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  1. Loganathan T, Mohamed PY
    Med J Malaysia, 2018 10;73(5):340-341.
    PMID: 30350821 MyJurnal
    In November 2016, a 28-year-old Malay man presented to the emergency department in respiratory distress, with a history of fever and sore throat. A clinical diagnosis of acute diphtheria was made and the patient was isolated and ventilated in the intensive care unit, and received diphtheria antitoxin and intravenous antibiotics. Initial laboratory findings failed to confirm diphtheria, leading to discontinuation of antibiotics and quarantine. Public health measures were reinstated after a reference laboratory cultured Corynebacterium diphtheriae. Although there was no contact with ill persons, investigation revealed incomplete immunisation history, and injection of high dose steroids prior to onset of symptoms.
  2. Loganathan T, Chan ZX, Pocock NS
    PLoS One, 2020;15(12):e0243629.
    PMID: 33296436 DOI: 10.1371/journal.pone.0243629
    BACKGROUND: For Malaysia, a nation highly dependent on migrant labour, the large non-citizen workforce presents a unique health system challenge. Although documented migrant workers are covered by mandatory healthcare insurance (SPIKPA), financial constraints remain a major barrier for non-citizen healthcare access. Malaysia recently extended protection for migrant workers under the national social security scheme (SOCSO), previously exclusive to citizens. This study aims to evaluate healthcare financing and social security policies for migrant workers to identify policy gaps and opportunities for intervention.

    METHODS: A total of 37 in-depth interviews were conducted of 44 stakeholders from July 2018 to July 2019. A mixed-methods analysis combining major themes from qualitative interviews with policy document reviews was conducted. Descriptive analysis of publicly available secondary data, namely revenues collected at government healthcare facilities, was conducted to contextualise the policy review and qualitative findings.

    RESULTS: We found that migrant workers and employers were unaware of SPIKPA enrolment and entitlements. Higher fees for non-citizens result in delayed care-seeking. While the Malaysian government nearly doubled non-citizen healthcare fees revenues from RM 104 to 182 million (USD 26 to 45 million) between 2014 to 2018, outstanding revenues tripled from RM 16 to 50 million (USD 4 to 12 million) in the same period. SPIKPA coverage is likely inadequate in providing financial risk protection to migrant workers, especially with increased non-citizens fees at public hospitals. Undocumented workers and other migrant populations excluded from SPIKPA contribution to unpaid fees revenues are unknown. Problems described with the previous Foreign Workers Compensation Scheme (FWCS), could be partially addressed by SOCSO, in theory. Nevertheless, questions remain on the feasibility of implementing elements of SOCSO, such as recurring payments to workers and next-of-kin overseas.

    CONCLUSION: Malaysia is moving towards migrant inclusion with the provision of SOCSO for documented migrant workers, but more needs to be done. Here we suggest the expansion of the SPIKPA insurance scheme to include all migrant populations, while broadening its scope towards more comprehensive coverage, including essential primary care.

  3. Loganathan T, Rui D, Pocock NS
    BMJ Open, 2020 Dec 02;10(12):e039800.
    PMID: 33268413 DOI: 10.1136/bmjopen-2020-039800
    OBJECTIVES: This paper explores policies addressing migrant worker's health and barriers to healthcare access in two middle-income, destination countries in Asia with cross-border migration to Yunnan province, China and international migration to Malaysia.

    DESIGN: Qualitative interviews were conducted in Rui Li City and Tenchong County in Yunnan Province, China (n=23) and Kuala Lumpur, Malaysia (n=44), along with review of policy documents. Data were thematically analysed.

    PARTICIPANTS: Participants were migrant workers and key stakeholders with expertise in migrant issues including representatives from international organisations, local civil society organisations, government agencies, medical professionals, academia and trade unions.

