title: Alcohol, hospital discharge, and socioeconomic risk factors for default from multidrug resistant tuberculosis treatment in rural South Africa: a retrospective cohort study.
abstract: BACKGROUND
  Default from multidrug-resistant tuberculosis (MDR-TB) treatment remains a major barrier to cure and epidemic control. We sought to identify patient risk factors for default from MDR-TB treatment and high-risk time periods for default in relation to hospitalization and transition to outpatient care.
  
  
  METHODS
  We retrospectively analyzed a cohort of 225 patients who initiated MDR-TB treatment between 2007 through 2010 at a rural TB hospital in the Western Cape Province, South Africa.
  
  
  RESULTS
  Fifty percent of patients were cured or completed treatment, 27% defaulted, 14% died, 4% failed treatment, and 5% transferred out. Recent alcohol use was common (63% of patients). In multivariable proportional hazards regression, older age (hazard ratio [HR]= 0.97 [95% confidence interval 0.94-0.99] per year of greater age), formal housing (HR=0.38 [0.19-0.78]), and steady employment (HR=0.41 [0.19-0.90]) were associated with decreased risk of default, while recent alcohol use (HR=2.1 [1.1-4.0]), recent drug use (HR=2.0 [1.0-3.6]), and Coloured (mixed ancestry) ethnicity (HR=2.3 [1.1-5.0]) were associated with increased risk of default (P<0.05). Defaults occurred throughout the first 18 months of the two-year treatment course but were especially frequent among alcohol users after discharge from the initial four-to-five-month in-hospital phase of treatment, with the highest default rates occurring among alcohol users within two months of discharge. Default rates during the first two months after discharge were also elevated for patients who received care from mobile clinics.
  
  
  CONCLUSIONS
  Among patients who were not cured or did not complete MDR-TB treatment, the majority defaulted from treatment. Younger, economically-unstable patients and alcohol and drug users were particularly at risk. For alcohol users as well as mobile-clinic patients, the early outpatient treatment phase is a high-risk period for default that could be targeted in efforts to increase treatment completion rates.
authors.affiliation: Division of Infectious Diseases, School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, United States of America.
authors.forename: Emily A
authors.initials: EA
authors.lastname: Kendall
authors.affiliation: Brewelskloof Hospital, Worcester, South Africa.
authors.forename: Danie
authors.initials: D
authors.lastname: Theron
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Molly F
authors.initials: MF
authors.lastname: Franke
authors.affiliation: Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.
authors.forename: Paul
authors.initials: P
authors.lastname: van Helden
authors.affiliation: Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Victor
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America ; Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Megan B
authors.initials: MB
authors.lastname: Murray
authors.affiliation: Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.
authors.forename: Robin M
authors.initials: RM
authors.lastname: Warren
authors.affiliation: Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa ; Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts, United States of America.
authors.forename: Karen R
authors.initials: KR
authors.lastname: Jacobson
mesh_terms: D000293:Adolescent; D000328:Adult; D000428:Alcohol Drinking / Q000453:epidemiology*; D000553:Ambulatory Care; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012424:Rural Population; D012959:Socioeconomic Factors; D013019:South Africa / Q000453:epidemiology; D013997:Time Factors; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy* / Q000453:epidemiology*