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1.  WHO Multidrug Therapy for Leprosy: Epidemiology of Default in Treatment in Agra District, Uttar Pradesh, India 
BioMed Research International  2015;2015:705804.
Aim. To study the magnitude of default, time of default, its causes, and final clinical outcome. Methods. Data collected in active surveys in Agra is analyzed. Patients were given treatment after medical confirmation and were followed up. The treatment default and other clinical outcomes were recorded. Results. Patients who defaulted have comparable demographic characteristics. However, among defaulters more women (62.7% in PB, 42.6% in MB) were seen than those in treatment completers (PB 52.7% and MB 35.9%). Nerve involvement was high in treatment completers: 45.7% in PB and 91.3% in MB leprosy. Overall default rate was lower (14.8%) in ROM than (28.8%) in standard MDT for PB leprosy (χ12 = 11.6, P = 0.001) and also for MB leprosy: 9.1% in ROM compared to 34.5% in MDT (χ12 = 6.0, P = 0.015). Default rate was not different (28.8% versus 34.5%, P > 0.05) in both types of leprosy given MDT. Most patients defaulted at early stage of treatment and mainly due to manageable side effects. Conclusion. The default in standard MDT both for PB and MB leprosy was observed to be significantly higher than in ROM treatment. Most defaults occurred at early stage of treatment and major contribution of default is due to side effects like drowsiness, weakness, vomiting, diarrhea, and so forth, related to poor general health. Although about half of the defaulters were observed to be cured 2.2% in PB-MDT and 10.9% of MB-MDT developed disability. This is an issue due to default. Attempts are needed to increase treatment compliance. The use of specially designed disease related health education along with easily administered drug regimens may help to reduce default.
PMCID: PMC4331159
2.  Determinants of Treatment Adherence Among Smear-Positive Pulmonary Tuberculosis Patients in Southern Ethiopia 
PLoS Medicine  2007;4(2):e37.
Defaulting from treatment remains a challenge for most tuberculosis control programmes. It may increase the risk of drug resistance, relapse, death, and prolonged infectiousness. The aim of this study was to determine factors predicting treatment adherence among smear-positive pulmonary tuberculosis patients.
Methods and Findings
A cohort of smear-positive tuberculosis patients diagnosed and registered in Hossana Hospital in southern Ethiopia from 1 September 2002 to 30 April 2004 were prospectively included. Using a structured questionnaire, potential predictor factors for defaulting from treatment were recorded at the beginning of treatment, and patients were followed up until the end of treatment. Default incidence rate was calculated and compared among preregistered risk factors. Of the 404 patients registered for treatment, 81 (20%) defaulted from treatment. A total of 91% (74 of 81) of treatment interruptions occurred during the continuation phase of treatment. On a Cox regression model, distance from home to treatment centre (hazard ratio [HR] = 2.97; p < 0.001), age > 25 y (HR = 1.71; p = 0.02), and necessity to use public transport to get to a treatment centre (HR = 1.59; p = 0.06) were found to be independently associated with defaulting from treatment.
Defaulting due to treatment noncompletion in this study setting is high, and the main determinants appear to be factors related to physical access to a treatment centre. The continuation phase of treatment is the most crucial time for treatment interruption, and future interventions should take this factor into consideration.
A prospective cohort study of smear-positive tuberculosis patients at an Ethiopian hospital found treatment default rates to be high; the main factors relate to physical access to the treatment centre.
Editors' Summary
Tuberculosis (TB) is one of the leading causes of death from infectious disease worldwide, and it kills around 1.7 million people each year. TB can be successfully treated but the treatment course is long (at least six months). In 1995 the World Health Organization set up “DOTS”, an international strategy for TB control. One of the links below explains what DOTS is in more detail. One of the main elements of DOTS involves the use of standard courses of drug treatment, with the recommendation that trained observers watch people take their treatment. These steps should prevent people from failing to complete their course of treatment, and the World Health Organization has set a target level of 85% for treatment success. However, people do often have problems sticking to treatment and the reasons for this are not clearly understood. Factors such as access to care and a person's social and financial situation might affect whether an individual sticks to their prescribed treatment.
Why Was This Study Done?
This study was carried out in Ethiopia, which has been recognized as being in the top 22 countries with the highest burden of tuberculosis. In the region of southern Ethiopia studied, the proportion of patients not completing their treatment has declined from 38% to 18% between 1994 and 2000. However, the World Health Organization's targets have not been met, with 20% of patients currently failing to complete treatment. These researchers wanted, therefore, to identify the factors that play a part in determining whether a patient completes their course of treatment. They hope that once such factors are identified, they could ultimately be overcome with appropriate interventions and the level of treatment success improved.
What Did the Researchers Do and Find?
The researchers carried out a cohort study, in which all patients diagnosed with clinical tuberculosis during a particular period of time at a major regional hospital in southern Ethiopia were included. Patients were followed up throughout their treatment course and then counted as either having defaulted from treatment (if they had been on treatment for at least 4 weeks and then interrupted for at least 8 weeks), or having completed. The researchers carried out interviews with each participant at the start of the study, to collect information on factors which might affect how each participant might stick to their treatment plan. These factors included basic information such as whether the patient was male or female, their age, marital status, educational level and occupation, as well as others including family income, whether their home was rural or urban, and the distance to the treatment centre. Finally, patients who stopped their treatment were asked an open-ended question: “Why did you stop taking TB medication?”
404 patients were included in the study and 20% defaulted, most of these within the first few months of treatment. The researchers found that a number of factors seemed to be linked to an increased chance that the person would default from treatment. These included age (patients over 25 were less likely to complete); living in a rural setting; having a lower level of education; greater distances from home to the treatment centre; the need for transport to get to treatment; and whether the patient was admitted to hospital in a serious condition. When defaulters were questioned about the reasons they did not complete treatment, the main reasons were related to physical access to the treatment clinic—for example that it was too far, they could not afford to get there, or were not able to walk to get treatment.
What Do These Findings Mean?
