Research

1. STUDY OF FACTORS PREDISPOSING TO TB DRUG
RESISTANCE IN
LONDIANI SUB COUNTY HOSPITAL
BY
BARNABAS KIPNGETICH CHEPKWONY
ADM NO: BCM/K/0540/2019
A DISSERTATION SUBMITTED TO UNIVERSITY OF
KABIANGA IN PARTIAL FULFILLMENT FOR THE
AWARD OF A DEGREE IN CLINICAL MEDICINE AND
SURGERY
SUPERVISOR
MR.JOSEPH NYARIKI

2.  Abstract
 Tuberculosis (TB) is an infectious disease caused by strains belonging to the Mycobacterium
tuberculosis complex. Multidrug resistant TB (MDR TB), defined as resistance to at least
isoniazid and rifampicin, has been spreading rapidly in recent years. In 2012, 3.6% of newly
diagnosed and 20% of retreatment cases were estimated to have MDR TB globally with
noticeable geographical variations in prevalence. Various reports demonstrated that, in
Africa, resistance to one or more anti-TB and MDR-TB ranges from 3% to 37.3% and 1.4%
to 11.6%, respectively.
 The importance of doing this study is that tuberculosis has proven to be a burden globally
and locally as a total of 1.5 million people died from TB in 2020 (including 214 000 people
with HIV). Worldwide, TB is the 13th leading cause of death and the second leading
infectious killer after COVID-19 (above HIV/AIDS). In 2020, an estimated 10 million
people fell ill with tuberculosis (TB) worldwide. 5.6 million Men, 3.3 million women and
1.1 million children. TB is present in all countries and age groups. But TB is curable and
preventable. In 2020, 1.1 million children fell ill with TB globally. Child and adolescent TB
is often overlooked by health providers and can be difficult to diagnose and treat. In 2020,
the 30 high TB burden countries accounted for 86% of new TB cases. Eight countries
account for two thirds of the total, with India leading the count, followed by China,
Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa. Multidrug-
resistant TB (MDR-TB) remains a public health crisis and a health security threat. Only
about one in three people with drug resistant TB accessed treatment in 2020. Globally, TB
incidence is falling at about 2% per year and between 2015 and 2020 the cumulative
reduction was 11%. This was over half way to the End TB Strategy milestone of 20%
reduction between 2015 and 2020. An estimated 66 million lives were saved through TB
diagnosis and treatment between 2000 and 2020. Globally, close to one in two TB-affected
households face costs higher than 20% of their household income, according to latest
national TB patient cost survey data. The world did not reach the milestone of 0% TB
patients and their households facing catastrophic costs as a result of TB disease by 2020.

3.  The justification for conducting this study is
prompted by the fact that new report warns that
some of the incremental progress made in the global
fight against tuberculosis (TB) could be lost with the
emergence and spread of drug-resistant strains of the
disease.
 The primary research method in this study is cross
sectional descriptive design, where factors
predisposing to TB drug resistance will be identified
and classified through a structured approach. This
study will first review various types of factors and
based on this method,a classification method will be
developed to categorize.

4. CHAPTER ONE
INTRODUCTION
 1.1 Background information
 Tuberculosis, commonly abbreviated as TB is a contagious disease that spreads as
a droplet infection. It is the leading death of young adults worldwide. Each year, 8
million people develop active TB and 3 million die. The largest number of cases in
South Africa, Asia region, which accounts for 33% of incident cases globally.
Overall, one–third of the world’s population is currently infected with the TB
bacilli every second.
 Mayo (2011), suggests that tuberculosis can result from a variety of causes
including bacteria that spread from person to person through microscopic droplets
released into the air. This can happen when someone with the untreated, active
forms of tuberculosis, coughs, speaks, sneezes, spits, laughs or sings. Another
cause is co-infection of HIV/AIDS which suppresses the immune system making it
difficult for the body to control the TB bacteria.Drug-resistant TB (DR-TB)
emerges when an anti-biotic fails to kill all of the bacteria it targets. The general
symptoms of TB include feeling of sickness or weakness, weight loss, fever and
night sweats. The symptoms of TB disease of the lungs may also include coughing,
chest pain, and coughing up blood. Symptoms of TB disease in other parts of the
body depend on the areas affected. (Carvalhoet al., 2008) also shows that the
Russian Federation is eleventh among the 22 high-burden TB countries. The
estimated detection rate of new sputum smear positive pulmonary cases and the
treatment success rate in 2007 were poor compared with other WHO regions. 51
percent of cases were diagnosed and 70 percent of them completed a full course of
anti-TB therapy. The low success rate is largely attributed to the increasing of drug
resistant TB cases.

