ORIGINAL ARTICLE

Factors Associated with Treatment Outcome of

Patients with Pulmonary Tuberculosis
in the Philippines, 2015 to 2016
Ian Oliver D. Macatangay,1 Sophia Anne S.P. Liao,1 Joshua Jason A. Dadural,1 Fatima Joy S. Gagui,1
Angelica Joy A. Galas,1 Raymond Dorutheo Francis A. San Antonio1 and Paul Adrian V. Pinlac2
1
College of Public Health, University of the Philippines Manila
2
Department of Epidemiology and Biostatistics, College of Public Health, University of the Philippines Manila

ABSTRACT

Objective. The study aims to determine the factors associated with unsuccessful treatment outcome among
patients who have undergone tuberculosis treatment.

Methods. An analytic cross-sectional study was employed through secondary data analysis of administrative
data collected by the National Tuberculosis Control Program from October 2015 to September 2016. Using
multiple logistic regression analysis, factors associated with unsuccessful treatment outcome were determined.

Results. Multiple logistic regression analysis revealed that belonging to age groups 25 to 34 (aOR=0.73; 95%CI
0.54-0.99) or 35 to 44 (aOR=0.75; 95%CI 0.56-0.99), being male (aOR=1.30; 95%CI 1.03-1.64), doing crafts
and related trades work (aOR=0.66; 95%CI 0.46-0.94), living in either a 4th class city (aOR=0.46; 95%CI
0.26-0.82), 1st class municipality (aOR=0.75; 95%CI 0.57-0.98), 4th class municipality (aOR=0.59; 95%CI
0.38-0.93), having a positive sputum smear result (aOR=1.60; 95%CI 1.29-2.00), having rifampicin-resistant/
multidrug-resistant tuberculosis (aOR=9.32; 95%CI 7.28-11.93), being a treatment after lost to follow-up case
(aOR=1.84; 95%CI 1.37-2.47) or a case with previously unknown treatment outcome (aOR=1.42; 95%CI 1.00-2.01)
were significant correlates of unsuccessful treatment outcome.

Conclusion. The study found that age, sex, occupation, residence, sputum smear results, drug resistance, and
history of previous treatment were associated with unsuccessful treatment outcome.

Key Words: tuberculosis, pulmonary, treatment outcome, regression analysis, Philippines

INTRODUCTION

Tuberculosis (TB) is still one of the leading causes

of death worldwide. The Western Pacific Region alone
had 1.8 million reported cases, 32% of which came from
the Philippines.1 Despite the implementation of various
strategies and control measures, the Philippines is one of 20
countries with the highest TB burden globally, and is also
4th among the largest number of estimated incident cases
in the world.2 The National TB Prevalence Survey (NTPS)
Paper presented at the 9th International Academic Consortium
for Sustainable Cities Conference, September 11-12, 2018, AG
of 2016 showed an increasing prevalence of both culture-
New World Manila Bay Hotel Malate, Manila, Philippines. confirmed TB cases and rifampicin-resistant/multidrug-
resistant TB (RR-/MDR-TB) cases in the country.1-3
Corresponding author: Ian Oliver D. Macatangay Although there is an increase in Treatment Success Rate
College of Public Health
University of the Philippines Manila
(TSR), tuberculosis remains as one of the top killers in the
625 Pedro Gil St., Ermita, Manila 1000, Philippines country. Even if the Philippines reached the Millennium
Email: [email protected] Development Goals (MDG) target of TSR >90%, some

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 Factors Associated with Treatment Outcome of Patients with PTB

