Spatiotemporal trends and risk factors of unsuccessful treatment outcomes among tuberculosis patients in Selangor, Malaysia

Tuberculosis (TB) remains the leading cause of mortality among the infectious diseases in Selangor, Malaysia. To identify the spatio-temporal trends and risk factors of unsuccessful treatment outcomes and determine the predictors and time to unsuccessful treatment outcomes in Selangor, Malaysia. Phase I was a retrospective cohort in Selangor (2014-2017) where 18136 respondents from TB registry were selected and their data was recorded using standardized data collection forms and then analyzed using SPSS version 25.0 (multiple logistic regression) to identify the risk factors of unsuccessful treatment outcomes (death, loss to follow-up, failure and not evaluated) and ArcGIS version 10.4 (Global Moran’s I and Getis and Ordi (Gi*) statistics) to analyze the spatial distribution, spatio-temporal clustering and develop hot-spot maps of TB and unsuccessful treatment outcomes. Phase II was a prospective cohort in Hulu Langat (2018-2020) where 340 respondents were new TB cases registered in government health clinics and their data was recorded using self-reported questionnaire and standardized data collection forms. Kaplan-Meier survival analysis with Log rank test was used to estimate the time to unsuccessful treatment outcomes and Cox proportional hazard model was used to calculate the hazard ratios of unsuccessful treatment outcomes at 95% confidence interval and level of significance set at 0.05. Unsuccessful treatment outcomes in Selangor were 25.1% with highest proportion being loss to follow-up (11%) and death (9.1%). Spatio-temporal clusters and hotspots of TB incidence and unsuccessful treatment outcomes varied in the study but were persistent in 5 sub-districts (Sungai Buloh, Damansara, Petaling, Ampang and Cheras). Risk factors of unsuccessful treatment outcomes in Selangor included male, age >35yrs, Non-Malaysians, urban area, unemployed, history of incarceration, smokers, human immunodeficiency virus (HIV) positive status, pulmonary tuberculosis, retreatment case, advanced chest x-ray, positive sputum at 2nd month of treatment, multi-drug resistant tuberculosis (MDR-TB), public hospital/ clinic as place of starting treatment, shorter duration of treatment and unsupervised directly observed therapy (DOT). Unsuccessful treatment outcomes in Hulu Langat were 20.0% with highest proportions being not evaluated (10.9%) and loss to follow-up (7.4%). Mean survival time to unsuccessful treatment outcome was 7.6 months with 80.0% occurring in the first 3 months of treatment. Risk factors of hazard probability of unsuccessful treatment outcomes in Hulu Langat were male, underweight, Malay ethnicity, cigarette/vaping, not done sputum at 2nd month of treatment and public mode of transport. Unsuccessful treatment outcomes in Selangor were high in certain districts and sub-districts. Hotspots of TB incidence and unsuccessful treatment outcomes clustered in the central region of Selangor. Strengthening of the existing TB control programs especially in the central eastern and western sub-districts is recommended. Programs aimed to reduce loss to follow-up and death needed within the first three months of treatment in Selangor. Engaging community/non-governmental organization (NGO) in TB management and DOT especially for Non-Malaysian and incarcerated TB patients. Integrating vaping de-addiction in the existing smoking cessation programs at the health clinic levels and providing free public transport to reach the health centers are recommended.

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