Predictors of Multidrug Resistant Tuberculosis Among Adult Tuberculosis Patients in Saint Peter Hospital, Addis Ababa,

Ethiopia: Case control study

By : Ermias D, Muluken Dessalegn

Amref Health Africa

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PLAN OF PRESENTATION

1Background

2Methodology

3Results and Discussions 4Conclusions and

Recommandations

Conclusion and Recom

mandation

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BACKGROUND

• Multidrug resistant TB (MDR-TB ) is caused by bacteria that are

resistant to the most effective anti-TB drugs (Isoniazid and

Rifampicin)

• According WHO(2013) estimates

Half million new MDR-TB cases in the world emerge every year

Only 3% get treatment

150,000 persons die every year

Ethiopia is – 7th among 22 high TB Burden countries

15th among 27 MDR-TBAmref Health Africa

Cont……..

• MDR-TB-is a major threat for successful TB control in Ethiopia and

others

• Very expensive

• Treatment requires prolonged chemotherapy using second line

• Drugs toxicity and less effective

• Did not receive major attention ( though burden cases are high )

• Understanding factors for MDR-TB is important for prevention and

control strategy

• Therefore, the aim of this study to look at the predictors of MDR TB

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Methodology Study design, area, and Population

Area: St. Peter Hospital

The only largest TB referral center in Ethiopia

Design: Hospital based unmatched case-control study design

• Conducted from Feb- March 2014

Population : All patients who were clinically diagnosed as TB at St. Peter

hospital

Cases (MDR-TB) : Tuberculosis patients with culture-proved mycobacterium

tuberculosis resistant at least to both Isoniazid (INH) and Rifampicin (RIF)

Controls (Non-MDR-TB): Tuberculosis patients with smear positive

mycobacterium tuberculosis who turned smear negative to the recent result

after 2nd, 5th,or 6th month of treatment course.

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Sample size determination

Calculated by EPI Info using the assumption for case control study design

Confidence interval 95% , Case to controls ration 1, Power -80%,

Percentage HIV cases among Non MDR-TB:26%

Odds ratio worth detecting :2.5 , and assuming a non-response rate of 10%

Total sample size :206( Cases=103 and control=103)

Ethical clearance

• Approved by DMU and GAMBY College of medical sciences IRB

• Ethical clearance -St. Peter hospital research center

• Informed verbal consent

• Anonymous, and Confidentiality was maintained

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Study variables

Socio-demographic: Age, Sex, Religion, Marital status, Educational status

Environmental factors type of living houses, use of tape water, social support, prison

history, and use of separated cocking room Behavioral variables

Smoking, Alcohol use, chat chewing, history of drug use other substance use type

TB treatment/ history related factors History of Tb, TB site, type of TB and DOTS follow up, Family

history of TB and MDR-TB, Treatment category Co–morbidity:

HIV Staus

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Data collection and analysis

Measurement tools and Data Collection Statistical Analysis

A pretested structured

questionnaire

• Study subjects selection: by

reviewing medical charts

• As safety precautions to prevent

the risk of TB,

data collectors used the N-95

respiratory mask

Patients wear surgical mask

• Data was entered, coded and cleaned by

Epi Info

• Analysis by SPSS V-20

• The analysis had two stages

Bivariate analysis -(cross tabs, COR)

Multivaraite:logistic Regression

• A significant (p < 0.05 and OR: 95% Cis)

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RESULT & DISCUSSION

Socio-demographic factors Sex : 52% cases and 38 % controls were females Age: The mean of age among cases: 30.5 (±9.26) and

controls 34.73(±11.28) years Income: 41% cases and 67 % controls earn less than or

equal to 500 ETB(25$) Employment: About 86% of cases and 61% of controls

were unemployed

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Table 1: Bivariate analysis of variables

Characteristics MDRTB Non MDR TB COR,95%CI p- valueSex Male 49(47.6%) 64(62.1%) 1

0.036 Female 54(52.4%) 39(37.9%) 1.808(1.04,3.15)Occupation

statusEmployed 14(13.6%) 40(38.8%) 1 0.001

Not employed 89(86.4%) 63(61.2%) 4.036(2.03,8.04)Monthly Income(b

≤500 42(40.8%) 69(67.0%) 0.418(0.18,.987) 0.047501-1000 28(27.2%) 14(13.6%) 1.375(0.51,3.74)1001-2000 17(16.5%) 9(8.7%) 1.30(0.43,3.96)

≥2000 16(15.5%) 11(10.7%) 1Residence AA 80(77.7%) 61(59.2%) 2.39(1.30,4.40) 0.005

Out of AA 23(22.3%) 42(40.8%) 1History of

pervious TBYes 96 (93.2%) 25 (24.3%) 42.79(17.57,104.17) 0.00No 7(6.8%) 78(75.7% 1

