The long term outcome and impact of multidrug-resistant tuberculosis in Henan Province, China

Abstract

China has the second largest burden of TB cases in the world and its burden of multidrug resistant TB (MDR-TB: resistant to the two principal chemotherapy agents - isoniazid and rifampicin) is also among the highest in the world. Henan, as one of the most populous provinces in China, bears the highest burdens of TB and MDR-TB cases in the country. Multi-drug resistant tuberculosis in Henan, particularly the impact on clinical and socioeconomic outcomes compared to non-MDR-TB, is poorly documented and requires investigation. The aim of this project was to understand the epidemiology and long term outcomes of MDR-TB in Henan, China. Two research components were employed to achieve the aim of the study. The first component characterised the epidemiology of TB and MDR-TB in Henan. Secondary data on surveillance for TB and data from periodic national surveys were used to describe epidemiological features of TB and drug resistance in Henan. For the second component, a prognostic cohort study was conducted. People with TB from 17 counties (150 non-MDR-TB & 100 MDR-TB patients) were sampled from the drug resistance survey dataset that had been generated by Henan TB Control and Prevention Institute in 2001 and long term (9-year) outcomes were ascertained. The first component of the study showed that the incidence of TB in Henan Province is in the middle range for China. In 2007, 3.0 percent of new and 21.7 percent of previously treated TB cases were MDR-TB. The second component of the study investigated 9-year outcomes for the prognostic cohort. Among MDR-TB patients at follow up the proportion who had died was twice that among non-MDR-TB patients (43.0% vs 21.6%). There was a much lower cure rate among MDR-TB patients (63.8%) than non-MDR-TB patients (92.0%). Socioeconomic outcomes also differed. The MDR-TB patients were less able to work, and more often changed their future plans and health behaviour. MDR cases had lower household incomes and were less wealthy. MDR-TB cases or relatives reported much higher TB treatment costs (30.2% vs 9.5% exceeding 10,000 Yuan), and more frequent loans (44.3% vs 26.1%) with less frequent loan repayment (19.0% vs 4.5%). Community impact was also investigated in the second part of this project. Overall, the study revealed little difference in community impact for the measured variables (reported stress, neighbour developing TB after the patient, number of registered TB patients in the community). One negative impact of MDR-TB noted for community residents was increased fear of TB. But there was no evidence that MDR-TB increased risk within the patients' communities. The main limitation of the prognostic cohort study was the difficulty in accurately categorising the social and economic outcomes many years after they occurred. Despite the limitation, this thesis produces original findings revealing and quantifying the adverse long term (9-year) clinical and socioeconomic outcomes of MDR-TB and impacts on patient, family and community in Henan Province, China. These findings will assist TB control policy and service in Henan Province and in the rest of China.