Risk factors for multidrug-resistant tuberculosis in urban Pakistan: A multicenter case–control study

Prevalence and Temporal Trends of Multidrug-resistant Tuberculosis in Iran from 1981 to 2023: A Systematic Review and Meta-analysis

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is a serious threat to global tuberculosis (TB) control efforts. This study aims to investigate the trend of MDR-TB prevalence in Iran over 20 years.

METHODS

A systematic literature search was conducted in various databases, including PubMed, Embase, and Web of Science, from 1981 to 2023. Studies reporting the prevalence of MDR-TB in Iran were included in the meta-analysis. Statistical analysis was performed using Comprehensive Meta-Analysis software.

RESULTS

A total of 58 studies from different provinces of Iran were included in the meta-analysis. The majority of studies were from Tehran (n = 33), Kermanshah (n = 5), Mashhad (n = 4), and Tabriz (n = 4) provinces. Overall, 1885 cases of MDR-TB were reported in Iran during the study period. The highest number of MDR-TB cases was reported in 2000 (582 cases) and the lowest in 2001 (1 case). An increasing trend in MDR-TB prevalence was observed, particularly between 2018 and 2019. The pooled prevalence of MDR-TB in Iran was 12.31% (95% CI: 11.83-12.80) using the fixed-effects model and 20.21% (95% CI: 15.70-26.01) using the random-effects model. No evidence of publication bias was found.

CONCLUSION

The results of this comprehensive meta-analysis highlight the increasing trend of MDR-TB in Iran over the past two decades. This underscores the urgent need for strengthening TB control strategies, including improved surveillance, case detection, treatment, and management of MDR-TB in the country. Developing diagnostic and treatment approaches for MDR-TB should be prioritized by Iranian medical universities and public health authorities.

Determinants of drug-resistant tuberculosis in Hunan province, China: a case-control study

BACKGROUND

Drug-resistant tuberculosis (DR-TB) is a major public health threat in Hunan Province, with an increasing clinical burden in recent years. This study aimed to identify socio-demographic and clinical factors associated with DR-TB in Hunan province, China.

METHODS

A case-control study was conducted in Hunan province. Cases were all DR-TB patients who were confirmed by culture and Drug susceptibility testing (DST) and enrolled at the DR-TB treatment center of Hunan Chest Hospital from 2013 to 2018. Controls were all Drug Susceptible TB (DS-TB) patients confirmed by DST and enrolled at the same hospital during the same period. A multivariable logistic regression model was fitted to identify factors significantly associated with DR-TB.

RESULTS

A total of 17,808 patients (15,534 DS-TB controls and 2274 DR-TB cases) were included in the study, with a mean age of 42.5 years (standard deviation (SD) ± 17.5 years) for cases and 46.1 years (SD ± 19.1 years) for controls. Age 15-64 years (Adjusted odds ratio (AOR = 1.5, 95% CI; 1.4, 1.8)), ethnic minorities (AOR = 1.5; 95% CI; 1.4, 1.8), and a history of previous TB treatment (AOR) = 1.84; 95% CI: 1.57, 2.15) was significantly associated with DR-TB. Being resident in a province outside Hunan was also a significant risk factor (AOR = 1.67; 1.27, 2.21) for DR-TB.

CONCLUSION AND RECOMMENDATIONS

To prevent the occurrence of DR-TB in Hunan Province, interventions should be targeted at high-risk demographic groups such as ethnic minorities, individuals of productive age, and residents living outside the province. Interventions must also be targeted to previously treated cases, suggesting the appropriateness of diagnosis, treatment, and follow-up. Understanding the risk factors at the province level helps design strategies for controlling DR-TB due to variations by socioeconomic differences, quality of health care, and healthcare access.

Predictors of multidrug-resistant tuberculosis in a teaching hospital in Ghana: A case-control study

Multidrug-resistant Tuberculosis (MDR-TB) remains a global health concern. The disease results in a prolonged treatment and hence, poses a financial burden to affected individuals and their families. The Ghana National TB Control Programme (NTP) has made extensive efforts to control the menace, however, it remains a concern. This study, therefore, aimed to determine the predictors of multidrug-resistant TB in the Cape Coast Teaching Hospital of Ghana. An unmatched case-control study involving 37 cases and 111 controls was conducted using data of TB cases registered for treatment between January 2018 and December 2020 at the Cape Coast Teaching Hospital. Socio-demographic, individual level and social characteristics information were collected from respondents through telephone surveys, face-to-face interviews and review of records using a structured questionnaire built in the Kobo Collect Toolbox. The data was exported to Stata version 16.0 for analysis. Chi-square test and multiple logistic regression were used to determine the predictors of MDR-TB. Associations were considered statistically significant at a 95% confidence interval with a p-value of less than 0.05. The results revealed that the majority (25 [67.6%]) of MDR-TB cases and controls (76 [68.5%]) were aged 30 years and above with a median age of 36.5 (IQR: 28-50) years for all respondents, while 20 (54.1%) of MDR-TB cases and 33 (29.7%) of controls lived in households with one room residences for their families. The following predictors for MDR-TB were identified: BCG vaccination status (AOR = 0.17,95% CI:0.07-0.45), long distance to health facility (AOR = 4.11, 95% CI: 1.55-10.87), number of rooms in residence (AOR = 0.37,95% CI: 0.14-0.99) and first place of visit upon noticing TB symptom (AOR = 4.22,95% CI:1.31-13.64). Predictors of MDR-TB in the current study were multi-faceted. Measures to control MDR-TB should target socio-demographic, health-seeking behaviour and social-related concerns.

Risk factors of multidrug resistant tuberculosis among patients with tuberculosis at selected multidrug resistance treatment initiative centres in southern Ethiopia: a case-control study

OBJECTIVE

To identify the risk factors for multidrug resistant tuberculosis (MDR-TB) among patients with TB at selected MDR-TB treatment initiative centres, southern Ethiopia, 2021.

