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The Situation of The Situation of Multidrug-Resistant Multidrug-Resistant

Tuberculosis in TurkeyTuberculosis in Turkey

Dr. Serir Aktoğu ÖzkanDr. Serir Aktoğu ÖzkanIzmir Training Hospital for Izmir Training Hospital for

Thoracic Diseases and SurgeryThoracic Diseases and Surgery

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ContributorsContributors Dr. Kemal TahaoğluDr. Kemal Tahaoğlu Dr. Turan KaragözDr. Turan Karagöz Dr. Şeref ÖzkaraDr. Şeref Özkara Dr. Haluk Celalettin ÇalışırDr. Haluk Celalettin Çalışır Dr. Emel ÇağlarDr. Emel Çağlar Dr. Özlen TümerDr. Özlen Tümer Dr. Seren Arpaz Dr. Seren Arpaz Dr. Tülay TörünDr. Tülay Törün Dr. Gönenç OrtaköylüDr. Gönenç Ortaköylü Dr. Onur Fevzi ErerDr. Onur Fevzi Erer

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Drug Resistance in IstanbulDrug Resistance in IstanbulDrug Resistance in IstanbulDrug Resistance in IstanbulNo drug resistance survey in Turkey No drug resistance survey in Turkey

Results from Central Laboratory of Istanbul Society Results from Central Laboratory of Istanbul Society Against Tuberculosis ,1999Against Tuberculosis ,1999

New New CasesCases

%% Old Old casescases

%%

Resist. to at Resist. to at least one least one

drugdrug

209209 19.919.9 131131 40.440.4

MDRMDR 3333 3.13.1 6060 18.518.5

TotalTotal 10461046 100100 324324 100100

Z.Kılıçaslan Eur J Clin Microbiol Infect Dis ,2002

6.1

5

2 3 4,1

28

18 17,1

0

10

20

30

1989-92 1999 2004

%

Primer MDR-TB Sekonder MDR-TB

Primary and Secondary MDR-TB in Istanbul, 1990-2004

1. New case: 315 Old case: 222- IUATLD 1994 2. New case : 1046 Old case: 324)- .Eur J Clin Microbiol Infect Dis 2002 3 New case. : 1614 Old case: : 251 Toraks 2006

(1) (2) (3)

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The Multidrug resistance rates in The Multidrug resistance rates in Izmir Chest Diseases HospitalIzmir Chest Diseases Hospital

19991999 20012001

No of patientsNo of patients

No of culturesNo of cultures980980

11 13211 13210061006

11 06911 069

Culture (+) Culture (+) samplessamples

420420 653653

MDR TBMDR TB 65 65 (6.6%)(6.6%) 58 58 (5.8%)(5.8%)

G. Şenol Journal of Infection 2005; 50: 306-11

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Several studies reporting MDR TB Several studies reporting MDR TB rates in Turkeyrates in Turkey

DateDate Author/Author/

LocalizatiLocalizationon

PatiePatient nt

NoNo

MDR TBMDR TB

New Old New Old TotalTotal

1972-1972-19991999

Kart et alKart et al

ZonguldaZonguldakk

KayseriKayseri

37183718 6.9 %6.9 %

107107

1976-1976-19971997

BengisunBengisun

AnkaraAnkara33193319

5.8 %5.8 %

194194

1999-1999-20012001

GüneriGüneri

İzmirİzmir474474 4.4 % 17.2 % 4.4 % 17.2 %

6.8 %6.8 %

17 15 17 15 3232

1997-1997-20032003

SürücüoğSürücüoğlulu

ManisaManisa

355355 4.4 % 22.4 % 4.4 % 22.4 % 7.37.3

2626

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Süreyyapaşa Chest Diseases Hospital Süreyyapaşa Chest Diseases Hospital January- December 2004January- December 2004

Totally 530 TB PatientsTotally 530 TB Patients Sputum culture positive 333 patientsSputum culture positive 333 patients 39 (11.7 %)39 (11.7 %) patients with MDR (HR patients with MDR (HR

resistance)resistance)

CuredCured DefauDefaultlt

FailedFailed DiedDied TotalTotal

NewNew 1818 00 00 11 1919

OldOld 1010 22 88 00 2020

Dr. Haluk Celalettin Çalışır Toraks 2006

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4 Centers for MDR-TB in Turkey

