Case enrollment
Data from 25,533 TB patients was abstracted, of whom 3,566 (13.9%) were recurrent TB cases. Of these recurrent TB cases 2,573 (72.2.3%) were in urban areas and 992 (27.8%) in rural areas (Figure 1). After excluding recurrent TB cases whose treatment outcomes were not documented because they transferred to another facility before the end of treatment, there were 2,565 (72.1%) recurrent TB cases in urban areas and 990 (27.9%) in rural areas.
Prevalence of recurrence among TB cases
The overall prevalence of recurrent TB was 14% (95% CI; 13.5 14.4). In urban setting the prevalence was 15.3% (n = 2,573; 95% CI: 14.8 15.9) and 11.3% (n = 992; 95% CI: 10.7 12.0) in rural areas (Table 1). TB recurrence in HIV negative TB cases was 10.0% (n = 499; 95% CI: 9.2 10.9) and 16.1% (n = 2,216; 95% CI: 15.5 16.7) in HIV seropositive positive recurrent TB cases. In men prevalence of recurrent TB was 13% (n = 1506; 95% CI: 12.4 13.6) and 14.9% (n = 2,049; 95% CI: 14.3 15.5) in women.
Demographic and clinical characteristics
The mean was 36.3 years (Standard deviation (SD) = 14.8) and most of the recurrent TB cases were male (n = 2,019; 56.9%) Of the total cases 2,745(77%) were recurrent cases due to relapse, 31 (0.9%) were recurrence after LTFU, 29 (0.8%) were recurrence after failure and 106 (3.0%) were classified as others (Table 2).
Of all the HIV seropositive cases of recurrent TB that were analyzed 1,712 (78.8%) cases were in urban areas whereas 461 (21.2%) were in rural areas (Table 2). Most patients received treatment within the first 14 days of registering in the TB clinic (n=3,135; 88.2%).
Treatment outcomes
Of the 3,555 patients who were included in the analysis 265 (7.5%) were cured and 2,877 (80.9%) completed treatment (Table 3). In the urban areas 111 (4.3%) cases died, 95 (3.7%) cases experienced treatment failure and 52 (2.0%) were LTFU. In the rural areas 51 (5.2%) died, 18 (1.8%) experienced TB treatment failure and 51 (5.2%) were LTFU.
Univariable and multivariable analysis results
In both the univariable and multivariable analysis place of TB treatment was statistically associated with all-cause mortality (Table 4). After adjusting for sex, age group, microbiological confirmation, and HIV status, recurrent TB cases treated in the rural settings were 70% more likely to die while on TB treatment. (aOR: 1.7, 95% CI: 1.2 2.7). HIV positive patients on ART 70% more likely to die when compared to HIV negative patients (aOR 1.7; 95% CI: 1.4 – 3.7).
For secondary outcomes of LTFU and TB treatment failure analyzed separately rural areas had worse TB treatment outcomes. After adjusting for calendar year of treatment, HIV and ART status recurrent TB patients in the rural areas where twice more likely to be LTFU as compare to those in urban areas (aOR 2.0, 95% CI: 1.3 3.0) (Table 5). For recurrent TB treatment failure, patients in rural areas were 70% more likely to experience treatment failure (aOR 1.7, 95% CI: 0.7 5.1) (Table 6).