The proportion of patients failing to complete their tuberculosis treatment here supports the view that the default rate in Ethiopia has been falling over the past two decades; but that it is still higher than that recommended by the World Health Organization. The researchers also found that physical access to treatment poses a significant barrier to completing treatment. In this study 72% of patients were within two hours' walk of the health facility, a much greater proportion than is the case for the general population in that region. These findings suggest that government initiatives will be needed in order to address the problem of access to treatment and therefore improve adherence. New initiatives are underway in Ethiopia to train health service workers who can provide community-based care.
Additional Information
World Health Organization (WHO) fact sheet on tuberculosis. More detailed information from WHO is available on DOTS, including the five key elements of DOTS
The US Centers for Disease Control and Prevention has a minisite dedicated to tuberculosis, including a questions-and-answers page
The Stop TB Partnership was established in 2000 to realize the goal of eliminating TB as a public health problem and, ultimately, to obtain a world free of TB. It comprises a network of international organizations, countries, donors from the public and private sectors, governmental and nongovernmental organizations, and individuals that have expressed an interest in working together to achieve this goal
Médecins Sans Frontières, an international medical humanitarian organization, has information on its website about its activities in Ethiopia
PMCID: PMC1796905  PMID: 17298164
3.  Risk Factors Associated with Default from Multi- and Extensively Drug-Resistant Tuberculosis Treatment, Uzbekistan: A Retrospective Cohort Analysis 
PLoS ONE  2013;8(11):e78364.
The Médecins Sans Frontières project of Uzbekistan has provided multidrug-resistant tuberculosis treatment in the Karakalpakstan region since 2003. Rates of default from treatment have been high, despite psychosocial support, increasing particularly since programme scale-up in 2007. We aimed to determine factors associated with default in multi- and extensively drug-resistant tuberculosis patients who started treatment between 2003 and 2008 and thus had finished approximately 2 years of treatment by the end of 2010.
A retrospective cohort analysis of multi- and extensively drug-resistant tuberculosis patients enrolled in treatment between 2003 and 2008 compared baseline demographic characteristics and possible risk factors for default. Default was defined as missing ≥60 consecutive days of treatment (all drugs). Data were routinely collected during treatment and entered in a database. Potential risk factors for default were assessed in univariate analysis using chi-square test and in multivariate analysis with logistic regression.
20% (142/710) of patients defaulted after a median of 6 months treatment (IQR 2.6–9.9). Factors associated with default included severity of resistance patterns (pre-extensively drug-resistant/extensively drug-resistant tuberculosis adjusted odds ratio 0.52, 95%CI: 0.31–0.86), previous default (2.38, 1.09–5.24) and age >45 years (1.77, 1.10–2.87). The default rate was 14% (42/294) for patients enrolled 2003–2006 and 24% (100/416) for 2007–2008 enrolments (p = 0.001).
Default from treatment was high and increased with programme scale-up. It is essential to ensure scale-up of treatment is accompanied with scale-up of staff and patient support. A successful first course of tuberculosis treatment is important; patients who had previously defaulted were at increased risk of default and death. The protective effect of severe resistance profiles suggests that understanding disease severity or fear may motivate against default. Targeted health education and support for at-risk patients after 5 months of treatment when many begin to feel better may decrease default.
PMCID: PMC3819387  PMID: 24223148
4.  Understanding non-compliance with WHO-multidrug therapy among leprosy patients in Assam, India 
The study was undertaken to assess the adherence to World Health Organization (WHO)-multidrug therapy (MDT) and its successful completion by the leprosy patients and the extent of such defaulting, its correlates and reasons.
Retrograde cohort analysis was conducted during the first quarter of 2007 from the cases registered for WHO-MDT treatment during 2002 to 2005 in Kamrup district of Assam, India.
A total of 254 leprosy cases reflected the treatment seeking behavior of registered cases during the study period. Majority of the cases were from urban areas and defaulter rate higher in urban areas. The study group consisted of 60.63% males and 39.37% females.. Both the compliance and default was higher in the age group of 16 to 30 years. Majority of defaulters (32.28%) had passed the high school leaving certificate examination had per capita monthly income between Rs 500 - 749 (30.71%) and belonged to social class IV (33.86%) and V (30.71%). Significant statistical association was found between gender, literacy status, per capita income per month and socioeconomic status with treatment outcome. On analysis for the reasons of defaulting treatment; majority (33.07%) defaulted treatment due to loss of occupational hours when they come for receiving drugs at health center, 25.98% defaulted due to adverse reactions of drugs and 18.11% feared social stigma among major causes.
The causes of defaulting treatment were related to gender, educational status, income as well as social class, or some combination of these. Recommendations, on strategic interventions to obviate the cause for noncompliance, were presented.
PMCID: PMC3137843  PMID: 21799610
Compliance; default; leprosy; multi-drug therapy
5.  Determinants of Tuberculosis treatment default in Morocco: Results from a National Cohort Study 
Studies have shown an association between smoking and tuberculosis (TB) infection, disease and TB-related mortality. We thus documented the impact of smoking and others factors on TB treatment default.
A cohort of 1039 new TB cases matched on smoking status was followed between 2004 and 2009 in eight Moroccan regions. Treatment default was defined according to international criteria. Univariate analyses were used to assess associations of treatment default with smoking status and demographic characteristics. Multivariate logistic regression was used to adjust for potential confounding.
Patients’ mean age was 35.0 ±13.2 years. The rate of treatment default was 30.2%. Default was significantly higher among men, smokers, persons living in urban areas and non-religious Muslims. After adjusting for confounding variables, factors that remained significantly associated with treatment default were: being male (OR = 3.2; 95% CI: 1.2-8.7), being a non-religious Muslim (OR = 2.0; 95% CI: 1.4-2.9) and living in an urban area OR = 3.0; 95% CI: 1.8-4.9).
The high rate found for default suggests important program's inadequacies and an urgent need for change. Therefore continued research of predictors of default and strategies to reinforce adherence is recommended.
