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

Background: 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. Methods: 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. Results: 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. Conclusion: 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

Spatiotemporal transmission and socio-climatic factors related to paediatric tuberculosis in north-western Ethiopia

The burden of tuberculosis (TB) in children reflects continuing and recent transmission within a population. This study aimed to identify spatiotemporal and socio-climatic factors associated with paediatric TB in north-western Ethiopia. Multivariate Poisson regression models were computed using a Bayesian framework. Estimates of parameters were generated using Markov chain Monte Carlo simulation. A total of 2,240 children aged under 15 years diagnosed with TB during the years 2013-2016 were included in the analysis. The annual TB incidence rates were 44 and 28 per 100,000 children, for children aged under 15 and 5 years, respectively. Spatial clustering of TB was observed in the border area of north-western Ethiopia. The spatio-temporal transmission of childhood TB was found to be associated with district level socio-climatic factors such as urbanisation [relative risk (RR): 1.8; 95% credible interval (CrI): 1.2, 2.6], lower educational status (RR: 1.5; 95% CrI: 1.0, 2.1), a high percentage of internal migration (RR: 1.3; 95% CrI: 1.0, 1.6), high temperature (RR: 1.3; 95% CrI: 1.0, 1.7) and high rainfall (RR: 1.5; 95% CrI: 1.1, 2.0). We conclude that interventions targeting hotspot districts with a high proportion of childhood TB are important to reduce TB transmission in northwest Ethiopia

Knowledge of Pregnant Women on Mother-to-Child Transmission of HIV in Meket District, Northeast Ethiopia

