The emerging threat of pre-extensively drug-resistant tuberculosis in West Africa: preparing for large-scale tuberculosis research and drug resistance surveillance
Identifieur interne : 000102 ( Pmc/Corpus ); précédent : 000101; suivant : 000103The emerging threat of pre-extensively drug-resistant tuberculosis in West Africa: preparing for large-scale tuberculosis research and drug resistance surveillance
Auteurs : Florian Gehre ; Jacob Otu ; Lindsay Kendall ; Audrey Forson ; Awewura Kwara ; Samuel Kudzawu ; Aderemi O. Kehinde ; Oludele Adebiyi ; Kayode Salako ; Ignatius Baldeh ; Aisha Jallow ; Mamadou Jallow ; Anoumou Dagnra ; Kodjo Dissé ; Essosimna A. Kadanga ; Emmanuel Oni Idigbe ; Catherine Onubogu ; Nneka Onyejepu ; Aissatou Gaye-Diallo ; Awa Ba-Diallo ; Paulo Rabna ; Morto Mane ; Moumine Sanogo ; Bassirou Diarra ; Zingue Dezemon ; Adama Sanou ; Madikay Senghore ; Brenda A. Kwambana-Adams ; Edward Demba ; Tutty Faal-Jawara ; Samrat Kumar ; Leopold D. Tientcheu ; Adama Jallow ; Samba Ceesay ; Ifedayo Adetifa ; Assan Jaye ; Mark J. Pallen ; Umberto D Lessandro ; Beate Kampmann ; Richard A. Adegbola ; Souleymane Mboup ; Tumani Corrah ; Bouke C. De Jong ; Martin AntonioSource :
- BMC Medicine [ 1741-7015 ] ; 2016.
Abstract
Drug-resistant tuberculosis (TB) is a global public health problem. Adequate management requires baseline drug-resistance prevalence data. In West Africa, due to a poor laboratory infrastructure and inadequate capacity, such data are scarce. Therefore, the true extent of drug-resistant TB was hitherto undetermined. In 2008, a new research network, the West African Network of Excellence for Tuberculosis, AIDS and Malaria (WANETAM), was founded, comprising nine study sites from eight West African countries (Burkina Faso, The Gambia, Ghana, Guinea-Bissau, Mali, Nigeria, Senegal and Togo). The goal was to establish Good Clinical Laboratory Practice (GCLP) principles and build capacity in standardised smear microscopy and mycobacterial culture across partnering laboratories to generate the first comprehensive West African drug-resistance data.
Following GCLP and laboratory training sessions, TB isolates were collected at sentinel referral sites between 2009–2013 and tested for first- and second-line drug resistance.
From the analysis of 974 isolates, an unexpectedly high prevalence of multi-drug-resistant (MDR) strains was found in new (6 %) and retreatment patients (35 %) across all sentinel sites, with the highest prevalence amongst retreatment patients in Bamako, Mali (59 %) and the two Nigerian sites in Ibadan and Lagos (39 % and 66 %). In Lagos, MDR is already spreading actively amongst 32 % of new patients. Pre-extensively drug-resistant (pre-XDR) isolates are present in all sites, with Ghana showing the highest proportion (35 % of MDR). In Ghana and Togo, pre-XDR isolates are circulating amongst new patients.
West African drug-resistance prevalence poses a previously underestimated, yet serious public health threat, and our estimates obtained differ significantly from previous World Health Organisation (WHO) estimates. Therefore, our data are reshaping current concepts and are essential in informing WHO and public health strategists to implement urgently needed surveillance and control interventions in West Africa.
Url:
DOI: 10.1186/s12916-016-0704-5
PubMed: 27806714
PubMed Central: 5094099
Links to Exploration step
PMC:5094099Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">The emerging threat of pre-extensively drug-resistant tuberculosis in West Africa: preparing for large-scale tuberculosis research and drug resistance surveillance</title><author><name sortKey="Gehre, Florian" sort="Gehre, Florian" uniqKey="Gehre F" first="Florian" last="Gehre">Florian Gehre</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff19">Institute of Tropical Medicine, Antwerp, Belgium</nlm:aff></affiliation></author><author><name sortKey="Otu, Jacob" sort="Otu, Jacob" uniqKey="Otu J" first="Jacob" last="Otu">Jacob Otu</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Kendall, Lindsay" sort="Kendall, Lindsay" uniqKey="Kendall L" first="Lindsay" last="Kendall">Lindsay Kendall</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Forson, Audrey" sort="Forson, Audrey" uniqKey="Forson A" first="Audrey" last="Forson">Audrey Forson</name><affiliation><nlm:aff id="Aff2">University of Ghana Medical School, Accra, Ghana</nlm:aff></affiliation><affiliation><nlm:aff id="Aff3">Korle-Bu Teaching Hospital, Accra, Ghana</nlm:aff></affiliation></author><author><name sortKey="Kwara, Awewura" sort="Kwara, Awewura" uniqKey="Kwara A" first="Awewura" last="Kwara">Awewura Kwara</name><affiliation><nlm:aff id="Aff4">Warren Alpert Medical School of Brown University, Providence, RI USA</nlm:aff></affiliation><affiliation><nlm:aff id="Aff5">The Miriam Hospital, Providence, RI USA</nlm:aff></affiliation></author><author><name sortKey="Kudzawu, Samuel" sort="Kudzawu, Samuel" uniqKey="Kudzawu S" first="Samuel" last="Kudzawu">Samuel Kudzawu</name><affiliation><nlm:aff id="Aff3">Korle-Bu Teaching Hospital, Accra, Ghana</nlm:aff></affiliation></author><author><name sortKey="Kehinde, Aderemi O" sort="Kehinde, Aderemi O" uniqKey="Kehinde A" first="Aderemi O." last="Kehinde">Aderemi O. Kehinde</name><affiliation><nlm:aff id="Aff6">College of Medicine, University of Ibadan, Ibadan, Nigeria</nlm:aff></affiliation><affiliation><nlm:aff id="Aff7">University College Hospital, Ibadan, Oyo 23402 Nigeria</nlm:aff></affiliation></author><author><name sortKey="Adebiyi, Oludele" sort="Adebiyi, Oludele" uniqKey="Adebiyi O" first="Oludele" last="Adebiyi">Oludele Adebiyi</name><affiliation><nlm:aff id="Aff7">University College Hospital, Ibadan, Oyo 23402 Nigeria</nlm:aff></affiliation></author><author><name sortKey="Salako, Kayode" sort="Salako, Kayode" uniqKey="Salako K" first="Kayode" last="Salako">Kayode Salako</name><affiliation><nlm:aff id="Aff7">University College Hospital, Ibadan, Oyo 23402 Nigeria</nlm:aff></affiliation></author><author><name sortKey="Baldeh, Ignatius" sort="Baldeh, Ignatius" uniqKey="Baldeh I" first="Ignatius" last="Baldeh">Ignatius Baldeh</name><affiliation><nlm:aff id="Aff8">National Public Health Laboratory Services, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Jallow, Aisha" sort="Jallow, Aisha" uniqKey="Jallow A" first="Aisha" last="Jallow">Aisha Jallow</name><affiliation><nlm:aff id="Aff8">National Public Health Laboratory Services, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Jallow, Mamadou" sort="Jallow, Mamadou" uniqKey="Jallow M" first="Mamadou" last="Jallow">Mamadou Jallow</name><affiliation><nlm:aff id="Aff8">National Public Health Laboratory Services, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Dagnra, Anoumou" sort="Dagnra, Anoumou" uniqKey="Dagnra A" first="Anoumou" last="Dagnra">Anoumou Dagnra</name><affiliation><nlm:aff id="Aff9">Laboratoire National de Reference Mycobacteria, Lome, Togo</nlm:aff></affiliation></author><author><name sortKey="Disse, Kodjo" sort="Disse, Kodjo" uniqKey="Disse K" first="Kodjo" last="Dissé">Kodjo Dissé</name><affiliation><nlm:aff id="Aff9">Laboratoire National de Reference Mycobacteria, Lome, Togo</nlm:aff></affiliation></author><author><name sortKey="Kadanga, Essosimna A" sort="Kadanga, Essosimna A" uniqKey="Kadanga E" first="Essosimna A." last="Kadanga">Essosimna A. Kadanga</name><affiliation><nlm:aff id="Aff9">Laboratoire