HIV status Yes 19(18.4%) 48(46.6%) 0.26(0.14,0.49) 0.00No 84(81.6%) 55(53.4%) 1

episodes of pervious TB

One 34(33.0%) 90(87.4%) 1Two and more 69(67.0%) 13(12.6%) 14.0573(6.89,28.63) 0.0047

Type of TB site Pulmonary 92(93.9%) 21(80.8%) 3.651(1.017,13.104)

Extra pulmonary 6(6.1%) 5(19.2%) 10.045Treatment

categoryCategory I 48(46.6% 96(94.1% 1Category IICategory IIICategory IV

39(37.9%)5(4.9%)11(10.7%)

2(2.0%)3(2.9%)1(1.0%)

39.00(9.03,168.37)3.33(0.76,14.54)2.82(1.27,175.44)

Ever Drug interrupted

Yes 24(23.3%) 10(9.7%) 2.82(1.27,6.26) 0.011No 79(76.7%) 93(90.3%) 1

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Table 2: Multivariate Analysis

Variables Factors Cases Controls COR(95%CI) AOR(95%CI)Sex Male 49(47.6%) 64(62.1%) 1 1

Female 54(52.4%) 39(37.9%) 1.808(1.04,3.15) 3.05(0.94,9.84)History of pervious TB

Yes 96(93.2%) 25(24.3%) 42.79(17.57,10.17) 20.35(5.13,80.58)No 7(6.8%) 78(75.7%) 1 1

Occupational status Employed 14(13.6%) 40(38.8%) 1 1Not employed 89(86.4%) 63(61.2%) 4.04(2.03,8.04) 0.47(0.12,1.92)

Income ≤500 42(40.8%) 69(67.0%) 0.42(0.18,0.99) 1.2(0.28,5.22)501-1000 28(27.2%) 14(13.6%) 1.38(0.51,3.74) 0.56(.09,3.36)

1001-2000 17(16.5%) 9(8.7%) 1.30(0.43,3.96) 1.37(0.20,9.19)≥2000 16(15.5%) 11(10.7%) 1 1

Residence AA 80(77.7%) 61(59.2%) 1 1Out of AA 23(22.3%) 42(40.8%) 2.39(1.30,4.40) 2.04(0.65,6.38)

HIV status Yes 19(18.4%) 48(46.6%) 0.26(.138,.487) 0.065(0.01,0.28)No 84(81.6%) 55(53.4%) 1 1

Episodes of TB one 34(33.0%) 90(87.4%) 1 1More than one 9(67.0%) 13(12.6%) 14.06(6.89,28.63) 15.67(4.18,58.71)

Type of TB site Pulmonary 92(93.9%) 21(80.8%) 3.651(1.017,13.10) 6.83(1.16,40.17)Extra pulmonary TB

6(6.1%) 5(19.2%) 1 1

Category of treatment

category I 48(46.6%) 96(94.1%) 1 1Category II 39(37.9%) 2(2.0%) 39.0(9.03,168.37) 16.14(2.40,108.56)Category III 5(4.9%) 3(2.9%) 3.33(0.76,14.54) 2.49(0.29,21.38)

Category IV 11(10.7%) 1(1.0%) 22.00(2.76,17.4) 7.77(0.55,109.3)Drug Interrupted for at least once

Yes 24(23.3) 10(9.7%) 2.82(1.27,6.26) 0.25(0.058,1.11)No 79(76.7%) 93(90.3%) 1 1

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Result & Discussion cont ….

• Previous history of tuberculosis and TB episode

The odds of MDR-TB were higher among those who had history of previous TB

and more than one episode (AOR :20 &15, respectively)

This might be due to:

the previous treatment outcome, default, treatment failure, or relapse

or the patient may have had MDR-TB initially• Consistent with

Study done in Uganda, South Africa also showed that multiple/previous

TB episodes and treatment failure were significantly associated with

MDR-TBAmref Health Africa

Result & Discussion cont ….

Treatment category Individuals who had category II treatment was higher among

MDR TB than Non-MDR-TB (AOR95%CI=16 (2.40, 108.56)

This might be related to: • Patients who fall to this group are individuals who had previous TB

treatment, relapse ,defaulters, or treatment failures

• Already they took first line combination of anti TB drug except

streptomycin on previous TB infection and they might have

already had MDR-TB at initiation of the category II regimen

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Result & Discussion cont ….

Type of TB• The odds of MDR-TB was 6 times higher among those who

have pulmonary TB than extra pulmonary

• This might be due to:

Smear-positive pulmonary TB individuals have a high bacterial load and

may not respond to the treatment within a short period of time

Or

Might be associated with diagnostic difficulties

Extra pulmonary MDR-TB the bacterial load is lower and difficult

for definite diagnosis comparing to pulmonary MDR-TB

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Conclusion and Recommendations

• History of previous TB, TB episode more than one time,

pulmonary type of TB, individuals who were treated with the

Category II regimen were predictors for MDR-TB

• The measures in controlling MDR-TB should give emphasize

those predictor factors

• Improving the diagnostic laboratory centers

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