Knowledge of pregnant women on the three periods of mother-to-child transmission (MTCT) of HIV has implication for child HIV acquisition. This study aims to assess the knowledge of pregnant women on mother-to-child transmission of HIV and to identify associated factors in Meket district, northeast Ethiopia. Logistic regression models were fitted to identify associated factors. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were used to determine the presence and strength of association. About onefifth (19%) of women were knowledgeable on mother-to-child transmission of HIV (95% CI: 15.5%, 22.4%). Being urban resident (AOR: 2.69, 95% CI: 1.48, 4.87), having primary education (AOR: 2.41, 95% CI: 1.03, 5.60), reporting receiving information on HIV from health care providers (AOR: 3.24, 95% CI: 1.53, 6.83), having discussion with partner about mother-to-child transmission of HIV (AOR: 2.64, 95% CI: 1.59, 4.39), and attending antenatal care (AOR: 5.80, 95% CI: 2.63, 12.77) were positively associated with increased maternal knowledge of mother-to-child transmission of HIV. Knowledge of mother-to-child transmission of HIV among pregnant women was low. Providing information, especially for rural women and their partners, is highly recommended. Background Vertical transmission of Human Immunodeficiency Virus (HIV) is still a major challenge in the world, especially in developing countries Without any intervention, the risk of a baby getting HIV infection from an infected mother ranges from 15% to 25% in the developed nations and from 25% to 35% in developing countries. HIV transmission rate and timing are estimated to be 5% to 10% during pregnancy, 10% to 15% during delivery and 5% to 20% through breast-feeding. In general mother to child transmission contributes 15-45% of HIV acquisition for children The national adult HIV prevalence in Ethiopia is 1.2% It is estimated that 138, 906 children less than 15 years are living with HIV in 2014. There are an estimated 3,886 new infections each year due to mother-to-child transmission According to Ethiopian Demographic and Health Survey (EDHS) report, about three-quarters of reproductive aged women know that HIV can be transmitted to a baby through breastfeeding Maternal knowledge on MTCT is a corner stone of effective implementation of the World Health Organization (WHO) recommendation of the four-pronged approach to reduce mother-to-child transmission of HIV Despite the large challenge of vertical transmission of HIV, there were also limited community-based studies on women knowledge on mother-to-child transmission of HIV. Hence, this study attempts to fill the gap through assessing the level of knowledge of MTCT of HIV and its associated factors at Meket district, Northeast Ethiopia. Methods Study Design, Population, and Setting. A communitybased cross-sectional study design was conducted in Meket district, northeast Ethiopia, from March 8 to 21, 2014. Meket district is located 665 km north of Addis Ababa, the Ethiopian capital city. The district has an estimated population size of 254,520 of which 59,939 are reproductive aged women, and an estimated 8,246 were pregnant women. Those pregnant women are living in Meket district were constituted our study population. Sample Size and Sampling Procedure. Sample size was determined using single population proportion formula with the assumptions of 95% level of confidence, 12% proportion of knowledgeable women on MTCT of HIV Operational Definitions. In the present study, pregnant woman was regarded as being knowledgeable on MTCT if she correctly identified the three different modes/periods of MTCT of HIV; otherwise she was classified as nonknowledgeable. Comprehensive knowledge of HIV was also measured if a pregnant woman correctly identified three modes of transmission of HIV (unsafe sexual practice, blood transfusion, and MTCT) and recognized two common misconceptions. Comprehensive knowledge about HIV/AIDS was measured after posing the following questions: (1) knowing that condom use and limiting sex partners to one uninfected partner are HIV prevention methods, (2) being aware that a healthy-looking person can have HIV, and (3) rejecting the two most common local misconceptions, that is, HIV/AIDS can be transmitted through mosquito bites and by supernatural means in Ethiopia Data Collection Procedures. Data were collected using pretested, structured, and interviewer administered questionnaire. The questionnaire was prepared after reviewing relevant literatures. Five female nurses supervised by two BSc health professionals collected the data. For eligible women who were not at home during our first attempt, the interviewers revisited the participant's home at least two times before excluding the participant. Training was given to the data collectors about informed consent, techniques of interviewing, data collection procedures, and different sections of the questionnaire. Supervisors and principal investigators checked the questionnaire on its completeness and consistency on the daily basis. Data Processing and Analysis. The data were entered into EPI info version 3.5.3 statistical software and then sorted, cleaned, and analyzed by using SPSS version 20 statistical package. Descriptive statistics were done to describe the study participants in relation to relevant variables. Both bivariate and multiple logistic regression analyses were carried out to see the effect of sociodemographic factors, maternal condition factors, and other factors on the knowledge of MTCT of HIV and to control cofounding. Odds ratios with 95% CI were computed to identify factors associated with mothers' MTCT knowledge. Ethical Consideration. Ethical clearance was obtained from the Research and Ethical Review Committee (REC) at the Institute of Public Health, College of Medicine and Health Science of University of Gondar. Permission letter was secured from Meket District Health Office. Written informed consent was taken from each study participant after reading the consent form. The purpose and benefit of the study and their right to withdraw at any time were also delivered to each participant prior to the interview. Confidentiality of the information was maintained throughout by using anonymity identifiers, keeping their privacy by interviewing them individually. Results Sociodemographic Characteristics of Pregnant Women. Five hundred forty-two pregnant women participated in the study (97.5% response rate). The majority (85.4%) were rural dwellers. The mean age of the study participants was 29.45 years (SD = 5.4). Four hundred and sixty (84.9%) were married, 196 (36.2%) were able to read and write, and nearly four-fifths (80.1%) were homemaker ( Journal of Pregnancy 3 Knowledge of Pregnant Women on MTCT. One hundred three (19%) (95% CI: 15.5%, 22.4%) were knowledgeable on MTCT of HIV. Most (84.5%) heard about mother to child transmission of HIV. Among those who heard MTCT, more than two-thirds (70.7%) mentioned labor/delivery as a time of HIV transition from mother to child. 225 (41.5%) pregnant women identified at least two periods of motherto-child transmission of HIV. Nearly two-thirds (63.8%) had comprehensive knowledge on HIV/AIDS, and another equivalent proportion of women heard about PITC Factors Associated with Knowledge of Pregnant Women on MTCT of HIV. In multivariable analysis, higher levels of maternal education status, having received information about HIV from health professionals, and reported discussion of MTCT and ANC with their partners were positively associated with knowledge of mother-to-child transmission of HIV. Those women who live in the urban settings were about three more like to be knowledgeable than their rural counterparts (AOR: 2.69, CI (1.48, 4.87)). Those literate mothers were about three times more likely to be knowledgeable than who did not read and write (AOR: 3.25, CI (1.55, 6.78)). Likewise, a woman was 2.41 times more likely to be knowledgeable if she had completed primary school as compared to those who did not read and write (AOR: 2.41, CI (1.04, 5.60)). Pregnant women who received information on HIV from health care providers were about three times more likely to be knowledgeable than women who had not received information (AOR: 3.24, CI (1.54, 6.83)). Women who had discussions with their partner were more likely to be knowledgeable than those who had not (AOR: 5.80, CI (2.63, 12.78)). Correspondingly, mothers who discussed MTCT with their partners were more likely to be knowledgeable than those who had not (AOR: 2.64, CI (1.59, 4.39)) Discussion Being knowledgeable on MTCT of HIV and the fact that the risk of transmission can be reduced by using antiretroviral drugs are critical in reducing MTCT of HIV. This can contribute greatly towards the achievement of the Millennium Development Goals related to HIV. This study revealed that 19% (95% CI: 15.5%, 22.4%) of respondents were knowledgeable on MTCT of HIV. This result is in line with a cross-sectional study conducted at Temeke District Hospital, Dar Es Salaam (15.7%) In the present study, nearly two-thirds of pregnant women had comprehensive knowledge on HIV/AIDS which is higher than studies in Yaoundé (23%) Knowledge of pregnant women on MTCT of HIV among pregnant women was significantly varied based on their place of residence. Those pregnant women residing in urban areas were more likely to be knowledgeable when compared to the rural residents. This finding is in line with studies conducted at Gondar and Hawassa towns in Ethiopia In this study, pregnant women who discussed and received information about HIV/AIDS from health care providers were more knowledgeable. They were found to be three times more likely to be knowledgeable than those who had not. Spouse discussion on antenatal care follow-up was also positively associated with knowledge of MTCT. Those pregnant women who had discussions with their partners were six times more likely to be knowledgeable than those who had not discussed the issue. This is similar to reports from other studies Pregnant women may receive information from a variety of sources about health services. Spouses having delivered information and participated in discussions about MTCT of HIV with their wives (40.6%) were associated with good knowledge of the subject. Accordingly, pregnant women who had discussion with their partners were more than two times more likely to have good knowledge of MTCT. This might be because partner discussion in this regard could enhance their knowledge. This study tried to assess pregnant women who did not attend health care facilities for ANC and HIV concerning their knowledge about MTCT of HIV. However, because of financial and time constraints, this study did not include the knowledge part of prevention of mother-to-child transmission of HIV. Conclusions Despite many efforts, the knowledge of pregnant women on mother-to-child transmission of HIV is low. If pregnant woman resides in urban environment, she attends school, if she receives information on HIV from health care providers, and if she attends antenatal care, she is more likely to be knowledgeable on MTCT of HIV. Strengthening women education and by reaching previously inaccessible parts of the community, integration of HIV, prevention of MTCT, and ANC service, is highly recommended. Moreover, strengthening discussion of MTCT with spouses is important

