Ministry of Justice
of the Azerbaijan Republic
 
 
 

The Factors Associated with Cure among Patients with Rifampicin-resistant Tuberculosis in a Prison Setting of Uniquely Low Default Rate (Abstract)

23.06.2015
Elmira Gurbanova143, Rafail Mehdiyev1, Nahmat Rahmanov2, Kai Blondal3, Alan Altraja4

1Main Medical Department of the Ministry of Justice of the Republic of Azerbaijan, Baku, Azerbaijan
2Specialized Treatment Institution for Detainees with Tuberculosis of Azerbaijan, Baku, Azerbaijan
3Department of Communicable Disease Prevention and Control, Reykjavik Health Care Services, Reykjavik, Iceland
4Department of Pulmonary Medicine, University of Tartu, Tartu, Estonia


Rationale: In 2013, a total of 1,580 cases of multidrug-resistant tuberculosis (TB) were notified among the 8,597 pulmonary TB cases in Azerbaijan (13% among the new and 28% among the retreatment cases). Treatment of rifampicin-resistant TB (RR-TB) started in the TB prison hospital in Azerbaijan in 2007, but the factors influencing the treatment outcome are still left unclear.

Objectives:To unravel the factors contributing to successful treatment outcome in RR-TB cases receiving treatment in the settings of the penitentiary system of Azerbaijan with a uniquely low loss-to-follow-up rate.

Methods: Cohort analysis of all RR-TB patients with available outcomes of treatment with second line anti-TB drugs (SLD) between 2007 and January 1st 2014 focusing on factors associated with cure. Collection of the data was based on standard medical records. Associations between explanatory variables and successful treatment outcome were first analyzed using univariate logistic regression analysis. The significant contributing factors (with a p-value less than 0.1) were included into the final multivariate logistic regression model (Table 1).

Results:A total of 438 cases with pulmonary RR-TB were included [mean age 38.2 yr., mean body mass index at treatment onset 19.7 kg/m2; mean duration of treatment 19.43 months (range, 0.06-36.63 months)]. Cavitation was present on the chest X-ray in 68.2% of cases;9.36% were human-immunodeficiency virus-positive; 66.44% were hepatitis C virus-positive, and 83.8% were re-treatment cases. The mean number of drugs to which the patients’ strains were resistant was 5.2 (range, 1-10); 2.06% of cases had extensively drug-resistant TB. Out of the 438 RR-TB patients, 325 (74.2%) were cured; 1 (0.2%) completed treatment; 35 (8.0%) died; 40 (9.1%) failed treatment, and 29 (6.6%) defaulted. The treatment success rate (“cured” + “completed”) was thus 74.4%.

Multivariate analysis showed that levofloxacin in the treatment regimen and the overall durability of treatment contributed to the successful treatment outcome, but positive culture result after 2 months of treatment and completion of treatment in the civilian sector after release went against it (Table 1).

Conclusion: Despite the difficult setting (e.g. high levels of drug resistance), the TB control programme in Azerbaijan’s penitentiary system achieved a high cure rate (74.2%). Duration of the treatment period, as well as keeping levofloxacin in the treatment regimen, increases the probability of cure. A positive culture after 2 months of treatment and continuation of treatment after release significantly decreases the chances of cure even in the penitentiary setting.

 
 

Table 1. Factors associated with favorable treatment outcome of rifampicin-resistant tuberculosis in the penitentiary setting in Azerbaijan.
Variable Crude Adjusted
  OR 95% CI p-value OR 95% CI p-value
Completion of treatment after release 0.53 0.32-0.86 0.011 0.27 0.10-0.74 0.011
Age (years) 0.97 0.94-0.99 0.037      
Type of prison: pre-trial vs. prison 0.63 0.40-0.99 0.048      
Body mass index at start of treatment (kg/m2) 1.12 1.03-1.22 0.009      
Body mass index <18 kg/m2 0.45 0.29-0.71 0.001      
Increase of body mass index by ≥2 kg/m2 by the 6th month of treatment 1.43 1.03-1.97 0.028      
Resistance to capreomycin 0.45 0.23-0.86 0.016      
Resistance to ofloxacin 0.20 0.09-0.44 0.0001      
Level of Education (higher vs. basic) 1.73 0.94-3.18 0.077      
Positive Sputum smear result at the 2nd month of treatment 0.47 0.29-0.75 0.002      
Positive culture result at the 2nd month of treatment 0.23 0.14-0.38 0.0001 0.10 0.03-0.34 0.0001
Diabetes 0.37 0.14-0.96 0.042      
Hemoptysis 0.43 0.20-0.92 0.032      
Abdominal pain at the 6th month of treatment 2.05 1.11-3.81 0.022      
Nausea at the sixth month of treatment 3.8 2.00-7.2 0.0001      
Nausea at the 12th month of treatment 4.3 2.65-7.2 0.0001      
Peripheral neuritis at the 12th month of treatment 3.7 1.1-12.2 0.033      
Dizziness at the 12th month of treatment 2.7 1.5-4.9 0.001      
Headache at the 6th month of treatment 1.7 1.14-2.79 0.011      
Headache at the 12th month of treatment 4.6 2.55-8.29 0.0001      
Loss of hearing at the 6th month of treatment 0.26 0.10-0.63 0.003      
Arthralgia at the 6th month of treatment 2.64 1.53-4.55 0.0001      
Levofloxacin in the treatment regimen 1.67 1.07-2.62 0.023 3.75 1.32-10.64 0.013
Cycloserine in the treatment regimen 2.66 1.24-5.68 0.011      
Number of effective drugs in the treatment regimen 1.19 0.99-1.44 0.063      
Duration of the overall course of treatment 1.46 1.35-1.58 0.0001 1.46 1.32-1.62 0.0001
CI, confidence interval; OR, odds ratio.