    RESULTS: Migrant health policies at destination countries were predominantly protectionist, concerned with preventing transmission of communicable disease and the excessive burden on health systems. In China, foreign wives were entitled to state-provided maternal health services while female migrant workers had to pay out-of-pocket and often returned to Myanmar for deliveries. In Malaysia, immigration policies prohibit migrant workers from pregnancy, however, women do deliver at healthcare facilities. Mandatory HIV testing was imposed on migrants in both countries, where it was unclear whether and how informed consent was obtained from migrants. Migrants who did not pass mandatory health screenings in Malaysia would runaway rather than be deported and become undocumented in the process. Excessive attention on migrant workers with communicable disease control campaigns in China resulted in inadvertent stigmatisation. Language and financial barriers frustrated access to care in both countries. Reported conditions of overcrowding and inadequate healthcare access at immigration detention centres raise public health concern.

    CONCLUSIONS: This study's findings inform suggestions to mainstream the protection of migrant workers' health within national health policies in two middle-income destination countries, to ensure that health systems are responsive to migrants' needs as well as to strengthen bilateral and regional cooperation towards ensuring better migration management.

  4. Loganathan T, Lee WS, Lee KF, Jit M, Ng CW
    PLoS One, 2015;10(5):e0125878.
    PMID: 25941805 DOI: 10.1371/journal.pone.0125878
    While healthcare costs for rotavirus gastroenteritis requiring hospitalization may be burdensome on households in Malaysia, exploration on the distribution and catastrophic impact of these expenses on households are lacking.
  5. Loganathan T, Chan ZX, de Smalen AW, Pocock NS
    PMID: 32722563 DOI: 10.3390/ijerph17155376
    Providing sexual and reproductive health (SRH) services to migrant workers is key to fulfilling sustainable developmental goals. This study aims to explore key informants' views on the provision of SRH services for migrant women in Malaysia, exploring the provision of SRH education, contraception, abortion, antenatal and delivery, as well as the management of gender-based violence. In-depth interviews of 44 stakeholders were conducted from July 2018 to July 2019. Data were thematically analysed. Migrant workers that fall pregnant are unable to work legally and are subject to deportation. Despite this, we found that insufficient SRH information and contraceptive access are provided, as these are seen to encourage promiscuity. Pregnancy, rather than sexually transmitted infection prevention, is a core concern among migrant women, the latter of which is not adequately addressed by private providers. Abortions are often seen as the only option for pregnant migrants. Unsafe abortions occur which are linked to financial constraints and cultural disapproval, despite surgical abortions being legal in Malaysia. Pregnant migrants often delay care-seeking, and this may explain poor obstetric outcomes. Although health facilities for gender-based violence are available, non-citizen women face additional barriers in terms of discrimination and scrutiny by authorities. Migrant women face extremely limited options for SRH services in Malaysia and these should be expanded.
  6. Loganathan T, Ng CW, Lee WS, Jit M
    Pediatr Infect Dis J, 2016 06;35(6):601-6.
    PMID: 27008464 DOI: 10.1097/INF.0000000000001129
    BACKGROUND: Rotavirus gastroenteritis (RVGE) results in substantial mortality and morbidity worldwide. However, an accurate estimation of the health and economic burden of RVGE in Malaysia covering public, private and home treatment is lacking.

    METHODS: Data from multiple sources were used to estimate diarrheal mortality and morbidity according to health service utilization. The proportion of this burden attributable to rotavirus was estimated from a community-based study and a meta-analysis we conducted of primary hospital-based studies. Rotavirus incidence was determined by multiplying acute gastroenteritis incidence with estimates of the proportion of gastroenteritis attributable to rotavirus. The economic burden of rotavirus disease was estimated from the health systems and societal perspective.

    RESULTS: Annually, rotavirus results in 27 deaths, 31,000 hospitalizations, 41,000 outpatient visits and 145,000 episodes of home-treated gastroenteritis in Malaysia. We estimate an annual rotavirus incidence of 1 death per 100,000 children and 12 hospitalizations, 16 outpatient clinic visits and 57 home-treated episodes per 1000 children under-5 years. Annually, RVGE is estimated to cost US$ 34 million to the healthcare provider and US$ 50 million to society. Productivity loss contributes almost a third of costs to society. Publicly, privately and home-treated episodes consist of 52%, 27% and 21%, respectively, of the total societal costs.

