Does Drug-Resistant Extrapulmonary Tuberculosis Hinder TB Elimination Plans? A Case from Delhi, India.

Sheelu Lohiya,Arun Ojha,Ashwani Khanna,Jaya Prasad Tripathy,Anuj Bhatnagar,Karuna Sagili,Ravinder Kumar,Vishal Khanna

doi:10.3390/tropicalmed5030109

Abstract

Extrapulmonary drug-resistant tuberculosis (DR-EPTB) poses a formidable diagnostic and therapeutic challenge.Besides associated with high morbidity, it is a major financial burden for the patient and the health system. In spite of this, it has often been neglected as it does not “pose” a visible public health threat. We study clinical profiles, treatment outcomes, and factors associated with unfavourable outcomes among DR-EPTB patients under programmatic settings in New Delhi, India, and evaluate how this could impact TB elimination. A retrospective analysis of all DR-EPTB patients registered at three nodal DR-TB centres in Delhi in 2016 was carried out. Of the 1261 DR-TB patients registered, 203 (16%) were DR-EPTB, with lymph nodes (118, 58%) being the most common site, followed by bone (69, 34%). Nearly 29% (n = 58) experienced adverse drug reactions with severe vomiting (26, 13 %), joint pain (21, 10%) and behavioral disorder (15, 7%). History of previous TB treatment was observed in a majority of the cases (87.7%). Nearly one-third of DR-EPTB cases (33%) had unfavourable treatment outcomes, with loss-to-follow-up (n = 40, 58%) or death (n = 14, 20%) being the most common unfavourable outcomes. In the adjusted analysis, weight band 31–50 kilograms (aRR = 1.8, 1.2–3.4) and h/o previous TB (aRR = 2.1, 1.1–4.8) were mainly associated with unfavourable outcomes. TB elimination efforts need to focus on all forms of TB, including DR-EPTB, leaving no one behind, in order to realise the dream of ending TB.

Highlights

Tuberculosis (TB) remains the top infectious killer, ranking above HIV/AIDS, with 10.0 million cases and 1.4 million deaths in 2018 [1]
Of the total 1261 DR-TB patients registered in the three selected DR-TB sites in Delhi in 2016, 1058 (84%) were pulmonary and 203 (16%) were DR-extrapulmonary TB (EPTB) cases, all of whom were included in the study
The key findings of our study are: (i) one in every six registered DR-TB patients has drug-resistant EPTB (DR-EPTB), (ii) lymph node is the most common site of involvement, followed by bone, in DR-EPTB patients, (iii) one-third of all DR-EPTB cases had unsuccessful treatment outcomes, and (iv) baseline weight, DR-TB centre and history of previous TB were significantly associated with unsuccessful treatment outcomes

Summary

Introduction

Tuberculosis (TB) remains the top infectious killer, ranking above HIV/AIDS, with 10.0 million cases and 1.4 million deaths in 2018 [1]. Mycobacterium tuberculosis (MTB), the causative agent, usually affects the lungs (pulmonary TB/PTB). MTB may spread through lymphatic or hematogenous routes to virtually any organ in the body, resulting in extrapulmonary TB (EPTB). While EPTB has existed for millennia, pulmonary TB has remained the prime focus of global TB control programmes. EPTB is often less contagious than PTB, and is overlooked even though it constitutes about 15% of all forms of TB, amounting to nearly 1 million incident cases notified in 2018, as per the WHO Global TB report [1]. EPTB results in significant morbidity and mortality due to various diagnostic and therapeutic challenges that lead to delayed care

Results

Discussion

Conclusion