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Rahman SMM, Ather MF, Nasrin R, Hoque MA, Khatun R, Rahman T, Uddin MKM, Ahmed S, Banu S. Performance of WHO-Endorsed Rapid Tests for Detection of Susceptibility to First-Line Drugs in Patients with Pulmonary Tuberculosis in Bangladesh. Diagnostics (Basel) 2022; 12:diagnostics12020410. [PMID: 35204501 PMCID: PMC8870910 DOI: 10.3390/diagnostics12020410] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/05/2022] [Accepted: 01/25/2022] [Indexed: 12/10/2022] Open
Abstract
The fast and accurate detection of susceptibility in drugs is a major challenge for a successful tuberculosis (TB) control programme. This study evaluated the performance of WHO-endorsed rapid diagnostic tools, such as BACTEC MGIT 960 SIRE (MGIT SIRE), GenoType MTBDRplus (MTBDRplus) and Xpert MTB/RIF (Xpert), for detecting susceptibility to first-line anti-TB drugs among pulmonary TB patients in Bangladesh. A total of 825 sputum samples with results from drug susceptibility testing (DST) against first-line anti-TB drugs in the MGIT SIRE, MTBDRplus and Xpert assays were evaluated and compared with the gold standard proportion susceptibility method of the Lowenstein–Jensen (LJ) medium. The overall sensitivities of MGIT SIRE were 97.6%, 90.0%, 61.3% and 44.9%, while specificities were 89.9%, 94.5%, 91.3% and 92.2% for detection of susceptibility to isoniazid (INH), rifampicin (RIF), streptomycin (STR) and ethambutol (EMB), respectively. For MTBDRplus, the sensitivities were 88.0% and 88.7%, and the specificities were 97.4% and 97.8% for the detection of susceptibility to INH and RIF, respectively. Xpert demonstrated a sensitivity and specificity of 94.8% and 99.5%, respectively, for the detection of RIF susceptibility. All tests performed significantly better in retreated TB patients compared with primary TB cases. For detection of RIF and INH susceptibility, all three assays showed almost perfect agreement with the LJ method, although MGIT SIRE exhibited low agreement for STR and EMB. Considering the high performance, shorter turnaround time and ease of use, molecular-based approaches Xpert and MTBDRplus can be widely implemented throughout the country for the rapid detection of drug-resistant TB.
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Haque M, Rashid T. Combatting drug-resistant tuberculosis in the midst of the ongoing COVID-19 pandemic: A formidable challenge for Bangladesh. ADVANCES IN HUMAN BIOLOGY 2022. [DOI: 10.4103/aihb.aihb_78_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Prevalence of Antibiotic-Resistant Pulmonary Tuberculosis in Bangladesh: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2020; 9:antibiotics9100710. [PMID: 33080862 PMCID: PMC7602942 DOI: 10.3390/antibiotics9100710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 11/16/2022] Open
Abstract
Resistance to anti-tuberculosis (anti-TB) antibiotics is a major public health concern for many high-TB burden countries in Asia, including Bangladesh. Therefore, to represent the overall drug-resistance pattern against TB in Bangladesh, a systematic review and meta-analysis was conducted. Databases such as PubMed, Scopus, and Google Scholar were searched to identify studies related to antibiotic-resistant TB. A total of 24 studies covering 13,336 patients with TB were secured and included. The random-effects model was used to calculate the summary estimates. The pooled prevalence of any, mono, multi, poly, and extensive anti-TB antibiotic-resistances were 45.3% [95% CI: 33.5–57.1], 14.3% [95% CI: 11.4–17.2], 22.2% [95% CI: 18.8–25.7], 7.7% [95% CI: 5.6–9.7], and 0.3% [95% CI: 0.0–1.0], respectively. Among any first and second-line anti-TB drugs, isoniazid (35.0%) and cycloserine (44.6%) resistances were the highest, followed by ethambutol (16.2%) and gatifloxacin (0.2%). Any, multi, and poly drug-resistances were higher in retreatment cases compared to the newly diagnosed cases, although mono drug-resistance tended to be higher in newly diagnosed cases (15.7%) than that in retreatment cases (12.5%). The majority (82.6%) of the included studies were of high quality, with most not exhibiting publication bias. Sensitivity analyses confirmed that all outcomes are robust and reliable. It is concluded that resistance to anti-TB drugs in Bangladesh is rampant and fast growing. Therefore, the implementation of a nationwide surveillance system to detect suspected and drug-resistant TB cases, as well as to ensure a more encompassing treatment management by national TB control program, is highly recommended.
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Sayadi M, Zare H, Jamedar SA, Hashemy SI, Meshkat Z, Soleimanpour S, Hoffner S, Ghazvini K. Genotypic and phenotypic characterization of Mycobacterium tuberculosis resistance against fluoroquinolones in the northeast of Iran. BMC Infect Dis 2020; 20:390. [PMID: 32487030 PMCID: PMC7268510 DOI: 10.1186/s12879-020-05112-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 05/20/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Fluoroquinolones are broad-spectrum antibiotics that are recommended, and increasingly important, for the treatment of multidrug-resistant tuberculosis (MDR-TB). Resistance to fluoroquinolones is caused by mutations in the Quinolone Resistance Determining Region (QRDR) of gyrA and gyrB genes of Mycobacterium tuberculosis. In this study, we characterized the phenotypic and genotypic resistance to fluoroquinolones for the first time in northeast Iran. METHODS A total of 123 Mycobacterium tuberculosis isolates, including 111 clinical and 12 collected multidrug-resistant isolates were studied. Also, 19 WHO quality control strains were included in the study. The phenotypic susceptibility was determined by the proportion method on Löwenstein-Jensen medium. The molecular cause of resistance to the fluoroquinolone drugs ofloxacin and levofloxacin was investigated by sequencing of the QRDR region of the gyrA and gyrB genes. RESULTS Among 123 isolates, six (4.8%) were fluoroquinolone-resistant according to phenotypic methods, and genotypically three of them had a mutation at codon 94 of the gyrA gene (Asp→ Gly) which was earlier reported to cause resistance. All three remaining phenotypically resistant isolates had a nucleotide change in codon 95. No mutations were found in the gyrB gene. Five of the 19 WHO quality control strains, were phenotypically fluoroquinolone-resistant, four of them were genotypically resistant with mutations at codon 90, 91 of the gyrA gene and one resistant strain had no detected mutation. CONCLUSIONS Mutation at codon 94 of the gyrA gene, was the main cause of fluoroquinolone resistance among M. tuberculosis isolates in our region. In 3/6 fluoroquinolone-resistant isolates, no mutations were found in either gyrA or gyrB. Therefore, it can be concluded that various other factors may lead to fluoroquinolone resistance, such as active efflux pumps, decreased cell wall permeability, and drug inactivation.