National de Reference Mycobacteria, Lome, Togo</nlm:aff></affiliation></author><author><name sortKey="Idigbe, Emmanuel Oni" sort="Idigbe, Emmanuel Oni" uniqKey="Idigbe E" first="Emmanuel Oni" last="Idigbe">Emmanuel Oni Idigbe</name><affiliation><nlm:aff id="Aff10">Nigerian Institute of Medical Research, Lagos, Nigeria</nlm:aff></affiliation></author><author><name sortKey="Onubogu, Catherine" sort="Onubogu, Catherine" uniqKey="Onubogu C" first="Catherine" last="Onubogu">Catherine Onubogu</name><affiliation><nlm:aff id="Aff10">Nigerian Institute of Medical Research, Lagos, Nigeria</nlm:aff></affiliation></author><author><name sortKey="Onyejepu, Nneka" sort="Onyejepu, Nneka" uniqKey="Onyejepu N" first="Nneka" last="Onyejepu">Nneka Onyejepu</name><affiliation><nlm:aff id="Aff10">Nigerian Institute of Medical Research, Lagos, Nigeria</nlm:aff></affiliation></author><author><name sortKey="Gaye Diallo, Aissatou" sort="Gaye Diallo, Aissatou" uniqKey="Gaye Diallo A" first="Aissatou" last="Gaye-Diallo">Aissatou Gaye-Diallo</name><affiliation><nlm:aff id="Aff11">Laboratoire Bactériologie Virologie Aristide Le Dantec Sénégal, Dakar, Senegal</nlm:aff></affiliation></author><author><name sortKey="Ba Diallo, Awa" sort="Ba Diallo, Awa" uniqKey="Ba Diallo A" first="Awa" last="Ba-Diallo">Awa Ba-Diallo</name><affiliation><nlm:aff id="Aff11">Laboratoire Bactériologie Virologie Aristide Le Dantec Sénégal, Dakar, Senegal</nlm:aff></affiliation></author><author><name sortKey="Rabna, Paulo" sort="Rabna, Paulo" uniqKey="Rabna P" first="Paulo" last="Rabna">Paulo Rabna</name><affiliation><nlm:aff id="Aff12">National Institute of Public Health, Bissau, Guinea-Bissau</nlm:aff></affiliation></author><author><name sortKey="Mane, Morto" sort="Mane, Morto" uniqKey="Mane M" first="Morto" last="Mane">Morto Mane</name><affiliation><nlm:aff id="Aff12">National Institute of Public Health, Bissau, Guinea-Bissau</nlm:aff></affiliation></author><author><name sortKey="Sanogo, Moumine" sort="Sanogo, Moumine" uniqKey="Sanogo M" first="Moumine" last="Sanogo">Moumine Sanogo</name><affiliation><nlm:aff id="Aff13">SEREFO Program, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali</nlm:aff></affiliation></author><author><name sortKey="Diarra, Bassirou" sort="Diarra, Bassirou" uniqKey="Diarra B" first="Bassirou" last="Diarra">Bassirou Diarra</name><affiliation><nlm:aff id="Aff13">SEREFO Program, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali</nlm:aff></affiliation></author><author><name sortKey="Dezemon, Zingue" sort="Dezemon, Zingue" uniqKey="Dezemon Z" first="Zingue" last="Dezemon">Zingue Dezemon</name><affiliation><nlm:aff id="Aff14">Centre Muraz and the National TB Program, Ouagadougou, Burkina Faso</nlm:aff></affiliation></author><author><name sortKey="Sanou, Adama" sort="Sanou, Adama" uniqKey="Sanou A" first="Adama" last="Sanou">Adama Sanou</name><affiliation><nlm:aff id="Aff14">Centre Muraz and the National TB Program, Ouagadougou, Burkina Faso</nlm:aff></affiliation></author><author><name sortKey="Senghore, Madikay" sort="Senghore, Madikay" uniqKey="Senghore M" first="Madikay" last="Senghore">Madikay Senghore</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff15">Microbiology and Infection Unit, Warwick Medical School, University of Warwick, Coventry, UK</nlm:aff></affiliation></author><author><name sortKey="Kwambana Adams, Brenda A" sort="Kwambana Adams, Brenda A" uniqKey="Kwambana Adams B" first="Brenda A." last="Kwambana-Adams">Brenda A. Kwambana-Adams</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff16">Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation></author><author><name sortKey="Demba, Edward" sort="Demba, Edward" uniqKey="Demba E" first="Edward" last="Demba">Edward Demba</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Faal Jawara, Tutty" sort="Faal Jawara, Tutty" uniqKey="Faal Jawara T" first="Tutty" last="Faal-Jawara">Tutty Faal-Jawara</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Kumar, Samrat" sort="Kumar, Samrat" uniqKey="Kumar S" first="Samrat" last="Kumar">Samrat Kumar</name><affiliation><nlm:aff id="Aff19">Institute of Tropical Medicine, Antwerp, Belgium</nlm:aff></affiliation></author><author><name sortKey="Tientcheu, Leopold D" sort="Tientcheu, Leopold D" uniqKey="Tientcheu L" first="Leopold D." last="Tientcheu">Leopold D. Tientcheu</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff22">Department of Biochemistry, Faculty of Science, University of Yaoundé 1, Yaoundé, Cameroon</nlm:aff></affiliation></author><author><name sortKey="Jallow, Adama" sort="Jallow, Adama" uniqKey="Jallow A" first="Adama" last="Jallow">Adama Jallow</name><affiliation><nlm:aff id="Aff23">National Tuberculosis/Leprosy Control Program, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Ceesay, Samba" sort="Ceesay, Samba" uniqKey="Ceesay S" first="Samba" last="Ceesay">Samba Ceesay</name><affiliation><nlm:aff id="Aff24">Health Services, Ministry of Health and Social Welfare, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Adetifa, Ifedayo" sort="Adetifa, Ifedayo" uniqKey="Adetifa I" first="Ifedayo" last="Adetifa">Ifedayo Adetifa</name><affiliation><nlm:aff id="Aff17">Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff18">Disease Control and Elimination, Medical Research Council Unit, Serrekunda, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Jaye, Assan" sort="Jaye, Assan" uniqKey="Jaye A" first="Assan" last="Jaye">Assan Jaye</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Pallen, Mark J" sort="Pallen, Mark J" uniqKey="Pallen M" first="Mark J." last="Pallen">Mark J. Pallen</name><affiliation><nlm:aff id="Aff15">Microbiology and Infection Unit, Warwick Medical School, University of Warwick, Coventry, UK</nlm:aff></affiliation></author><author><name sortKey="D Lessandro, Umberto" sort="D Lessandro, Umberto" uniqKey="D Lessandro U" first="Umberto" last="D Lessandro">Umberto D Lessandro</name><affiliation><nlm:aff id="Aff16">Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff18">Disease Control and Elimination, Medical Research Council Unit, Serrekunda, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff19">Institute of Tropical Medicine, Antwerp, Belgium</nlm:aff></affiliation></author><author><name sortKey="Kampmann, Beate" sort="Kampmann, Beate" uniqKey="Kampmann B" first="Beate" last="Kampmann">Beate Kampmann</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff20">Department of Paediatrics, Imperial College London, London, UK</nlm:aff></affiliation></author><author><name sortKey="Adegbola, Richard A" sort="Adegbola, Richard A" uniqKey="Adegbola R" first="Richard A." last="Adegbola">Richard A. Adegbola</name><affiliation><nlm:aff id="Aff21">GSK Vaccines, Wavre, Belgium</nlm:aff></affiliation></author><author><name sortKey="Mboup, Souleymane" sort="Mboup, Souleymane" uniqKey="Mboup S" first="Souleymane" last="Mboup">Souleymane Mboup</name><affiliation><nlm:aff id="Aff11">Laboratoire Bactériologie Virologie Aristide Le Dantec Sénégal, Dakar, Senegal</nlm:aff></affiliation></author><author><name sortKey="Corrah, Tumani" sort="Corrah, Tumani" uniqKey="Corrah T" first="Tumani" last="Corrah">Tumani Corrah</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="De Jong, Bouke C" sort="De Jong, Bouke C" uniqKey="De Jong B" first="Bouke C." last="De Jong">Bouke C. De Jong</name><affiliation><nlm:aff id="Aff19">Institute of Tropical