3.1. Characteristics of the study participants
The clinical and sociodemographic characteristics of the TB cases is shown in Table 1. From 2014 to 2017, a total of 1553 TB cases were registered in 25 refugee camps. The mean age of the total TB cases was 27.2 years, 430 (27.7%) were children under 15 years, 998(52.4%) were adults 15–44 years, 850 (54.7%) were male, and 690 (44.4%) were female.
Among the total TB cases notifed, 1108 cases (72.0%) were PTB, 431 (28.0%) EPTB, and1527 (98.8%) new and relapse cases. Among the PTB cases, 677 (61.1%) were smear positive (PTB+), and 431 (38.9%) were clinically diagnosed (pulmonary smear negative plus smear unknown/not done). Among the 1527 new and relapse cases, 1093 (70.4%) were pulmonary cases, of whom 666 (60.9%) were bacteriologically confirmed and 427 (39.1%) were clinically diagnosed.
Of the total 1553 TB cases notified, 858 (55.2%) were from Gambella refugee area and 221 (14.2%) were from Dollo Addo. The remaining Afar, Asossa, Mizan, and Shire refugee areas contributed 3.4%, 4.7%, 5.1% and 6.6% of the total TB cases notified, respectively (Table 1). The number of notified TB cases for each refugee area and refugee health facility/refugee camp are presented in Supplement 1.
Table 1 Sociodemographic and clinical characteristics of the notified TB cases (n=1553) among the refugee camps in Ethiopia, 2014–2017.
Characteristic
|
2014,
N (%)
|
2015,
N (%)
|
2016 ,
N (%)
|
2017,
N (%)
|
Total
N (%)
|
Total TB cases of all Forms
|
138
|
354
|
473
|
588
|
1553
|
Age group
<15
15-29
30-44
45-59
>= 60
Not documented
|
26 (18.8)
50 (36.2)
39 (28.3)
15 (10.9)
6 (4.3)
3 (2.2)
|
92 (26.0)
107 (30.2)
87 (24.6)
43 (12.1)
23 (6.5)
2 (0.6)
|
135 (28.5)
141 (29.8)
107 (22.6)
46 (9.7)
39 (8.3)
4 (1.0)
|
177 (30.1)
152 (25.9)
132 (22.4)
79 (13.4)
44 (7.5)
4 (0.7)
|
430 (27.7)
450 (29.0)
365 (23.5)
183 (11.8)
112 (7.2)
13 (0.8)
|
Mean age, years
|
28.0
|
27.1
|
26.8
|
27.0
|
27.2
|
Sex
Male
Female
Not documented
|
80 (58.0)
57 (41.3)
1 (0.7)
|
193 (54.5)
160 (45.2)
1 (0.3)
|
247 (52.2)
222 (46.9)
4 (0.9)
|
330 (56.1)
251 (42.7)
7 (1.2)
|
850 (54.7)
690 (44.4)
13 (0.8)
|
Type of TB
PTB
EPTB
Not documented
|
106 (76.8)
32 (23.2)
0
|
279 (78.8)
73 (20.6)
2 (0.6)
|
334 (70.6)
134 (28.3)
5 (1.1)
|
389 (66.2)
192 (32.7)
7 (1.1)
|
1108 (71.3)
431 (27.8)
14 (0.9)
|
Type of TB by diagnostic category
PTB+
Clinically diagnosed PTB*
EPTB
Not documented
|
47 (34.0)
59 (42.8)
32 (23.2)
0
|
162 (45.8)
117 (33.1)
73 (20.6)
2 (0.5)
|
216 (45.7)
118 (25.0)
134 (28.3)
5 (1.0)
|
252 (42.9)
137 (23.3)
192 (32.6)
7 (1.2)
|
677 (43.6)
431 (27.7)
431 (27.8)
14 (0.9)
|
TB patient by previous treatment history:
New and relapse**
Treatment after Failure
Lost to Follow up to Treatment
Others
Not documented
|
137 (99.3)
0
1 (0.7)
0
0
|
347 (98.0)
0
3 (0.8)
1 (0.3)
3 (0.8)
|
462 (97.7)
1 (0.2)
5 (1.1)
2 (0.4)
3 (0.6)
|
581 (98.8)
1 (0.2)
4 (0.6)
1 (0.2)
1 (0.2)
|
1527 (98.3)
2 (0.1)
13 (0.8)
4 (0.3)
7 (0.5)
|
New and relapse PTB patients:
Bacteriologically confirmed cases:
Clinically diagnosed cases:
|
105 (76.6)
46 (43.8)
59 (56.2)
|
276 (80.4)
161 (58.3)
115 (41.7)
|
328 (71.0)
210 (64.0)
118 (36.0)
|
384 (66.1)
249 (64.8)
135 (35.2)
|
1093 (71.6)
666 (60.9)
427 (39.1)
|
HIV status
Positive
Negative
Not documented
|
10 (8.6)
106 (91.4)
22 (15.9)
|
48 (15.3)
265 (84.7)
41 (11.6)
|
50 (13.2)
329 (86.8)