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Affiliation(s)
- Mahdieh Sayadi
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hosna Zare
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeed Amel Jamedar
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Isaac Hashemy
- Department of Clinical Biochemistry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Meshkat
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saman Soleimanpour
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sven Hoffner
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Kiarash Ghazvini
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Van Deun A, Decroo T, Kya Jai Maug A, Hossain MA, Gumusboga M, Mulders W, Ortuño-Gutiérrez N, Lynen L, de Jong BC, Rieder HL. The perceived impact of isoniazid resistance on outcome of first-line rifampicin-throughout regimens is largely due to missed rifampicin resistance. PLoS One 2020; 15:e0233500. [PMID: 32421749 PMCID: PMC7233532 DOI: 10.1371/journal.pone.0233500] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/06/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Meta-analyses on impact of isoniazid-resistant tuberculosis informed the World Health Organization recommendation of a levofloxacin-strengthened rifampicin-based regimen. We estimated the effect of initial rifampicin resistance (Rr) and/or isoniazid resistance (Hr) on treatment failure or relapse. We also determined the frequency of missed initial and acquired Rr to estimate the impact of true Hr. METHODS Retrospective analysis of 7291 treatment episodes with known initial isoniazid and rifampicin status obtained from individual patient databases maintained by the Damien Foundation Bangladesh over 20 years. Drug susceptibility test results were confirmed by the programme's designated supra-national tuberculosis laboratory. To detect missed Rr among isolates routinely classified as Hr, rpoB gene sequencing was done randomly and on a sample selected for suspected missed Rr. RESULTS Initial Hr caused a large recurrence excess after the 8-month regimen for new cases (rifampicin for two months), but had little impact on rifampicin-throughout regimens: (6 months, new cases; 3.8%; OR 0.8, 95%CI:0.3,2.8; 8 months, retreatment cases: 7.3%, OR 1.8; 95%CI:1.3,2.6). Rr was missed in 7.6% of randomly selected "Hr" strains. Acquired Rr was frequent among recurrences on rifampicin-throughout regimens, particularly after the retreatment regimen (31.9%). It was higher in mono-Hr (29.3%; aOR 3.5, 95%CI:1.5,8.5) and poly-Hr (53.3%; aOR 10.2, 95%CI 4.4,23.7) than in susceptible tuberculosis, but virtually absent after the 8-month new case regimen. Comparing Bangladesh (low Rr prevalence) with a high Rr prevalence setting,true Hr corrected for missed Rr caused only 2-3 treatment failures per 1000 TB cases (of whom 27% were retreatments) in both. CONCLUSIONS Our analysis reveals a non-negligible extent of misclassifying as isoniazid resistance of what is actually missed multidrug-resistant tuberculosis. Recommending for such cases a "strengthened" regimen containing a fluoroquinolone provokes a direct route to extensive resistance while offering little benefit against the minor role of true Hr tuberculosis in rifampicin-throughout first-line regimen.
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Affiliation(s)
- Armand Van Deun
- Biomedical Department, Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Tom Decroo
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Research Foundation Flanders, Brussels, Belgium
| | | | | | - Murid Gumusboga
- Biomedical Department, Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Wim Mulders
- Biomedical Department, Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Lutgarde Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bouke C. de Jong
- Biomedical Department, Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Hans L. Rieder
- Tuberculosis Consultant Services, Kirchlindach, Switzerland
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Kabir S, Tahir Z, Mukhtar N, Sohail M, Saqalein M, Rehman A. Fluoroquinolone resistance and mutational profile of gyrA in pulmonary MDR tuberculosis patients. BMC Pulm Med 2020; 20:138. [PMID: 32393213 PMCID: PMC7216623 DOI: 10.1186/s12890-020-1172-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 04/29/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Fluoroquinolones (FQs) are potential drugs that inhibit DNA synthesis and are used in the treatment of multidrug-resistant tuberculosis (TB) and short-term anti-TB regimens. In recent years, a high proportion of FQ resistance has been observed in Mycobacterium tuberculosis isolates. The development of FQ resistance in multidrug-resistant TB negatively impacts patient treatment outcome and is a serious threat to control of TB. METHODS The study included a total of 562 samples from patients with pulmonary TB that had been on anti-tuberculosis therapy. MTBDRsl assays were performed for the molecular detection of mutations. Sequence analysis was performed for the characterization and mutational profiling of FQ-resistant isolates. RESULTS FQ resistance was observed in 104 samples (18.5%), most of which were previously treated and treatment failure cases. A total of 102 isolates had mutations in DNA gyrase subunit A (gyrA), while mutations in gyrB were observed in only two isolates. Mutational analysis revealed that the mutations mostly alter codons 94 (replacing aspartic acid with glycine, D94G) and 90 (replacing alanine with valine, A90V). In MDR and treatment failure cases, resistance to FQs was most commonly associated with the D94G mutation. In contract, a high proportion of A90V mutations were observed in isolates that were newly diagnosed. CONCLUSION The findings suggest that genotypic assays for FQ resistance should be carried out at the time of initial diagnosis, before starting treatment, in order to rule out mutations that impact the potential use of FQs in treatment and to control drug resistance.
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Affiliation(s)
- Saba Kabir
- Department of Microbiology and Molecular Genetics (MMG), University of the Punjab, New Campus Lahore, Lahore, 54590, Pakistan
| | | | - Nadia Mukhtar
- University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Muhammad Sohail
- Department of Microbiology and Molecular Genetics (MMG), University of the Punjab, New Campus Lahore, Lahore, 54590, Pakistan
| | | | - Abdul Rehman
- Department of Microbiology and Molecular Genetics (MMG), University of the Punjab, New Campus Lahore, Lahore, 54590, Pakistan.
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Uddin MKM, Rahman A, Ather MF, Ahmed T, Rahman SMM, Ahmed S, Banu S. Distribution and Frequency of rpoB Mutations Detected by Xpert MTB/RIF Assay Among Beijing and Non-Beijing Rifampicin Resistant Mycobacterium tuberculosis Isolates in Bangladesh. Infect Drug Resist 2020; 13:789-797. [PMID: 32210593 PMCID: PMC7073589 DOI: 10.2147/idr.s240408] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 02/07/2020] [Indexed: 12/19/2022] Open
Abstract
Background Rifampicin resistance (RR) is a key indicator of multidrug-resistant tuberculosis (MDR-TB) and 95% of the RR is associated with the mutation in the 81-bp rifampicin resistance determining region (RRDR) of the rpoB gene of Mycobacterium tuberculosis complex (MTBC). The Xpert MTB/RIF (Xpert) assay uses five overlapping molecular beacon probes (A-E) complementary to RRDR region that detect MTBC and mutations associated with RR. The objective of the study was to investigate the distribution and frequency of mutations detected by Xpert assay among Beijing and non-Beijing RR-TB isolates. Methods A total of 205 randomly selected RR-TB specimens detected by Xpert assay were included in this study. A portion of specimens was further subjected to culture, MTBDRplus test and the positive culture isolates were genotyped by spoligotyping. Results We found that the most frequent mutation occurred at probe E (S531L) binding region in both Beijing and non-Beijing isolates (61.9% and 66.9%, respectively). The Beijing family had higher mutation rates than non-Beijing (19.0% vs 12.4%) at probe B (D516V) while the non-Beijing family had higher mutations at probe D (H526D or H526Y) than the Beijing (13.2% vs 10.7%) family. Mutations at probes Aand C were less common in both Beijing and non-Beijing isolates. There was no significant difference (P=0.36) in the occurrence of mutations at different probes between Beijing and non-Beijing isolates. Conclusions The study results revealed that the most frequent mutation occurs in the region of probe E and the least common mutations at probe A and C among both Beijing and non-Beijing RR-TB cases. This first insight into the probe mutation variation and frequencies among the RR-TB cases in Bangladesh forms the baseline information for further investigation.
