Disease Characteristics and Treatment Outcome in Elderly Tuberculosis Patients on DOTS
Author(s): Geeta Pardeshi, Dilip Deshmukh
Vol. 32, No. 4 (2007-10 - 2007-12)
ISSN No. 0970-0218
Geeta Pardeshi, Dilip Deshmukh
Introduction
Elderly are at increased risk to get tuberculosis.1 Although
several published works have looked for differences
between younger and older tuberculosis patients, they
usually provide different findings.1-3 It has been suggested
that the characteristics of tuberculosis in older people
are different from those observed in young adult patients
and that they should be classified as separate entities.
When these differences are ignored, the establishment
of a diagnosis may be delayed, leading to an increase in
morbidity and mortality in the older group. The aim of the
study is to describe the disease characteristics and study
treatment outcome in the elderly tuberculosis patients.
Materials and Methods
The study was conducted at District Tuberculosis center,
Yavatmal. RNTCP was initiated in the district in August
2002. In the year December 2004, the entire district was
covered under DOTS. The district has an annualized
total case detection rate of 134 per lakh population and
cure rate of 85%.
A retrospective cohort study was conducted in two of
the four tuberculosis units (TUs) under DTC, which were
selected by simple random sampling. The population
covered by the two selected TUs was 5,77,398 and
6,87,063 respectively. All patients above 15 years of age
registered in the two selected TUs for DOTS from January
2003 to December 2004 were included in the sample.
The two groups for comparison included were patients
aged 60 years and above and between 15 to 59 years
as the control group.
The data variables included age, category, type and
treatment outcome. The definitions of terminologies such
as new sputum positive case, new smear negative, new
extrapulmonary, retreatment, default, relapse, death and
failure were as described under the Revised National
Tuberculosis Program. The statistical analysis was done
using chi square test and calculation of relative risk with
95% confidence interval.
Results
A total of 3441 patients were registered at the two
tuberculosis units, of which 367 (10.66%) were aged sixty
years and above. The ratio of new pulmonary tuberculosis
to new extrapulmonary tuberculosis was 14:1 in the
elderly and 7.7:1 in the control group. The ratio of new
smear negative to new smear positive patients was 1.44:1
in the elderly and 1.13:1 in the control group.
The distribution of the patients according to the disease
classification is shown in Table 1. The proportion of new
smear positive and retreatment cases was comparable
in the two study groups. The proportion of new smear
negative cases was significantly more in the elderly
while the proportion of new extrapulmonary cases was
significantly less in this group of patients.
A comparison of the treatment outcome in the two
study groups was done for new smear positive, new
extrapulmonary, new smear negative and the retreatment
group [Table 2].
The cure and treatment completion rate in the new smear
positive patients was 74% in the elderly and 83% in the
control group. The default rate was significantly more in
the elderly as compared to the control group. There was
no significant difference in the death rate and failure rate
between the two groups.
The treatment completion rate was significantly less in
the elderly patients than the control group of patients
with new smear negative and new extrapulmonary
tuberculosis. The death rate was significantly more
in the elderly patients than the control group of these
patients. Of the total deaths in the elderly patients 63%
had occured in the new smear negative and new extrapulmonary
patients while 34% of the total deaths in
control group patients had occured in these patients.
Even amongst patients with new smear negative
and new extrapulmonary tuberculosis without serious
illness i.e. on Category III DOTS regimen the death rate
was significantly more in the elderly (13 %;24/182) than the
control group (3.69%;50/1353) [RR=3.56(2.24-5.61)].
