87

Vol. 7 No. 3 September–December 2018

Research Report

DETERMINANT FACTORS OF DROP OUT (DO) AMONG MULTI

DRUGS RESISTANCE TUBERCULOSIS (MDR TB) PATIENTS AT
JAKARTA PROVINCE IN 2011 TO 2015

Sitti Farihatun1, Putri Bungsu2a

1 Graduate Student of Epidemiology Department, Public Health Faculty, Universitas Indonesia
2 Lecturer of Epidemiology Department, Public Health Faculty, Universitas Indonesia
a Corresponding author: putri.bungsu10@ui.ac.id

ABSTRACT
The prevalence of Drop out (DO) among Multi Drugs Resistant Tuberculosis (MDR TB) patients increases every year in Jakarta
Province. The latest data of 2016 contains 367 drug resistant TB patients and 78 patients (21.2%) were DO. This study was aimed to
analyze the determinant factors of Drop Out (DO) among MDR TB patients in Jakarta Province between 2011 to 2015 based on risk
factors of age, sex, HIV status, sputum test, type of patient, number of previous treatments and number of drugs resistance. This study
was used secondary data that source from cohort registration e-TB Manager from DKI Jakarta Health Office with total 516 samples.
The design study was an observational cross sectional quantitative study. DO is a condition of patients who have been treated and
drop out of treatment for 2 consecutive months or more. The crude prevalence of DO among MDR TB patients was 44.6%. Trend of
DO among MDR TB was increased since 2011 to 2015. There was a further increase more than 10% in every year. The proportion of
DO among MDR TB in Jakarta was more than 64 years old (63.6%), male (47.3%), patients with status HIV negative (44.9%), patients
that never or ever consumed drugs less than 1 month (61.2%), and patients with >2 drugs resistance (45.7%). The results of this study
indicated that proportion of DO among MDR TB patients at Jakarta Province in 2011-2015 was high. Therefore, it is necessary efforts
that can decrease DO cases among MDR TB patients. This study was expected to be a reference for Jakarta Province Health Office
in implement P2TB Program implementation and reach target precisely.

Keywords: Drop Out, MDR, Tuberculosis, Jakarta, determinant factors

ABSTRAK
Prevalensi Drop Out/ Putus Obat (DO) pada pasien Tuberkulosis Multi Drugs Resistant (TB MDR) terus meningkat setiap tahunnya
di Provinsi DKI Jakarta. Data terakhir di tahun 2016 tercatat sebanyak 367 pasien TB MDR dan 78 pasien (21.2%) berstatus DO.
Penelitian ini bertujuan untuk menganalisis faktor determinan kejadian Drop Out (DO) pada pasien TB MDR di Provinsi DKI Jakarta
pada tahun 2011 sampai 2015 berdasarkan faktor risiko umur, jenis kelamin, status HIV, hasil test sputum, tipe pasien, riwayat
pengobatan TB sebelumnya (jumlah), dan jumlah resistansi obat. Data yang digunakan adalah data sekunder yang bersumber dari data
register kohort e-TB Manager dengan jumlah sampel sebanyak 516 sampel. Desain penelitian ini adalah studi kuantitatif observational
cross sectional. DO ada studi ini adalah kondisi pasien yang telah diobati dan putus pengobatan selama 2 bulan berturut-turut atau
lebih. Prevalensi DO pasien TB MDR pada penelitian ini yaitu 44.6% yang merupakan prevalensi kasar. Tren kejadian DO pada
penelitian ini cenderung mengalami peningkatan dari tahun 2011 hingga 2015 dan prevalensi DO terus melebihi angka 10% setiap
tahunnya. Proporsi DO pada pasien TB MDR di Provinsi DKI Jakarta tahun 2011-2015 banyak terjadi pada pasien dengan usia >64
(63.6%), jenis kelamin laki-laki (47.3%), status HIV negatif (44.9%), pasien yang belum pernah atau pernah menelan obat namun
kurang <1 bulan (58.8%), dan paling banyak pada pasien dengan jumlah resistansi >2 obat (45.7%). Hasil penelitian ini menunjukkan
bahwa proporsi kasus DO pada pasien TB MDR di Provinsi DKI Jakarta tahun 2011-2015 masih tinggi. Oleh karena itu, perlu adanya
88 Indonesian Journal of Tropical and Infectious Disease, Vol. 7 No. 3 September–December 2018: 87–92

