First national survey of anti-tuberculosis drug resistance and risk factors for drug resistance in Azerbaijan

First national survey of anti-tuberculosis drug resistance and risk factors for drug resistance in Azerbaijan

 

  1. Scientific Research Institute of Lung Disease, Baku, Azerbaijan
  2. TADR Test & Evaluation Lead Biological Threat Reduction Program Branch of Battelle Memorial Institute in Georgia
  3. Forsungszentrum Borstel, Borstel, Germany
  4. Azerbaijan State Medicine University, Lung diseases department
  5. World Health Organization Country Office, Baku, Azerbaijan
  6. World Health Organization Regional Office for Europe, Tuberculosis and M/XDR-TB Programme, Division of Communicable Diseases, Health Security & Environment, Copenhagen, Denmark
  7. The International Union Against Tuberculosis and Lung Diseases (Union)
  8. London School of Hygiene and Tropical Medicine

 

Key words:

Operational research

SORT IT

Drug-resistant tuberculosis

Azerbaijan

Prisons

 

Short running title:

Anti-TB drug resistance in Azerbaijan


ABSTRACT

Setting: Civilian sector of the Republic of Azerbaijan

Objectives: To determine among new and previously treated pulmonary TB cases, anti-TB drug resistance patterns and their association with socio-demographic and clinical characteristics.

Design: National cross-sectional survey conducted in 2012-2013.

Results: There were 789 patients (549 new and 240 previously treated). Of these, 231 (42%) new and 146 (61%) previously treated patients were resistant to any anti-TB drug, with 72 (13%) new and 66 (28%) previously treated having MDR-TB. Amongst MDR-TB cases, 38% of new and 47% of previously treated had pre-XDR/XDR-TB. In previously treated cases, 53% of those who had failed treatment had MDR-TB/XDR-TB which was fifteen times higher than in relapse cases (OR 15.0, 95%CI 5.9-38.9). The only characteristic significantly associated with MDR-TB/XDR-TB was a history of having been in prison for previously treated patients (OR 2.7 [95%CI 1.0-7.0]).

Conclusion: Azerbaijan remains a high MDR-TB burden country with several important risk factors contributing to this drug-resistance epidemic. There is an urgent need to implement several country-wide control activities that include earlier detection of drug resistance in individual patients, regular routine surveillance of drug-resistance in the population and strengthening of basic TB control measures.

 

INTRODUCTION

 

The Republic of Azerbaijan is one of the 18 high tuberculosis (TB) priority countries of the World Health Organization (WHO) European Region and also among the 27 high multidrug-resistant (MDR)-TB burden countries in the world.1 High MDR-TB burden countries are defined by WHO as having at least 4000 MDR-TB cases per annum and/or at least 10% of MDR-TB among newly registered TB cases.2 These high MDR-TB countries were identified within the framework of the WHO global project on anti-TB drug resistance. For this project, countries report on levels and patterns of anti-TB drug resistance which are obtained either by routine surveillance data or by surveys.3

The first anti-TB Drug Resistance Survey (DRS) in the Republic of Azerbaijan was conducted from August 2006 to July 2007 and covered the civilian sector in Baku city only.4 The DRS revealed high levels of drug resistance: 22.3% (95% CI 19-26%) MDR-TB was found among new cases and 55.8% (95% CI 52-60%) among previously treated TB cases, and extensively drug resistant (XDR)-TB was found in 12.8% of all identified MDR-TB cases. Five years later, in 2012, the country had an estimated 2800 MDR-TB cases, of which 800 were in patients with new pulmonary TB.2 Despite this high level of estimated drug resistance, treatment success rates among new smear-positive pulmonary TB cases in the last few years have increased from 59% in 2005 and have reached 77% in the last 2 years.2 This relatively high level of treatment success suggests that levels of drug resistance in the whole country might be lower than the rate found in the previous survey in Baku in 2007.