5.  1.2 Statement of the problem
 . A total of 1.5 million people died from TB in 2020
(including 214 000 people with HIV). Worldwide, TB
is the 13th leading cause of death and the second
leading infectious killer after COVID-19 (above
HIV/AIDS).In 2020, an estimated 10 million people
fell ill with tuberculosis (TB) worldwide. 5.6 million
Men, 3.3 million women and 1.1 million children.
TB is present in all countries and age groups. But TB
is curable and preventable. 1.1 million Children fell
ill with TB globally. Child and adolescent TB is often
overlooked by health providers and can be difficult
to diagnose and treat.Multidrug-resistant TB (MDR-
TB) remains a public health crisis and a health
security threat. Only about one in three people with
drug resistant TB accessed treatment in 2020.

6.  1.3 Study justification
 1.3.1 Practical significance
 The study findings will equip the researcher with practical
experience, knowledge and skills in the area of research so that the
researcher can be able to conduct and offer
 The study findings will help the government of Kenya to have a clear
picture on why some tuberculosis patients resist to tuberculosis
drugs and make the necessary changes to the problems and assist
in health problem.
 1.3.2 Theoretical significance
 The study findings will provide background information to students
who will be conducting the same investigation and will form part or
they will use it for references.
 After my research, the document will be an important source of
information to the library of the university of kabianga.
 1.4Study objectives
 1.4.1 Broad objective
 To determine factors predisposing to TB drug resistance.
 1.4.2Specific objective
 To determine socio-demographic of TB patients.
 To determine the knowledge of TB patients on the importance of
completing tuberculosis drug dosage.
 To find out the relationship that exists in DR-TB patients infected
with other ill-related conditions.

7.  1.5 Study question
 How factors contributing to TB drug resistance
impacts on routine treatment of the patient?
 1.6 Limitation of the study
 The study will include only those patients who
have given consent to be interviewed.
 1.7 Delimitation of the study
 The study will be based among TB patients
attending Londiani Sub County Hospital

8. CHAPTER TWO
LITERATURE REVIEW
 2.1 Socio-demographic characteristics
 According to (Ogboi et al, 2010), TB is one of the killer
diseases of great antiquity especially in developing
countries and contributes significantly to health
instability and economic loss. The Directly Observed
Treatment (DOTs) course is the recommended standard
of care in treatment of TB worldwide. In a study aimed at
examining the social-demographic characteristics of
patients present at primary health care centre, the
records of all TB patients seen at SablonGari
Comprehensive Health Center Zaria, Kaduna state
Nigeria between May 2005-2006 were scrutinized and
reviewed. The main variables studied were age,
education, occupational and unemployment status. A
total of 694 case records were reviewed comprising of
58.4% of males and 41.6% of females with a mean age of
32.78 years (±) 15.10. The proportion of sputum smear
positive samples was 12% with high preponderance of
smear positive cases in the age group 20-29 years.

9.  There was a relationship between sputum positive, unemployment, education and
occupation status. More significantly, there was need for the National TB and Leprosy
control programme to take cognizance of social-demographic factors in designing
efficientTB Control Programe in Nigeria.Another study that was conducted in Peru as
well showed that more than half of the patients 60.8% were male and the mean age was
31.4 years. (Ministerioet al, 2006). (Thiamet al,2007), demonstrates in their study that
women had higher rate of death following default than men. This finding was consistent
with previous work in Peru by (Mitnicket al, 2003) and other studies from resource-
poor setting. In addition(Holmes et al, 1998), in a review of sex differences in the
epidemiology of TB that indicate women are more likely than men to experience poor
TB treatment outcomes. The association between female gender and death following
default was alternated when there was control for poor bacteriologic response at time of
default; less than one year of initiated
 2.2 Knowledge of patients on the importance of completing drug dosage
 A treatment interruption is defined as any time that a patient misses a prescribed dose of
MDR-TB treatment for at least 1 day but for a period of less than 2 consecutive months.
Using MDR-TB category IV treatment cards, data on whether or not a patient took the
dose for each day of treatment was abstracted by a trained data abstractor and recorded
onto standardized forms designed for the study. Each patient therefore contributed a
trajectory of time for the entire treatment course, with dates demarking time periods for
when the patient missed doses (treatment interruptions) and those when the patient was
on treatment between interruptions (time on treatment).