upaya untuk dapat mengurangi jumlah kasus DO pada pasien TB MDR. Diharapkan penelitian ini dapat menjadi acuan bagi Dinas
Kesehatan Provinsi DKI Jakarta dalam menjalankan program P2TB yang lebih baik dan tepat sasaran.

Kata kunci: Drop Out, MDR, Tuberkulosis, Jakarta, Faktor Determinan

INTRODUCTION didn’t take the medication for 2 consecutive months or more

before the end of treatment. Inclusion criteria of this study
Multi Drug Resistant Tuberculosis (MDR TB) is a include were patients with pulmonary MDR TB, age >15
condition in which Mycobacterium tuberculosis resistant to years, domiciled in Jakarta Province, pulmonary MDR TB
the type of first-line drugs treatment such as rifampicin and patients have been evaluated the final results of treatment,
isoniazid simultaneously, with or without being followed by and pulmonary MDR TB patients that data were recorded
other first-line drugs resistance treatment.1 The number of fully in e-TB Manager of Jakarta Provincial Health Office.
incidences of MDR TB in the world by 2014 was estimated Exclusion criteria were pulmonary MDR TB patients who
to be 300.000 new cases of MDR TB and by 2014 increased died and failed treatment related to discontinued treatment
to 480.000 new cases of MDR TB.2 In Indonesia, the or requires a permanent change in MDR TB treatment;
number of confirmed cases of MDR TB discovery was mixture of two or more MDR drugs. This study was
likely to increase from 2009 to 2015.3 The spread of MDR using secondary data (e-TB Manager) from Jakarta
TB cases is mostly found in the provinces of Jakarta, West Provincial Health Office with total 516 samples. The
Java, and East Java.3 analysis data used Chi-Square through STATA 12 software.
MDR TB takes 20-26 months of treatment, expensive This study has obtained permission from the owner of the
requires, more complex treatment, and more side effects of data Jakarta Provincial Health Office) with letter number
drug sensitive TB, making it difficult to be controlled.1 The 1713/SDK/XI/2017. In addition, this study also has passed
bmain factor in TB treatment failure was treatment ethical approval from Ethical Committee of Public Health
termination before the trial period was completed; it’s called Faculty, Universitas Indonesia Reg number: 08/UN2.F10/
as Drop Out (DO) cases.4 DO is a condition of patients PPM.00.02/2018. Name of respondents/patients withheld
who have been treated and drop out from treatment for by using ID for privacy of respondents.
2 consecutive months or more.1
In Indonesia, the rate of DO among patients with drug
resistant TB in 2009 was 10.7%. Unfortunately, this number RESULT AND DISCUSSION
increased in 2013 to 28.7%.5 DO rates among TB patients
exceeding 10% can result in a high proportion of future re- Firstly, the total of eligible sample who include in this
treatment cases.4 study was 602 samples. Then, there were 86 samples have
In Jakarta Province, the number of drug resistant TB been excluded which was consist of 71 of patients died and
patients based on e-TB Manager surveillance data in 15 of failed treatment. So, the percentage of participant
Jakarta Provincial Health Office 2011-2016 was tended to rate was 85.7%. Table 1 was showed the percentage of
increase. While the rate of DO among drug resistant TB multidrugs tuberculosis patients in this study.
patients from 2011 to 2016 was very volatile, but the DO Table 1 was showed the results of this study indicated
number of drug resistant TB patients was always more than the prevalence of DO among patients with MDR TB at DKI
10% annually. The latest data of 2016 contained 367 drug Jakarta Province in 2011-2015 was 44.6%.
resistant TB patients and 78 patients (21.2%) were DO. The Figure 1 was described about the prevalence of MDR
purpose of this study was to analyze the determinant factors TB patients at DKI Jakarta Province in 2011-2015 increased
of Drop Out (DO) among MDR TB patients in Jakarta from 2011 to 2014, then it was decreased by 2015 to
Province between 2011 to 2015. 24.6%. While the prevalence of MDR TB patients at DKI
Jakarta Province in 2011-2015 tends to increased and >10%
each year. The highest prevalence of DO occured in 2015
MATERIAL AND METHOD (53.50%) and the lowest in 2011 (16.7%).