PMCID: PMC3670204  PMID: 23734266
Tuberculosis; Morocco; Treatment default
6.  Analysis of reasons for noncompliance with laser treatment in patients of diabetic retinopathy 
To identify the underlying reasons for noncompliance among Chinese patients undergoing laser photocoagulation treatment for diabetic retinopathy (DR).
Prospective cohort study.
A total of 262 patients with DR with indications for panretinal photocoagulation and focal laser treatment were recruited.
Those who did not complete the prescribed laser treatment were categorized into 2 types of defaulters: Type 1 defaulters were those who did not initiate laser treatment as scheduled; type 2 defaulters were those who did not complete the entire laser sessions, including terminating midterm or defaulting prompt supplement of laser treatment. A standardized questionnaire was given to the 2 types of defaulters to collect information about the reasons for noncompliance. Data were analyzed and subjected to χ2 test or Fisher exact statistical tests.
The noncompliance rate was 45.5%, which is significantly greater than some developed countries. Unawareness of the necessity for treatment and unawareness of the importance to complete treatment were 2 main reasons leading to noncompliance, representing 28.8% and 36.0%, respectively. Unawareness of the necessity for treatment and fear of laser treatment were more important for type 1 defaulters (29 vs 6 and 11 vs 0, respectively), whereas unawareness of completeness of laser treatment was overweighed in type 2 defaulters (27 vs 13 patients; all P < 0.01). These results were likely related to the lack of knowledge about the potential consequences of DR, the underlying principle of laser treatment, and panretinal photocoagulation procedures.
Developing appropriate education programs targeting specific reasons will help to improve the compliance in patients with DR.
PMCID: PMC3947385  PMID: 23561600 CAMSID: cams4159
7.  Default from tuberculosis treatment in Tashkent, Uzbekistan; Who are these defaulters and why do they default? 
In Tashkent (Uzbekistan), TB treatment is provided in accordance with the DOTS strategy. Of 1087 pulmonary TB patients started on treatment in 2005, 228 (21%) defaulted. This study investigates who the defaulters in Tashkent are, when they default and why they default.
We reviewed the records of 126 defaulters (cases) and 132 controls and collected information on time of default, demographic factors, social factors, potential risk factors for default, characteristics of treatment and recorded reasons for default.
Unemployment, being a pensioner, alcoholism and homelessness were associated with default. Patients defaulted mostly during the intensive phase, while they were hospitalized (61%), or just before they were to start the continuation phase (26%). Reasons for default listed in the records were various, 'Refusal of further treatment' (27%) and 'Violation of hospital rules' (18%) were most frequently recorded. One third of the recorded defaulters did not really default but continued treatment under 'non-DOTS' conditions.
Whereas patient factors such as unemployment, being a pensioner, alcoholism and homelessness play a role, there are also system factors that need to be addressed to reduce default. Such system factors include the obligatory admission in TB hospitals and the inadequately organized transition from hospitalized to ambulatory treatment.
PMCID: PMC2492865  PMID: 18647400
8.  Determinants of Default from Pulmonary Tuberculosis Treatment in Kuwait 
The Scientific World Journal  2014;2014:672825.
Objectives. To determine the prevalence and risk factors of default from pulmonary tuberculosis treatment in Kuwait. Design. Retrospective study. Patients and methods. We studied all patients who were registered for pulmonary tuberculosis treatment between January 1, 2010, and December 31, 2012, and admitted into TB wards in El Rashid Center or treated in the outpatient clinic in TB Control Unit. Results. There were 110 (11.5%) patients who defaulted from treatment. Fifty-six percent of those who defaulted did so in the first 2 months of treatment and 86.4% of them were still bacteriologically positive at the time of default. Key risk factors associated with noncompliance were male sex, low educational level, non-Kuwaiti nations, history of default, and history of concomitant diabetes mellitus, liver disease, or lung cancer. Multiple drug resistance was also associated with default from treatment. Conclusion. Default from treatment may be partially responsible for the persistent relatively high rates of tuberculosis in Kuwait. Health professionals and policy makers should ensure that all barriers to treatment are removed and that incentives are used to encourage treatment compliance.
PMCID: PMC3997844  PMID: 24955415
9.  Risk Factors and Mortality Associated with Default from Multidrug-Resistant Tuberculosis Treatment 
Completing treatment for multidrug-resistant (MDR) tuberculosis (TB) may be more challenging than completing first-line TB therapy, especially in resource poor settings. The objectives of this study were to (1) identify risk factors for default from MDR TB therapy; (2) quantify mortality among patients who default; and (3) identify risk factors for death following default.
We performed a retrospective chart review to identify risk factors for default and conducted home visits to assess mortality among patients who defaulted.
67 of 671 patients (10.0%) defaulted. The median time to default was 438 days (interquartile range [IQR]: 152−710), and 40.3% of patients had culture-positive sputum at the time of default. Substance use (hazard ratio [HR]: 2.96, 95% confidence interval [CI]: [1.56, 5.62], p-value [p]=0.001), substandard housing conditions (HR: 1.83, CI: [1.07, 3.11], p=0.03), later year of enrollment (HR: 1.62, CI: [1.09, 2.41], p=0.02) and health district (p=0.02) predicted default in a multivariable analysis. Severe adverse events did not predict default. Of 47 (70.1%) patients who defaulted and were successfully traced, 25 (53.2%) had died. Poor bacteriologic response, less than a year of treatment at default, low education level, and diagnosis with a psychiatric disorder significantly predicted death after default in a multivariable analysis.
The proportion of patients who defaulted from MDR TB treatment was relatively low. The large proportion of patients who defaulted while culture-positive underscores the public health importance of minimizing default. Prognosis for patients who defaulted was poor. Interventions aimed at preventing default may reduce TB-related mortality.
PMCID: PMC2577177  PMID: 18462099
tuberculosis; multidrug-resistance; default; mortality; Peru
10.  Factors associated with default from treatment among tuberculosis patients in nairobi province, Kenya: A case control study 
BMC Public Health  2011;11:696.