10.  2.3 Relationship between DR-TB and other ill-related
conditions
 According toDe et al, (2011), there have been times
when the high incidence of tuberculosis in mental illness
was interpreted to mean that perhaps tuberculosis may
cause mental illness or that mental illness forms a
strong predisposition to tuberculosis. Sarturiuset
al,(2007), said that the literature suggests the mutual
influence and relationship between physical and mental
illness, and many studies report the nature and
prevalence of co-morbid physical illness with severe
mental disorders. Research in this direction is mainly
concerned with studying physical morbidity among
psychiatrically ill individuals but studies to delineate
psychiatric profile of physically ill persons have also
received attention. The causal relationships between
mental disorders and tuberculosis are complex. Severe
mental disorders are associated with high risk of
tuberculosis acquisition and transmission and with
poorer adherence to anti-TB treatment. Conversely,
diagnosis with tuberculosis increases risk of psychiatric
co morbidity(Raviglioneet al, 2006).

11. CHAPTER THREE
RESEARCH METHODOLOGY
 3.1 Research design
 A cross-sectional descriptive study will be used to determine how drug
resistance affects the TB treatment among patients attending londiani sub
county hospital.
 3.2Study variables
 3.2.1 Independent variables
 Gender
 Age
 Marital status
 Factors affecting TB treatment
 3.2.2 Dependent variables
 Drug resistance
 3.3 Criteria for selection
 3.3.1 Inclusion criteria
 The study will include all those patients who attend TB clinic and who will
give consent to be interviewed.
 3.3.2 Exclusion criteria
 The study will exclude those patients who attend TB clinic and has not given
consent to be interviewed.
 3.4Study site
 The study will be conducted at londiani sub county referral hospital in
Kericho County

12.  3.5Target population
 The study targeted TB patients who attends londiani sub county Hospital during the
study period.
 3.6 Sampling procedure
 The researcher will use a simple random-sampling method to get the sample size from
the available respondents.
 3.7 Sample size determination
 The desired sample size (nf) was thus estimated to be 155 respondents.
 3.8 Data collection instruments
 A structured questionnaire will be used to collect data on the study of drug resistant as a
factor affecting treatment of TB from each respondent / patients
 3.9 Data analysis and presentation
 The collected data will be analyzed using calculator and computer package that is Ms-
excel.Data was presented in frequency tables, charts and graphs and percentages were
used for interpretation purposes.
 3.9.1Ethical consideration
 Confidentiality will be assured to the respondents verbally by the researcher and
permission to conduct the study will be obtained from the Ministry from the ministry of
health through the medical superintendent londiani sub county hospital. A letter of
approval will be used for introduction purpose and permission will be obtained obtained
from the Medical superintendent, londiani sub county hospital.

13. REFERENCES
i. Alisjahbana, B., Sahiratmadja, E., Nelwan, E.J.,
Purva, A.M., Ahmed, Y., OttenhoffTH,et al. The
effects of type 2 diabetes mellitus in the
presentation and treatment response of PTB. Clin.
Infect. Dis., 2007,45:428-435.
ii. Bang, D., Andersen, P.H., Andersen, A.B.,
Thomsen, V., Isonized resistant tuberculosis in
Denmark; Mutations, transmission, and treatment
outcome. J. Infect., 2010,60:452-457.
iii. Chanda, M., Mwakazanga, D., Vereecken, K.,
Khondowe, S., Kapata, N., Shamputa, I., Herman,
and Leen Rigouts: Tropical Diseases Research
Centre, Biomedical Sciences Department,
iv. Churchill Davidson, (2008).Medical Dictionary 16th
edition.
v. Churchill, Livingstone Dictionary. (2008). 16th
edition.

