Abstracts
OBJECTIVE:
To determine the drug resistance profile of Mycobacterium tuberculosis in Mozambique.
METHODS:
We analyzed secondary data from the National Tuberculosis Referral Laboratory, in the city of Maputo, Mozambique, and from the Beira Regional Tuberculosis Referral Laboratory, in the city of Beira, Mozambique. The data were based on culture-positive samples submitted to first-line drug susceptibility testing (DST) between January and December of 2011. We attempted to determine whether the frequency of DST positivity was associated with patient type or provenance.
RESULTS:
During the study period, 641 strains were isolated in culture and submitted to DST. We found that 374 (58.3%) were resistant to at least one antituberculosis drug and 280 (43.7%) were resistant to multiple antituberculosis drugs. Of the 280 multidrug-resistant tuberculosis cases, 184 (65.7%) were in previously treated patients, most of whom were from southern Mozambique. Two (0.71%) of the cases of multidrug-resistant tuberculosis were confirmed to be cases of extensively drug-resistant tuberculosis. Multidrug-resistant tuberculosis was most common in males, particularly those in the 21-40 year age bracket.
CONCLUSIONS:
M. tuberculosis resistance to antituberculosis drugs is high in Mozambique, especially in previously treated patients. The frequency of M. tuberculosis strains that were resistant to isoniazid, rifampin, and streptomycin in combination was found to be high, particularly in samples from previously treated patients.
Extensively drug-resistant tuberculosis; Tuberculosis; Tuberculosis, multidrug-resistant
OBJETIVO:
Avaliar o perfil de resistência de Mycobacterium tuberculosis aos tuberculostáticos em Moçambique.
MÉTODOS:
Foram analisados dados secundários do Laboratório Nacional de Referência da Tuberculose, em Maputo, Moçambique, e do Laboratório Regional de Referência da Tuberculose, na Beira, Moçambique. Os dados foram relativos a amostras positivas à cultura e submetidas ao teste de sensibilidade aos tuberculostáticos de primeira linha durante o período de janeiro a dezembro de 2011. Os resultados do teste de sensibilidade foram analisados, e sua frequência foi comparada com o tipo de paciente e sua proveniência.
RESULTADOS:
Foram analisadas 641 cepas, isoladas em cultura e submetidas ao teste de sensibilidade. Das 641 cepas, 374 (58,3%) foram resistentes a pelo menos um tuberculostático e 280 (43,7%) revelaram-se multirresistentes. Dos 280 casos de tuberculose multirresistente, 184 (65,7%) eram pacientes com tratamento prévio, a maioria dos quais era oriunda da zona sul do país. Confirmou-se que 2 (0,71%) dos casos de tuberculose multirresistente eram casos de tuberculose extensivamente resistente a drogas. O sexo masculino foi o mais afetado, particularmente na faixa etária de 21 a 40 anos.
CONCLUSÕES:
A resistência de M. tuberculosis aos tuberculostáticos é elevada em Moçambique, especialmente em indivíduos com tratamento prévio. A resistência de M. tuberculosis à combinação de isoniazida, rifampicina e estreptomicina foi elevada, especialmente em amostras provenientes de indivíduos com tratamento prévio.
Tuberculose extensivamente resistente a drogas; Tuberculose; Tuberculose resistente a múltiplos medicamentos
Introduction
Tuberculosis (TB) remains a serious public health problem in many low- and middle-income countries in Africa, Asia, and the former Soviet Union.( 11. World Health Organization. Global Tuberculosis Control 2010. Geneva: WHO; 2010. ) According to the World Health Organization, nearly 9 million new TB cases are recorded globally each year, 4 million of which are infectious TB cases. In many countries, the number of TB cases has quadrupled, despite the implementation of effective strategies to combat the disease.( 22. World Health Organization. Global tuberculosis control: WHO report 2011. Geneva: WHO; 2011. )
Not only has the number of studies of antituberculosis drug resistance increased (from 1
in 2008 to 10 in 2011), but the number of countries providing representative drug
resistance data has also increased (from 19 to 22), Mozambique being one such
country.(
33. Mozambique National Control Program of Tuberculosis. Annual report.
Maputo: Mozambique NCPT; 2011.
