applicable	5897	81.78
Currently on cotrimoxazole
Yes	968	13.42
No	346	4.80
Not applicable	5897	81.78
Diabetes
No	4559	63.22
Yes	41	0.57
Unknown	2611	36.21
Contact with PTB +
No	6475	89.79
yes	736	10.21
Contact with MDR-TB
No	7156	99.24
Yes	55	0.76
Followed by CHWs
No	3473	48.16
Yes	3738	51.84
BMI at treatment initiation
BMI < 18.5	4581	63.53
BMI > = 18.5	2630	36.47
TB-nutrition support provided
Yes	1228	17.03
No	5983	82.97

The mean patient age included in the analysis was 39 ± 14.68 years with 5281(73.24%) being males and 1930 (26.76%) females.

Comparison Between Socio-demographic, Clinical Factors And Sputum Smear Non-conversion

Factors like age (20–39 and 40–59 years) and residence of the patient (Northern Province), history of first-line TB treatment failure, BMI less than 18.5, follow up by CHWs, showed a marked association with sputum smear non-conversion. Patients aged between 20–39 years old were 1.7 times more likely to have sputum smear non-conversion (OR = 1.7, 95% CI: 1.01–2.8), and those aged between 40–59 years old were 2 times more likely to have sputum smear non-conversion (OR = 2, 95% CI: 1.2–3.3) compared to patients less than 20 years old (OR = 0.5, 95% CI: 0.4–0.9). Patients who lived in the Northern province were 1.4 times more likely to have sputum smear non-conversion after 2 months of treatment (OR = 1.4, 95% CI: 1.6-2) compared to those in the western province (OR = 1.2, 95% CI: 0.9–1.5) (Table 3).

Table 3

Comparison of socio-demographic factors with sputum smear non-conversion after 2 months of TB treatment among smear-positive PTB patients in Rwanda from July 2019 to June 2021
Socio-demographic features	Two-months sputum smear outcome
	Converted	Not converted
	N (%)	N (%)	COR	95% CI	P-value
Age category
< 20years	305 (94.7)	17 (5.3)	Ref
20–39 years	3516 (91.5)	328 (8.5)	1.7	1.01–2.8	0.044
40–59 years	2021 (90)	224 (10)	2.0	1.2–3.3	0.008
60 years and above	737 (92.1)	63 (7.9)	1.5	0.9–2.7	0.129
Sex
Male	4812 (91.1)	469 (8.8)	1.06	0.9–1.3	0.563
Female	1767 (91.5)	163 (8.5)	Ref
Residence (Province)
East	1613 (90.9)	161 (9.1)	1.04	0.8–1.3	0.763
Kigali city	1888 (92.5)	153 (7.5)	0.84	0.6–1.1	0.215
North	577 (87.8)	80 (12.2)	1.44	1.06–1.1	0.021
South	1489 (91.3)	141 (8.7)	0.9	0.75–1.3	0.93
West	1012 (91.3)	97 (8.7)	Ref

Patients with a history of first-line TB treatment failure were 2.1 times more likely to have sputum smear non-conversion after 2 months of treatment (OR = 2.1, 95% CI: 1.2–3.9) compared to those who were treated for the first time (New) (OR = 0.9, 95% CI: 0.7–1.3). Sputum smear non-conversion after 2 months of TB treatment was significantly associated with patient’s BMI at TB treatment initiation, where patients who had BMI less than 18.5 were 1.5 times more likely to have sputum smear non-conversion after 2 months of treatment (OR = 1.5, 95% CI: 1.2–1.8) compared to those with BMI > = 18.5 (OR = 0.7, 95% CI: 0.6–0.8). Patients who were being followed up by CHWs during TB treatment were 1.3 times more likely to have sputum smear non-conversion after 2 months of treatment (OR = 1.3, 95% CI: 1.1–1.6) compared to those who were not followed up by CHWs (OR = 0.7, 95% CI: 0.6–0.9) (Table 4).