Successful treatment of tuberculosis (TB) involves taking anti-tuberculosis drugs for at least six months. Poor adherence to treatment means patients remain infectious for longer, are more likely to relapse or succumb to tuberculosis and could result in treatment failure as well as foster emergence of drug resistant tuberculosis. Kenya is among countries with high tuberculosis burden globally. The purpose of this study was to determine the duration tuberculosis patients stay in treatment before defaulting and factors associated with default in Nairobi.
A Case-Control study; Cases were those who defaulted from treatment and Controls those who completed treatment course between January 2006 and March 2008. All (945) defaulters and 1033 randomly selected controls from among 5659 patients who completed treatment course in 30 high volume sites were enrolled. Secondary data was collected using a facility questionnaire. From among the enrolled, 120 cases and 154 controls were randomly selected and interviewed to obtain primary data not routinely collected. Data was analyzed using SPSS and Epi Info statistical software. Univariate and multivariate logistic regression analysis to determine association and Kaplan-Meier method to determine probability of staying in treatment over time were applied.
Of 945 defaulters, 22.7% (215) and 20.4% (193) abandoned treatment within first and second months (intensive phase) of treatment respectively. Among 120 defaulters interviewed, 16.7% (20) attributed their default to ignorance, 12.5% (15) to traveling away from treatment site, 11.7% (14) to feeling better and 10.8% (13) to side-effects. On multivariate analysis, inadequate knowledge on tuberculosis (OR 8.67; 95% CI 1.47-51.3), herbal medication use (OR 5.7; 95% CI 1.37-23.7), low income (OR 5.57, CI 1.07-30.0), alcohol abuse (OR 4.97; 95% CI 1.56-15.9), previous default (OR 2.33; 95% CI 1.16-4.68), co-infection with Human immune-deficient Virus (HIV) (OR 1.56; 95% CI 1.25-1.94) and male gender (OR 1.43; 95% CI 1.15-1.78) were independently associated with default.
The rate of defaulting was highest during initial two months, the intensive phase of treatment. Multiple factors were attributed by defaulting patients as cause for abandoning treatment whereas several were independently associated with default. Enhanced patient pre-treatment counseling and education about TB is recommended.
PMCID: PMC3224095  PMID: 21906291
11.  Time of Default in Tuberculosis Patients on Directly Observed Treatment 
Default remains an important challenge for the Revised National Tuberculosis Control Programme, which has achieved improved cure rates.
This study describes the pattern of time of default in patients on DOTS.
Settings and Design:
Tuberculosis Unit in District Tuberculosis Centre, Yavatmal, India; Retrospective cohort study.
Materials and Methods:
This analysis was done among the cohort of patients of registered at the Tuberculosis Unit during the year 2004. The time of default was assessed from the tuberculosis register. The sputum smear conversion and treatment outcome were also assessed.
Statistical Analysis:
Kaplan-Meier plots and log rank tests.
Overall, the default rate amongst the 716 patients registered at the Tuberculosis Unit was 10.33%. There was a significant difference in the default rate over time between the three DOTS categories (log rank statistic= 15.49, P=0.0004). Amongst the 331 smear-positive patients, the cumulative default rates at the end of intensive phase were 4% and 16%; while by end of treatment period, the default rates were 6% and 31% in category I and category II, respectively. A majority of the smear-positive patients in category II belonged to the group ‘treatment after default’ (56/95), and 30% of them defaulted during re-treatment. The sputum smear conversion rate at the end of intensive phase was 84%. Amongst 36 patients without smear conversion at the end of intensive phase, 55% had treatment failure.
Patients defaulting in intensive phase of treatment and without smear conversion at the end of intensive phase should be retrieved on a priority basis. Default constitutes not only a major reason for patients needing re-treatment but also a risk for repeated default.
PMCID: PMC2946677  PMID: 20927282
Control; Default; Directly observed treatment–short course (DOTS); Tuberculosis
12.  Factors influencing default at a hospital colposcopy clinic. 
Quality in Health Care  1992;1(4):236-240.
OBJECTIVE--To identify factors reducing compliance at diagnosis, treatment, and review stages among women referred with abnormal cervical smears to a hospital colposcopy clinic. DESIGN--Retrospective analysis of sociodemographic data from hospital notes of the attenders and defaulters during one year (1989-90) and prospective collection of information by structured interviews of a sample of defaulters and attenders during five months (May-September 1990). SETTING--One hospital colposcopy clinic. PATIENTS--238 women defaulting on two consecutive occasions and 188 attending regularly (retrospective analysis) and a subset of 40 defaulters and 24 attenders (interview sample). MAIN MEASURES--Sociodemographic data and interview responses about attitudes, behaviour, choice, accessibility cultural understanding, communications, and emotional response. RESULTS--22 (12%) women defaulted at diagnosis, 24(13%) at treatment, 39(21%) at the first check up after treatment, and 84(45%) at the review stage; 19(10%) defaulted from the first check up after diagnostic examination revealed no need for treatment. Age and social class differed between the two groups. 181(76%) defaulters were under 30 compared with 91(48%) attenders; 14(6%) compared with 41(23%) were over 40(p < 0.001). The proportion of women in social classes 4 and 5 was 33%(20/60) for defaulters and 21%(25/120) for attenders (p < 0.05) and unemployed was 66%(158/238) and 36%(68/188) respectively. 63(28%) defaulters were pregnant compared with 11(6%) attenders (p < 0.001). More defaulters came from gynaecology or antenatal clinics. Most defaulters (93%) had child care responsibilities and they knew and understood less about colposcopy. Their explicit reasons for defaulting included child care commitments and fear and their implicit reasons lack of understanding, inaccessibility of information, and staff attitudes. CONCLUSIONS--Compliance may be improved by promoting women's understanding of treatment and encouraging health professionals to develop a service more sensitive to the various needs of women in different socioeconomic groups.
PMCID: PMC1055032  PMID: 10136870
13.  Risk factors for tuberculosis treatment failure, default, or relapse and outcomes of retreatment in Morocco 
BMC Public Health  2011;11:140.