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Atatürk Chest Diseases HospitalAtatürk Chest Diseases Hospital

Bed numberBed number 550550 TB bed number:TB bed number: 150 150 Number of hospitalized TB patients /year: 1500Number of hospitalized TB patients /year: 1500 The treatment of MDR-TB has been done since 1991The treatment of MDR-TB has been done since 1991 Drug susceptibilty test can be done in every patientDrug susceptibilty test can be done in every patient After evaluating for compliance, the patients are After evaluating for compliance, the patients are

treated with minör anti tb drugstreated with minör anti tb drugs There is no data regarding treatment resultsThere is no data regarding treatment results

Dr. Şeref ÖzkaraDr. Şeref Özkara

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Izmir Chest Diseases HospitalIzmir Chest Diseases Hospital

Bed number:Bed number: 450 450 (2005)(2005)

TB bed number:TB bed number: 7878 Number of hospitalized patient: Number of hospitalized patient: 16 88416 884 Number of hospitalized TB patient:Number of hospitalized TB patient: 770770 The treatment of MDR-TB has been done The treatment of MDR-TB has been done

since 1998since 1998 270 patients with MDR TB were treated until 270 patients with MDR TB were treated until

December 2005December 2005

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Treatment results of 61 Treatment results of 61 patients with MDR-TB in Izmir patients with MDR-TB in Izmir

Chest Diseases HospitalChest Diseases HospitalPatient NoPatient No %%

CuredCured 2222 3636

CompletedCompleted 99 1515

DefaultDefault 99 1515

FailedFailed 11

DiedDied 1313 2121

TransferredTransferred 22

Lost at followupLost at followup 55

TotalTotal 6161

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Treatment resultsTreatment results of MDR-TB 1998-of MDR-TB 1998-20052005

Case Case numbernumber

%% DOT(+DOT(+))

DOT(-)DOT(-)

CuredCured 66 7575 33 33

DiedDied 22 2525 11 11

treatmtreatmentent

22 22

Nazilli Dispensary

CuredCured 33 100100 33

treatmtreatmentent

Aydın Dispensary

Dr. Seren Arpaz

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ISTANBULPopulation: 12-15 millionPoverty, migration, inequality, insufficient infrastructure2 centers for TB

Marmara Sea

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Yedikule Chest Diseases HospitalYedikule Chest Diseases HospitalMDR-TB 2001-2005MDR-TB 2001-2005

Bed number : 408 Bed number : 408 (2005) (2005) Number of hospitalized patient: Number of hospitalized patient: 10 533 10 533 (2005)(2005) Number of hospitalized TB patient:Number of hospitalized TB patient: 1 697 1 697 (2005)(2005) Mean hospitalization time of TB patients:Mean hospitalization time of TB patients: 23 days 23 days MDR-TB patients were treated related to the MDR-TB patients were treated related to the

orders of The Committee of Resistance since orders of The Committee of Resistance since 20012001

Treatment results of 178 patients with MDR-Treatment results of 178 patients with MDR-TB are available in the period of 2001-2005 TB are available in the period of 2001-2005

Dr. Emel Çağlar, Dr. Gönenç OrtaköylüDr. Emel Çağlar, Dr. Gönenç Ortaköylü

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Characteristics of patients with MDR-TB Characteristics of patients with MDR-TB in Yedikule Chest Diseases Hospital in Yedikule Chest Diseases Hospital

(2001-2005) N= 178(2001-2005) N= 178

AgeAge 38 (17-66)38 (17-66)

Sex (Male/Female)Sex (Male/Female) 166/12166/12

Median no. of drugs Median no. of drugs previously usedpreviously used

4.64.6

Median no. of Median no. of resistant drugresistant drug

3.13.1

Median no. of drugs Median no. of drugs used in study used in study regimen regimen

5.95.9

SurgerySurgery 19 (%10)19 (%10)

Median Median hospitalization hospitalization

71.8 day71.8 dayDr. Emel Çağlar, Dr. Gönenç Dr. Emel Çağlar, Dr. Gönenç OrtaköylüOrtaköylü

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Characteristics of patients with Characteristics of patients with MDR-TB in Yedikule Chest MDR-TB in Yedikule Chest

