Determinants of multidrug‐resistant tuberculosis in São Paulo—Brazil: a multilevel Bayesian analysis of factors associated with individual, community and access to health services

Objective Multidrug‐resistant tuberculosis (MDR‐TB) remains a serious public health problem worldwide. Accordingly, this study sought to identify individual, community and access to health services risk factors for MDR‐TB. Methods Retrospective cohort of all TB cases diagnosed between 2006 and 2016 in the state of São Paulo. A Bayesian spatial hierarchical analysis with a multilevel design was carried out. Results It was identified that the history of previous TB treatment (Odds Ratios [OR]:13.86, 95% credibility interval [95% CI]:12.06–15.93), positive sputum culture test (OR: 5.26, 95% CI: 4.44–6.23), diabetes mellitus (OR: 2.34, 95% CI: 1.87–2.91), residing at a standard address (OR: 2.62, 95% CI: 1.91–3.60), positive sputum smear microscopy (OR: 1.74, 95% CI: 1.44–2.12), cavitary pulmonary TB (OR: 1.35, 95% CI: 1.14–1.60) and diagnosis performed due to spontaneous request (OR: 1.26; 95% CI: 1.10–1.46) were associated with MDR‐TB. Furthermore, municipalities that performed HIV tests in less than 42.65% of patients with TB (OR: 1.50, 95% CI: 1.25–1.79), that diagnosed TB cases only after death (OR: 1.50, 95% CI: 1.17–1.93) and that had more than 20.16% of their population with income between ¼ and ½ of one minimum wage (OR: 1.56, 95% CI: 1.30–1.87) were also related to the MDR‐TB. Conclusions Knowledge of these predictive factors may help to develop more comprehensive disease prevention strategies for MDR‐TB, avoiding the risks expressed regarding drug resistance expansion. Objectif La tuberculose multirésistante (TB‐MDR) reste un grave problème de santé publique dans le monde. Cette étude visait à identifier les facteurs de risque individuels, communautaires et d'accès aux services de santé pour la TB‐MDR. Méthodes Analyse de cohorte rétrospective de tous les cas de TB diagnostiqués entre 2006 et 2016 dans l'Etat de São Paulo par analyse bayésienne spatiale à plusieurs niveaux. Résultats Les antécédents de traitements antituberculeux (Rapports de cotes [OR]: 13,86, Intervalle de confiance à 95% [IC95%]: 12.06‐15.93), un test de culture d'expectorations positif (OR: 5,26, IC95%: 4,44‐6,23), le diabète sucré (OR: 2,34, IC95%: 1,87‐2,91), la résidence à une adresse standard (OR: 2,62, IC95%: 1,91‐3,60), la microscopie à frottis positif (OR: 1,74, IC95%: 1,44‐2,12), la TB pulmonaire (OR: 1,35, IC95%: 1,14‐1,60) et le diagnostic réalisé en raison d'une demande spontanée (OR: 1,26; IC95%: 1,10‐1,46) étaient associés à la TB‐MDR. Les municipalités qui ont effe