Patients with tuberculosis require retreatment if they fail or default from initial treatment or if they relapse following initial treatment success. Outcomes among patients receiving a standard World Health Organization Category II retreatment regimen are suboptimal, resulting in increased risk of morbidity, drug resistance, and transmission.. In this study, we evaluated the risk factors for initial treatment failure, default, or early relapse leading to the need for tuberculosis retreatment in Morocco. We also assessed retreatment outcomes and drug susceptibility testing use for retreatment patients in urban centers in Morocco, where tuberculosis incidence is stubbornly high.
Patients with smear- or culture-positive pulmonary tuberculosis presenting for retreatment were identified using clinic registries in nine urban public clinics in Morocco. Demographic and outcomes data were collected from clinical charts and reference laboratories. To identify factors that had put these individuals at risk for failure, default, or early relapse in the first place, initial treatment records were also abstracted (if retreatment began within two years of initial treatment), and patient characteristics were compared with controls who successfully completed initial treatment without early relapse.
291 patients presenting for retreatment were included; 93% received a standard Category II regimen. Retreatment was successful in 74% of relapse patients, 48% of failure patients, and 41% of default patients. 25% of retreatment patients defaulted, higher than previous estimates. Retreatment failure was most common among patients who had failed initial treatment (24%), and default from retreatment was most frequent among patients with initial treatment default (57%). Drug susceptibility testing was performed in only 10% of retreatment patients. Independent risk factors for failure, default, or early relapse after initial treatment included male gender (aOR = 2.29, 95% CI 1.10-4.77), positive sputum smear after 3 months of treatment (OR 7.14, 95% CI 4.04-13.2), and hospitalization (OR 2.09, 95% CI 1.01-4.34). Higher weight at treatment initiation was protective. Male sex, substance use, missed doses, and hospitalization appeared to be risk factors for default, but subgroup analyses were limited by small numbers.
Outcomes of retreatment with a Category II regimen are suboptimal and vary by subgroup. Default among patients receiving tuberculosis retreatment is unacceptably high in urban areas in Morocco, and patients who fail initial tuberculosis treatment are at especially high risk of retreatment failure. Strategies to address risk factors for initial treatment default and to identify patients at risk for failure (including expanded use of drug susceptibility testing) are important given suboptimal retreatment outcomes in these groups.
PMCID: PMC3053250  PMID: 21356062
14.  Risk Factors for Treatment Default among Re-Treatment Tuberculosis Patients in India, 2006 
PLoS ONE  2010;5(1):e8873.
Under India's Revised National Tuberculosis Control Programme (RNTCP), >15% of previously-treated patients in the reported 2006 patient cohort defaulted from anti-tuberculosis treatment.
To assess the timing, characteristics, and risk factors for default amongst re-treatment TB patients.
For this case-control study, in 90 randomly-selected programme units treatment records were abstracted from all 2006 defaulters from the RNTCP re-treatment regimen (cases), with one consecutively-selected non-defaulter per case. Patients who interrupted anti-tuberculosis treatment for >2 months were classified as defaulters.
1,141 defaulters and 1,189 non-defaulters were included. The median duration of treatment prior to default was 81 days (25%–75% interquartile range 44–117 days) and documented retrieval efforts after treatment interruption were inadequate. Defaulters were more likely to have been male (adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI] 1.2–1.7), have previously defaulted anti-tuberculosis treatment (aOR 1.3 95%CI 1.1–1.6], have previous treatment from non-RNTCP providers (AOR 1.3, 95%CI 1.0–1.6], or have public health facility-based treatment observation (aOR 1.3, 95%CI 1.1–1.6).
Amongst the large number of re-treatment patients in India, default occurs early and often. Improved pre-treatment counseling and community-based treatment provision may reduce default rates. Efforts to retrieve treatment interrupters prior to default require strengthening.
PMCID: PMC2810342  PMID: 20111727
15.  Predictors of default from follow-up care in a cervical cancer screening program using direct visual inspection in south-western Nigeria 
Increasingly evidence is emerging from south East Asia, southern and east Africa on the burden of default to follow up care after a positive cervical cancer screening/diagnosis, which impacts negatively on cervical cancer prevention and control. Unfortunately little or no information exists on the subject in the West Africa sub region. This study was designed to determine the proportion of and predictors and reasons for default from follow up care after positive cervical cancer screen.
Women who screen positive at community cervical cancer screening using direct visual inspection were followed up to determine the proportion of default and associated factors. Multivariate logistic regression was used to determine independent predictors of default.
One hundred and eight (16.1%) women who screened positive to direct visual inspection out of 673 were enrolled into the study. Fifty one (47.2%) out of the 108 women that screened positive defaulted from follow-up appointment. Women who were poorly educated (OR: 3.1, CI: 2.0 – 5.2), or lived more than 10 km from the clinic (OR: 2.0, CI: 1.0 – 4.1), or never screened for cervical cancer before (OR: 3.5, CI:3:1–8.4) were more likely to default from follow-up after screening positive for precancerous lesion of cervix . The main reasons for default were cost of transportation (48.6%) and time constraints (25.7%).
The rate of default was high (47.2%) as a result of unaffordable transportation cost and limited time to keep the scheduled appointment. A change from the present strategy that involves multiple visits to a “see and treat” strategy in which both testing and treatment are performed at a single visit is recommended.
PMCID: PMC3986612  PMID: 24678898
Cervical cancer; Direct visual inspection; VIA; VILI; Default
16.  The impact of knowledge and attitudes on adherence to tuberculosis treatment: a case-control study in a Moroccan region 
Although tuberculosis (TB) care is provided free of charge in Morocco, a high number of patients voluntarily interrupt their treatment before the end. Treatment Default is a major obstacle in the fight against the disease. The purpose of this study was to describe the impact of knowledge and attitudes toward TB on treatment adherence.