) Treatment failure, poor adherence to treatment, and spontaneous mutations
in Mycobacterium tuberculosis strains have contributed to the emergence
of new multidrug-resistant TB (MDR-TB) cases, which can later develop into extensively
drug-resistant TB (XDR-TB) cases.(
44. Chonde TM, Basra D, Mfinanga SG, Range N, Lwilla F, Shirima RP, et
al. National anti-tuberculosis drug resistance study in Tanzania. Int J Tuberc Lung
Dis. 2010;14(8):967-72.
5. Sharma SK, Kaushik G, Jha B, George N, Arora SK, Gupta D, et al.
Prevalence of multidrug-resistant tuberculosis among newly diagnosed cases of
sputum-positive pulmonary tuberculosis. Indian J Med Res.
2011;133:308-11.
-
66. Samo Gudo P, Cuna Z, Coelho E, Maungate S, Borroni E, Miotto P, et
al. Is MDR-TB on the rise in Mozambique? Results of a national drug resistance
survey. Eur Respir J. 2011;38(1):222-4.
https://doi.org/10.1183/09031936.0018201...
) Recent drug resistance studies have identified high rates of MDR-TB in
southern Africa, and 69 countries (including Mozambique) had reported at least one case
of XDR-TB by the end of 2010.(
22. World Health Organization. Global tuberculosis control: WHO report
2011. Geneva: WHO; 2011.
,
77. Faustini A, Hall AJ, Perucci CA. Risk factors for multidrug resistant
tuberculosis in Europe: a systematic review. Thorax. 2006
Feb;61(2):158-63.
https://doi.org/10.1136/thx.2005.045963...
,
88. USAID (United States Agency for International Development) [homepage
on the Internet]. Washington, DC: USAID [cited 2013 Jan 21] Mozambique: Tuberculosis
Profile 2009. Available from:.
http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/africa/mozambique_profile.html
Available from:.
ht...
) In Mozambique, drug-resistant TB is thought to be a major problem. The 2008
Mozambican national antituberculosis drug resistance survey showed that, of all MDR-TB
cases, 3.5% were newly diagnosed TB cases and 11.2% occurred among individuals who had
previously been treated for TB; in 2011, 47,452 cases of all forms of TB were
detected,(
33. Mozambique National Control Program of Tuberculosis. Annual report.
Maputo: Mozambique NCPT; 2011.
) although none were reported to be cases of XDR-TB.
Because of the increasing number of cases of MDR-TB( 44. Chonde TM, Basra D, Mfinanga SG, Range N, Lwilla F, Shirima RP, et al. National anti-tuberculosis drug resistance study in Tanzania. Int J Tuberc Lung Dis. 2010;14(8):967-72. ) and the emergence of XDR-TB in Mozambique, we sought to evaluate M. tuberculosis resistance to antituberculosis drugs in previously treated and untreated TB patients in Mozambique. We also sought to determine the magnitude of antituberculosis drug resistance in the country, in order to inform the National Tuberculosis Control Program of the efficacy of TB control measures and treatment, as well as to design effective treatment regimens and strategies for all TB patients in the country.
Methods
This was a cross-sectional study based on secondary laboratory data for the period of January to December of 2011. The data were based on 641 positive TB cultures from the National Tuberculosis Referral Laboratory, located in the city of Maputo, Mozambique, and the Beira Regional Tuberculosis Referral Laboratory, located in the city of Beira, Mozambique. These two laboratories serve all 11 of the provinces of Mozambique.
An MDR-TB case was defined as an individual infected with an isolate resistant to at
least isoniazid and rifampin, confirmed cases of XDR-TB being excluded.(
99. Rocha JL, Dalcolmo MP, Borga L, Fedele D, Marques MG. Tuberculose
multirresistente. Pulmão RJ. 2008;17(1):27-32.
10. Arora VK, Sarin R, Singla R, Khalid UK, Mathuria K, Singla N, et al.
DOTS-plus for patients with multidrug-resistant tuberculosis in India: early results
after three years. Indian J Chest Dis Allied Sci. 2007;49(2):75-80.