Diseases Hospital Diseases Hospital (2001-2005) N= 178(2001-2005) N= 178

Treatment successTreatment success 116 (%65.2)116 (%65.2)

CuredCured 68 (%38.2)68 (%38.2)

Probable curedProbable cured 48 (%27)48 (%27)

FailedFailed 9 (%5.1)9 (%5.1)

DefaultDefault 16 (%9)16 (%9)

TransferredTransferred 3 (%1.7)3 (%1.7)

DiedDied 16 (%9)16 (%9)

Dr. Emel Çağlar, Dr. Gönenç Dr. Emel Çağlar, Dr. Gönenç OrtaköylüOrtaköylü

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Süreyyapaşa Chest Diseases Süreyyapaşa Chest Diseases

HospitalHospital

Bed number : Bed number : 1020 1020 Number of hospitalized patients /year: 16 000Number of hospitalized patients /year: 16 000 Number of hospitalized TB patients /year: 2 500Number of hospitalized TB patients /year: 2 500 Treatment of MDR-TB has been done since 1992Treatment of MDR-TB has been done since 1992 Second-line drugs have been provided by Social Second-line drugs have been provided by Social

Security SystemSecurity System The patients with MDR-TB could be hospitalized for The patients with MDR-TB could be hospitalized for

long period and default rate was lowlong period and default rate was low

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Süreyyapaşa Chest Diseases HospitalSüreyyapaşa Chest Diseases Hospital 1992 – 2004 MDR-TB1992 – 2004 MDR-TB

No of patientsNo of patients 252252

Age (yr)Age (yr) 37.9 (14 - 68) 37.9 (14 - 68)

SexSex

MaleMale

FemaleFemale204 (%81)204 (%81)

48 (%19)48 (%19)

Duration of disease (mo)Duration of disease (mo) 75.6 (0-416)75.6 (0-416)

Primary resistancePrimary resistance

Secondary resistanceSecondary resistance60 (%23.8)60 (%23.8)

192 (%76.2)192 (%76.2)

“The Treatment of MDR-TB in Turkey”

K. Tahaoğlu et al. N Eng J Med, 2001

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Süreyyapaşa Chest Diseases HospitalSüreyyapaşa Chest Diseases Hospital 1992 – 1992 – 2004 MDR-TB2004 MDR-TB

Drug resistanceDrug resistance 4.1 (4 - 9)4.1 (4 - 9)

Median no of drugs used in Median no of drugs used in

study regimenstudy regimen 5.4 (3 – 9)5.4 (3 – 9)

Median no of active drugsMedian no of active drugs 4.5 (1 – 8)4.5 (1 – 8)The mean duration of The mean duration of hospitalization (day)hospitalization (day)

179 (30 - 450)179 (30 - 450)

SurgerySurgery 66 (%26.2)66 (%26.2)

K. Tahaoğlu et al. N Eng J Med, 2001

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Süreyyapaşa Chest Diseases HospitalSüreyyapaşa Chest Diseases Hospital 1992 – 2004 MDR-TB1992 – 2004 MDR-TBTreatment ResultsTreatment Results

CuredCured 176 (%70)176 (%70)

Probable curedProbable cured 17 (%7)17 (%7)

FailedFailed 16 (%6)16 (%6)

DiedDied 18 (%7)18 (%7)

DefaultDefault 25 (%10)25 (%10)

RelapseRelapse 3 (%1)3 (%1)

K. Tahaoğlu et al. N Eng J Med, 2001

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Süreyyapaşa Chest Diseases Süreyyapaşa Chest Diseases

HospitalHospital 1994 – 2000 MDR-TB1994 – 2000 MDR-TB

No of patientsNo of patients 142142

Age 8yr)Age 8yr) 39 (16 - 65) 39 (16 - 65)

SexSex

MaleMale 142142

Duration of disease (mo)Duration of disease (mo) 93.6(1-420)93.6(1-420)

Primary resistancePrimary resistance

Secondary resistanceSecondary resistance21 (%15)21 (%15)

12 (%85)12 (%85)

Dr. Turan Karagöz

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Süreyyapaşa Chest Diseases HospitalSüreyyapaşa Chest Diseases Hospital 1994 – 1994 – 2000 MDR-TB2000 MDR-TB