94 (26.6)
|
57 (10.9)
464 (89.1)
67 (11.4)
|
165 (10.6)
1164 (75.0)
224 (14.4)
|
ART initiation
Yes
No
|
4 (40.0)
6 (60.0)
|
44 (91.7)
4 (8.3)
|
38 (76.0)
12 (24.0)
|
48 (84.2)
9 (15.8)
|
134 (81.2)
31 (18.8)
|
TB cases by refugee areas
Shire
Afar
Gambella
Mizan
Asossa
Jijiga
Dollo Ado
|
21 (15.2)
0
43 (31.2)
2 (1.4)
14 (10.1)
45 (32.6)
13 (9.4)
|
28 (7.9)
0
159 (44.9)
30 (8.5)
29 (8.2)
42 (11.9)
66 (18.6)
|
26 (5.5)
6 (1.3)
288 (60.9)
18 (3.8)
16 (3.4)
45 (9.5)
74 (15.6)
|
28 (4.8)
47 (8.0)
368 (62.6)
29 (4.9)
14 (2.4)
34 (5.8)
68 (11.6)
|
103 (6.6)
53 (3.4)
858 (55.2)
79 (5.1)
73 (4.7)
166 (10.7)
221 (14.2)
|
PTB+: Smear-positive pulmonary TB
*Clinically diagnosed PTB: includes smear-negative pulmonary TB and pulmonary smear unknown/not done
**New and relapse: includes cases for which the treatment history is unknown (not recorded) and transfer in; and it excludes cases that have been re-registered as treatment after failure, as treatment after lost to follow up or as other previously treated with unknown or undocumented treatment outcome
3.2. Overall trends in TB case notification, 2014 to 2017
Trends in total case notification, by type of TB and treatment history
From 2014 to 2017: the number of notified TB cases of all forms increased from 138 to 588 cases. Among the notified cases, the percentage of EPTB increased from 23.2% to 32.7%, while PTB decreased from 76.8% to 66.2%. Among the PTB cases, the percentage of smear-positive pulmonary TB (PTB+) increased from 34.3% in 2014 to 42.9% % in 2017, and that of clinically diagnosed PTB (smear-negative pulmonary TB plus pulmonary smear unknown/not done) continuously declined from 42.8% in 2014 to 23.3% in 2017 (Table 1, Fig 1). Among the pulmonary new and relapse cases, those bacteriologically confirmed increased from 43.8% in 2014 to 64.8% in 2017, and those clinically diagnosed declined from 56.2% to 35.2% (Table 1).
By treatment history, 97.7%-99.0% of the TB patients registered during the study period were new and relapse; whereas on average 0.1%, 0.8%, 0.3% and 0.5%, respectively, were treatment after failure, lost to follow up to treatment, and “others” (Table 1).
Trends in cases notification stratified by gender
There was disparity in the notified TB cases by gender. The average number of notified cases for men was 213 (standard deviation, SD = 105) and for women was 173 (SD = 86) (P = 0.39). From 2014 to 2017, the number of notified cases increased for men (from 80 to 330 cases) and for women (from 57 to 251 cases). The proportion of notified cases was predominated by men over the study period (> 52%), with the male-to-female (M:F) notification ratio consistently >1.1:1. However, the M:F ratio continuously declined from 1.4 in 2014 to 1.1 in 2016, and then increased to 1.3 in 2017 (Table 1).
Trends in case notification stratified by age categories
Over the study period, the largest contributor to the total TB cases notified were age 15-29 years followed by 30-44 years. However, from 2014 to 2017, the contribution of age 15-44 years decreased from 64.9% to 48.3%, and that above 45 years gently increased from 4.4% to 7.5%. Although children (<15 years) were the third largest contributor to the total TB cases in 2014 (19.0%), their share continuously increased over the study period and become the largest contributor by 2017 (30.1%) (Table 1, Fig 2).
