Risk factors for tuberculosis treatment failure, default, or relapse and outcomes of retreatment in Morocco
© Dooley et al; licensee BioMed Central Ltd. 2011
Received: 5 October 2010
Accepted: 28 February 2011
Published: 28 February 2011
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.
Tuberculosis (TB) continues to be a global public health problem, with an estimated 9.4 million incident cases of TB and 1.8 million deaths in 2008. Drug resistance and obstacles to successful directly observed therapy short-course (DOTS) impede disease control. Among patients being retreated for TB because of initial treatment failure, default from initial treatment, or relapse following initial treatment, drug resistance is common and retreatment outcomes inferior[2, 3].
Patients who fail, default from, or relapse after completion of standard first-line TB treatment and present for retreatment were previously grouped together by the World Health Organization (WHO) as Category II cases, and, in settings where individual drug susceptibility testing (DST) was not universally accessible, these patients were often treated with a standard retreatment regimen of first-line agents (a regimen that adds a single drug to the standard initial TB treatment regimen). Retreatment outcomes, however, are often poor, especially in patients with treatment failure or default. DST may help identify those patients with multidrug-resistant (MDR) TB so that the appropriate antibiotics can be administered. Identifying local patient characteristics that confer higher risk of relapse, failure, or default from primary TB treatment may help inform country-specific prevention strategies aiming to reduce the need for retreatment, resulting in cost savings and diminished morbidity and transmission.
In Morocco, the incidence of TB in 2008 was 81 per 100,000 overall but was significantly higher in several urban centers, or "hot spots". Of the roughly 28,000 new TB cases nationally each year, 12% are retreatment cases. National TB treatment guidelines in 2007 and 2008 recommended a Category I treatment regimen -- 2 months of isoniazid, rifampin, pyrazinamide, and streptomycin followed by 4 months of rifampin and isoniazid (2SHRZ/4RH) -- for new smear-positive cases and a Category II regimen -- 2HRZES/1RHEZ/5RHE (E = ethambutol) -- for retreatment cases. Beginning in 2009, ethambutol replaced streptomycin in Category I regimens. Among retreatment cases in Morocco, 12.2% are infected with Mycobacterium tuberculosis strains that are resistant to rifampin and isoniazid, or MDR TB. National guidelines suggest drug susceptibility testing (DST) for all retreatment patients.
This retrospective cohort study examines the efficacy of standard TB retreatment in urban centers in Morocco, evaluates the uptake of DST testing for retreatment patients, and, using a nested case-control design, explores the risk factors that led to the need for retreatment in the first place.
Morocco's National Tuberculosis Program (NTP) is well-established. TB care is provided free of charge by the Ministry of Health. Regional TB programs are divided into sectors, and each sector has a public health center (CDTMR) staffed by a specialist in TB care. TB clinical care is provided at CDTMR, while TB medications are delivered via DOTS at local clinics or dispensaries. M. tuberculosis culture and DST are performed at the National Reference Laboratory at the National Institute of Hygiene (INH) in Rabat or at the regional reference laboratory at the Institute Pasteur in Casablanca (IPM). National guidelines recommend DST for all retreatment patients. We chose nine urban CDTMR in high-incidence settings in Rabat, Casablanca, Fes, Tangier, and El Jedida as sites.
A retrospective cohort study of retreatment cases focusing on patient characteristics, treatment outcomes, and drug susceptibility was conducted. To determine the risk factors for failure, relapse, or default after initial treatment that led to the need for retreatment, a nested case-control study was performed.
Moroccan patients with smear- or culture-confirmed pulmonary TB presenting for retreatment between June 2007 and August 2008 were identified using clinic registries. Those who had failed initial treatment, had relapse after completing initial treatment, or defaulted after at least two months of initial treatment were included in the cohort study. Among patients in the cohort study, those whose initial treatment had ended within two years of starting their retreatment regimen were eligible to be included in the nested case-control study as cases. The rationale for the two-year limit was to make it more likely that initial treatment charts would be available, to ensure that standards of practice for initial TB treatment would be similar across cases, and to increase the likelihood that recurrent disease represented relapse rather than reinfection. Controls were chosen from among patients with successful initial treatment without failure, default, or early relapse selected from the same center and treatment week.
As per national guidelines, a patient with positive sputum smears for acid-fast bacilli after 5 months of continuous Category I treatment had treatment failure. A patient with initial treatment success after TB therapy of sufficient length (9 months for severe disease, 6 months for all others) that developed recurrent TB had treatment relapse. Treatment default was defined as interruption of treatment for ≥2 consecutive months. Treatment success was defined as treatment completion or cure. Retreatment patients were those receiving their first retreatment regimen after relapse, failure, or default.
