Specific characteristics of tuberculosis in low default, but high multidrug–resistance prison setting
Date
2019-05-27
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Abstract
Tuberkuloosi (TB), selhulgas ravimresistentse TB-i, esinemissagedus vanglas viibivate inimeste seas on 28 korda kõrgem kui tavaelanikkonna hulgas. Hilinenud diagnostika ja ravi suurendab TB-I levikut vanglates ja ühsikonnas tervikuna ning tõstab ebasoodsa ravitulemuse tõenäosust. TB-i ja eriti multiresistentset TB-i põdevate patsientide ravi edukuse määr on kogu maailmas madal, kusjuures viibimist kinnipidamisasutuses peetakse üheks ebasoodsa ravitulemuse riskiteguriks. Elmira Gurbanova uuring viidi läbi Aserbaidžaani Vabariigi kinnipidamisasutustes. Aserbaidžaan kuulub 30 kõrge RR-TB-i haigestumisega riigi hulka maailmas. Uuringu eesmärk oli hinnata Maailma Terviseorganisatsioon (MTO) poolt soovitatava sõeluuringu, diagnostika ja ravi mõju TB-i ja ravimresistentse TB-i esinemissagedusele vanglas, mida iseloomustab kõrge ravimresistentse TB-i esinemissagedus ja madal ravikatkestamise tase.
Selleks, et hinnata tuberkuloosi sõeluuringu mõju TB-i haigestumisele ja ravitulemustele enne ja pärast kiirtestide, nagu Xpert MTB / RIF ja vedelkultuuri, kasutuselevõttu, kaasati uuringusse 2315 TB-i põdevat patsienti 19-st vanglast. Tuvastati, et kiirtestide kasutuselevõtt TB-i diagnostikaalgoritmides alandas suhteliselt lühikese aja jooksul vastavalt 3-, 10- ja 5-kordselt kogu TB-i haigestumist, mikroskoopial positiivsete uute juhtude esinemissagedust ja RIF-resistentsete juhtude esinemissagedust. Lisaks, peale kiirtestide kasutuselvõttu olid ravitulemused paremad patsientidel, keda raviti esimese rea TB-I ravimitega.
Selleks, et tuvastada, kas selliste juhtude, kus erinevate määramismeetoditega, nagu Xpert MTB/RIF ja MGIT-vedelkultuur, saadud rifampitsin (RIF)-tundlikkuse määramistulemused lahknevad, testiti 532 patsiendilt võetud proove mõlema meetodiga. Analüüsiti, kas RIF-tundlikkuse esinemissagedus sõltub sellest, kas kasutatakse ühte ja sama rögaproovi või järjestikuseid, eri aegadel kogutud rögaproove. Vastuolulisi RIF-tundlikkuse tulemusi esines 6,2% proovidest. Leiti, et lahknevate RIF-tundlikkuse tulemuste määr ei sõltu sellest, kas kasutatakse üht ja sama proovi või erinevaid järjestikuseid proove. Kõige sagedamini täheldatud lahknevate tulemuste muster oli selline, kus RIF-resistentsus Xpert MTB/ RIF-l kombineerus RIF-tundlikkusega MGIT-kultuuris ning kus RIF-resistentsus oli peamiselt tingitud L511P mutatsioonist. RIF-resistentsuse kliiniline tähendus on aga sellistel juhtudel tõenäoliselt vähene, kuna raitulemused oluliselt ei erinenud.
Kasutades Aserbaidžaani kinnipidamisasutuste eelist, mis seisneb madalas ravikatkestajate hulgas, analüüsiti RIF-resistentse TB-ga patsientide ebasoodsa ravitulemusega seotud riksifaktorid. Uuringusse kaasati 444 kinnipidamisasutustes viibivat RIF-resistentse TB-ga patsienti. Efektiivne ravitulemus saavutati 78,4%-l haigetest. Suurema arvu efektiivsete bakteritsiidsete ravimite kasutamine pärast RIF-resistentse TB-i ravikuuri kuuendat kuud oli peamiseks efektiivse raviga seotud teguriks. Olukord, kus kopsudes ei olnud nähtavaid patoloogiale viitavaid radioloogilisi muutusi ja kehamassiindeks oli vähemalt 18,5 kg/m2, suurendab samuti oluliselt efektiivse ravi tõenäosust. Vangustusega seotud teguritel, nagu karistuse liik või varasemate vangistuste arv, ei olnud ravitulemustele olulist mõju.
