Prevalence of and risk factors for multidrug-resistant tuberculosis in Iran and its neighboring countries: systematic review and meta-analysis

Risk factors associated with multidrug-resistant tuberculosis in areas with a moderate tuberculosis burden

BACKGROUND

The emergence of multidrug-resistant tuberculosis (MDR-TB) or rifampicin-resistant (RR) TB poses a significant challenge for TB control initiatives on a global scale. This study's aim was to estimate the incidence of MDR-/RR-TB and identify the risk factors associated with their incidence in four provinces in northern Iran.

METHODS

Drug susceptibility testing was conducted using the proportion method on Lowenstein-Jensen media. The demographic and clinical data were collected from the Iranian TB registry.

RESULTS

Among 1083 individuals diagnosed with TB, 27 (2.5%) were identified as having MDR-/RR-TB, while 73 cases (6.7%) were any drug resistant (ADR). The statistical analysis revealed a significant association between marital status and MDR-/RR-TB (p=0.003). In addition, significant associations were observed between ADR-TB and gender (p=0.035) and previous treatment for TB (p=0.02).

CONCLUSIONS

Our findings provide important information on the drug resistance pattern of Mycobacterium tuberculosis strains, as well as risk factors in northern Iran. Given the identified risk factors, creative approaches to promote treatment adherence in TB patients, particularly divorced/widowed women and individuals with a previous history of TB treatment, are required.

Trends and risk factors for drug-resistant tuberculosis among children in Sichuan, China: A 10-year retrospective analysis, 2013-2022

To investigate the status of the drug-resistant tuberculosis (DR-TB) among children in Sichuan, and to find out the risk factors and high-risk population related to drug resistance among children. The clinical data of tuberculosis patients ≤14 years old with culture-confirmed tuberculosis hospitalized in Chengdu Public Health Clinical Center from January 2013 through December 2022 were collected. Clinical data such as gender, age, ethnicity, history of anti-TB treatment, history of exposure to tuberculosis, nutritional status, and specific drug resistance of the children were collected and recorded. The drug resistance of children in different age groups (0-4 years old, 5-9 years old, 10-14 years old) and different periods (2013-2017 and 2018-2022) were grouped and compared. Logistic regression analysis was to analyze analysis of risk factors of drug resistance in children. A total of 438 children with culture-confirmed tuberculosis were screened. Among them, 26.19% (11/42) were 0 to 4 years old, 33.33% (22/66) were 5 to 9 years old, and 36.67% (121/330) were 10 to 14 years old among the resistant children. There was no statistically significant difference in the resistance rate among the 3 groups (P = .385). The proportions of DR-TB, monoresistant tuberculosis, polydrug-resistant tuberculosis were decreased during 2019 to 2022 compared with 2013 to 2017 (P < .0001). The resistance rates of drug resistant, monoresistant, polydrug-resistant, isoniazid-resistant, and rifampicin resistant during 2018 to 2022 were decreased compared with those from 2013 to 2017 (P < .05), but the multi-drug resistance rate was not decreased (P = .131, without statistical difference). The results of logistic regression analysis showed that male gender OR = 1.566 (95% CI 1.035-2.369), a history of antituberculosis therapy OR = 4.049 (95% CI 1.442-11.367), and pulmonary and extrapulmonary tuberculosis OR = 7.335 (95% CI 1.401-38.392) were risk factors for the development of drug resistance; but fever OR = 0.581 (95% CI 0.355-0.950) was Protective factor. The total drug resistance rate of children in Sichuan showed a downward trend, but the rate of multi-drug-resistant tuberculosis was still at a high level, and the form of drug resistance was still severe. Absence of fever, male, retreatment, and pulmonary concurrent with extrapulmonary tuberculosis are risk factors for DR-TB in children.

Health condition of Afghan refugees residing in Iran in comparison to Germany: a systematic review of empirical studies

BACKGROUND

The re-emerging dominance of the Taliban in Afghanistan in 2021 caused a new wave of Afghan refugees heading Iran and neighboring countries. Iran in the Middle East and Germany in Europe are two major host countries to the largest populations of Afghan refugees. In both countries, several studies have been done to assess the health condition of refugees.

OBJECTIVES

To systematically review the existing literature to identify similarities and differences of health conditions of Afghan refugees living in the two countries, and to synthesize evidence on the health status and health care access of these populations.