DST results were reviewed at INH and IPM to identify sites that used DST testing services. At clinics chosen as study sites, the TB registry and medical records of included patients were reviewed. For retreatment patients, information from initial TB treatment was collected if initial treatment was within two years of retreatment, and this information was used for risk factor analyses. This study was approved by the Ministry of Health of Morocco and by the Institutional Review Board of the Johns Hopkins University School of Medicine.
Drug Susceptibility Testing
Smear microscopy and culture were performed using standard methods. Specimens demonstrating growth of M. tuberculosis on Lowenstein-Jensen medium were tested for susceptibility to isoniazid, rifampin, ethambutol, and streptomycin using the proportion method. Critical concentrations were as follows: RIF 40 mcg/mL, INH 0.2 mcg/mL, streptomycin 4 mcg/mL, and ethambutol 2 mcg/mL. DST quality control was provided by the Supranational Laboratory at the Institute Pasteur of Algiers, as per standard laboratory operating procedures.
Data analyses were performed in EpiInfo™ (Version 3.3.2, Centers for Disease Control, Atlanta, GA) except for multivariate logistic regressions, which were performed using STATA software, version 10.0 (StataCorp LP, College Station, Texas). Demographic and clinical characteristics of cases and controls during initial TB treatment were compared using Pearson's χ2 or Fisher's exact tests for categorical variables and student's t tests for continuous variables. Variables known to be risk factors for relapse, failure, or default as well as factors found to be associated with these outcomes in univariate analyses were included in multivariable logistic regression models. Significance tests were two-sided with p-values of ≤ 0.05 considered statistically significant.
Tuberculosis retreatment patients: population description, treatment outcomes, and DST results
291 patients with smear- or culture-positive pulmonary TB presenting for retreatment were identified and included in the study. Of retreatment cases, 232 (80%) had relapsed after completing an initial treatment regimen, 21 (7%) had failed an initial treatment regimen, and 38 (13%) had defaulted from initial treatment. The mean age was 37 years (IQR 27-46), and 78% were men. HIV and diabetes mellitus were rare (recorded for 1 and 3 patients, respectively).
A standard Category II retreatment regimen was used in 272 (93%) of 291 patients. Retreatment outcomes were as follows: 172 (59%) cured, 26 (9%) completed treatment, 7 (2%) died, 73 (25%) defaulted, and 11 (4%) failed. Retreatment was successful in 173 (74%) of relapse patients, 10 (48%) of failure patients, and 15 (41%) of default patients.(p < 0.01) Not surprisingly, retreatment failure was more common among patients who had failed initial treatment (24%) than among relapse (3%) or default (0%) patients (p < 0.01). Default was very common among retreatment patients at 25% overall and was particularly high among patients with initial treatment default (57%) (vs. 20% among relapse patients and 24% among failure patients (p < 0.01)). Among relapse patients, the median time from the end of initial treatment to diagnosis of relapse was 7.0 years (range 9 months to 44 years).
Only 30 (10%) of 291 retreatment patients had DST testing performed with results available in the chart. Of three patients being retreated because of initial treatment failure who were tested, all had resistance to HRS, none of five being retreated because of default from initial treatment who were tested had pan-sensitive M. tuberculosis, and 3 of 22 (14%) patients who were being retreated because of relapse within two years after initial TB treatment had MDR-TB.
Risk factors for relapse, failure, or default from initial TB treatment: results of the nested case-control study
Patient and disease characteristics of individuals receiving standard initial tuberculosis treatment, comparing patients with treatment relapse, failure, or default (cases) to patients with treatment success without relapse (controls)
(N = 80)
(N = 266)
At treatment initiation
Male gender (n, %)
Marital status (n, %)§
Other (widowed, divorced)
Medical comorbidities (n,%)*
Cavity on chest x-ray (n,%)‡
Age (mean, sd)
Weight at treatment initiation (mean, sd)
Habits (n, %)√
Illicit drug use
Sputum smear conversion to negative by 3 months (n,%)†
Weight gain after two months of treatment (kg, sd)**
Weight gain over initial treatment period (5-6 months) (kg, sd)**
Missed doses during intensive phase
In a multivariable logistic regression analysis, patients undergoing initial treatment for TB were at higher risk of a composite endpoint of failure, default, or relapse within two years if they were male (OR = 2.29, 95% CI 1.10-4.77), failed to have sputum smear conversion to negative by 3 months of treatment (OR 7.14, 95% CI 4.04-13.2), or required hospitalization during treatment (OR 2.09, 95% CI 1.01-4.34). There was a trend towards increased risk of this composite endpoint among those with poor weight gain (less than 10% by two months of treatment) or missed doses during the intensive phase of treatment, but these differences did not reach statistical significance. Odds of the composite outcome were 4% lower for each 1 kilogram increase in weight at treatment initiation (OR 0.96, 95% CI 0.93-0.99). Alcohol use and HIV were uncommon (2% and <1%, respectively).