DESIGN

An unmatched case-control study was employed.

SETTING

Multidrug resistance treatment initiative centres in southern Ethiopia (Nigist Elen Mohamed Memorial Comprehensive Specialized Hospital and Butajira General Hospital).

PARTICIPANTS

A total sample size of 392 (79 cases and 313 controls) were selected by the systematic sampling technique. Cases were all patients with TB with culture proven or line probe assay confirmed Mycobacterium tuberculosis resistant to at least both isoniazid and rifampicin and registered on second-line TB treatment. Controls were all patients with bacteriological (molecular) proven drug-susceptible TB strains and whose recent smear results were turned to negative and registered as cured. Both bivariate and multivariable logistic regression analysis was used to identify risk factors of MDR-TB infections.

MAIN OUTCOME MEASURE

Identifying the risk factors for MDR-TB.

RESULTS

A total of 392 participants (79 cases and 313 controls) were interviewed. Multivariable analysis showed that direct contact with known patients with TB (AOR =4.35; 95% CI: 1.45 to 9.81), history of previous TB treatment (AOR=2.51; 95% CI: 1.50 to 8.24), history of cigarette smoking (AOR=3.24; 95% CI :2.17 to 6.91) and living in rural area (AOR=4.71; 95% CI :3.13 to 9.58) were identified risk factors for MDR-TB infections.

CONCLUSIONS

The study findings revealed that direct contact with known patients with TB, previous history of TB treatment, history of cigarette smoking and rural residence were potential risk factors for the occurrence of MDR-TB. In order to reduce the burden of drug resistance, strategies of controlling MDR-TB in the study area should emphasise on enhancing public health education and reducing treatment interruptions of patients with TB and drug-resistant TB.

Impact and cost-effectiveness evaluation of nutritional supplementation and complementary interventions for tuberculosis treatment outcomes under mukti pay-for-performance model in Madhya Pradesh, India: A study protocol

Background

A.

"pay-for-performance" (P4P) intervention model for improved tuberculosis (TB) outcomes, called "Mukti," has been implemented in an underdeveloped tribal area of central India. The target of this project is to improve nutritional status, quality of life (QoL), and treatment outcomes of 1000 TB patients through four interventions: food baskets, personal counseling, peer-to-peer learning and facilitation for linkage to government schemes. The current study aims to assess the success of this model by evaluating its impact and cost-effectiveness using a quasi-experimental approach.

Methods

Data for impact assessment have been collected from 1000 intervention and control patients. Study outcomes such as treatment completion, sputum negativity, weight gain, and health-related QoL will be compared between matched samples. Micro costing approach will be used for assessing the cost of routine TB services provision under the national program and the incremental cost of implementing our interventions. A decision and Markov hybrid model will estimate long-term costs and health outcomes associated with the use of study interventions. Measures of health outcomes will be mortality, morbidity, and disability. Cost-effectiveness will be assessed in terms of incremental cost per quality-adjusted life-years gained and cost per unit increase in patient weight in intervention versus control groups.

Results

The evidence generated from the present study in terms of impact and cost-effectiveness estimates will thus help to identify not only the effectiveness of these interventions but also the optimal mode of financing such measures. Our estimates on scale-up costs for these interventions will also help the state and the national government to consider scale-up of such interventions in the entire state or country.

Discussion

The study will generate important evidence on the impact of nutritional supplementation and other complementary interventions for TB treatment outcomes delivered through P4P financing models and on the cost of scaling up these to the state and national level in India.

Genotypic Distribution and the Epidemiology of Multidrug Resistant Tuberculosis in Upper Northern Thailand

The epidemiology and genotypes of multidrug-resistant tuberculosis (MDR-TB), a global public health threat, remain limited. The genotypic distribution and factors associated with MDR-TB in upper northern Thailand between 2015 and 2019 were investigated. The DNA sequencing of rpoB, katG, and inhA promoter of 51 multidrug-resistant Mycobacterium tuberculosis isolates revealed nine patterns of the rpoB gene mutation distributed in seven provinces. The S531L mutation was the most common mutation in all provinces. The rpoB mutation in Chiang Rai, Chiang Mai, and Lampang was highly diverse compared to other areas. Here, the mutation profiles that have yet to be reported in northern Thailand (H526P, Q513P, and H526C) were detected in Chiang Rai province. The S315T katG mutation was the most common genotype associated with INH resistance, especially in Chiang Mai and Lampang. Further analysis of data from 110 TB patients (42 MDR-TB and 68 drug-susceptible TB) revealed that <60 years of age was a significant factor associated with MDR-TB (OR = 0.316, 95% CI 0.128−0.784, p = 0.011) and ≥60 years of age was a significant factor associated with the S315T katG-mutation (OR = 8.867, 95% CI 0.981−80.177, p = 0.047). This study highlighted the necessity for continuous surveillance and risk factor monitoring for effective control of MDR-TB.

Drug Resistance Patterns and Trends in Patients with Suspected Drug-Resistant Tuberculosis in Dalian, China: A Retrospective Study

Purpose

The emergence of drug-resistant tuberculosis (DR-TB) represents a threat to the control of tuberculosis. This study aimed to estimate the patterns and trends of DR-TB in patients with suspected DR-TB. In addition, risk factors for multidrug-resistant tuberculosis (MDR-TB) were identified among suspected DR-TB patients in Dalian, China.

Patients and Methods

A total of 5661 patients with suspected DR-TB from Jan 1, 2013 to Dec 31, 2020 were included in the final analysis. The resistance pattern of all resistant strains was determined by drug susceptibility testing (DST) using the conventional Lowenstein-Jensen Proportion Method (LJ). DR-TB trends were estimated from 2013 to 2020. During the research period, the chi-square test was employed to analyze the significance of linear drug-resistance trends across time. Bivariate and multivariate logistic regression were performed to assess factors associated with MDR-TB.