-
1111. Sharma SK, Mohan A. Multidrug-resistant tuberculosis. Indian J Med
Res. 2004;120(4):354-76.
) Cases of MDR-TB resistant to a fluoroquinolone and a second-line injectable
drug other than streptomycin were defined as XDR-TB cases.(
1212. Raviglione M, Smith IM. XDR Tuberculosis--implications for global
public health. N Engl J Med. 2007;356(7):656-9.
https://doi.org/10.1056/NEJMp068273...
13. Balabanova Y, Radiulyte B, Davidaviciene E, Hooper R, Ignatyeva O,
Nikolayevskyy V, et al. Survival of drug resistant tuberculosis patients in
Lithuania: retrospective national cohort study. BMJ Open.
2011;1(2):e000351.
https://doi.org/10.1136/bmjopen-2011-000...
14. Moodley P, Shah NS, Tayob N, Connolly C, Zetola N, Gandhi N, et al.
Spread of extensively drug-resistant tuberculosis in KwaZulu-Natal province, South
Africa. PLoS One. 2011;6(5):e17513.
https://doi.org/10.1371/journal.pone.001...
-
1515. Ministério da Saúde. Secretaria de Vigilância em
Saúde. Programa Nacional de Controle da Tuberculose. Manual de
Recomendações para o Controle da Tuberculose no Brasil. Brasília:
Ministério da Saúde; 2010.
) If an MDR-TB or XDR-TB patient was registered for treatment and had never
received TB treatment for longer than 4 weeks, the patient was considered to have
primary drug resistance. Patients with MDR-TB/XDR-TB undergoing retreatment and having
had the first episode of TB before 2011 were assumed to have acquired drug
resistance.
All samples underwent smear microscopy and culture. All culture-positive samples underwent first-line drug susceptibility testing (DST), which was performed by means of the ratio method. Of the MDR-TB samples, 71 were sent to the Supranational TB Referral Laboratory in Milan, Italy, for second-line DST.
Secondary data from the National Tuberculosis Referral Laboratory (demographic data and DST results) were collected from a WixDisa database (version 04.16.04.652; Disa, South Africa) and the laboratory record book, whereas those from the Beira Regional Tuberculosis Referral Laboratory were retrieved from a Microsoft Excel database. All positive culture results and DST results were entered into an Epi Info 3.5.1 database and analyzed. We calculated ORs and their 95% CIs in order to determine the association of previously treated and untreated patients with the results of DST.
The study was reviewed and approved by the Research Ethics Committee of the National Institute of Health, in Maputo, Mozambique. Informed consent was not required, because the study was based on secondary data and we had no access to any identifying patient information.
Results
A total of 641 TB culture-positive samples (561 samples from the National Tuberculosis Referral Laboratory and 80 from the Beira Regional Tuberculosis Referral Laboratory) were analyzed during the study period. Table 1 shows the distribution of MDR-TB and XDR-TB patients by gender and age bracket.
Of the 641 samples, 430 (67.1%) were from previously treated TB patients and 280 (43.7%) were from MDR-TB patients (Table 2). Of those 280 samples, 148 (53%) were from males and 191 (68.2%) were from individuals in the 21-40 year age bracket. There were 2 XDR-TB patients, both in the 21-40 year age bracket.
Of the MDR-TB samples that were sent to the Supranational TB Referral Laboratory for second-line DST, 2 were confirmed to be XDR-TB samples; of those, 1 was from a previously treated patient, and 1 was from a previously untreated patient (Figure 1).
Proportion of multidrug-resistant tuberculosis (MDR) and extensively drug-resistant tuberculosis (XDR) cases by patient treatment history.
Among of the 641 samples evaluated, the most common drug resistance pattern was monoresistance to isoniazid (in 5.8%), followed by monoresistance to rifampin (in 3.4%). Table 3 shows the distribution of specific drug resistance patterns by history of TB treatment.
Table 4 shows the distribution of multidrug resistance patterns by history of TB treatment. Most of the M. tuberculosis samples, particularly those from previously treated patients, were found to be resistant to isoniazid, rifampin, and streptomycin in combination.