The design study was an observational

cross sectional quantitative study. Independent Table 1. Description of prevalence of DO among MDR
TB Patients
variables include predisposing factors (age, sex,
and HIV status), and enabling factors (duration of Patient Status N %
treatment, adherence, previous TB treatment history, and Not DO (Recover and 286 55.4
number of drugs resistances). Dependent variable was DO Treatment Complete)
among MDR TB patients. The definition of DO in this study DO 230 44.6
was MDR TB patients who didn’t come for treatment and Total 516 100
Farihatun dan Bungsu: Determinant Factors of Drop Out (DO) 89

33.7%.11
The high prevalence rate of DO which find in this
study can be attributed to the limitations of this study. In
this study, a considerable number of patients couldn’t be
included in the study because they did not met the inclusion
criteria and the exclusion criteria, so the proportion of
MDR TB patients at DKI Jakarta Province in 2011-2015
was high.
Table 2 was showed correlation between predisposing
factors and DO among MDR TB patients. The results
showed that the age group of 45-64 years had significant
association with DO of MDR TB patients with p = 0.042
and DO risk in MDR TB patients increased with age of
MDR TB patients. While gender and HIV status had no
significant relationship with DO among MDR TB patients.
Figure 1. Trend of prevalence of DO among MDR
TB Patients
This study is in line with Lalor’s research, et al. in 2013
that indicating an association between age and incidence
of DO in patients with MDR TB (P value 0.022), which
In some previous studies, the prevalence of DO among patients aged >45 years had a risk of 1.71 (95% CI: 1.07-
MDR TB patients was lower than the prevalence of DO 2.73) for experienced DO compared to patients aged ≤45
obtained in this study (44.6%) (Figure 1).6 The prevalence years of MDR.9 Other previous study was showed that
of MDR TB patients with DO in previous studies in age had an effect on decreasing the success of MDR TB
Russia was showed 12% prevalence of DO MDR TB treatment and was statistically significant (OR = 0.955;
patients.6 Studies which conducted in Lima City, Peru 95% CI = 0.921-0.991; p = 0.014).12 The older age of
showed as much as 10%.7 Studies which conducted in MDR TB sufferers were more likely to have a risk of drop
KwaZulu-Natal, South Africa showed the prevalence of out or have a tendency to experience irregularity in taking
DO in patients with MDR by 21%.8 A study in Uzbekistan medication because the older age needs additional support
which showed a large prevalence of DO in patients with to access TB treatment.13
MDR TB by 20%.9 It was indicated that the prevalence The proportion of sex-based DOs is more prevalent in
of DO in MDR TB patients might be influenced by males than in females. However, they did not show much
other factors such as geography, environmental, and different proportions. The statistical test was showed no
behavioral variations.9 significant relationship between male and female. It was
From previous similar studies in Indonesia, the findings found that men had a risk of DO 1.151 times (95% CI:
of prevalence results in this study reached 41.1% higher 0.715-1.852) than women. Previous studies was showed
than previous studies.10 A study that has been done at that sex were not statistically correlated with DO among
Persahabatan Hospital in 2010 was showed the prevalence MDR TB patients with OR values of 1.6 (95% CI: 0.8-
of DO in patients with MDR TB was 34.5%.10 In Githrif’s 3.0).7,14 In addition, studies were also showed that there
study (2016) was mentioned that the prevalence of DO was no significant association between gender and DO
in patients with MDR TB at Gresik in 2011-2015 was

