Factors contributing to the high prevalence of multidrug resistance/rifampicin resistance in patients with tuberculosis: a cross-sectional, qualitative epidemiological study from the Khabarovsk Krai region of Russia | BMC Infectious Diseases

Characteristics of the study population

During the study period, in all health facilities in the region, 2661 patients were diagnosed with tuberculosis, of which 1544 patients had active pulmonary tuberculosis, and 101 patients were excluded from the study due to resistance types other than MDR/RR-TB, three patients were excluded due to an incomplete set of variables leaving 1440 patients for further analysis (Fig. 2).

Figure 2

Patient registration flowchart. PCR polymerase chain reaction, summer time drug sensitivity tests, MR/RR-TB multidrug-resistant/rifampicin-resistant tuberculosis

The participants had a median age of 41 years and 73.5% of them were men. MDR/RR was detected in 618 participants (42.9%, 95% CI 40.3% to 45.5%). The proportion of participants residing in cities was 69.4% and 989 of them (68.7%) had no record of employment. By type of residence, 61.5% lived in separate apartments and 151 (10.5%) were homeless at the time of TB diagnosis. There was 2.01 times more homelessness among retreatment cases than among newly diagnosed cases (16.5% vs 8.2%). Alcoholism was reported in 3.5% of all cases and in 62.5% of cases tuberculosis was actively discovered during annual chest x-ray in primary health care (PHF) facilities. More than half of all cases (55.1%) had evidence of cavitary disease. Disabilities were reported in 6% of the entire sample, while 8.3% tested positive for HIV. 78 patients (5.4%) were in detention or had an official history of incarceration at the time of diagnosis. Overall, incarcerated patients had a much higher prevalence of MDR/RR (93.6%, 95% CI 85.6% to 97.8%) compared to the population without a history of imprisonment ( 40.0%, 95% CI 37.4% to 42.7%) (p

Of the 1440 patients, 394 were retreatment patients, totaling 27.4% of the overall sample. Re-treatment patients had a higher prevalence of MDR/RR (64.6%, 95% CI 59.8% to 69.4%) than new patients (34.8%, 95% CI 31.8 % to 37.7%) (p

Table 1 Demographic and clinical characteristics of recruited patients:

Factors associated with MDR/RR-TB

Data from 1440 patients underwent logistic regression analysis. The strongest associative factors for MDR/RR-TB were a history of imprisonment and a history of previous treatment. In these cases, the risk of having MDR/RR-TB was 16.53 (95% CI 5.37 to 50.88, p

Other influencing factors included presence of disability (AOR is 2.32, 95% CI 1.38 to 3.89, p=0.001), cavitary disease (AOR is 1.76, CI 95% CI 1.37 to 2.25, p

Table 2 Analysis for estimation of prevalence of MDR/RR-TB in the entire sample (n=1440)

The multilevel model for newly diagnosed patients consisted of 1047 cases. Of these, 364 had MDR/RR-TB (34.7%). History of imprisonment was the strongest associative factor, with an 11.9-fold increased risk of MDR/RR-TB (95% CI 2.94 to 43.78, p

Of the remaining factors, three showed an association with the presence of MDR/RR-TB. Cases with underlying cavitary disease were 1.96 times more likely to have MDR/RR-TB (95% CI 1.46 to 2.63, p

Table 3 Analysis for estimated prevalence of MDR-TB in new cases (n=1046) and retreatment cases (n=394)

393 retreatment patients were analyzed in the separate multilevel model. Four variables were found to be significant, with history of incarceration remaining the strongest associative factor. These patients were 38.5 times more likely to have MDR/RR-TB (95% CI 3.64 to 407.42, p=0.002). The presence of a disability resulted in a 4.43-fold increased likelihood of acquiring MDR/RR-TB (95% CI 1.47 to 13.38, p = 0.008). The last two significant variables were formal employment records (AOR 4.32, 95% CI 1.74 to 10.71, p=0.002) and being actively discovered by PHF (AOR 1.79, 95% CI 1.05 to 3.05, p=0.03) (Table 3) .

Interpretation of interviews

Health care providers have confirmed that former prisoners are the most problematic group of TB patients. Tuberculosis care in prisons is provided on site, by medical staff who are often undertrained and have insufficient funding and equipment. This medical service is not controlled by the authorities of the general tuberculosis care system and operates without supervision. Lack of centralized control, coupled with poor food and living conditions, overcrowding, neglect of treatment regimens by medical staff and prison inmates, make prisons breeding grounds for resistance to drugs. After release, prisoners mostly disappear from epidemiological surveillance and, even if they present themselves for further treatment, they often do not respect the follow-up regime and procedures and there are no legal tools allowing providers health care providers to impose surveillance on them.

Among those interviewed, there was consensus that the main barrier to full patient adherence is the duration of treatment. Patients become progressively fatigued as treatment progresses, particularly those with drug resistance, whose regimens typically last 24 months or longer.

In these cases, all patients with MDR/RR-TB receive inpatient treatment for at least twelve months in the TBDF. After this period, the patient can be transferred to an outpatient treatment regimen. This option is reserved for patients who have proven themselves to be trustworthy, show full compliance during inpatient treatment, and do not actively secrete mycobacterium tuberculosis so as not to be a continued source of infection to others. Patients who do not meet these criteria continue their treatment in hospital until the end of the course. Such prolonged treatment, coupled with insufficient awareness of the consequences of intermittent treatment, leads patients to forgo treatment, usually as soon as symptoms disappear.

The outpatient phase of treatment regimens offers many opportunities for patients to drop out for a variety of reasons. The local TBDF, in collaboration with the NGO Russian Red Cross, is trying to address this issue by providing more in-depth patient education on TB treatment, distributing free monthly food parcels and reimbursing medical expenses. travel to fully compliant patients. According to the doctors, this has been particularly effective in encouraging economically disadvantaged patients to continue their treatment.

Neither patients nor health care providers reported that adverse effects were a significant problem in achieving full adherence to treatment. During an inpatient stay, patients are closely monitored for the appearance of adverse effects, where they are also given medication for the prevention of side effects. Doctors declare that they are equipped with all the drugs necessary for the effective management of adverse effects.

The monitoring of the occurrence of adverse events in outpatients is carried out by a mandatory monthly examination. The only problem here is that during the outpatient phase of treatment, patients pay out of pocket for drugs to combat minor side effects, but if any adverse effects occur during this phase, doctors try to hospitalize these patients in TBDF so that they can receive free medicines and avoid a financial burden. The same cannot be said of the medical service in penitentiary establishments, according to patients, monitoring procedures are almost non-existent and drugs to combat adverse events are rare. Thus, it is common for inmates to stop medication as soon as an adverse event occurs.

Doctors and health care officials reported that TBDFs in the region are adequately stocked with quality anti-TB drugs and all necessary diagnostic equipment.

Health care providers reported that previous treatment outcomes and history contributed to the development of resistance, contrary to our findings that simply having a history of previous treatment increases the risk of resistance being present, regardless of its result. The same applies to social status and living conditions which, according to our statistical data, do not influence the development of resistance, but from a clinical point of view, socially disadvantaged patients (especially the homeless shelter) are more prone to contracting MDR/RR-TB. Another important problem that was not supported by data, but reported by respondents, is a greater frequency of alcohol and substance abuse. The prevalence of MDR/RR-TB in these groups is significantly higher than average.

Physicians did not report any association between the presence of disability and the risk of developing MDR/RR-TB, but they did report that some patients deliberately do not comply with treatment to worsen their condition and acquire MDR/RR-TB status. disability to receive social security benefits.