Discussion
Most of the MDR-TB patients were male and in the 21-40 year age bracket (Table 1). The high occurrence of MDR-TB among males
and working-age individuals is probably due to the high number of Mozambican males
working in South African mines, which constitute a high-risk environment for TB and
other infectious diseases. These males often return to their home country whenever they
become ill, thereby increasing the risk of infection among their wives and close
contacts. The fact that working-age individuals constitute the most commonly affected
age group is due to the fact that many such individuals, in search of better pay and,
consequently, better living conditions, work in the close quarters of the aforementioned
mines. Our results are consistent with those reported in other studies.(
33. Mozambique National Control Program of Tuberculosis. Annual report.
Maputo: Mozambique NCPT; 2011.
,
1616. Jain A, Dixit P. Multidrug-resistant to extensively drug resistant
tuberculosis: what is next? J Biosci. 2008;33(4):605-16.
https://doi.org/10.1007/s12038-008-0078-...
17. Anaga M, Anand SI, Nanadal PH, GokulShankar RM. Extensively drug
resistant tuberculosis (XDR-TB) - a potential threat. J Basic Clin Pharm.
2011;2(1):27-32.
18. European Centre for Disease Prevention and Control. Management of
contacts of MDR TB and XDR TB patients. Stockholm: ECDC; 2012. p.
1-28.
19. Nunes EA, De Capitani EM, Coelho E, Panunto AC, Joaquim OA, Ramos
Mde C. Mycobacterium tuberculosis and nontuberculous mycobacterial isolates among
patients with recent HIV infection in Mozambique. J Bras Pneumol.
2008;34(10):822-8.
https://doi.org/10.1590/S1806-3713200800...
20. Baliza M, Bach AH, Queiroz GL, Melo IC, Carneiro MM, Albuquerque Mde
F, et al. High frequency of resistance to the drugs isoniazid and rifampicin among
tuberculosis cases in the City of Cabo de Santo Agostinho, an urban area in
Northeastern Brazil. Rev Soc Bras Med Trop. 2008;41(1):11-6.
https://doi.org/10.1590/S0037-8682200800...
-
2121. Prasad R. Multidrug and extensively drug-resistant tuberculosis
management: Evidences and controversies, Lung India. 2012;29(2)154-9
10.4103/0970-2113.95321.
https://doi.org/10.4103/0970-2113.95321...
)
The proportion of MDR-TB samples was higher than was that of non-MDR-TB samples, the difference being statically significant (p < 0.001). Most of the MDR-TB samples were from previously treated patients, and the fact that there were 2 XDR-TB samples shows that there might be more cases of XDR-TB not diagnosed as such. Therefore, further efforts are needed in order to improve diagnosis and treatment.
The results of the present study show that M. tuberculosis monoresistance to isoniazid
and rifampin was most common in samples from previously treated patients, as was M.
tuberculosis resistance to isoniazid, rifampin, and streptomycin in combination.
Although previous treatment can influence the onset of resistance to isoniazid,
rifampin, and streptomycin in combination, we found no statistically significant
difference between previously treated and untreated patients regarding resistance to
this drug combination. This finding is consistent with those of similar studies
conducted in Brazil, Portugal, and Turkey,(
2121. Prasad R. Multidrug and extensively drug-resistant tuberculosis
management: Evidences and controversies, Lung India. 2012;29(2)154-9
10.4103/0970-2113.95321.
https://doi.org/10.4103/0970-2113.95321...
22. Mac-Arthur A, Gloyd S, Perdigão P, Noya A, Sacarlal J, Kreiss
J. Characteristics of drug resistance and HIV among tuberculosis patients in
Mozambique. Int J Tuberc Lung Dis: 2001;5(10):894-902.
23. Natal S, Valente JG, Sánchez AR, Penna ML. Isoniazid and
rifampicin resistance and prior treatment for tuberculosis [Article in Portuguese].
Cad Saude Publica. 2003;19(5):1277-81.
https://doi.org/10.1590/S0102-311X200300...