14.  APPENDICES
 Appendix I: A sample of the questionnaire used in the study
 Questionnaire No. …………………
 Date of interview……………………
 Instructions
 Answer the questions below by ticking in the boxes provided.
 Do not write your name on the paper.
 Use a pencil to tick the appropriate answer in the boxes.
 Read the questions carefully before answering.
 SECTION A
 1. How old are you?
 20-24 [ ]
 25-29 [ ]
 30-34 [ ]
 35-39 [ ]
 40-44 [ ]
 45+ [ ]
 2. Gender
 Male [ ] b) Female [ ]
 3. What is your religion?
 Catholic [ ]
 Protestant [ ]
 Muslim [ ]
 Others (specify)…………………………………………………………………
 4. What is your level of education?
 Primary [ ]
 Secondary [ ]
 College/Tertiary [ ]
 Others (specify)..........................................................................................................
 5. What do you do for a living?

15.  Skilled labor [ ]
 Self-employed [ ]
 Casual [ ]
 None [ ]
 Others (specify)………………………………………………………………………
 6. What is your current marital status?
 Single [ ]
 Married [ ]
 Divorced [ ]
 Separated [ ]

 SECTION B
 7. Where do you live?................................................................................................................
 8. Which type of house do you live in?
 Temporary house [ ]
 Permanent house [ ]
 Semi-permanent house [ ]
 Others (specify)………………………………………………………………………...
 9. How big is your house?
 Single-room [ ]
 Double-room [ ]
 Two-bedroom [ ]
 Others (specify)…………………………………………………………………
 10. What is your range of earning in Ksh.?
 1,000-3,000 [ ]
 3,001-5,000 [ ]
 5,001-9,000 [ ]
 Above 9,000 [ ]
 11. Do you know the importance of nutrition while on TB treatment?

16.  It boosts the immunity of the body. [ ]
 It prevents one from being malnourished [ ]
 It reduces the risk of re-infection [ ]
 Others (specify)…………………………………………………………………...

 SECTION C
 12. Have you ever heard of the disease known as TB?
 Yes [ ] b) No [ ]
 13. If yes from where?
 Hospital [ ]
 Church [ ]
 Chief Camp [ ]
 Others specify………………………………………………..
 14. Did you ever suspect that you have TB?
 Yes [ ] b) No [ ]
 15. If yes, what were the signs and symptoms?
 ……………………………………………………………………………………………………...................................
..............................................................................................................
 ………………………………………………………………
 16. If No why?
 …………………………………………………………………………………………………………………………………
………………………………………………………………….
 17. Do you know how TB is transmitted?
 ……………………………………………................................................................................
 18. Have you ever heard of the word drug resistance?
 Yes [ ]
 No [ ]
 19. If yes in (5) above from where did you get the information?
 Hospital [ ]
 Media or Television [ ]

17.  Church [ ]
 Friends/relatives [ ]
 Others (specify)………………………………………………………………
 20. Do you know some of the causes of TB drug resistance?
 ………………………………………………………………………………………………
 ………………………………………………………………………………………………
 21.Do you know the importance of completing TB treatment?
 ……………………………………………………………………………………………
 SECTION D
 22. Apart from TB which other condition do you suffer from?
 …………………………………………………………………………………………………
…………………………………………………………………………………………………
 23. Which condition came first?
 TB [ ]
 The one mentioned above
 …………………………………………………………………………………………………
 24. What did you do when you suspected that you have TB?
 …………………………………………………………………………………………………
 …………………………………………………………………………………………………

18. APPENDIX 2.
TIME FRAME/DURATION OF THE PROJECT
APPENDIX3.
BUDGET
Pilot study one week from June 1st-7th 2022
Data analysis one month from July 1st -30th 2022
Report preparation one month from raugust1st-30th 202
Item cost
Transport 6000
Lunch 1500
Stationary 2000
Total 9500

19. Thank You for
your
cooperation.