Table 4

Comparison of clinical factors associated with sputum smear non-conversion after 2 months of TB treatment among smear-positive PTB patients in Rwanda from July 2019 to June 2021
Clinical features	Converted	Not converted
Clinical features	N (%)	N (%)	COR	95% CI		P-value
HIV status
Negative	5363 (90.9)	534 (9.1)	Ref
Positive	1216 (92.5)	98 (7.5)	0.8	0.64–1.01		0.064
History of HIV
HIV negative	5363 (90.9)	534 (9.1)	Ref
Newly tested Positive	332 (91.7)	30 (8.3)	0.9	0.6–1.3		0.62
People living with HIV	884 (92.9)	68 (7.1)	0.8	0.59-1.0		0.054
TB treatment History
New	5958 (91.4)	563 (8.6)	Ref
Relapse	524 (91.1)	51 (8.9)	1.03		0.8–1.4	0.847
Treatment after failure of the first-line	65 (83.3)	13 (16.7)	2.1	1.1–3.9		0.015
Treatment after lost to follow up	22 (81.5)	5 (18.5)	2.4		0.9–6.4	0.078
Other previously treated	10 (100)	0	1	Empty
Currently on ART
Yes	1147 (92.6)	92 (7.4)	Ref
No	69 (92)	6 (8)	1.1	0.4–2.5		0.854
Not applicable	5363 (91)	534 (9)	1.2	0.9–1.5		0.066
Currently on cotrimoxazole
Yes	897 (92.7)	71 (7.3)	Ref
No	319 (92.2)	27 (7.8)	1.1	0.7–1.7		0.776
Not applicable	5363 (91)	534 (9)	1.2	0.9–1.6		0.081
Contact with PTB +
No	5906 (91.2)	569 (8.8)	Ref
yes	673 (91.4)	63 (8.6)	0.9	0.7–1.3		0.836
Followed by CHWs
No	3211 (92.5)	262 (7.5)	Ref
Yes	3368 (90.1)	370 (9.9)	1.3	1.1–1.6		< 0.001
BMI at treatment initiation
BMI < 18.5	4130 (90.2)	451 (9.8)	1.5	1.2–1.8		< 0.001
BMI > = 18.5	2449 (93.1)	181 (6.9)	Ref
TB-nutrition support provided
Yes	1112 (90.5)	116 (9.5)	Ref
No	5467 (91.4)	516 (8.6)	0.9	0.7–1.1		0.354

Factors Associated With Sputum Smear Non-conversion Among Spptb Patients

The factors found to be statistically significantly associated with sputum smear non-conversion after 2 months of treatment in multivariate logistic regression analysis are shown in (Table 5) below. They included age group of 20–39 years old (AOR = 1.7, 95% CI: 1.04–2.86) and 40–59 years old (AOR = 2, 95% CI: 1.18–3.3), living in Northern province (AOR = 1.4, 95% CI: 1.05-2.0), history of first-line TB treatment failure (AOR = 2, 95% CI: 1.1–3.6), follow up by CHWs during TB treatment (AOR = 1.2, 95% CI: 1.04–1.5) and BMI less than 18.5 at TB initiation (AOR = 1.5, 95% CI: 1.25–1.8) (Table 5).

Table 5

**Factors associated with sputum smear no-conversion after two months of TB treatment among smear-positive PTB patients in Rwanda from July 2019 to June 2021**
Factors	Adjusted Odds ratio	95% CI	P-value
Age category
< 20 years	Ref
20–39 years	1.7	1.04–2.8	0.033
40–59 years	2	1.18–3.3	0.009
60 years and above	1.4	0.81–2.5	0.207
Residence (Province)
West	Ref
East	0.9	0.75–1.3	0.914
Kigali city	0.9	0.69–1.2	0.543
North	1.4	1.05-2.0	0.022
South	0.9	0.71–1.2	0.642
TB treatment history
New	Ref
Relapse	1.01	0.75–1.4	0.905
Treatment after failure of first-line	2	1.1–3.6	0.028
Treatment after lost to follow up	2.4	0.9–6.5	0.073
Other previously treated	1	Empty
Followed by CHWs
No	Ref
Yes	1.2	1.04–1.5	0.013
BMI at treatment initiation
BMI less than 18.5	1.5	1.25–1.8	< 0.001
BMI > 18.5	Ref