Table 1: Disease classifi cation in the elderly and control group
Elderly (%) N=367
Control (%) N=3074
χ2
RR (95% CI)
New smear positive
120 (32.7)
1068 (34.74)
0.52
0.94 (0.8-1.09)
New smear negative
173 (47.14)
1216 (39.56)
7.51*
1.19 (1.05-1.33)
New extrapulmonary
21 (5.72)
295 (9.6)
5.44*
0.59 (0.38-090)
Retreatment
53 (14.44)
495 (16.10)
0.55
0.89 (0.68-1.15)
*P<0.05
Table 2: Treatment outcome in elderly and control group
New smear positive
Elderly (%) N=120
Control (%) N=1068
χ2
RR (95% CI)
Cure/Treatment completion
89 (74.17)
888 (83.15)
5.35*
0.89 (0.79-0.98)
Default
17 (14.17)
83 (7.77)
4.92*
1.82 (1.11-2.98)
Death
10 (8.33)
61 (5.71)
0.89
1.45 (0.76-2.70)
Failure
4 (3.33)
36 (3.37)
0.00
0.98 (0.36-2.58)
New smear negative
Elderly (%) N=173
Control (%) N=1216
χ2
RR (95% CI)
Cure/Treatment completion
134 (77.46)
1049 (86.27)
8.62*
0.89 (0.82-0.96)
Default
14 (8.09)
97 (7.98)
0.00
1.01 (0.59-1.70)
Death
20 (11.56)
53 (4.36)
14.36*
2.65 (1.62-4.28)
Failure
5 (2.89)
17 (1.40)
1.31
2.06 (0.79-5.32)
New extrapulmonary
Elderly (%) N=21
Control (%) N=295
χ2
RR (95% CI)
Cure/Treatment completion
14 (66.67)
262 (88.81)
6.80*
0.75 (0.52-0.93)
Default
2 (9.52)
27 (9.15)
0.00
1.04 (0.27-3.39)
Death
5 (23.81)
5 (1.69)
24.48*
14.04 (4.58-42.27)
Failure
0 (0.00)
1 (1.40)
0.00
0 (0.00-53.49)
Retreatment
Elderly (%) N=53
Control (%) N=495
χ2
RR (95% CI)
Cure/Treatment completion
38 (71.70)
309 (62.42)
1.39
1.14 (0.92-1.33)
Default
10 (18.87)
102 (20.61)
0.01
0.01 (0.50-1.57)
Death
5 (9.43)
55 (11.11)
0.02
0.84 (0.35-1.90)
Failure
0 (0.00)
29 (5.86)
2.21
0 (0.00-1.16)
*P<0.05, Statistically significant
There was no significant difference in the treatment
outcome between the two groups of patients put on
retreatment after either relapse, failure, default or other
reasons. In this group the cure and treatment completion
rate was 72% and 63% in the elderly and control group
respectively and the default rate 18.875 and 20.61%
respectively in elderly and control group.
Discussion
The ratio of pulmonary tuberculosis to extrapulmonary
tuberculosis and the proportion of new smear negative
cases to new smear positive cases was more in the elderly
than in the control group. The variable clinical picture of
tuberculosis in the elderly and the major differences have
been summarized in a meta analytical review.3
The lower rates of favourable outcome in the elderly new
smear positive patients was mainly due to the high default
rate. This has been attributed to poor tolerance of therapy,
other concomittant illnesses and operational factors which
pose problems for regular visits to DOTS centres.1,3 It is
essential to identify and address the specific reasons for
default in the elderly patients. The idea of Community
providers for providing DOTS at the door steps for the
elderly has been suggested in a study.1
The default rate was more than 15% for the patients put
on retreatment in both the groups. A higher defaulter rate
for the retreatment group has been reported under RNTCP
programme.4 The lower treatment completion rates in the
extrapulmonary and smear negative cases was mainly due
to the higher risk of death in these groups. This increased
risk of death was seen even when patients in these groups
without serious illness were compared. Higher death rates
have been noted in the elderly patients.2,4 Apart from the
increased physiological risk of death, the vague symptoms
in the elderly, diagnostic problems and concomittant illness
could be some of the contributing factors for the increased
death rate in the elderly.3,5 Concomittant diseases like
cardiovascular diseases, COPD, Diabetes mellitus and
malignancy have been found to be frequently present
in the older patients with tuberculosis.3,5 Screening the patients for these diseases and managing them
appropriately will be important.
A significant proportion of the patients registered
under RNTCP are aged 60 years and above. The
diagnostic problems in the elderly, especially in smear
negative tuberculosis; the increased risk of default
in new smear positive elderly patients and death in
new extrapulmonary and new smear negative elderly
patients needs to be studied further to plan effective
interventions along these lines.
References
- Arora VK, Singla N, Sarin R. Profile of geriatric patients
under DOTS in revised national tuberculosis programme.
Indian J Chest Dis Allied Sci 2003;45:231-5.
- Gaur SN, Dhingra VK, Rajpal S, Aggarwal JR, Meghna.
Tuberculosis in the elderly and their treatment outcome
under DOTS. Indian J Tuberc 2004;51:83-7.
- Sood R. The problem of geriatric tuberculosis. J Acad Clin
Med 2000;5:156-62.
- Available from: http://tbcindia.org/perfor.asp#. [Last
accessed on 2006 Jan 7].
- Perez-Guzman C, Vargas MH, Torres-Cruz A, Villarreal-
Velarde H. Does aging modify Pulmonary Tuberculosis? A
meta-analytical review. Chest 1999;116:961-7.
Department of Preventive and Social Medicine,
S.V.N.G.M.C., Yavatmal, Maharashtra, India
Correspondence to:
Dr. Geeta Pardeshi,
‘Prasthal’, Opposite Head Post Office, Station road, Akola – 444001,
Maharashtra, India.
