A critical call to effectively manage drug resistance tuberculosis

In this blog Abimbola O Williams highlights her research into the effectiveness of Community-based management compared with traditional hospitalization in the treatment of drug-resistant tuberculosis, which was recently published in Global Health Research and Policy

People who have drug resistant tuberculosis are often classified as having resistance to treatment with at least 2 of the most powerful first-line TB drugs, Isoniazid and Rifampicin (Multidrug resistance TB) or to the major second-line drugs, fluoroquinolones and injectable drugs (extensively drug-resistant TB).

Currently, the World Health Organization (WHO) lists a total of 27 high burden MDR-TB countries having a large number of MDR-TB and XDR-TB cases. This burden varies from country to country and poses a significant threat to treatment and management of tuberculosis.

Treatment and management of DR-TB has focused on traditional hospitalization. However, factors such as adherence to treatment, hospital bed space, social factors (i.e. income, distance to healthcare facilities), etc. further limit access to treatment, thereby further increasing the TB burden.

Over the last few years, community based TB management has been implemented and have been shown to have a significant treatment success rate, reduced treatment failure rate, and increased adherence to treatment.

Community based TB management programs cover a wide range of activities on prevention, diagnosis, treatment, and care of DR-TB services including community mobilization to generate demand for TB and TB/HIV activities. With this, patients can be easily monitored by the nearest directly observed therapy short course-plus (DOTS-TB plus) provider within their community.

TB programs have advocated for the increasing need for community based management of TB patients with the ultimate goal of providing a patient centered care in the face of dwindling funding on TB/HIV programming, especially in developing countries.

What did we do?

We compared the effect of community based treatment with traditional hospitalization in improving treatment success rate among MDR-TB and XDR-TB patients. We utilized a systematic literature review and meta-analysis to calculate a pooled treatment success rates from 9 high burden MDR-TB and XDR-TB countries. In total, data from 16 studies were extracted and involving 3344 patients from nine countries; Bangladesh, China, Ethiopia, Kenya, India, South Africa, Philippines, Russia, and Uzbekistan.

What we found

We observed a higher treatment success rate in studies that implemented a community-based treatment (Point estimate = 0.68, p < 0.01) compared to traditional hospitalization (Point estimate = 0.57, p < 0.01). We also explored the treatment failure rates in both methods, and observed a lower treatment failure rate in community managed cases (Point estimate = 0.07, p < 0.01) compared to traditional hospitalization (Point estimate = 0.188, p < 0.01).

To further understand the differences that could explain the heterogeneity, we conducted a sub group analysis, and found that studies without HIV co-infected patients, DOTS-Plus implemented throughout therapy, treatment duration > 18 months, and regimen with drugs >5 reported higher treatment success rate. We further conducted a meta-regression model to assess whether treatment effect estimates differed by patient age, adverse effect, default rate, and treatment duration, thus explaining any of the heterogeneity in the study. We found that the age of patients, adverse events, treatment duration, and lost to follow up explains some of the heterogeneity of treatment effects between studies.

Our conclusion

Our analysis shows that community-based management improved treatment outcomes. A mix of interventions with DOTS Plus throughout therapy and treatment duration > 18 months as well as strategies in place for lost to follow up and adverse events should be considered in MDR-TB and XDR-TB interventions, as they positively influenced treatment success.

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