Risk factors for relapse, failure, or default from initial TB treatment, a subgroup analysis.
(OR, 95% CI)
(OR, 95% CI)
Relapse (N = 35)
Lack of sputum smear conversion to negative by 3 months
Missed doses during the intensive phase
Treatment failure (N = 18)
Lack of sputum smear conversion to negative by 3 months
Treatment default (N = 27)
Missed doses during the intensive phase
Hospitalization during treatment
In this study of 291 patients undergoing retreatment for TB, outcomes differed considerably by group -- 74% of patients with relapse, 48% of patients with failure, and 41% of patients with default had treatment success -- similar to previous studies[5, 7]. Default from retreatment was extremely common at 25%, higher than previous country-wide estimates. This may reflect temporal changes in treatment completion but more likely represents differences in study populations, as we focused on TB "hot spots", or urban centers with comparatively high TB incidence. Recent studies have demonstrated that, in urban settings, adherence is linked to patient knowledge about TB and provision of disease-specific education by the health care provider to the patient. In busy urban clinics, time for education may be limited. Default from retreatment was most frequent among those who had defaulted from initial treatment, while failure was most common among those with previous failure. Although retreatment guidelines are often the same for patients with failure, default from, or relapse after initial treatment, these results suggest that groups may benefit from different management strategies[9, 10]. For example, treatment failure is commonly due to drug resistance, while recurrence may be due to poor adherence, high mycobacterial burden (such as in cavitary disease), or exogenous reinfection. Default patients may require intensified case management and education, rather than more intensive treatment.
The present study shows that, even when available, drug susceptibility testing is underutilized. It was performed in only 10% of retreatment patients. All 3 failure patients who underwent DST testing had MDR-TB, while 3 of 22 of relapse patients and 0 of 5 default patients tested did. While these DST results were only available for three failure patients and, therefore, not representative, these data and those from other studies suggest that MDR risk is not uniform among retreatment subgroups, with increased prevalence of MDR among patients with initial treatment failure[2, 11–13]. According to a population-based study conducted among retreatment cases in Morocco, 12.2% had MDR-TB, but the study did not divide retreatment patients into failure, relapse, or default subgroups. Taken together, these findings support use of DST in all retreatment patients, earlier DST testing in those with clinical and microbiological indications of impending treatment failure, and use of second-line drugs for retreatment of patients with initial treatment failure until DST results are known. In Morocco, DOTS coverage is 100%, and concerted efforts to dramatically enhance DST use are underway.
Published medical risk factors for failure or relapse include HIV infection, diabetes mellitus, low body weight, cavitation on chest x-ray, high bacterial burden, short treatment duration, drug resistance, and positive culture after two months of treatment[14–16]. Sociodemographic factors include unemployment, drug abuse, alcoholism, smoking, and poor treatment adherence. Treatment default is known to be associated with substance abuse, foreign birth, male gender, previous default, low socioeconomic status, psychiatric illness, unemployment, migration, side effects, [17, 18] long distance to the clinic, social stigma, and poorly-implemented DOTS but, of course, differ by setting [16, 19–21]. In our study population, HIV infection is rare; among TB patients, less than 1% are HIV-infected (unpublished data, Morocco NTP). Further, alcohol use in Morocco is uncommon, and smoking is extremely uncommon among women. Moreover, in the urban clinics studied, the majority of patients are non-immigrants, the clinics are geographically accessible, and DOTS coverage is 100%. Thus, many traditional risk factors for poor TB treatment outcomes are less prominent in Morocco, making it harder to prospectively identify patients at risk. However, continued sputum smear positivity after 3 months of treatment is a strong predictor of subsequent poor outcomes, and should prompt DST testing in all patients. As missed treatment doses may herald impending default, enhanced communication between the local clinics that dispense TB treatment and physicians at the regional health centers that prescribe it may be one country-specific strategy to help pinpoint those individuals who are missing doses and are at high risk of defaulting altogether. Small sample sizes limited our ability to evaluate subgroups, but even so, we were able to identify male sex, substance use (tobacco, alcohol, or illicit drug use), and missed doses during the intensive phase as likely risk factors for treatment default. Higher odds of hospitalization probably reflected the need for hospitalization to ensure adherence rather than increased disease severity. Further exploring risk factors for treatment default may help control programs identify those likely to benefit from targeted interventions such as health education, substance abuse counseling, enhanced tracking, or reinforcement of DOTS supervision[22, 23].
