Attrition and its risk factors among drug susceptible tuberculosis patients attending Kampala Capital City Authority health facilities in Kampala-Uganda.

Abstract

ABSTRACT Introduction: Despite significant progress made in improving tuberculosis (TB) treatment outcomes in Uganda, high death and lost to follow-up rates among TB patients remains one of the biggest obstacles in achieving the global targets. TB patients who do not complete treatment pose the greatest risk of increased community transmission and development of drug resistance. Kampala city public health facilities stagnated in achieving treatment success despite the involvement of extension community health workers, however, there is still paucity of information regarding time to attrition and risk factors associated with mortality and lost to follow-up among TB patients in Kampala. Objective: This study aimed at analyzing time to attrition due to death or lost to follow-up and associated risk factors among TB patients on first line anti-TB treatment in Kampala City, Uganda from January 2018 to December 2020. Methods: A concurrent explanatory mixed methods design was used employing a retrospective cohort study design based on medical records review in the five diagnostic and treatment units (DTUs) of Kampala city, Uganda. We reviewed 900 randomly selected medical records of TB patients on first line anti-TB treatment from the five DTUs from January 2018 to December 2020 as the end of follow-up date. Medical records of patients transferred in from another district/facility were excluded in the study. We analyzed data using STATA V.14. The Cox’s proportional hazard model was used to model the outcome of interest. Time to death and time to lost to follow-up were used as outcome measures. Explanatory variables with p-value <0.05 were considered statistically significant predictors. The final model was reported in terms of adjusted hazard ratios (aHR) with 95% confidence interval (CI). Thirty (30) previously lost to follow-up patients participated in the qualitative study. Qualitative data was analyzed using content analysis through the stages of familiarizing with the content of interview transcriptions and recordings that were summarized into codes and themes to explain the phenomena using open code software version 4.2. Results: Of the 900 TB patients’ records reviewed, 66 (7.3%) had died and 105 (11.7%) were lost to follow-up during treatment. 65.1% of the deaths occurred early during the first two months of treatment initiation. While 56.2% of lost to follow-up was documented after 3-5 months of treatment initiation. The factors that were significantly associated with increased risk of mortality (p-value<0.05) included advancing age+55 years (aHR=4.07, 95%CI:1.25-13.20) being single (aHR=1.93, 95%CI:1.06-3.54), clinically diagnosed TB (aHR=1.68, 95%CI:1.03-2.77), retreatment TB (aHR=3.59, 95%CI:1.06-12.50), whereas being HIV negative (aHR=0.20, 95%CI:0.11-0.38), not having comorbidities (aHR= 0.45, 95%CI:0.23-0.88), non-alcohol consumer (aHR=0.15, 95%CI:0.08-0.31) and being a non-smoker (aHR:0.42, 95%CI:0.22-0.81) were associated with reduced risks of mortality. However, factors associated with increased likelihood of lost to follow-up were being single (aHR=3.18, 95%CI:1.99-5.08), retreatment TB (aHR=6.70, 95%CI:4.11-11.09), HIV negative status (aHR=0.60, 95%CI:0.41-0.89), not having treatment supporter (aHR=3.85, 95%CI:2.02-7.33), and no CB-DOTs (aHR=1.82, 95%CI0.94-3.53), while female sex (aHR=0.47, 95%CI:0.35-0.94), not drinking alcohol (aHR=0.36, 95%CI:0.22-0.60) and being non-smoker (aHR=0.41, 95%CI:0.25-0.65) were protective. Feeling better, using herbal medicine, relocation, drug side effects, having HIV, social stigma, economic challenges, Alcohol drinking, smoking and waiting time at clinics were patients reasons for lost to follow-up during treatment. Conclusion: High mortality (7.3%) and lost to follow-up rates (11.7%) were observed among TB patients on first line anti-tuberculosis treatment in Kampala city. These figures are unacceptably higher than the recommended target of < 5% for all TB programs. Majority of TB deaths (65.1%) occurred early during the first two months of initial phase. However, lost to follow-up treatment was more frequently observed after 3-5 months of treatment initiation (56.2%) in the continuation phase. Risk factors associated with mortality include advancing age +55year, being single, TB/HIV co-infection, clinical TB disease, comorbid, previous TB treatment, alcohol drinking and being a smoker. Whereas factors associated with lost to follow-up include male sex, being single, being HIV negative, previous TB treatment, alcohol drinking, being a smoker, not having a treatment supporter and not being on CB-DOTs. However, being on both digital and non-digital CB-DOTS was protective. The study calls for strengthening efforts in mitigating mortality due to TB. Additionally, previously treated TB patients should be targeted for individualized care and must be on effective CB-DOTs.