Mortality and associated factors of patients with extensive drug-resistant tuberculosis: an emerging public health crisis in China

Abstract

BackgroundLimited treatment options of extensive drug-resistant tuberculosis (XDR-TB) have led to its high mortality worldwide. Relevant data about mortality of XDR-TB patients in literature are limited and likely underestimate the real situation in China, since the majority of patients with XDR-TB are lost to follow-up after discharge from TB hospitals. In this study, we sought to investigate the mortality and associated risk factors of Human Immunodeficiency Virus (HIV)-negative patients with XDR-TB in China.MethodsAll patients who were diagnosed with XDR-TB for the first time in four TB care centers across China between March 2013 and February 2015 were consecutively enrolled. Active tracking through contacting patients or family members by phone or home visit was conducted to obtain patients’ survival information by February 2017. Multivariable Cox regression models were used to evaluate factors associated with mortality.ResultsAmong 67 patients enrolled, the mean age was 48.7 (Standard Deviation [SD] = 16.7) years, and 51 (76%) were men. Fourteen patients (21%) were treatment naïve at diagnosis indicating primary transmission. 58 (86.8%) patients remained positive for sputum smear or culture when discharged. During a median follow-up period of 32 months, 20 deaths occurred, with an overall mortality of 128 per 1000 person-years. Among patients who were dead, the median survival was 5.4 months (interquartile range [IQR]: 2.2–17.8). Seventeen (85%) of them died at home, among whom the median interval from discharge to death was 8.4 months (IQR: 2.0–18.2). In Cox proportional hazards regression models, body mass index (BMI) < 18.5 kg/m2 (adjusted hazard ratio [aHR] = 4.5, 95% confidence interval [CI]: 1.3–15.7), smoking (aHR = 4.7, 95%CI:1.7–13.2), or a clinically significant comorbidity including heart, lung, liver, or renal disorders or auto-immune diseases (aHR = 3.5, 95%CI: 1.3–9.4), were factors independently associated with increased mortality.ConclusionOur study suggested an alarming situation of XDR-TB patients in China with a sizable proportion of newly transmitted cases, a high mortality rate, and a long period in community. This observation calls for urgent actions to improve XDR-TB case management in China, including providing regimens with high chances of cure and palliative care, and enhanced infection control measures.

Poor treatment outcome and its predictors among drug-resistant tuberculosis patients in Ethiopia: A systematic review and meta-analysis

“…Patients with lower BMI (<18.5 kg/m 2 ) had 2.45 the risk to develop poor treatment outcomes. Studies that were done by Dheda et al (2012), Kurbatova et al (2012), Leimane et al (2005), Nair et al (2017), andBei et al (2018) also supported this. The other risk factor was anemia; patients with any type of anemia had 2.33 times the risk to have a poor treatment outcome compared to their counterparts.…”

“…The pooled incidence density rate of mortality in this study was 9.28/1000 PMs. Likewise, Balbanova et al (Balabanova et al, 2011) from Eastern Europe, Ali et al (2019) from Sudan and Bei et al (2018) from China reported 9.12/1000PMs, 10.44/1000 PMs, and 10.67/1000 PMs respectively. The case of China was among XDR-TB patients.…”

“…Likewise, non-HIV comorbidity or coinfection doubles the risk of poor treatment outcomes. Supportive shreds of evidence are reported by Balabanova et al (2016), Chung-Delgado et al (2015, Gadallah et al (2016), Mohd Shariff et al (2016), and Bei et al (2018. Low compliance, lack of intensive care facility, and acute adverse outcomes might contribute to the poor treatment outcome in DR-TB patients co-infected with other comorbidities.…”

“…The poor treatment outcome is the share of different risk factors. Among the risk factors are being HIV positive, the weight of the patient, age of the patient, presence of other comorbidities or co-infections, smoking, alcohol, patient condition, delay to start treatment, resistance to more than two anti-TB drugs and involvement of TB outside the lungs are reported (Chung-Delgado et al, 2015;Ketema et al, 2019;Bajehson et al, 2019;Balabanova et al, 2016;Chingonzoh et al, 2018;Khan et al, 2015;Farley et al, 2011;Li et al, 2016;Makhmudova et al, 2019;Kurbatova et al, 2012;Bei et al, 2018;Alene et al, 2017;Limenih and Workie, 2019;Woldeyohannes et al, 2019).…”

Associations of ambient air pollutants with regional pulmonary tuberculosis incidence in the central Chinese province of Hubei: a Bayesian spatial-temporal analysis

“…According to information recently published by the World Health Organization (WHO), the 20 countries with the highest TB burden based on the absolute number of incident cases and 10 countries with the highest TB burden based on the severity of the disease are all developing countries [5]. As a developing country with a high TB burden, China is currently facing a serious health problem due to the prevalence of tuberculosis [5,6]. Despite a decrease in smear-positive TB cases, from 170 to 59 cases per 100,000 individuals during 1990-2010, TB has always ranked among the top five on the national list of notifiable infectious diseases in China [7].…”