As a retrospective chart review, our risk factor evaluation was limited by the availability of data present in clinical charts. Information about tobacco, alcohol, and illicit drug use was not routinely recorded, for example. Classifying those with missing substance use data as nonusers likely biased analyses of this risk factor toward the null; however, estimates of smoking, tobacco, and illicit drug use were similar to national substance use statistics. Also, in cases of recurrence, it was not possible to distinguish between relapse and reinfection, so we limited our risk factor analysis to those who had received initial TB treatment within two years of recurrence and were, thus, more likely to have true relapse. Our ability to identify independent risk factors in subgroup analyses was limited by small sample sizes; questions regarding risk factors in these subgroups would best be answered in larger, prospective studies. Finally, DST testing was not universally performed in retreatment patients, so selection bias is possible, as clinicians are more likely to send those at high risk of resistance for testing. In our study, 20% of retreatment patients with DST had MDR-TB, compared with 12% in a national prevalence survey.
Patients presenting for TB retreatment - those with relapse, failure of initial treatment, or default -- are often grouped together and treated with a standard Category II retreatment regimen. However, these groups have distinct demographic and clinical characteristics, important differences in retreatment outcomes, and likely have different rates of drug resistant M. tuberculosis. Default from retreatment is common in high-incidence urban centers in Morocco, pointing to the need for strategies to address adherence. DST is essential for identifying retreatment patients with drug resistance, but even when available, it is underutilized, likely due to practical constraints. Preventing the need for retreatment in the first place is the best strategy given the individual and public health consequences of poor initial TB treatment outcomes, so strategies to identify and address country-specific risk factors are warranted to maximize treatment success.
The authors wish to thank Professor Mohammed Hassar for his assistance with obtaining DST results from the IPM; Dr. Afrah Akdi for her patience in teaching KED and JK about TB treatment in the field in Morocco; Amir Mohareb for his help with data collection in multiple Moroccan cities; Mrs. Radia Sabounie for her help retrieving DST results at the National TB Reference Laboratory; Dr. Baya Benhassine for her French translations; Dr. Jonathan Golub for his input and assistance; Dr. Khalil Ghanem for his thoughtful reading of the manuscript; and the CDTMR doctors and nurses who so kindly allowed us access to their patient charts and helped us in so many ways. KED is supported by NIH K23AI080842.
- World Health Organization: Global tuberculosis control - epidemiology, strategy, financing. WHO Report. 2009, [http://www.who.int/tb/publications/global_report/2009/en/index.html] , WHO/HTM/TB/2009.411
- Becerra MC, Freeman J, Bayona J, Shin SS, Kim JY, Furin JJ, Werner B, Sloutsky A, Timperi R, Wilson ME, Pagano M, Farmer PE: Using treatment failure under effective directly observed short-course chemotherapy programs to identify patients with multidrug-resistant tuberculosis. Int J Tuberc Lung Dis. 2000, 4 (2): 108-114.PubMed
- Chiang CY, Hsu CJ, Huang RM, Lin TP, Luh KT: Antituberculosis drug resistance among retreatment tuberculosis patients in a referral center in Taipei. J Formos Med Assoc. 2004, 103 (6): 411-415.PubMed
- World Health Organization: Treatment of tuberculosis. Guidelines for national programmes. WHO/CDS/TB/2003.313. Geneva, Switzerland. 2003, 3
- Ottmani SE, Zignol M, Bencheikh N, Laasri L, Chaouki N, Mahjour J: Results of cohort analysis by category of tuberculosis retreatment cases in Morocco from 1996 to 2003. Int J Tuberc Lung Dis. 2006, 10 (12): 1367-1372.PubMed
- World Health Organization: Anti-tuberculosis resistance in the world: WHO/IUATLD global project on anti-tuberculosis drug surveillance 2002-2007, Report number 4. 2008
