Spatial patterns of multidrug resistant tuberculosis and relationships to socio-economic, demographic and household factors in northwest Ethiopia

<div><p>Background</p><p>Understanding the geographical distribution of multidrug-resistant tuberculosis (MDR-TB) in high TB burden countries such as Ethiopia is crucial for effective control of TB epidemics in these countries, and thus globally. We present the first spatial analysis of multidrug resistant tuberculosis, and its relationship to socio-economic, demographic and household factors in northwest Ethiopia.</p><p>Methods</p><p>An ecological study was conducted using data on patients diagnosed with MDR-TB at the University of Gondar Hospital MDR-TB treatment centre, for the period 2010 to 2015. District level population data were extracted from the Ethiopia National and Regional Census Report. Spatial autocorrelation was explored using Moran’s I statistic, Local Indicators of Spatial Association (LISA), and the Getis-Ord statistics. A multivariate Poisson regression model was developed with a conditional autoregressive (CAR) prior structure, and with posterior parameters estimated using a Bayesian Markov chain Monte Carlo (MCMC) simulation approach with Gibbs sampling, in WinBUGS.</p><p>Results</p><p>A total of 264 MDR-TB patients were included in the analysis. The overall crude incidence rate of MDR-TB for the six-year period was 3.0 cases per 100,000 population. The highest incidence rate was observed in Metema (21 cases per 100,000 population) and Humera (18 cases per 100,000 population) districts; whereas nine districts had zero cases. Spatial clustering of MDR-TB was observed in districts located in the Ethiopia-Sudan and Ethiopia-Eritrea border regions, where large numbers of seasonal migrants live. Spatial clustering of MDR-TB was positively associated with urbanization (RR: 1.02; 95%CI: 1.01, 1.04) and the percentage of men (RR: 1.58; 95% CI: 1.26, 1.99) in the districts; after accounting for these factors there was no residual spatial clustering.</p><p>Conclusion</p><p>Spatial clustering of MDR-TB, fully explained by demographic factors (urbanization and percent male), was detected in the border regions of northwest Ethiopia, in locations where seasonal migrants live and work. Cross-border initiatives including options for mobile TB treatment and follow up are important for the effective control of MDR-TB in the region.</p></div

Map of the study area, northwest Ethiopia.

<p>Map of the study area, northwest Ethiopia.</p

Poisson regression model for the association of socio-economic, demographic, housing condition and spatially structured random effect at the district level with cases of multidrug-resistant tuberculosis in northwest Ethiopia, 2010 to 2015.

<p>Poisson regression model for the association of socio-economic, demographic, housing condition and spatially structured random effect at the district level with cases of multidrug-resistant tuberculosis in northwest Ethiopia, 2010 to 2015.</p

A multivariable fixed effects Poisson regression model of socio-economic and demographic factors influencing district-level incidence of multidrug resistant tuberculosis per 100,000 population in northwest Ethiopia, 2010 to 2015.

<p>A multivariable fixed effects Poisson regression model of socio-economic and demographic factors influencing district-level incidence of multidrug resistant tuberculosis per 100,000 population in northwest Ethiopia, 2010 to 2015.</p

Choropleth maps showing the geographical distribution of the percentage of the district (a) who are male and (b) who live in urban communities across northwest Ethiopia, 2010 to 2015.

<p>Choropleth maps showing the geographical distribution of the percentage of the district (a) who are male and (b) who live in urban communities across northwest Ethiopia, 2010 to 2015.</p

Spatial clustering of multidrug-resistant tuberculosis incidence in northwest Ethiopia, 2010 to 2015, based on: a) Local indicators of spatial association using Anselin Local Moran’s I statistic; and b) and the Getis-Ord Gi* statistic.

<p>Spatial clustering of multidrug-resistant tuberculosis incidence in northwest Ethiopia, 2010 to 2015, based on: a) Local indicators of spatial association using Anselin Local Moran’s I statistic; and b) and the Getis-Ord Gi* statistic.</p

The performance of smear and culture conversion at different months after commencement of treatment for multi-drug resistant tuberculosis to predict treatment outcome (successful vs poor treatment outcomes), for patients from Hunan Chest and Gondar University Hospitals, 2010 to 2014.

<p>The performance of smear and culture conversion at different months after commencement of treatment for multi-drug resistant tuberculosis to predict treatment outcome (successful vs poor treatment outcomes), for patients from Hunan Chest and Gondar University Hospitals, 2010 to 2014.</p

Discriminatory performance of risk scores for differentiating poor treatment outcomes from successful treatment outcomes among patients with multi drug resistant tuberculosis, using smear and culture conversion at two months only, as well as other demographic and clinical factors, from Hunan Chest and Gondar University Hospitals, 2010–2014.

<p>Discriminatory performance of risk scores for differentiating poor treatment outcomes from successful treatment outcomes among patients with multi drug resistant tuberculosis, using smear and culture conversion at two months only, as well as other demographic and clinical factors, from Hunan Chest and Gondar University Hospitals, 2010–2014.</p

Association of initial sputum smear and culture conversion at different months with treatment success in patients with multidrug resistant tuberculosis from Gondar University and Hunan Chest Hospital, 2010–2014, and adjusted odds ration with 95% confidence interval.

<p>Association of initial sputum smear and culture conversion at different months with treatment success in patients with multidrug resistant tuberculosis from Gondar University and Hunan Chest Hospital, 2010–2014, and adjusted odds ration with 95% confidence interval.</p

Number of patients with sputum smear and culture conversion after 2, 4, 6, and 12 months of treatment for multidrug resistant tuberculosis, among patients from Hunan Chest and Gondar University Hospitals, 2010 to 2014, stratified by successful and poor treatment outcomes.

<p>Number of patients with sputum smear and culture conversion after 2, 4, 6, and 12 months of treatment for multidrug resistant tuberculosis, among patients from Hunan Chest and Gondar University Hospitals, 2010 to 2014, stratified by successful and poor treatment outcomes.</p