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Affiliation(s)
| | - Arfatur Rahman
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh.,Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), Parkville VIC 3052, Australia
| | - Md Fahim Ather
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Tanvir Ahmed
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | | | - Shahriar Ahmed
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Sayera Banu
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
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Prevalence and genetic profiles of isoniazid resistance in tuberculosis patients: A multicountry analysis of cross-sectional data. PLoS Med 2020; 17:e1003008. [PMID: 31961877 PMCID: PMC6974034 DOI: 10.1371/journal.pmed.1003008] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 12/05/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The surveillance of drug resistance among tuberculosis (TB) patients is central to combatting the global TB epidemic and preventing the spread of antimicrobial resistance. Isoniazid and rifampicin are two of the most powerful first-line anti-TB medicines, and resistance to either of them increases the risk of treatment failure, relapse, or acquisition of resistance to other drugs. The global prevalence of rifampicin resistance is well documented, occurring in 3.4% (95% CI 2.5%-4.4%) of new TB patients and 18% (95% CI 7.6%-31%) of previously treated TB patients in 2018, whereas the prevalence of isoniazid resistance at global and regional levels is less understood. In 2018, the World Health Organization (WHO) recommended a modified 6-month treatment regimen for people with isoniazid-resistant, rifampicin-susceptible TB (Hr-TB), which includes rifampicin, pyrazinamide, ethambutol, and levofloxacin. We estimated the global prevalence of Hr-TB among TB patients and investigated associated phenotypic and genotypic drug resistance patterns. METHODS AND FINDINGS Aggregated drug resistance data reported to WHO from either routine continuous surveillance or nationally representative periodic surveys of TB patients for the period 2003-2017 were reviewed. Isoniazid data were available from 156 countries or territories for 211,753 patients. Among these, the global prevalence of Hr-TB was 7.4% (95% CI 6.5%-8.4%) among new TB patients and 11.4% (95% CI 9.4%-13.4%) among previously treated TB patients. Additional data on pyrazinamide and levofloxacin resistance were available from 6 countries (Azerbaijan, Bangladesh, Belarus, Pakistan, the Philippines, and South Africa). There were no cases of resistance to both pyrazinamide and levofloxacin among Hr-TB patients, except for the Philippines (1.8%, 95% CI 0.2-6.4) and Belarus (5.3%, 95% CI 0.1-26.0). Sequencing data for all genomic regions involved in isoniazid resistance were available for 4,563 patients. Among the 1,174 isolates that were resistant by either phenotypic testing or sequencing, 78.6% (95% CI 76.1%-80.9%) had resistance-conferring mutations in the katG gene and 14.6% (95% CI 12.7%-16.8%) in both katG and the inhA promoter region. For 6.8% (95% CI 5.4%-8.4%) of patients, mutations occurred in the inhA promoter alone, for whom an increased dose of isoniazid may be considered. The main limitations of this study are that most analyses were performed at the national rather than individual patient level and that the quality of laboratory testing may vary between countries. CONCLUSIONS In this study, the prevalence of Hr-TB among TB patients was higher than the prevalence of rifampicin resistance globally. Many patients with Hr-TB would be missed by current diagnostic algorithms driven by rifampicin testing, highlighting the need for new rapid molecular technologies to ensure access to appropriate treatment and care. The low prevalence of resistance to pyrazinamide and fluoroquinolones among patients with Hr-TB provides further justification for the recommended modified treatment regimen.
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Walsh KF, Souroutzidis A, Vilbrun SC, Peeples M, Joissaint G, Delva S, Widmann P, Royal G, Pry J, Bang H, Pape JW, Koenig SP. Potentially High Number of Ineffective Drugs with the Standard Shorter Course Regimen for Multidrug-Resistant Tuberculosis Treatment in Haiti. Am J Trop Med Hyg 2019; 100:392-398. [PMID: 30594266 DOI: 10.4269/ajtmh.18-0493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) outcomes are poor partly because of the long treatment duration; the World Health Organization conditionally recommends a shorter course regimen to potentially improve treatment outcomes. Here, we describe the drug susceptibility patterns of a cohort of MDR-TB patients in Haiti and determine the number of likely effective drugs if they were treated with the recommended shorter course regimen. We retrospectively examined drug susceptibility patterns of adults initiating MDR-TB treatment between 2008 and 2015 at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections in Port-au-Prince, Haiti. First- and second-line drug susceptibility testing (DST) was analyzed and used to determine the number of presumed effective drugs. Of the 239 patients analyzed, 226 (95%), 183 (77%), 135 (57%), and 38 (16%) isolates were resistant to high-dose isoniazid, ethambutol, pyrazinamide, and ethionamide, respectively. Eight patients (3%) had resistance to either a fluoroquinolone or a second-line injectable and none had extensively resistant TB. Of the 239 patients, 132 (55%) would have fewer than five likely effective drugs in the intensive phase of the recommended shorter course regimen and 121 (51%) would have two or fewer likely effective drugs in the continuation phase. Because of the high rates of resistance to first-line TB medications, about 50% of MDR-TB patients would be left with only two effective drugs in the continuation phase of the recommended shorter course regimen, raising concerns about the effectiveness of this regimen in Haiti and the importance of using DST to guide treatment.