METHODS

Related electronic databases and grey literature of Iran and Germany on the health of Afghan refugees were scanned and searched up for the period 2000-2020. Key terms were formed by combining "Afghan refugees or immigrants or populations or asylum seekers", "Physical or mental health", "Healthcare service or access or use", "Iran or Germany". Empirical studies were considered if they contained samples of Afghan refugees with particular outcomes for Afghans. Results were categorized for both countries in the three main areas of physical health, mental health, and access/use of healthcare services.

RESULTS

Nine hundred twenty-two documents were extracted, of which 75 full-texts were finally reviewed. 60 documents belonged to the health condition of Afghan refugees residing in Iran including 43 in physical health, 6 in mental health, 8 in healthcare access and use, and 3 in multiple aspects of health, and 15 belonged to Germany including 7 in physical health, 4 in mental health, 2 in healthcare access and use, and 2 in multiple aspects of health. A less explicit evaluation of the overall health condition of Afghan refugees was observable, particularly for Germany. While matches on the study subject exist for both countries, in comparison to Germany, we extracted more quantitative and qualitative health studies on Afghan refugees of the mentioned areas from Iran. German health studies were rare, less qualitative, and more on the health condition of diverse refugee groups in general.

CONCLUSIONS

Wide gaps and unanswered questions related to mental health and overall health status of the Afghan refugee population are observable, especially in Germany. Our systematic review identified the gap in evidence, which we would recommend to bridge using a wider lens to comprehensively assess the overall condition of refugees considering associations between health and socio-economic and cultural determinants instead of a one-dimensional approach. Further, within health studies on refugee populations, we recommend stratification of results by the country of origin to capture the within-group diversity among refugees with different countries of origin.

Risk factors associated with drug-resistant tuberculosis in Ethiopia: A systematic review and meta-analysis

The emergence of drug-resistant tuberculosis (DR-TB) is becoming a challenge to the national TB control programmes including Ethiopia. Different risk factors are associated with DR-TB. Identifying these risk factors in a local setting is important to strengthen the effort to prevent and control DR-TB. Thus, this study aimed to assess the risk factors associated with DR-TB in Ethiopia. The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist was followed to conduct this study. We systematically searched the articles from electronic databases and grey literature sources. We used the JBI tools to assess the quality of studies. Data were analysed using STATA version 15. We estimated the pooled odds ratio (OR) along with 95% Confidence Interval (CI). The forest plot and I2 heterogeneity test were used to assess heterogeneity among studies. We explored the presence of publication bias through visual inspection of the funnel plot and Egger's regression test. After screening 2238 articles, 27 studies were included in the final analysis. Based on the pooled analysis of the OR, unemployment (OR; 2.71, 95% CI; 1.64, 3.78), previous TB history (OR; 4.83, 95% CI; 3.02, 6.64), contact with known TB patient (OR; 1.72, 95% CI; 1.05, 2.40), contact with the known multi-drug resistant (MDR) TB patient (OR; 2.54, 95% CI; 1.46, 3.63) and having pulmonary TB (PTB; OR; 1.80, 95% CI; 1.14, 2.45) were found to be the risk factors of DR-TB, while elders (OR; 0.77, 95%CI; 0.60, 0.95) including above 45 years (OR; 0.76, 95%CI; 0.55, 0.97) and males (OR; 0.86, 95%CI; 0.76, 0.97) had lower DR-TB risk, compared to their counterparts. A previous history of TB treatment is a major risk factor for acquiring DR-TB in Ethiopia that might be due to poor adherence during the first-line anti-TB treatment. Besides, having contact with a TB patient, contact with an MDR-TB patient, having PTB and being unemployed were the risk factors of DR-TB in Ethiopia. Thus, active screening of TB contacts for DR-TB might help to detect DR-TB cases as early as possible and could help to mitigate its further transmission across the community.

Prevalence and Drug Resistance Pattern of Mycobacterium tuberculosis Isolated from Tuberculosis Patients in Basra, Iraq