regions were found to have differences in TSR based on the It was identified through the treatment outcome column,
2014 NSP TB Cohort, namely: Regions IV-B, Autonomous as indicated in the NTP database. It was classified into two
Region of Muslim Mindanao (ARMM), and the National main categories namely successful and unsuccessful outcome,
Capital Region (NCR).4 Moreover, TSR among drug- based on the NTP Manual of Procedures.7 Successful
resistant (DR-TB) cases did not reach the 2016 target of 75% outcome was further classified into (1) “cured” which refers
(i.e., only reaching 49%), and is far from the updated 85% to a patient with bacteriologically-confirmed TB at the
target established in PhilSTEP1.3 beginning of treatment who was smear- or culture- negative
According to the Global Tuberculosis Report 2017, it in the last month of treatment and on at least one previous
is essential to analyze the treatment outcome as it would occasion in the continuation phase and (2) “treatment
be helpful in understanding the epidemic of the disease completed” which refers to a patient who completed
and in monitoring the progress of the control programs treatment without evidence of failure but with no record to
implemented by the country so that any perceived beneficial show that sputum smear or culture results in the last month
adjustments in the national and local strategies are done.2 of treatment and on at least one previous occasion were
Although various studies worldwide have assessed the negative, either because tests were not done or the results
factors that may be associated with treatment outcome, are unavailable. On the other hand, unsuccessful treatment
significant results vary across countries. In the Philippines, outcome includes (1) “lost to follow-up” which pertains to a
only a few studies have looked into the risk factors associated patient whose treatment was interrupted for two consecutive
with specific outcomes such as death and lost to follow-up.5,6 months or more, (2) “treatment failed” which refers to
Hence, a study done in a Philippine setting might offer a a patient whose sputum smear or culture is positive at 5
unique and local perspective of the factors considered, months or later during treatment OR a clinically-diagnosed
especially to those that appear to be inconclusive in many patient (child or extra- pulmonary TB) for whom sputum
studies globally (i.e., occupation, residence type, drug examination cannot be done and who does not show clinical
resistance, and hypertension). Given this concern, the study improvement anytime during treatment, and (3) “died”
aims to determine the factors associated with unsuccessful which pertains to a patient who dies for any reason during
treatment outcome among patients who have undergone the course of treatment. This study took particular interest in
tuberculosis treatment in the Philippines. the occurrence of unsuccessful treatment outcome.
The independent variables, which were identified from
MATERIALS AND METHODS existing literature and selected based on its availability
in the given NTP database, included sociodemographic,
Study Design and Period TB-related, and health history factors.5,6,8-31 For this study,
The National Tuberculosis Control Program (NTP) the occupation was classified based on the Philippine
of the Department of Health (DOH) is responsible for Standard Occupational Classifications (PSOC) while
collecting quarterly reports submitted by Directly Observed residence the type was classified based on the Philippine
Treatment Short Course (DOTS) facilities nationwide. Standard Geographical Code (PSGC), both from the
An analytic cross-sectional study was conducted through a Philippine Statistics Authority (PSA). TB-related factors
secondary data analysis of administrative data collected by included sputum smear results, Xpert MTB/Rif results,
the program from October 2015 to September 2016, which drug resistance, and history of previous treatment. The
is the most recent one-year data available by the time the definition and categories for the said variables were
study was conducted. The most recent data available was used based on the NTP Manual of Procedures.7 Lastly, health
to provide a more accurate reflection of the characteristics history factors included diabetes, hypertension, alcohol
of the current patient population. This was limited to a one- consumption, and smoking consumption.
year time span with the assumption that the characteristics
of the previous populations (i.e. in the last 5 years at most) Inclusion and Exclusion Criteria
in terms of factors related to treatment outcome were not The study included patients registered in the NTP
expected to differ from the current population. from October 2015 to September 2016 with known
treatment outcome, as well as those who were 18 to 99
Target Population years old. Excluded from the study were those who have
The target population consisted of all pulmonary undergone more than two treatment courses. A total of
tuberculosis (PTB) patients in the Philippines. The study 422,551 anonymized patient records were obtained from
involved the total enumeration all PTB patients registered the NTP database. Applying all the criteria resulted in the
in the NTP of the DOH from the chosen time span. inclusion of 338,376 patient records for descriptive analysis.
However, only 3,701 patient records were included in the
Study Variables logistic regression analysis since those with missing data,
The dependent variable is the treatment outcome which especially the four health history variables (i.e., diabetes,
refers to the status of the patient after undergoing treatment. hypertension, alcohol consumption, and smoking status),