Table 2. The Correlation between predisposing factors and DO among MDR TB patients

Patient Status
Variable Predisposing Factors Not DO Not DO PR (CI 95%) P Value
N (%) N (%)
Age (Years)
15-24 23 (69.7%) 10 (30.3%) Ref Ref
25-44 105 (63.6%) 60 (36.4%) 1.314 (0.586 – 2.947) 0.507
45-64 46 (48.9%) 48 (51.1%) 2.4 (1.031 – 5.589) 0.042*
> 64 4 (40%) 6 (60%) 3.45 (0.96 – 14.958) 0.098
Gender
Female 69 (61.1%) 44 (38.9%) 1.151 (0.715 – 1.852) 0.646
Male 109 (57.7%) 80 (42.3%)
HIV status
Negative 134 (56.8%) 102 (43.2%) Ref Ref
Positive 4 (80%) 1 (20%) 0.328 (0.036 – 2.983) 0.323
Unknown 40 (65.6%) 21 (34.4%) 0.69 (0.383 – 1.241) 0.215
90 Indonesian Journal of Tropical and Infectious Disease, Vol. 7 No. 3 September–December 2018: 87–92

incidence in MDR TB patients, it was found that male MDR was done in South Africa which had a high prevalence of
TB patients had a risk of 1.4 times (95% CI: 0.96-2.05) to HIV cases. The absence of any association in this study can
have DO compared with female MDR TB patients (p value occur due to the large number of MDR TB patients whose
0.083).9 Regarding to the research from Indonesia, this HIV status is unknown. In addition, data on TB-HIV co-
study is in line with several previous which were research infection may also have unreported data on e-TB Manager
which were that showed there was no sex relationship so that the proportion of HIV-positive TB patients was low
with the incidence of MDR patient TB patients.11,15,16 In (under reporting).
contrast, previous study is showed Brust’s research, et al. The results of sputum examination is an early indication
in 2010, a significant association between sex with DO in to be able to know the presence of BTA. The status of this
MDR TB patients, which men had 1.9 times greater risk BTA examination may reflect the extent of lesions in the
(95% CI 1.2-3.1) to have DO than women.8 Other study lung. 3+ bacilli on initial pre-treatment can be used as
was suggested that women were more likely to seek health a predictor for difficult conversion after two months of
care and tend to be more adherent to treatment with DOTS treatment. The longer the time required for conversion
compared with men (Wu et al., 2013). Different opinions will be the longer the initial treatment. This may affect the
were also obtained from studies in Africa, Bangladesh, and patient in treatment and may cause the patient to drop out
Syria which was stated that married women tend to have to (Nwokeukwu & Awujo, 2013).
ask their husbands for permission to come to health services The proportion of DO in MDR TB patients between
for TB treatment (Ibrahim et al., 2014). patients was exposed to smear positive with smear negative
The proportion of DO patients with MDR TB in patients did not show much different numbers. The proportion of
with HIV negative status was higher than the proportion DO in MDR TB patients was more prevalent in patients
of MDR patients with HIV positive status. The result of exposed to smear negative than the proportion of DO in
statistical test was showed that there was no significant smear positive patients. The result of statistical test was
relationship between HIV status and DO with MDR TB showed that patients who had sputum smear + at the
patients with p value = 1.00 (p > 0.05). The results of this beginning of treatment had a risk of having positive smear-
study were consistent with the study in Nigeria in 2011-2012 positive MDR TB patients at 0.836 (95% CI: 0.504–1.385)
which shows that HIV status has no statistically significant risk of drop out compared to negative smear-negative
association with DO in MDR TB patients. 17 Similar MDR TB patients. This study was showed similar results
research in Sagamu, Nigeria by Daniel, et al. and Hasker’s with the previous research which is showed no significant
research, et al. was showed similar results that HIV status relationship between sputum examination result and DO
had no significant relationship with the occurrence of DO incidence, the value of crude OR 1.15 (95% CI: 0.7-1.89)
in MDR TB patients.18,19 In contrast, in KwaZulu-Natal, and adjusted OR 1.02 (95% CI: 0.43-1.30) (Table 3).18 In
South Africa in 2000-2003 was showing that patients with contrast, the results of Alobu’s research, et al. was showed a
HIV-positive status (TB-HIV co-infection) have risk factors significant relationship between sputum examination results
that can increase DO of MDR TB by 2 times (95% CI: and the incidence of DO in MDR TB patients, which the
1.3-3.1). This might be happened because of the research value of crude OR 2.1 (95% CI: 1.4-3.1) and adjusted OR

