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Community- vs. hospital-based management of multidrug-resistant TB in Pakistan

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BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18–24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.

METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.

RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI –0.02 to 0.15; P = 0.144).

CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.

Keywords: Pakistan; ambulatory; community-based; hospital-based management; multidrug-resistant; tuberculosis

Document Type: Research Article

Affiliations: 1: Common Management Unit (TB, HIV/AIDS and Malaria), Islamabad, Pakistan 2: Common Management Unit (TB, HIV/AIDS and Malaria), Islamabad, Pakistan, University of Bergen, Bergen, Norway 3: Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan 4: Association for Social Development, Islamabad, Pakistan 5: National TB Control Program, Islamabad, Pakistan 6: University of Bergen, Bergen, Norway, National TB Control Program, Islamabad, Pakistan 7: Ojha Institute of Chest Diseases, Karachi, Pakistan 8: Gulab Devi Chest Hospital, Lahore, Pakistan 9: TB Samli Sanatorium Hospital, Murree, Pakistan 10: National Institute of Health, Islamabad, Pakistan 11: Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, UK

Publication date: October 1, 2022

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