-
2424. World Health Organization/International Union Against Tuberculosis
and Lung Disease. Anti-tuberculosis drug-resistance in the world. Fourth global
report--drug resistance surveillance 2002-2007. Geneva: WHO; 2008.
) as well as with those of studies conducted in Mozambique, South Africa,
Tanzania, Iran, and New Delhi.(
66. Samo Gudo P, Cuna Z, Coelho E, Maungate S, Borroni E, Miotto P, et
al. Is MDR-TB on the rise in Mozambique? Results of a national drug resistance
survey. Eur Respir J. 2011;38(1):222-4.
https://doi.org/10.1183/09031936.0018201...
,
1313. Balabanova Y, Radiulyte B, Davidaviciene E, Hooper R, Ignatyeva O,
Nikolayevskyy V, et al. Survival of drug resistant tuberculosis patients in
Lithuania: retrospective national cohort study. BMJ Open.
2011;1(2):e000351.
https://doi.org/10.1136/bmjopen-2011-000...
,
2525. Qi YC, Ma MJ, Li DJ, Chen MJ, Lu QB, Li XJ, et al.
Multidrug-resistant and extensively drug-resistant tuberculosis in multi-ethnic
region, Xinjiang Uygur Autonomous Region, China. PLoS One.
2012;7(2):e32103.
https://doi.org/10.1371/journal.pone.003...
26. Shamaei M, Marjani M, Chitsaz E, Kazempour M, Esmaeili M, Farnia P,
et al. First-line anti-tuberculosis drug resistance patterns and trends at the
national TB referral center in Iran--eight years of surveillance. Int J Infect Dis.
2009;13(5):e236-40.
https://doi.org/10.1016/j.ijid.2008.11.0...
-
2727. Otsuka A, Determinação da faixa etária com maior
incidência de tuberculose em Sorocaba - SP nos anos de 2004 e 2005. Rev
Eletronica Biologia. 2008;1(1):62-76.
)
Treatment failure, poor adherence to treatment, and spontaneous mutations in
M. tuberculosis strains probably played a major
role in the emergence of MDR-TB, which can progress to XDR-TB.(
44. Chonde TM, Basra D, Mfinanga SG, Range N, Lwilla F, Shirima RP, et
al. National anti-tuberculosis drug resistance study in Tanzania. Int J Tuberc Lung
Dis. 2010;14(8):967-72.
,
55. Sharma SK, Kaushik G, Jha B, George N, Arora SK, Gupta D, et al.
Prevalence of multidrug-resistant tuberculosis among newly diagnosed cases of
sputum-positive pulmonary tuberculosis. Indian J Med Res.
2011;133:308-11.
,
1414. Moodley P, Shah NS, Tayob N, Connolly C, Zetola N, Gandhi N, et al.
Spread of extensively drug-resistant tuberculosis in KwaZulu-Natal province, South
Africa. PLoS One. 2011;6(5):e17513.
https://doi.org/10.1371/journal.pone.001...
,
1515. Ministério da Saúde. Secretaria de Vigilância em
Saúde. Programa Nacional de Controle da Tuberculose. Manual de
Recomendações para o Controle da Tuberculose no Brasil. Brasília:
Ministério da Saúde; 2010.
,
2828. Ahmad MS, Muayad AM. Risk factors for multi-drug resistant
tuberculosis: a review. Duhok Med J. 2010;4(2):1-7.
) This could explain why the number of MDR-TB cases was higher among
previously treated patients and shows that further efforts are needed to ensure rapid
diagnosis of MDR-TB/XDR-TB and access to treatment with second-line drugs in Mozambique.
In order to manage drug-resistant forms of TB and prevent further cases of MDR-TB and
XDR-TB, a comprehensive approach similar to that used in cases of drug-susceptible TB is
needed to ensure rapid detection and appropriate treatment, as are public health
measures to cure patients and prevent further transmission of the disease,(
1212. Raviglione M, Smith IM. XDR Tuberculosis--implications for global
public health. N Engl J Med. 2007;356(7):656-9.
https://doi.org/10.1056/NEJMp068273...
,
1313. Balabanova Y, Radiulyte B, Davidaviciene E, Hooper R, Ignatyeva O,
Nikolayevskyy V, et al. Survival of drug resistant tuberculosis patients in
Lithuania: retrospective national cohort study. BMJ Open.