- Mak A, Thomas A, Del Granado M, Zaleskis R, Mouzafarova N, Menzies D: Influence of multidrug resistance on tuberculosis treatment outcomes with standardized regimens. Am J Respir Crit Care Med. 2008, 178 (3): 306-312. 10.1164/rccm.200802-240OC.View ArticlePubMed
- Mulenga C, Mwakazanga D, Vereecken K, Khondowe S, Kapata N, Shamputa IC, Meulemans H, Rigouts L: Management of pulmonary tuberculosis patients in an urban setting in Zambia: a patient's perspective. BMC Public Health. 2010, 10: 756-10.1186/1471-2458-10-756.PubMed CentralView ArticlePubMed
- Zignol M, Wright A, Jaramillo E, Nunn P, Raviglione MC: Patients with previously treated tuberculosis no longer neglected. Clin Infect Dis. 2007, 44 (1): 61-64. 10.1086/509328.View ArticlePubMed
- Espinal MA: Time to abandon the standard retreatment regimen with first-line drugs for failures of standard treatment. Int J Tuberc Lung Dis. 2003, 7 (7): 607-608.PubMed
- Quy HT, Lan NT, Borgdorff MW, Grosset J, Linh PD, Tung LB, van Soolingen D, Raviglione M, Co NV, Broekmans J: Drug resistance among failure and relapse cases of tuberculosis: is the standard re-treatment regimen adequate?. Int J Tuberc Lung Dis. 2003, 7 (7): 631-636.PubMed
- Temple B, Ayakaka I, Ogwang S, Nabanjja H, Kayes S, Nakubulwa S, Worodria W, Levin J, Joloba M, Okwera A, Eisenach KD, McNerney R, Elliott AM, Smith PG, Mugerwa RD, Ellner JJ, Jones-Lopez EC: Rate and amplification of drug resistance among previously-treated patients with tuberculosis in Kampala, Uganda. Clin Infect Dis. 2008, 47 (9): 1126-1134. 10.1086/592252.PubMed CentralView ArticlePubMed
- Lew W, Pai M, Oxlade O, Martin D, Menzies D: Initial drug resistance and tuberculosis treatment outcomes: systematic review and meta-analysis. Ann Intern Med. 2008, 149 (2): 123-134.View ArticlePubMed
- Thomas A, Gopi PG, Santha T: Predictors of relapse among pulmonary tuberculosis patients treated in a DOTS programme in South India. Int J Tuberc Lung Dis. 2005, 9: 556-561.PubMed
- Pulido F, Pena JM, Rubio R: Relapse of tuberculosis after treatment in human immunodeficiency virus-infected patients. Arch Intern Med. 1997, 157: 227-232. 10.1001/archinte.157.2.227.View ArticlePubMed
- Panjabi R, Comstock GW, Golub JE: Recurrent tuberculosis and its risk factors: adequately treated patients are still at high risk. Int J Tuberc Lung Dis. 2007, 11 (8): 828-837.PubMed
- Comolet TM, Rakotomalala R, Rajaonarioa H: Factors determining compliance with tuberculosis treatment in an urban environment, Tamatave, Madagascar. Int J Tuberc Lung Dis. 1998, 2 (11): 891-897.PubMed
- Mishra P, Hansen EH, Sabroe S, Kafle KK: Adherence is associated with the quality of professional-patient interaction in Directly Observed Treatment Short-course, DOTS. Patient Educ Couns. 2006, 63 (1-2): 29-37. 10.1016/j.pec.2005.08.006.View ArticlePubMed
- Hasker E, Khodjikhanov M, Usarova S, Asamidinov U, Yuldashova U, van der Werf MJ, Uzakova G, Veen J: Default from tuberculosis treatment in Tashkent, Uzbekistan; who are these defaulters and why do they default?. BMC Infect Dis. 2008, 8: 97-10.1186/1471-2334-8-97.PubMed CentralView ArticlePubMed
- Cayla JA, Caminero JA, Rey R, Lara N, Valles X, Galdos-Tanguis H, Working Group on Completion of Tuberculosis Treatment in Spain: Current status of treatment completion and fatality among tuberculosis patients in Spain. Int J Tuberc Lung Dis. 2004, 8 (4): 458-464.PubMed
- Holtz TH, Lancaster J, Laserson KF, Wells CD, Thorpe L, Weyer K: Risk factors associated with default from multidrug-resistant tuberculosis treatment, South Africa, 1999-2001. Int J Tuberc Lung Dis. 2006, 10 (6): 649-655.PubMed
- Volmink J, Garner P: Systematic review of randomised controlled trials of strategies to promote adherence to tuberculosis treatment. BMJ. 1997, 315 (7120): 1403-1406.PubMed CentralView ArticlePubMed
- Thiam S, LeFevre AM, Hane F, Ndiaye A, Ba F, Fielding KL, Ndir M, Lienhardt C: Effectiveness of a strategy to improve adherence to tuberculosis treatment in a resource-poor setting: a cluster randomized controlled trial. JAMA. 2007, 297 (4): 380-386. 10.1001/jama.297.4.380.View ArticlePubMed
- Website of the Ministry of Health of Morocco. [http://srvweb.sante.gov.ma/Programmes/Pages/default.aspx]
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/140/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.