Medicine, Antwerp, Belgium</nlm:aff></affiliation></author><author><name sortKey="Antonio, Martin" sort="Antonio, Martin" uniqKey="Antonio M" first="Martin" last="Antonio">Martin Antonio</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff15">Microbiology and Infection Unit, Warwick Medical School, University of Warwick, Coventry, UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff17">Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27806714</idno><idno type="pmc">5094099</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5094099</idno><idno type="RBID">PMC:5094099</idno><idno type="doi">10.1186/s12916-016-0704-5</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000102</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000102</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">The emerging threat of pre-extensively drug-resistant tuberculosis in West Africa: preparing for large-scale tuberculosis research and drug resistance surveillance</title><author><name sortKey="Gehre, Florian" sort="Gehre, Florian" uniqKey="Gehre F" first="Florian" last="Gehre">Florian Gehre</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff19">Institute of Tropical Medicine, Antwerp, Belgium</nlm:aff></affiliation></author><author><name sortKey="Otu, Jacob" sort="Otu, Jacob" uniqKey="Otu J" first="Jacob" last="Otu">Jacob Otu</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Kendall, Lindsay" sort="Kendall, Lindsay" uniqKey="Kendall L" first="Lindsay" last="Kendall">Lindsay Kendall</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Forson, Audrey" sort="Forson, Audrey" uniqKey="Forson A" first="Audrey" last="Forson">Audrey Forson</name><affiliation><nlm:aff id="Aff2">University of Ghana Medical School, Accra, Ghana</nlm:aff></affiliation><affiliation><nlm:aff id="Aff3">Korle-Bu Teaching Hospital, Accra, Ghana</nlm:aff></affiliation></author><author><name sortKey="Kwara, Awewura" sort="Kwara, Awewura" uniqKey="Kwara A" first="Awewura" last="Kwara">Awewura Kwara</name><affiliation><nlm:aff id="Aff4">Warren Alpert Medical School of Brown University, Providence, RI USA</nlm:aff></affiliation><affiliation><nlm:aff id="Aff5">The Miriam Hospital, Providence, RI USA</nlm:aff></affiliation></author><author><name sortKey="Kudzawu, Samuel" sort="Kudzawu, Samuel" uniqKey="Kudzawu S" first="Samuel" last="Kudzawu">Samuel Kudzawu</name><affiliation><nlm:aff id="Aff3">Korle-Bu Teaching Hospital, Accra, Ghana</nlm:aff></affiliation></author><author><name sortKey="Kehinde, Aderemi O" sort="Kehinde, Aderemi O" uniqKey="Kehinde A" first="Aderemi O." last="Kehinde">Aderemi O. Kehinde</name><affiliation><nlm:aff id="Aff6">College of Medicine, University of Ibadan, Ibadan, Nigeria</nlm:aff></affiliation><affiliation><nlm:aff id="Aff7">University College Hospital, Ibadan, Oyo 23402 Nigeria</nlm:aff></affiliation></author><author><name sortKey="Adebiyi, Oludele" sort="Adebiyi, Oludele" uniqKey="Adebiyi O" first="Oludele" last="Adebiyi">Oludele Adebiyi</name><affiliation><nlm:aff id="Aff7">University College Hospital, Ibadan, Oyo 23402 Nigeria</nlm:aff></affiliation></author><author><name sortKey="Salako, Kayode" sort="Salako, Kayode" uniqKey="Salako K" first="Kayode" last="Salako">Kayode Salako</name><affiliation><nlm:aff id="Aff7">University College Hospital, Ibadan, Oyo 23402 Nigeria</nlm:aff></affiliation></author><author><name sortKey="Baldeh, Ignatius" sort="Baldeh, Ignatius" uniqKey="Baldeh I" first="Ignatius" last="Baldeh">Ignatius Baldeh</name><affiliation><nlm:aff id="Aff8">National Public Health Laboratory Services, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Jallow, Aisha" sort="Jallow, Aisha" uniqKey="Jallow A" first="Aisha" last="Jallow">Aisha Jallow</name><affiliation><nlm:aff id="Aff8">National Public Health Laboratory Services, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Jallow, Mamadou" sort="Jallow, Mamadou" uniqKey="Jallow M" first="Mamadou" last="Jallow">Mamadou Jallow</name><affiliation><nlm:aff id="Aff8">National Public Health Laboratory Services, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Dagnra, Anoumou" sort="Dagnra, Anoumou" uniqKey="Dagnra A" first="Anoumou" last="Dagnra">Anoumou Dagnra</name><affiliation><nlm:aff id="Aff9">Laboratoire National de Reference Mycobacteria, Lome, Togo</nlm:aff></affiliation></author><author><name sortKey="Disse, Kodjo" sort="Disse, Kodjo" uniqKey="Disse K" first="Kodjo" last="Dissé">Kodjo Dissé</name><affiliation><nlm:aff id="Aff9">Laboratoire National de Reference Mycobacteria, Lome, Togo</nlm:aff></affiliation></author><author><name sortKey="Kadanga, Essosimna A" sort="Kadanga, Essosimna A" uniqKey="Kadanga E" first="Essosimna A." last="Kadanga">Essosimna A. Kadanga</name><affiliation><nlm:aff id="Aff9">Laboratoire National de Reference Mycobacteria, Lome, Togo</nlm:aff></affiliation></author><author><name sortKey="Idigbe, Emmanuel Oni" sort="Idigbe, Emmanuel Oni" uniqKey="Idigbe E" first="Emmanuel Oni" last="Idigbe">Emmanuel Oni Idigbe</name><affiliation><nlm:aff id="Aff10">Nigerian Institute of Medical Research, Lagos, Nigeria</nlm:aff></affiliation></author><author><name sortKey="Onubogu, Catherine" sort="Onubogu, Catherine" uniqKey="Onubogu C" first="Catherine" last="Onubogu">Catherine Onubogu</name><affiliation><nlm:aff id="Aff10">Nigerian Institute of Medical Research, Lagos, Nigeria</nlm:aff></affiliation></author><author><name sortKey="Onyejepu, Nneka" sort="Onyejepu, Nneka" uniqKey="Onyejepu N" first="Nneka" last="Onyejepu">Nneka Onyejepu</name><affiliation><nlm:aff id="Aff10">Nigerian Institute of Medical Research, Lagos, Nigeria</nlm:aff></affiliation></author><author><name sortKey="Gaye Diallo, Aissatou" sort="Gaye Diallo, Aissatou" uniqKey="Gaye Diallo A" first="Aissatou" last="Gaye-Diallo">Aissatou Gaye-Diallo</name><affiliation><nlm:aff id="Aff11">Laboratoire Bactériologie Virologie Aristide Le Dantec Sénégal, Dakar, Senegal</nlm:aff></affiliation></author><author><name sortKey="Ba Diallo, Awa" sort="Ba Diallo, Awa" uniqKey="Ba Diallo A" first="Awa" last="Ba-Diallo">Awa Ba-Diallo</name><affiliation><nlm:aff id="Aff11">Laboratoire Bactériologie Virologie Aristide Le Dantec Sénégal, Dakar, Senegal</nlm:aff></affiliation></author><author><name sortKey="Rabna, Paulo" sort="Rabna, Paulo" uniqKey="Rabna P" first="Paulo" last="Rabna">Paulo Rabna</name><affiliation><nlm:aff id="Aff12">National Institute of Public Health, Bissau, Guinea-Bissau</nlm:aff></affiliation></author><author><name sortKey="Mane, Morto" sort="Mane, Morto" uniqKey="Mane M" first="Morto" last="Mane">Morto Mane</name><affiliation><nlm:aff id="Aff12">National Institute of Public Health, Bissau, Guinea-Bissau</nlm:aff></affiliation></author><author><name sortKey="Sanogo, Moumine" sort="Sanogo, Moumine" uniqKey="Sanogo M" first="Moumine" last="Sanogo">Moumine Sanogo</name><affiliation><nlm:aff id="Aff13">SEREFO Program, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali</nlm:aff></affiliation></author><author><name sortKey="Diarra, Bassirou" sort="Diarra, Bassirou" uniqKey="Diarra B" first="Bassirou" last="Diarra">Bassirou Diarra</name><affiliation><nlm:aff id="Aff13">SEREFO Program, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali</nlm:aff></affiliation></author><author><name sortKey="Dezemon, Zingue" sort="Dezemon, Zingue" uniqKey="Dezemon Z" first="Zingue" last="Dezemon">Zingue Dezemon</name><affiliation><nlm:aff id="Aff14">Centre Muraz and