The country, therefore, decided to conduct another survey, but this time nationwide, to obtain up-to-date information on anti-TB drug resistance among pulmonary TB cases. It was anticipated that the survey findings would also assist the National TB Programme in forecasting and procurement of anti-TB drugs, optimization of standard treatment regimens and targeting specific groups for rapid diagnostic tests, for example with Xpert MTB/RIF. The nationwide anti-TB drug resistance survey was designed in collaboration with the WHO Regional Office for Europe, and a detailed survey protocol was developed in line with WHO guidelines.5 Specific objectives of the current study were to determine among new and previously treated pulmonary TB cases in the general population (excluding the penitentiary setting):- i) anti-TB drug resistance patterns, ii) anti-TB drug resistance patterns between different categories of previously treated cases, and iii)  socio -demographic and clinical characteristics associated with anti-TB drug resistance patterns.

 

METHODS

Study Design:

This was a national cross sectional survey.

Setting:

The Republic of Azerbaijan is the largest country in the Caucasus region. It is divided into 59 rayons, has 11 cities and includes the Autonomous Republic of Nakhchivan. In 2012, the population of the Republic of Azerbaijan was estimated to be 9,235,000. In 2012, there were 8140 TB cases notified; 4616 new cases and 3524 previously treated cases.2 The proportion of smear positive TB cases was low: only 36% of new notified TB had a positive smear microscopy result. The national TB laboratory network includes the National TB Reference Laboratory (NRL) in Baku, five regional culture laboratories and 67 peripheral microscopy laboratories. A sputum transportation system covers the country. In 2012, among the 2800 MDR-TB cases estimated by WHO, 596 MDR-TB cases were diagnosed in the civilian sector (MDR-TB case detection rate of 21%).2

National drug resistance survey:

Patients: The patient recruitment for the survey started on 28 October 2012 and was completed by 30 April 2013. All patients in the country aged 15 years or more suspected of pulmonary TB submitted at least two sputum specimens. Patients with long-lasting TB disease (i.e. failure after any kind of anti-TB treatment on two or more occasions), who provided sputum specimens later than five days after starting TB treatment or who had extra-pulmonary TB were excluded from the survey. The sputum specimens were transported to the NRL two times a week. Collected samples were subjected to microscopy and culture on Lowenstein-Jensen (LJ) and Mycobacterial Growth Indicator Tube (MGIT) medium.

Laboratory procedures: All culture positive isolates were subjected to drug susceptibility testing (DST) on LJ medium for first-line anti-TB drugs (FLD) (isoniazid, rifampicin, streptomycin, ethambutol, and pyrazinamide), and MDR isolates were further subjected to DST for second-line anti-TB drugs (SLD) (Ofloxacin, Capreomycin, Amikacin, Prothionamide, Cycloserine, and Para-amino-salicylic acid). To control the quality of DST, all culture positive isolates were also subjected to line probe assay testing (LPA) (MTBDRplus, Hain Life Sciences, Nehren, Germany) according to the instructions of the manufacturer. For external quality assurance of DST all positive cultures were sent to the Supranational Reference Laboratory (SRL) in Borstel, Germany for re-testing.

Questionnaire and data variables: A standard questionnaire was completed for each participant documenting socio-demographic and clinical characteristics. The questionnaire was piloted in two regions for two weeks in 2012 and subsequently edited in order to obtain more accurate responses. At the sputum collection sites study participants were registered in a dedicated DRS journal and were assigned a unique patient DRS number. Data variables included: gender, age, migration, living in capital, social status, living condition, finance condition, smoking, alcohol use, drug use, prison history, HIV status, type and category of TB and DST results for FLD and SLD.