The contribution of children (< 15 years) to EPTB continuously increased and remained at highest level across the years. Of the total EPTB cases notified in 2014, 2015, 2016 and 2017, 40.6%, 45.2%, 58.2%, and 65.1%, respectively, were children under 15 years of age.
TB case notification segregated by age group and gender
The percentage of notified TB cases for men was higher (>50%) than for women in all the age categories (<15, 15–29, 30-44, 45-59 and >60 years old) across the years (2014-2017), except for age 60, <15 and 30-44 years in 2014, 2015 and in 2017, where men constituted 50%, 49.5%, and 49.2%, respectively (Fig 3).
3.3. Trends in HIV testing and antiretroviral treatment coverage
HIV testing was performed in 1329 (85.6%) of the 1553 notified cases, among those 165 (12.4%) were HIV positive (Table 1). The percentage of TB patients tested for HIV increased from 84.1% in 2014 to 88.6% in 2017. The percentage of TB patients tested HIV positive was decreased from 15.3% in 2015 to 10.9% in 2017, whereas antiretroviral treatment (ART) coverage increased from 40% in 2014 to 84.2% in 2017 (Table 1).
3.4. Trends in TB Treatment outcomes, 2014 to 2017
Trend of treatment outcome was evaluated for a total of 1553 TB cases of all forms registered during the study period (Table 2). Treatment success rate for all TB cases remained lower at a range of 72.4% to 79.4%. On average 24.7% of the patients were cured (increasing from 18.8% in 2014 to 27.7% in 2017) and 50.5% with treatment completed (decreasing from 56.5% in 2014 to 46.6% in 2017). On average 24.8% of the patients had unfavorable treatment outcome, including 11.5% not evaluated, 8.0% LTFU, 4.8% died and 0.5% treatment failed. Of the LTFU cases in 2016 and 2017, 56.1% and 78% % were males, respectively.
Table 2 Trends of TB treatment outcomes for TB cases of all forms registered for treatment (n=1553) in refugee camps in Ethiopia, 2014–2017.
Treatment outcomes
|
Years
|
Total, n%
|
2014, n (%)
|
2015, n (%)
|
2016, n (%)
|
2017, n (%)
|
Total cases
|
138
|
354
|
473
|
588
|
1553
|
Cured
|
26 (18.8)
|
75 (21.2)
|
119 (25.2)
|
163 (27.7)
|
383 (24.7)
|
completed
|
78 (56.5)
|
206 (58.2)
|
225 (47.5)
|
274 (46.6)
|
783 (50.4)
|
Failed
|
1 (0.7)
|
4 (1.1)
|
1 (0.2)
|
2 (0.3)
|
8 (0.5)
|
LTFU
|
11 (8.0)
|
20 (5.6)
|
42 (8.9)
|
51 (8.7)
|
124 (8.0)
|
Died
|
5 (3.6)
|
19 (5.4)
|
24 (5.1)
|
26 (4.4)
|
74 (4.8)
|
Not evaluated
|
17 (12.3)
|
30 (8.5)
|
62 (13.1)
|
72 (12.2)
|
181 (11.7)
|
Success rate
|
104 (75.3)
|
281 (79.4)
|
344 (72.7)
|
437 (74.3)
|
1166 (75.1)
|
Data are presented as numbers (%)
LTFU before treatment initiation
LTFU of smear positive PTB patients before starting treatment will have negative impact on clinical outcome and TB transmission. In the refugee camps, among TB cases who were smear positive PTB and registered in the laboratory log book in 2014, 2015, 2015 and 2017, respectively, 23 (29.1%), 22 (27.9%), 18 (22.8%), and 16 (20.3%) were not registered in the Unit TB register and treatment outcome was not recorded (LTFU before treatment). Of the 16 LTFU before treatment in 2017, all were from Gambella refugee area, where 8 (50.0%) were from Kule, 5 (31.3%) from Terkedi, and 1 (6.2%) from Pugnido Agnewak refugee health facilities.