the National TB Program, Ouagadougou, Burkina Faso</nlm:aff></affiliation></author><author><name sortKey="Sanou, Adama" sort="Sanou, Adama" uniqKey="Sanou A" first="Adama" last="Sanou">Adama Sanou</name><affiliation><nlm:aff id="Aff14">Centre Muraz and the National TB Program, Ouagadougou, Burkina Faso</nlm:aff></affiliation></author><author><name sortKey="Senghore, Madikay" sort="Senghore, Madikay" uniqKey="Senghore M" first="Madikay" last="Senghore">Madikay Senghore</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff15">Microbiology and Infection Unit, Warwick Medical School, University of Warwick, Coventry, UK</nlm:aff></affiliation></author><author><name sortKey="Kwambana Adams, Brenda A" sort="Kwambana Adams, Brenda A" uniqKey="Kwambana Adams B" first="Brenda A." last="Kwambana-Adams">Brenda A. Kwambana-Adams</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff16">Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation></author><author><name sortKey="Demba, Edward" sort="Demba, Edward" uniqKey="Demba E" first="Edward" last="Demba">Edward Demba</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Faal Jawara, Tutty" sort="Faal Jawara, Tutty" uniqKey="Faal Jawara T" first="Tutty" last="Faal-Jawara">Tutty Faal-Jawara</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Kumar, Samrat" sort="Kumar, Samrat" uniqKey="Kumar S" first="Samrat" last="Kumar">Samrat Kumar</name><affiliation><nlm:aff id="Aff19">Institute of Tropical Medicine, Antwerp, Belgium</nlm:aff></affiliation></author><author><name sortKey="Tientcheu, Leopold D" sort="Tientcheu, Leopold D" uniqKey="Tientcheu L" first="Leopold D." last="Tientcheu">Leopold D. Tientcheu</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff22">Department of Biochemistry, Faculty of Science, University of Yaoundé 1, Yaoundé, Cameroon</nlm:aff></affiliation></author><author><name sortKey="Jallow, Adama" sort="Jallow, Adama" uniqKey="Jallow A" first="Adama" last="Jallow">Adama Jallow</name><affiliation><nlm:aff id="Aff23">National Tuberculosis/Leprosy Control Program, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Ceesay, Samba" sort="Ceesay, Samba" uniqKey="Ceesay S" first="Samba" last="Ceesay">Samba Ceesay</name><affiliation><nlm:aff id="Aff24">Health Services, Ministry of Health and Social Welfare, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Adetifa, Ifedayo" sort="Adetifa, Ifedayo" uniqKey="Adetifa I" first="Ifedayo" last="Adetifa">Ifedayo Adetifa</name><affiliation><nlm:aff id="Aff17">Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff18">Disease Control and Elimination, Medical Research Council Unit, Serrekunda, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Jaye, Assan" sort="Jaye, Assan" uniqKey="Jaye A" first="Assan" last="Jaye">Assan Jaye</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="Pallen, Mark J" sort="Pallen, Mark J" uniqKey="Pallen M" first="Mark J." last="Pallen">Mark J. Pallen</name><affiliation><nlm:aff id="Aff15">Microbiology and Infection Unit, Warwick Medical School, University of Warwick, Coventry, UK</nlm:aff></affiliation></author><author><name sortKey="D Lessandro, Umberto" sort="D Lessandro, Umberto" uniqKey="D Lessandro U" first="Umberto" last="D Lessandro">Umberto D Lessandro</name><affiliation><nlm:aff id="Aff16">Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff18">Disease Control and Elimination, Medical Research Council Unit, Serrekunda, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff19">Institute of Tropical Medicine, Antwerp, Belgium</nlm:aff></affiliation></author><author><name sortKey="Kampmann, Beate" sort="Kampmann, Beate" uniqKey="Kampmann B" first="Beate" last="Kampmann">Beate Kampmann</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff20">Department of Paediatrics, Imperial College London, London, UK</nlm:aff></affiliation></author><author><name sortKey="Adegbola, Richard A" sort="Adegbola, Richard A" uniqKey="Adegbola R" first="Richard A." last="Adegbola">Richard A. Adegbola</name><affiliation><nlm:aff id="Aff21">GSK Vaccines, Wavre, Belgium</nlm:aff></affiliation></author><author><name sortKey="Mboup, Souleymane" sort="Mboup, Souleymane" uniqKey="Mboup S" first="Souleymane" last="Mboup">Souleymane Mboup</name><affiliation><nlm:aff id="Aff11">Laboratoire Bactériologie Virologie Aristide Le Dantec Sénégal, Dakar, Senegal</nlm:aff></affiliation></author><author><name sortKey="Corrah, Tumani" sort="Corrah, Tumani" uniqKey="Corrah T" first="Tumani" last="Corrah">Tumani Corrah</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation></author><author><name sortKey="De Jong, Bouke C" sort="De Jong, Bouke C" uniqKey="De Jong B" first="Bouke C." last="De Jong">Bouke C. De Jong</name><affiliation><nlm:aff id="Aff19">Institute of Tropical Medicine, Antwerp, Belgium</nlm:aff></affiliation></author><author><name sortKey="Antonio, Martin" sort="Antonio, Martin" uniqKey="Antonio M" first="Martin" last="Antonio">Martin Antonio</name><affiliation><nlm:aff id="Aff1">Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff15">Microbiology and Infection Unit, Warwick Medical School, University of Warwick, Coventry, UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff17">Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation></author></analytic><series><title level="j">BMC Medicine</title><idno type="eISSN">1741-7015</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Drug-resistant tuberculosis (TB) is a global public health problem. Adequate management requires baseline drug-resistance prevalence data. In West Africa, due to a poor laboratory infrastructure and inadequate capacity, such data are scarce. Therefore, the true extent of drug-resistant TB was hitherto undetermined. In 2008, a new research network, the West African Network of Excellence for Tuberculosis, AIDS and Malaria (WANETAM), was founded, comprising nine study sites from eight West African countries (Burkina Faso, The Gambia, Ghana, Guinea-Bissau, Mali, Nigeria, Senegal and Togo). The goal was to establish Good Clinical Laboratory Practice (GCLP) principles and build capacity in standardised smear microscopy and mycobacterial culture across partnering laboratories to generate the first comprehensive West African drug-resistance data.</p></sec><sec><title>Methods</title><p>Following GCLP and laboratory training sessions, TB isolates were collected at sentinel referral sites between 2009–2013 and tested for first- and second-line drug resistance.</p></sec><sec><title>Results</title><p>From the analysis of 974 isolates, an unexpectedly high prevalence of multi-drug-resistant (MDR) strains was found in new (6 %) and retreatment patients (35 %) across all sentinel sites, with the highest prevalence amongst retreatment patients in Bamako, Mali (59 %) and the two Nigerian sites in Ibadan and Lagos (39 % and 66 %). In Lagos, MDR is already spreading actively amongst 32 % of new patients. Pre-extensively drug-resistant (pre-XDR) isolates are present in all sites, with Ghana showing the highest proportion (35 % of MDR). In Ghana and Togo, pre-XDR isolates are circulating amongst new patients.</p></sec><sec><title>Conclusions</title><p>West African drug-resistance prevalence poses a previously underestimated, yet serious public health threat, and our estimates obtained differ significantly from previous World Health Organisation (WHO) estimates. Therefore, our data are reshaping current concepts and are essential in informing WHO and public health strategists to implement urgently needed surveillance and control interventions in West Africa.