Sample size: The 100% sampling method was chosen because the Republic of Azerbaijan is a small country with a small number of diagnostic facilities and a well-established sputum transportation system from all diagnostic centers to the NRL. The sample size for culture positive patients was calculated following WHO guidelines,4 and assumptions for simple random sampling included: (i) the number of new and retreatment sputum smear and/or culture positive pulmonary cases notified in 2011; (ii) WHO estimates of the proportions of MDR-TB among notified TB cases; (iii) a 95% confidence interval and an absolute precision of 4% and 10% for new cases and previously treated TB cases, respectively, so that in both groups a relative precision of <20% was achieved; and (iv) a sample size inflation accounting for 20% for expected loss of samples. Consequently, a total of 544 culture positive pulmonary TB patients would need to be enrolled in the survey: 435 new and 109 previously treated patients from the civil sector.

Data validation: This included:- i) re-interviewing of at least 10% of patients,  ii) monitoring visits to TB facilities to compare the data of patients registered for treatment and the data of patients whose sputum was sent to the NRL for the study, iii) DST re-checking at the SRL and iv) validating the patient treatment category using an electronic database of new TB patients, registered in 2009-2012.

Analysis and statistics:

Patient data were double-entered into EpiData (EpiData Association, Odense, Denmark). In order to determine the anti-TB drug resistance patterns among new and previously treated TB cases, frequencies of drug resistance were tabulated. The MDR- and XDR-TB rates among new and previously treated cases were then calculated. We also compared the proportion of samples of new and previously treated cases of any rifampicin-resistance sent from TB diagnostic facilities in Baku with all other regions in Azerbaijan.

In order to determine the factors associated with anti-TB drug resistance patterns, univariable and multivariable logistic regression was carried out. All data variables collected were included in the regression models. Levels of significance were set at 5%.

Ethics approval:

Permission and approval for the study was obtained from the Ethics Committee of the Ministry of Health of Azerbaijan Republic. Ethics approval was also obtained from the International Union Against Tuberculosis and Lung Disease, Paris, France.

 

RESULTS:

 

There were 789 bacteriologically confirmed pulmonary TB cases included in the survey, of whom 549 were new patients and 240 were previously treated. Anti-TB drug resistance patterns amongst new and previously treated cases are shown in Table 1. Among all new and previously treated cases, 231 (42%) and 146 (61%) were resistant to any anti-TB drug, and 72 (13%) and 66 (28%) had MDR-TB respectively. Amongst the cases of MDR-TB, 18 (25%) of new and 20 (31%) of previously treated cases had pre-XDR-TB, and 13% of new and 16% of previously treated TB cases had XDR-TB. Compared to cases of drug-sensitive TB, those with poly-resistance and MDR-TB (including XDR-TB) had a significantly increased odds of having been previously treated for TB (P<0.05). Those with MDR-TB had an odds ratio of 3.1 (95% CI 2.0-4.7) for being previously treated compared with cases of drug-sensitive TB. Amongst all MDR-TB cases, 57 (79%) new and 52 (79%) previously treated cases were additionally resistant to streptomycin and ethambutol. There was a non-significant higher proportion of any rifampicin-resistance and MDR-TB amongst samples of new and previously treated cases sent from diagnostic facilities in Baku (39%) compared to all other regions in Azerbaijan (35%).

Patterns and comparisons of drug resistance in and between patients with previously treated TB are shown in Tables 2A-B. In Table 2A, patients with relapse TB are compared with those who failed treatment and patients who failed treatment has a significantly higher odds of mono- and poly- resistance and particularly of MDR- and XDR-resistance with an odds ratio of 15.2 (95%CI 6.0-39.0). In Table 2B, patients with relapse TB are compared with those who returned after being lost-to-follow-up (LFU) and patients who were LFU had a significantly higher odds of MDR-TB (OR=2.5; 95%CI 1.0-6.0).

Demographic, social and HIV characteristics of new and previously treated patients, in relation to whether they had drug-sensitive / non-MDR-drug resistance or MDR-/XDR, are shown in Table 3 and Table 4 respectively. For previously treated patients, those with MDR-/XDR-TB were significantly more likely to have been in prison compared with those who had drug-sensitive / non-MDR-TB. There were otherwise no differences between the two groups.

