Characteristics and treatment outcomes of tuberculosis pediatric patients

who “transfer-out” to health facilities in West Java, Indonesia:

a descriptive cross-sectional study

Heda Melinda Nataprawira, Lianda Tamara, Tammy Utami Dewi, Ahmad Hafidz

Department of Child Health, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, Indonesia

Received Month February, 2015; revised Month X, XXXX; accepted Month X, XXXX

Abstract

Background : Child Tuberculosis (TB) in high burden countries need a standardized recording and reporting system on case finding and treatment outcomes. During TB treatment, pediatric patients transfer-out and transfer-in to different health facilities due to Indonesia geographic consist of many islands. This condition indicate role of primary healthcare to facilitate TB treatment nearby. But there are few data from any national TB programme about whether this process happens and if so to what extent. The aim of this study therefore was to describe the characteristics and outcomes of TB patients that transferred into health facilities in West Java under the national TB programme. Specific objectives were to determine i) the proportion of a cohort of TB patients registered as transfer-out, ii) the characteristics and treatment outcomes of these transfer-out patients and iii) whether their treatment outcomes had been communicated back to their respective referral districts after completion of TB treatment.Methods: Data were abstracted from patient files and district TB registers for all transfer-out TB patients registered from 2010 to 2014 within Hasan Sadikin Hospital Bandung. All the parent of the patients in registry documents were contacted by phone calls and evaluated for the treatment outcome. Descriptive statistics were calculated. Results: Of the 1,632 registered pediatric TB patients in 2010 to 2014, 89 had transferred-out: 52 (58%) were males and overall median age of 7 years. Most transfer-out patients (74%) came during the intensive phase of TB treatment. Only 23 patients out of 89 were successfully contacted by phone call. From 23 transfer-out patients had 100% treatment success, but in 66 patients, treatment outcome status was not evaluated. Overall, 15% transfer-out TB patients had their TB treatment outcomes reported back to their referral districts.Conclusion: There is need to devise better strategies of following up TB patients to their referral Directly Observed Treatment (DOT) centers from TB diagnosing centers to ensure that they arrive promptly and on time. Recording and reporting of information must improve and this can be done through training and supervision. Use of mobile phones and other technology to communicate TB treatment outcomes back to the referral districts would seem the obvious way to move forward on these issues.

Keywords: Tuberculosis, Transfer-out, Treatment outcomes, Indonesia, TB-09 form

BackgroundTuberculosis (TB) remains a major global health problem. It causes ill-health among millions of people each year and ranks as the second leading cause of death from an infectious disease worldwide, after the human immunodeficiency virus (HIV). The latest estimates included in this report are that there were almost 9 million new cases in 2011 and 1.4 million TB deaths. 1 TB in children data across Indonesia shows the proportion of cases between TB in children in all cases of TB in 2010 is 9,4%, later became 8.5% in 2011 and 8.2% in 2012. 2 The World Health Organization has for nearly 20 years implemented a Stop TB Strategy for global and national TB control, and one of its cornerstones is a standardized recording and reporting system. The DOTS (directly observed therapy short-course) strategy remains at the heart of the STOP TB partnership strategy. To achieve effective TB control, and nip the emergence and spread of drug-resistant TB bacilli, five key elements must be in place:3

• Political commitment;• Case detection by sputum smear microscopy;• Standardized appropriately administered treatment regimen of 6–8 months with

first-line anti-TB drugs • Uninterrupted supply of essential anti-TB drugs • A standardized recording and reporting system that allows for monitoring and

evaluation of treatment outcomes.

An effective recording and reporting system incorporates the laboratory register, the patient treatment card, and the TB patient register. The TB patient register is maintained at local treatment units and comprises a list of all persons who have been diagnosed with TB. It contains entries for sex, date of birth, age, gender, address, phone, medications if required, status of follow-up smears, origin of patient, and treatment outcome.3 The World Health Organization (WHO) defines “transfer out” as one of the 6 categories for tuberculosis (TB) treatment outcome. In Indonesia, TB-09 is known as “transfer-out” categories. A transfer out is a patient who has been transferred to another recording and reporting unit and whose treatment outcome is unknown.2, 4, 5 Every patient who transfers out from the original registration unit should in theory “transfer-in” to a new TB registration unit in a different reporting district. However, the original registration unit maintains the responsibility for reporting on their treatment outcomes.6 Patients who are transferred from referral hospital to another health facilities carry with them a transfer out form (TB-09) from the referral hospital, which includes details such as patient name, referral hospital and district, sex, age, treatment category, type of TB and transfer-out date. These transfer-out patients are registered in the TB register before referral for DOTS at their nearest municipal clinic. It is important to know the transfer result and treatment outcome, especially when patients who are sputum-smear positive are transferred, because without proper TB treatment, infectious TB cases can transmit TB to others. The higher the transfer-out rate, the more important it is to trace the final treatment results to avoid an incomplete evaluation of the treatment.7

There are few data from national TB programme about whether or to what extent this process happens. The aim of this study therefore was to describe the characteristics and outcomes of TB patients that transferred into health facilities in West Java under the national TB programme. Specific objectives were to determine i) the proportion of a cohort of TB patients registered as transfer-out, ii) the characteristics and treatment outcomes of these transfer-out patients and iii) whether their treatment outcomes had been communicated back to their respective referral districts after completion of TB treatment.