Results

From 2013 to 2020, the resistance rates of rifampicin (RFP) and isoniazid (INH) decreased significantly, whereas the resistance rates of ethambutol (EMB) and streptomycin (SM) increased in patients with suspected DR-TB. From 2013 to 2020, the prevalence of DR-TB decreased in all patients from 34.71% to 28.01% with an average annual decrease of 3.02%. Among new cases, from 2013 to 2020, the prevalence of DR-TB (from 26.67% to 24.75%), RFP-resistant TB (RR-TB) (from 15.09% to 3.00%) and MDR-TB (from 6.08% to 2.62%) showed a significant downward trend. Among patients with a previous treatment history, DR-TB (from 54.70% to 37.50%), RR-TB (from 44.16% to 11.49%) and MDR-TB (from 26.90% to 10.34%) showed a significant downward trend from 2013 to 2020. Males (AOR 1.28, 95% CI 1.035–1.585), patients 45 to 64 years of age (AOR 1.75, 95% CI 1.342–2.284), patients 65 years and older (AOR 1.65, 95% CI 1.293–2.104), rural residents (AOR 1.24, 95% CI 1.014–1.519) and a previous treatment history (AOR 3.94, 95% CI 3.275–4.741) were risk factors for MDR-TB.

Conclusion

The prevalence of DR-TB, RR-TB and MDR-TB was significantly reduced from 2013 to 2020. Considerable progress has been made in the prevention and treatment of DR-TB during this period. However, the increasing rate of drug resistance in EMB and SM should be taken seriously. Suspected DR-TB patients who are male, older than 45 years of age, live in rural areas, and have a history of TB treatment should be given priority by health care providers.

The dynamic impacts of environmental-health and MDR-TB diseases and their influence on environmental sustainability at Chinese hospitals

The purpose of this study is to identify at what extent multidrug-resistant tuberculosis (MDR-TB) diseases effect on environmental health issues in selected provinces of Chinese hospitals. In survival analysis approach, this study employs the Cox proportional hazard model (CPM) to incorporate the duration of event, probability of occurrence of an event, and the issue of right censoring. An advantage of using CPM is that one does not need to specify the distribution of baseline hazard H₀ (t) as it considers a common value for all units in population. The results indicate that male and travel expenditures have negative association with the duration of cure. Furthermore, the medical expenditures and the spatial characteristic of time expenditure have positive association with the duration of cure of MDR-TB patients. The inconsistent behavior of males in taking medicines as compared to females and males is also more prone to tuberculosis (TB).

Diagnostic utility of GenoType MTBDRsl assay for the detection of moxifloxacin-resistant mycobacterium tuberculosis, as compared to phenotypic method and whole-genome sequencing

Background

Recently, moxifloxacin (MFX)-resistant results of Mycobacterium tuberculosis (Mtb) obtained by GenoType MTBDRsl (second-line line probe assay [SL-LPA]) have been stratified to determine their resistance level; however, its accuracy has not been well studied. Therefore, the study aimed to evaluate the diagnostic accuracy of SL-LPA, with phenotypic drug susceptibility testing (pDST) and whole-genome sequencing (WGS) for the detection of MFX-resistant Mtb and their resistance level.

Methods

A total of 111 sputum samples were subjected to SL-LPA according to the diagnostic algorithm of the National Tuberculosis Elimination Program. Results were compared with pDST of MFX (at critical concentration [CC, 0.25 μg/ml] and clinical breakpoint [CB, 1.0 μg/ml] using BACTEC mycobacterial growth indicator tube-960), and WGS.

Results

At CC, SL-LPA and pDST yielded concordant results of MFX for 104 of 111 (94%). However, at CB, 23 of 30 (77%) isolates carrying gyrA mutation known to confer low-level resistance to MFX were scored as susceptible by pDST. Among 46 Mtb isolates carrying gyrA mutations known to confer high-level resistance to MFX, 36 (78%) isolates yielded concordant results, while 10 (22%) isolates were scored as susceptible at CB by pDST. WGS identified gyrA mutations in all isolates suggested by SL-LPA.

Conclusion

It is concluded that the stratification of MFX-resistant results by SL-LPA/genotypic method is not very well correlated with pDST (at CB), and hence, pDST may not be completely replaced by SL-LPA. gyrA D94G and gyrAA90V are the most prevalent mutations in MFX-resistant Mtb.

Risk factors for mortality and multidrug resistance in pulmonary tuberculosis in Guatemala: A retrospective analysis of mandatory reporting

•

National TB cohort analyzing risk factors associated with MDR-TB and mortality in Guatemala.

•

Indigenous ethnicity and prior TB treatment were associated with increased risk of mortality and MDR-TB.

•

HIV/Unknown HIV status were associated with increased mortality and diabetes with risk for MDR-TB.

Background

Risk factors for mortality and MDR-TB in Guatemala are poorly understood. We aimed to identify risk factors to assist in targeting public health interventions.

Methods

We performed a retrospective study of adults with pulmonary TB reported to the Guatemalan TB Program between January 1, 2016 and December 31, 2017. The primary objective was to determine risk factors for mortality in pulmonary TB. The secondary objective was to determine risk factors associated with MDR-TB.

Results

Among 3,945 patients with pulmonary TB, median age was 39 years (IQR 25–54), 59% were male, 25% of indigenous ethnicity, 1.1% had MDR-TB and 3.9% died. On multivariable analysis, previous TB treatment (odds ratio [OR] 3.57, CI 2.24–5.68 [p < 0.001]), living with HIV (OR 3.98, CI 2.4–6.17 [p < 0.001]), unknown HIV diagnosis (OR 2.65, CI 1.68–4.18 [p < 0.001]), indigenous ethnicity (OR 1.79, CI 1.18–2.7 [p = 0.005]), malnutrition (OR 7.33, CI 3.24–16.59 [p < 0.001]), and lower educational attainment (OR 2.86, CI 1.43–5.88 [p = 0.003]) were associated with mortality. Prior treatment (OR 53.76, CI 25.04–115.43 [p < 0.001]), diabetes (OR 4.13, CI 2.04–8.35 [p < 0.001]), and indigenous ethnicity (OR 11.83, CI 1.46–95.73 [p = 0.02]) were associated with MDR-TB.