In this study, we explored the factors associated with sputum smear non-conversion after 2 months of treatment among SPPTB patients. Our analysis of 7211 PTB cases with documented follow-up sputum smear results after the second month of treatment, between July 2019 and June 2021, showed that the overall sputum smear non-conversion rate was 9%. This is transformed into a smear conversion rate of 91% which is significantly higher than the conversion rate of 78% and 82.8 revealed by studies conducted in Mumbai and Kota Kinabalu Malaysia respectively[17, 18]. We also found that age (20–39, 40-59years), residence (Northern Province), history of first-line treatment failure, being followed up by CHWs, and BMI less than 18.5 at TB treatment initiation were independently associated with sputum smear non-conversion after 2 months of treatment.

In this study, we found that smear positive PTB patients aged between 20 and 39 years had a significantly high risk of having sputum smear non-conversion after 2 months of treatment. Our findings were different from the results shown by a study conducted in YAOUNDÉ, Cameroon which revealed that there was no significant association between age below 40 years and sputum smear non-conversion after 2 months of treatment[19]. We have also seen that the age group of 40–59 years was significantly associated with sputum smear non-conversion after 2 months of treatment, these findings were similar to those of the study conducted in Sahary Hospital, Riyadh, Saudi Arabia[20].

The present study reported no significant association between gender and sputum smear non-conversion after 2 months of treatment among SPPTB patients. Other studies elsewhere have also reported similar results[21, 22]. However different results were reported by a study in Eden district, Western Cape, South Africa where they found that the male gender was significantly associated with sputum smear non-conversion after 2 months of treatment[12]. In our findings, SPPTB patients living in the Northern Province of Rwanda were 1.4 times more likely to have sputum smear non-conversion after 2 months of treatment compared to others living in the Western province. Surprisingly, the Northern province was the one with a low proportion 657 (9.1%) of SPPTB cases countrywide. Though in this study, we were not able to establish the association between residence and sputum smear conversion because we think that this association may be due to behavior factors like alcohol, smoking habit, and patient’s knowledge and attitude towards TB which are not captured by the electronic reporting system.

In most studies, people with HIV positive were more likely to have sputum smear non-conversion after 2 months of treatment compared to others without HIV[6, 12]. These findings were quite different from our study findings where we found that there was no association between HIV positive and sputum smear non-conversion after 2 months of treatment. This could be due to the specialist-driven treatment adherence training provided to HIV-positive patients that also had a positive impact on these patients while they were taking their anti-TB treatments, thereby influencing their two months sputum conversion. In line with research conducted in other settings [3, 6], patients with diabetes mellitus (DM) had a higher risk for two-month sputum smear non-conversion than those without DM. However, we could not evaluate DM as a risk factor since only forty-one patients had DM in our study. This number is relatively low, compared to that in the above-mentioned studies. In our study, SPPTB patients who had a history of first-line treatment failure (re-treatment) were twice more likely to have sputum smear non-conversion after 2 months of treatment compared to those who were new to anti-TB treatment. These findings were similar to those of studies conducted in Sharkia Governorate and northern Malaysia [23, 24]. Re-treated PTB patients found to have sputum smear non-conversion after 2 months of treatments would be examined additionally by sputum culture and be treated further based on drug sensitivity testing [23].

