Tajikistan has a high burden of rifampicin-resistant TB (RR-TB), with 2,700 new cases estimated for 2021 (28/100,000 population). TB is spread among household members through close interaction and children exposed through household contact progress to disease rapidly and frequently.
METHODS
We retrospectively analysed programmatic data from household contact tracing in Dushanbe over 50 months. We calculated person-years of follow-up, contact tracing yield, number needed to screen (NNS) and number needed to test (NNT) to find one new case, and time to diagnosis.
RESULTS
We screened 6,654 household contacts of 830 RR-TB index cases; 47 new RR-TB cases were detected, 43 in Year 1 and 4 in Years 2 or 3. Ten were aged <5 years; 46/47 had TB symptoms, 34/45 had chest radiographs consistent with TB, 11/35 were Xpert Ultra-positive, 29/32 were tuberculin skin test-positive and 28/47 had positive TB culture and phenotypic drug susceptibility results. The NNS to find one RR-TB case was 141.57 and the NNT was 34.49. The yields for different types of contacts were as follows: 0.7% for screened contacts, 2.9% for tested contacts, 17.0% for symptomatic contacts and 12.1% for symptomatic contacts aged below 5 years.
CONCLUSION
RR-TB household contact tracing was feasible and productive in Tajikistan, a low middle-income country with an inefficient healthcare delivery system.
BACKGROUND
Drug-resistant TB (DR-TB) remains a major public health threat. In 2022, Uzbekistan reported 2,117 cases of DR-TB, with 69% tested for fluoroquinolone resistance. Limited information is available on the prevalence of resistance to bedaquiline, linezolid, and fluoroquinolone, which are key components of the all-oral treatment regimen for rifampicin-resistant TB in Uzbekistan.
METHODS
A retrospective study was conducted using extensive programmatic data from 2019 to 2023 in Uzbekistan. We assessed second-line drug-resistant TB (SLDR-TB) rates using phenotypic drug susceptibility testing (pDST). Demographic and clinical characteristics associated with SLDR-TB were analysed using multivariable logistic regression models based on the Allen-Cady approach.
RESULTS
In total, 2,405 patients with TB who had undergone pDST were included (median age 40 years, 47% female). The overall SLDR-TB resistance rate was 24% (95% CI 22-26). Prevalence of resistance to bedaquiline, linezolid, moxifloxacin, levofloxacin, and amikacin were respectively 3.1%, 0.8%, 15%, 13%, and 12%. Risk factors for SLDR-TB were resistance to rifampicin and/or isoniazid, exposure to clofazimine, retreatment status, contact with drug-susceptible TB case or DR-TB case, and diabetes.
CONCLUSIONS
The high prevalence of SLDR-TB is of major concern, emphasising the need for baseline pDST in RR-TB treatment. Identified risk factors can aid early detection of at-risk individuals and inform clinical practice.
Background
Isoniazid (INH, H) resistance is the most common drug-resistant TB pattern, with treatment success rates lower than those in drug-susceptible TB. The WHO recommends a 6-month regimen of rifampicin (RIF, R), ethambutol (EMB, E), pyrazinamide (PZA, Z), and levofloxacin (Lfx) (6REZLfx) for INH-resistant, RIF-susceptible TB (HRRS-TB). Uzbekistan has a high burden of TB (62/100,000 population) and multidrug-resistant TB (12/100,000 population).
Methods
We conducted a retrospective, descriptive study of microbiologically confirmed HRRS-TB using routinely collected programmatic data from 2009 to 2020.
Results
We included 854 HRRS-TB cases. Treatment success was 80.2% overall. For REZLfx, the treatment success rate was 92.0% over a short treatment duration, with no amplifications to RIF or second-line anti-TB drug resistance. We documented 46 regimens with REZLfx plus linezolid (success 87.0%) and 539 regimens using kanamycin or capreomycin (success 76.6%). We identified 37 treatment failures (4.3%), 30 deaths (3.5%), 25 resistance amplifications (2.9%), including eight to RIF (0.9%), and 99 lost to follow-up (LTFU) cases (11.6%). Unsuccessful outcomes were more common with older age, diabetes, chest X-ray cavities, smear positivity, smear-positive persistence, and male sex. LTFU was more common with injection-containing regimens.
Conclusions
REZLfx is a safe and effective first-line treatment for INH-resistant, RIF-susceptible TB. Treatment success was lower and LTFU was higher for injection-containing regimens.
Tuberculosis (TB) drugs and their import are costly. We assessed how shorter TB drug regimens, which were non-inferior or superior in recent TB trials, can affect the costs for purchasing and importing TB drugs.