Conclusions

In Guatemala, both previous TB treatment and indigenous ethnicity were associated with higher TB mortality and MDR-TB risk among patients with pulmonary TB.

Magnitude of Multidrug Resistance and Associated Factors of Pulmonary Tuberculosis Among Adult Smear Positive Patients in Eastern Ethiopia

BACKGROUND

In Ethiopia, multidrug resistant tuberculosis is a major public health problem. However, information is scarce regarding MDR-TB and associated factors.

OBJECTIVE

The study was aimed to assess the magnitude of multidrug resistance and associated factors of pulmonary tuberculosis among adult smear-positive patients in Harari regional state health facilities, eastern Ethiopia.

METHODS

A cross-sectional study was conducted among 395 adult smear-positive pulmonary tuberculosis patients attending health facilities from March to October 2019. Smear-positive sputum samples were collected from health facilities, and transported to Harari Health Research and Regional Laboratory, and tested for drug susceptibility using a line probe assay. Data were analyzed using Statistical Package for Social Sciences version 20. Bivariate and multivariable logistic regression analyses with 95% confidence intervals were carried out to identify factors associated with multidrug-resistant tuberculosis.

RESULTS

The overall magnitude of multidrug-resistant tuberculosis was 3.8% (15/395) (95% CI: 2.0-5.8%). Being male (AOR = 4.9; 95% CI: 1.16, 20.5), patients with a previous history of tuberculosis (AOR = 4.9; 95% CI: 1.5, 29.6), treatment failure (AOR = 8.5; 95% CI: 1.61, 45.3), treatment default (AOR = 10.38; 95% CI: 1.86, 58.0), human immunodeficiency virus co-infection (AOR = 9.83.95% CI: 3, 21, 30.1) and a previous history of contact with multidrug-resistant tuberculosis patients (AOR = 14.4; 95% CI: 3.1, 67.6) had higher odds of multidrug-resistant tuberculosis.

CONCLUSION

The overall magnitude of multidrug-resistant tuberculosis was high. Strengthening the tuberculosis control program by giving special attention to HIV co-infected patients,  treatment failure and default, previously infected patients as well as to those individuals who have a history of contact with multidrug-resistant tuberculosis infected patients .

A cohort study analyzing the impact of socioeconomic and spatial characteristics alongside treatment regimens on the environmental-health outcomes of the MDR-TB treatment in Pakistan

This study identifies and analyzes a number of factors that correlate with the environmental-health outcome of multi-drug resistance tuberculosis (MDR-TB) treatment in Pakistan. Survival analysis is carried out by applying the multivariable Cox Proportional Hazard model on secondary data of 369 patients registered at three main MDR-TB sites in Pakistan during 2012-2017. Results show that there is no difference in survival of patients between the two treatment arms, hospital and ambulatory care. Male gender and travel expenditure are found to be negatively associated with the environmental-health outcome, whereas spatial characteristic of time expenditure is positively related to it supporting distance bias approach. Medical expenditure is also positively related to the environmental-health outcome. The study concludes that availability of affordable and accessible health services, better environmental conditions, and ambulatory care based on WHO recommendation as well as health education along with social protection schemes should be ensured by the government to improve environmental-health outcome in the resource-scarce setting in Pakistan.

Evaluation of risk factors associated with the development of MDR- and XDR-TB in a tertiary care hospital: a retrospective cohort study

BACKGROUND

Drug resistant tuberculosis (DR-TB) infringes substantial burden in terms of longer treatment duration, morbidity and mortality. Timely identification of patients at risks of DR-TB will aid individualized treatment. Current study was aimed to ascertain several factors associated with DR-TB among patients attending a tertiary care hospital.

METHODS

This retrospective study was conducted among patients with confirmed diagnosis of DR-TB and drug susceptible TB (DS-TB) seeking medical care from a tertiary care hospital during 2014-2019. The types of DR-TB included were rifampicin resistant tuberculosis (RR-TB), Multidrug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB). Appropriate statistical methods were implied to evaluate the factors associated with DR-TB.

RESULTS

Out of 580 patients, DS-TB was diagnosed in 198 (34.1%) patients while DR-TB was present in 382 patients. Of resistance cases, RR-TB, MDR-TB and XDR-TB were diagnosed in 176 (30.3%), 195 (33.6%) and 11 (1.9%) patients, respectively. Significant differences (P < 0.05) in demographics and clinico-laboratory characteristics were observed between patients with DS-TB and DR-TB. Logistic regression analysis revealed age ≤38 years (OR: 2.5), single marital status (OR: 11.1), tobacco use (OR: 2.9), previous treatment (OR: 19.2), treatment failure (OR: 9.2) and cavity on chest X-ray (OR: 30.1) as independent risk factors for MDR-TB. However, XDR-TB was independently associated with age group of ≤38 years (OR: 13.6), students (OR: 13.0), previous treatment (OR: 12.5), cavity on chest X-ray (OR: 59.6). The independent risk factors associated with RR-TB are age ≤38 years (OR: 2.8), females (OR: 5.7), unemployed (OR: 41.5), treatment failure (OR: 4.9), previous treatment (OR: 38.2) and cavity on chest X-ray (OR: 4.3). ROC curve analysis accentuate the excellent predictive accuracy of all logistic regression models as shown by AUC (0.968, P < 0.001) for MDR-TB, AUC (0.941, P < 0.001) for XDR-TB and AUC (0.962, P < 0.001) for RR-TB.

CONCLUSIONS

Current study demonstrates a sizeable extent of resistant cases among pulmonary TB patients. This study presaged significant risk of DR-TB among females, young adults, unemployed, smokers, patients with previous treatment failure and cavitation on chest X-ray. Timely identification of high risk patients will give pronounced advantages regarding appropriate choices of prevention, treatment and disease control.