Development of a risk score for prediction of poor treatment outcomes among patients with multidrug-resistant tuberculosis

Background Treatment outcomes among patients treated for multidrug-resistant tuberculosis (MDR-TB) are often sub-optimal. Therefore, the early prediction of poor treatment outcomes may be useful in patient care, especially for clinicians when they have the ability to make treatment decisions or offer counselling or additional support to patients. The aim of this study was to develop a simple clinical risk score to predict poor treatment outcomes in patients with MDR-TB, using routinely collected data from two large countries in geographically distinct regions. Methods We used MDR-TB data collected from Hunan Chest Hospital, China and Gondar University Hospital, Ethiopia. The data were divided into derivation (n = 343; 60%) and validation groups (n = 227; 40%). A poor treatment outcome was defined as treatment failure, lost to follow up or death. A risk score for poor treatment outcomes was derived using a Cox proportional hazard model in the derivation group. The model was then validated in the validation group. Results The overall rate of poor treatment outcome was 39.5% (n = 225); 37.9% (n = 86) in the derivation group and 40.5% (n = 139) in the validation group. Three variables were identified as predictors of poor treatment outcomes, and each was assigned a number of points proportional to its regression coefficient. These predictors and their points were: 1) history of taking second-line TB treatment (2 points), 2) resistance to any fluoroquinolones (3 points), and 3) smear did not convert from positive to negative at two months (4 points). We summed these points to calculate the risk score for each patient; three risk groups were defined: low risk (0 to 2 points), medium risk (3 to 5 points), and high risk (6 to 9 points). In the derivation group, poor treatment outcomes were reported for these three groups as 14%, 27%, and 71%, respectively. The area under the receiver operating characteristic curve for the point system in the derivation group was 0.69 (95% CI 0.60 to 0.77) and was similar to that in the validation group (0.67; 95% CI 0.56 to 0.78; p = 0.82). Conclusion History of second-line TB treatment, resistance to any fluoroquinolones, and smear non-conversion at two months can be used to estimate the risk of poor treatment outcome in patients with MDR-TB with a moderate degree of accuracy (AUROC = 0.69)

