Treatment default amongst patients with tuberculosis in urban Morocco: predicting and explaining default and post-default sputum smear and drug susceptibility results.
METHODS
Public tuberculosis (TB) clinics in urban Morocco.


OBJECTIVE
Explore risk factors for TB treatment default and develop a prediction tool. Assess consequences of default, specifically risk for transmission or development of drug resistance.


METHODS
Case-control study comparing patients who defaulted from TB treatment and patients who completed it using quantitative methods and open-ended questions. Results were interpreted in light of health professionals' perspectives from a parallel study. A predictive model and simple tool to identify patients at high risk of default were developed. Sputum from cases with pulmonary TB was collected for smear and drug susceptibility testing.


RESULTS
91 cases and 186 controls enrolled. Independent risk factors for default included current smoking, retreatment, work interference with adherence, daily directly observed therapy, side effects, quick symptom resolution, and not knowing one's treatment duration. Age >50 years, never smoking, and having friends who knew one's diagnosis were protective. A simple scoring tool incorporating these factors was 82.4% sensitive and 87.6% specific for predicting default in this population. Clinicians and patients described additional contributors to default and suggested locally-relevant intervention targets. Among 89 cases with pulmonary TB, 71% had sputum that was smear positive for TB. Drug resistance was rare.


CONCLUSIONS
The causes of default from TB treatment were explored through synthesis of qualitative and quantitative data from patients and health professionals. A scoring tool with high sensitivity and specificity to predict default was developed. Prospective evaluation of this tool coupled with targeted interventions based on our findings is warranted. Of note, the risk of TB transmission from patients who default treatment to others is likely to be high. The commonly-feared risk of drug resistance, though, may be low; a larger study is required to confirm these findings.
Directorate of Epidemiology and Disease Control, Ministry of Health, Rabat, Morocco.
Imad
I
Cherkaoui
National Institute of Hygiene, Ministry of Health, Rabat, Morocco.
Radia
R
Sabouni
Moulay Youssef University Hospital, CHU Ibn Sina, Rabat, Morocco.
Iraqi
I
Ghali
University of Washington School of Medicine, Seattle, Washington, United States of America.
Darya
D
Kizub
Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
Alexander C
AC
Billioux
National TB Control Program, Directorate of Epidemiology and Disease Control, Ministry of Health, Rabat, Morocco.
Kenza
K
Bennani
Moulay Youssef University Hospital, CHU Ibn Sina, Rabat, Morocco.
Jamal Eddine
JE
Bourkadi
National TB Control Program, Directorate of Epidemiology and Disease Control, Ministry of Health, Rabat, Morocco.
Abderrahmane
A
Benmamoun
National Institute of Hygiene, Ministry of Health, Rabat, Morocco.
Ouafae
O
Lahlou
National Institute of Hygiene, Ministry of Health, Rabat, Morocco.
Rajae El
RE
Aouad
Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
Kelly E
KE
Dooley
D000995:Antitubercular Agents / Q000627:therapeutic use*; D016022:Case-Control Studies; D006801:Humans; D009018:Morocco; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification*; D010349:Patient Compliance; D012307:Risk Factors; D013183:Sputum / Q000382:microbiology*; D014376:Tuberculosis / Q000188:drug therapy*; D014505:Urban Population
D000995:Antitubercular Agents