DISCUSSION

This was the first national drug resistance survey in Azerbaijan. Among new and previously treated TB cases, the prevalence of MDR-TB was 13% and 28% respectively, confirming the hypothesis that serious drug resistance has decreased since the Baku anti-TB drugs resistance survey was conducted in 2006-2007.4 However, the rate of resistance to any anti-TB drug including MDR- and XDR-TB remained high, and removes any grounds for complacency. A history of previous treatment was a significant risk factor for all types of drug-resistance. Amongst those who have been previously treated, treatment failure was the highest risk factor for MDR- and XDR-TB. Finally, a history of being in prison was a significant risk factor for any rifampicin-resistance including both MDR-TB/XDR-TB among both new and previously treated cases.

The strengths of this study were the nationwide coverage, the large number of patients included that exceeded the sample size calculation and the 100% sampling of all diagnostic facilities in the civilian sector. The study also incorporated rigorous sample validation measures to ensure the accuracy of reported data. The questionnaire included socio-demographic characteristics and the HIV status of patients, information which was not available in previous surveys. Thus, we were able to assess risk factors associated with any rifampicin resistance and M/XDR-TB. Due attention was also paid to following internationally agreed recommendations for the conduct and reporting of observational studies.10,11

There were some limitations to this study. First, the survey did not include patients with long-standing chronic TB disease. The previous 2007 DRS in Baku,4 however, did include these patients, and this makes a direct head-to-head comparison difficult. Second, the survey did not include data from the prison sector, in which high rates of MDR-TB have been found in detainees: 10% of detainees were found with MDR-TB in 2012. 2,6-8

Despite the apparent decrease in MDR-TB over the last few years, the overall high rate of MDR-TB in Azerbaijan places the country amongst the high MDR-TB burden countries in the world, and highlights the need for continued robust TB control efforts. The finding that nearly a third of new and previously treated cases had poly-drug resistance emphasizes the need for DST as soon as possible after each and every TB diagnosis, given the high risk of poly-drug resistant conversion to MDR-TB.9 The high proportion of MDR-TB patients who were also resistant to streptomycin and ethambutol is of concern. This effectively means that these drugs can no longer be included in treatment regimens for these patients, and especially those who have pre-XDR and XDR-TB.

This study confirms previous published findings that treatment failure is highly associated with drug-resistance.12-17 In Azerbaijan, the practice is that many new and previously treated patients are placed on first-line treatment before DST results are available. Furthermore, the coverage of first-line DST in Azerbaijan in 2010 was only 15% and 48% among new and previously treated cases respectively.18 Given that patients who had MDR-TB/XDR-TB had nearly 15 times the odds of previous treatment failure, any patient who has failed treatment should be urgently prioritized for rapid DST that includes rapid molecular techniques such as GenXpert MTB/RIF which potentially allows a diagnosis of TB and rifampicin-resistance within 2 hours.19

Interestingly, of all the socio-demographic risk factors assessed, only one factor (namely having a history of being in prison) was significantly associated with MDR-TB/XDR-TB. It is known that the rate of MDR-TB in the prison setting of Azerbaijan is high.2,6-8 However, recent reform in prison TB infection control in Azerbaijan has led to a successful decline in the rate of new infections and an improvement in treatment success even for patients with MDR-TB in this setting.20 The association between a history of being in prison and MDR-TB/XDR-TB, which was found in this study, might be because individuals were released from prison before the reform measures were implemented or because those released from the prison sector did not have adequate continuity of TB care after re-entering the community. These issues need further study.