    CONCLUSIONS: RVGE represents a considerable health and economic burden in Malaysia. Much of the burden lies in privately or home-treated episodes and is poorly captured in previous studies. This study provides vital information for future evaluation of cost-effectiveness, which are necessary for policy-making regarding universal vaccination.

  7. Loganathan T, Rui D, Ng CW, Pocock NS
    PLoS One, 2019;14(7):e0218669.
    PMID: 31269052 DOI: 10.1371/journal.pone.0218669
    BACKGROUND: Malaysia is widely credited to have achieved universal health coverage for citizens. However, the accessibility of healthcare services to migrant workers is questionable. Recently, medical fees for foreigners at public facilities were substantially increased. Mandatory health insurance only covers public hospital admissions and excludes undocumented migrants. This study explores barriers to healthcare access faced by documented and undocumented migrant workers in Malaysia.

    METHODS: We use qualitative data from 17 in-depth interviews conducted with key informants from civil society organisations, trade unions, academia, medical professionals, as well as migrant workers and their representatives. We interviewed doctors working in public hospitals and private clinics frequented by migrants. Data were analysed using thematic analysis.

    RESULTS: We found that healthcare services in Malaysia are often inaccessible to migrant workers. Complex access barriers were identified, many beyond the control of the health sector. Major themes include affordability and financial constraints, the need for legal documents like valid passports and work permits, language barriers, discrimination and xenophobia, physical inaccessibility and employer-related barriers. Our study suggests that government mandated insurance for migrant workers is insufficient in view of the recent increase in medical fees. The perceived close working relationship between the ministries of health and immigration effectively excludes undocumented migrants from access to public healthcare facilities. Language barriers may affect the quality of care received by migrant workers, by inadvertently resulting in medical errors, while preventing them from giving truly informed consent.

    CONCLUSIONS: We propose instituting migrant-friendly health services at public facilities. We also suggest implementing a comprehensive health insurance to enable healthcare access and financial risk protection for all migrant workers. Non-health sector solutions include the formation of a multi-stakeholder migration management body towards a comprehensive national policy on labour migration which includes health.

  8. de Smalen AW, Chan ZX, Abreu Lopes C, Vanore M, Loganathan T, Pocock NS
    BMJ Open, 2021 01 18;11(1):e041379.
    PMID: 33462099 DOI: 10.1136/bmjopen-2020-041379
    BACKGROUND: A large number of international migrants in Malaysia face challenges in obtaining good health, the extent of which is still relatively unknown. This study aims to map the existing academic literature on migrant health in Malaysia and to provide an overview of the topical coverage, quality and level of evidence of these scientific studies.

    METHODS: A scoping review was conducted using six databases, including Econlit, Embase, Global Health, Medline, PsycINFO and Social Policy and Practice. Studies were eligible for inclusion if they were conducted in Malaysia, peer-reviewed, focused on a health dimension according to the Bay Area Regional Health Inequities Initiative (BARHII) framework, and targeted the vulnerable international migrant population. Data were extracted by using the BARHII framework and a newly developed decision tree to identify the type of study design and corresponding level of evidence. Modified Joanna Briggs Institute checklists were used to assess study quality, and a multiple-correspondence analysis (MCA) was conducted to identify associations between different variables.

    RESULTS: 67 publications met the selection criteria and were included in the study. The majority (n=41) of studies included foreign workers. Over two-thirds (n=46) focused on disease and injury, and a similar number (n=46) had descriptive designs. The average quality of the papers was low, yet quality differed significantly among them. The MCA showed that high-quality studies were mostly qualitative designs that included refugees and focused on living conditions, while prevalence and analytical cross-sectional studies were mostly of low quality.

    CONCLUSION: This study provides an overview of the scientific literature on migrant health in Malaysia published between 1965 and 2019. In general, the quality of these studies is low, and various health dimensions have not been thoroughly researched. Therefore, researchers should address these issues to improve the evidence base to support policy-makers with high-quality evidence for decision-making.