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Affiliation(s)
- Kathleen F Walsh
- Center for Global Health, Weill Cornell Medicine, New York, New York
| | | | - Stalz Charles Vilbrun
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Guy Joissaint
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Sobieskye Delva
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Pamphile Widmann
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Gertrude Royal
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jake Pry
- Centre for Infectious Diseases Research (CIDRZ), Lusaka, Zambia.,Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, California
| | - Heejung Bang
- Centre for Infectious Diseases Research (CIDRZ), Lusaka, Zambia
| | - Jean W Pape
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Serena P Koenig
- Division of Global Health Equity, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
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Daru P, Matji R, AlMossawi HJ, Chakraborty K, Kak N. Decentralized, Community-Based Treatment for Drug-Resistant Tuberculosis: Bangladesh Program Experience. GLOBAL HEALTH: SCIENCE AND PRACTICE 2018; 6:594-602. [PMID: 30287534 PMCID: PMC6172109 DOI: 10.9745/ghsp-d-17-00345] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 08/14/2018] [Indexed: 11/29/2022]
Abstract
Shifting from hospital- to community-based management of drug-resistant TB, increased treatment enrollment, reduced treatment initiation delays, improved follow-up and adherence, and lowered treatment failure, and was associated with higher cure rates and lower mortality. Background: Bangladesh is a highly populous country where the prevalence of drug-resistant tuberculosis (DR-TB) is growing. With the rapid increase in DR-TB notifications through GeneXpert technology, it was imperative to come up with a new treatment strategy that could keep up with the increase of patients diagnosed. Intervention: Intervention was designed to support national transition of DR-TB management of World Health Organization-approved long course (20-to-24-month regimen) treatment from a hospital-based approach to the decentralized model of community-based programmatic management of DR-TB (cPMDT). In close coordination with the Ministry of Health and Family Welfare and National TB Program, patients were initiated into treatment at hospitals and then transferred to community-based care. A cadre of directly observed therapy providers supported treatment at the household level, supervised by the outpatient DR-TB teams. Methods: We conducted a descriptive pre- and post-intervention study of all 1,946 DR-TB patients enrolled in treatment nationwide between May 2012 and June 2015. Data were collected from hospitals, patient cards, district records, and diagnostic laboratories through the National TB Program. Intervention results were assessed in comparison with the baseline (2011) indicators. Results: During the intervention period, treatment enrollment of 1,946 diagnosed DR-TB patients through the national program increased from 50% in 2011 to 100% in 2015. The delay between diagnosis and treatment initiation decreased from 69 days in 2011 to 6 days in 2014. Most (95%) of the patients completed all scheduled follow-up smear and culture tests. By the sixth month of treatment, 99% of patients had negative smear conversion and 98% had negative culture conversion. The treatment success rate increased from 70% in 2011 to 76% in 2015 at the end of the intervention period. The results also indicate a decline between baseline and end line from 34% to 9% for patients died, 34% to 10% for loss to follow-up, and 1.7% to 0% for treatment failure. Conclusions: Community-based management is an effective approach for increasing access to quality-assured DR-TB treatment. Using existing structures and resources, the intervention demonstrated that favorable treatment outcomes can be achieved and sustained by treating patients with DR-TB at their homes.
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Affiliation(s)
- Paul Daru
- University Research Co., LLC, Dhaka, Bangladesh
| | | | | | | | - Neeraj Kak
- University Research Co., LLC, Chevy Chase, MD, USA.
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Molecular characterization and drug susceptibility profile of Mycobacterium tuberculosis isolates from Northeast Bangladesh. INFECTION GENETICS AND EVOLUTION 2018; 65:136-143. [PMID: 30048809 DOI: 10.1016/j.meegid.2018.07.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/24/2018] [Accepted: 07/22/2018] [Indexed: 12/14/2022]
Abstract
Tuberculosis (TB) remains a major public health problem worldwide including in Bangladesh. Molecular epidemiological tools provide genotyping profiles of Mycobacterium tuberculosis (M. tuberculosis) strains that can give insight into the transmission of TB in a specific region. The objective of the study was to identify the genetic diversity and drug susceptibility profile of M. tuberculosis strains circulating in the northeast Bangladesh. A total of 244 smear-positive sputum specimens were collected from two referral hospitals in Mymensingh and Netrakona districts. The isolated strains were genotyped by deletion analysis, spoligotyping, and MIRU-VNTR typing. We also analyzed the distributions of drug susceptibility pattern and demographic data among different genotypes. All isolates were identified as M. tuberculosis and among them 167 strains (68.44%) were 'ancestral' and the remaining 77 (31.56%) were 'modern' type. Spoligotyping analysis yielded 119 distinct patterns, among them, 86 isolates had unique patterns and the remaining 158 were grouped into 33 distinct clusters containing 2 to 18 isolates. The predominant spoligotypes belong to the EAI lineage strains, comprising 66 (27.04%) isolates followed by Beijing (7.38%), T1 (6.15%), CAS1-Delhi (5.33), LAM9 (3.28%), MANU-2 and X2. MIRU-VNTR analysis revealed 167 isolates (68%) had unique patterns, whereas 77 (32%) were grouped into 26 clusters and the rate of recent transmission was 20.9%, suggesting that the majority of TB cases in this region are caused by the reactivation of previous TB infections rather than recent transmission. About 136 (55.7%) isolates were sensitive to four anti-TB drugs, 69 (28.3%) were resistant to one or more (except rifampicin and isoniazid combination) drugs and 39 (15.9%) were MDR. In conclusion, our study provides a first insight into molecular characterization and drug resistance profile of M. tuberculosis strains in northeast Bangladesh which will ultimately contribute to the national TB control program.
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12
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Nathavitharana RR, Daru P, Barrera AE, Mostofa Kamal SM, Islam S, Ul-Alam M, Sultana R, Rahman M, Hossain MS, Lederer P, Hurwitz S, Chakraborty K, Kak N, Tierney DB, Nardell E. FAST implementation in Bangladesh: high frequency of unsuspected tuberculosis justifies challenges of scale-up. Int J Tuberc Lung Dis 2018; 21:1020-1025. [PMID: 28826452 DOI: 10.5588/ijtld.16.0794] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
SETTING National Institute of Diseases of the Chest and Hospital, Dhaka; Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka; and Chittagong Chest Disease Hospital, Chittagong, Bangladesh. OBJECTIVE To present operational data and discuss the challenges of implementing FAST (Find cases Actively, Separate safely and Treat effectively) as a tuberculosis (TB) transmission control strategy. DESIGN FAST was implemented sequentially at three hospitals. RESULTS Using Xpert® MTB/RIF, 733/6028 (12.2%, 95%CI 11.4-13.0) patients were diagnosed with unsuspected TB. Patients with a history of TB who were admitted with other lung diseases had more than twice the odds of being diagnosed with unsuspected TB as those with no history of TB (OR 2.6, 95%CI 2.2-3.0, P < 0.001). Unsuspected multidrug-resistant TB (MDR-TB) was diagnosed in 89/1415 patients (6.3%, 95%CI 5.1-7.7). Patients with unsuspected TB had nearly five times the odds of being diagnosed with MDR-TB than those admitted with a known TB diagnosis (OR 4.9, 95%CI 3.1-7.6, P < 0.001). Implementation challenges include staff shortages, diagnostic failure, supply-chain issues and reliance on external funding. CONCLUSION FAST implementation revealed a high frequency of unsuspected TB in hospitalized patients in Bangladesh. Patients with a previous history of TB have an increased risk of being diagnosed with unsuspected TB. Ensuring financial resources, stakeholder engagement and laboratory capacity are important for sustainability and scalability.