This study has several important implications. First, it is vital to detect drug resistance early on in all new and previously treated patients through rapid or conventional DST, including the use of Xpert MTB/RIF, and therefore there is a need for complete coverage of these diagnostic services in the country. Second, there needs to be on-going and frequent monitoring of TB drug-resistance in the whole country, including the penitentiary sector, through routine surveillance. Third, the NTP needs to strengthen basic TB control measures which include a) decreasing the incorrect registration of disease category in patients which anecdotally occurs in peripheral facilities and b) implementing direct observation of treatment in patients on first line therapy, as this has been shown to reduce the risk of drug resistance.21,22 Fourth, as we were not able to measure the prevalence of MDR-TB amongst chronic TB cases or prisoners, future studies should include these high-risk populations and should also assess reasons for the high-risk of MDR-TB amongst former prisoners in the civilian population. Fifth, the study showed a clear need for 3rd line anti-TB medicines for the treatment patients with pre-XDR and XDR-TB.

In conclusion, Azerbaijan remains a high MDR-TB burden country with several important risk factors contributing to this epidemic of drug-resistance. There is an urgent need to implement several country-wide activities to begin to reverse the tide.

ACKNOWLEDGEMENT

This research was conducted through the Structured Operational Research and Training Initiative (SORT IT), a global partnership led by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization (WHO/TDR). The specific SORT IT programme which resulted in this publication was jointly developed and implemented by: WHO-TDR; WHO Regional Office for Europe; the Operational Research Unit (LUXOR), Médecins Sans Frontières, Brussels Operational Center, Luxembourg; the Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, France; The Union South-East Asia Regional Office, Delhi, India.

FUNDING

The programme was funded by the United States Agency for International Development (USAID) and managed by WHO/TDR. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

CONFLICT OF INTEREST

No conflict declared.

The authors alone are responsible for the content of this paper which may not necessarily represent the policies, decisions or views of the World Health Organization.

In accordance with WHO’s open-access publication policy for all work funded by WHO or authored/co-authored by WHO staff members, the WHO retains the copyright of this publication through a Creative Commons Attribution IGO licence (http://creativecommons.org/licenses/by/3.0/igo/legalcode) which permits unrestricted use, distribution and reproduction in any medium provided the original work is properly cited.

 

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Table 1: Drug resistance patterns among new and previously treated tuberculosis patients in Azerbaijan, 2012-2013

 

Type of resistance New

(n, %)

Previously treated (n, %) OR 95% CI p-value
Total 549 240
Sensitive for all anti-TB drugs 318 (58) 94 (40) 1  
Any resistance 231 (42) 146 (61) 2.1 1.6-2.9 <0.0001
  – Any resistance to H 148 (27) 115 (48)  
  – Any resistance to R 73 (13) 68 (28)
  – Any resistance to E 70 (13) 63 (26)
  – Any resistance to S 212 (39) 134 (56)
Mono-resistance 97 (18) 35 (15) 1.2 0.8-1.9 0.4
  – Mono H 15 (3) 6 (3)
  – Mono R 1 (0,2) 1 (0,4)
  – Mono E 1 (0,2)
  – Mono S 80 (15) 28 (12)
Poly-resistance 62 (11) 45 (19) 2.4 1.6-3.8 0.0001
MDR 72 (13) 66 (28) 3.1 2.1-4.7 <0.0001
  Pre-XDR (resistance to fluoroquinolones only) 8 (11) 9 (14)  
  Pre-XDR (resistance to injectable drugs only) 10 (14) 11 (17)  
  XDR 9 (13) 10 (16)  

 

OR=odds ratio, CI=confidence interval, TB=tuberculosis, H=izoniazid, R=rifampicin, S=streptomycin, E=ethambutol, Z=pyrazinamid, MDR= multi-drug resistance (resistance to at least isoniazid and rifampin), XDR=extensively drug resistance (resistance to at least isoniazid and rifampicin, and to any fluoroquinolone, and to any of the second-line injectables (amikacin, capreomycin, and kanamycin).