E-mail: geetashrikar(at)yahoo.com
Received: 08.09.06
Accepted: 21.01.07
ISSN No. 0970-0218
Geeta Pardeshi, Dilip Deshmukh
Introduction
Elderly are at increased risk to get tuberculosis.1 Although several published works have looked for differences between younger and older tuberculosis patients, they usually provide different findings.1-3 It has been suggested that the characteristics of tuberculosis in older people are different from those observed in young adult patients and that they should be classified as separate entities. When these differences are ignored, the establishment of a diagnosis may be delayed, leading to an increase in morbidity and mortality in the older group. The aim of the study is to describe the disease characteristics and study treatment outcome in the elderly tuberculosis patients.
Materials and Methods
The study was conducted at District Tuberculosis center, Yavatmal. RNTCP was initiated in the district in August 2002. In the year December 2004, the entire district was covered under DOTS. The district has an annualized total case detection rate of 134 per lakh population and cure rate of 85%.
A retrospective cohort study was conducted in two of the four tuberculosis units (TUs) under DTC, which were selected by simple random sampling. The population covered by the two selected TUs was 5,77,398 and 6,87,063 respectively. All patients above 15 years of age registered in the two selected TUs for DOTS from January 2003 to December 2004 were included in the sample. The two groups for comparison included were patients aged 60 years and above and between 15 to 59 years as the control group.
The data variables included age, category, type and treatment outcome. The definitions of terminologies such as new sputum positive case, new smear negative, new extrapulmonary, retreatment, default, relapse, death and failure were as described under the Revised National Tuberculosis Program. The statistical analysis was done using chi square test and calculation of relative risk with 95% confidence interval.
Results
A total of 3441 patients were registered at the two tuberculosis units, of which 367 (10.66%) were aged sixty years and above. The ratio of new pulmonary tuberculosis to new extrapulmonary tuberculosis was 14:1 in the elderly and 7.7:1 in the control group. The ratio of new smear negative to new smear positive patients was 1.44:1 in the elderly and 1.13:1 in the control group.
The distribution of the patients according to the disease classification is shown in Table 1. The proportion of new smear positive and retreatment cases was comparable in the two study groups. The proportion of new smear negative cases was significantly more in the elderly while the proportion of new extrapulmonary cases was significantly less in this group of patients.
A comparison of the treatment outcome in the two study groups was done for new smear positive, new extrapulmonary, new smear negative and the retreatment group [Table 2].
The cure and treatment completion rate in the new smear positive patients was 74% in the elderly and 83% in the control group. The default rate was significantly more in the elderly as compared to the control group. There was no significant difference in the death rate and failure rate between the two groups.
The treatment completion rate was significantly less in the elderly patients than the control group of patients with new smear negative and new extrapulmonary tuberculosis. The death rate was significantly more in the elderly patients than the control group of these patients. Of the total deaths in the elderly patients 63% had occured in the new smear negative and new extrapulmonary patients while 34% of the total deaths in control group patients had occured in these patients. Even amongst patients with new smear negative and new extrapulmonary tuberculosis without serious illness i.e. on Category III DOTS regimen the death rate was significantly more in the elderly (13 %;24/182) than the control group (3.69%;50/1353) [RR=3.56(2.24-5.61)].
Table 1: Disease classifi cation in the elderly and control group
| Elderly (%) N=367 | Control (%) N=3074 | χ2 | RR (95% CI) | |
|---|---|---|---|---|
| New smear positive | 120 (32.7) | 1068 (34.74) | 0.52 | 0.94 (0.8-1.09) |
| New smear negative | 173 (47.14) | 1216 (39.56) | 7.51* |
1.19 (1.05-1.33) |
| New extrapulmonary | 21 (5.72) | 295 (9.6) | 5.44* |
0.59 (0.38-090) |
| Retreatment | 53 (14.44) | 495 (16.10) | 0.55 | 0.89 (0.68-1.15) |
*P<0.05
Table 2: Treatment outcome in elderly and control group
| New smear positive | ||||
| Elderly (%) N=120 | Control (%) N=1068 | χ2 | RR (95% CI) | |
| Cure/Treatment completion | 89 (74.17) | 888 (83.15) | 5.35* |
0.89 (0.79-0.98) |
| Default | 17 (14.17) | 83 (7.77) | 4.92* |