  9. Loganathan T, Jit M, Hutubessy R, Ng CW, Lee WS, Verguet S
    Trop Med Int Health, 2016 Nov;21(11):1458-1467.
    PMID: 27503549 DOI: 10.1111/tmi.12766
    OBJECTIVES: To evaluate rotavirus vaccination in Malaysia from the household's perspective. The extended cost-effectiveness analysis (ECEA) framework quantifies the broader value of universal vaccination starting with non-health benefits such as financial risk protection and equity. These dimensions better enable decision-makers to evaluate policy on the public finance of health programmes.

    METHODS: The incidence, health service utilisation and household expenditure related to rotavirus gastroenteritis according to national income quintiles were obtained from local data sources. Multiple birth cohorts were distributed into income quintiles and followed from birth over the first five years of life in a multicohort, static model.

    RESULTS: We found that the rich pay more out of pocket (OOP) than the poor, as the rich use more expensive private care. OOP payments among the poorest although small are high as a proportion of household income. Rotavirus vaccination results in substantial reduction in rotavirus episodes and expenditure and provides financial risk protection to all income groups. Poverty reduction benefits are concentrated amongst the poorest two income quintiles.

    CONCLUSION: We propose that universal vaccination complements health financing reforms in strengthening Universal Health Coverage (UHC). ECEA provides an important tool to understand the implications of vaccination for UHC, beyond traditional considerations of economic efficiency.

  10. Pocock NS, Chan Z, Loganathan T, Suphanchaimat R, Kosiyaporn H, Allotey P, et al.
    PLoS One, 2020;15(4):e0231154.
    PMID: 32251431 DOI: 10.1371/journal.pone.0231154
    BACKGROUND: Cultural competency describes interventions that aim to improve accessibility and effectiveness of health services for people from ethnic minority backgrounds. Interventions include interpreter services, migrant peer educators and health worker training to provide culturally competent care. Very few studies have focussed on cultural competency for migrant service use in Low- and Middle-Income Countries (LMIC). Migrants and refugees in Thailand and Malaysia report difficulties in accessing health systems and discrimination by service providers. In this paper we describe stakeholder perceptions of migrants' and health workers' language and cultural competency, and how this affects migrant workers' health, especially in Malaysia where an interpreter system has not yet been formalised.

    METHOD: We conducted in-depth interviews with stakeholders in Malaysia (N = 44) and Thailand (N = 50), alongside policy document review in both countries. Data were analysed thematically. Results informed development of Systems Thinking diagrams hypothesizing potential intervention points to improve cultural competency, namely via addressing language barriers.

    RESULTS: Language ability was a core tenet of cultural competency as described by participants in both countries. Malay was perceived to be an easy language that migrants could learn quickly, with perceived proficiency differing by source country and length of stay in Malaysia. Language barriers were a source of frustration for both migrants and health workers, which compounded communication of complex conditions including mental health as well as obtaining informed consent from migrant patients. Health workers in Malaysia used strategies including google translate and hand gestures to communicate, while migrant patients were encouraged to bring friends to act as informal interpreters during consultations. Current health services are not migrant friendly, which deters use. Concerns around overuse of services by non-citizens among the domestic population may partly explain the lack of policy support for cultural competency in Malaysia. Service provision for migrants in Thailand was more culturally sensitive as formal interpreters, known as Migrant Health Workers (MHW), could be hired in public facilities, as well as Migrant Health Volunteers (MHV) who provide basic health education in communities.

    CONCLUSION: Perceptions of overuse by migrants in a health system acts as a barrier against system or institutional level improvements for cultural competency, in an already stretched health system. At the micro-level, language interventions with migrant workers appear to be the most feasible leverage point but raises the question of who should bear responsibility for cost and provision-employers, the government, or migrants themselves.