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Roca, A" uniqKey="Roca A">A Roca</name></author><author><name sortKey="Afolabi, Mo" uniqKey="Afolabi M">MO Afolabi</name></author><author><name sortKey="Saidu, Y" uniqKey="Saidu Y">Y Saidu</name></author><author><name sortKey="Kampmann, B" uniqKey="Kampmann B">B Kampmann</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Miiro, Gm" uniqKey="Miiro G">GM Miiro</name></author><author><name sortKey="Oukem Boyer, Oo" uniqKey="Oukem Boyer O">OO Oukem-Boyer</name></author><author><name sortKey="Sarr, O" uniqKey="Sarr O">O Sarr</name></author><author><name sortKey="Rahmani, M" uniqKey="Rahmani M">M Rahmani</name></author><author><name sortKey="Ntoumi, F" uniqKey="Ntoumi F">F Ntoumi</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Ardito, F" uniqKey="Ardito F">F Ardito</name></author><author><name sortKey="Posteraro, B" uniqKey="Posteraro B">B Posteraro</name></author><author><name sortKey="Sanguinetti, M" uniqKey="Sanguinetti M">M Sanguinetti</name></author><author><name sortKey="Zanetti, S" uniqKey="Zanetti S">S Zanetti</name></author><author><name sortKey="Fadda, G" uniqKey="Fadda G">G Fadda</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Ani, Ae" uniqKey="Ani A">AE Ani</name></author><author><name sortKey="Idoko, J" uniqKey="Idoko J">J Idoko</name></author><author><name sortKey="Dalyop, Yb" uniqKey="Dalyop Y">YB Dalyop</name></author><author><name sortKey="Pitmang, Sl" uniqKey="Pitmang S">SL Pitmang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Daniel, O" uniqKey="Daniel O">O Daniel</name></author><author><name sortKey="Osman, E" uniqKey="Osman E">E Osman</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kehinde, Ao" uniqKey="Kehinde A">AO Kehinde</name></author><author><name sortKey="Adebiyi, Eo" uniqKey="Adebiyi E">EO Adebiyi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lawson, L" uniqKey="Lawson L">L Lawson</name></author><author><name sortKey="Yassin, Ma" uniqKey="Yassin M">MA Yassin</name></author><author><name sortKey="Abdurrahman, St" uniqKey="Abdurrahman S">ST Abdurrahman</name></author><author><name sortKey="Parry, Cm" uniqKey="Parry C">CM Parry</name></author><author><name sortKey="Dacombe, R" uniqKey="Dacombe R">R Dacombe</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Otu, A" uniqKey="Otu A">A Otu</name></author><author><name sortKey="Umoh, V" uniqKey="Umoh V">V Umoh</name></author><author><name sortKey="Habib, A" uniqKey="Habib A">A Habib</name></author><author><name sortKey="Ansa, V" uniqKey="Ansa V">V Ansa</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sangare, L" uniqKey="Sangare L">L Sangare</name></author><author><name sortKey="Diande, S" uniqKey="Diande S">S Diande</name></author><author><name sortKey="Badoum, G" uniqKey="Badoum G">G Badoum</name></author><author><name sortKey="Dingtoumda, B" uniqKey="Dingtoumda B">B Dingtoumda</name></author><author><name sortKey="Traore, As" uniqKey="Traore A">AS Traore</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sangare, L" uniqKey="Sangare L">L Sangare</name></author><author><name sortKey="Diande, S" uniqKey="Diande S">S Diande</name></author><author><name sortKey="Kouanda, S" uniqKey="Kouanda S">S Kouanda</name></author><author><name sortKey="Dingtoumda, Bi" uniqKey="Dingtoumda B">BI Dingtoumda</name></author><author><name sortKey="Mourfou, A" uniqKey="Mourfou A">A Mourfou</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Saleri, N" uniqKey="Saleri N">N Saleri</name></author><author><name sortKey="Badoum, G" uniqKey="Badoum G">G Badoum</name></author><author><name sortKey="Ouedraogo, M" uniqKey="Ouedraogo M">M Ouedraogo</name></author><author><name sortKey="Dembele, Sm" uniqKey="Dembele S">SM Dembele</name></author><author><name sortKey="Nacanabo, R" uniqKey="Nacanabo R">R Nacanabo</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Adegbola, Ra" uniqKey="Adegbola R">RA Adegbola</name></author><author><name sortKey="Hill, P" uniqKey="Hill P">P Hill</name></author><author><name sortKey="Baldeh, I" uniqKey="Baldeh I">I Baldeh</name></author><author><name sortKey="Otu, J" uniqKey="Otu J">J Otu</name></author><author><name sortKey="Sarr, R" uniqKey="Sarr R">R Sarr</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Van Deun, A" uniqKey="Van Deun A">A Van Deun</name></author><author><name sortKey="Maug, Ak" uniqKey="Maug A">AK Maug</name></author><author><name sortKey="Salim, Ma" uniqKey="Salim M">MA Salim</name></author><author><name sortKey="Das, Pk" uniqKey="Das P">PK Das</name></author><author><name sortKey="Sarker, Mr" uniqKey="Sarker M">MR Sarker</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kuaban, C" uniqKey="Kuaban C">C Kuaban</name></author><author><name sortKey="Noeske, J" uniqKey="Noeske J">J Noeske</name></author><author><name sortKey="Rieder, Hl" uniqKey="Rieder H">HL Rieder</name></author><author><name sortKey="Ait Khaled, N" uniqKey="Ait Khaled N">N Ait-Khaled</name></author><author><name sortKey="Abena Foe, Jl" uniqKey="Abena Foe J">JL Abena Foe</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Piubello, A" uniqKey="Piubello A">A Piubello</name></author><author><name sortKey="Harouna, Sh" uniqKey="Harouna S">SH Harouna</name></author><author><name sortKey="Souleymane, Mb" uniqKey="Souleymane M">MB Souleymane</name></author><author><name sortKey="Boukary, I" uniqKey="Boukary I">I Boukary</name></author><author><name sortKey="Morou, S" uniqKey="Morou S">S Morou</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">BMC Med</journal-id><journal-id journal-id-type="iso-abbrev">BMC Med</journal-id><journal-title-group><journal-title>BMC Medicine</journal-title></journal-title-group><issn pub-type="epub">1741-7015</issn><publisher><publisher-name>BioMed Central</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27806714</article-id><article-id pub-id-type="pmc">5094099</article-id><article-id pub-id-type="publisher-id">704</article-id><article-id pub-id-type="doi">10.1186/s12916-016-0704-5</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group></article-categories><title-group><article-title>The emerging threat of pre-extensively drug-resistant tuberculosis in West Africa: preparing for large-scale tuberculosis research and drug resistance surveillance</article-title></title-group><contrib-group><contrib contrib-type="author" equal-contrib="yes"><name><surname>Gehre</surname><given-names>Florian</given-names></name><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff19">19</xref></contrib><contrib contrib-type="author" equal-contrib="yes"><name><surname>Otu</surname><given-names>Jacob</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author" equal-contrib="yes"><name><surname>Kendall</surname><given-names>Lindsay</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Forson</surname><given-names>Audrey</given-names></name><xref ref-type="aff" rid="Aff2">2</xref><xref ref-type="aff" rid="Aff3">3</xref></contrib><contrib contrib-type="author"><name><surname>Kwara</surname><given-names>Awewura</given-names></name><xref ref-type="aff" rid="Aff4">4</xref><xref ref-type="aff" rid="Aff5">5</xref></contrib><contrib contrib-type="author"><name><surname>Kudzawu</surname><given-names>Samuel</given-names></name><xref ref-type="aff" rid="Aff3">3</xref></contrib><contrib contrib-type="author"><name><surname>Kehinde</surname><given-names>Aderemi O.