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were dropped from this analysis. In addition, patient disease. Similarly, 99.85% of the patients with data on
records with the following categories were also excluded: hypertension (n=17,885) were reported to have the said
unclassified residence and/or occupation, not done Xpert disease. More than half (61.97%) of the patients with
MTB/RIF and/or direct sputum smear microscopy, and/or relevant data (n=32,041) were reported to consume
invalid/no result/error for Xpert MTB/RIF. Given that, the alcohol. Likewise, 60.26% of the patients with relevant
resulting number of patient records for the logistic regression data (n=43,264) had a history of smoking.
analysis exceeded the minimum sample size of 3,037. Table 1 describes the distribution of patients with
respect to their treatment outcome. Majority of the patients
Data Processing and Analysis completed their treatment and almost one-third were said
A coding manual was prepared for data re-coding to be cured. This indicates a treatment success rate (TSR)
of all information obtained from the NTP. The data was of 91.27% (95%CI 91.18- 91.37) for all PTB patients
processed in Microsoft Excel 2013 and was screened for registered in the NTP from October 2015 to September
inconsistencies and incompleteness prior to analysis, which 2016. Among the unsuccessful outcomes, patients who were
involved descriptive and analytical methods. Odds ratios lost to follow-up were more frequent (5.07%) compared to
(ORs) were determined with a 5% level of significance using the other categories.
simple and multiple logistic regression analyses through
STATA version 12. Table 1. Treatment Outcome of PTB Patients Registered in the
NTP, October 2015 – September 2016 (n=338,376)
Ethical Considerations Treatment Outcome Frequency Percent (%) 95% CI
This research was subjected to ethics review by the Cured 106,408 31.45 31.29–31.60
University of the Philippines Manila Research Ethics Treatment Completed 202,443 59.83 59.66–59.99
Board (UPMREB) and has been endorsed favorably by the Lost to Follow-up 17,162 5.07 5.00–5.15
said committee. Treatment Failed 1,865 0.55 0.53–0.57
Died 10,498 3.10 3.04–3.16
RESULTS a Definitions of the categories are stated in “Materials and Methods:
Study Variables”
Characteristics of PTB Patients Registered in the
NTP Among all the patients who were drug susceptible,
The mean age of the patients was 46.02 years old majority of them had a successful treatment outcome. On
(±17.04 years) and 33.98% of them were 55 to 99 years the other hand, 60.30% (95%CI 58.65-61.93) of patients
old. Most of the patients in the study were males (66.44%). with RR-/MDR-TB had an unsuccessful treatment
Their occupations were varied but the majority of those with outcome. For those with XDR-TB, 8 had an unsuccessful
jobs were skilled agricultural, forestry, and fishery workers treatment outcome. (Table 2)
(20.04%). Majority resided in 1st Class areas wherein
27.09% live in 1st Class Cities while 27.85% live in 1st Factors Associated with Treatment Outcome of
Class Municipalities. In addition, 14.74% came from Region PTB Patients (Table 3)
IV-A, 13.96% from NCR, and 10.33% from Region III. Among the predetermined factors analyzed, only age
Among those who had results for direct sputum was not found to be associated with treatment outcome,
smear microscopy (n=317,053), most had negative results without controlling for the other variables. The simple
(60.8%). It was identified in the data given by the NTP logistic regression analysis showed that being male increases
that majority of the patients (66.14%) did not undergo the the odds of having unsuccessful treatment outcome by
Xpert MTB/RIF assay. MTB was detected in 17.37% of 40% (OR=1.40; 95%CI 1.14-1.72). Being professionals
the patients who underwent the assay, although their results (OR=0.34; 95%CI 0.12-0.95), skilled agricultural, forestry,
on Rifampicin resistance varied. On the other hand, 98.97% and fishery workers (OR=0.66; 95%CI 0.49-0.88), and
of the patients were drug-susceptible while only 1.01% craft and related trades workers (OR=0.70; 95%CI 0.50-
were RR-/MDR-TB. Only 10 out of the 338,376 patients 0.97) were less likely of having unsuccessful treatment
had extensively-drug resistant TB. It must be noted that outcome, similarly to patients who resided in a 4th Class
drug resistance was based on the DR- TB Bacteriologic City (OR=0.32; 95%CI 0.18-0.56), 1st Class Municipality
Status, as indicated in the database. With regard to their (OR=0.72; 95%CI 0.56-0.95), 2nd Class Municipality
history of previous TB treatment, majority of the patients (OR=0.55; 95%CI 0.37- 0.81), 3rd Class City (OR=0.64;
were new cases (86.42%) while approximately 14% had 95%CI 0.41-0.99), or 4th Class Municipality (OR=0.42;
been previously treated (i.e., relapse, treatment after failure, 95%CI 0.27-0.64).
and treatment after lost to follow-up). The analysis also revealed that the odds of having an
Out of the 71,589 patients with data on diabetes unsuccessful treatment outcome of patients with positive
mellitus, more than 99.99% were reported to have the sputum smear results were nearly three times higher than