Drug-resistant Mycobacterium tuberculosis (DR-MTB) is a major health threat to human beings. This study aimed to evaluate the prevalence and drug resistance profile of MTB. Data were collected from 2,296 newly diagnosed, and 246 retreated tuberculosis (TB) patients who attended the Advisory Clinic for Chest Diseases and Respiratory in Basra province from January 2016 to December 2020. Both new diagnostic and retreated TB cases showed that DR-MTB cases were significantly higher at age 15–34 years, pulmonary TB, and urban residents but with no significant difference regarding gender. The drugs resistance was significantly higher among the retreated cases compared with the new diagnostic patients (20.3% vs. 2.4%, p < 0.0001), with the percentage of the resistance to first-line drugs in primary and secondary cases including isoniazid (1% and 17.1%), rifampicin (0.78% and 15.8%), ethambutol (0.56% and 8.5%), streptomycin (1.3% and 9.75%). Notice that the most common drug resistance was against streptomycin with 1.3% in new patients and against isoniazid (17.1%) in retreated patients. The rate of total drug-resistant TB, multi-drug resistant TB, mono-drug resistant TB, and rifampicin-resistant TB among new tuberculosis cases increased in this period from 2.2 to 6.7%, 0.17 to 1.6%, 0.85 to 4%, and 0.17 to 4%, with a percentage change of 204.54, 841.17, 370.58, 22.5%, respectively. The rates of poly drug-resistant TB and ethambutol-resistant-TB dropped in this period by 15.96%, and 0.7%, with a decrease from 1.19 to 1% and from 1 to 0.3%, respectively. Similarly, the increase of drug-resistant TB among secondary cases has also occurred. In conclusion, the temporal trend showed an increase in the rate of drug resistance of M. tuberculosis since 2016, with a predominant multi-drug-resistant TB and isoniazid-resistant TB.

Drug resistance and its risk factors among extrapulmonary tuberculosis in Ethiopia: A systematic review and meta-analysis

Background

Drug-resistant tuberculosis and extrapulmonary tuberculosis are the world major public health issues. Although some primary studies have been reported on the burden of drug-resistant tuberculosis in extrapulmonary tuberculosis patients in Ethiopia, there is no systematic review and meta-analysis that attempt to summarize the available literature. Thus, we aimed to estimates the prevalence of drug-resistance in extrapulmonary tuberculosis patients and summarize the risk factors associated with the occurrence of extrapulmonary tuberculosis in Ethiopia.

Methods

We conducted a systematic review of the published primary studies on extrapulmonary drug-resistant tuberculosis in Ethiopia.

Results

Eight observational studies were included in this review from different regions of Ethiopia. The overall pooled prevalence of rifampicin resistance was 6% (95% CI 0.03–0.10), while isoniazid resistance was 7% (95% CI 0.03–0.12). The pooled prevalence of multidrug-resistant tuberculosis was 4% (95% CI 0.01–0.07). Previous tuberculosis treatment history and male gender are frequently reported risk factors for developing drug-resistant tuberculosis in extrapulmonary tuberculosis patients.

Conclusion

The current review has identified a high proportion of resistance to rifampicin, isoniazid, and multidrug-resistant tuberculosis in patients with extrapulmonary tuberculosis in Ethiopia. Clinicians should request drug susceptibility testing for all patients with presumptive extrapulmonary tuberculosis to detect drug-resistance.

Evaluation of Accuracy of Microplate Alamar Blue Assay and Proportion Method for Prompt Detection of Mycobacterium tuberculosis and Clinical Isolates of Multidrug-resistant M. tuberculosis

Background: Tuberculosis is appraised to cause the deaths of more than a billion people in the last decades. Objectives: The current study compares the performance of microplate Alamar blue assay for clinical isolates of Mycobacterium tuberculosis and multidrug-resistant tuberculosis. Microplate Alamar blue assay was performed in a central tuberculosis laboratory at Golestan University of Medical Sciences in Gorgan, Iran. Methods: In the first step, the microplate Alamar blue assay was used for the detection of 78 clinical isolates in the Golestan regional tuberculosis reference laboratory, and the results were compared with those of the proportion assay. In the second step, the microplate Alamar blue assay and the proportion assay were used for the drug-susceptibility of 35 isolates. Results: In the microplate Alamar blue assay, the sensitivity was 100 (90.97 - 100), with a specificity of 74.36 (57.87 - 86.96), positive predictive value of 79.59 (65.66 - 89.76), and negative predictive value of 100 (88.06 - 100). For the microplate Alamar blue assay with rifampin, the sensitivity was 100 (89.11 - 100), specificity was 100 (29.24 - 100), positive predictive value was 100 (89.11 - 100), and negative predictive value was 100 (29.24 - 100). For the microplate Alamar blue assay with isoniazid, the sensitivity was 84.38 (67.21 - 94.72), specificity was 66.67 (9.43 - 99.16), positive predictive value was 96.43 (81.65 - 99.91), and negative predictive value was 28.57 (3.67 - 70.96). Conclusions: We found high accuracy between the microplate Alamar blue assay with rifampin and the proportion assay. The rapid and low-cost microplate Alamar blue assay is an inexpensive and appropriate assay for the detection of rifampin-resistant tuberculosis in low-income countries.