The risk of multidrug- or rifampicin-resistance in males versus females with tuberculosis

Males are at an increased risk of tuberculosis (TB) disease compared to females. Additionally, several risk factors for multidrug-resistant (MDR) or rifampicin-resistant (RR) TB disease are more common in males, hence male TB patients may have a higher relative risk of MDR/RR-TB than female TB patients.We used sex-disaggregated data of TB patients reported to the World Health Organization for 106 countries to calculate male-to-female (M:F) risk ratios of having MDR/RR-TB.There was no evidence of either sex being more at risk of MDR/RR-TB in 81% (86 out of 106) of countries, with an overall random-effects weighted M:F risk ratio of 1.04 (95% CI 0.97-1.11). In 12% (13 out of 106) of countries there was evidence that males were more at risk, while in 7% (seven out of 106), females were more at risk. The risk of having TB that was MDR/RR increased for males compared to females as MDR/RR-TB incidence increased, and was higher for males than females in the former Soviet Union, where the risk ratio was 1.16 (1.06-1.28). Conversely, the risk increased for females compared to males as gross domestic product purchase power parity increased, and was higher for females than males in countries where the majority of TB burden was found in the foreign-born population, where the risk ratio was 0.84 (0.75-0.94).In general, the risk of MDR/RR-TB, among those with TB, is the same for males as for females. However, males in higher MDR/RR-TB burden countries, particularly the former Soviet Union, face an increased risk that their infection is MDR/RR-TB, highlighting the need for a sex-differentiated approach to TB case-finding and care.

Determinants of Drug-Resistant Tuberculosis in Southern Ethiopia: A Case-Control Study

Background

In most developing countries, including in Ethiopia, the magnitude and risk factors of drug-resistant tuberculosis (DR-TB) are expected to be high. However, this is not well reported because of lack of laboratory facilities, poor surveillance system and limited reporting. The aim of this study was to determine the risk factors of DR-TB among TB patients in southern Ethiopia.

Patients and Methods

Facility-based case–control study was conducted from November 2016 to January 2017 in Sidama Zone and Gurage Zone of the southern Ethiopia region. DR-TB cases were confirmed by drug-susceptibility testing who were on treatment for DR-TB at Yirgalem and Butajira Hospitals. Controls were smear-positive pulmonary tuberculosis (TB) patients who were taking first-line anti-TB medications and sputum smear-negative at the 5^th month of commencing TB treatment. Data were entered and cleaned using EPI-Info version 7 software and analyzed using SPSS version 22 statistical software.

Results

A total of 84 cases and 243 controls participated in the study. About 59% (49 cases) and 55% (132 controls) were male. The median (interquartile range) age was 28 (21–37) years for cases and 27 (25–33) years for controls. Living in a one-roomed house (adjusted odds ratio [AOR]: 6.8, 95% CI: 1.8–25.8), history of contact with DR-TB cases (AOR: 6.8, 95% CI: 1.8–25.3), treatment failure TB cases (AOR: 4.2, 95% CI: 1.1–15.5) and relapsed TB cases (AOR: 4.8, 95% CI: 1.3–18.1) were independent factors associated with DR-TB.

Conclusion

Providing standardized first-line regimen for new case and retreatment TB cases and practicing basic TB-infection control measures could help to minimize the spread of DR-TB.

Different macrophage polarization between drug-susceptible and multidrug-resistant pulmonary tuberculosis

BACKGROUND

Macrophages play a key role in the infection process, and alternatively activated macrophages (M2 polarization) play important roles in persistent infection via the immune escape of pathogens. This suggests that immune escape of pathogens from host immunity is an important factor to consider in treatment failure and multidrug-resistant tuberculosis (MDR-TB)/extensively drug-resistant tuberculosis (XDR-TB). In this study, we investigated the association between macrophage polarization and MDR-TB/XDR-TB and the association between macrophage polarization and the anti-TB drugs used.

METHODS

iNOS and arginase-1, a surface marker of polarized macrophages, were quantified by immunohistochemical staining and imaging analysis of lung tissues of patients who underwent surgical treatment for pulmonary TB. Drug susceptibility/resistance and the type and timing of anti-tuberculosis drugs used were investigated.

RESULTS

The M2-like polarization rate and the ratio of the M2-like polarization rate to the M1-like polarization rate were significantly higher in the MDR-TB/XDR-TB group than in the DS-TB group. The association between a high M2-like polarization rate and MDR-TB/XDR-TB was more pronounced in patients with a low M1-like polarization rate. Younger age and a higher M2-like polarization rate were independent associated factors for MDR-TB/XDR-TB. The M2-like polarization rate was significantly higher in patients who received anti-TB drugs containing pyrazinamide continuously for 4 or 6 weeks than in those who received anti-TB drugs not containing pyrazinamide.

CONCLUSIONS

The M2-like polarization of macrophages is associated with MDR-TB/XDR-TB and anti-TB drug regimens including pyrazinamide or a combination of pyrazinamide, prothionamide and cycloserine.

Factors associated with multi-drug-resistant tuberculosis in Dakar, Senegal, 2010-2016

According to the World Health Organization, multidrug-resistant tuberculosis (MDR-TB) represents a major obstacle towards successful TB treatment and control. In Dakar, MDR-TB management began in 2010 with the strengthening of diagnostic resources. The objective of this study was to identify the factors associated with multidrug-resistant tuberculosis in Dakar between 2010 and 2016. We conducted a case-control study from January 10 to February 28, 2017 in tuberculosis centers in Dakar. of 169 cases and 507 controls. We used logistic regression with Epi-info version 7.2.1. to estimate the odds ratios of association. Factors significantly associated with MDR-TB were: residing in a periurban area (ORa=1.8; 95% CI (1.5-4.9); p=0.024), presence of MDR-TB in the entourage of patient (ORa=7.0; 95% CI (6.1-9.5); p=0.002), previous treatment failure (ORa=29.5; 95% CI (27.3-30.1); p=0.000), treatment not directly observed by a health care provider (ORa=4.3; 95% CI (4.1-7,2); p=0.000) and irregularity of treatment (ORa=1.7; 95% CI (0.5-5.4); p=0.037). Focusing interventions on population at-risk will prevent MDR-TB.