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Table 2. Treatment Outcome and Drug Resistance of PTB Patients in the Philippines, October 2015 – September 2016 (n=338,376)
Treatment
Cured Lost to Follow-Up Treatment Failed Died
Drug Resistance n a Completed a a a
n (%) 95%CI a n (%) 95%CI n (%) 95%CI n (%) 95%CI
n (%) 95%CI
Drug Susceptibleb 334,880 105,444 (31.49) 202,001 (60.32) 15,643 (4.67) 1,812 (0.54) 9,980 (2.98)
(31.33–31.64) (60.15–60.49) (4.60–4.74) (0.52–0.57) (2.92–3.04)
RR-/MDR-TBc 3,423 958 (27.99) 401 (11.71) 1,500 (43.82) 52 (1.52) 512 (14.96)
(26.51–29.52) (10.68–12.84) (42.17–45.49) (1.16–1.99) (13.80–16.19)
XDR-TBd 10 1 (10.00) 1 (10.00) 4 (40.00) 0 (0.00) 4 (40.00)
(0.89–57.84) (0.89–57.84) (12.51–75.65) (12.51–75.65)
Unspecified Resistancee 63 5 (7.94) 40 (63.49) 15 (23.81) 1 (1.59) 2 (3.17)
(3.26–18.07) (50.65–74.66) (14.69–36.19) (0.21–10.95) (0.76–12.24)
a Row percentage
b Drug-Susceptible refers to non-resistance to any first-line anti-TB drug as indicated in the database.
c RR-/MDR-TB (Rifampicin/Multidrug Resistant TB) refers to any resistance to Rifampicin, with the exception of those identified as XDR- TB.
d XDR-TB (Extensively Drug-Resistant TB) refers to resistance to any fluoroquinolone and to at least one of three second-line injectable drugs
(Capreomycin, Kanamycin, and Amikacin), in addition to multidrug resistance.
e Unspecified Resistance would refer to the resistance that cannot be classified under the previously stated categories

Table 3. Significant Correlates of Unsuccessful Treatment Outcome of PTB Patients in the Philippines, October 2015 – September
2016 (n=3,701)
Variable n Unsuccessful TO n (%) Unadjusted OR (95% CI) p-value Adjusted OR (95% CI) p-value
Age
25–34 years old 542 77 (14.21) 0.86 (0.55 - 1.33) 0.502 0.73 (0.54 - 0.99) 0.044
35–44 years old 606 86 (14.19) 0.87 (0.56 - 1.34) 0.525 0.75 (0.56 - 0.99) 0.046
Sex
Male 2,508 388 (15.47) 1.36 (1.06 - 1.75) 0.016 1.3 (1.03 - 1.64) 0.026
Occupation
Craft and related trades workers 396 48 (12.12) 0.56 (0.38 - 0.82) 0.003 0.66 (0.46 - 0.94) 0.02
Residence Type
4th Class City 218 14 (6.42) 0.32 (0.18 - 0.56) 0.003 0.46 (0.26 - 0.82) 0.008
1st Class Municipality 650 88 (13.54) 0.72 (0.56 - 0.95) 0.008 0.75 (0.57 - 0.98) 0.037
4th Class Municipality 303 25 (8.25) 0.42 (0.27 - 0.64) 0.009 0.59 (0.38 - 0.93) 0.023
Sputum Smear Results
Positive 2,698 280 (10.38) 2.85 (2.36 - 3.44) <0.001 1.6 (1.29 - 2.00) <0.001
Drug Resistance
RR-/MDR-TB 405 218 (53.83) 7.29 (3.31 - 16.03) <0.001 9.32 (7.28 - 1.93) <0.001
History of Previous TB Treatment
Treatment after Lost to Follow-up 366 88 (24.04) 1.79 (1.27 - 2.52) 0.001 1.84 (1.37 - 2.47) <0.001
Previous Treatment Outcome Unknown 265 61 (23.02) 1.38 (0.93 - 2.05) 0.111 1.42 (1.00 - 2.01) 0.048

