[论文解读] Resistance to TB drugs in KwaZulu-Natal: causes and prospects for control

Kristina Wallengren, Fabio Scano+10 more|arXiv (Cornell University)|Jul 9, 2011

Tuberculosis Research and Epidemiology参考文献 3被引用 6

一句话总结

本研究利用省级结核病登记数据、药物敏感性测试结果及现场考察，调查南非夸祖鲁-纳塔尔省多药耐药（MDR）和广泛耐药（XDR）结核病的驱动因素。研究识别出拥挤、通风不良的医疗设施——特别是图盖拉费里的苏格兰国教会医院（Church of Scotland Hospital, COSH）——由于感染控制措施不足及结核病与艾滋病联合管理不善，成为XDR结核病传播的关键放大器。研究呼吁加强治疗监管、感染控制和艾滋病护理，以遏制传播和耐药性产生。

ABSTRACT

In 2005 there was an outbreak of XDR (extensively drug resistant) TB in Tugela Ferry, which is served by the Church of Scotland Hospital (COSH), in the uMzinyathi District, KwaZulu-Natal, South Africa. An investigation was carried out to determine if XDR TB was occurring elsewhere in the province, and to develop hypotheses for the rise in drug resistance with a view to developing a strategy for the control of MDR (multi-drug resistant) and XDR TB in the province and elsewhere. TB incidence and treatment success rates, for each of the 11 districts in the province, were obtained from the provincial electronic TB register for the years 2002-2007. The results of culture and drug sensitivity tests for the years 2002 to 2007 in each of the districts were compiled and culture taking practices were compared to the number of MDR TB cases. Interviews were conducted with key personnel in affected sites. In 2007, 2799, or 2.3% of 119,218 notified TB cases in the province were multi-drug resistant (MDR), and of these 270 (9.6%) were XDR. The two worst affected districts were uMzinyathi where 226 (4.1%) of 5522 notified TB cases were MDR, and of these 120 (53%) were extensively drug resistant (XDR), and uMkhanyakude where 337 (4.8%) of 6991 notified TB cases were MDR, but of these only four or (1.2%) were XDR. The worst affected medical centre was COSH where 164 or 9.8% of notified TB cases were MDR and of these 99 (60%) were XDR. Very high rates of XDR TB in the province are only found in uMzinyathi district even though MDR TB is common in most other districts. XDR may arisen at COSH because of the early and effective integration of the TB and HIV programmes in overcrowded and poorly ventilated facilities particular to COS.H To control XDR TB better management of both susceptible and resistant forms of TB is needed including treatment supervision, infection control and HIV management.

研究动机与目标

• 调查夸祖鲁-纳塔尔省MDR和XDR结核病发病率上升的原因，特别是2005年图盖拉费里XDR结核病爆发之后的情况。
• 利用省级结核病登记数据和实验室数据，评估全省11个区药物耐药结核病的分布与负担。
• 评估医疗系统因素（如设施拥挤、通风不良以及结核病与艾滋病服务整合）对XDR结核病发生与传播的影响。
• 制定基于证据的策略，以控制夸祖鲁-纳塔尔省及类似高负担地区MDR和XDR结核病的传播。

提出的方法

• 对2002年至2007年省级电子结核病登记数据进行回顾性分析，按区统计结核病发病率和治疗成功率。
• 汇编2002年至2007年的培养和药物敏感性测试结果，以确定各地区MDR和XDR结核病病例数。
• 比较结核病培养实践与MDR结核病病例检测率，评估诊断表现和报告完整性。
• 对受影响的医疗机构（包括苏格兰国教会医院）进行现场考察，并对关键人员进行访谈，以评估结构与运营因素。
• 运用描述性流行病学与空间分析，识别高负担区和医疗机构，特别是uMzinyathi区和COSH。
• 整合临床、运营与公共卫生数据，提出关于XDR结核病发生与控制的假设。

实验结果

研究问题

• RQ1 2002年至2007年间，夸祖鲁-纳塔尔省MDR和XDR结核病的地理与人口学模式如何？
• RQ2 为何XDR结核病在苏格兰国教会医院和uMzinyathi区不成比例地出现并传播？
• RQ3 医疗设施条件（如拥挤、通风不良以及HIV/结核病整合）如何影响耐药结核病的发生与传播？
• RQ4 诊断实践与实验室报告在本省检测与监测MDR和XDR结核病中发挥何种作用？
• RQ5 在高负担地区，需要哪些系统性与操作性干预措施以控制MDR和XDR结核病的传播？

主要发现

• 2007年，夸祖鲁-纳塔尔省报告的结核病病例中，2.3%（119,218例中的2,799例）为MDR，其中9.6%（270例）为XDR。
• uMzinyathi区报告的XDR结核病负担最高，53%（226例MDR中的120例）为XDR，而uMkhanyakude区仅为1.2%（337例MDR中的4例）。
• 苏格兰国教会医院（COSH）的MDR率在全省最高，达9.8%（1,674例中的164例），其中60%（164例MDR中的99例）为XDR。
• XDR结核病集中于单一医疗机构——COSH，表明本地医疗条件而非区域传播，是XDR出现的关键因素。
• XDR结核病的高发生率与在拥挤、通风不良的住院病房中早期有效整合结核病与艾滋病服务密切相关。
• 研究结论认为，控制XDR结核病需加强易感与耐药结核病的综合管理，包括感染控制、治疗监管和艾滋病护理。