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Affiliation(s)
- R R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - P Daru
- University Research Co., Washington DC
| | - A E Barrera
- Faculty of Nursing Science, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - S M Mostofa Kamal
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - S Islam
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - M Ul-Alam
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - R Sultana
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - M Rahman
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - Md S Hossain
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - P Lederer
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
| | - S Hurwitz
- Division of Biostatistics, Brigham and Women's Hospital Center for Clinical Investigation, Boston, Massachusetts
| | | | - N Kak
- University Research Co., Washington DC
| | - D B Tierney
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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13
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Zignol M, Cabibbe AM, Dean AS, Glaziou P, Alikhanova N, Ama C, Andres S, Barbova A, Borbe-Reyes A, Chin DP, Cirillo DM, Colvin C, Dadu A, Dreyer A, Driesen M, Gilpin C, Hasan R, Hasan Z, Hoffner S, Hussain A, Ismail N, Kamal SMM, Khanzada FM, Kimerling M, Kohl TA, Mansjö M, Miotto P, Mukadi YD, Mvusi L, Niemann S, Omar SV, Rigouts L, Schito M, Sela I, Seyfaddinova M, Skenders G, Skrahina A, Tahseen S, Wells WA, Zhurilo A, Weyer K, Floyd K, Raviglione MC. Genetic sequencing for surveillance of drug resistance in tuberculosis in highly endemic countries: a multi-country population-based surveillance study. THE LANCET. INFECTIOUS DISEASES 2018; 18:675-683. [PMID: 29574065 PMCID: PMC5968368 DOI: 10.1016/s1473-3099(18)30073-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/05/2018] [Accepted: 01/30/2018] [Indexed: 12/02/2022]
Abstract
Background In many countries, regular monitoring of the emergence of resistance to anti-tuberculosis drugs is hampered by the limitations of phenotypic testing for drug susceptibility. We therefore evaluated the use of genetic sequencing for surveillance of drug resistance in tuberculosis. Methods Population-level surveys were done in hospitals and clinics in seven countries (Azerbaijan, Bangladesh, Belarus, Pakistan, Philippines, South Africa, and Ukraine) to evaluate the use of genetic sequencing to estimate the resistance of Mycobacterium tuberculosis isolates to rifampicin, isoniazid, ofloxacin, moxifloxacin, pyrazinamide, kanamycin, amikacin, and capreomycin. For each drug, we assessed the accuracy of genetic sequencing by a comparison of the adjusted prevalence of resistance, measured by genetic sequencing, with the true prevalence of resistance, determined by phenotypic testing. Findings Isolates were taken from 7094 patients with tuberculosis who were enrolled in the study between November, 2009, and May, 2014. In all tuberculosis cases, the overall pooled sensitivity values for predicting resistance by genetic sequencing were 91% (95% CI 87–94) for rpoB (rifampicin resistance), 86% (74–93) for katG, inhA, and fabG promoter combined (isoniazid resistance), 54% (39–68) for pncA (pyrazinamide resistance), 85% (77–91) for gyrA and gyrB combined (ofloxacin resistance), and 88% (81–92) for gyrA and gyrB combined (moxifloxacin resistance). For nearly all drugs and in most settings, there was a large overlap in the estimated prevalence of drug resistance by genetic sequencing and the estimated prevalence by phenotypic testing. Interpretation Genetic sequencing can be a valuable tool for surveillance of drug resistance, providing new opportunities to monitor drug resistance in tuberculosis in resource-poor countries. Before its widespread adoption for surveillance purposes, there is a need to standardise DNA extraction methods, recording and reporting nomenclature, and data interpretation. Funding Bill & Melinda Gates Foundation, United States Agency for International Development, Global Alliance for Tuberculosis Drug Development.
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Affiliation(s)
- Matteo Zignol
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland.
| | - Andrea Maurizio Cabibbe
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland; San Raffaele Scientific Institute, Milan, Italy
| | - Anna S Dean
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Philippe Glaziou
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Natavan Alikhanova
- Scientific Research Institute of Lung Diseases, Ministry of Health, Baku, Azerbaijan
| | - Cecilia Ama
- National Tuberculosis Reference Laboratory, Manila, Philippines
| | - Sönke Andres
- National Reference Laboratory for Mycobacteria, Borstel Research Centre, Borstel, Germany
| | - Anna Barbova
- Central Reference Laboratory on Tuberculosis Microbiological Diagnostics, Ministry of Health, Kiev, Ukraine
| | | | | | | | - Charlotte Colvin
- Bureau for Global Health, US Agency for International Development, Washington, DC, USA
| | - Andrei Dadu
- Regional Office for Europe, World Health Organization, Copenhagen, Denmark
| | - Andries Dreyer
- National Institute for Communicable Diseases, Sandringham, South Africa
| | - Michèle Driesen
- Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Christopher Gilpin
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Rumina Hasan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Zahra Hasan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Sven Hoffner
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Alamdar Hussain
- National Reference Laboratory, National Tuberculosis Control Programme, Islamabad, Pakistan
| | - Nazir Ismail
- National Institute for Communicable Diseases, Sandringham, South Africa; Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - S M Mostofa Kamal
- Department of Pathology and Microbiology, National Institute of Diseases of the Chest and Hospital, Dhaka, Bangladesh
| | - Faisal Masood Khanzada
- National Reference Laboratory, National Tuberculosis Control Programme, Islamabad, Pakistan
| | | | - Thomas Andreas Kohl
- Molecular and Experimental Mycobacteriology, Borstel Research Centre, Borstel, Germany
| | - Mikael Mansjö
- Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden
| | | | - Ya Diul Mukadi
- Bureau for Global Health, US Agency for International Development, Washington, DC, USA
| | - Lindiwe Mvusi
- Tuberculosis Control and Management Unit, National Department of Health, Pretoria, South Africa
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Borstel Research Centre, Borstel, Germany
| | - Shaheed V Omar
- National Institute for Communicable Diseases, Sandringham, South Africa
| | - Leen Rigouts
- Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium; Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Ivita Sela
- Department of Mycobacteriology, Tuberculosis and Lung Disease Centre, Riga East University Hospital, Riga, Latvia
| | - Mehriban Seyfaddinova
- Scientific Research Institute of Lung Diseases, Ministry of Health, Baku, Azerbaijan
| | - Girts Skenders
- Department of Mycobacteriology, Tuberculosis and Lung Disease Centre, Riga East University Hospital, Riga, Latvia
| | - Alena Skrahina
- Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Sabira Tahseen
- National Reference Laboratory, National Tuberculosis Control Programme, Islamabad, Pakistan
| | - William A Wells
- Bureau for Global Health, US Agency for International Development, Washington, DC, USA
| | - Alexander Zhurilo
- National Institute of Phthisiology And Pulmonology, National Academy of Medical Science of Ukraine, Kiev, Ukraine
| | - Karin Weyer
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Katherine Floyd
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Mario C Raviglione
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
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14
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Tagliani E, Hassan MO, Waberi Y, De Filippo MR, Falzon D, Dean A, Zignol M, Supply P, Abdoulkader MA, Hassangue H, Cirillo DM. Culture and Next-generation sequencing-based drug susceptibility testing unveil high levels of drug-resistant-TB in Djibouti: results from the first national survey. Sci Rep 2017; 7:17672. [PMID: 29247181 PMCID: PMC5732159 DOI: 10.1038/s41598-017-17705-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/29/2017] [Indexed: 01/15/2023] Open
Abstract
Djibouti is a small country in the Horn of Africa with a high TB incidence (378/100,000 in 2015). Multidrug-resistant TB (MDR-TB) and resistance to second-line agents have been previously identified in the country but the extent of the problem has yet to be quantified. A national survey was conducted to estimate the proportion of MDR-TB among a representative sample of TB patients. Sputum was tested using XpertMTB/RIF and samples positive for MTB and resistant to rifampicin underwent first line phenotypic susceptibility testing. The TB supranational reference laboratory in Milan, Italy, undertook external quality assurance, genotypic testing based on whole genome and targeted-deep sequencing and phylogenetic studies. 301 new and 66 previously treated TB cases were enrolled. MDR-TB was detected in 34 patients: 4.7% of new and 31% of previously treated cases. Resistance to pyrazinamide, aminoglycosides and capreomycin was detected in 68%, 18% and 29% of MDR-TB strains respectively, while resistance to fluoroquinolones was not detected. Cluster analysis identified transmission of MDR-TB as a critical factor fostering drug resistance in the country. Levels of MDR-TB in Djibouti are among the highest on the African continent. High prevalence of resistance to pyrazinamide and second-line injectable agents have important implications for treatment regimens.