Determinants of treatment failure among tuberculosis patients in Kandahar City, Afghanistan: A 5-year retrospective cohort study

Background

Tuberculosis (TB) is a preventable and treatable chronic disease. Afghanistan is among the high-TB-burden countries. The aim of this study is to find the determinants of treatment failure among TB patients in Kandahar City, Afghanistan.

Methods

This was a retrospective cohort study conducted in Kandahar City during a period of 5 years (August 2014-July 2019). For data analysis; descriptive statistics, Chi-square test, and logistic regression were used.

Results

Among 1416 TB patients, 894/1416 (63.1%) had pulmonary TB (PTB), whereas 522/1416 (36.9%) had extrapulmonary TB (EPTB). Mean age in these patients was 34.7 years while most of them were females in PTB (530/894 [59.3%]) and EPTB (340/522 [65.1%]) patients. Sputum smear was positive in 618/860 (71.9%) and 16/404 (4%) of PTB and EPTB patients, respectively. TB treatment failure was more in PTB (56/894 [6.3%]) than EPTB (4/522 [0.8%]). Chi-square test of TB cases showed that statistically significant determinants that may cause the treatment failure were re-treatment cases (crude odds ratio [COR] 7.7, P < 0.001), absence of fever (COR 5.2, P < 0.001), absence of cough (COR 1.7, P = 0.004), living in rural areas (COR 1.4, P = 0.035), and no weight loss (COR 1.3, P = 0.033). Binary logistic regression of the statistically significant variables revealed only absence of fever (adjusted odds ratio 6.0, P < 0.001) as the risk factor for treatment failure in TB patients.

Conclusion

TB is still a major threat for Kandahar City. Low treatment success rate and increased number of defaulted cases are the major threats.

Rifampicin resistance among notified pulmonary tuberculosis (PTB) cases in South-Southern Nigeria

Background

Rifampicin resistant pulmonary tuberculosis (RR-PTB) remains a global health burden especially in low income countries and among HIV positive individuals.

Objective

This study seeks to measure the prevalence of RR-PTB among confirmed PTB cases in Delta State South-Southern, Nigeria and to determine the correlation between various factors affecting the prevalence of RRTB among notified pulmonary TB cases.

Material and methods

The study is cross-sectional and retrospective in design and was carried out in Delta State, South-Southern Nigeria among participants with notified pulmonary TB cases. Gene Xpert registers for the selected facilities (Central Hospital Warri, Central Hospital Sapele and Federal Medical Center Asaba) for the year 2017 were retrieved, data extracted and analyzed.

Result

Prevalence of RR-PTB was 7.3% (47/643). Majority (11.3% and 11.4%) of RR-PTB cases were among ages 0–20 and 61–80 years respectively. The male group and HIV negative participants gave rates of 9.1% and 7.8% respectively. Rates reported for location of residence revealed that Delta Central had a rate that doubled Delta South and tripled Delta North.

Conclusion

Although our study figures are lower when compared to other reports for the study region, age grades 0–20 and 61–80 years, the male gender and residence in Delta Central were highlighted as independent variables that influence the distribution of RR-PTB. While a call for the sustenance and if possible augmentation of control and eradication efforts is of high essence, further studies aimed at identifying and understanding co-variables to the ones highlighted are recommended.

Effect of passive exposure to cigarette smoke on blood pressure in children and adolescents: a meta-analysis of epidemiologic studies

Background

Hypertension is an emerging disease in children and adolescents resulting in future morbidities. Cigarette smoking is one of the most studied contributing factors in this regard; however, there are contradictory results among different studies. Therefore, the present meta-analysis tends to assess the relationship between passive exposure to cigarette smoke and blood pressure in children and adolescents.

Method

Medline, Embase, Scopus, EBSCO, and Web of Sciences were systematically reviewed for observational studies up to May, 2017, in which the relationship between cigarette smoking and hypertension were assessed in children and adolescents. The meta-analysis was performed with a fixed effect or random effects model according to the heterogeneity.

Results

Twenty-nine studies were included in present meta-analysis incorporating 192,067 children and adolescents. Active smoking (pooled OR = 0.92; 95% CI: 0.79 to 1.05) or passive exposure to cigarette smoke (pooled OR = 1.01; 95% CI: 0.93 to 1.10) were not associated with developing hypertension in the study population. Despite the fact that active cigarette smoking did not significantly affect absolute level of systolic and diastolic blood pressure, it was shown that passive exposure to cigarette smoke leads to a significant increase in absolute level of systolic blood pressure (pooled coefficient = 0.26; 95% CI: 0.12 to 0.39).

Conclusion

Both active and passive cigarette smoking were not associated with developing hypertension in children and adolescents. However, passive cigarette smoke was associated with higher level of systolic blood pressure in children and adolescents.

Factors Associated with the Development of Secondary Multidrug-resistant Tuberculosis

Background

Spread of multidrug-resistant tuberculosis (TB) is a threat to India's TB control program. We conducted this study with the objective to determine the risk factors for the development of secondary multidrug-resistant TB.

Methods

We conducted an unmatched case-control study involving 247 multidrug-resistant TB patients as "cases" and 494 individuals who were declared as "cured" after category I DOTS treatment as "controls." Data were collected through face-to-face interviews and review of treatment records. Multivariable logistic regressions were used to analyze the collected data.