Table 3. Distribution of DO among MDR TB Patients in 2011-2015 based on enabling factors

Patient Status
Variable Enabling Factors No DO DO PR (CI 95%) P Value
N (%) N(%)
Sputum test
Negatif 48 (55.8%) 38 (44.2%)
Positif 130 (60.2%) 86 (39.8%) 0.836 (0.504 – 1.385) 0.571
Type of Patient
New 3 (50%) 3 (50%) Ref Ref
Recurent 58 (58.6%) 41 (41.4%) 0.707 (0.136 – 3.679) 0.680
Defaulter 22 (55%) 18 (45%) 0.818 (0.147 – 4.557) 0.819
Failed in Category 1 41 (63.1%) 24 (36.9%) 0.585 (0.109 – 3.134) 0.532
Failed in Category 2 49 (61.2%) 31 (38.8%) 0.633 (0.12 – 3.335) 0.589
Others (Unclear) 5 (41.7%) 7 (58.3%) 1.4 (0.195 – 10.032) 0.738
Number of Previous Treatment
≤2 times of treatment 150 (60%) 100 (40%)
>2 times of treatment 28 (53.8%) 24 (46.2%) 1.286 (0.705 – 2.345) 0.506
Number of drugs
2 drugs 48 (57.8%) 35 (42.2%) Ref Ref
3 drugs 55 (55.6%) 44 (44.4%) 1.097 (0.609 – 1.977) 0.758
≥4 drugs 75 (62.5%) 45 (37.5%) 0.823 (0.465 – 1.457) 0.504
Farihatun dan Bungsu: Determinant Factors of Drop Out (DO) 91