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Affiliation(s)
- Elisa Tagliani
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | | | - Yacine Waberi
- National TB Reference Laboratory, Djibouti, Djibouti
| | - Maria Rosaria De Filippo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dennis Falzon
- World Health Organization/Global TB Programme, Geneva, Switzerland
| | - Anna Dean
- World Health Organization/Global TB Programme, Geneva, Switzerland
| | - Matteo Zignol
- World Health Organization/Global TB Programme, Geneva, Switzerland
| | | | | | - Hawa Hassangue
- Programme National de Lutte contre la Tuberculose, Djibouti, Djibouti
| | - Daniela Maria Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
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15
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Kendall EA, Fojo AT, Dowdy DW. Expected effects of adopting a 9 month regimen for multidrug-resistant tuberculosis: a population modelling analysis. THE LANCET RESPIRATORY MEDICINE 2016; 5:191-199. [PMID: 27989591 PMCID: PMC5332590 DOI: 10.1016/s2213-2600(16)30423-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 11/29/2022]
Abstract
Background In May, 2016, WHO endorsed a 9 month regimen for multidrug-resistant tuberculosis that is cheaper and potentially more effective than the conventional, longer (20–24 month) therapy. We aimed to investigate the population-level implications of scaling up this new regimen. Methods In this population modelling analysis, we developed a dynamic transmission model to simulate the introduction of this short-course regimen as an instantaneous switch in 2016. We projected the corresponding percentage reduction in the incidence of multidrug-resistant tuberculosis by 2024 compared with continued use of longer therapy. In the primary analysis in a representative southeast Asian setting, we assumed that the short-course regimen would double treatment access (through savings in resources or capacity) and achieve long-term efficacy at levels seen in preliminary cohort studies. We then did extensive sensitivity analyses to explore a range of alternative scenarios. Findings Under the optimistic assumptions in the primary analysis, the incidence of multidrug-resistant tuberculosis in 2024 would be 3·3 (95% uncertainty range 2·2–5·6) per 100 000 population with the short-course regimen and 4·3 (2·9–7·6) per 100 000 population with continued use of longer therapy—ie, the short-course regimen could reduce incidence by 23% (10–38). Incidence would be reduced by 14% (4–28) if the new regimen affected only treatment effectiveness and by 11% (3–24) if it affected only treatment availability. Under more pessimistic assumptions, the short-course regimen would have minimal effect and even potential for harm—eg, when 30% of patients are ineligible for the new regimen because of second-line drug resistance, we projected a change in incidence of −2% (−20 to +28). The new regimen's effect was greater in settings with more ongoing transmission of multidrug-resistant tuberculosis, but results were otherwise similar across settings with different levels of tuberculosis incidence and prevalence of multidrug resistance. Interpretation The short-course regimen has potential to substantially lessen the multidrug-resistant tuberculosis epidemic, but this effect depends on its long-term efficacy, its ability to expand treatment access, and the role of second-line drug resistance. Funding US National Institutes of Health and Bill & Melinda Gates Foundation.
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Affiliation(s)
- Emily A Kendall
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Anthony T Fojo
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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16
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Diarra B, Goita D, Tounkara S, Sanogo M, Baya B, Togo ACG, Maiga M, Sarro YS, Kone A, Kone B, M'Baye O, Coulibaly N, Kassambara H, Cisse A, Belson M, Polis MA, Otu J, Gehre F, Antonio M, Dao S, Siddiqui S, Murphy RL, de Jong BC, Diallo S. Tuberculosis drug resistance in Bamako, Mali, from 2006 to 2014. BMC Infect Dis 2016; 16:714. [PMID: 27894266 PMCID: PMC5126865 DOI: 10.1186/s12879-016-2060-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 11/22/2016] [Indexed: 12/02/2022] Open
Abstract
Background Although Drug resistance tuberculosis is not a new phenomenon, Mali remains one of the “blank” countries without systematic data. Methods Between 2006 and 2014, we enrolled pulmonary TB patients from local TB diagnostics centers and a university referral hospital in several observational cohort studies. These consecutive patients had first line drug susceptibility testing (DST) performed on their isolates. A subset of MDR was subsequently tested for second line drug resistance. Results A total of 1186 mycobacterial cultures were performed on samples from 522 patients, including 1105 sputa and 81 blood samples, yielding one or more Mycobacterium tuberculosis complex (Mtbc) positive cultures for 343 patients. Phenotypic DST was performed on 337 (98.3%) unique Mtbc isolates, of which 127 (37.7%) were resistant to at least one drug, including 75 (22.3%) with multidrug resistance (MDR). The overall prevalence of MDR-TB was 3.4% among new patients and 66.3% among retreatment patients. Second line DST was available for 38 (50.7%) of MDR patients and seven (18.4%) had resistance to either fluoroquinolones or second-line injectable drugs. Conclusion The drug resistance levels, including MDR, found in this study are relatively high, likely related to the selected referral population. While worrisome, the numbers remained stable over the study period. These findings prompt a nationwide drug resistance survey, as well as continuous surveillance of all retreatment patients, which will provide more accurate results on countrywide drug resistance rates and ensure that MDR patients access appropriate second line treatment. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-2060-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- B Diarra
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali. .,Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - D Goita
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - S Tounkara
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - M Sanogo
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - B Baya
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - A C G Togo
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - M Maiga
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - Y S Sarro
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - A Kone
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - B Kone
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - O M'Baye
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - N Coulibaly
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - H Kassambara
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - A Cisse
- Laboratoire National de Référence des Mycobactéries (LNR), Institut National de Recherche en Santé publique (INRSP), Bamako, Mali
| | - M Belson
- CCRB, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - M A Polis
- CCRB, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - J Otu
- Vaccines and Immunity Theme, Atlantic Boulevard, Medical Research Council (MRC), Fajara, Banjul, The Gambia
| | - F Gehre
- Vaccines and Immunity Theme, Atlantic Boulevard, Medical Research Council (MRC), Fajara, Banjul, The Gambia.,Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - M Antonio
- Vaccines and Immunity Theme, Atlantic Boulevard, Medical Research Council (MRC), Fajara, Banjul, The Gambia.,Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,Microbiology and Infection Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - S Dao