Spatio-temporal epidemiology of the tuberculosis incidence rate in Iran 2008 to 2018

Background

Effective reduction of tuberculosis (TB) requires information on the distribution of TB incidence rate across time and location. This study aims to identify the spatio-temporal pattern of TB incidence rate in Iran between 2008 and 2018.

Methods

This cross-sectional study was conducted on aggregated TB data (50,500 patients) at the provincial level provided by the Ministry of Health in Iran between 2008 and 2018. The Anselin Local Moran’s I and Getis-Ord Gi* were performed to identify the spatial variations of the disease. Furthermore, spatial scan statistic was employed for purely temporal and spatio-temporal analyses. In all instances, the null hypothesis of no clusters was rejected at p ≤ 0.05.

Results

The overall incidence rate of TB decreased from 13.46 per 100,000 (95% CI: 13.19–13.73) in 2008 to 10.88 per 100,000 (95% CI: 10.65–11.11) in 2018. The highest incidence rate of TB was observed in southeast and northeast of Iran for the whole study period. Additionally, spatial cluster analysis discovered Khuzestan Province, in the West of the country, having significantly higher rates than neighbouring provinces in terms of both total TB and smear-positive pulmonary TB (SPPTB). Purely temporal analysis showed that high-rate and low-rate clusters were predominantly distributed in the time periods 2010–2014 and 2017–2018. Spatio-temporal results showed that the statistically significant clusters were mainly distributed from centre to the east during the study period. Some high-trend TB and SPPTB statistically significant clusters were found.

Conclusion

The results provided an overview of the latest TB spatio-temporal status In Iran and identified decreasing trends of TB in the 2008–2018 period. Despite the decreasing incidence rate, there is still need for screening, and targeting of preventive interventions, especially in high-risk areas. Knowledge of the spatio-temporal pattern of TB can be useful for policy development as the information regarding the high-risk areas would contribute to the selection of areas needed to be targeted for the expansion of health facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11157-1.

Tuberculosis in Iran: a historical overview from al-Tabari, Rhazes, Avicenna and Jorjani to Abolhassan Ziyā-Zarifi. Old and new pioneers in the fight against tuberculosis: challenges, pitfalls and hopes

Tuberculosis is a serious respiratory infectious disease, caused by Mycobacterium tuberculosis bacteria. It has always represented a permanent, serious public health challenge over the course of human history, because of its severe epidemiological, clinical and societal implications. The present review aims at over-viewing the contributions of the Iranian medicine to the control, management and treatment of tuberculosis, from the glorious past of the eighth-ninth centuries to the present, from Ali Abu al-Hasan Ahmad ibn Sahl-e Rabban al-Tabari to Rhazes, Avicenna, Jorjani and Abolhassan Ziyā-Zarifi. However, despite the efforts, tuberculosis and, in particular, multidrug-resistant tuberculosis still represent a great public health concern in Iran. On the other hand, this country can capitalize on its millennial, incredibly rich story of major achievements in the battle against tuberculosis to develop and implement ad hoc public health programs for the control of the disorder, including targeted and specialized interventions.

Determining Mycobacterium tuberculosis Drug Resistance and Risk Factors for Multidrug-Resistant Tuberculosis in Sputum Smear-Positive Tuberculosis Outpatients in Anhui Province, China, 2015-2016

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is currently a major problem in China. The prevention and treatment work for MDR-TB patients started late in Anhui province. To determine the prevalence of MDR-TB in sputum smear-positive TB patients (SSPTBPs) and analyze the risk factors for MDR-TB in Anhui province, we conducted an investigation of drug resistance among SSPTB outpatients from September 2015 to August 2016.

METHODS

A stratified cluster-randomized sampling method was used to obtain a representative sample. It was estimated that 2290 new cases and 440 previously treated cases of SSPTBPs needed to be recruited from 40 survey sites. Isolates were tested for resistance to six first-line and second-line anti-TB drugs. Information from patient questionnaire survey was used to identify factors linked to MDR-TB.