those with negative results and those who used other In the multiple logistic regression analysis, it was
diagnostic tests (OR=2.85; 95%CI 2.36-3.44). Patients found that patients who were between 25 to 34 years old
whose Xpert MTB/RIF test detected both MTB and (aOR=0.73; 95%CI 0.54-0.99) and 35 to 44 years old
Rifampicin resistance were more than 11 times more (aOR=0.75; 95%CI 0.56-0.99) were less likely to have
likely to have unsuccessful treatment outcome (OR=11.29; unsuccessful treatment outcome. Males were found to
95%CI 8.75-14.56). Patients with RR-/MDR-TB were be 30% more likely of having an unsuccessful outcome
also 11.29 times more likely to have an unsuccessful (aOR=1.30; 95%CI 1.03-1.64) than females. The odds
treatment outcome than those who were drug susceptible of having unsuccessful treatment outcome decreased by
(95%CI 8.99-14.18). Furthermore, patients who were 34% for patients who were craft and related trades workers
categorized as relapse cases (OR=1.61; 95%CI 1.28-2.04), (aOR=0.66; 95%CI 0.46-0.94). Those who are living in
treatment after failure cases (OR=5.36; 95%CI 3.29-8.73), a 1st class municipality (aOR=0.75; 95%CI 0.57-0.98),
treatment after lost to follow-up cases (OR=3.17; 95%CI 4th class city (aOR=0.46; 95%CI 0.26-0.82), or 4th class
2.34-4.27), and cases with previously unknown treatment municipality (aOR=0.59; 95%CI 0.38-0.93) were less
outcome (OR=2.99; 95%CI 2.13-4.19) had higher odds of likely to have unsuccessful treatment outcome. Having a
having unsuccessful treatment outcome. positive sputum smear result increased the odds of having

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unsuccessful treatment outcome by 60% (aOR=1.60; 95%CI sectional survey of presumptive TB patients in Zambia.16
1.29-2.00). Patients with RR-/MDR-TB were 9.32 times In addition, smoking and alcohol consumption might
more likely to have an unsuccessful treatment outcome have contributed to the association established as they act
(95%CI 7.28-11.93). Moreover, treatment after lost to as possible confounders since studies found associations
follow-up cases (aOR=1.84; 95%CI 1.37-2.47) and cases between the vices and treatment outcome.17,18
with previously unknown treatment outcome (aOR=1.42; The multiple logistic regression analysis showed
95% 1.00-2.01) had higher odds of having an unsuccessful that occupation was associated with treatment outcome;
treatment outcome. Among all the variables included in specifically, people whose occupations were classified under
the model, the study revealed that there was no sufficient craft and related trades work were found to be less likely
evidence to conclude that Xpert MTB/RIF result was of having an unsuccessful treatment outcome. Occupation,
associated with TB treatment outcome. as well as education, can be used to assess the social status
of an individual, which can affect a person’s risk for health
DISCUSSION problems as well as the quality of health care service.18 Lower
income, along with poor education levels, can be associated
Multiple regression analysis showed that males, patients with poorer health behavior since their living conditions,
with RR/MDR-TB, those with a positive sputum smear as well as practices, may promote the propagation and
result, those with a history of having lost to follow up, or progression of the disease. Studies associating treatment
unknown previous treatment outcome before retreatment outcome with social status have found similar findings,
were more likely of having unsuccessful treatment outcome. where those who were unemployed were more likely to die
Among the 338,376 PTB patients included in the study, or be lost to follow-up.8,19,20 Moreover, low educational level