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - S Siddiqui
- CCRB, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - R L Murphy
- Global Health, Northwestern University, Chicago, IL, USA
| | - B C de Jong
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - S Diallo
- SEREFO Program, University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
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17
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Zignol M, Dean AS, Alikhanova N, Andres S, Cabibbe AM, Cirillo DM, Dadu A, Dreyer A, Driesen M, Gilpin C, Hasan R, Hasan Z, Hoffner S, Husain A, Hussain A, Ismail N, Kamal M, Mansjö M, Mvusi L, Niemann S, Omar SV, Qadeer E, Rigouts L, Ruesch-Gerdes S, Schito M, Seyfaddinova M, Skrahina A, Tahseen S, Wells WA, Mukadi YD, Kimerling M, Floyd K, Weyer K, Raviglione MC. Population-based resistance of Mycobacterium tuberculosis isolates to pyrazinamide and fluoroquinolones: results from a multicountry surveillance project. THE LANCET. INFECTIOUS DISEASES 2016; 16:1185-1192. [PMID: 27397590 PMCID: PMC5030278 DOI: 10.1016/s1473-3099(16)30190-6] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 05/31/2016] [Accepted: 06/10/2016] [Indexed: 02/06/2023]
Abstract
Background Pyrazinamide and fluoroquinolones are essential antituberculosis drugs in new rifampicin-sparing regimens. However, little information about the extent of resistance to these drugs at the population level is available. Methods In a molecular epidemiology analysis, we used population-based surveys from Azerbaijan, Bangladesh, Belarus, Pakistan, and South Africa to investigate resistance to pyrazinamide and fluoroquinolones among patients with tuberculosis. Resistance to pyrazinamide was assessed by gene sequencing with the detection of resistance-conferring mutations in the pncA gene, and susceptibility testing to fluoroquinolones was conducted using the MGIT system. Findings Pyrazinamide resistance was assessed in 4972 patients. Levels of resistance varied substantially in the surveyed settings (3·0–42·1%). In all settings, pyrazinamide resistance was significantly associated with rifampicin resistance. Among 5015 patients who underwent susceptibility testing to fluoroquinolones, proportions of resistance ranged from 1·0–16·6% for ofloxacin, to 0·5–12·4% for levofloxacin, and 0·9–14·6% for moxifloxacin when tested at 0·5 μg/mL. High levels of ofloxacin resistance were detected in Pakistan. Resistance to moxifloxacin and gatifloxacin when tested at 2 μg/mL was low in all countries. Interpretation Although pyrazinamide resistance was significantly associated with rifampicin resistance, this drug may still be effective in 19–63% of patients with rifampicin-resistant tuberculosis. Even though the high level of resistance to ofloxacin found in Pakistan is worrisome because it might be the expression of extensive and unregulated use of fluoroquinolones in some parts of Asia, the negligible levels of resistance to fourth-generation fluoroquinolones documented in all survey sites is an encouraging finding. Rational use of this class of antibiotics should therefore be ensured to preserve its effectiveness. Funding Bill & Melinda Gates Foundation, United States Agency for International Development, Global Alliance for Tuberculosis Drug Development.
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Affiliation(s)
- Matteo Zignol
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland.
| | - Anna S Dean
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | | | - Sönke Andres
- National and Supranational Reference Laboratory for Mycobacterium, Borstel, Germany
| | | | | | - Andrei Dadu
- Regional Office for Europe, World Health Organization, Copenhagen, Denmark
| | - Andries Dreyer
- National Institute for Communicable Diseases, Sandringham, South Africa
| | - Michèle Driesen
- Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Christopher Gilpin
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Rumina Hasan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Zahra Hasan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Sven Hoffner
- Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden; Department of Microbiology, Tumor and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Ashaque Husain
- National Tuberculosis Control Programme, Dhaka, Bangladesh
| | - Alamdar Hussain
- National Tuberculosis Reference Laboratory, National Tuberculosis Control Programme, Islamabad, Pakistan
| | - Nazir Ismail
- National Institute for Communicable Diseases, Sandringham, South Africa; University of Pretoria, Pretoria, South Africa
| | - Mostofa Kamal
- National Institute of Diseases of the Chest and Hospital, Dhaka, Bangladesh
| | - Mikael Mansjö
- Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden
| | - Lindiwe Mvusi
- Tuberculosis Control and Management, National Department of Health, Pretoria, South Africa
| | - Stefan Niemann
- National and Supranational Reference Laboratory for Mycobacterium, Borstel, Germany
| | - Shaheed V Omar
- National Institute for Communicable Diseases, Sandringham, South Africa
| | - Ejaz Qadeer
- National Tuberculosis Control Programme, Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan
| | - Leen Rigouts
- Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium; Biomedical Sciences, Antwerp University, Antwerp, Belgium
| | - Sabine Ruesch-Gerdes
- National and Supranational Reference Laboratory for Mycobacterium, Borstel, Germany
| | | | | | - Alena Skrahina
- Republican Research and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Sabira Tahseen
- National Tuberculosis Reference Laboratory, National Tuberculosis Control Programme, Islamabad, Pakistan
| | - William A Wells
- Bureau for Global Health, US Agency for International Development, Washington, DC, USA
| | - Ya Diul Mukadi
- Bureau for Global Health, US Agency for International Development, Washington, DC, USA
| | | | - Katherine Floyd
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Karin Weyer
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Mario C Raviglione
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
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18
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Yuen CM, Kurbatova EV, Tupasi T, Caoili JC, Van Der Walt M, Kvasnovsky C, Yagui M, Bayona J, Contreras C, Leimane V, Ershova J, Via LE, Kim H, Akksilp S, Kazennyy BY, Volchenkov GV, Jou R, Kliiman K, Demikhova OV, Vasilyeva IA, Dalton T, Cegielski JP. Association between Regimen Composition and Treatment Response in Patients with Multidrug-Resistant Tuberculosis: A Prospective Cohort Study. PLoS Med 2015; 12:e1001932. [PMID: 26714320 PMCID: PMC4700973 DOI: 10.1371/journal.pmed.1001932] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 11/20/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND For treating multidrug-resistant tuberculosis (MDR TB), the World Health Organization (WHO) recommends a regimen of at least four second-line drugs that are likely to be effective as well as pyrazinamide. WHO guidelines indicate only marginal benefit for regimens based directly on drug susceptibility testing (DST) results. Recent evidence from isolated cohorts suggests that regimens containing more drugs may be beneficial, and that DST results are predictive of regimen effectiveness. The objective of our study was to gain insight into how regimen design affects treatment response by analyzing the association between time to sputum culture conversion and both the number of potentially effective drugs included in a regimen and the DST results of the drugs in the