</given-names></name><xref ref-type="aff" rid="Aff6">6</xref><xref ref-type="aff" rid="Aff7">7</xref></contrib><contrib contrib-type="author"><name><surname>Adebiyi</surname><given-names>Oludele</given-names></name><xref ref-type="aff" rid="Aff7">7</xref></contrib><contrib contrib-type="author"><name><surname>Salako</surname><given-names>Kayode</given-names></name><xref ref-type="aff" rid="Aff7">7</xref></contrib><contrib contrib-type="author"><name><surname>Baldeh</surname><given-names>Ignatius</given-names></name><xref ref-type="aff" rid="Aff8">8</xref></contrib><contrib contrib-type="author"><name><surname>Jallow</surname><given-names>Aisha</given-names></name><xref ref-type="aff" rid="Aff8">8</xref></contrib><contrib contrib-type="author"><name><surname>Jallow</surname><given-names>Mamadou</given-names></name><xref ref-type="aff" rid="Aff8">8</xref></contrib><contrib contrib-type="author"><name><surname>Dagnra</surname><given-names>Anoumou</given-names></name><xref ref-type="aff" rid="Aff9">9</xref></contrib><contrib contrib-type="author"><name><surname>Dissé</surname><given-names>Kodjo</given-names></name><xref ref-type="aff" rid="Aff9">9</xref></contrib><contrib contrib-type="author"><name><surname>Kadanga</surname><given-names>Essosimna A.</given-names></name><xref ref-type="aff" rid="Aff9">9</xref></contrib><contrib contrib-type="author"><name><surname>Idigbe</surname><given-names>Emmanuel Oni</given-names></name><xref ref-type="aff" rid="Aff10">10</xref></contrib><contrib contrib-type="author"><name><surname>Onubogu</surname><given-names>Catherine</given-names></name><xref ref-type="aff" rid="Aff10">10</xref></contrib><contrib contrib-type="author"><name><surname>Onyejepu</surname><given-names>Nneka</given-names></name><xref ref-type="aff" rid="Aff10">10</xref></contrib><contrib contrib-type="author"><name><surname>Gaye-Diallo</surname><given-names>Aissatou</given-names></name><xref ref-type="aff" rid="Aff11">11</xref></contrib><contrib contrib-type="author"><name><surname>Ba-Diallo</surname><given-names>Awa</given-names></name><xref ref-type="aff" rid="Aff11">11</xref></contrib><contrib contrib-type="author"><name><surname>Rabna</surname><given-names>Paulo</given-names></name><xref ref-type="aff" rid="Aff12">12</xref></contrib><contrib contrib-type="author"><name><surname>Mane</surname><given-names>Morto</given-names></name><xref ref-type="aff" rid="Aff12">12</xref></contrib><contrib contrib-type="author"><name><surname>Sanogo</surname><given-names>Moumine</given-names></name><xref ref-type="aff" rid="Aff13">13</xref></contrib><contrib contrib-type="author"><name><surname>Diarra</surname><given-names>Bassirou</given-names></name><xref ref-type="aff" rid="Aff13">13</xref></contrib><contrib contrib-type="author"><name><surname>Dezemon</surname><given-names>Zingue</given-names></name><xref ref-type="aff" rid="Aff14">14</xref></contrib><contrib contrib-type="author"><name><surname>Sanou</surname><given-names>Adama</given-names></name><xref ref-type="aff" rid="Aff14">14</xref></contrib><contrib contrib-type="author"><name><surname>Senghore</surname><given-names>Madikay</given-names></name><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff15">15</xref></contrib><contrib contrib-type="author"><name><surname>Kwambana-Adams</surname><given-names>Brenda A.</given-names></name><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff16">16</xref></contrib><contrib contrib-type="author"><name><surname>Demba</surname><given-names>Edward</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Faal-Jawara</surname><given-names>Tutty</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Kumar</surname><given-names>Samrat</given-names></name><xref ref-type="aff" rid="Aff19">19</xref></contrib><contrib contrib-type="author"><name><surname>Tientcheu</surname><given-names>Leopold D.</given-names></name><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff22">22</xref></contrib><contrib contrib-type="author"><name><surname>Jallow</surname><given-names>Adama</given-names></name><xref ref-type="aff" rid="Aff23">23</xref></contrib><contrib contrib-type="author"><name><surname>Ceesay</surname><given-names>Samba</given-names></name><xref ref-type="aff" rid="Aff24">24</xref></contrib><contrib contrib-type="author"><name><surname>Adetifa</surname><given-names>Ifedayo</given-names></name><xref ref-type="aff" rid="Aff17">17</xref><xref ref-type="aff" rid="Aff18">18</xref></contrib><contrib contrib-type="author"><name><surname>Jaye</surname><given-names>Assan</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Pallen</surname><given-names>Mark J.</given-names></name><xref ref-type="aff" rid="Aff15">15</xref></contrib><contrib contrib-type="author"><name><surname>D’Alessandro</surname><given-names>Umberto</given-names></name><xref ref-type="aff" rid="Aff16">16</xref><xref ref-type="aff" rid="Aff18">18</xref><xref ref-type="aff" rid="Aff19">19</xref></contrib><contrib contrib-type="author"><name><surname>Kampmann</surname><given-names>Beate</given-names></name><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff20">20</xref></contrib><contrib contrib-type="author"><name><surname>Adegbola</surname><given-names>Richard A.</given-names></name><xref ref-type="aff" rid="Aff21">21</xref></contrib><contrib contrib-type="author"><name><surname>Mboup</surname><given-names>Souleymane</given-names></name><xref ref-type="aff" rid="Aff11">11</xref></contrib><contrib contrib-type="author"><name><surname>Corrah</surname><given-names>Tumani</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>de Jong</surname><given-names>Bouke C.</given-names></name><xref ref-type="aff" rid="Aff19">19</xref></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Antonio</surname><given-names>Martin</given-names></name><address><phone>002204496074</phone><email>mantonio@mrc.gm</email></address><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff15">15</xref><xref ref-type="aff" rid="Aff17">17</xref></contrib><aff id="Aff1"><label>1</label>Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia</aff><aff id="Aff2"><label>2</label>University of Ghana Medical School, Accra, Ghana</aff><aff id="Aff3"><label>3</label>Korle-Bu Teaching Hospital, Accra, Ghana</aff><aff id="Aff4"><label>4</label>Warren Alpert Medical School of Brown University, Providence, RI USA</aff><aff id="Aff5"><label>5</label>The Miriam Hospital, Providence, RI USA</aff><aff id="Aff6"><label>6</label>College of Medicine, University of Ibadan, Ibadan, Nigeria</aff><aff id="Aff7"><label>7</label>University College Hospital, Ibadan, Oyo 23402 Nigeria</aff><aff id="Aff8"><label>8</label>National Public Health Laboratory Services, Banjul, The Gambia</aff><aff id="Aff9"><label>9</label>Laboratoire National de Reference Mycobacteria, Lome, Togo</aff><aff id="Aff10"><label>10</label>Nigerian Institute of Medical Research, Lagos, Nigeria</aff><aff id="Aff11"><label>11</label>Laboratoire Bactériologie Virologie Aristide Le Dantec Sénégal, Dakar, Senegal</aff><aff id="Aff12"><label>12</label>National Institute of Public Health, Bissau, Guinea-Bissau</aff><aff id="Aff13"><label>13</label>SEREFO Program, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali</aff><aff id="Aff14"><label>14</label>Centre Muraz and the National TB Program, Ouagadougou, Burkina