Table of Content Volume 3 Issue 1 - July 2017

 

A study of alcohol use and abuse among patients with multidrug-resistant tuberculosis reported at urban health centre of tertiary care teaching hospital in Mumbai

 

Raghuveer Chandel¹, Yogita Bavaskar^2*, Mohan Doibale³

 

¹Assistant Professor, ²Assistant Professor, ³Professor and HOD, Department of Community Medicine, Government Medical College, Aurangabad, Maharashtra, INDIA.

 

Abstract               Background: The prevalence of multidrug resistant tuberculosis (MDR-TB) in India, in newly diagnosed cases is 2.1% and in previously treated cases is 13% to 17%. MDR-TB is much more fatal whenever associated with alcohol consumption. Consumption of alcohol worsens the course of MDR-TB due to changes in drug pharmacokinetics. Literature shows alcohol uses to be associated with higher rates of MDR-TB elsewhere in the world. Therefore this study was planned to study how alcohol use is associated with MDR-TB. Objectives: 1. To describe the pattern of alcohol use in MDR-TB patients and 2. To determine whether alcohol use is associated with the development of MDR-TB. Methods: A case control study was conducted in patients attending urban health training center during the period of June to November 2014. A total 76 cases with gene x-pert diagnosis of pulmonary MDR-TB and 76 control group I of patients with confirmed non-MDR pulmonary TB on gene x-pert and 76 control group II, participants from the general population without prior history of TB. To measure alcohol consumption, Alcohol use disorders identification test (AUDIT)-10 questionnaire was used. To find the significant association between different variables and cases, chi square test and Kruskal-Wallis tests were applied. Results: About 34.21% of MDR-TB cases reported alcohol consumption. MDR-TB cases had significantly higher mean scores of different domains of alcohol consumption as per WHO AUDIT-10 score. Alcohol abuse was found to be significantly associated with MDR tuberculosis. Conclusion: The finding of our study stress the fact that alcohol addiction among MDR-TB is unacceptably high that may worsen the cure rate of cases.

Key Words: Alcohol use, Alcohol abuse, MDR Tuberculosis.

 

 

INTRODUCTION

Multidrug-resistant (MDR) TB is TB with resistance to the two most effective anti-tuberculosis drugs, isoniazid and rifampicin. Globally, 5% of TB cases were estimated to have had MDR TB in 2013 (3.5% of new and 20.5% of previously treated TB cases).¹ The actual number of cases may be a lot greater since surveillance for MDR-TB is inadequate because of the lack of laboratory resources around the world for testing drug sensitivity. As India is a developing country, MDR-TB is a growing threat. The World Health Organization (WHO) estimated 650,000 cases of MDR-TB around the world in 2010.² Then in 2012, WHO estimated about 450000 new MDR TB cases.³ In India, the prevalence of MDR-TB in newly diagnosed cases is less than 2.1% and in previously treated cases is 13% to 17%.⁴ It is much more fatal whenever associated with HIV and alcohol consumption etc. In Mumbai reports have shown that there is consistently higher levels of MDR-TB in Mumbai (24%-30% of new cases and 11%-67% of treated cases) than in other parts of India, at (the corresponding figures from other parts of the country are 1%-13% and 12%-40%, respectively).⁵ India is generally regarded as a traditional ‘dry’ or ‘abstaining’ culture. There are many forms of excessive drinking that cause substantial risk or harm to the individual.. Another clinical reason for a worsened course of MDR TB in heavy drinkers is the changes of drug pharmacokinetics.⁶ Literature also shows these alcohol uses to be the ones associated with higher rates of MDR-TB elsewhere in the world.^7,8 Given the huge burden of TB in India and the consequences of imbibing alcohol while on treatment, this is a matter of rising concern and has to be addressed by the healthcare providers targeting TB in India. It is thus important to look at the other social risk factors for MDR-TB because they help us better understand the behaviors of individuals that lead to the disease and how these behaviors can be altered.⁹ Therefore, it is necessary to study how alcohol use is associated with MDR-TB. Such studies would help to determine associations between MDR-TB and some of its social and behavioral risk factors mainly alcohol use. As India is a developing country with high prevalence of alcohol consumption and MDR-TB, study on ‘Association between alcohol consumption and MDR-TB’ would be crucial for control of MDR-TB and may suggest modifications in control strategies of MDR-TB. Therefore this study was planned to study alcohol use and abuse among patients with multidrug-resistant tuberculosis (MDR-TB) reported at urban health centre of Lokmanya Tilak municipal Medical College, Mumbai.