METHODS
We estimated the drug costs and import costs of 39 longer and shorter TB drug regimens using TB drug prices from the Global Drug Facility and import cost estimates for a TB program in Karakalpakstan, Uzbekistan. Drug regimens from recent TB trials were compared with TB drug regimens following present or past World Health Organization recommendations.
RESULTS
We estimated an import cost of $4.19 and a drug cost of $43 per standard 6-month drug-sensitive (DS)-TB regimen. A new 17-week DS-TB regimen from the TBTC Study 31 currently requires more tablets and is more expensive to import ($6.08) and purchase ($233). The TB program can substantially decrease import costs ($2.26–14) and drug costs ($391–2308) per multidrug-resistant (MDR)-TB regimen when using new 6-month or shorter drug regimens from the Nix-TB, NExT, TB PRACTECAL, ZeNix, or BEAT TB trials instead of 9–20-month regimens with import costs of $9.96–507 and drug costs of $354–15 028. For a commonly used 20-month all-oral, bedaquiline-containing MDR-TB regimen, we estimated costs of $41 for drug import and $1773 for drug purchase.
CONCLUSIONS
The implementation of a new and shorter DS-TB regimen may increase the costs for drug purchase and import. The implementation of new and shorter MDR-TB regimens may decrease the costs for drug purchase and/or drug import.
MSF and the MoHS implemented a partnership model of free and accessible maternal and child healthcare at primary and hospital-level health facilities in Tonkolili District, Sierra Leone, in order to reduce barriers to care and improve health outcomes. We conducted a health-seeking behaviour (HSB) study in 2021 to evaluate impact and change since a previous HSB study conducted in 2016/17. We also compared MSF-supported primary health unit (PHU) catchment areas with MSF-unsupported PHU’s. In addition, we explored adolescent reproductive health, family planning, and female genital mutilation (FGM).
METHODS
Study design was mixed-methods, similar to that used in 2016/17, including a quantitative household survey, structured interviews with key informants, and qualitative in-depth interviews (IDI’s). We randomly selected 60 clusters; 30 in MSF-supported areas, and 30 in unsupported areas. IDI’s explored topics identified through the survey, and were conducted with purposively-sampled participants, and analyzed thematically.
ETHICS
This study was approved by the Sierra Leone Ethical and Scientific Review Committee and by the MSF Ethics Review Board
RESULTS
Between February and August 2021, 1,164 women and 1,177 carers (of 1,559 children aged under 5) participated in the survey; 59 structured interviews and 42 IDI’s were conducted. Compared to the 2016/17 study, access to healthcare improved, with the proportion of women delivering in a health facility increasing from 52.0% (95% confidence intervals (CI) 42-64) to 90.9% (95% CI 89.2-92.5), and the proportion of mothers reporting at least one barrier to accessing care decreasing from 90.0% (95% CI 80-95) to 45.9% (95% CI 43.0-48.8). Outcomes of care also improved over this period, with under-5 mortality decreasing from 1.55 per 10,0000/day (95% CI 1.30-1.86) to 0.25 per 10,000/day (95% CI 0.17-0.36).When comparing unsupported PHU’s versus supported areas in 2021, complications during labour or delivery were higher in unsupported areas (10.9%; 95% CI 8.6-13.6) vs 7.2% (95% CI 5.3-9.7), as was stillbirth (4.5%; 95% CI 3.1-6.5) vs 1.4% (95% CI 0.6-2.8). Under-5 mortality was 0.44 per 10,000/day (95% CI 2.4-7.2) in unsupported areas and 0.17 per 10,000/day (95% CI 0.8-2.9) in supported areas. 42.9% (95% CI 34.7-51.4) of adolescents in unsupported areas and 39.7% (95% CI 31.3- 48.7) in supported areas reported unmet need for contraception. More than 90% (96.6%, 95% CI 95.3-97.5) of women reported FGM. Qualitative data suggests that communities recognized the importance of delivering in a health facility with trained assistance. Nevertheless, health staff and community members felt the current fine system for home births was applied inflexibly in circumstances when distance, transport, or cost restricted or delayed access.
CONCLUSION
Since 2016/17, access to healthcare and outcomes have improved in all areas, but improvement has been greatest in areas where, in addition to hospital care, MSF supported MoHS PHU’s. This provides evidence for ongoing implementation and scale-up of comprehensive models of care. Progress made must not overshadow areas requiring further attention, such as care for adolescents, access to contraception, and the need to reduce stillbirths.
CONFLICTS OF INTEREST
None declared.