 


Table 2: Drug resistance patterns among previously treated tuberculosis patients in Azerbaijan, 2012-2013

Table 2A: Comparison between those who relapsed and who failed treatment

  Relapse

N (%)

Failure

N (%)

OR 95% CI p value
Total 92 75    
Sensitive for all anti-TB drugs 48 (52) 12 (16) 1  
Mono- or poly-resistance 34 (37) 25 (33) 2.9 1.3-6.6 0.0096
MDR/XDR 10 (11) 38 (51) 15.2 6.0-39.0 <0,0001

 

 

Table 2B: Comparison between those who relapsed and who returned after lost-to-follow-up

 

  Relapse

N (%)

Lost to follow up

N (%)

OR 95% CI P value
Total 92 71    
Sensitive for all anti-TB drugs 48 (52) 35 (50) 1
Mono- or poly-resistance 34 (37) 18 (25) 0.7 0.3-1.5 0.4
MDR/XDR 10 (11) 18 (25) 2.5 1.0-6.0 0.04

 

OR=odds ratio, CI=confidence interval, TB=tuberculosis, MDR= multi-drug resistance (resistance to at least isoniazid and rifampin), XDR=extensively drug resistance (resistance to at least isoniazid and rifampicin, and to any fluoroquinolone, and to any of the second-line injectables (amikacin, capreomycin, and kanamycin).

 

 

 

Table 3: Demographic, social and HIV characteristics of new pulmonary TB patients in relation to patterns of drug resistance in Azerbaijan, 2012-2013

 

  Sensitive/non-rifampicin-resistance

N (%)

Rifampicin-resistance1

N (%)

OR 95% CI p-value
Total 549 73
Gender          
  Male 338 (87) 51 (13) 1
Female 138 (86) 22 (14) 1.1 0.6-1.8 0.8
Age group        
  15-24 122 (87) 18 (13) 1
  25-34 117 (85) 20 (15) 1.2 0.6-2.3 0.7
  35-44 102 (89) 13 (11) 0.9 0.4-1.8 0.7
  45-54 68 (83) 14 (17) 1.4 0.7-3.0 0.4
  55-64 45 (90) 5 (10) 0.8 0.3-2.1 0.6
  ≥ 65 22 (88) 3 (12) 0.9 0.3-3.4 0.9
Migration2        
  No 435 (87) 64 (13) 1
  Yes 41 (82) 9 (18) 1.5 0.7-3.2 0.3
Social status    
  Unemployed 374 (86) 59 (14) 1
  Working 41 (85) 7 (15) 1.1 0.5-2.5 0.8
  Retired 40 (91) 4 (9) 0.6 0.2-1.8 0.4
  Disabled 8 (89) 1 (11) 0.8 0.1-6.5 0.8
  Student 13 (87) 2 (13) 1 0.2-4.4 1
Living condition    
  Owner 435 (87) 64 (13) 1
  Renting 29 (81) 7 (19) 1,6 0.7-3.9 0,3
  Hostel 5 (83) 1 (17) 1,4 0.2-11.8 0,8
  Homeless 7 (87) 1 (13) 1,0 0.1-8.0 1
Financial condition    
  Low 248 (85) 44 (15) 1
  Middle 218 (87) 28 (13) 0.7 0.4-1.2 0.2
  High 2 (100) 0
  Unknown 8 (89) 1 (11)
Smoking2        
  No 243 (86) 40 (14) 1
  Yes 233 (88) 33 (12) 0.9 0.5-1.4 0.5
Alcohol use3        
  No 333 (86) 52 (14) 1
  Yes 143 (87) 21 (13) 0.9 0.5-1.6 0.8
Drug use4    
  No 471 (87) 72 (13) 1
  Yes 0 1 (100)
  Unknown 5 (100) 0
Prison history5    
  No 465 (87) 69 (13) 1  
  Yes 10 (71) 4 (29) 2.7 0.8-8.8 0.1
  Unknown 1 (100) 0
HIV status        
  Negative 397 (88) 55 (12) 1
  Positive 1 (100) 0
  Unknown 78 (81) 18 (19)

 

HIV=human immunodeficiency virus, OR=odds ratio, CI=confidence interval, MDR= multi-drug resistance (resistance to at least isoniazid and rifampin), XDR=extensively drug resistance (resistance to at least isoniazid and rifampicin, and to any fluoroquinolone, and to any of the second-line injectables (amikacin, capreomycin, and kanamycin).