RESULTS

Finally, a total of 3047 SSPTBPs were recruited from 40 survey sites; of these, 2530 specimens were successfully cultured and had drug susceptibility testing done. The proportions of rifampin resistant (RR)-TB were 11.42% (289/2530, 95% CI: 10.18-12.66%), 7.64% (163/2133, 95% CI: 6.38-8.62%) and 31.74% (126/397, 95% CI: 27.38-36.60%) in all cases, new cases and previously treated cases, respectively, and the proportions of confirmed MDR-TB were 7.63% (193/2530, 95% CI: 6.59-8.66%), 4.97% (106/2133, 95% CI: 4.05-5.89%) and 21.91% (87/397, 95% CI: 17.83-26.00%), respectively. The ofloxacin resistance rate in previously treated SSPTBPs reached 21.66% (95% CI: 17.33-26.75%). Patients who had received two or more anti-TB treatment courses were significantly associated with MDR-TB compared to patients who have received one anti-TB course.

CONCLUSION

MDR-TB prevalence was high among SSPTBPs in Anhui province, and past anti-TB treatment course was associated with MDR-TB.

Is latent tuberculosis infection challenging in Iranian health care workers? A systematic review and meta-analysis

Background

The high chances of getting latent tuberculosis infection (LTBI) among health care workers (HCWs) will an enormous problem in low and upper-middle-income countries.

Method

Search strategies were done through both national and international databases include SID, Barakat knowledge network system, Irandoc, Magiran, Iranian national library, web of science, Scopus, PubMed/MEDLINE, OVID, EMBASE, the Cochrane library, and Google Scholar search engine. The Persian and the English languages were used as the filter in national and international databases, respectively. Medical Subject Headings (MeSH) terms was used to controlling comprehensive vocabulary. The search terms were conducted without time limitation till January 01, 2019.

Results

The prevalence of LTBI in Iranian’s HCWs, based on the PPD test was 27.13% [CI95%: 18.64–37.7]. The highest prevalence of LTBI in Iranian’s HCWs were estimated 41.4% [CI95%: 25.4–59.5] in the north, and 33.8% [CI95%: 21.1–49.3] in the west. The lowest prevalence of LTBI was evaluated 18.2% [CI95%: 3.4–58.2] in the south of Iran. The prevalence of LTBI in Iranian’s HCWs who had work-experience more than 20 years old were estimated 20.49% [CI95%: 11–34.97]. In the PPD test, the prevalence of LTBI in Iranian’s HCWs who had received the Bacille Calmette–Guérin (BCG) was estimated 15% [CI95%: 3.6–47.73]. While, in the QFT, the prevalence of LTBI in Iranian’s HCWs in non-vaccinated was estimated 25.71% [CI95%: 13.96–42.49].

Conclusions

This meta-analysis shows the highest prevalence of LTBI in Iranian’s HCWs in the north and the west probably due to neighboring countries like Azerbaijan and Iraq, respectively. It seems that Iranian’s HCWs have not received the necessary training to prevent of TB. We also found that BCG was not able to protect Iranian’s HCWs from TB infections, completely.

Prevalence and factors associated with multidrug/rifampicin resistant tuberculosis among suspected drug resistant tuberculosis patients in Botswana

Background

To investigate the prevalence and factors associated with the prevalence of multidrug/rifampicin-resistant tuberculosis among suspected drug resistant tuberculosis patients in Botswana.

Methods

A retrospective review of medical records of suspected drug resistant tuberculosis patients receiving care at public health facilities in Botswana was conducted from January, 2013 and December, 2014. Patient characteristics and drug susceptibility data were abstracted from 2568 medical records on to a pre-tested checklist form. The prevalence of multidrug/rifampicin resistance was computed. Bivariate and multivariate logistic regression was carried out to determine the factors associated with the prevalence of multidrug/rifampicin in the study population.

Results

Overall, multidrug/ rifampicin - resistance among suspected drug resistant tuberculosis patients in Botswana were found in 139 (5.4%) cases with 1.3% among new cases and 7.7% among previously treated tuberculosis patients. Being a previously treated tuberculosis patient and having a positive smear were found to be factors associated with the prevalence of multidrug/rifampicin-resistant tuberculosis (p < 0.05). However, age, sex, living in urban area and HIV status were not associated with this disease (p > 0.05).

Conclusion

This study highlights a low burden of multidrug/rifampicin resistant tuberculosis among suspected drug resistant tuberculosis patients receiving care at public health facilities in Botswana. Strategies in controlling MDR/RR-TB should emphasize on effective implementation of Directly Observation Treatment – short course strategy, continuous surveillance of drug resistance cases, prevention of the development of new cases of MDR/RR-TB and to treat existing patients. Further interventions should focus on strengthening TB infection control activities.