MethodStudy designThis was a descriptive cross-sectional study design using TB-09 register.

Study settingThis study was conducted in Respirology and DOTS Clinic, Department of Child Health, Hasan Sadikin General Hospital. We reviewed TB register between 1 January 2010 until 31 December 2014, to select transfer-out patients. Inclusion criteria were children under 14 years old age, which had been transferred-out to the health facilities in West Java, Indonesia. While patients who cannot be reached by phone call were defined as exclusion criteria. The selection of subject were made by consecutive sampling method with a population of children aged 1 to 14 years old who received TB treatment in Respirology and DOTS Clinic, Department of Child Health, Hasan Sadikin General Hospital who had been transferred out to health facilities in West Java, Indonesia. All the patients were contacted by phone calls and evaluated for the treatment outcome.

ResultProportion of TB patients registered as transfer-outOf the 1,632 registered pediatric TB patients in 2010 to 2014, there were 89 patients registered with TB-09, of whom only 23 transfer-out patients were successfully contacted by phone call.

Characteristic and treatment outcomes of transfer-out patients.Most of the patients who transferred-out into other health facilities in West Java were males (N=52,58%) and overall median age of 6 years. Most transfer-out patients (74%) came during the intensive phase of TB treatment. Only 23 patients out of 89 were successfully contacted by phone call. From 23 transfer-out patients had 100% treatment success, but in 66 patients, treatment outcome status was not evaluated. Overall, 15% transfer-out TB patients had their TB treatment outcomes reported back to DOTS Clinic in Hasan Sadikin General Hospital.

Figure 1 Flow of data collection on patients diagnosed at Hasan Sadikin General Hospital over a 4-year period: numbers transferred out to health centers and results of transfer

Table 1 Characteristic and Demographic Feature in Transfer-Out Patient (n=89) in Hasan Sadikin General Hospital

DiscussionThis study, the first of its kind in Indonesia, shows that although a large proportion of patients transferred-out to other health facilities in West Java out of the total number of patients registered, the management according to guidelines was poor with only 15% of treatment outcomes being notified back to DOTS Clinic in Hasan Sadikin General Hospital. Treatment outcomes of patients who transferred-out were rather small, and to those reported from patients registered in their original units, although there was a high proportion of patients not evaluated and with missing outcomes. The reasons for this are unclear, but may relate to poor documentation in registers and treatment cards or death, lost-to-follow-up and further transfer-outs, which did not come to the health facilities. Whatever the reasons, this is unsatisfactory and needs correction. However, despite the high proportion of missing outcomes, 23 transferred-out patients are all 100% successful in their treatment outcome.

Finally, the majority of transfer-out TB patient did not have their outcomes communicated to DOTS Clinic in Hasan Sadikin General Hospital. This means the referring units would report these patients as “transfer-out”, while they could report on true outcomes if only communication had occurred. The conventional means of communication has been in the past through submission of treatment outcome request forms by the referral hospital to the receiving health facilities through the postal system. Reasons for not communicating TB treatment outcomes are unclear.There are none published work on the issue of transfer-in and transfer-out in TB patients in Indonesia. In Indonesia it was very common for TB patients to transfer-out, but the procedures for transferring–in and matching the two sets of patients was very poor. This is an area in need of improvement. The strengths of this study were that a large number of patients were evaluated and the work was done through the routine system. TB officers must visit the health centers in their catchment area on a regular basis. The current study suggests that some transfers from health centers occur during the continuation phase, with the transfer information not being passed to the TB officer and consequently not being recorded in the main TB register. Similarly, some transfer-out patients to a new district may go straight to a health center and never report to the TB officer at the hospital; this information is also not passed on to the TB office. TB officers therefore need to train and supervise health center staff on management of transfers, and during visits they should collect transfer forms and other vital data in the health center registers for entering into the main TB register.8

Study limitations included the usual problem of completeness and accuracy of routinely recorded program data and the fact that patients with unevaluated outcomes could not be traced by phone call in order to establish their true outcomes.

ConclusionIn conclusion, there is need to devise better strategies of following up TB patients to their referral DOT centers from TB diagnosing centers to ensure that they arrive promptly and on time with drugs supplies uninterrupted. There is a need to improve on recording and reporting of information and this can be done through training and supervision. Use of mobile phones and other technology to communicate TB treatment outcomes back to the referral districts would seem the obvious way to move forward on this issue.

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