Journal Article

Multidrug-resistant tuberculosis outbreak associated with poor treatment adherence and delayed treatment: Arua District, Uganda, 2013–2017

Kwesiga, Benon, Ario, Alex R., Zhu, Bao-Ping, Birungi, Doreen, Biribawa, Claire, Okethwangu, Denis, Turyahabwe, Stavia

2019

Overview

Background 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. Methods 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. Results 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. Conclusion 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.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Adhesion / Antitubercular agents / Care and treatment / Case studies / Commodities / Communities / Control methods / Drug resistance / Global health security / Health care facilities / Hospital facilities / Infection control / Infectious Diseases / Internal Medicine / Isoniazid / Leprosy / Masks / Measurement methods / Medical Microbiology / Medical records / Medicine / Medicine & Public Health / Microbial drug resistance / Multidrug resistance / Multidrug resistant organisms / Multidrug-resistant tuberculosis / Mycobacterium tuberculosis / Outbreaks / Parasitology / Patient compliance / Patients / Prevention / Public health / Refugees / Research Article / Rifampicin / Rifampin / Risk analysis / Risk factors / Secondary infection / Sputum / Tropical Medicine / Tuberculosis / Tuberculosis and other mycobacterial diseases