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Meressa D, Hurtado RM, Andrews JR, Diro E, Abato K, Daniel T, Prasad P, Prasad R, Fekade B, Tedla Y, Yusuf H, Tadesse M, Tefera D, Ashenafi A, Desta G, Aderaye G, Olson K, Thim S, Goldfeld AE. Achieving high treatment success for multidrug-resistant TB in Africa: initiation and scale-up of MDR TB care in Ethiopia--an observational cohort study. Thorax 2015; 70:1181-8. [PMID: 26506854 PMCID: PMC4680185 DOI: 10.1136/thoraxjnl-2015-207374] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 09/03/2015] [Indexed: 11/26/2022]
Abstract
Background In Africa, fewer than half of patients receiving therapy for multidrug-resistant TB (MDR TB) are successfully treated, with poor outcomes reported for HIV-coinfected patients. Methods A standardised second-line drug (SLD) regimen was used in a non-governmental organisation–Ministry of Health (NGO-MOH) collaborative community and hospital-based programme in Ethiopia that included intensive side effect monitoring, adherence strategies and nutritional supplementation. Clinical outcomes for patients with at least 24 months of follow-up were reviewed and predictors of treatment failure or death were evaluated by Cox proportional hazards models. Results From February 2009 to December 2014, 1044 patients were initiated on SLD. 612 patients with confirmed or presumed MDR TB had ≥24 months of follow-up, 551 (90.0%) were confirmed and 61 (10.0%) were suspected MDR TB cases. 603 (98.5%) had prior TB treatment, 133 (21.7%) were HIV coinfected and median body mass index (BMI) was 16.6. Composite treatment success was 78.6% with 396 (64.7%) cured, 85 (13.9%) who completed treatment, 10 (1.6%) who failed, 85 (13.9%) who died and 36 (5.9%) who were lost to follow-up. HIV coinfection (adjusted HR (AHR): 2.60, p<0.001), BMI (AHR 0.88/kg/m2, p=0.006) and cor pulmonale (AHR 3.61, p=0.003) and confirmed MDR TB (AHR 0.50, p=0.026) were predictive of treatment failure or death. Conclusions We report from Ethiopia the highest MDR TB treatment success outcomes so far achieved in Africa, in a setting with severe resource constraints and patients with advanced disease. Intensive treatment of adverse effects, nutritional supplementation, adherence interventions and NGO-MOH collaboration were key strategies contributing to success. We argue these approaches should be routinely incorporated into programmes.
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Affiliation(s)
- Daniel Meressa
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia St. Peter's Tuberculosis Specialized Hospital, Addis Ababa, Ethiopia
| | - Rocío M Hurtado
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jason R Andrews
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ermias Diro
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia University of Gondar Hospital, Gondar, Ethiopia
| | - Kassim Abato
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia
| | - Tewodros Daniel
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia
| | - Paritosh Prasad
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Current affiliation: Pulmonary and Critical Care Medicine Division, University of Rochester Medical Center, Rochester, New York, USA
| | - Rebekah Prasad
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Current affiliation: Pediatrics Department, University of Rochester Medical Center, Rochester, New York, USA
| | - Bekele Fekade
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia
| | - Yared Tedla
- St. Peter's Tuberculosis Specialized Hospital, Addis Ababa, Ethiopia
| | - Hanan Yusuf
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia University of Gondar Hospital, Gondar, Ethiopia
| | - Melaku Tadesse
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia
| | - Dawit Tefera
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia University of Gondar Hospital, Gondar, Ethiopia
| | - Abraham Ashenafi
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia
| | - Girma Desta
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia
| | | | - Kristian Olson
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sok Thim
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Cambodian Health Committee, Phnom Penh, Cambodia
| | - Anne E Goldfeld
- Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia Cambodian Health Committee, Phnom Penh, Cambodia Program in Cellular and Molecular Medicine, Children's Hospital Boston, Boston, Massachusetts, USA
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