Sequelae of multidrug-resistant tuberculosis: protocol for a systematic review and meta-analysis

Introduction: The sequelae of multidrug-resistant tuberculosis (MDR-TB) are poorly understood and inconsistently reported. We will aim to assess the existing evidence for the clinical, psychological, social and economic sequelae of MDR-TB and to assess the health-related quality of life in patients with MDR-TB. Methods and analysis: We will perform a systematic review and meta-analysis of published studies reporting sequelae of MDR-TB. We will search PubMed, SCOPUS, ProQuest, Web of Science and PsychINFO databases up to 5 September 2017. MDR-TB sequelae will include any clinical, psychological, social and economic effects as well as health-related quality of life that occur after MDR-TB treatment or illness. Two researchers will screen the titles and abstracts of all citations identified in our search, extract data, and assess the scientific quality using standardised formats. Providing there is appropriate comparability in the studies, we will use a random-effects meta-analysis model to produce pooled estimates of MDR-TB sequelae from the included studies. We will stratify the analyses based on treatment regimen, comorbidities (such as HIV status and diabetes mellitus), previous TB treatment history and study setting. Ethics and dissemination: As this study will be based on published data, ethical approval is not required. The final report will be disseminated through publication in a peer-reviewed scientific journal and will also be presented at relevant conferences

Mapping tuberculosis treatment outcomes in Ethiopia

Background: Tuberculosis (TB) is the leading cause of death from an infectious disease in Ethiopia, killing more than 30 thousand people every year. This study aimed to determine whether the rates of poor TB treatment outcome varied geographically across Ethiopia at district and zone levels and whether such variability was associated with socioeconomic, behavioural, health care access, or climatic conditions. Methods: A geospatial analysis was conducted using national TB data reported to the health management information system (HMIS), for the period 2015-2017. The prevalence of poor TB treatment outcomes was calculated by dividing the sum of treatment failure, death and loss to follow-up by the total number of TB patients. Binomial logistic regression models were computed and a spatial analysis was performed using a Bayesian framework. Estimates of parameters were generated using Markov chain Monte Carlo (MCMC) simulation. Geographic clustering was assessed using the Getis-Ord Gi* statistic, and global and local Moran's I statistics. Results: A total of 223,244 TB patients were reported from 722 districts in Ethiopia during the study period. Of these, 63,556 (28.5%) were cured, 139,633 (62.4%) completed treatment, 6716 (3.0%) died, 1459 (0.7%) had treatment failure, and 12,200 (5.5%) were lost to follow-up. The overall prevalence of a poor TB treatment outcome was 9.0% (range, 1-58%). Hot-spots and clustering of poor TB treatment outcomes were detected in districts near the international borders in Afar, Gambelia, and Somali regions and cold spots were detected in Oromia and Amhara regions. Spatial clustering of poor TB treatment outcomes was positively associated with the proportion of the population with low wealth index (OR: 1.01; 95%CI: 1.0, 1.01), the proportion of the population with poor knowledge about TB (OR: 1.02; 95%CI: 1.01, 1.03), and higher annual mean temperature per degree Celsius (OR: 1.15; 95% CI: 1.08, 1.21). Conclusions: This study showed significant spatial variation in poor TB treatment outcomes in Ethiopia that was related to underlying socioeconomic status, knowledge about TB, and climatic conditions. Clinical and public health interventions should be targeted in hot spot areas to reduce poor TB treatment outcomes and to achieve the national End-TB Strategy targets