The present study reported a significant association between BMI less than 18.5 at TB treatment initiation and two-month sputum smear non-conversion. Similar findings were reported by several studies [6, 25, 26]. A possible explanation for this is that undernutrition tends to increase disease complications (low immunity), thereby reducing the chance of sputum smear conversion [27]. Moreover, PTB patients who were being followed up by CHWs during TB treatment were 1.2 times more likely to have sputum smear non-conversion after 2 months of treatment compared to those who were being followed up by clinicians. This could be a result of limited service provided by CHWs due to their heavy workload, as well as low level of their skill. Several studies conducted in different countries like Brazil [28], Ethiopia [29], Malawi [30], South Africa [31], and Uganda [32] showed that using CHWs in the follow up of non-hospitalized TB patients was a cost-effective alternative to the hospital-based treatment approach, but one study pointed out the importance of accurate training and supervision of CHWs in attaining universal health goals [32].

Limitation Of The Study

The main limitation of our study was linked to the use of system data (secondary data). For some study subjects, there was a problem of missing data. Moreover, the reporting system did not capture some data of essential variables which might have an influence on sputum smear non-conversion of SPPTB patients, like clinical variables (adherence level, and viral load), socio-economic and socio-demographic characteristics (income, educational level, marital status, distance to the health facility) as well as behavioral factors (knowledge and attitude toward TB, alcohol consumption, smoking habit, illicit drug use) were not recorded.

Our study showed that sputum smear non-conversion at 9% is considered low and acceptable in following WHO targets and recommendations. We also found age (20–39, 40–59 years), residing in the Northern Province, and history of first-line treatment failure, being followed up by CHWs, and BMI less than 18.5 at TB treatment initiation to be independently associated with sputum smear non-conversion after 2 months of treatment. Based on the findings of our study we recommend the following: Reinforcement of nutritional support to PTB patients by national TB program, SPPTB cases with identified risk factors for non-conversion, should be closely monitored throughout their treatment period by their respective health facilities. Likewise, the National TB control program should invest in patient adherence counseling and education to mitigate sputum smear non-conversion risk factors, and to improve conversion. Improvement of follow-up of TB patients by CHWs through mentorship and close supervision by the national TB program and their respective health facilities should be enhance. Prospective studies which can collect most data on important variables, including ones found missing in this study, should be conducted preferably jointly with the national TB program. That would facilitate the identification of more factors associated with sputum smear non-conversion.

Our findings highlighted a critical need for enhanced TB surveillance system to explore further factors contributing to sputum smear non-conversion in the Northern Province, and to inform the implementation of interventions and maximize the indicators for TB treatment success rate. The RBC will need to ensure that the national electronic TB reporting system (e-TB) is robust enough in content and delivery, so that future data input should capture these missing data and other critical variables especially initial sputum smear grading during diagnosis, socioeconomic status, and behavior characteristics of patients. These will strongly help in the optimization of national TB control programs to maximize indicators for TB treatment success rate.

AFB

Acid-Fast Bacilli

AOR

Adjusted Odds Ratio

ART

Antiretroviral Therapy

Bacteriologically Confirmed

BMI

Body Mass Index

CHWs

Community Health Workers

Confidence Interval

COR

Crude Odds Ratio

Diabetes Mellitus

EPTB

Extra-Pulmonary Tuberculosis

FETP

Field Epidemiology and Training Program

HIV

Human Immunodeficiency Virus

Fiscal Year

IRB

Institutional Review Board

MDR

Multi-Drug Resistant

MTB

Mycobacterium Tuberculosis

PTB

Pulmonary Tuberculosis

SNPTB

Smear Negative Pulmonary Tuberculosis

SPPTB

Smear Positive Pulmonary Tuberculosis

Tuberculosis

WHO

World Health Organization

I declare that this research entitled factors associated with sputum smear non-conversion after two months of tuberculosis treatment among smear-positive pulmonary tuberculosis patients in Rwanda is original research. It has not been submitted anywhere for publication purpose. The collaborative and cited contributions have been indicated clearly and acknowledged where references have been provided on all supporting literatures and resources.

Ethics approval and consent to participate

This study was approved by the University of Rwanda ethic committee (Reference number 280/CMHS IRB/2022). The patients were not required to provide consent for participation in this study; access to anonymized tuberculosis data for this study was provided by Rwanda Biomedical Center.