2011;1(2):e000351.
https://doi.org/10.1136/bmjopen-2011-000...
,
2929. Comunidad de Madrid. Consejeria de Sanidad y Servicios Sociales.
Boletín Epidemiológico de la Comunidad de Madrid. Registro de casos de
tuberculosis de la Comunidad de Madrid-1996; 1998.
,
3030. Lambregts-van Weezenbeek CS. Drug-resistant tuberculosis. In:
European Respiratory Society. Tuberculosis. Eur Respir Monograph vol 8; 1997. p.
298-326.
) given that the epidemic of drug-resistant TB has spread.(
1313. Balabanova Y, Radiulyte B, Davidaviciene E, Hooper R, Ignatyeva O,
Nikolayevskyy V, et al. Survival of drug resistant tuberculosis patients in
Lithuania: retrospective national cohort study. BMJ Open.
2011;1(2):e000351.
https://doi.org/10.1136/bmjopen-2011-000...
,
1515. Ministério da Saúde. Secretaria de Vigilância em
Saúde. Programa Nacional de Controle da Tuberculose. Manual de
Recomendações para o Controle da Tuberculose no Brasil. Brasília:
Ministério da Saúde; 2010.
,
2828. Ahmad MS, Muayad AM. Risk factors for multi-drug resistant
tuberculosis: a review. Duhok Med J. 2010;4(2):1-7.
)
The classification of drug resistance as primary or acquired is used as an indicator of
the efficacy of national tuberculosis control programs and in the adjustment and
development of such programs. Unsupervised treatment can lead to an increase in the
number of MDR-TB cases among previously treated patients. Although the directly observed
treatment, short-course strategy has been adopted in Mozambique, the efficacy of this
strategy needs to be evaluated. Cases of MDR-TB and XDR-TB must be effectively managed,
second-line drugs being carefully used in order to reduce the morbidity, mortality, and
transmission of MDR-TB and prevent the development of XDR-TB.(
1212. Raviglione M, Smith IM. XDR Tuberculosis--implications for global
public health. N Engl J Med. 2007;356(7):656-9.
https://doi.org/10.1056/NEJMp068273...
,
1515. Ministério da Saúde. Secretaria de Vigilância em
Saúde. Programa Nacional de Controle da Tuberculose. Manual de
Recomendações para o Controle da Tuberculose no Brasil. Brasília:
Ministério da Saúde; 2010.
,
2929. Comunidad de Madrid. Consejeria de Sanidad y Servicios Sociales.
Boletín Epidemiológico de la Comunidad de Madrid. Registro de casos de
tuberculosis de la Comunidad de Madrid-1996; 1998.
) In addition, better integration of the National Tuberculosis Control
Program activities and activities such as counseling and home-based care could assist in
controlling TB in the country.
In conclusion, antituberculosis drug resistance is high in laboratory-confirmed cases of TB in Mozambique, especially among previously treated patients. It is possible that XDR-TB strains are circulating in the population, given that we identified 2 XDR-TB cases in the present study (1 being in a previously treated patient and 1 being in a previously untreated patient). Resistance to isoniazid, rifampin, and streptomycin in combination was found to be high, particularly in previously treated patients.
Acknowledgments
We would like to thank the staff of the National Tuberculosis Referral Laboratory and the Beira Regional Tuberculosis Referral Laboratory, for providing the data for analysis.
References
-
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-
2World Health Organization. Global tuberculosis control: WHO report 2011. Geneva: WHO; 2011.
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4Chonde TM, Basra D, Mfinanga SG, Range N, Lwilla F, Shirima RP, et al. National anti-tuberculosis drug resistance study in Tanzania. Int J Tuberc Lung Dis. 2010;14(8):967-72.
-
5Sharma SK, Kaushik G, Jha B, George N, Arora SK, Gupta D, et al. Prevalence of multidrug-resistant tuberculosis among newly diagnosed cases of sputum-positive pulmonary tuberculosis. Indian J Med Res. 2011;133:308-11.