Faso</aff><aff id="Aff15"><label>15</label>Microbiology and Infection Unit, Warwick Medical School, University of Warwick, Coventry, UK</aff><aff id="Aff16"><label>16</label>Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK</aff><aff id="Aff17"><label>17</label>Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK</aff><aff id="Aff18"><label>18</label>Disease Control and Elimination, Medical Research Council Unit, Serrekunda, The Gambia</aff><aff id="Aff19"><label>19</label>Institute of Tropical Medicine, Antwerp, Belgium</aff><aff id="Aff20"><label>20</label>Department of Paediatrics, Imperial College London, London, UK</aff><aff id="Aff21"><label>21</label>GSK Vaccines, Wavre, Belgium</aff><aff id="Aff22"><label>22</label>Department of Biochemistry, Faculty of Science, University of Yaoundé 1, Yaoundé, Cameroon</aff><aff id="Aff23"><label>23</label>National Tuberculosis/Leprosy Control Program, Banjul, The Gambia</aff><aff id="Aff24"><label>24</label>Health Services, Ministry of Health and Social Welfare, Banjul, The Gambia</aff></contrib-group><pub-date pub-type="epub"><day>3</day><month>11</month><year>2016</year></pub-date><pub-date pub-type="pmc-release"><day>3</day><month>11</month><year>2016</year></pub-date><pub-date pub-type="collection"><year>2016</year></pub-date><volume>14</volume><elocation-id>160</elocation-id><history><date date-type="received"><day>6</day><month>8</month><year>2016</year></date><date date-type="accepted"><day>28</day><month>9</month><year>2016</year></date></history><permissions><copyright-statement>© The Author(s). 2016</copyright-statement><license license-type="OpenAccess"><license-p><bold>Open Access</bold>This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>) applies to the data made available in this article, unless otherwise stated.</license-p></license></permissions><abstract id="Abs1"><sec><title>Background</title><p>Drug-resistant tuberculosis (TB) is a global public health problem. Adequate management requires baseline drug-resistance prevalence data. In West Africa, due to a poor laboratory infrastructure and inadequate capacity, such data are scarce. Therefore, the true extent of drug-resistant TB was hitherto undetermined. In 2008, a new research network, the West African Network of Excellence for Tuberculosis, AIDS and Malaria (WANETAM), was founded, comprising nine study sites from eight West African countries (Burkina Faso, The Gambia, Ghana, Guinea-Bissau, Mali, Nigeria, Senegal and Togo). The goal was to establish Good Clinical Laboratory Practice (GCLP) principles and build capacity in standardised smear microscopy and mycobacterial culture across partnering laboratories to generate the first comprehensive West African drug-resistance data.</p></sec><sec><title>Methods</title><p>Following GCLP and laboratory training sessions, TB isolates were collected at sentinel referral sites between 2009–2013 and tested for first- and second-line drug resistance.</p></sec><sec><title>Results</title><p>From the analysis of 974 isolates, an unexpectedly high prevalence of multi-drug-resistant (MDR) strains was found in new (6 %) and retreatment patients (35 %) across all sentinel sites, with the highest prevalence amongst retreatment patients in Bamako, Mali (59 %) and the two Nigerian sites in Ibadan and Lagos (39 % and 66 %). In Lagos, MDR is already spreading actively amongst 32 % of new patients. Pre-extensively drug-resistant (pre-XDR) isolates are present in all sites, with Ghana showing the highest proportion (35 % of MDR). In Ghana and Togo, pre-XDR isolates are circulating amongst new patients.</p></sec><sec><title>Conclusions</title><p>West African drug-resistance prevalence poses a previously underestimated, yet serious public health threat, and our estimates obtained differ significantly from previous World Health Organisation (WHO) estimates. Therefore, our data are reshaping current concepts and are essential in informing WHO and public health strategists to implement urgently needed surveillance and control interventions in West Africa.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Tuberculosis</kwd><kwd>Extensively drug-resistant tuberculosis</kwd><kwd>West Africa</kwd><kwd>Drug-resistance surveillance</kwd><kwd>Capacity building</kwd></kwd-group><funding-group><award-group><funding-source><institution>EDTCP</institution></funding-source><award-id>CB. 2007. 41700.007</award-id></award-group></funding-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2016</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1"><title>Background</title><p>West Africa comprises 15 countries and is home to 245 million inhabitants who are highly affected by communicable diseases. A limited sub-regional health and laboratory infrastructure leaves the region especially vulnerable not just to major infectious diseases, such as tuberculosis (TB), malaria, meningitis and human immunodeficiency virus (HIV), but also to devastating emerging epidemics, including the largest ever Ebola outbreak [<xref ref-type="bibr" rid="CR1">1</xref>]. Creating laboratory capacity and fostering regional collaborations within West Africa will allow countries to respond with rapid concerted action to emerging public health threats and to conduct clinical trials to address local health needs and inform global health policies. To close knowledge gaps, leading scientists and research institutes from the sub-region joined forces to establish the West African Network of Excellence for TB, AIDS and Malaria (WANETAM) [<xref ref-type="bibr" rid="CR2">2</xref>]. Funded by the European and Developing Countries Clinical Trials Partnership (EDCTP), WANETAM’s mission from 2008–2014 has been to build capacity to train members in standardised laboratory techniques essential to prepare the region for clinical trials and public health relevant diagnostics and research [<xref ref-type="bibr" rid="CR2">2</xref>]. The network is the first of its kind and comprises nine sentinel sites from eight West African countries: one Portuguese-speaking, four French-speaking and three English-speaking countries (see Fig. <xref rid="Fig1" ref-type="fig">1</xref>).<fig id="Fig1"><label>Fig. 1</label><caption><p>Participating WANETAM sites. Coordinated by the Medical Research. Council Unit (<italic>MRC</italic>), The Gambia, the following partner sites were part of the capacity building activities and drug resistance surveys: (1) Senegal, Laboratoire Bactériologie Virologie, Le Dantec, Dakar; (2) The Gambia, National Public Health Laboratory Services, Banjul; (3) Guinea-Bissau, National Institute of Public Health (<italic>INASA</italic>), Bissau; (4) Mali, SEREFO (HIV/TB Research and Training Center) FMOS, University of STT, Bamako; (5) Burkina Faso, Centre Muraz and the National TB Program (<italic>NTP</italic>), Ouagadougou; (6) Ghana, Korle Bu Teaching Hospital, Accra; (7) Togo, Laboratoire National de Référence (<italic>LNR</italic>) des Mycobactéries, Lome; (8) Nigeria, Nigerian Institute of Medical Research (<italic>NIMR</italic>), Lagos; (9) Nigeria, College of Medicine, University of Ibadan</p></caption><graphic xlink:href="12916_2016_704_Fig1_HTML" id="MO1"></graphic></fig></p><p>Within the TB work package, spearheaded by the Medical Research Council (MRC) Unit, The Gambia, emphasis was on assessing the distribution of drug-resistant <italic>Mycobacterium tuberculosis</italic> in