The full name of the institutional Review Board that waived informed consent for participation in this study is called University of Rwanda, College of medicine and health sciences Institutional Review Board.

I declare that all methods in this study were carried out in accordance with relevant guidelines and regulations of studies involving human beings. Because the data were extracted from the electronic system, we did consent the study participants, but the dataset was kept in confidential folder and was de-identified(no names extracted).

Consent for publication

Not applicable

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No funds were required for this research

Authors' contributions

GG designed the project, carried out the data analysis, interpretation of the results and wrote the preliminary reports with input from AN and JN. Results were discussed until a consensus was reached among the authors. GG, AN, KJN and JN, drafted the manuscript, all authors read and approved the submission of this manuscript

Acknowledgements

The authors would like to appreciate the collaboration between the School of Public Health, University of Rwanda and TB and other respiratory communicable disease division (TB & ORD) in the RBC. Sincere thanks are also given to those who were directly or indirectly involved in making the research a success.

M. Gizachew Beza, E. Hunegnaw, and M. Tiruneh, “Prevalence and Associated Factors of Tuberculosis in Prisons Settings of East Gojjam Zone, Northwest Ethiopia,” Int. J. Bacteriol., vol. 2017, pp. 1–7, 2017, doi: 10.1155/2017/3826980.
L. P. Y. Mohd Anwar S. A., Salmiah M. S., S. M. Saliluddin and Doctor, “actors delaying sputum conversion in smear positive pulmonary tuberculosis : a systematic,” Int. J. Public Heal. Clin. Sci., vol. 5, no. 3, 2018, [Online]. Available: https://1library.net/document/zxv7orlv-factors-delaying-sputum-conversion-positive-pulmonary-tuberculosis-systematic.html
E. Ejeta, G. Beyene, G. Balay, Z. Bonsa, and G. Abebe, “Factors associated with unsuccessful treatment outcome in tuberculosis patients among refugees and their surrounding communities in Gambella Regional State, Ethiopia,” PLoS One, vol. 13, no. 10, pp. 1–15, 2018, doi: 10.1371/journal.pone.0205468.
WHO, “Global tuberculosis report 2020,” 2020. [Online]. Available: https://doi.org/10.1016/j.ijid.2022.03.011
F. R. Kayigamba, M. I. Bakker, V. Mugisha, M. Gasana, and M. F. S. Van Der Loeff, “Sputum completion and conversion rates after intensive phase of tuberculosis treatment : an assessment of the Rwandan control program,” 2012, [Online]. Available: https://bmcresnotes.biomedcentral.com/track/pdf/10.1186/1756-0500-5-357.pdf
M. A. Asemahagn, “Sputum smear conversion and associated factors among smear-positive pulmonary tuberculosis patients in East Gojjam Zone, Northwest Ethiopia: a longitudinal study,” BMC Pulm. Med., vol. 21, no. 1, pp. 1–10, 2021, doi: 10.1186/s12890-021-01483-w.
World Health Organization, Global tuberculosis report 2021 ISBN. 2021. [Online]. Available: https://apps.who.int/iris/bitstream/handle/10665/360605/9789240046856-eng.pdf
Rwanda MoH, “Annual Report: Tuberculosis, National Communicable, Respiratory Program, Diseases,” 2020. [Online]. Available: https://www.rbc.gov.rw/fileadmin/user_upload/TB/TB_Report_2019-2020.pdf
J. Izudi, I. K. Tamwesigire, and F. Bajunirwe, “J Clin Tuberc Other Mycobact Dis Sputum smear non-conversion among adult persons with bacteriologically con fi rmed pulmonary tuberculosis in rural eastern Uganda,” J Clin Tuberc Other Mycobact Dis, vol. 20, p. 100168, 2020, doi: 10.1016/j.jctube.2020.100168.