8.73% were found to have an unsuccessful treatment was found to be associated with poor patient adherence to
outcome. This means that the NTP successfully reached PTB treatment in a study conducted by Choi in 2016.21
the 90% target for TSR for 2016 despite having TSRs of The study found that those who are living in a 1st
three regions (i.e. Region VIII, NCR, and CAR) falling class municipality, 4th class city, or 4th class municipality
short from the target. According to the NTP, this high TSR were less likely to have an unsuccessful treatment outcome.
could be related to the countrywide implementation of TB According to the World Health Organization, poor living
treatment programs, decentralization of treatment services, conditions worsen infectious diseases. The high rate of urban
the participation of community volunteers, and other migration leading to overpopulation and overcrowding,
strategies that improved case holding. The decentralization which is a significant factor for disease transmission.22 This
allowed the patients to have access to treatment and be situation may also be seen in the National Capital Region,
followed-up regularly within their communities.4 a congested and dense region where 48.33% of those under
the 1st income class city resided. The NTPS 2016 found that
Sociodemographic Factors among those who were treated in 2011 onwards, more patients
Most studies showed that there was an increasing in rural areas received anti-TB drugs compared to those in
likelihood of having an unsuccessful treatment outcome urban areas, despite a high proportion of rural dwellers not
as one ages.8-13 According to these studies, the reported taking any action in response to TB symptoms (43.2%).3 Low
trend may be attributed to the increased risk of having utilization of health services may also be attributed to cities,
comorbidities, immunosuppression, and unfavorable even though they are characterized to have a multitude of
drug reactions, as well as physical deterioration.8,10,11 health and social services when compared to rural areas.22
This is somehow seen in the NTPS 2016 where younger According to Cetrangolo et al., lack of information on
participants of the survey did not take any action when benefits as well as the perception of poor quality of healthcare
presented with TB symptoms because they were concerned services also serves as barriers towards the provision of
of being absent at work or school with the 15 to 24-year- health services.23 This may be seen from the results in
old age group having the highest proportion for this the NTPS 2016, where a higher proportion of urban
occurrence (45.9%). This was attributed to the superior dwellers admitted themselves to self-medication (44.6%)
strategies and better coping mechanisms of older patients.14 which may be attributed to the urban dwellers’ perception
It should be noted that these results, as also shown by their that their symptoms were insignificant, in addition to
confidence intervals, were of borderline significance. the fact that they were not at ease with or did not trust
The study presented the same result compared to the their healthcare providers.
trend in other researches where males were more likely
to have an unsuccessful treatment outcome compared to TB-Related Factors
females.8,15 In the NTPS 2016, more females (23.3%) were The results revealed that patients who tested positive in
found to consult with a healthcare worker as compared to the DSSM test were 60% more likely to have an unsuccessful
males (15.9%), which may indicate better health-seeking treatment outcome compared to those who had a negative
behaviors of females than males, that is also seen in a cross- result, as seen in other studies.8,13,24,25 This association