MATERIALS AND METHODS

Study Design: A case control study was carried out in the Urban Health Centre of Lokmanya Tilak Muncipal Medical College and General Hospital, Mumbai (which is teriary care teaching hospital) during June 2014 to November 2014. Cases were patients with Gene xpert diagnosis of pulmonary MDR-TB. To better control for potential, not measurable, confounders, two different control groups were selected: 1) control group I, patients with confirmed non-MDR pulmonary TB on Gene xpert. 2) Control group II, participants from the general population without prior history of TB. Urban Health Center is 126 bedded hospital having both Inpatient department and Outpatient department. It has DOTs center with Gene Xpert (CBNAAT-Cartridge Based Nuclei Acid Amplification Test) machine for MDR-TB cases.

Sampling method

Sample size calculation¹⁰

n = z1-a/2 {1 /[P1( 1 –P1)] + 1 /[P1(1- P1)]} /[loge(1- e)2 =76 Cases + 76 Controls

Two-sided confidence level (1-alpha) = 95; Power (% chance of detecting) = 80

Ratio of Controls to Cases=2; Proportion of cases with exposure=6.6*

Least extreme Odds Ratio to be detected: = 5.00

Sample Size – Cases- 76; Sample Size – Controls -152

Total sample size:-228; Thus, in this study total 228 patients were included.

*The figure of 6.6 was derived after conducting pilot study among 15 MDR-TB subjects.

Matching: All the MDR-TB cases were matched with controls for following variables viz. Geographical area, gender, religion, socio-economic status, and type of family etc

Sampling Unit: Sampling unit was “individual”

Sampling technique: DOTS center is run on daily basis at Urban Health Center. Number of registration of new MDR-TB patients at the center was 1-2 and follow-up MDR-TB cases were 3-4 per day. All these cases were approached for interview purpose after obtaining verbal consent. Thus, over a period of two months sample of 76 cases was covered. Those with negative report of CB-NAAT were labelled as TB. All these cases were approached for interview purpose after obtaining verbal consent. Thus, over a period of another two months sample of 76 controls was covered. For getting controls from general population, visit to OPDs ward was done at Urban Health Center. Patients and their relatives were asked about history of cardinal feature of TB viz. cough >15 days, loss of appetite, loss of weight and evening rise of temperature. They were asked past history of Tuberculosis. The person answering ‘No’ for all questions was labelled as ‘having no tuberculosis’ and were included in the study as a control from general population. To measure alcohol consumption, Alcohol Use Disorders Identification Test (AUDIT)-10 questionnaires was used. We used a cut-off score of ⩾8 to define heavy drinking. Those who were addicted were classified as per WHO AUDIT score. Alcohol status of cases and controls was asked by using WHO AUDIT-10 questionnaire. The questionnaire consists of ten questions which were asked in face to face interview. The AUDIT’s-10 questions cover the three conceptual domains of consumption, dependence symptoms and alcohol-related consequences that are intended to parallel the World Health Organization concepts of hazardous drinking, alcohol dependence and alcohol related harm. Addicted subjects were referred to deaddiction center at Urban Health Center which runs every Wednesday and Saturday. Those who needed higher care were referred to specialty center at tertiary center. Institutional ethics committee permission was taken prior to initiation of study.

 

 

 

 

Data Analysis

Data was analyzed using SPSS software 23 version, Open Epi Software Version 3.3, Microsoft Excel 2013. Data was compiled, tabulated, and mean and proportions were calculated. To find the significant association between different variables and cases, chi square test, Kruskal-Wallis test, Independent t test were applied whenever necessary.

RESULTS

The present study included 228 subjects of which 76 were cases and 152 controls (two control groups) viz; control TB and control general population includes 76 subjects each.

 

Table 1: Socio-demographic Profile of MDR-TB cases and control groups

 

 

 

As seen in Table 1 that the mean age of patients were 32.61 ±13.05 yrs and 30.16 ±7.06 yrs in male and female subjects respectively. Out of 228 study subject 127(55.7%) were males and 101(44.29%) were females. Majority of population were Hindu 118(51.75%) followed by Muslim 101(44.2%) and very few were Christian 9(3.9%). The study subjects were mostly belonging to Nuclear family 158(69.29%) followed by Joint family 69(30.26%), only one were from third generation family. Majority (70.17%) were from poor or lower middle socio-economic class. In MDR-TB and TB study subjects were both single and married whereas married subjects were more in general population (81.60%). Most of the study subjects had education up to high school or middle school. Most of the MDR-TB and TB subjects had unskilled occupation and were students, whereas most of the controls were housewife (28.90%), skilled (31.60%) and unskilled jobs (28.90%).