Effects of zinc and vitamin A supplementation on prognostic markers and treatment outcomes of adults with pulmonary tuberculosis: a systematic review and meta-analysis

Introduction: Undernutrition is a major risk factor for tuberculosis (TB), which is estimated to be responsible for 1.9 million TB cases per year globally. The effectiveness of micronutrient supplementation on TB treatment outcomes and its prognostic markers (sputum conversion, serum zinc, retinol and haemoglobin levels) has been poorly understood. This study aimed to determine the effect of zinc and vitamin A supplementation on prognostic markers and TB treatment outcomes among adults with sputum-positive pulmonary TB. Methods: A systematic literature search for randomised controlled trials (RCTs) was performed in PubMed, Embase and Scopus databases. Meta-analysis with a random effect model was performed to estimate risk ratio (RR) and mean difference (MD), with a 95% CI, for dichotomous and continuous outcomes, respectively. Results: Our search identified 2195 records. Of these, nine RCTs consisting of 1375 participants were included in the final analyses. Among adults with pulmonary TB, zinc (RR: 0.94, 95% CI: 0.86 to 1.03), vitamin A (RR: 0.90, 95% CI: 0.80 to 1.01) and combined zinc and vitamin A (RR: 0.98, 95% CI: 0.89 to 1.08) supplementation were not significantly associated with TB treatment success. Combined zinc and vitamin A supplementation was significantly associated with increased sputum smear conversion at 2 months (RR: 1.16, 95% CI: 1.03 to 1.32), serum zinc levels at 2 months (MD: 0.86 μmol/L, 95% CI: 0.14 to 1.57), serum retinol levels at 2 months (MD: 0.06 μmol/L, 95% CI: 0.04 to 0.08) and 6 months (MD: 0.12 μmol/L, 95% CI: 0.10 to 0.14) and serum haemoglobin level at 6 months (MD: 0.29 μg/dL, 95% CI: 0.08 to 0.51), among adults with pulmonary TB. Conclusions: Providing zinc and vitamin A supplementation to adults with sputum-positive pulmonary TB during treatment may increase early sputum smear conversion, serum zinc, retinol and haemoglobin levels. However, the use of zinc, vitamin A or both was not associated with TB treatment success

Sequelae of multidrug-resistant tuberculosis: protocol for a systematic review and meta-analysis

Introduction The sequelae of multidrug-resistant tuberculosis (MDR-TB) are poorly understood and inconsistently reported. We will aim to assess the existing evidence for the clinical, psychological, social and economic sequelae of MDR-TB and to assess the health-related quality of life in patients with MDR-TB. Methods and analysis We will perform a systematic review and meta-analysis of published studies reporting sequelae of MDR-TB. We will search PubMed, SCOPUS, ProQuest, Web of Science and PsychINFO databases up to 5 September 2017. MDR-TB sequelae will include any clinical, psychological, social and economic effects as well as health-related quality of life that occur after MDR-TB treatment or illness. Two researchers will screen the titles and abstracts of all citations identified in our search, extract data, and assess the scientific quality using standardised formats. Providing there is appropriate comparability in the studies, we will use a random-effects meta-analysis model to produce pooled estimates of MDR-TB sequelae from the included studies. We will stratify the analyses based on treatment regimen, comorbidities (such as HIV status and diabetes mellitus), previous TB treatment history and study setting

Methods used in the spatial analysis of tuberculosis epidemiology: a systematic review