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 Factors Associated with Treatment Outcome of Patients with PTB

might be due to the extensive disease severity at diagnosis Limitations of the Study
compounded by other health factors and vices, advanced The analytic cross-sectional study design has an
disease progression, and mixed infection of different MTB inherent limitation of difficulty in establishing a temporal
strains.26,27 It may also be explained by the poor response relationship between exposure and outcome. Moreover,
to treatment due to the presence of drug resistance, delays misclassification bias may have been present. Since
in treatment initiation and patient presentation to health the data used were primarily collected for clinical and
facilities, and poor patient monitoring throughout the administrative purposes, data quality in terms of its
course of treatment.27 completeness and accuracy could not be fully ensured
Similar to the obtained results, a study by Aibana for this study. On the part of the researchers, further
et al. did not find any significant association between misclassification bias was minimized by ensuring accurate
GeneXpert results and poor treatment outcome of people data re-coding and editing.
with MDR-TB, as compared to those who did not perform The study results may only be reflective of the registered
the test (aOR=1.31; 95%CI 0.62-2.73).28 However, a population since some characteristics may be different to
follow-up of a clinical trial has shown that TB-related those not enrolled in these facilities. It is also possible that
mortality among patients is lower among those diagnosed the characteristics of the patients included in the study
via GeneXpert as compared to those who were diagnosed significantly differ between those with complete data since
via sputum smear microscopy29; nonetheless, unfavorable some variables and categories were no longer included in the
outcomes in both groups were contributed by loss to follow- regression analysis. STATA automatically drops records with
up. Furthermore, patients with indeterminate Rifampicin- missing data and performs regression analysis only on entries
resistance may be due to a mixed infection of drug- (i.e., patient records) with complete data on all variables for
susceptible and drug-resistant MTB strains. Although mixed analysis. Hence, the possibility of selection bias cannot be
infections are associated with poor treatment outcome, ruled out. It must be noted that although treatment outcome
this cannot be concluded in the data analyzed for logistic may be dependent on comorbidities, it was not included in
regression as those included were found to have successful the logistic regression model; hence, its possible confounding
treatment outcome.30 effect on other factors was not taken into account. The
According to Sengul et al., patients with Rifampicin study used the method of restriction, inclusion and
resistance (cOR=1.4; 95%CI 1.1-1.9), and multidrug exclusion criteria, and multiple logistic regression analysis in
resistance (cOR=1.6; 95%CI 1.1-2.2) were more likely controlling the effects of other variables such as confounding.
to have unsuccessful treatment outcome.11 Similarly, in
this study, an association between drug resistance and CONCLUSION
unsuccessful treatment outcome was also observed, where
RR-/MDR-TB patients were 9.32 times (95% CI 8.71- The study found that male patients, those with
13.62) more likely of having an unsuccessful outcome. rifampicin or multidrug resistance (RR/MDR-TB), a
Given that RR-/MDR-TB patients are treated for about 18 positive sputum smear result, a history of having lost
months or longer, the length of regimen and combination of to follow up, or unknown previous treatment outcome
drugs may cause intolerable adverse reactions to patients and before retreatment were more likely of having unsuccessful
may likely affect their treatment adherence.11 treatment outcome. These agreed with the results of other
In this study, it was revealed that patients who had studies conducted in several settings.
their treatment after being lost to follow-up were almost On the contrary, age groups 25 to 34 years old and 35
two times more likely of having an unsuccessful treatment to 44 years old, craft and related trades workers, and residing
outcome. The study also showed that patients whose in 1st income class municipality, 4th income class city, and
previous treatment outcome was unknown were also more 4th income class municipality were found to be less likely
likely to have an unsuccessful treatment outcome. These of having unsuccessful treatment outcome. In addition,
findings were consistent with other studies that have it may be worthwhile to note that TB-related factors may
shown the significant association of retreatment cases be more associated with unsuccessful treatment outcome
with unsuccessful treatment outcome.8-11,31 These may be compared to socio-demographic factors since the confidence
explained by the findings of the study by da Silva Garrido intervals of the latter group were of borderline significance.
et al. which shows that previous defaulting (i.e., treatment
after lost to follow-up) was a risk factor (aOR=3.20; 95%CI Recommendations
2.25-4.57) for re-defaulting (i.e., an unsuccessful treatment For policymakers and TB program managers, TB
outcome of being lost to follow-up).11 The NTPS 2016 patients with the prognosticating factors for unsuccessful
suggested that patients are likely to default from treatment treatment outcome (i.e., as identified by this study) may
because of the side effects of drugs, a far distance of the require better attention in terms of treatment monitoring.
health center, weakness of the patient to go to the health TB DOTS facilities are recommended to further improve
center, cost of drugs, and the stock-out of drugs.3 their compliance with the protocols of the NTP with regard

