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Achieving high treatment success for multidrug-resistant TB in Africa: initiation and scale-up of MDR TB care in Ethiopia—an observational cohort study
  1. Daniel Meressa1,2,
  2. Rocío M Hurtado1,3,
  3. Jason R Andrews3,4,
  4. Ermias Diro1,5,
  5. Kassim Abato1,
  6. Tewodros Daniel1,
  7. Paritosh Prasad1,*,
  8. Rebekah Prasad1,**,
  9. Bekele Fekade1,
  10. Yared Tedla2,
  11. Hanan Yusuf1,5,
  12. Melaku Tadesse1,
  13. Dawit Tefera1,5,
  14. Abraham Ashenafi1,
  15. Girma Desta1,
  16. Getachew Aderaye7,
  17. Kristian Olson1,6,
  18. Sok Thim1,8,
  19. Anne E Goldfeld1,8,9
  1. 1Global Health Committee and Zahara Children's Program, Addis Ababa, Ethiopia
  2. 2St. Peter's Tuberculosis Specialized Hospital, Addis Ababa, Ethiopia
  3. 3Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
  4. 4Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
  5. 5University of Gondar Hospital, Gondar, Ethiopia
  6. 6Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
  7. 7Hallelujah Clinic, Addis Ababa, Ethiopia
  8. 8Cambodian Health Committee, Phnom Penh, Cambodia
  9. 9Program in Cellular and Molecular Medicine, Children's Hospital Boston, Boston, Massachusetts, USA
  10. *Current affiliation: Pulmonary and Critical Care Medicine Division, University of Rochester Medical Center, Rochester, New York, USA
  11. **Current affiliation: Pediatrics Department, University of Rochester Medical Center, Rochester, New York, USA
  1. Correspondence to Dr Anne Goldfeld, Program in Cellular and Molecular Medicine, Children's Hospital Boston, Harvard Medical School, 200 Longwood Avenue, Boston, MA 02115, USA; Anne.Goldfeld{at}childrens.harvard.edu

Abstract

Background In Africa, fewer than half of patients receiving therapy for multidrug-resistant TB (MDR TB) are successfully treated, with poor outcomes reported for HIV-coinfected patients.

Methods A standardised second-line drug (SLD) regimen was used in a non-governmental organisation–Ministry of Health (NGO-MOH) collaborative community and hospital-based programme in Ethiopia that included intensive side effect monitoring, adherence strategies and nutritional supplementation. Clinical outcomes for patients with at least 24 months of follow-up were reviewed and predictors of treatment failure or death were evaluated by Cox proportional hazards models.

Results From February 2009 to December 2014, 1044 patients were initiated on SLD. 612 patients with confirmed or presumed MDR TB had ≥24 months of follow-up, 551 (90.0%) were confirmed and 61 (10.0%) were suspected MDR TB cases. 603 (98.5%) had prior TB treatment, 133 (21.7%) were HIV coinfected and median body mass index (BMI) was 16.6. Composite treatment success was 78.6% with 396 (64.7%) cured, 85 (13.9%) who completed treatment, 10 (1.6%) who failed, 85 (13.9%) who died and 36 (5.9%) who were lost to follow-up. HIV coinfection (adjusted HR (AHR): 2.60, p<0.001), BMI (AHR 0.88/kg/m2, p=0.006) and cor pulmonale (AHR 3.61, p=0.003) and confirmed MDR TB (AHR 0.50, p=0.026) were predictive of treatment failure or death.

Conclusions We report from Ethiopia the highest MDR TB treatment success outcomes so far achieved in Africa, in a setting with severe resource constraints and patients with advanced disease. Intensive treatment of adverse effects, nutritional supplementation, adherence interventions and NGO-MOH collaboration were key strategies contributing to success. We argue these approaches should be routinely incorporated into programmes.

  • Tuberculosis

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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