M. S. van der L. Felix R. Kayigamba, Mirjam I. Bakker, Veronicah Mugisha, Ludwig De Naeyer, Michel Gasana, Frank Cobelens, “Adherence to tuberculosis treatment , sputum smear conversion and mortality : a retrospective cohort study,” PLoS One, 2014, [Online]. Available: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0073501
J. A. and H. D. Fabrice Nembot Djouma, Michel Noubom, “Delay in sputum smear conversion and outcomes of smear-positive tuberculosis patients : a retrospective cohort study in,” BMC Infect. Dis., pp. 1–7, 2015, doi: 10.1186/s12879-015-0876-1.
M. Mlotshwa et al., “Risk factors for tuberculosis smear non- conversion in Eden district , Western Cape , South Africa , 2007 – 2013 : a retrospective cohort study,” BMC Infect. Dis., pp. 1–12, 2016, doi: 10.1186/s12879-016-1712-y.
A. I. Fibriana, M. Z. Saefurrohim, A. A. Setiana, M. Azam, and A. D. Pratama, “Predictors of smear non-conversion among new-treatment pulmonary tuberculosis : a single center case-control study in Indonesia,” Med. J. Indones., vol. 29, no. 4, pp. 410–416, 2020, [Online]. Available: https://mji.ui.ac.id/journal/index.php/mji/article/view/4216/1999
K. A. D. Souza et al., “Journal of Infection and Public Health Factors associated with month 2 smear non-conversion among Category 1 tuberculosis patients in Karachi , Pakistan,” vol. 11, pp. 283–285, 2018, doi: 10.1016/j.jiph.2017.06.009.
E. Commiesie, D. Stijnberg, D. Marín, F. Perez, and M. Sanchez, “Determinants of sputum smear nonconversion in smear-positive pulmonary tuberculosis patients in Suriname , 2010 – 2015,” pp. 1–8, 2019.
R. Kayigamba, “Aspects of tuberculosis and HIV diagnosis, care and treatment in Rwandan health facilities: operational studies,” 2014, [Online]. Available: http://dare.uva.nl/record/1/418378
R. Parikh, G. Nataraj, S. Kanade, V. Khatri, and P. Mehta, “Time to sputum conversion in smear positive pulmonary TB patients on category I DOTS and factors delaying it,” J. Assoc. Physicians India, vol. 60, no. 8, pp. 22–26, 2012.
K. Mokti et al., “Predictors of delayed sputum smear conversion among pulmonary tuberculosis patients in Kota Kinabalu, Malaysia,” PubMed.gov, vol. 31, no. July, 2021, [Online]. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8341317/pdf/medi-100-e26841.pdf
C. Kuaban, R. Bame, L. Mouangue, S. Djella, and C. Yomgni, “Non conversion of sputum smears in new smear positive pulmonary tuberculosis patients in Yaoundé , Cameroon,” East Afr. Med. J., vol. 86, no. 5, pp. 219–225, 2009.
R. Singla, M. M. Osman, N. Khan, N. Al-Sharif, M. O. Al-Sayegh, and M. A. Shaikh, “Factors predicting persistent sputum smear positivity among pulmonary tuberculosis patients 2 months after treatment,” Int. J. Tuberc. Lung Dis., vol. 7, no. 1, pp. 58–64, 2003.
V. Yellappa, V. Kandpal, D. Lall, and A. Tabassum, “Determinants of sputum conversion at two months of treatment under National Tuberculosis Programme , South India,” vol. 5, no. 12, pp. 1–5, 2016, doi: 10.5455/ijmsph.2016.20062016529.
S. Pajankar, R. Khandekar, M. Amer, A. Amri, M. Redha, and A. Lawati, “Factors Influencing Sputum Smear Conversion at One and Two Months of Tuberculosis Treatment,” vol. 23, no. 4, pp. 263–268, 2008.
M. El-Shabrawy and D. A. El-Shafei, “Evaluation of treatment failure outcome and its predictors among pulmonary tuberculosis patients in Sharkia Governorate, 2013–2014,” Egypt. J. Chest Dis. Tuberc., vol. 66, no. 1, pp. 145–152, 2017, doi: 10.1016/j.ejcdt.2015.11.002.