Treatment outcomes by gender, age, and type of TB
There was a variation in treatment success rate by gender, age category and type of TB (Fig 4). From 2015 to 2017, treatment success rate was relatively higher for females and declined for both sexes (from 80.6% to 75.7% for female; from 78.2% to 73.6% for male) (Fig 4A). Lowest treatment success rate was observed in the oldest age (60+ years old) over the study period, although it increased from 50.0% in 2014 to 65.9% in 2017. The treatment success rate was highest for children (<15 years) in 2014 (80.8%) and 2015 (85.9%), but declined in 2016 (70.4%) and in 2017 (71.3%). Treatment success rate for the younger age group (15-29 years old) was remained stable (74.8%-78.9%) over the study period (Fig 4B). Treatment success for PTB was higher over the years (except in 2015) than in EPTB, but declined gently from 2015 to 2017 in both groups (Fig 4C).
3.5. Factors associated with unsuccessful TB treatment outcomes
Based on a multivariable analysis, factors associated with unsuccessful TB treatment outcome (LTFU, failure, and died) were pretreatment weight < 40 Kg (adjusted odds ratio [aOR] = 1.5, 95% confidence interval (CI): 0.9–2.3, P =0.05); age 45-59 years (aOR =2.4, 95% CI:1.3–4.7, P =0.008); age >60 years (aOR =4.3, 95% CI:2.3–9.1, P <0.001), and HIV infection (aOR = 3.6, 95% CI:2.3–5.8, P <0.001) (Table 3)
Table 3. Factors associated with unsuccessful TB treatment outcomes among TB cases of all Forms in refugee camps in Ethiopia (2014– 2017)
Characteristics
|
Successful outcomes
|
Unsuccessful outcomes
|
X2,
p-value
|
Bivariate analysis
|
Multivariable analysis
|
|
|
|
|
OR (95%CI)
|
P value
|
Adjusted OR (95% CI)
|
P value
|
Gender
Male
Female
|
637 (84.3)
522 (86.0)
|
119 (15.7)
85 (14.0)
|
0.80;
0.37
|
1
1.04 (0.8-1.3)
|
0.74
|
|
|
Age group
<15
15-29
30-44
45-59
>= 60
|
321 (86.5)
349 (87.0)
286 (89.4)
130 (77.8)
72 (69.2)
|
50 (13.5)
52 (13.0)
34 (10.6)
37 (22.16)
32 (30.8)
|
33.7;
<0.001
|
1
0.9 (0.6-1.4)
0.8 (0.5-1.2)
1.8 (1.1-2.9)
2.8 (1.7-4.8)
|
0.8
0.3
0.01
0.001
|
2.4 (1.3-4.7)
4.3 (2.3-9.1)
|
0.008
<0.001
|
Pre-treatment weight, kg
> 40
< 40
|
576 (86.9)
215 (80.5)
|
87 (13.1)
52 (19.5)
|
6.0;
0.01
|
1
1.3 (0.9-1.8)
|
0.08
|
1.5 (0.9-2.3)
|
0.05
|
Type of TB
P/Neg
PTB+
Smear not done
EPTB
|
314 (82.6)
528 (87.9)
4 (80.0)
313 (83.2)
|
66 (17.4)
73 (12.1)
1 (20.0)
63 (16.8)
|
6.5;
0.09
|
1
0.6 (0.4-0.9)
1.2 (0.1-10.8)
0.9 (0.6-1.4)
|
0.02
0.8
0.8
|
0.6 (0.4-1.0)
|
0.06
|
Category of TB patients
New and Relapse
Failure
LTFU
Others(O)
|
1146 (85.0
2 (100)
8 (72.7)
3 (75.0)
|
202 (15.0)
0
3 (27.3)
1 (25.0)
|
1.9;
0.6
|
1
2.1 (0.6-8.1)
1.8 (0.2-18.3)
|
0.2
0.6
|
|
|
HIV status
Negative
Positive
|
934 (87.8)
102 (72.3)
|
130 (12.2)
39 (27.7)
|
24.6;
<0.001
|
1
1.6 (1.3-2.0)
|
<0.001
|
3.6 (2.3-5.8)
|
<0.001
|
ART initiated? *
Yes
No
|
89 (74.8)
148 (83.6)
|
30 (25.2)
29 (16.4)
|
3.5;
0.06
|
1
0.9 (0.3-1.0)
|
0.06
|
|
|
* Odds ratio (OR) (95%CI) are based on 268 HIV positive study participants;
X2 = chi square;
P value < 0.05 was considered statistically significant.