Case-control study of 290 TB patients (85 defaulters and 205 controls). A defaulter was defined as a TB patient who interrupted treatment for two months or longer. Socio-demographic measurements, knowledge and attitude were collected by face to face anonymous questionnaire. Khi-square test was conducted to examine differences in TB attitudes and knowledge according to treatment adherence.
The mean age of participants was 31.7 ± 12.0 years. Monthly income was under 2000 MAD (180 €) for 82% of them. Over sixty four percent were illiterate or had a basic educational level. Microbial cause was known by 17.2% respondents; 20.5% among adherent patients versus 9.4% (p=0.02). The fact that the disease is curable was more known by adherent patients: 99.0% versus 88.2% (p < 0.01). Eighty tree per cent of patients had been informed about treatment duration and consequences of not completing treatment: 89.0% among adherent patients versus 69.7% (p<0.001). The main reason evoked for defaulting was the sensation of being cured (72.9% of defaulters).
This study shows a poor knowledge on TB especially among non adherent patients. This finding justifies the need to incorporate patient's education into current TB case management.
PMCID: PMC3428172  PMID: 22937192
Tuberculosis; Non-adherence; DOT; knowledge; attitudes; treatment; Morocco
17.  A Retrieval System for Patients with Avoidable Blindness Due to Diabetic Retinopathy who do not Present for Ophthalmic Assessment in Oman 
Many patients with diabetes do not present for eye examinations, foregoing the recommended management for diabetic eye care. Proactive steps are being taken in Oman to retrieve defaulters (patients who do not present or “no-show”) with Sight Threatening Diabetic Retinopathy (STDR). We present the outcomes of the defaulter retrieval system in five regions of Oman in 2009.
Materials and Methods:
Ophthalmologists examine eyes periodically, family physicians focus on primary prevention of Diabetic Retinopathy (DR) and medical retina specialists manage DR in Oman. A person with proliferative stage of DR (PDR) and/or Diabetic Macular Edema (DME) in either eye is considered as STDR and is registered at regional hospitals. The eye care staff identify the defaulters and the hospital staff help them retrieve the defaulters. The reminder of reappointment is sent using the text messages on telephone. The glycemic control of STDR cases was also noted in Nizwa Hospital.
We registered 654 STDR cases, of which 494 (75%) were defaulters. Lack of awareness, transport, absence of a decision maker, and fear of laser treatment were the main causes for defaulting. We successfully retrieved 328 (66.4%) defaulters. The retrieval rates among male and female patients were 51.2% and 82%, respectively. The retrieval varied by region. In Nizwa hospital, 114 of 131 STDR cases (85%) had poor glycemic control.
Defaulter retrieval system could help healthcare providers to identify and motivate patients with STDR towards better compliance. Primary prevention measures among STDR cases were poor and need further focus.
PMCID: PMC3119298  PMID: 21731317
Defaulter; Diabetes Mellitus; Diabetic Retinopathy
18.  Treatment Outcome and Follow-up of Tuberculosis Patients Put on Directly Observed Treatment Short-course Under Rural Health Training Center, Paithan, Aurangabad in India 
Revised National Tuberculosis Control Program (RNTCP) was found successful in achieving its objectives; still there is concern of relapse cases and defaulters.
The aim of this study is to know the treatment outcome, to assess the reasons for relapse, default, death of patient and to assess the follow-up status of tuberculosis (TB) patients put on directly observed treatment short-course (DOTS).
Subjects and Methods:
This cross-sectional survey was conducted in 140 TB patients put on DOTS during year 2005-2007 under Rural Health Training Center, Paithan. The personal interview was carried out by an investigator with pre-tested questionnaire during month of July-August 2008.
Out of total 140, 125 TB cases could be traced: Category I 48% (60/125), Category II 16% (20/125) and Category III 36% (45/125). Cure rate among Category I was calculated to be 61.7% (37/60). Defaulters were observed to be 18.3% (11/60), 25% (5/20) and 20% (9/45) among Category I, Category II and Category III respectively. Death rate was higher (5%) among patients of Category II. During the follow-up visit, 82.4% (103/125) were found to be alive while 17.6% (22/125) dead. A total of 18 deaths were related with TB and its sequelae. Around 20% (5/25) defaulted because of feeling of well-being. During the follow-up visit, 5.8% (6/103) were again put on DOTS.
Defaulters were high in present study. The majority of patients left the treatment due to feeling well. This can be tackled by effective counseling. Higher percentage of the patients showed improvement in their weight after completion of DOTS treatment. More emphasis was to be given toward existing TB patients to get successful results of RNTCP.
PMCID: PMC3991944  PMID: 24761242
Defaulters; Follow-up; Treatment outcome
19.  Alcohol, Hospital Discharge, and Socioeconomic Risk Factors for Default from Multidrug Resistant Tuberculosis Treatment in Rural South Africa: A Retrospective Cohort Study 
PLoS ONE  2013;8(12):e83480.
Default from multidrug-resistant tuberculosis (MDR-TB) treatment remains a major barrier to cure and epidemic control. We sought to identify patient risk factors for default from MDR-TB treatment and high-risk time periods for default in relation to hospitalization and transition to outpatient care.
We retrospectively analyzed a cohort of 225 patients who initiated MDR-TB treatment between 2007 through 2010 at a rural TB hospital in the Western Cape Province, South Africa.
Fifty percent of patients were cured or completed treatment, 27% defaulted, 14% died, 4% failed treatment, and 5% transferred out. Recent alcohol use was common (63% of patients). In multivariable proportional hazards regression, older age (hazard ratio [HR]= 0.97 [95% confidence interval 0.94-0.99] per year of greater age), formal housing (HR=0.38 [0.19-0.78]), and steady employment (HR=0.41 [0.19-0.90]) were associated with decreased risk of default, while recent alcohol use (HR=2.1 [1.1-4.0]), recent drug use (HR=2.0 [1.0-3.6]), and Coloured (mixed ancestry) ethnicity (HR=2.3 [1.1-5.0]) were associated with increased risk of default (P<0.05). Defaults occurred throughout the first 18 months of the two-year treatment course but were especially frequent among alcohol users after discharge from the initial four-to-five-month in-hospital phase of treatment, with the highest default rates occurring among alcohol users within two months of discharge. Default rates during the first two months after discharge were also elevated for patients who received care from mobile clinics.