Results

The mean duration for which cases took first-line anti-TB drug was 19.7 months. The mean duration between initial diagnosis of TB and diagnosis of multi-drug resistant TB (MDR-TB) was 28.3 months. In our study, 26.7%, 50.2%, and 23.1% of MDR-TB cases had one, two, or more previous episodes of TB before being diagnosed as MDR-TB. In multivariable analysis, low or no formal education (album-oriented rock [AOR] =1.63 [confidence interval (CI) = 1.03-3.11]), labor occupation (AOR = 2.15 [CI = 1.18-3.90]), smoking (AOR = 2.56 [CI = 1.19-3.26]), having HIV (AOR = 9.45 [CI = 6.80-15.9]), migration for job (AOR = 3.70 [CI = 1.96-5.67]), stopping TB treatment due to comorbid conditions (AOR = 8.86 [CI = 5.45-11.2]), and having type 2 diabetes (AOR = 3.4 [CI = 1.96-5.16]) were associated with MDR-TB.

Conclusions

Government of India should devise strategy to prevent interruption of treatment to stop the emergence and spread of MDR-TB. We need to better integrate TB control activities with diabetes and tobacco control programs for better health outcome among patients.

Drug resistance profile of Mycobacterium tuberculosis and predictors associated with the development of drug resistance

OBJECTIVES

Drug-resistant tuberculosis (DR-TB) is a major challenge to national TB control programmes in developing countries. In the Pakistan province of Punjab, the extent and development of DR-TB is not well known. The current study was therefore conducted to assess the incidence and predictors of DR-TB in Punjab Province.

METHODS

Drug susceptibility testing was performed for 863 confirmed culture-positive Mycobacterium tuberculosis isolates using the proportion method. Patients were enrolled in the Programmatic Management of Drug-Resistant TB Unit of Gulab Devi Chest Hospital (Lahore, Pakistan) from August 2011 to September 2013. Data analysis was performed using IBS SPSS Statistics v.20. Multivariate logistic regression analysis was performed to assess risk factors for DR-TB.

RESULTS

The rate of resistance to at least one drug (i.e. DR-TB) was 35.0% (302/863) and the rate of multidrug-resistant TB (MDR-TB) was 30.0% (259/863). Among DR-TB cases, the number of females was relatively higher (167/302; 55.3%) compared with males. The majority of DR-TB patients resided in a rural area (229/302; 75.8%). Significant predictors of DR-TB were age 18-45 years, previous TB treatment, rural residence, being a housewife, being married, duration of sickness >1year and unemployment.

CONCLUSION

The problem of DR-TB in Pakistan is significant. The strongest risk factors were young age and previous anti-TB treatment. Being married, being a housewife, rural residence and unemployment were also risk factors, culminating in an urgent need for effective control, early diagnosis and treatment policies for DR-TB.

Clinical risk factors associated with multidrug-resistant tuberculosis (MDR-TB) in Mali

Background

MDR-TB is a major threat to global TB control. In 2015, 580,000 were treated for MDR-TB worldwide. The worldwide roll-out of GeneXpert MTB/RIF^® has improved diagnosis of MDR-TB; however, in many countries laboratories are unable to assess drug resistance and clinical predictors of MDR-TB could help target suspected patients. In this study, we aimed to determine the clinical factors associated with MDR-TB in Bamako, Mali.

Methods

We performed a cross-sectional study of 214 patients with presumed MDR-TB admitted to University of Bamako Teaching Hospital, Point-G between 2007 and 2016. We calculated crude and adjusted odds ratios for MDR-TB disease diagnosis using SPSS.

Results

We found that age ≤40years (OR = 2.56. 95% CI: 1.44–4.55), two courses of prior TB treatment (OR = 3.25,95% CI: 1.44–7.30), TB treatment failure (OR = 3.82,95% CI 1.82–7.79), sputum microscopy with 3+ bacilli load (OR = 1.98, 95% CI: 1.13–3.48) and a history of contact with a TB patient (OR = 2.48, 95% CI: 1.11–5.50) were significantly associated with confirmation of MDR-TB disease. HIV was not a risk factor for MDR-TB (aOR = 0.88, 95% CI: 0.34–1.94).

Conclusion

We identified several risk factors that could be used to identify MDR-TB suspects and prioritize them for laboratory confirmation. Prospective studies are needed to understand factors associated with TB incidence and clinical outcomes of TB treatment and disease.

Risk factors of multidrug-resistant tuberculosis in China: A meta-analysis

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) brings major challenges to the health care workers (HCWs). This study is to determine the risk factors for MDR-TB, latent tuberculosis infection (LTBI), and tuberculosis (TB) disease among HCWs in China.

METHODS

A meta-analysis was conducted to evaluate the risk factors for MDR-TB, LTBI, and TB disease among HCWs using a random-effects model, and the pooled odds ratios (ORs) with 95% confidence interval (CI) were used as effect indicators.

RESULTS

We identified 46 eligible studies and found eight factors were associated with MDR. The ORs with 95% CI are migrant population 1.96 (95% CI, 1.50-2.57), low family income 2.23 (95% CI, 1.74-2.85), retreatment 7.22 (95% CI, 5.63-9.26), anti-TB treatment history 5.65 (95% CI, 4.80-6.65), multiple episodes of treatment 3.28 (95% CI, 2.60-4.13), adverse reactions 3.48 (95% CI, 2.54-4.76), interrupted treatment 3.18 (95% CI, 2.60-3.89), and lung cavities 1.42 (95% CI, 1.14-1.77). Work duration as a HCW for 5 years and above increased the risk of LTBI and TB. HCWs aged 30 years and above were more susceptible to TB (OR = 1.70, 95% CI: 1.37-2.09).

CONCLUSION

The risk factors for MDR-TB in China are possibly migrant population, low family income, retreatment, anti-TB treatment history, adverse reactions, interrupted treatment, and lung cavities. Longer work duration and greater age are risk factors for LTBI and TB among HCWs.

Risk factors of multidrug-resistant tuberculosis: A global systematic review and meta-analysis

OBJECTIVES

Since the risk of multidrug-resistant tuberculosis (MDR-TB) may depend on the setting, we aimed to determine the associations of risk factors of MDR-TB across different regions.