1 Any rifampicin-resistance including mono-rifampicin-resistance, polydrug-rifampicin-resistance, and MDR/XDR resistance.

2 Migration=history of emigration during the previous 3 years

3 Smoking=daily smoking (undefined amount)

4 Alcohol use=daily drinking (undefined amount)

5 Drug use=history of taken any illicit drugs at the moment or in the past

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 4: Demographic, social and HIV characteristics of previously treated pulmonary TB patients in relation to patterns of drug resistance in Azerbaijan, 2012-2013

 

 

 

Sensitive/non-rifampicin-resistance

N (%)

Rifampicin-resistance1

N (%)

OR 95%CI p-value
Total 172 68
Gender
Male 146 (74) 52 (26) 1
Female 26 (62) 16 (38) 1.7 0.9-3.5 0.1
Age group (yrs)
15-24 27 (71) 11 (29) 0,9 1
25-34 39 (72) 15 (28) 0,9 0.4-2.4 0.9
35-44 50 (72) 19 (28) 1,5 0.4-2.2 0.9
45-54 32 (63) 19 (37) 0,1 0.6-3.6 0.4
55-64 21 (95) 1 (5) 2,5 0.0-1.0 0.04
≥ 65 3 (50) 3 (50) 0,9 0.4-14.1 0.3
Migration2
No 148 (71) 60 (29) 1
Yes 24 (75) 8 (25) 0.8 0.3-1.9 0.6
Social status
Unemployed 139 (73) 52 (27) 1
Working 13 (68) 6 (32) 1.2 0.4-3.4 0.7
Retired 13 (76) 4 (24) 0.8 0.3-2.6 0.7
Disabled 6 (55) 5 (45) 2.2 0.7-7.6 0.2
Student 1 (50) 1 (50) 2.7 0.2-43.5 0.5
Living condition
Owner 158 (71) 64 (29) 1
Renting 9 (75) 3 (25) 0.8 0.2-3.1 0.8
Hostel 4 (100) 0
Homeless 1 (50) 1 (50) 2.5 0.2-40.1 0.5
Financial condition
Low 105 (69) 46 (31) 1
Middle 67 (76) 21 (24) 0.7 0.4-1.3 0.3
High 0 0
Unknown 0 1 (100)
Smoking3
No 74 (70) 32 (30) 1
Yes 98 (73) 36 (27) 0.8 0.5-1.5 0.6
Alcohol use4
No 112 (71) 46 (29) 1
Yes 55 (67) 27 (33) 1.4 0.8-2.5 0.2
Drug use5
No 168 (73) 63 (27) 1
Yes 2 (67) 1 (33) 1.3 0.1-15.0 0.8
Unknown 2 (33) 4 (67)
Prison history
No 163 (74) 58 (26) 1  
Yes 9 (50) 9 (50) 2.8 1.1-7.4 0.037
Unknown 0 1 (100)
HIV status
Negative 159 (73) 59 (27) 1
Positive 0 0
Unknown 13 (59) 9 (41)

 

HIV=human immunodeficiency virus, OR=odds ratio, CI=confidence interval, MDR= multi-drug resistance (resistance to at least isoniazid and rifampin), XDR=extensively drug resistance (resistance to at least isoniazid and rifampicin, and to any fluoroquinolone, and to any of the second-line injectables (amikacin, capreomycin, and kanamycin).

1 Any rifampicin-resistance including mono-rifampicin-resistance, polydrug-rifampicin-resistance, and MDR/XDR resistance.

2 Migration=history of emigration during the previous 3 years

3 Smoking=daily smoking (undefined amount)

4 Alcohol use=daily drinking (undefined amount)

5 Drug use=history of taken any illicit drugs at the moment or in the past