Primary and secondary anti-tuberculosis drug resistance in Ethiopia

Hamusse S, Teshome D, Hussen M, Demissie M, Lindtjorn B. Primary and secondary anti-tuberculosis drug resistance in Hitossa District of Arsi Zone, Oromia Regional State, Central Ethiopia. BMC Public Health 2016; 16(1):

Background: Multidrug-resistant tuberculosis (MDR-TB) drugs which is resistant to the major first-line anti-TB drugs, Isoniazid and Rifampicin, has become a major global challenge in tuberculosis (TB) control programme. However, its burden at community level is not well known. Thus, the aim of study was to assess the prevalence of primary and secondary resistance to any first line anti-TB drugs and MDR TB in Hitossa District of Oromia Regional State, Central Ethiopia.

Methods: Population based cross- sectional study was conducted on individuals aged ≥15 years. Those with symptoms suggestive of TB were interviewed and two sputum specimens were collected from each and examined using Lowenstein-Jensen (LJ) culture medium. Further, the isolates were confirmed by the Ziehl-Neelsen microscopic examination method. Drug susceptibility test (DST) was also conducted on LJ medium using a simplified indirect proportion method. The resistance strains were then determined by percentage of colonies that grew on the critical concentration of Isoniazid, Streptomycin, Rifampicin and Ethambutol.

Results: The overall resistance of all forms of TB to any first-line anti-TB drug was 21.7 %. Of the total new and previously treated culture positive TB cases, 15.3 and 48.8 % respectively were found to be a resistant to any of the first-line anti-TB drugs. Further, of all forms of TB, the overall resistance of MDR-TB was 4.7 %. However, of the total new TB cases, 2.4 % had primary while 14.3 % had secondary MDR-TB. Resistance to any of the first-line anti-TB drugs (adjusted odd ratio (AOR), 8.1; 95 % CI: 2.26–29.30) and MDR-TB (AOR), 7.1; 95 % CI: 2.6–43.8) was found to be linked with previous history of anti-TB treatment.

Conclusions: The study has identified a high rate of primary and secondary resistance to any of the first-line anti-TB drugs and MDR-TB in the study area. The resistance may have resulted from sub-optimal performance of directly observed treatment short-course (DOTS) programme in the detecting infectious TB cases and cure rates in the study area. Anti-TB drug resistance is linked with previous TB treatment. There is a need to strengthen DOTS and DOTS-Plus programmes and expand MDR-TB diagnostic facilities in order to timely diagnose MDR-TB cases and provide appropriate treatment to prevent the spread of MDR-TB in Ethiopia.

Accessibility to TB control services improves in South Ethiopia

Dangisso, M. H., et al. (2015). “Accessibility to tuberculosis control services and tuberculosis programme performance in southern Ethiopia.” Glob Health Action 8: 29443.

BACKGROUND: Despite the expansion of health services and community-based interventions in Ethiopia, limited evidence exists about the distribution of and access to health facilities and their relationship with the performance of tuberculosis (TB) control programmes. We aim to assess the geographical distribution of and physical accessibility to TB control services and their relationship with TB case notification rates (CNRs) and treatment outcome in the Sidama Zone, southern Ethiopia.

DESIGN: We carried out an ecological study to assess physical accessibility to TB control facilities and the association of physical accessibility with TB CNRs and treatment outcome. We collected smear-positive pulmonary TB (PTB) cases treated during 2003-2012 from unit TB registers and TB service data such as availability of basic supplies for TB control and geographic locations of health services. We used ArcGIS 10.2 to measure the distance from each enumeration location to the nearest TB control facilities. A linear regression analysis was employed to assess factors associated with TB CNRs and treatment outcome.

RESULTS: Over a decade the health service coverage (the health facility-to-population ratio) increased by 36% and the accessibility to TB control facilities also improved. Thus, the mean distance from TB control services was 7.6 km in 2003 (ranging from 1.8 to 25.5 km) between kebeles (the smallest administrative units) and had decreased to 3.2 km in 2012 (ranging from 1.5 to 12.4 km). In multivariate linear regression, as distance from TB diagnostic facilities (b-estimate=-0.25, p<0.001) and altitude (b-estimate=-0.31, p<0.001) increased, the CNRs of TB decreased, whereas a higher population density was associated with increased TB CNRs. Similarly, distance to TB control facilities (b-estimate=-0.27, p<0.001) and altitude (b-estimate=-0.30, p<0.001) were inversely associated with treatment success (proportion of treatment completed or cured cases).

CONCLUSIONS: Accessibility to TB control services improved despite the geographic variations. TB CNRs were higher in areas where people had better access to diagnostic and treatment centres. Community-based interventions also played an important role for the increased CNRs in most areas.

New Article: Trends in TB case notification over fifteen years in Arsi in Ethiopia

Hamusse SD, Demissie M, Lindtjorn B. Trends in TB case notificationover fifteen years: the case notification of 25 Districts of Arsi Zone of Oromia Regional State, Central Ethiopia. BMC public health 2014; 14(1): 304.

Background  The aims of tuberculosis (TB) control programme are to detect TB cases and treat them to disrupt transmission, decrease mortality and avert the emergence of drug resistance. In 1992, DOTS strategy was started in Arsi zone and since 1997 it has been fully implemented. However, its impact has not been assessed. The aim of this study was, to analyze the trends in TB case notification and make a comparison among the 25 districts of the zone.

