Multidrug-resistant tuberculosis surveillance and cascade of care in Madagascar: a five-year (2012-2017) retrospective study

Abstract

Background: In Madagascar, the multidrug-resistant tuberculosis (MDR-TB) surveillance programme was launched in late 2012 wherein previously treated TB cases and symptomatic MDR-TB contacts (hereafter called presumptive MDR-TB cases) undergo drug susceptibility testing. This retrospective review had per aim to provide an update on the national MDR-TB epidemiology, assess and enhance programmatic performance and assess Madagascar's MDR-TB cascade of care.

Methods: For 2012-2017, national TB control programme notification, clinical management data and reference laboratory data were gathered. The development and coverage of the surveillance programme, the MDR-TB epidemiology and programmatic performance indicators were assessed using descriptive, logistic and spatial statistical analyses. Data for 2017 was further used to map Madagascar's TB and MDR-TB cascade of care.

Results: The geographical coverage and diagnostic and referral capacities of the MDR-TB surveillance programme were gradually expanded whereas regional variations persist with regard to coverage, referral rates and sample referral delays. Overall, the rate of MDR-TB among presumptive MDR-TB cases remained relatively stable, ranging between 3.9% in 2013 and 4.4% in 2017. Most MDR-TB patients were lost in the second gap of the cascade pertaining to MDR-TB cases reaching diagnostic centres but failing to be accurately diagnosed (59.0%). This poor success in diagnosis of MDR-TB is due to both the current use of low-sensitivity smear microscopy as a first-line diagnostic assay for TB and the limited access to any form of drug susceptibility testing. Presumptive MDR-TB patients' sample referral took a mean delay of 28 days before testing. Seventy-five percent of diagnosed MDR-TB patients were appropriately initiated on treatment, and 33% reached long-term recurrence-free survival.

Conclusions: An expansion of the coverage and strengthening of MDR-TB diagnostic and management capacities are indicated across all regions of Madagascar. With current limitations, the surveillance programme data is likely to underestimate the true MDR-TB burden in the country and an updated national MDR-TB prevalence survey is warranted. In absence of multiple drivers of an MDR-TB epidemic, including high MDR-TB rates, high HIV infection rates and inter-country migration, Madagascar is in a favourable starting position for MDR-TB control and elimination.

Keywords: Cascade of care; Drug susceptibility testing; Epidemiology; Madagascar; Multidrug-resistant tuberculosis; Surveillance.

Fig. 1

Development of MDR-TB surveillance programme infrastructures and referral rates of presumptive MDR-TB patients, MDR-TB surveillance programme, Madagascar, 2012–2017. a 2012. b 2013. c 2014. d 2015. e 2016. f 2017

Fig. 2

Absolute number of indicated and referred presumptive MDR-TB cases and associated referral rate, MDR-TB surveillance programme, Madagascar, 2012–2017

Fig. 3

Sample referral delays, MDR-TB surveillance programme, Madagascar, 2012–2017

Fig. 4

Diagnosed rifampicin monoresistance, isoniazid monoresistance and multidrug-resistance, MDR-TB surveillance programme, Madagascar, 2012–2017

Fig. 5

Geographic distribution of MDR-TB cases per region, MDR-TB surveillance programme, Madagascar, 2012–2017. a Referral rates of presumptive MDR-TB cases. b MDR-TB patients’ absolute numbers. c MDR-TB incidence rate per 100,000 population

Fig. 6

Cascade of care, Madagascar, 2017. a TB all forms. b Presumptive MDR-TB cases. c MDR-TB patients. Percentage represent the amount of patients lost at every gap of the cascade of care (e.g. 17% of prevalent cases of TB all forms do not reach diagnostic and treatment centres and 26% of patients reaching diagnostic and treatment centres are not diagnosed)