Among patients who were not cured or did not complete MDR-TB treatment, the majority defaulted from treatment. Younger, economically-unstable patients and alcohol and drug users were particularly at risk. For alcohol users as well as mobile-clinic patients, the early outpatient treatment phase is a high-risk period for default that could be targeted in efforts to increase treatment completion rates.
PMCID: PMC3862731  PMID: 24349518
20.  Risk factors and timing of default from treatment for non-multidrug-resistant tuberculosis in Moldova 
The Republic of Moldova, Eastern Europe, 2007–2010. Moldova has among the highest reported nationwide proportions of TB patients with multidrug-resistant tuberculosis (MDR-TB) worldwide.
To assess risk factors and timing of default from treatment for non-MDR-TB. Default has been associated with increased mortality and amplification of drug resistance and may contribute to the high MDR-TB rates in Moldova.
A retrospective analysis of routine surveillance data on all non-MDR-TB patients reported.
14.7% of non-MDR-TB patients defaulted from treatment during the study period. Independent risk factors for default included sociodemographic factors (i.e. homelessness, living alone, less formal education and spending substantial time outside Moldova in the year prior to diagnosis) and health-related factors (i.e. HIV-coinfection, greater lung pathology, and increasing TB drug resistance). TB treatment is usually initiated within an institutional setting in Moldova and the default risk was highest in the month following the hospitalized treatment phase (among civilians) and after leaving prison (among those diagnosed while incarcerated).
Targeted interventions to increase treatment adherence for patients at highest risk of default and improving the continuity of care for patients transitioning from institutional to community care may substantially reduce the default risk.
PMCID: PMC3710709  PMID: 23407226
Eastern Europe; hospitalization; prisons; drug resistance
21.  Why do patients default from follow-up at a genitourinary clinic?: a multivariate analysis. 
Genitourinary Medicine  1995;71(6):393-395.
OBJECTIVE--Firstly to compare the proportion of patients defaulting from follow up at a genitourinary medicine clinic with those attending other hospital based clinics. Secondly to determine which factors are associated with non attendance at a city centre genitourinary medicine clinic. METHODOLOGY--The proportion of patients who defaulted at a genitourinary medicine clinic, a general medical clinic, a general surgical clinic and a dermatology clinic during March 1995 were compared. A multivariate logistic regression analysis was performed comparing attenders and non attenders at the genitourinary medicine clinic with respect to time of appointment, diagnosis, previous contacts with clinic staff, potential domestic commitments and patient demographics in a prospective case control study. RESULTS--The default rate at the genitourinary medicine clinic was 15% compared with 13%, 15% and 14% for medical, surgical and dermatology clinics respectively. Patients who defaulted from the genitourinary medicine clinic (167) were compared with 172 attenders and significant differences found for timing of appointments, area of residence, frequency of counselling by the health advisor and age of the patient. Other factors such as the diagnosis, whether a woman had children, sexual orientation, whether negative results had been given over the phone, source of referral, sex of patient, employment status and the weather were not found to be significantly associated with defaulting from an appointment. CONCLUSIONS--The time of the appointment and being seen by a health advisor were the only variables identified over which the clinic has control and therefore could potentially reduce non attendance rates.
PMCID: PMC1196112  PMID: 8566981
22.  Patient- and provider-level risk factors associated with default from tuberculosis treatment, South Africa, 2002: a case-control study 
BMC Public Health  2012;12:56.
Persons who default from tuberculosis treatment are at risk for clinical deterioration and complications including worsening drug resistance and death. Our objective was to identify risk factors associated with tuberculosis (TB) treatment default in South Africa.
We conducted a national retrospective case control study to identify factors associated with treatment default using program data from 2002 and a standardized patient questionnaire. We defined default as interrupting TB treatment for two or more consecutive months during treatment. Cases were a sample of registered TB patients receiving treatment under DOTS that defaulted from treatment. Controls were those who began therapy and were cured, completed or failed treatment. Two respective multivariable models were constructed, stratified by history of TB treatment (new and re-treatment patients), to identify independent risk factors associated with default.
The sample included 3165 TB patients from 8 provinces; 1164 were traceable and interviewed (232 cases and 932 controls). Significant risk factors associated with default among both groups included poor health care worker attitude (new: AOR 2.1, 95% CI 1.1-4.4; re-treatment: AOR 12, 95% CI 2.2-66.0) and changing residence during TB treatment (new: AOR 2.0, 95% CI 1.1-3.7; re-treatment: AOR 3.4, 95% CI 1.1-9.9). Among new patients, cases were more likely than controls to report having no formal education (AOR 2.3, 95% CI 1.2-4.2), feeling ashamed to have TB (AOR 2.0, 95% CI 1.3-3.0), not receiving adequate counseling about their treatment (AOR 1.9, 95% CI 1.2-2.8), drinking any alcohol during TB treatment (AOR 1.9, 95% CI 1.2-3.0), and seeing a traditional healer during TB treatment (AOR 1.9, 95% CI 1.1-3.4). Among re-treatment patients, risk factors included stopping TB treatment because they felt better (AOR 21, 95% CI 5.2-84), having a previous history of TB treatment default (AOR 6.4, 95% CI 2.9-14), and feeling that food provisions might have helped them finish treatment (AOR 5.0, 95% CI 1.3-19).
Risk factors for default differ between new and re-treatment TB patients in South Africa. Addressing default in both populations with targeted interventions is critical to overall program success.
PMCID: PMC3306745  PMID: 22264339
Tuberculosis; treatment default; non-adherence; South Africa
23.  Risk of developing disability in pre and post-multidrug therapy treatment among multibacillary leprosy: Agra MB Cohort study 
BMJ Open  2012;2(2):e000361.