Z. Bhatti, A. H. Khan, S. A. S. Sulaiman, M. Laghari, and I. A. B. H. Ali, “Determining the risk factors associated with delayed sputum conversion at the end of the intensive phase among tuberculosis patients,” East. Mediterr. Heal. J., vol. 27, no. 8, pp. 755–763, 2021, doi: 10.26719/2021.27.8.755.
B. Dursun and N. Capan, “Factors influencing sputum smear and culture conversion time among patients with new case pulmonary tuberculosis,” vol. 306, no. February, pp. 231–235, 2007, doi: 10.1111/j.1742-1241.2006.01131.x.
S. Diktanas et al., “Factors associated with persistent sputum positivity at the end of the second month of tuberculosis treatment in Lithuania,” Tuberc. Respir. Dis. (Seoul)., vol. 81, no. 3, pp. 233–240, 2018, doi: 10.4046/trd.2017.0096.
K. Mueller-wieland, “Tuberculosis and nutrition,” Dtsch. Med. J., vol. 12, pp. 145–149, 2009, [Online]. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813110/pdf/LI-26-9.pdf
E. Santo, L. M. Guidoni, and J. E. Golub, “Cost-effectiveness of community health worker versus home-based guardians for directly observed treatment of tuberculosis in Vitória , Espírito Santo State , Brazil Custo-efetividade dos agentes comunitários de saúde versus supervisores domiciliares na re,” Scielo Brazil, vol. 27, no. 5, pp. 944–952, 2011, [Online]. Available: https://www.scielo.br/j/csp/a/mkcvgLk5bBh4NKLCVLFJWHr/?format=pdf&lang=en
D. G. Datiko and B. Lindtjørn, “Cost and cost-effectiveness of treating smear-positive tuberculosis by health extension workers in Ethiopia: An ancillary cost-effectiveness analysis of community randomized trial,” PLoS One, vol. 5, no. 2, pp. 1–7, 2010, doi: 10.1371/journal.pone.0009158.
K. Floyd, J. Skeva, T. Nyirenda, F. Gausi, and F. Salaniponi, “Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Lilongwe District, Malawi,” Int. J. Tuberc. Lung Dis., vol. 7, no. 9 SUPPL. 1, pp. 29–37, 2003.
E. Sinanovic, K. Floyd, L. Dudley, V. Azevedo, R. Grant, and D. Maher, “Cost and cost-effectiveness of community-based care for tuberculosis in Cape Town, South Africa,” Int. J. Tuberc. Lung Dis., vol. 7, no. 9 SUPPL. 1, pp. 56–62, 2003.
D. Okello, K. Floyd, F. Adatu, R. Odeke, and G. Gargionis, “Cost and cost-effectiveness of community-based care for tuberculosis patients in rural Uganda,” Int. J. Tuberc. Lung Dis., vol. 7, no. 9 SUPPL. 1, pp. 72–79, 2003.

No competing interests reported.

Download PDF

Journal Publication

published 15 Jun, 2023

Read the published version in BMC Infectious Diseases →

Editorial decision: Major revision
13 Feb, 2023
Reviews received at journal
04 Feb, 2023
Reviewers agreed at journal
28 Jan, 2023
Reviewers invited by journal
15 Dec, 2022
Editor assigned by journal
15 Dec, 2022
Editor invited by journal
15 Dec, 2022
Submission checks completed at journal
15 Dec, 2022
First submitted to journal
06 Dec, 2022

You are reading this latest preprint version

Prevalence and factors associated with sputum smear non-conversion after two months of tuberculosis treatment among smear-positive pulmonary tuberculosis patients in Rwanda: a cross-sectional study

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Study design and setting

Study Population

Sampling

Results

Characteristics of the study participants

Comparison Between Socio-demographic, Clinical Factors And Sputum Smear Non-conversion

Factors Associated With Sputum Smear Non-conversion Among Spptb Patients

Discussion

Limitation Of The Study

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1