Rapid tests reduce the burden of tuberculosis in Azerbaijan prisons: special emphasis on rifampicin-resistance.

AIMS: To evaluate the impact of addition of rapid tests for tuberculosis (TB) to mass screening and passive case finding on the burden of TB in high-incidence prisons of Azerbaijan. MATERIALS AND METHODS: All new and relapse TB cases notified in 01.01.2009-31.12.2015 were retrospectively included. RESULTS: 2,315 TB patients were identified in 19 prisons. Implementation of the rapid tests to the case finding algorithms lead to 3-, 10- and 5-fold decrease in the annual rates of the notified, smear-positive and RIF-resistant TB cases, respectively. After introduction of rapid tests into the screening algorithms, there were significant linear trends towards decrease in the notified (p=0.009), smear-positive (p=0.011) and RIF-resistant TB cases (p=0.02) with the annual rates of decrease (95% confidence interval (CI)) being -435 (-614; -255), -356 (-517; -195), and -99 (-160; -38), respectively. Utilization of rapid tests also significantly increased treatment success with first-line drugs among all cases, cases detected by mass screening and those, detected by passive case finding [adjusted odds ratio (aOR)=2.38, 95% CI:1.86-3.05, aOR=4.56, 95% CI:2.64-7.89 and aOR=2.60, 95% CI:1.81-3.75, respectively]. CONCLUSIONS: Introduction of rapid tests into the screening lead to decline in the burden of TB and RIF-resistance, and improved outcomes of treatment with first-line drugs in prisons.

Los tests rápidos reducen la carga asociada a la tuberculosis en las prisiones de Azerbaiyán: importancia de la resistencia a rifampicina / Rapid tests reduce the burden of tuberculosis in Azerbaijan prisons: special emphasis on rifampicin-resistance

Objetivos: Evaluar el impacto de los tests rápidos para tuberculosis (TB) añadidos a los sistemas de cribado y de búsqueda pasiva de casos en la carga de enfermedad de TB en centros penitenciarios con alta incidencia de la misma en Azerbaiyán. Material y métodos: Inclusión retrospectiva de todos los casos nuevos y recurrentes de TB notificados desde el 1 de enero de 2009 hasta el 31 de diciembre de 2015. Resultados: Se identificaron un total de 2315 pacientes en 19 centros penitenciarios diferentes. Se implementaron los tests rápidos a los algoritmos de identificación de casos con la consiguiente reducción en las tasas anuales de los casos de TB notificados, los casos de baciloscopia positiva y los de TB resistente a la rifampicina (a una tercera, décima y quinta parte respectivamente). Tras la introducción de los tests rápidos en los algoritmos de cribado se observó una tendencia lineal significativa a la reducción de los casos notificados (p=0,009), los casos de baciloscopia positiva (p=0,011) y los de TB resistente a la rifampicina (p=0,02) con tasas anuales de reducción (con intervalo de confianza al 95%) de -432 (-614;-255), -356 (-517; -195) y -99 (-160;-38) respectivamente. La utilización de los tests rápidos también se tradujo en un incremento significativo del éxito terapéutico con fármacos de primera línea en todos los casos: los detectados por cribado y los identificados por búsqueda pasiva [odds ratio ajustado (Ora)= 2.38, IC95% 1,86-3,05; ORa=4,56, IC 95%:2,64-7,89 y ORa=2,60, IC 95% :1,81-3,75, respectivamente]. Conclusiones: La introducción de los tests rápidos en los sistemas de cribado de TB conllevan reducciones en la carga de enfermedad y en la resistencia a rifampicina con mejores resultados terapéuticos con fármacos de primera línea en centros penitenciarios

Aims: To evaluate the impact of addition of rapid tests for tuberculosis (TB) to mass screening and passive case finding on the burden of TB in high-incidence prisons of Azerbaijan. Materials and methods: All new and relapse TB cases notified in 01.01.2009-31.12.2015 were retrospectively included. Results: 2,315 TB patients were identified in 19 prisons. Implementation of the rapid tests to the case finding algorithms lead to 3-, 10- and 5-fold decrease in the annual rates of the notified, smear-positive and RIF-resistant TB cases, respectively. After introduction of rapid tests into the screening algorithms, there were significant linear trends towards decrease in the notified (p=0.009), smear-positive (p=0.011) and RIF-resistant TB cases (p=0.02) with the annual rates of decrease (95% confidence interval (CI)) being -435 (-614; -255), -356 (-517; -195), and -99 (-160; -38), respectively. Utilization of rapid tests also significantly increased treatment success with first-line drugs among all cases, cases detected by mass screening and those, detected by passive case finding [adjusted odds ratio (aOR)=2.38, 95% CI:1.86-3.05, aOR=4.56, 95% CI:2.64-7.89 and aOR=2.60, 95% CI:1.81-3.75, respectively]. Conclusions: Introduction of rapid tests into the screening lead to decline in the burden of TB and RIF-resistance, and improved outcomes of treatment with first-line drugs in prisons

Predictors of cure in rifampicin-resistant tuberculosis in prison settings with low loss to follow-up.