If leprosy is a public health problem, it is due to the disabilities it causes. Surprisingly little is known about the risk of disabilities. Even now, mainly cross-sectional studies report disability prevalence. The present study aims to report the risk of disability in pre and post-WHO multidrug therapy (MDT) in multibacillary leprosy patients and to assess the extent of the incidence of disability.
The study design is prospective and the setting is an institutional field area. Patients were detected during 2001–6 field surveys. Of the 289 multibacillary patients, 146 completed the study. Both sexes were involved. The primary outcome planned was to study cure of disease, relapses and disability in patients receiving MDT. The secondary outcome was to measure reaction and default. Assessment was done clinically. Data have been analysed using SPSS software, logistic, survival analysis was performed and the χ2 test of significance was used.
An important risk factor was found to be three or more nerves involved with odds of 3.73 (1.24–11.2), and delay in treatment; 2.27 (1.04–4.96) at the pre-MDT stage and three or more nerves involved with odds of 2.81 (1.0–7.9) at the post-MDT stage. The incidence of disability was found to be 2.74/100 person-years; 2.69 in the MDT arm and 2.84 in defaulters, with slightly higher disability among early defaulters (3.08) than among late defaulters (2.30). The study suggests that the incidence of disability could be slightly higher if treatment is not completed.
Early treatment for leprosy is a must for reducing the risk of disability, and treatment delay would increase the risk of disability. It is important to note that the incidence of disability between defaulters and those completing treatment was not found to be significantly different.
Article summary
Article focus
What are the risk factors associated with disability at the pre-MDT and post-MDT stage?
What is the risk of disability among leprosy patients, patients completing treatment versus defaulters?
Do early defaulters have a higher incidence of disability than late defaulters?
Key messages
This study clearly demonstrates that risk factors for disability at detection and in a prospective cohort are the same, ie, an increasing number of nerves thickening. It also reveals that the incidence of disability although high among defaulters (2.84/100 person-years) is not significantly higher than in those completing treatment (2.42/100 person-years); nor does it differ significantly among early versus late defaulters (3.08 vs 2.30). In addition, it shows that treatment with ROM has much better prevention than in MDT groups. All this together implies that even a few months of treatment could be as good as completing treatment as far as the development of disability is concerned, but treatment must be started.
Strength and limitations of this study
The strength of the study is that it is based on a closely followed prospective cohort for a good length of time and patients were clinically assessed and monitored. However, one limitation could be that the ROM arm could not be completed due to WHO withdrawal. This could have provided more comparable data.
PMCID: PMC3330256  PMID: 22454186
24.  Risk Factors Associated with Default among New Smear Positive TB Patients Treated Under DOTS in India 
PLoS ONE  2010;5(4):e10043.
Poor treatment adherence leading to risk of drug resistance, treatment failure, relapse, death and persistent infectiousness remains an impediment to the tuberculosis control programmes. The objective of the study was to identify predictors of default among new smear positive TB patients registered for treatment to suggest possible interventions to set right the problems to sustain and enhance the programme performance.
Methodology & Principal Findings
Twenty districts selected from six states were assigned to six strata formed, considering the geographic, socio-cultural and demographic setup of the area. New smear positive patients registered for treatment in two consecutive quarters during III quarter 2004 to III quarter 2005 formed the retrospective study cohort. Case control analysis was done including defaulted patients as “cases” and equal number of age and sex matched patients completing treatment as “controls”. The presence and degree of association between default and determinant factors was computed through univariate and multivariate logistic regression analysis. Data collection was through patient interviews using pre-tested semi structured questionnaire and review of treatment related records. Information on a wide range of socio demographic and patient related factors was obtained. Among the 687 defaulted and equal numbers of patients in completed group, 389 and 540 patients respectively were satisfactorily interviewed. In the logistic regression analysis, factors independently associated with default were alcoholism [AOR-1.72 (1.23–2.44)], illiteracy [AOR-1.40 (1.03–1.92)], having other commitments during treatment [AOR-3.22 (1.1–9.09)], inadequate knowledge of TB [AOR-1.88(1.35–2.63)], poor patient provider interaction [AOR-1.72(1.23–2.44)], lack of support from health staff [AOR-1.93(1.41–2.64)], having instances of missed doses [AOR-2.56(1.82–3.57)], side effects to anti TB drugs [AOR-2.55 (1.87–3.47)] and dissatisfaction with services provided [AOR-1.73 (1.14–2.6)].
Majority of risk factors for default were treatment and provider oriented and rectifiable with appropriate interventions, which would help in sustaining the good programme performance.
PMCID: PMC2850369  PMID: 20386611
25.  Factors Associated with Tuberculosis Treatment Default in an Endemic Area of the Brazilian Amazon: A Case Control-Study 
PLoS ONE  2012;7(6):e39134.
Treatment default is a serious problem in tuberculosis control because it implies persistence of infection source, increased mortality, increased relapse rates and facilitates the development of resistant strains.
This study analyzed tuberculosis treatment default determinants in the Amazonas State to contribute in planning appropriate control interventions.
Observational study with a retrospective cohort using Brazilian Disease Notification System data from 2005 to 2010. A nested case control study design was used. Patients defaulting from treatment were considered as ‘cases’ and those completing treatment as ‘controls’. In the analysis, 11,312 tuberculosis patients were included, 1,584 cases and 9,728 controls.
Treatment default was observed to be associated to previous default (aOR 3.20; p<0.001), HIV positivity (aOR 1.62; p<0.001), alcoholism (aOR 1.51; p<0.001), low education level (aOR 1.35; p<0.001) and other co-morbidities (aOR 1.31; p = 0.05). Older patients (aOR 0.98; p = 0.001) and DOT (aOR 0,72; p<0.01) were considered as protective factor for default.
Associated factors should be considered in addressing care and policy actions to tuberculosis control. Information on disease and treatment should be intensified and appropriate to the level of education of the population, in order to promote adherence to treatment and counter the spread of multidrug resistance to anti-TB drugs.
PMCID: PMC3373579  PMID: 22720052

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