High Prevalence of Multidrug-Resistant Tuberculosis, Swaziland, 2009–2010

Elisabeth Sanchez-Padilla

, Themba Dlamini, Alexandra Ascorra, Sabine Rüsch-Gerdes, Zerihun Demissie Tefera, Philippe Calain, Roberto de la Tour, Frauke Jochims, Elvira Richter, and Maryline Bonnet

Author affiliations: Epicentre, Paris, France (E. Sanchez-Padilla, A. Ascorra, M. Bonnet); National Tuberculosis Control Programme, Mbabane, Swaziland (T. Dlamini); National Reference Center for Mycobacteria, Borstel, Germany (S. Rüsch-Gerdes, E. Richter); Médecins Sans Frontières, Geneva, Switzerland (Z.D. Tefera, P. Calain, R. de la Tour, F. Jochims)

Abstract

In Africa, although emergence of multidrug-resistant (MDR) tuberculosis (TB) represents a serious threat in countries severely affected by the HIV epidemic, most countries lack drug-resistant TB data. This finding was particularly true in the Kingdom of Swaziland, which has the world’s highest HIV and TB prevalences. Therefore, we conducted a national survey in 2009–2010 to measure prevalence of drug-resistant TB. Of 988 patients screened, 420 new case-patients and 420 previously treated case-patients met the study criteria. Among culture-positive patients, 15.3% new case-patients and 49.5% previously treated case-patients harbored drug-resistant strains. MDR TB prevalence was 7.7% and 33.8% among new case-patients and previously treated case-patients, respectively. HIV infection and past TB treatment were independently associated with MDR TB. The findings assert the need for wide-scale intervention in resource-limited contexts such as Swaziland, where diagnostic and treatment facilities and health personnel are lacking.

Despite efforts to control the tuberculosis (TB) epidemic, there were an estimated 9.4 million incident cases of TB worldwide in 2009 (1). The HIV epidemic and the emergence of anti-TB drug resistance represent serious threats for achieving the Stop TB Partnership’s goal of eliminating TB as a public health problem by 2050 (2). HIV co-infected patients are more likely to show development of active TB. Even though antiretroviral therapy for HIV reduces this risk, TB remains 5× more frequent in persons living with HIV/AIDS (3). Indeed, 30% of the patients in whom TB was diagnosed in 2008 worldwide were in Africa, possibly because of the HIV epidemic affecting the continent (1).

Patients infected with a Mycobacterium spp. strain resistant to rifampin and isoniazid, which defines a multidrug-resistant (MDR) TB strain, do not respond to World Health Organization (WHO) standardized directly observed short-course chemotherapy and require longer, more toxic, and more expensive treatment. Timely identification of patients with MDR TB enables rapid initiation of adequate treatment, thus preventing the patient from spreading the disease and from acquiring further resistance.

Ideally, routine drug susceptibility testing (DST) should be conducted before initiation of treatment in all patients with TB, but this is not achievable in most high-prevalence countries because of poor access to bacterial culture and DST tools. For the same reasons, in most countries with a high prevalence of TB, no surveillance of anti-TB drug resistance is conducted. Periodic surveys of a representative sample of patients with TB often constitute the only available sources of information on the prevalence of drug resistance (4). In the last WHO report on resistance to anti-TB drugs, data from periodic surveys with relatively recent data were available for only 21 of 46 African countries (5).

The Kingdom of Swaziland, in southern Africa, is the country with the world’s highest HIV prevalence (26% among adults in 2007) and TB incidence rate per capita (1,257 cases per 100,000 population in 2009) (6,7). In 2007, in collaboration with the Ministry of Health and Social Welfare of Swaziland, Médecins Sans Frontières started an integrated HIV/TB project in Shiselweni in southern Swaziland.

In Swaziland, the last national anti-TB drug resistance survey had been conducted in 1995 and reported an MDR TB prevalence of 0.9% among new TB case-patients and 9.1% among previously treated case-patients (5). Several factors could have potentially resulted in an increase of MDR TB in the country in recent years and in emergence of extensively drug-resistant (XDR) TB, which is defined as MDR TB resistant to >1 injectable second-line drug and any fluoroquinolone. The National TB Control Programme in Swaziland had reported relatively poor TB treatment success rates (68% and 48% for new and retreatment smear-positive TB case-patients, respectively, in 2008), with high failure rates (7% in new case-patients and 11% in retreated case-patients) (1). Additionally, Swaziland borders the province of KwaZulu-Natal in South Africa, where an outbreak of XDR TB was reported in 2005 among HIV co-infected patients (8); many citizens of Swaziland regularly cross the border to work in South African mines. In 2007, the Ministry of Health and Social Welfare conducted a rapid survey among high-risk patients to detect the occurrence of XDR TB and reported 4 patients with XDR TB and an 18.5% MDR TB prevalence among previously treated case-patients (9). These findings justified the need for a new national anti-TB drug resistance survey that measured the current prevalence of MDR TB among new and previously treated patients with TB in Swaziland.