-
6Samo Gudo P, Cuna Z, Coelho E, Maungate S, Borroni E, Miotto P, et al. Is MDR-TB on the rise in Mozambique? Results of a national drug resistance survey. Eur Respir J. 2011;38(1):222-4.
» https://doi.org/10.1183/09031936.00182010 -
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» https://doi.org/10.1136/thx.2005.045963 -
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» Available from:. http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/africa/mozambique_profile.html -
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-
10Arora VK, Sarin R, Singla R, Khalid UK, Mathuria K, Singla N, et al. DOTS-plus for patients with multidrug-resistant tuberculosis in India: early results after three years. Indian J Chest Dis Allied Sci. 2007;49(2):75-80.
-
11Sharma SK, Mohan A. Multidrug-resistant tuberculosis. Indian J Med Res. 2004;120(4):354-76.
-
12Raviglione M, Smith IM. XDR Tuberculosis--implications for global public health. N Engl J Med. 2007;356(7):656-9.
» https://doi.org/10.1056/NEJMp068273 -
13Balabanova Y, Radiulyte B, Davidaviciene E, Hooper R, Ignatyeva O, Nikolayevskyy V, et al. Survival of drug resistant tuberculosis patients in Lithuania: retrospective national cohort study. BMJ Open. 2011;1(2):e000351.
» https://doi.org/10.1136/bmjopen-2011-000351 -
14Moodley P, Shah NS, Tayob N, Connolly C, Zetola N, Gandhi N, et al. Spread of extensively drug-resistant tuberculosis in KwaZulu-Natal province, South Africa. PLoS One. 2011;6(5):e17513.
» https://doi.org/10.1371/journal.pone.0017513 -
15Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de Controle da Tuberculose. Manual de Recomendações para o Controle da Tuberculose no Brasil. Brasília: Ministério da Saúde; 2010.
-
16Jain A, Dixit P. Multidrug-resistant to extensively drug resistant tuberculosis: what is next? J Biosci. 2008;33(4):605-16.
» https://doi.org/10.1007/s12038-008-0078-8 -
17Anaga M, Anand SI, Nanadal PH, GokulShankar RM. Extensively drug resistant tuberculosis (XDR-TB) - a potential threat. J Basic Clin Pharm. 2011;2(1):27-32.
-
18European Centre for Disease Prevention and Control. Management of contacts of MDR TB and XDR TB patients. Stockholm: ECDC; 2012. p. 1-28.
-
19Nunes EA, De Capitani EM, Coelho E, Panunto AC, Joaquim OA, Ramos Mde C. Mycobacterium tuberculosis and nontuberculous mycobacterial isolates among patients with recent HIV infection in Mozambique. J Bras Pneumol. 2008;34(10):822-8.
» https://doi.org/10.1590/S1806-37132008001000011 -
20Baliza M, Bach AH, Queiroz GL, Melo IC, Carneiro MM, Albuquerque Mde F, et al. High frequency of resistance to the drugs isoniazid and rifampicin among tuberculosis cases in the City of Cabo de Santo Agostinho, an urban area in Northeastern Brazil. Rev Soc Bras Med Trop. 2008;41(1):11-6.
» https://doi.org/10.1590/S0037-86822008000100003 -
21Prasad R. Multidrug and extensively drug-resistant tuberculosis management: Evidences and controversies, Lung India. 2012;29(2)154-9 10.4103/0970-2113.95321.
» https://doi.org/10.4103/0970-2113.95321 -
22Mac-Arthur A, Gloyd S, Perdigão P, Noya A, Sacarlal J, Kreiss J. Characteristics of drug resistance and HIV among tuberculosis patients in Mozambique. Int J Tuberc Lung Dis: 2001;5(10):894-902.
-
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» https://doi.org/10.1590/S0102-311X2003000500006 -
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*
Study carried out at the National Institute of Health of the National Ministry of Health, Maputo, Mozambique.
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**
A versão completa em português deste artigo está disponível em www.jornaldepneumologia.com.br
Publication Dates
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Publication in this collection
Mar-Apr 2014
History
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Received
21 Jan 2013 -
Accepted
20 Jan 2014