  11. Loganathan T, Chan ZX, Hassan F, Ong ZL, Majid HA
    PLoS One, 2022;17(2):e0263404.
    PMID: 35108343 DOI: 10.1371/journal.pone.0263404
    Education is a fundamental human right. Yet there remain gaps in our understanding of undocumented children in Malaysia and their vulnerabilities in education access. This study aims to describe and contextualise undocumented children in Malaysia and their access to education. We conducted a desk review and in-depth interviews with 33 key stakeholders from June 2020 to March 2021. Framework analysis was conducted. Salient themes were geographical location and legal identity in terms of citizenship and migration status. We found that the lack of legal identity and non-recognition by the State was the root cause of vulnerability, experienced uniformly by undocumented populations in Malaysia. Only undocumented children with Malaysian parents or guardians can enter public schools under the Malaysian government's 'Zero Reject Policy'. Most undocumented and non-citizen children must rely on informal education provided by alternative or community learning centres that typically lack standardised curricula, resources, and accreditation for education progression beyond primary levels. Nevertheless, as non-citizen groups are diverse, certain groups experience more privilege, while others are more disadvantaged in terms of the quality of informal education and the highest level of education accessible. In Peninsular Malaysia, a very small proportion of refugees and asylum-seekers may additionally access tertiary education on scholarships. In Sabah, children of Indonesian migrant workers have access to learning centres with academic accreditation supported by employers in plantations and the Indonesian Consulate, whereas Filipino migrants who were initially recognised as refugees are now receiving little government or embassy support. Stateless Rohingya refugees in Peninsular Malaysia and Bajau Laut children at Sabah are arguably the most marginalised and have the poorest educational opportunities at basic literacy and numeracy levels, despite the latter receiving minimal governmental education support. Implementing a rights-based approach towards education would mean allowing all children equal opportunity to access and thrive in high-quality schools.
  12. Loganathan T, Ng CW, Lee WS, Hutubessy RCW, Verguet S, Jit M
    Health Policy Plan, 2018 Mar 01;33(2):204-214.
    PMID: 29228339 DOI: 10.1093/heapol/czx166
    Cost-effectiveness thresholds (CETs) based on the Commission on Macroeconomics and Health (CMH) are extensively used in low- and middle-income countries (LMICs) lacking locally defined CETs. These thresholds were originally intended for global and regional prioritization, and do not reflect local context or affordability at the national level, so their value for informing resource allocation decisions has been questioned. Using these thresholds, rotavirus vaccines are widely regarded as cost-effective interventions in LMICs. However, high vaccine prices remain a barrier towards vaccine introduction. This study aims to evaluate the cost-effectiveness, affordability and threshold price of universal rotavirus vaccination at various CETs in Malaysia. Cost-effectiveness of Rotarix and RotaTeq were evaluated using a multi-cohort model. Pan American Health Organization Revolving Fund's vaccine prices were used as tender price, while the recommended retail price for Malaysia was used as market price. We estimate threshold prices defined as prices at which vaccination becomes cost-effective, at various CETs reflecting economic theories of human capital, societal willingness-to-pay and marginal productivity. A budget impact analysis compared programmatic costs with the healthcare budget. At tender prices, both vaccines were cost-saving. At market prices, cost-effectiveness differed with thresholds used. At market price, using 'CMH thresholds', Rotarix programmes were cost-effective and RotaTeq were not cost-effective from the healthcare provider's perspective, while both vaccines were cost-effective from the societal perspective. Using other CETs, both vaccines were not cost-effective at market price, from the healthcare provider's and societal perspectives. At tender and cost-effective prices, rotavirus vaccination cost ∼1 and 3% of the public health budget, respectively. Using locally defined thresholds, rotavirus vaccination is cost-effective at vaccine prices in line with international tenders, but not at market prices. Thresholds representing marginal productivity are likely to be lower than those reflecting human capital and individual preference measures, and may be useful in determining affordable vaccine prices.