Background: Tuberculosis (TB) transmission often occurs within a household or community, leading to heterogeneous spatial patterns. However, apparent spatial clustering of TB could reflect ongoing transmission or co-location of risk factors and can vary considerably depending on the type of data available, the analysis methods employed and the dynamics of the underlying population. Thus, we aimed to review methodological approaches used in the spatial analysis of TB burden. Methods: We conducted a systematic literature search of spatial studies of TB published in English using Medline, Embase, PsycInfo, Scopus and Web of Science databases with no date restriction from inception to 15 February 2017. The protocol for this systematic review was prospectively registered with PROSPERO (CRD42016036655). Results: We identified 168 eligible studies with spatial methods used to describe the spatial distribution (n = 154), spatial clusters (n = 73), predictors of spatial patterns (n = 64), the role of congregate settings (n = 3) and the household (n = 2) on TB transmission. Molecular techniques combined with geospatial methods were used by 25 studies to compare the role of transmission to reactivation as a driver of TB spatial distribution, finding that geospatial hotspots are not necessarily areas of recent transmission. Almost all studies used notification data for spatial analysis (161 of 168), although none accounted for undetected cases. The most common data visualisation technique was notification rate mapping, and the use of smoothing techniques was uncommon. Spatial clusters were identified using a range of methods, with the most commonly employed being Kulldorff's spatial scan statistic followed by local Moran's I and Getis and Ord's local Gi(d) tests. In the 11 papers that compared two such methods using a single dataset, the clustering patterns identified were often inconsistent. Classical regression models that did not account for spatial dependence were commonly used to predict spatial TB risk. In all included studies, TB showed a heterogeneous spatial pattern at each geographic resolution level examined. Conclusions: A range of spatial analysis methodologies has been employed in divergent contexts, with all studies demonstrating significant heterogeneity in spatial TB distribution. Future studies are needed to define the optimal method for each context and should account for unreported cases when using notification data where possible. Future studies combining genotypic and geospatial techniques with epidemiologically linked cases have the potential to provide further insights and improve TB control

Comparison of the validity of smear and culture conversion as a prognostic marker of treatment outcome in patients with multidrug-resistant tuberculosis

Background The World Health Organization (WHO) has conditionally recommended the use of sputum smear microscopy and culture examination for the monitoring of multidrug-resistant tuberculosis (MDR-TB) treatment. We aimed to assess and compare the validity of smear and culture conversion at different time points during treatment for MDR-TB, as a prognostic marker for end-of-treatment outcomes. Methods We undertook a retrospective observational cohort study using data obtained from Hunan Chest Hospital, China and Gondar University Hospital, Ethiopia. The sensitivity and specificity of culture and sputum smear conversion for predicting treatment outcomes were analysed using a random-effects generalized linear mixed model. Results A total of 429 bacteriologically confirmed MDR-TB patients with a culture and smear positive result were included. Overall, 345 (80%) patients had a successful treatment outcome, and 84 (20%) patients had poor treatment outcomes. The sensitivity of smear and culture conversion to predict a successful treatment outcome were: 77.9% and 68.9% at 2 months after starting treatment (difference between tests, p = 0.007); 95.9% and 92.7% at 4 months (p = 0.06); 97.4% and 96.2% at 6 months (p = 0.386); and 99.4% and 98.9% at 12 months (p = 0.412), respectively. The specificity of smear and culture non-conversion to predict a poor treatment outcome were: 41.6% and 60.7% at 2 months (p = 0.012); 23.8% and 48.8% at 4 months (p<0.001); and 20.2% and 42.8% at 6 months (p<0.001); and 15.4% and 32.1% (p<0.001) at 12 months, respectively. The sensitivity of culture and smear conversion increased as the month of conversion increased but at the cost of decreased specificity. The optimum time points after conversion to provide the best prognostic marker of a successful treatment outcome were between two and four months after treatment commencement for smear, and between four and six months for culture. The common optimum time point for smear and culture conversion was four months. At this time point, culture conversion (AUROC curve = 0.71) was significantly better than smear conversion (AUROC curve = 0.6) in predicting successful treatment outcomes (p < 0.001). However, the validity of smear conversion (AUROC curve = 0.7) was equivalent to culture conversion (AUROC curve = 0.71) in predicting treatment outcomes when demographic and clinical factors were included in the model. The positive and negative predictive values for smear conversion were: 57.3% and 65.7% at two months, 55.7% and 85.4% at four months, and 55.0% and 88.6% at six months; and for culture conversions it was: 63.7% and 66.2% at two months, 64.4% and 87.1% at four months, and 62.7% and 91.9% at six months, respectively. Conclusions The validity of smear conversion is significantly lower than culture conversion in predicting MDR-TB treatment outcomes. We support the WHO recommendation of using both smear and culture examination rather than smear alone for the monitoring of MDR-TB patients for a better prediction of successful treatment outcomes. The optimum time points to predict a future successful treatment outcome were between two and four months after treatment commencement for sputum smear conversion and between four and six months for culture conversion. The common optimum times for culture and smear conversion together was four months