 

Table 2: Addiction among study population (n=76)

As seen in Table 2 that 34(44.73%) out of 76 MDR-TB cases were having addiction to alcohol, tobacco or any other thing. Addiction was relatively more common in control general population. Among MDR-TB cases with addiction, alcohol consumption (34.21%) was more common. On the other side, tobacco addiction was more common in both control groups.

Table 3: Pattern of alcohol use in study population (n=69)

Mean score of each domain of alcoholism for three groups were shown in Table 3. Out of 228 study participants, 69(30.2%) gave history of alcohol addiction. Difference between mean scores of all alcohol domains was highly significant.

 

 

 

Table 4: Association of alcohol addiction and MDR-TB

χ2-value =38.038, df=2, p=0.000 (<0.05)

 

It was seen from Table 4 that the data of AUDIT score showed a skewed distribution so a non-parametric test like Kruskal-Wallis test was applied to see the difference. As the computed value was greater than the table value, the mean AUDIT score of three groups (MDR-TB, TB controls, and General population) differ significantly. Alcohol abuse was found to be significantly associated with MDR tuberculosis. On looking at the mean of these three groups, we found mean AUDIT score of TB and general population was comparable but mean of MDR-TB was apparently highest among the groups.

 

DISCUSSION

Multi-drug-resistant tuberculosis (MDR-TB) though not a new problem, has gained a global attention due to its outbreak in immune-compromised as well as in non-immune compromised patients.

Socio-demographic Profile

Out of total of 228 study subjects in the present study, majority were in between 21 to 40 yrs age group, very few were from pediatric and elderly group. The socio-demographic factors like gender, religion, type of family and socio-economic status of all subjects were matched for the purpose of comparability. Most of the study participants were male and belonging to Hindu religion. Majority of them were poor and it is not surprising because the study area was slum. More than half of the study participants had nuclear type of family. It is obvious because of high cost plus small residential area available in the urban slum. Similarly many Indian studies have demonstrated same demographic characteristics.^11-14 Considerable proportion of MDR-TB and TB cases was ummarried. It may be because this diseased people are getting low preference for marriage. In general, people are afraid of developing tuberculosis and would like to stay away from the cases. One of the unfortunate finding of this study was high proportion of MDR-TB and TB cases were students with questionable continuation of their education. Negligible proportion of MDR-TB cases had skilled jobs. Poor health and low education of MDR-TB case might be a common hurdle for getting selected for skilled jobs.

Pattern of alcohol use

In the present study, though MDR-TB cases showed overall low addictions, but alcohol consumption was high. Similarly many Indian studies have demonstrated high prevalence of alcohol addiction (16.8% to 21.4%).^11-15 MDR-TB cases had significantly higher mean scores of different domains of alcohol consumption as per WHO AUDIT-10 score. Similarly study done by Zetola NM et al⁸ in Botwana Russia applied AUDIT score among MDR-TB patients and found higher scores as is evident in the present study. Alcohol use by TB patients has been studied by various researchers. Suhadev M et al¹⁶ in their study reported 52% of the tuberculosis patients scoring greater than 8 on the AUDIT score. Studies by Peltzer K et al¹⁷ in South Africa and Shin S et al¹⁸ in Russia observed high AUDIT score value in different domains of alcohol consumption. Our study demonstrates hazardous drinking among MDR-TB patients. Likewise Millar A et al¹⁹ in his study, alcohol use during treatment was negatively associated with favourable outcome (p<0.001), and positively associated with death (p<0.0001) and default of MDR-TB cases (p<0.05). Study by Shin S et al¹⁸ also concluded that alcohol use was significantly associated with poor treatment outcome of TB. The relationship between alcohol use and drug resistance in TB has been already confirmed by various researchers also.^7,8,9

 

CONCLUSION

The present study concluded that the alcohol addiction among MDR-TB was unacceptably high that may worsen the cure rate of cases. Considering the threat of XDR-TB, defaulters and deaths, study would like to suggest some strategies, primary health workers like MPW, ANM etc. should be trained to detect TB/MDR-TB cases having alcohol history and refer them to de-addiction center. IEC exhibition with strong and catchy messages on ‘Alcohol addictions’ at different OPDs especially DOTS center of hospital would help in creating awareness. Health education is an effective tool that brings significant behavioural changes in community.

 

REFERENCES