Uganda Public Health Fellowship Program, Kampala, Uganda.
National Tuberculosis and Leprosy Program, Ministry of Health, Kampala, Uganda.
BMC Infect Dis. 2019 May 7;19(1):387. doi: 10.1186/s12879-019-4014-3.
In August 2017, the Uganda Ministry of Health was notified of increased cases of multidrug-resistant tuberculosis (MDR-TB) in Arua District, Uganda during 2017. We investigated to identify the scope of the increase and risk factors for infection, evaluate health facilities' capacity to manage MDR-TB, and recommend evidence-based control measures.
We defined an MDR-TB case-patient as a TB patient attending Arua Regional Referral Hospital (ARRH) during 2013-2017 with a sputum sample yielding Mycobacterium tuberculosis resistant to at least rifampicin and isoniazid, confirmed by an approved drug susceptibility test. We reviewed clinical records from ARRH and compared the number of MDR-TB cases during January-August 2017 with the same months in 2013-2016. To identify risk factors specific for MDR-TB among cases with secondary infection, we conducted a case-control study using persons with drug-susceptible TB matched by sub-county of residence as controls. We observed infection prevention and control practices in health facilities and community, and assessed health facilities' capacity to manage TB.
We identified 33 patients with MDR-TB, of whom 30 were secondary TB infection cases. The number of cases during January-August 2017 was 10, compared with 3-4 cases in January-August from 2013 to 2016 (p = 0.02). Men were more affected than women (6.5 vs 1.6/100,000, p < 0.01), as were cases ≥18 years old compared to those < 18 years (8.7 vs 0.21/100,000, p < 0.01). In the case-control study, poor adherence to first-line anti-TB treatment (aOR = 9.2, 95% CI: 2.3-37) and initiating treatment > 15 months from symptom onset (aOR = 11, 95% CI: 1.5-87) were associated with MDR-TB. All ten facilities assessed reported stockouts of TB commodities. All 15 ambulatory MDR-TB patients we observed were not wearing masks given to them to minimize community infection. The MDR-TB ward at ARRH capacity was 4 patients but there were 11 patients.
The number of cases during January-August in 2017 was significantly higher than during the same months in 2013-2016. Poor adherence to TB drugs and delayed treatment initiation were associated with MDR-TB infection. We recommended strengthening directly-observed treatment strategy, increasing access to treatment services, and increasing the number of beds in the MDR-TB ward at ARRH.
2017 年 8 月，乌干达卫生部收到报告称，乌干达阿鲁阿地区 2017 年耐多药结核病（MDR-TB）病例有所增加。我们开展了调查，以确定增加的范围和感染的危险因素，评估卫生机构管理耐多药结核病的能力，并提出基于证据的控制措施建议。
我们将 2013 年至 2017 年期间在阿鲁阿地区转诊医院就诊且痰样本经证实对利福平及异烟肼至少一种耐药的结核病患者定义为耐多药结核病病例患者，该耐药性由经批准的药敏试验证实。我们查阅了阿鲁阿地区转诊医院的临床记录，并将 2017 年 1 月至 8 月的耐多药结核病病例数与 2013 年至 2016 年同期进行了比较。为了确定继发感染病例中耐多药结核病的特定危险因素，我们对来自不同地区的耐多药结核病患者进行了病例对照研究，以符合居住条件的药物敏感性结核病患者作为对照。我们观察了卫生机构和社区中的感染预防和控制措施，并评估了卫生机构管理结核病的能力。
我们共发现 33 例耐多药结核病患者，其中 30 例为继发结核病感染病例。2017 年 1 月至 8 月期间，耐多药结核病病例数为 10 例，而 2013 年至 2016 年同期为 3-4 例（p=0.02）。男性比女性更容易感染（6.5/100000 比 1.6/100000，p<0.01），18 岁及以上的患者比 18 岁以下的患者更容易感染（8.7/100000 比 0.21/100000，p<0.01）。在病例对照研究中，未遵医嘱服用一线抗结核药物（比值比[aOR]，9.2；95%置信区间[CI]：2.3-37）和症状出现后 15 个月以上开始治疗（aOR，11；95%CI：1.5-87）与耐多药结核病相关。我们评估的所有 10 家机构均报告结核病商品库存短缺。我们观察到的 15 名门诊耐多药结核病患者均未佩戴发给他们的口罩，以尽量减少社区感染。阿鲁阿地区转诊医院耐多药结核病病房的容量为 4 人，但有 11 人入住。
2017 年 1 月至 8 月的病例数明显高于 2013 年至 2016 年同期。未遵医嘱服用结核病药物和延迟治疗开始与耐多药结核病感染相关。我们建议加强直接观察治疗策略，增加治疗服务的可及性，并增加阿鲁阿地区转诊医院耐多药结核病病房的床位。
