Risk factors associated with multidrug-resistant tuberculosis in Espírito Santo, Brazil

Fregona, Geisa; Cosme, Lorrayne Belique; Moreira, Cláudia Maria Marques; Bussular, José Luis; Dettoni, Valdério do Valle; Dalcolmo, Margareth Pretti; Zandonade, Eliana; Maciel, Ethel Leonor Noia

doi:10.1590/S1518-8787.2017051006688

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Original Articles • Rev. Saúde Pública 51 (0) • 2017 • https://doi.org/10.1590/S1518-8787.2017051006688 copy

Risk factors associated with multidrug-resistant tuberculosis in Espírito Santo, Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To analyze the prevalence and factors associated with multidrug-resistant tuberculosis in Espírito Santo, Brazil.

METHODS

This is a cross-sectional study of cases of tuberculosis tested for first-line drugs (isoniazid, rifampicin, pyrazinamide, ethambutol, and streptomycin) in Espírito Santo between 2002 and 2012. We have used laboratory data and registration of cases of tuberculosis – from the Sistema Nacional de Agravos de Notificação and Sistema para Tratamentos Especiais de Tuberculose. Individuals have been classified as resistant and non-resistant and compared in relation to the sociodemographic, clinical, and epidemiological variables. Some variables have been included in a logistic regression model to establish the factors associated with resistance.

RESULTS

In the study period, 1,669 individuals underwent anti-tuberculosis drug susceptibility testing. Of these individuals, 10.6% showed resistance to any anti-tuberculosis drug. The rate of multidrug resistance observed, that is, to rifampicin and isoniazid, has been 5%. After multiple analysis, we have identified as independent factors associated with resistant tuberculosis: history of previous treatment of tuberculosis [recurrence (OR = 7.72; 95%CI 4.24–14.05) and re-entry after abandonment (OR = 3.91; 95%CI 1.81–8.43)], smoking (OR = 3.93; 95%CI 1.98–7.79), and positive culture for Mycobacterium tuberculosis at the time of notification of the case (OR = 3.22; 95%CI 1.15–8.99).

CONCLUSIONS

The partnership between tuberculosis control programs and health teams working in the network of Primary Health Care needs to be strengthened. This would allow the identification and monitoring of individuals with a history of previous treatment of tuberculosis and smoking. Moreover, the expansion of the offer of the culture of tuberculosis and anti-tuberculosis drug susceptibility testing would provide greater diagnostic capacity for the resistant types in Espírito Santo.

Tuberculosis, Multidrug-Resistant, epidemiology; Drug Resistance, Multiple, Bacterial; Recurrence; Risk Factors; Socioeconomic Factors

Variable	n	%
Profile of resistance
Total strains tested	1,669	100
Non-resistant	1,491	89.3
Any resistance	178	10.7
H	139	8.3
R	95	5.7
Z	48	2.9
E	22	1.3
S	58	3.5
Monoresistance (total)	67	4.0
H	36	2.1
R	6	0.4
Z	2	0.1
E	7	0.4
S	16	0.9
Polyresistance (total)	26	1.5
H+Z	1	0.1
H+E	5	0.3
H+S	8	0.5
R+Z	3	0.2
Z+S	3	0.2
E+S	1	0.1
H+Z+S	3	0.2
H+E+S	1	0.1
R+E+S	1	0.1
MDR-TB (total)	85	5.1
RH	38	2.3
RH+Z	17	1.0
RH+E	2	0.1
RH+S	9	0.5
RH+Z+E	3	0.2
RH+Z+S	14	0.8
RH+Z+E+S	2	0.1

