Understanding how geographic, demographic and treatment history impact health outcomes of patients with multi-drug-resistant tuberculosis in Pakistan, 2014–2017

Abstract

Tuberculosis (TB) is one of the top 10 leading causes of morbidity and mortality worldwide [1]. In 2017, approximately 10 million people were infected with TB and 1.3 million patients faced mortality [1]. Patients with active TB can infect up to 10–15 people over a year. There is a greater risk of transmission in overcrowded areas with limited air ventilation including large family units, prisons and slums [1, 2]. Without proper diagnosis and treatment, roughly 45% of non-HIV positive TB patients face mortality [1]. With the help of global organizations and national TB treatment and control programmes, the global incidence of TB is declining by approximately 2% each year [1]. The World Health Organization (WHO) TB-strategy aims to end the TB epidemic and encourages partners to fund national TB programmes to improve diagnosis and treatment of TB. The goal is to ultimately decrease death rates by 90% and decrease incidence rates by 80% [1]. To achieve these goals, the decline in TB incidence needs to reach approximately 4–5% per year [1]. The WHO 2018 TB report identified multidrug resistant TB (MDR-TB) as the leading factor hindering that goal [1]. The incidence and spread of MDR-TB has drastically increased, where approximately 558 000 new cases of MDR-TB were diagnosed in 2017 causing more than 230 000 deaths globally [1]. MDR-TB is identified by resistance to the two most powerful anti-TB treatment drugs including isoniazid and rifampicin [3]. Patients with MDR-TB are required to start second-line anti-TB drugs (SLDs), which are limited, expensive, less effective and more toxic [1,2]. Therapy duration is one of the major limitations of second-line treatments, which may require up to two years of consistent use. Since TB affects mostly developing countries, long treatment durations and associated costs become a major challenge. In 2015, 15% of new TB cases were reported as MDR-TB, which drastically increased to 24% by 2017 [1]. Even with significant improvements in molecular tests and diagnostic methods, MDR-TB is still on the rise where the success rate of treatments is between 50 and 60% [1]. Additional characteristics including socioeconomic and sociocultural factors need to be considered when targeting and treating patients with MDR-TB.

Re-evaluating the merits of decentralization as a core strategy for effective delivery of drug-resistant tuberculosis care in Pakistan

“…Iqbal et al . found that distance to treatment sites was associated with unfavourable treatment outcomes, and our analysis replicates these findings ( Iqbal et al. , 2020 ).…”

Risk factors of MDR-TB and impacts of COVID-19 pandemic on escalating of MDR-TB incidence in lower-middle-income countries: A scoping review

“…Of 17 articles, 13 were indexed in SCImago Journal & Country Rank, with three articles categorized in quartile 1 (Q1) [ 13 - 15 ], seven in quartile 2 (Q2) [ 16 - 22 ] and three in quartile 3 (Q3) [ 23 - 25 ] while other four articles were not indexed [ 26 - 29 ]. Three articles were published in 2012 [ 14 , 23 , 26 ] and 2019 [ 18 - 20 ] each; two in 2013 [ 16 , 24 ], 2015 [ 25 , 28 ], 2020 [ 13 , 21 ] and 2021 [ 15 , 22 ] each; one in 2014 [ 27 ], 2016 [ 29 ] and 2017 [ 17 ] each. No article published in 2018 and 2022.…”

“…India was the country where most studies were conducted (four articles) [ 13 , 16 , 19 , 27 ], followed by Egypt (three articles) [ 26 , 28 , 29 ], Pakistan (three articles) [ 14 , 21 , 23 ], and one article each from Iran [ 24 ], Tanzania [ 25 ], Vietnam [ 17 ], Swaziland [ 18 ], Yemen [ 20 ], Ghana [ 15 ] and Cameroon [ 22 ]. Most of those articles were cohort studies which consisted of six retrospective [ 17 , 21 , 22 , 26 , 28 , 29 ] and five prospective studies [ 16 , 20 , 24 , 25 , 27 ], four cross-sectional studies [ 13 - 15 , 19 ] and the rest were case-control studies [ 18 , 23 ].…”

“…Patients also have been avoiding traveling at particular distances to reach healthcare facilities, which prevents patients from receiving the necessary follow-up treatments for TB. Most patients who travel less than 50 km had a much higher chance of being recovered from TB than patients who travel more than 100 km to reach the healthcare facilities, which possibly leading to the development of widespread drug-resistant TB (MDR-TB or XDR-TB) [ 21 ]. Moreover, patients with low socioeconomic status are more likely to develop resistance to TB medications, especially during the COVID-19 pandemic as the generating MDR-TB may happen in this group of patients due to limited access to healthcare facilities in their residence areas [ 26 ].…”

“…The distance between the patient’s residence and the medical facilities is one of the causes [ 22 ]. For instance, despite Pakistan having 34 operational PMDT sites, patients still must travel great distances to access healthcare [ 21 ]. Long travel distances and related costs may prevent patients from receiving the necessary follow-up treatments for MDR-TB, possibly leading to the development of widespread extensively drug-resistant TB (XDR-TB) [ 21 ].…”