Compared with the general population, prevalence of TB including its drug-resistant forms among prisoners is up to 28 times higher. Delayed diagnosis and treatment increase TB transmission and prevalence in prisons, which spills over the community. Treatment success rates among patients with TB and multidrug-resistant TB are globally low and historically, imprisonment is considered a risk factor for poor treatment outcome. Elmira Gurbanova’s study was performed in prisons of Azerbaijan, which is among the 30 high rifampicin resistant (RR) TB-burden countries in the world. The study aimed to evaluate the impact of the WHO-recommended screening, diagnostics, and treatment to the burden of TB and multi/extremely drug-resistant TB (M/XDR-TB) in the high-burden, but low-default prison settings. To evaluate the impact of TB screening on the notification and treatment outcomes in prisons before and after introduction of Xpert MTB/RIF and Mycobacteria growth indicator tube (MGIT) culture into the screening algorithms, a total of 2,315 TB patients were identified in 19 prisons and analyzed at this study. The 3-, 10-, and 5-fold significant decrease in the annual rates of the notified, smear-positive, and RR-TB cases, respectively, with significant linear trends towards decrease was identified. The treatment success with first-line drugs also increased significantly. To identify the rate of discordant rifampicin (RIF) susceptibility results by Xpert MTB/RIF and MGIT when the same sputum sample or sequential ones are used for the tests, samples from 532 patients were prospectively tested with both methods. Out of the tested samples, 6.2% had discordant RIF-susceptibility results. No significant association of the discordant RIF-susceptibility results with application of both tests on one sample versus sequential ones was found. L511P mutation accounted significantly on the discrepancy among those RIF-resistant on Xpert MTB/RIF, but sensitive on MGIT, while no significant association was identified between the outcomes of treatment with the first- or second-line drugs and the presence of any mutation. To identify the pure factors associated with the cure among RR-TB patients, taking the advantage of very low loss-to-follow-up rate among patients with TB in Azerbaijan prisons, 444 RR-TB patients identified and enrolled into the treatment, of them 78.4% were cured. Higher number of effective bactericidal drugs in the regimen after the 6th month of treatment, chest x-ray without visible pathology, and BMI ≥18.5 at the treatment start significantly increased the chances for cure. The prison-related factors, such as the type of sentence or number of previous imprisonments, had no significant impact on the treatment outcomes.
Compared with the general population, prevalence of TB including its drug-resistant forms among prisoners is up to 28 times higher. Delayed diagnosis and treatment increase TB transmission and prevalence in prisons, which spills over the community. Treatment success rates among patients with TB and multidrug-resistant TB are globally low and historically, imprisonment is considered a risk factor for poor treatment outcome. Elmira Gurbanova’s study was performed in prisons of Azerbaijan, which is among the 30 high rifampicin resistant (RR) TB-burden countries in the world. The study aimed to evaluate the impact of the WHO-recommended screening, diagnostics, and treatment to the burden of TB and multi/extremely drug-resistant TB (M/XDR-TB) in the high-burden, but low-default prison settings. To evaluate the impact of TB screening on the notification and treatment outcomes in prisons before and after introduction of Xpert MTB/RIF and Mycobacteria growth indicator tube (MGIT) culture into the screening algorithms, a total of 2,315 TB patients were identified in 19 prisons and analyzed at this study. The 3-, 10-, and 5-fold significant decrease in the annual rates of the notified, smear-positive, and RR-TB cases, respectively, with significant linear trends towards decrease was identified. The treatment success with first-line drugs also increased significantly. To identify the rate of discordant rifampicin (RIF) susceptibility results by Xpert MTB/RIF and MGIT when the same sputum sample or sequential ones are used for the tests, samples from 532 patients were prospectively tested with both methods. Out of the tested samples, 6.2% had discordant RIF-susceptibility results. No significant association of the discordant RIF-susceptibility results with application of both tests on one sample versus sequential ones was found. L511P mutation accounted significantly on the discrepancy among those RIF-resistant on Xpert MTB/RIF, but sensitive on MGIT, while no significant association was identified between the outcomes of treatment with the first- or second-line drugs and the presence of any mutation. To identify the pure factors associated with the cure among RR-TB patients, taking the advantage of very low loss-to-follow-up rate among patients with TB in Azerbaijan prisons, 444 RR-TB patients identified and enrolled into the treatment, of them 78.4% were cured. Higher number of effective bactericidal drugs in the regimen after the 6th month of treatment, chest x-ray without visible pathology, and BMI ≥18.5 at the treatment start significantly increased the chances for cure. The prison-related factors, such as the type of sentence or number of previous imprisonments, had no significant impact on the treatment outcomes.
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Keywords
kinnipidamiskohad, tuberkuloos, diagnostika (med.), sõeluuringud, ravimiresistentsus, Aserbaidžaan