Factors associated with poor treatment outcomes among tuberculosis patients in Kyangwali Refugee Settlement, Uganda, 2016–2017

{"Background": "Communicable diseases account for most deaths in complex emergencies, including refugee settings. Tuberculosis (TB) and HIV/AIDS are increasingly important causes of morbidity and mortality in refugee populations. Uganda hosts over 68,703 refugees in Kyangwali Refugee Settlement, one of the largest settlements in Africa, within a district of 625,568 nationals. Despite global efforts, TB burden remains high, with Uganda having an annual TB prevalence of 159/100,000 in 2015 and 253/100,000 in 2016, and TB-related mortality at 12/100,000 population. Information about treatment outcomes among TB patients in refugee populations in Uganda is limited. This study aimed to describe treatment outcomes and identify factors associated with poor treatment outcomes among TB patients in Kyangwali Refugee Settlement.", "Methods": "A retrospective cohort study was conducted using patient data from TB registers at Kikuube Health Centre IV and Rwenyawawa Health Centre II from January 2016 to December 2017. All TB patients registered during this period with complete demographic information and a recorded treatment outcome were included. The dependent variable was TB treatment outcome categorized as favorable (cured and treatment completed) or unfavorable (treatment failed, died, lost to follow-up, or not evaluated), as defined by WHO. Independent variables included weight (>50 kg vs \u226450 kg), HIV status, smoking status, alcohol use, patient category (new or retreatment), and history of TB. Data were collected using a pretested paper data abstraction tool. Univariate, bivariate, and multivariate analyses were conducted using logistic regression to identify factors associated with unfavorable treatment outcomes, reporting adjusted odds ratios with 95% confidence intervals. Administrative approval was obtained from the Ministry of Health of Uganda, and the study was cleared as non-research by the US Centers for Disease Control and Prevention.", "Key Results": "Of 304 TB patients registered, 212 (69.7%) had complete information and were included in the analysis. The median age was 36 years (IQR: 26\u201348.5); 146 (68.9%) were male, and 109 (51.4%) were refugees. Overall, 41 (19.3%) were HIV positive, and 216 (97%) had pulmonary TB (63.2% bacteriologically confirmed, 34.0% clinically diagnosed, 2.8% extra-pulmonary). The largest age group was 21\u201340 years (44.3%), followed by 41\u201360 (33.0%), 0\u201320 (14.6%), and 61\u201380 (8.0%). Of the 212 patients, 141 (66.5%) completed treatment (favorable outcome), while 71 (33.5%) had unfavorable outcomes: 53 (25%) lost to follow-up, 13 (6.1%) died, and 5 (2.4%) had treatment failure. No patients were categorized as cured. At bivariate analysis, increasing age was significantly associated with unfavorable outcomes: 21\u201340 years (cOR=2.6, 95% CI: 1.12\u20135.87, p=0.03), 41\u201360 years (cOR=4.3, 95% CI: 1.76\u201310.6, p<0.01), and >60 years (cOR=6.5, 95% CI: 1.54\u201327.18, p=0.01) compared to \u226420 years. Sex, nationality, HIV status, TB history, disease classification, MDR status, patient type, smear status, and weight were not statistically significantly associated with treatment outcomes.", "Clinical Implications": "The treatment success rate of 66.5% in Kyangwali Refugee Settlement is substantially lower than the 85% target recommended by WHO, though similar to the pooled rate of 69.4% reported across 18 Ugandan sites. Increasing age was the only significant predictor of unfavorable outcomes, consistent with studies from Finland, Portugal, and the United States. Older patients are vulnerable due to comorbidities and physiological deterioration, compounded by challenges in healthcare access for refugees. The finding that MDR-TB patients had lower odds of unfavorable outcomes (though not statistically significant) may reflect improved management strategies including initial admission and close monitoring. These findings underscore the need for innovative approaches to improve treatment success rates, with particular focus on persons aged 41\u201380 years. Enhanced access to healthcare for all population categories and adoption of MDR-TB-like management strategies for all TB patients are recommended."}