OBJECTIVE: To determine the factors predictive of cure among inmates with pulmonary rifampicin-resistant tuberculosis (R(R)-TB). DESIGN: A total of 444 new and previously treated patients with pulmonary R(R)-TB who started treatment with second-line anti-tuberculosis drugs in the penitentiary system of Azerbaijan during the period 1 April 2007-28 February 2013 were retrospectively subjected to multivariate logistic regression analysis. RESULTS: Of the 444 patients, 78.4% were cured. A higher number of effective bactericidal drugs in the regimen at months 7-12 and 13-18, normal chest X-ray and body mass index ⩾18.5 kg/m(2) at the treatment start significantly increased the chances of cure both in all cases (aOR 2.29, aOR 4.39, aOR 1.18, aOR 1.98 and aOR 1.97, respectively) and in retreatment cases (aOR 3.88, aOR 5.02, aOR 1.17, aOR 2.26 and aOR 1.90, respectively). There was no added benefit of using moxifloxacin (MFX) as compared to levofloxacin (LVX) in case of resistance to ofloxacin. CONCLUSION: The use of a higher number of effective bactericidal drugs after month 6 of treatment for R(R)-TB was found to be the main factor associated with cure. No added benefit of using MFX instead of LVX was found. High cure rates can be achieved among vulnerable population groups such as prisoners if comprehensive TB control measures are in place to ensure low loss to follow-up.

Overall and cause-specific mortality among patients with tuberculosis and multidrug-resistant tuberculosis.

OBJECTIVE: To assess overall and cause-specific mortality among patients with tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB) in Estonia. DESIGN: A total of 2449 patients diagnosed with active respiratory TB from 1 January 2002 to 31 December 2009 were followed up retrospectively until 31 December 2011. To estimate the risk of death, standardised mortality ratios (SMR) and mortality rate ratios (RR) were calculated. RESULTS: The SMR for all-cause mortality among those diagnosed with TB was 5.30 (95%CI 4.85-5.75) in males and 10.00 (95%CI 8.25-11.74) in females. The relative risk of death from TB was higher among MDR-TB patients (adjusted RR in males 2.98, 95%CI 2.00-4.44, and in females 3.26, 95%CI 1.42-7.50) than among non-MDR-TB patients. Among the cohort of successfully treated patients, the SMR for all-cause mortality was 3.46 (95%CI 3.08-3.84) in males and 6.24 (95%CI 4.86-7.88) in females. Lower education level and foreign ethnicity contributed to the higher risk of mortality. Previous history of successfully treated MDR-TB did not increase the risk of death compared to successfully treated non-MDR-TB. CONCLUSIONS: Mortality among successfully treated TB and MDR-TB patients remained higher than among the general population. It was influenced by foreign ethnicity and lower education but, importantly, not by previous history of MDR-TB.

Predictors of recurrence of multidrug-resistant and extensively drug-resistant tuberculosis.

OBJECTIVE: To assess the treatment outcome of the first Green Light Committee (GLC) approved countrywide management of multidrug-resistant (MDR-) and extensively drug-resistant tuberculosis (XDR-TB) in Estonia and to evaluate risk factors contributing to TB recurrence over 8 years of follow-up. DESIGN: Prospective assessment of MDR- and XDR-TB patients starting second-line anti-tuberculosis drug treatment between 1 August 2001 and 31 July 2003, with follow-up until 31 December 2010. RESULTS: In 211 MDR- and XDR-TB patients, treatment success was 61.1%; 22.3% defaulted, 8.5% failed and 8.1% died. TB recurrence among successfully treated patients was 8.5%, with no significant difference between XDR-TB and MDR-TB. TB recurrence was associated with resistance to all injectables (HR 2.27, 95%CI 1.16-5.06, P = 0.046), resistance to a greater number of drugs (HR 1.35, 95%CI 1.11-1.64, P = 0.003), and sputum smear positivity (HR 2.16, 95%CI 1.16-4.00, P = 0.016). A history of previous TB treatment was associated with TB recurrence among successfully treated patients (HR 4.28, 95%CI 1.13-16.15, P = 0.032). CONCLUSIONS: The internationally recommended Category IV treatment regimens are sufficiently effective to cure 75% of adherent MDR- and XDR-TB patients. A history of previous treatment, resistance to all injectable agents and resistance to a greater number of drugs increase the recurrence of MDR- and XDR-TB.

Countrywide management of pulmonary tuberculosis reverses increasing incidence.

OBJECTIVE: To evaluate the impact of countrywide management of tuberculosis (TB) and the availability of second-line drugs (SLDs) on the notification rates of pulmonary TB (PTB) overall and of multidrug-resistant TB (MDR-TB), taking into account human immunodeficiency virus (HIV) co-infection and the national economy in Estonia. DESIGN: Retrospective analysis of notification rates and treatment outcomes of PTB and MDR-TB during 1998-2006. RESULTS: The annual notification rates of both PTB and MDR-TB decreased significantly, by on average 3.3 (P = 0.007) and 1.7 (P = 0.008) cases per 100,000 population, respectively. The accelerating impact of SLD availability on the annual decline was significant for both PTB overall and MDR-TB (P = 0.003 and P = 0.025, respectively). During 1998-2006, an increase in TB-HIV co-infection (P = 0.009) significantly affected the notification rates of both PTB overall and MDR-TB (P < 0.001 and P < 0.001, respectively). The negative impact of TB-HIV co-infection was counterbalanced by the availability of SLDs, the decrease in the MDR-TB rate and the increase in gross domestic product (GDP) per capita, as confirmed by multivariate analysis. CONCLUSION: Countrywide access to SLDs and the coordinated effect of programmatic conditions can, in parallel with increasing GDP, reverse the increasing notification rates of PTB and MDR-TB in the context of an HIV epidemic.