Abstract
BackgroundIn Madagascar, the multidrug-resistant tuberculosis (MDR-TB) surveillance programme was launched in late 2012 wherein previously treated TB cases and symptomatic MDR-TB contacts (hereafter called presumptive MDR-TB cases) undergo drug susceptibility testing. This retrospective review had per aim to provide an update on the national MDR-TB epidemiology, assess and enhance programmatic performance and assess Madagascar’s MDR-TB cascade of care.MethodsFor 2012–2017, national TB control programme notification, clinical management data and reference laboratory data were gathered. The development and coverage of the surveillance programme, the MDR-TB epidemiology and programmatic performance indicators were assessed using descriptive, logistic and spatial statistical analyses. Data for 2017 was further used to map Madagascar’s TB and MDR-TB cascade of care.ResultsThe geographical coverage and diagnostic and referral capacities of the MDR-TB surveillance programme were gradually expanded whereas regional variations persist with regard to coverage, referral rates and sample referral delays. Overall, the rate of MDR-TB among presumptive MDR-TB cases remained relatively stable, ranging between 3.9% in 2013 and 4.4% in 2017. Most MDR-TB patients were lost in the second gap of the cascade pertaining to MDR-TB cases reaching diagnostic centres but failing to be accurately diagnosed (59.0%). This poor success in diagnosis of MDR-TB is due to both the current use of low-sensitivity smear microscopy as a first-line diagnostic assay for TB and the limited access to any form of drug susceptibility testing. Presumptive MDR-TB patients’ sample referral took a mean delay of 28 days before testing. Seventy-five percent of diagnosed MDR-TB patients were appropriately initiated on treatment, and 33% reached long-term recurrence-free survival.ConclusionsAn expansion of the coverage and strengthening of MDR-TB diagnostic and management capacities are indicated across all regions of Madagascar. With current limitations, the surveillance programme data is likely to underestimate the true MDR-TB burden in the country and an updated national MDR-TB prevalence survey is warranted. In absence of multiple drivers of an MDR-TB epidemic, including high MDR-TB rates, high HIV infection rates and inter-country migration, Madagascar is in a favourable starting position for MDR-TB control and elimination.
Highlights
In Madagascar, the multidrug-resistant tuberculosis (MDR-TB) surveillance programme was launched in late 2012 wherein previously treated TB cases and symptomatic MDR-TB contacts undergo drug susceptibility testing
An expansion of the coverage and strengthening of MDR-TB diagnostic and management capacities are indicated across all regions of Madagascar
In 2018, according to World Health Organization (WHO) estimates, the combined rates of MDR-TB and rifampicin-resistant TB had reached 0.5% for primary and 5.9% for secondary resistance, leading to a total incidence of 1.6/100,000 population [2]. Beyond these estimates, which rely on sparse quantity and quality of data, the understanding of the drug-resistant TB epidemiology in Madagascar relies on (i) a one-time surveillance data review with limited scope from 2014, (ii) small-scale studies focusing on urban subpopulations and (iii) nationwide limited capacity for routine drug susceptibility testing (DST), including rifampicin resistance testing with GeneXpert MTB/RIF (Cepheid, CA, USA) [3, 4]
Summary
In Madagascar, the multidrug-resistant tuberculosis (MDR-TB) surveillance programme was launched in late 2012 wherein previously treated TB cases and symptomatic MDR-TB contacts (hereafter called presumptive MDR-TB cases) undergo drug susceptibility testing. In 2018, according to World Health Organization (WHO) estimates, the combined rates of MDR-TB and rifampicin-resistant TB had reached 0.5% for primary and 5.9% for secondary resistance, leading to a total incidence of 1.6/100,000 population [2] Beyond these estimates, which rely on sparse quantity and quality of data, the understanding of the drug-resistant TB epidemiology in Madagascar relies on (i) a one-time surveillance data review with limited scope from 2014, (ii) small-scale studies focusing on urban subpopulations and (iii) nationwide limited capacity for routine drug susceptibility testing (DST), including rifampicin resistance testing with GeneXpert MTB/RIF (Cepheid, CA, USA) [3, 4]. Surveillance of TB drug resistance in Madagascar is lacking behind standards put forward by the WHO [5]
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