METHODS

A systematic review and meta-analysis was performed with Pubmed and Embase databases. Information was retrieved on 37 pre-defined risk factors of MDR-TB. We estimated overall Mantel-Haenszel odds ratio as a measure of the association.

RESULTS

Factors of previous TB disease and treatment are the most important risk factors associated with MDR-TB. There was also a trend towards increased risk of MDR-TB for patients 40 years and older, unemployed, lacking health insurance, smear positive, with non-completion and failure of TB treatment, showing adverse drug reaction, non-adherent, HIV positive, with COPD and with M. Tuberculosis Beijing infection. Effect modification by geographical area was identified for several risk factors such as male gender, married patients, urban domicile, homelessness and history of imprisonment.

CONCLUSIONS

Assessment of risk factors of MDR-TB should be conducted regionally to develop the most effective strategy for MDR-TB control. Across all regions, factors associated with previous TB disease and treatment are essential risk factors, indicating the appropriateness of diagnosis, treatment and monitoring are an important requirements.

Risk factors for the occurrence of multidrug-resistant tuberculosis among patients undergoing multidrug-resistant tuberculosis treatment in East Shoa, Ethiopia

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is resistant to the two main first-line anti-tuberculosis drugs: rifampicin and isoniazid. It is a major threat to public health worldwide. The objective of this study was to assess the potential risk factors for multidrug-resistant tuberculosis among patients undergoing MDR-TB treatment at two community hospitals in Ethiopia.

METHODS

A case-control study design was conducted from February 1, 2016, to April 29, 2016. TB-positive patients with MDR-TB and non-MDR-TB were considered as cases and controls, respectively. A total of 219 study participants were included in the study. An interviewer-administered structured questionnaire was used to collect primary data from the patients, and a checklist was used to collect data from the clinical records. Bivariate and multivariate logistic regression analyses were used to assess the potential risk factors for the occurrence of MDR-TB.

RESULTS

The odds of developing MDR-TB were higher in patients previously treated with anti-TB drugs (odds ratio [OR] = 6.1, 95%CI: 2.92-12.62, P < 0.001), those with a history of contact with known TB patients (OR = 2.1, 95%CI: 1.04-4.43, P < 0.001), those living in a rural setting (OR = 5.6, 95%CI: 2.14-14.46, P = 0.001), those with a history of alcohol consumption (OR = 4.3, 95%CI: 2.29-10.49, P < 0.001) and those without a job (OR = 2.4, 95%CI: 1.06-5.42, P = 0.001).

CONCLUSIONS

The study revealed that contact with known TB patients, previous TB treatment, residence area, lack of a job, and alcohol consumption were potential risk factors for the occurrence of MDR-TB. Enhancing public health education, intensifying directly observed therapy programmes for all TB patients and designing control strategies are recommended.

Association of Immune Factors with Drug-Resistant Tuberculosis: A Case-Control Study

Background

Presently, studies of factors associated with drug-resistant tuberculosis (TB) focus on patients’ socio-demographic characteristics and living habits, to the exclusion of biochemical indicators, especially immune factors. This study was carried out to determine whether immune factors are associated with drug-resistant TB.

Material/Methods

A total of 227 drug-resistant pulmonary TB patients and 225 drug-susceptible pulmonary TB patients were enrolled in this study. Information on socio-demographic characteristics and biochemical indicators were obtained through their clinical records. Non-conditional logistic regression was used to analyze the association of these indicators with drug-resistant TB.

Results

There were significant differences in re-treatment, marital status, alanine aminotransferase (ALT), blood uric acid (BUA), carcino-embryonic antigen (CEA), T-spot, and CD3 and CD4 counts between the 2 groups. In multivariable analysis, re-treatment [Odds Ratio (OR)=5.290, 95% Confidence Interval [CI]=2.652–10.551); CD3 (OR=1.034, 95% CI=1.001–1.068); CD4 (OR=1.035, 95% CI =1.001–1.070) and IgM (OR=1.845, 95% CI=1.153–2.952) were associated with drug-resistant TB.

Conclusions

These results suggest the need for greater attention to re-treatment cases and immune function when treating drug-resistant TB.

[Risk factors for multidrug-resistant tuberculosis in the city of Kinshasa in the Democratic Republic of Congo]

Introduction

L'objectif de cette étude était de déterminer les facteurs de risque associés à la tuberculose multi résistance à Kinshasa en République Démocratique du Congo.

Méthodes

Il s'agissait d'une étude cas témoins. Les cas comprenaient tous les patients tuberculeux résistants à la rifampicine et à l'isoniazide notifiés à Kinshasa de janvier 2012 à juin 2013. Les témoins étaient les patients tuberculeux traités durant la même période que les cas et qui à la fin du traitement étaient déclarés guéris. Pour cette étude, nous avons obtenu une clairance éthique.

Résultats

L’échantillon était constitué de 213 participants dont 132 hommes (62%) et 81 femmes (38%). L’âge médian était de 31ans (16-73 ans). Les facteurs associés significatifs (p< 0,05) à la tuberculose multi résistante étaient le non-respect des heures de prise de médicaments (0R = 111) (80% chez les cas et 4% chez les témoins), l’échec au traitement (0R = 20) (76% chez les cas et 13% chez les témoins); la notion de tuberculose multi résistante dans la famille (0R = 6.4) (28% chez les cas et 6% chez les témoins); la méconnaissance de la tuberculose multi résistante (0R = 3.2) (31% chez les cas et 59% chez les témoins); un séjour en prison (0R = 7.6) (10% chez les cas et 1% chez les témoins) et l'interruption du traitement (0R = 6.1) ( 59% chez les cas et 19% chez les témoins).

Conclusion

L’émergence de la tuberculose multi résistante peut être évitée par la mise en place des stratégies de diagnostic et de traitement appropriées.