1.82 (1.11-2.98) |
| Death | 10 (8.33) | 61 (5.71) | 0.89 | 1.45 (0.76-2.70) |
| Failure | 4 (3.33) | 36 (3.37) | 0.00 | 0.98 (0.36-2.58) |
| New smear negative | ||||
| Elderly (%) N=173 | Control (%) N=1216 | χ2 | RR (95% CI) | |
| Cure/Treatment completion | 134 (77.46) | 1049 (86.27) | 8.62* |
0.89 (0.82-0.96) |
| Default | 14 (8.09) | 97 (7.98) | 0.00 | 1.01 (0.59-1.70) |
| Death | 20 (11.56) | 53 (4.36) | 14.36* |
2.65 (1.62-4.28) |
| Failure | 5 (2.89) | 17 (1.40) | 1.31 | 2.06 (0.79-5.32) |
| New extrapulmonary | ||||
| Elderly (%) N=21 | Control (%) N=295 | χ2 | RR (95% CI) | |
| Cure/Treatment completion | 14 (66.67) | 262 (88.81) | 6.80* |
0.75 (0.52-0.93) |
| Default | 2 (9.52) | 27 (9.15) | 0.00 | 1.04 (0.27-3.39) |
| Death | 5 (23.81) | 5 (1.69) | 24.48* |
14.04 (4.58-42.27) |
| Failure | 0 (0.00) | 1 (1.40) | 0.00 | 0 (0.00-53.49) |
| Retreatment | ||||
| Elderly (%) N=53 | Control (%) N=495 | χ2 | RR (95% CI) | |
| Cure/Treatment completion | 38 (71.70) | 309 (62.42) | 1.39 | 1.14 (0.92-1.33) |
| Default | 10 (18.87) | 102 (20.61) | 0.01 | 0.01 (0.50-1.57) |
| Death | 5 (9.43) | 55 (11.11) | 0.02 | 0.84 (0.35-1.90) |
| Failure | 0 (0.00) | 29 (5.86) | 2.21 | 0 (0.00-1.16) |
*P<0.05, Statistically significant
There was no significant difference in the treatment outcome between the two groups of patients put on retreatment after either relapse, failure, default or other reasons. In this group the cure and treatment completion rate was 72% and 63% in the elderly and control group respectively and the default rate 18.875 and 20.61% respectively in elderly and control group.
Discussion
The ratio of pulmonary tuberculosis to extrapulmonary tuberculosis and the proportion of new smear negative cases to new smear positive cases was more in the elderly than in the control group. The variable clinical picture of tuberculosis in the elderly and the major differences have been summarized in a meta analytical review.3
The lower rates of favourable outcome in the elderly new smear positive patients was mainly due to the high default rate. This has been attributed to poor tolerance of therapy, other concomittant illnesses and operational factors which pose problems for regular visits to DOTS centres.1,3 It is essential to identify and address the specific reasons for default in the elderly patients. The idea of Community providers for providing DOTS at the door steps for the elderly has been suggested in a study.1
The default rate was more than 15% for the patients put on retreatment in both the groups. A higher defaulter rate for the retreatment group has been reported under RNTCP programme.4 The lower treatment completion rates in the extrapulmonary and smear negative cases was mainly due to the higher risk of death in these groups. This increased risk of death was seen even when patients in these groups without serious illness were compared. Higher death rates have been noted in the elderly patients.2,4 Apart from the increased physiological risk of death, the vague symptoms in the elderly, diagnostic problems and concomittant illness could be some of the contributing factors for the increased death rate in the elderly.3,5 Concomittant diseases like cardiovascular diseases, COPD, Diabetes mellitus and malignancy have been found to be frequently present in the older patients with tuberculosis.3,5 Screening the patients for these diseases and managing them appropriately will be important.
A significant proportion of the patients registered under RNTCP are aged 60 years and above. The diagnostic problems in the elderly, especially in smear negative tuberculosis; the increased risk of default in new smear positive elderly patients and death in new extrapulmonary and new smear negative elderly patients needs to be studied further to plan effective interventions along these lines.
References
- Arora VK, Singla N, Sarin R. Profile of geriatric patients under DOTS in revised national tuberculosis programme. Indian J Chest Dis Allied Sci 2003;45:231-5.
- Gaur SN, Dhingra VK, Rajpal S, Aggarwal JR, Meghna. Tuberculosis in the elderly and their treatment outcome under DOTS. Indian J Tuberc 2004;51:83-7.
- Sood R. The problem of geriatric tuberculosis. J Acad Clin Med 2000;5:156-62.
- Available from: http://tbcindia.org/perfor.asp#. [Last accessed on 2006 Jan 7].
- Perez-Guzman C, Vargas MH, Torres-Cruz A, Villarreal- Velarde H. Does aging modify Pulmonary Tuberculosis? A meta-analytical review. Chest 1999;116:961-7.
Department of Preventive and Social Medicine, S.V.N.G.M.C., Yavatmal, Maharashtra, India
Correspondence to:
Dr. Geeta Pardeshi,
‘Prasthal’, Opposite Head Post Office, Station road, Akola – 444001,
Maharashtra, India.
E-mail: geetashrikar(at)yahoo.com
Received: 08.09.06
Accepted: 21.01.07