Characteristic	Total		Groups				p*

			Non-resistant		Resistant

	n	%	n	%	n	%
Gender	1,576
Male		71.0	991	71.0	132	76.0	0.120
Female		29.0	412	29.0	41	24.0
Race	1,428
White		29.0	362	29.0	55	33.0	0.236
Non-white		71.0	900	71.0	111	67.0
Education level (years)	1,145
Illiterate		8.0	79	8.0	9	7.0	0.749
1 to 4		28.0	282	28.0	37	29.0
5 to 8		39.0	400	39.0	44	34.0
9 to 12		21.0	209	21.0	32	25.0
≥ 12		5.0	47	5.0	6	5.0
Age (years)	1,557
< 20		8.0	105	8.0	14	8.0	0.258
20-39		52.0	734	53.0	81	48.0
40-59		33.0	448	32.0	65	39.0
≥ 60		7.0	102	7.0	8	5.0
Institutionalization	881
No		89.0	680	89.0	106	93.0	0.165
Yes		11.0	87	11.0	8	7.0
HIV	1,193
Positive		11.0	112	11.0	14	10.0	0.842
Negative		89.0	942	89.0	125	90.0
Alcohol	909
Yes		35.0	267	34.0	54	45.0	0.021
No		65.0	521	66.0	67	55.0
Diabetes	769
Yes		8.0	54	8.0	11	10.0	0.529
No		92.0	605	92.0	99	90.0
Mental illness	815
Yes		2.0	17	2.0	3	3.0	0.908
No		98.0	683	98.0	112	97.0
Smoking	609
Yes		13.0	48	9.0	32	34.0	< 0.001
No		87.0	467	91.0	62	66.0
Use of drugs	604
Yes		12.0	65	12.0	9	13.0	0.908
No		88.0	468	88.0	62	87.0

Characteristic	Total		Groups				p^a

			Non-resistant		Resistant

	n	%	n	%	n	%
Type of case	1,575
New case		74.0	1,083	77.0	77	45.0	< 0.001
Recurrence		14.0	155	11.0	70	40.0
Re-entry after abandonment		10.0	136	10.0	23	13.0
Transfer		2.0	28	2.0	3	2.0
Number of previous treatments	1,576
No treatment		80.0	1,183	84.0	80	46.0	< 0.001
1		13.0	150	11.0	52	30.0
2		6.0	59	4.0	29	17.0
≥ 3		1.0	11	1.0	12	7.0
Chest x-ray	1,487
Suspected		98.0	1,298	98.0	161	98.0	0.587
Normal		2.0	24	2.0	4	2.0
Tuberculin test	384
No reaction		18	65	19	3	7	0.122
Weak reaction		7	22	6	4	9
Strong reaction		76	253	74	37	84
Type	1,575
Pulmonary		94	1323	94	162	94	0.916
Extrapulmonary		2	34	2	5	3
Pulmonary + Extrapulmonary		3	45	3	6	3
Sputum smear microscopy	1,514
Positive		83	1,121	83	143	85	0.675
Negative		17	224	17	26	15
Sputum culture	1,124
Positive		89	863	88	138	95	0.023
Negative		11	115	12	8	5
Other material culture	127
Positive	87	69	74	69	13	65	0.713
Negative	40	31	33	31	7	35
Ending	1,571
Cure		82	1,156	83	131	77	< 0.001
Abandonment		8	108	8	11	6
Death by TB		2	28	2	5	3
Death by other causes		3	40	3	6	4
Transfer		4	59	4	6	4
MDR-TB^b		1	3	0	11	6

Characteristic	Crude OR			Adjusted OR

	p	OR	95%CI	p	OR	95%CI
Type of treatment
New case		1			1
Recurrence	< 0.001	6.35	4.41–9.15	< 0.001	7.72	4.24–14.05
Re-entry after abandonment	0.001	2.38	1.44–3.92	0.001	3.91	1.81–8.43
Transfer	0.508	1.51	0.45–5.07	0.999
Number of previous treatments*
No treatment		1
1	< 0.001	5.13	3.48–7.56
2	< 0.001	7.27	4.41–11.97
≥ 3	< 0.001	16.13	6.90–37.70
Alcohol
Yes	0.022	1.57	1.07–2.32	0.933	1.03	0.55–1.92
No		1			1
Smoking
Yes	< 0.001	5.02	2.99–8.45	< 0.001	3.93	1.98–7.79
No		1			1
Sputum culture
Positive	0.027	2.30	1.10–4.81	0.026	3.22	1.15–8.99
Negative		1			1

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[1] Correspondence: Flávia Silva Arbex Borim. Programa de Pós-graduação em Gerontologia, Faculdade de Ciências Médicas – Unicamp. Av. Tessalia Vieira de Camargo, 126. 13083-887 Campinas, SP, Brasil. E-mail: flarbex@hotmail.com