Cure Rate of Tuberculosis Cases Diagnosed in Eastern Province, Saudi Arabia During Years 2000 & 2001

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis. It appears as pulmonary TB (80%), extra pulmonary, or a combination of both types. A treatment protocol for TB was recommended by the World Health Organization (WHO) in 1995 called Directly Observed Treatment Short-course (DOTS), which involves observing patients swallow their pills, and has been shown to improve TB treatment completion rates.[1] DOTS was implemented in Saudi Arabia as a preliminary stage in 8 regions in the third quarter of 1998, then expanded to the whole country by the end of 1999.[2]

This study aims to assess the cure rate among TB patients diagnosed in the Eastern province of Saudi Arabia, during a two year period from January 1st 2000 to December 31st 2001. To achieve this objective, a retrospective cross-sectional study was conducted, reviewing all TB cases diagnosed at different health institutes in the Eastern Province during the study period. The medical files of TB patients were reviewed at each hospital. TB cases were categorized according to MOH instruction (WHO definition). Cure Rate was estimated by considering the number of those who were cured or had completed the treatment as the nominator and the total number of TB patients, except those who had died, transferred out or deported, as the denominator.

During years 2000 & 2001, a total of 451 TB cases were diagnosed; 81% pulmonary and 19% extra pulmonary. The majority of Pulmonary (83%) and Extra Pulmonary (61%) cases had been diagnosed at MOH Chest hospital. The number of TB cases was slightly higher during year 2000 (n=240) than year 2001. There was a significant difference between the mean age of Pulmonary TB cases (38.5 years ±15.3) and Extra Pulmonary TB cases (32.3 ±11.8), p<0.05. The majority of TB cases were males whether Pulmonary (72.1%) or Extra Pulmonary (69.4%). Saudis accounted for 39% of Pulmonary and 21% of Extra Pulmonary TB cases. The majority of TB cases were newly diagnosed, whether for Pulmonary (96.9%) or Extra Pulmonary (96.5%). Almost all the Pulmonary TB cases 95.6%, had been admitted into hospital, the mean duration of hospitalization was 61.3 ± 36.4 days (Range 1-273 days); compared to 64.7% of Extra Pulmonary TB cases who had been admitted into hospital with a mean duration of hospitalization of 24.3 ± 19.5 days (Range 1-66 days).

Symptoms recorded at time of admission for 366 Pulmonary TB cases were cough (92.2%), fever (75.2%), weight loss (67.1%), anorexia (52.1%), night sweat (48.5%), chest pain (26.7%), and haemoptysis (18.1%). The most common type of Extra Pulmonary TB was either Pleural Effusion (39.8%) or Cervical lymphadenitis (36.2%), Axillary lymphadenitis (7.2%), Submandibular and cervical lymphadenitis were 3.6% each, and 9.6% for other locations. The final outcomes of Pulmonary TB were as follows: 35.2% were deported, 21% completely cured, 10.9% lost to follow up, 18.6% completed their treatment but not cultured, 6.6% transferred to other health institutes, 4.9% defaulted, 1.9% died before treatment was completed, and 0.8% failed treatment. The final outcomes for Extra Pulmonary TB were: 47.1% completed their treatment but not cultured, 22.4% lost to follow up, 20% deported, 5.9% completely cured, 2.4% transferred to other health institute, 1.2% defaulted, 1.2% died before treatment was completed, and none had treatment failure. Patient and health care factors associated with cure rate of TB are shown in table 1. There was no significant association between the cure rate of Pulmonary TB and severity of infection at the time of starting treatment.

Tuberculosis remains a common health problem in Saudi Arabia, particularly among expatriate workers from Southeast Asia, where the disease is endemic with a high prevalence.[3] This may be aggravated by living in overcrowded houses, inadequate nutrition, poor hygienic habits, and poor health awareness, which play a major role in transmission of the disease. The majority of expatriate workers in Saudi Arabia are laborers, unskilled or technical workers, and drivers which may explain the predominance of males in our study. Also, most cases appeared in the adult middle age group in accordance with many studies showing the same pattern.[4]

The Chest hospital was the best among all health units in the Eastern province in terms of diagnosis and treatment of TB. This relatively high percentage came through the high application of DOTS, admission of cases in the intensive phase for the first two months and close follow up in the continuation phase.

The cure rates were reasonably good for both Pulmonary and Extra Pulmonary TB, but better results would be obtained if calculated only those cases that had been diagnosed and reported to the Regional TB organizer. One of the major duties of the organizer is to ensure that any diagnosed TB case will receive the allocated treatment. The study demonstrated a miss-communication be-tween different health institutes and the organizer regarding the cases that did not show up for treatment. Unless the TB patient was treated, most of the health institutes did not report the case, which leads to a biased estimate of the cure rate for the regional health directorate.

Our study showed improved cure rates to other studies conducted in Saudi Arabia.[5] The DOTS strategy leads to a decline in treatment failure rate. However, defaulters were high in number as a result of patients interrupting their treatment. There are many obstacles for bringing patients back to therapy, whether as a result of inability to contact them due to wrong addresses or phone numbers, or noncompliance. Compliance of patients is imperative for the success of TB treatment and control programs.[5]

The study showed reduction of resistance to anti-tuberculous drugs under DOTS strategy, which is almost similar to the result of the study that conducted by Al-Rubaish et al.[6] It showed low drug resistance compared to other regions in Saudi Arabia such as Gizan (42%), Taif (23%) and Riyadh (13%).[6,7]

Although DOTS strategy in Saudi Arabia is effective in controlling TB, it is only best practiced in chest hospitals during the intensive phase (first two months of treatment), since patients are admitted and under direct supervision and evaluation of health workers. It is essential that the awareness of the importance of DOTS be strengthened among patients and their families to render it a well-functioning and successful program. Furthermore, improvement of the health system and facilities in other health units by simplifying DOTS application, which may reduce many of the obstacles such as patient noncompliance.

Enhancing the referral process of TB patients to chest hospitals for treatment and follow up is recommended. Pulmonary TB cases should be admitted for the intensive phase at least, in order to improve the cure rate. Physician's skills in TB diagnosis and treatment should be enhanced. It is also worthwhile to strengthen DOTS strategy.