  13. Loganathan T, Ong ZL, Hassan F, Chan ZX, Majid HA
    PLoS One, 2023;18(6):e0286793.
    PMID: 37267412 DOI: 10.1371/journal.pone.0286793
    In Malaysia, marginalised non-citizen children are excluded from formal education at public schools. Recognising education as a fundamental human right, the barriers and facilitators to educational access among refugee and asylum-seeker, migrant, stateless and undocumented children in Malaysia were explored. Qualitative data were collected via 32 in-depth interviews with multiple stakeholders. Data were thematically analysed and organised at three socio-ecological levels. At the 'legislative and policy' level, the requirement of citizenship documents only allows some stateless children to access public schools. Yet, many informal learning centres are not state-endorsed, as they are unable to fulfil licensing criteria. Importantly, denying the right to work for adult refugees and other undocumented people demotivates the pursuit of education among children. At the 'individual and family' level, financial constraints constitute a major reason for school dropouts, especially through expectations on boys to work. Cultural norms partly contribute to the lower enrolment of Rohingya refugee girls in secondary education, but gender parity is maintained for most in primary education. Another factor is proximity to learning centres, which links to safety concerns and transportation costs. Those who accessed public schools reported bullying by local children, which parallels institutional discrimination against marginalised non-citizens. At the 'community and educational institutions' level, inadequate funding for learning centres limits their ability to invest in physical facilities, teachers' salaries and others. Despite difficult operating conditions, learning centres address diverse school readiness, educational backgrounds, and language competencies among students by having sensitised teachers, placement tests and preparatory classes at school entry, and options for vocational training. We propose the gradual inclusion of all children in public schools and the immediate state recognition and support of learning centres. Correspondingly, realising the 'Right to Work' for refugees and stateless peoples will be synergistic in advancing universal education access for all children.
  14. Loganathan T, Chan ZX, Hassan F, Kunpeuk W, Suphanchaimat R, Yi H, et al.
    PLoS One, 2021;16(12):e0259546.
    PMID: 34855770 DOI: 10.1371/journal.pone.0259546
    The COVID-19 pandemic disrupted schooling for children worldwide. Most vulnerable are non-citizen children without access to public education. This study aims to explore challenges faced in achieving education access for children of refugee and asylum-seekers, migrant workers, stateless and undocumented persons in Malaysia during the pandemic. In-depth interviews of 33 stakeholders were conducted from June 2020 to March 2021. Data were thematically analysed. Our findings suggest that lockdowns disproportionately impacted non-citizen households as employment, food and housing insecurity were compounded by xenophobia, exacerbating pre-existing inequities. School closures disrupted school meals and deprived children of social interaction needed for mental wellbeing. Many non-citizen children were unable to participate in online learning due to the scarcity of digital devices, and poor internet connectivity, parental support, and home learning environments. Teachers were forced to adapt to online learning and adopt alternative arrangements to ensure continuity of learning and prevent school dropouts. The lack of government oversight over learning centres meant that measures taken were not uniform. The COVID-19 pandemic presents an opportunity for the design of more inclusive national educational policies, by recognising and supporting informal learning centres, to ensure that no child is left behind.
  15. Kosiyaporn H, Julchoo S, Phaiyarom M, Sinam P, Kunpeuk W, Pudpong N, et al.
    Glob Health Res Policy, 2020 12 08;5(1):53.
    PMID: 33372646 DOI: 10.1186/s41256-020-00181-0
    BACKGROUND: In addition to healthcare entitlements, 'migrant-friendly health services' in Thailand include interpretation and cultural mediation services which aim to reduce language and cultural barriers between health personnel and migrants. Although the Thai Government started implementing these services in 2003, challenges in providing them still remain. This study aims to analyse the health system functions which support the interpretation and cultural mediation services of migrant health worker (MHW) and migrant health volunteer (MHV) programmes in Thailand.