2.3 (95% CI: 1.5–3.6).17 The others study was showed a research of Franke, et al. (2008) indicating no significant
significant relationship between sputum and DO results, but association between the number of previous treatments
the OR values which were obtained in this study resulted and the incidence of DO in MDR TB patients. Patients
in protective PR, with OR values of 0.57 (95% CI: 0.33 - with previous treatment amounts >2 treatments had a risk
0.97) and adjusted OR 0.42 (0.024 - 0.75).19 of 1.2 times (95% CI: 0.70-2.05) for dropouts compared to
The statistical results were showed that there was no patients with previous treatment ≤2 times of treatment.
relationship between the types of patients with DO among Researchers have not found previous research which
MDR TB patients. It was found that the “other” type results indicating that there was a significant relationship
(unclear history) of patient group had a risk of 1.4 times between the number of previous treatments and the
(95% CI: 0.195-10.032) for drop out compared to the new incidence of DO in MDR TB patients, but based on the
patient type group. Patients who were failed in treatment results of research Franke, et al. in 2008, the value of OR
of second category had 0.633 (95% CI: 0.12-3.335) times >1 means that the number of previous treatments is a risk
of risk to have DO compared with new patients. Patients factor for the incidence of DO in patients with MDR TB, so
who were failed at first category had 0.585 times (95% the researchers included this number of previous treatment
CI: 0.109-3.134) of risk having DO experience compared factors to be investigated as independent variables of
with new patients. Defaulter patients had a risk of 0.818 research and variables are substantially important.7
times (95% CI: 0.147-4.557) to have DO compared with The amount of OAT resistance is divided into resistant
new patients. Recurrent patients had a risk of 0.707 times to 2 drugs, 3 drugs and ≥4 drugs. The proportion of DO
(95% CI: 0.136-3.679) to have DO compared with new in patients with drug resistant MDR 3 was higher than the
patients. proportion of DO in the group of other OAT resistance
This research is in line with some previous research levels. The result of statistical test was showed that there
which indicate that the type of patient did not have statistical was no relationship between the amount of OAT resistance
correlation with DO in MDR TB patients.18,17,20 In contrast, with DO patient of MDR TB. The results of this study was
previous study Santha study, et al. (2002) and Lalor, et al. indicated that the patient group of the ≥4 drug resistance
(2013) were showed that the type of patient had a significant group had a risk of 0.823 times (95% CI: 0.465-1.457) for
association with DO in MDR TB patients. In the Santha drop out compared to the 2-drug resistance group.
study, et al (2002) were showed re-treatment patients had The researchers also have not found previous research
OR 2.5 (95% CI: 1.5-4.3) of having DO compared with which their results related to the variable amount of OAT
the new patient type and adjusted OR 2.8 times (95% CI : resistance indicating a statistically significant relationship
1.6-4.9).9,21 Research from Lalor, et al. (2013) was showed between the amount of OAT resistance and the incidence
that the type of patient defaulter had a risk of 2.10 (95% of DO in patients with MDR TB, but the researcher still
CI: 1.02-4.37) for DO compared with the new patient type incorporates this amount of OAT resistance factor to be
and adjusted OR 2.38 (95% CI: 1.09-5.24), patients failed studied as an important independent variable of research.
in category 2 had a risk of 0.57 times (95% CI: 0.35 to From the results of this study it is known that the number
0.93) to have DO compared with the new patient type and of drug resistance has a risk of 1.097 times (95% CI: 0.609-
adjusted OR 0.85 (95% CI: 0.49-1.49). 1.977) for drop out compared to the 2-drug resistance
The proportion of DO patients with MDR TB in patients group.
in the previous treatment group group was >2 times more
than patients with previous treatment amount ≤2 times.
The results of statistical tests showed that there was no CONCLUSION
statistically significant relationship between the amount of
previous treatment with DO in MDR TB patients. It was Determinant factors that associated with DO in MDR
found that patients with previous treatment >times had a TB patients in DKI Jakarta Province 2011-2015 is aged 45-
risk of 1.286 (95% CI: 0.705-2.345) for drop out compared 64 years old. While the others variables are not proved by
to patients with previous treatment ≤2 times. statistically to have association with DO among MDR TB
In fact, most MDR TB patients in Indonesia are patients in this study. The age group that significantly associated
with a history of previous TB treatment. Treatment which with the incidence of DO in MDR TB patients was 45-64
performed previously treated petients with first-line OAT, years who had a risk of 2.4 times (95% CI: 1.031-5.589)
requires treatment with second-line OAT, where second- for DO compared to the 15-24 age group.
line OAT is more complicated in its management, and
second-line OATs have more and more severe side effects
than first-line OAT, thus allowing MDR TB patients to ACKNOWLEDGEMENT
drop out.1
This study was showed similar results with previous The authors thank to Jakarta Province Health Office
study which was showed there was no relationship between especially Vector and Zoonotic Contagious Diseases
the number of previous treatments and the incidence of Section, Diseases Control and Prevention Department who
DO (p value = 1.0).20 This study is also in line with the gave us permission for using TB surveillance data.
92 Indonesian Journal of Tropical and Infectious Disease, Vol. 7 No. 3 September–December 2018: 87–92

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