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to collecting patient information to ensure completeness 2. World Health Organization. Global tuberculosis report 2017
of data for both surveillance and research purposes. Lastly, [Internet]. 2017 [cited 2017 Oct]. Available from http://apps.who.int/
medicinedocs/documents/s23360en/s23360en.pdf
the study may be useful in resource allocation, developing 3. Department of Health. National Tuberculosis Prevalence Survey
patient-centered care, treatment models, interventions, 2016 [Internet]. 2016 [cited 2017 Nov]. Available from http://ntps.
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For future researches, collection of primary data on other tb_burden.pdf
variables that were not further analyzed in this study and 5. Shimazaki T, Marte SD, Saludar NR, Dimaano EM, Salva EP,
may not be routinely collected by the NTP may be essential. Ariyoshi K, et al. Risk factors for death among hospitalised tuberculosis
patients in poor urban areas in Manila, The Philippines. Int J Tuberc
Other study designs such as case-control and cohort studies Lung Dis. 2013;17(11):1420-6.
must be conducted in the hopes of establishing temporal 6. Tupasi TE, Garfin AG, Kurbatova EV, Mangan JM, Orillaza-Chi
sequence between exposure and the outcome and provide R, Naval LC, et al. Factors associated with loss to follow-up during
stronger evidence of causality. Also, future studies may not treatment for multidrug-resistant tuberculosis, the Philippines, 2012–
2014. Emerg Infect Dis. 2016; 22(3):491-502.
limit their studies to a one-year time span and check if the 7. National Tuberculosis Control Program. National Tuberculosis
assumption of the study is true. Researchers may use higher Control Program Manual of Procedures: 5th edition [Internet].
statistical methods to look into the association between 2014 [cited 2017 Oct]. Available from http://www.ntp.doh.gov.ph/
the said variables and each of the five treatment outcomes. downloads/NTP_MOP_5th_Edition.pdf
8. Gadoev J, Asadov D, Tillashaykhov M, Tayler-Smith K, Isaakidis
Areas on which future studies would be beneficial are: (1) P, Dadu A, et al. Factors associated with unfavorable treatment
the association of income classifications of residence with outcomes in new and previously treated TB patients in Uzbekistan:
tuberculosis treatment outcome and (2) the interactions a five year countrywide study. PloS One. 2015; 10(6):e0128907.
of all the variables which were found to be associated 9. Gebrezgabiher G, Romha G, Ejeta E, Asebe G, Zemene E, Ameni
G. Treatment outcome of tuberculosis patients under directly
with tuberculosis treatment outcome to further explore observed treatment short course and factors affecting outcome
the underlying mechanisms explaining their association in Southern Ethiopia: a five-year retrospective study. PLoS ONE.
with the outcome. 2016; 11(2)1:e0150560.
10. Berhe G, Enquselassie F, Aseffa A. Treatment outcome of smear-
positive pulmonary tuberculosis patients in Tigray Region, Northern
Acknowledgments Ethiopia. BMC Public Health. 2012; 12:537.
The researchers would like to express their utmost 11. Sengul A, Akturk UA, Aydemir Y, Kaya N, Kocak ND, Tasolar
gratitude to Dr. Mario S. Baquilod, Officer in Charge of FT. Factors affecting successful treatment outcomes in pulmonary
the Disease Prevention and Control Bureau, Dr. Anna tuberculosis: a single-center experience in Turkey, 2005–2011. J Infect
Dev Ctries. 2015; 9(8):821-8.
Marie Celina G. Garfin, NTP Manager, Ms. Donna Mae 12. Vasankari T, Holmström P, Ollgren J, Liippo K, Kokki M, Ruutu P.
G. Gaviola, Project Coordinator for Data and Information, Risk factors for poor tuberculosis treatment outcome in Finland:
and the rest of the NTP-DOH team; Dr. Jacinto Blas a cohort study. BMC Public Health. 2007; 7:291.
V. Mantaring III, Chairperson of the University of the 13. Jackson C, Stagg HR, Doshi A, Pan D, Sinha A, Batra R, et al.
Tuberculosis treatment outcomes among disadvantaged patients in
Philippines Manila - Research Ethics Board (UPMREB), India. Public Health Action. 2017; 7(2):134-40.
and Professor Edlyn Jimenez, UPMREB Coordinator; Dr. 14. Kigozi G, Heunis C, Chikobvu P, Botha S, van Rensburg D. Factors
Ma. Susan T. Yanga-Mabunga, Committee Chairperson, and influencing treatment default among tuberculosis patients in a high
the respected members of the PH 197/199 Committee; and burden province of South Africa. Int J Infect Dis. 2017; 54:95-102.
15. Atif M, Sulaiman SA, Shafie AA, Ali I, Asif M, Babar ZU. Treatment
the faculty and staff of the Department of Epidemiology outcome of new smear positive pulmonary tuberculosis patients in
and Biostatistics of the College of Public Health. Penang, Malaysia. BMC Infect Dis. 2014; 14:399.
16. Silva MR, Pereira JC, Costa RR, Dias JA, Guimarães MDC, Leite
Statement of Authorship ICG. Drug addiction and alcoholism as predictors for tuberculosis
treatment default in Brazil: a prospective cohort study. Epidemiol
All authors approved the final version submitted. Infect. 2017; 145(16):3516-24.
17. Trajman A, Durovni B, Saraceni V, Menezes A, Cordeiro-Santos
Author Disclosure M, Cobelens F, et al. Impact on patients’ treatment outcomes of
The authors declare no conflict of interest. XpertMTB/RIF implementation for the diagnosis of tuberculosis:
follow-up of a stepped-wedge randomized clinical trial. PLoS One.
2015; 10(4):e0123252.
Funding Source 18. Hollingshead AB. Two factor index of social position. New Haven:
None. Yale University Press; 1957.
19. Li T,  Zhang H,  Wang LX,  Pang Y,  DU X. Description and factors
affecting the referral of presumptive tuberculosis patients in China.
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