    METHODS: In-depth interviews were conducted in two migrant-populated provinces using purposive and snowball sampling. A total of fifty key informants were recruited, including MHWs, MHWs, health professionals, non-governmental organisation (NGO) staff and policy stakeholders. Data were triangulated using information from policy documents. The deductive thematic analysis was classified into three main themes of evolving structure of MHW and MHV programmes, roles and responsibilities of MHWs and MHVs, and supporting systems.

    RESULTS: The introduction of the MHW and MHV programmes was one of the most prominent steps taken to improve the migrant-friendliness of Thai health services. MHWs mainly served as interpreters in public facilities, while MHVs served as cultural mediators in migrant communities. Operational challenges in providing services included insufficient budgets for employment and training, diverse training curricula, and lack of legal provisions to sustain the MHW and MHV programmes.

    CONCLUSION: Interpretation and cultural mediation services are hugely beneficial in addressing the health needs of migrants. To ensure the sustainability of current service provision, clear policy regulation and standardised training courses should be in place, alongside adequate and sustainable financial support from central government, NGOs, employers and migrant workers themselves. Moreover, regular monitoring and evaluation of the quality of services are recommended. Finally, a lead agency should be mandated to collaborate with stakeholders in planning the overall structure and resource allocation for the programmes.

  16. Tok PSK, Liew SM, Wong LP, Razali A, Loganathan T, Chinna K, et al.
    PLoS One, 2020;15(4):e0231986.
    PMID: 32320443 DOI: 10.1371/journal.pone.0231986
    INTRODUCTION: The monitoring of tuberculosis (TB) treatment outcomes and examination of the factors affecting these outcomes are important for evaluation and feedback of the national TB control program. This study aims to assess the TB treatment outcomes among patients registered in the national TB surveillance database in Malaysia from 2014 until 2017 and identify factors associated with unsuccessful treatment outcomes and all-cause mortality.

    MATERIALS AND METHODS: Using registry-based secondary data, a retrospective cohort study was conducted. TB patients' sociodemographic characteristics, clinical disease data and treatment outcomes at one-year surveillance were extracted from the database and analyzed. Logistic regression analysis was used to determine factors associated with unsuccessful treatment outcomes and all-cause mortality.

    RESULTS: A total of 97,505 TB cases (64.3% males) were included in this study. TB treatment success (cases categorized as cured and completed treatment) was observed in 80.7% of the patients. Among the 19.3% patients with unsuccessful treatment outcomes, 10.2% died, 5.3% were lost to follow-up, 3.6% had outcomes not evaluated while the remaining failed treatment. Unsuccessful TB treatment outcomes were found to be associated with older age, males, foreign nationality, urban dwellers, lower education levels, passive detection of TB cases, absence of bacille Calmette-Guerin (BCG) scar, underlying diabetes mellitus, smoking, extrapulmonary TB, history of previous TB treatment, advanced chest radiography findings and human immunodeficiency virus (HIV) infection. Factors found associated with all-cause mortality were similar except for nationality (higher among Malaysians) and place of residence (higher among rural dwellers), while smoking and history of previous TB treatment were not found to be associated with all-cause mortality.

    CONCLUSIONS: This study identified various sociodemographic characteristics and TB disease-related variables which were associated with unsuccessful TB treatment outcomes and mortality; these can be used to guide measures for risk assessment and stratification of TB patients in future.

  17. Tok PSK, Wong LP, Liew SM, Razali A, Mahmood MI, Chinnayah T, et al.
    PLoS One, 2023;18(9):e0289222.
    PMID: 37676902 DOI: 10.1371/journal.pone.0289222
    BACKGROUND: Loss to follow-up (LTFU) is an unsuccessful treatment outcome for tuberculosis (TB) patients. In Malaysia, LTFU affects around 1 in 20 TB patients. Integration of qualitative research methods and evidence will provide a better understanding of LTFU and its underlying issues. In this study, we qualitatively explored TB patients' experiences in receiving treatment and their reasons for leaving TB care.

    METHOD: In-depth interviews of 15 patients with a history of LTFU were conducted from January to September 2020. Interview guides were developed to explore TB patients' experiences while receiving treatment, including challenges faced and reasons for treatment interruption. Data were thematically analysed using the framework method.

    RESULTS: We identified 11 emerging themes that occurred at four levels of interaction with TB patients. First, at the patient personal level, TB beliefs referring to patients' perception of illness and wellness, patients' perceived role of traditional and complementary medicine, and substance abuse were important. Second, the healthcare system and treatment factors that were highlighted included the organisation of care and treatment, interaction with healthcare professionals, particularly in communication and counselling, and TB medications' side effects. Third, structural factors including financial burden, logistical and transportation issues and work-related factors were identified to be barriers to treatment continuation. Fourth, the interpersonal level interaction of patients should not be neglected; this includes family relationships and support as well as peer influence.

    CONCLUSION: Study findings put forth issues and challenges faced by TB patients while receiving treatment and underscore areas where actions can be taken. This will contribute to informing the development and implementation of future TB control strategies that are responsive to TB patients' needs and concerns, to effectively address LTFU and ensure better treatment completion rates among TB patients in Malaysia.

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