Drug resistanceDrug resistance 3.8 (2 - 7)3.8 (2 - 7)

Median no of drugs used in Median no of drugs used in study regimenstudy regimen

5.4 (3 – 8)5.4 (3 – 8)

The mean duration of The mean duration of hospitalization (day)hospitalization (day)

261(68- 978)261(68- 978)

Surgery Surgery 34 (%24)34 (%24)

Dr. Turan Karagöz

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Süreyyapaşa Chest Diseases HospitalSüreyyapaşa Chest Diseases Hospital 1994 – 2000 MDR-TB1994 – 2000 MDR-TB

CuredCured 99 (%70)99 (%70)

FailedFailed 9 (%6)9 (%6)

DiedDied 19 (%13)19 (%13)

DefaultDefault 15 (%11)15 (%11)

RelapseRelapse --

Dr. Turan Karagöz

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Süreyyapaşa Chest Diseases HospitalSüreyyapaşa Chest Diseases Hospital 2000- 2004 MDR-TB2000- 2004 MDR-TB

No of patientsNo of patients 9696

Age (yr)Age (yr) 40 (14 - 66) 40 (14 - 66)

SexSex

MaleMale

FemaleFemale 77 (%80.3)77 (%80.3)

19 (%19.7)19 (%19.7)

Primary resistancePrimary resistance

Secondary resistanceSecondary resistance42 (%56.3)42 (%56.3)

54 (%43.7)54 (%43.7)

Dr. Turan Karagöz

238

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Süreyyapaşa Chest Diseases HospitalSüreyyapaşa Chest Diseases Hospital , ,2000- 2004 MDR-TB Treatment Results2000- 2004 MDR-TB Treatment Results

CuredCured 88 (%92)88 (%92)

Probable curedProbable cured --

FailedFailed 4 (%4)4 (%4)

DiedDied 3 (%3)3 (%3)

DefaultDefault 1 (%1)1 (%1)

Dr. Turan Karagöz

%70

%6%13%11

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Heybeliada Göğüs Hastalıkları ve Heybeliada Göğüs Hastalıkları ve Göğüs Cerrahi Merkezi E.A.H.Göğüs Cerrahi Merkezi E.A.H.

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Heybeliada Chest Diseases HospitalHeybeliada Chest Diseases Hospital

297 patients with MDR-TB was treated 297 patients with MDR-TB was treated related to the orders of The Committee of related to the orders of The Committee of Resistance between December 1996-Resistance between December 1996-December 2004. Treatment was December 2004. Treatment was completed in 228 patients. Surgery was completed in 228 patients. Surgery was done in 46 patients.done in 46 patients.

Diagnosis was based on BACTEC method Diagnosis was based on BACTEC method and susceptibility tests. and susceptibility tests.

At least five new drugs were used:At least five new drugs were used: Aminoglycoside(minumum 6 mo) Aminoglycoside(minumum 6 mo)

+quinolones+ +quinolones+ protionamide+cycloserine+PASprotionamide+cycloserine+PAS

Dr.M.Kurutepe,A.Saygı,A.Hazar,G.Yurteri

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Treatment results of 228 Treatment results of 228 patients with MDR-TB in patients with MDR-TB in

Heybeliada Chest Hospital, Heybeliada Chest Hospital, IstanbulIstanbul

TotalTotal %%

CuredCured 154154 6868

FailedFailed 55 22

DefaultDefault 6060 2626

DeathDeath 99 44

TotalTotal 228228 100100

2 cases relapsed after cure

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Last CommentsLast Comments

Insufficient registry and reporting systemInsufficient registry and reporting system There are a lot of problems in terms of diagnosis There are a lot of problems in terms of diagnosis

of MDR-TB (over diagnosis or insufficient of MDR-TB (over diagnosis or insufficient diagnosis)diagnosis)

There are a lot of problems in management of There are a lot of problems in management of patients with MDR-TBpatients with MDR-TB

Therapy is not directly observedTherapy is not directly observed Insufficient using bacteriologic methods during Insufficient using bacteriologic methods during

followupfollowup Cure rates are low in some centersCure rates are low in some centers There is potential to solve this problem in TurkeyThere is potential to solve this problem in Turkey