regimen. METHODS AND FINDINGS We analyzed data from the Preserving Effective Tuberculosis Treatment Study (PETTS), a prospective observational study of 1,659 adults treated for MDR TB during 2005-2010 in nine countries: Estonia, Latvia, Peru, Philippines, Russian Federation, South Africa, South Korea, Thailand, and Taiwan. For all patients, monthly sputum samples were collected, and DST was performed on baseline isolates at the US Centers for Disease Control and Prevention. We included 1,137 patients in our analysis based on their having known baseline DST results for at least fluoroquinolones and second-line injectable drugs, and not having extensively drug-resistant TB. These patients were followed for a median of 20 mo (interquartile range 16-23 mo) after MDR TB treatment initiation. The primary outcome of interest was initial sputum culture conversion. We used Cox proportional hazards regression, stratifying by country to control for setting-associated confounders, and adjusting for the number of drugs to which patients' baseline isolates were resistant, baseline resistance pattern, previous treatment history, sputum smear result, and extent of disease on chest radiograph. In multivariable analysis, receiving an average of at least six potentially effective drugs (defined as drugs without a DST result indicating resistance) per day was associated with a 36% greater likelihood of sputum culture conversion than receiving an average of at least five but fewer than six potentially effective drugs per day (adjusted hazard ratio [aHR] 1.36, 95% CI 1.09-1.69). Inclusion of pyrazinamide (aHR 2.00, 95% CI 1.65-2.41) or more drugs to which baseline DST indicated susceptibility (aHR 1.65, 95% CI 1.48-1.84, per drug) in regimens was associated with greater increases in the likelihood of sputum culture conversion than including more drugs to which baseline DST indicated resistance (aHR 1.33, 95% CI 1.18-1.51, per drug). Including in the regimen more drugs for which DST was not performed was beneficial only if a minimum of three effective drugs was present in the regimen (aHR 1.39, 95% CI 1.09-1.76, per drug when three effective drugs present in regimen). The main limitation of this analysis is that it is based on observational data, not a randomized trial, and drug regimens varied across sites. However, PETTS was a uniquely large and rigorous observational study in terms of both the number of patients enrolled and the standardization of laboratory testing. Other limitations include the assumption of equivalent efficacy across drugs in a category, incomplete data on adherence, and the fact that the analysis considers only initial sputum culture conversion, not reversion or long-term relapse. CONCLUSIONS MDR TB regimens including more potentially effective drugs than the minimum of five currently recommended by WHO may encourage improved response to treatment in patients with MDR TB. Rapid access to high-quality DST results could facilitate the design of more effective individualized regimens. Randomized controlled trials are necessary to confirm whether individualized regimens with more than five drugs can indeed achieve better cure rates than current recommended regimens.
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Affiliation(s)
- Courtney M. Yuen
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | | | - Janice Campos Caoili
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Tropical Disease Foundation, Manila, Philippines
| | | | - Charlotte Kvasnovsky
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Medical Research Council, Pretoria, South Africa
| | | | - Jaime Bayona
- Partners In Health, Boston, Massachusetts, United States of America
| | | | - Vaira Leimane
- Riga East University Hospital Centre of Tuberculosis and Lung Diseases, Riga, Latvia
| | - Julia Ershova
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Laura E. Via
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - HeeJin Kim
- Korean Institute of Tuberculosis, Seoul, Republic of Korea
| | - Somsak Akksilp
- Department of Disease Control, Ministry of Public Health, Bangkok, Thailand
| | | | | | - Ruwen Jou
- Taiwan Centers for Disease Control, Taipei, Taiwan
| | | | - Olga V. Demikhova
- Central Tuberculosis Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Irina A. Vasilyeva
- Central Tuberculosis Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Tracy Dalton
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - J. Peter Cegielski
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
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19
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Rifat M, Hall J, Oldmeadow C, Husain A, Hinderaker SG, Milton AH. Factors related to previous tuberculosis treatment of patients with multidrug-resistant tuberculosis in Bangladesh. BMJ Open 2015; 5:e008273. [PMID: 26351185 PMCID: PMC4563275 DOI: 10.1136/bmjopen-2015-008273] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Previous tuberculosis (TB) treatment status is an established risk factor for multidrug-resistant TB (MDR-TB). This study explores which factors related to previous TB treatment may lead to the development of multidrug resistant in Bangladesh. DESIGN We previously conducted a large case-control study to identify risk factors for developing MDR-TB in Bangladesh. Patients who had a history of previous TB treatment, either MDR-TB or non-MDR-TB, were interviewed about their previous treatment episode. This study restricts analysis to the strata of patients who have been previously treated for TB. Information was collected through face-to-face interviews and record reviews. Unadjusted and multivariable logistic regression was used for data analysis. SETTING Central-level, district-level and subdistrict-level hospitals in rural and urban Bangladesh. RESULTS The strata of previously treated patients include a total of 293 patients (245 current MDR-TB; 48 non-MDR-TB). Overall, 54% of patients received previous TB treatment more than once, and all of these patients were multidrug resistant. Patients with MDR-TB were more likely to have experienced the following factors: incomplete treatment (OR 4.3; 95% CI 1.7 to 10.6), adverse reactions due to TB treatment (OR 8.2; 95% CI 3.2 to 20.7), hospitalisation for symptoms associated with TB (OR 16.9; CI 1.8 to 156.2), DOTS (directly observed treatment, short-course) centre as treatment unit (OR 6.4; CI 1.8 to 22.8), supervised treatment (OR 3.8; CI 1.6 to 9.5); time-to-treatment centre (OR 0.984; CI 0.974 to 0.993). CONCLUSIONS Incomplete treatment, hospitalisation for TB treatment and adverse reaction are the factors related to previous TB treatment of patients with MDR-TB. Although the presence of supervised treatment (DOT), less time-to-treatment centres and being treated in DOTS centres were relatively higher among the patients with MDR-TB compared with patients without MDR-TB, these findings include information of their most recent TB treatment episode only. Most (64.5%) of the patients with MDR-TB had received TB treatment more than once.
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Affiliation(s)
- Mahfuza Rifat
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
- Health Nutrition and Population Programme, BRAC, Dhaka, Bangladesh
| | - John Hall
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Christopher Oldmeadow
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Ashaque Husain
- National Tuberculosis Control Programme, Dhaka, Bangladesh
| | - Sven Gudmund Hinderaker
- The Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Abul Hasnat Milton
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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