Methods  A total of 41,965 TB patients registered for treatment in the study area between 1997 and 2011 were included in the study. Data on demographic characteristics, treatment unit, year of treatment and disease category were collected for each patient from the TB Unit Registers.

Results  The trends in all forms of TB and smear positive pulmonary TB (PTB+) case notification increased from 14.3 to 150 per 100,000 population, with an increment of 90.4% in fifteen years. Similarly, PTB+ case notificationincreased from 6.9 to 63 per 100,000 population, an increment of 89% in fifteen years. The fifteen-year average TB case notification of all forms varied from 60.2 to 636 (95% CI: 97 to 127, P<0.001) and PTB+ from 10.9 to 163 per 100,000 population (95% CI: 39 to 71, p<0.001) in the 25 districts of the zone. Rural residence (AOR, 0.23; 95% CI: 0.21 to 0.26) and districts with population ratio to DOTS sites of more than 25,000 population (AOR, 0.40; 95% CI: 0.35 to 0.46) were associated with low TB case notification. TB case notifications were significantly more common among 15-24 years of age (AOR, 1.19; 95% CI:1.03 to 1.38), PTB- (AOR, 1.46; 95% CI: 1.33 to 64) and EPTB (AOR, 1.49; 95% CI; 1.33 to 1.60) TB cases.

Conclusions  The introduction and expansion of DOTS in Arsi zone has improved the overall TB case notification. However, there is inequality in TBcase notification across 25 districts of the zone. Further research is, recommended on the prevalence, incidence of TB and TB treatment outcome to see the differences in TB distribution and performance of DOTS in treatment outcomes among the districts.

Biomass fuel in households and risk of tuberculosis

Woldesemayat EM, Datiko DG, Lindtjorn B. Use of biomass fuel in households is not a risk factor for pulmonary tuberculosis in South Ethiopia. The international journal of tuberculosis and lung disease.  2014;18(1):67-72.

SETTING: Rural settings of Sidama Zone in southern Ethiopia.

OBJECTIVE: To investigate the association between exposure to biomass fuel smoke and tuberculosis (TB).

DESIGN: A matched case control study in which cases were adult smear-positive pulmonary tuberculosis (PTB) patients on DOTS-based treatment at rural health insti- tutions. Age-matched controls were recruited from the community.

R E S U LT S : Of 355 cases, 350 (98.6%) use biomass fuel for cooking, compared to 801/804 (99.6%) controls. PTB was not associated with exposure to the biomass fuel smoke. None of the factors such as heating the house, type of stove, presence of kitchen, presence ofadequate cooking room ventilation, light source and number of rooms in the house was associated with the presence of TB. However, TB determinants such as sex, household contact with TB, history of TB treatment, smoking and presence of a smoker in the household have previously shown an association with TB.

CONCLUSION: We found no evidence of an association between the use of biomass fuel and TB. Low statistical power due to the selection of neighbourhood controls might have contributed to this negative finding. We would advise that future protocols should not use neigh- bourhood controls and that they should include measure- ments of indoor air pollution and of exposure duration.

Ethiopian community health workers improve TB Care

Some years ago we did two trials [1 2] to improve case finding of tuberculosis in South Ethiopia. Our study from Sidama in South Ethiopia showed that involving Health Extension workers in Tuberculosis control improved the case detection (from 69 to 122 %) for smear-positive patients and females in particular [1]. We advised that this intervention could be used as an option to improve case detection and provide patient-centred services in high-burden countries. In a later study, we showed that this intervention is a cost-effective treatment alternative to the health service and to the patients and their caregivers [3].

We advised there is both an economic and public health reason to consider involving HEWs in TB treatment in Ethiopia.

Now a large consortium (Stop TB Partnership’s TB REACH initiative and implemented by the Southern Region Health Bureau and the Liverpool school of Tropical Medicine in collaboration with the Ministry of Health and the Global Fund) has scaled up this intervention in Sidama [4]. Their findings are similar to our earlier research: “Community-based interventions made TB diagnostic and treatment services more accessible to the poor, women, elderly and children, doubling the notification rate (from 64 to 127%) and improving treatment result. They advise that this approach could improve TB diagnosis and treatment in other high burden settings”.

I hope that they also present some findings on how this good intervention can be made sustainable in settings such as Sidama.

References

1. Datiko DG, Lindtjørn B. Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS One 2009;4(5):e5443 doi: 10.1371/journal.pone.0005443[published Online First: Epub Date]|.

2. Shargie EB, Morkve O, Lindtjorn B. Tuberculosis case-finding through a village outreach programme in a rural setting in southern Ethiopia: community randomized trial. Bull World Health Organ 2006;84(2):112-9 

3. Datiko DG, Lindtjorn B. Cost and cost-effectiveness of smear-positive tuberculosis treatment by Health Extension Workers in Southern Ethiopia: a community randomized trial. PLoS One 2010;5(2):e9158 doi: 10.1371/journal.pone.0009158[published Online First: Epub Date]|.

4. Yassin MA, Datiko DG, Tulloch O, et al. Innovative Community-Based Approaches Doubled Tuberculosis Case Notification and Improve Treatment Outcome in Southern Ethiopia. PLoS ONE 2013;8(5):e63174doi: 10.1371/journal.pone.0063174[published Online First: Epub Date]|.