West Africa, as routine TB surveillance mechanisms and data on TB resistance are scarce in the region [<xref ref-type="bibr" rid="CR3">3</xref>]. Detecting multi-drug-resistant tuberculosis (MDR-TB), defined as <italic>Mycobacterium tuberculosis</italic> resistant to rifampicin and isoniazid, is increasingly important, as drug resistance has emerged as one of the biggest challenges for TB control [<xref ref-type="bibr" rid="CR4">4</xref>]. Furthermore, it is crucial to understand whether prevalent MDR isolates in the region will be susceptible to second-line drugs or have already acquired resistance to the quinolones or injectable aminoglycosides (pre-extensively drug-resistant [pre-XDR]) or resistance to both classes (extensively drug-resistant [XDR]), as these phenotypes are associated with a worse prognosis [<xref ref-type="bibr" rid="CR4">4</xref>]. Besides the comparably low success rates of curing patients infected with MDR-TB (48 %) [<xref ref-type="bibr" rid="CR4">4</xref>], in most West African countries either adequate MDR therapy is not readily available or sub-optimal treatment regimens are in use. If we can show that drug-resistant TB is important in WANETAM countries, this will justify implementation of standardised (inter)national drug susceptibility testing (DST) surveillance systems and roll-out of adequate MDR treatment programs across West Africa. In addition, an international TB drug resistance study prepares the region for future multi-centre clinical TB trials of new regimens for MDR-TB.</p></sec><sec id="Sec2"><title>Methods</title><sec id="Sec3"><title>Training activities</title><p>The MRC Unit, The Gambia, was a named WANETAM Node of Excellence (NoE) and became the focal point for coordinating Good Clinical Laboratory Practice (GCLP) and all TB-related activities. In order to prepare the WANETAM network for a multi-centre study (and future clinical trials), common standards between the study sites had to be implemented. This was achieved by conducting a series of initial workshops (see Table <xref rid="Tab1" ref-type="table">1</xref>).<table-wrap id="Tab1"><label>Table 1</label><caption><p>Capacity building and training activities within WANETAM</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Year</th><th>Workshop title</th><th>Content</th><th>Duration</th><th>Location</th><th>Number of trainees</th></tr></thead><tbody><tr><td>2010</td><td>Good Clinical Laboratory Practice (GCLP)</td><td>Principles of GCLP</td><td>1 week</td><td>MRC</td><td>18</td></tr><tr><td rowspan="4">2011</td><td rowspan="4">Basic Mycobacteriology</td><td>Microscopy</td><td rowspan="4">4 weeks</td><td rowspan="4">MRC</td><td rowspan="4">18</td></tr><tr><td>Isolation of mycobacteria</td></tr><tr><td>Solid and liquid culture</td></tr><tr><td>Storage of isolates</td></tr><tr><td>2013</td><td>IATA Certification Training</td><td>Shipment of isolates</td><td>2 days</td><td>Benin</td><td>23</td></tr><tr><td rowspan="4">2012</td><td rowspan="4">Molecular Epidemiology of MDR-TB in West Africa</td><td>Boiled lysate/genomic DNA extraction</td><td rowspan="4">2 weeks</td><td rowspan="4">MRC</td><td rowspan="4">18</td></tr><tr><td>Polymerase chain reaction (PCR)</td></tr><tr><td>Hain MTBDR<italic>plus</italic></td></tr><tr><td>Spoligotyping</td></tr><tr><td rowspan="4">2013</td><td rowspan="4">Rapid Detection, Rapid Action: TB diagnosis with GeneXpert</td><td>Background on RT-PCR testing</td><td rowspan="4">1 week</td><td rowspan="4">MRC</td><td rowspan="4">18</td></tr><tr><td>GeneXpert technology and maintenance</td></tr><tr><td>Practical Xpert MTB/RIF</td></tr><tr><td>Result interpretation</td></tr><tr><td>2013</td><td>From Bench to Genome, a Simplified Perspective</td><td>Bioinformatics course</td><td>1 day</td><td>MRC</td><td>18</td></tr><tr><td rowspan="3">2014</td><td rowspan="3">Data Analysis and Publishing</td><td>Statistics</td><td rowspan="3">1 week</td><td rowspan="3">MRC</td><td rowspan="3">18</td></tr><tr><td>Critical appraisal of data</td></tr><tr><td>Writing skills</td></tr><tr><td>2010–2014</td><td>12 Visits to Partner Sites</td><td>Customised training</td><td>8 weeks</td><td>WANETAM sites</td><td>–</td></tr></tbody></table><table-wrap-foot><p><italic>MTBDRplus</italic> assay for rapid detection of multi-drug-resistant TB, <italic>Xpert MTB/RIF</italic> assay for rapid detection of TB and resistance to rifampicin</p></table-wrap-foot></table-wrap></p><p>In parallel, laboratories of partner institutes were initially assessed in their proficiency towards performing routine diagnostics, including smear microscopy, culture and isolate storage. To assist the member countries in their efforts to implement the current state-of-the-art diagnostics, several regional workshops, during which participants received not only theoretical knowledge but also hands-on practice in laboratory activities, were conducted (see Table <xref rid="Tab1" ref-type="table">1</xref>). To guarantee comparability of diagnostic techniques between study sites, all assays were performed according to disseminated Standard Operating Procedures (SOPs) and GCLP. The initial workshops conveyed basic diagnostic methods, such as microscopy, solid/liquid culture and storage of isolates, which provided essential knowledge needed for conducting drug resistance surveys. To reinforce the knowledge gained and to troubleshoot arising problems, there were 12 customised on-site visits (consisting of 8 weeks in total) of MRC staff to partner laboratories. Additional training included a variety of DNA extraction protocols and advanced molecular methods such as phenotypic DST testing or the Hain GenoType MTBDR<italic>plus</italic> and GenXpert MTB/RIF for genotypic DST testing. Training in a basic genotyping method (spoligotyping) was provided for early detection of potential outbreaks of resistant clones. For an overview of the conducted workshops and their detailed content, see Table <xref rid="Tab1" ref-type="table">1</xref>.</p></sec><sec id="Sec4"><title>Sample collection and shipment</title><p>We collected consecutive TB isolates from new and retreatment patients (according to WHO case definitions [<xref ref-type="bibr" rid="CR3">3</xref>]) from nine West African partner institutes (see Fig. <xref rid="Fig1" ref-type="fig">1</xref>) in the following eight West African countries: Burkina Faso, The Gambia, Ghana, Guinea-Bissau, Mali, Nigeria, Senegal and Togo. The isolates were collected between 2009–2013 from the TB referring centres in each capital city, and for Togo these represented countrywide samples. Nigeria was the only country with two sites, one in Lagos and the other in Ibadan. Conducting a standardised sampling approach was challenging, as the catchment areas of recruited patients between the partner sites varied. For example, the Nigerian Institute of Medical Research (NIMR) in Lagos is a countrywide referral centre for patients with suspected drug-resistant TB, whereas in The Gambia all of the patients were recruited from the Greater Banjul Area. All isolates were processed according to common SOPs and shipped to MRC fully compliant with the International Air Transport Association (IATA) Dangerous Goods Regulations (<ext-link ext-link-type="uri" xlink:href="https://www.iata.org/services/Microsites/DGR/en/index.html">https://www.iata.org/services/Microsites/DGR/en/index.html</ext-link>) [<xref ref-type="bibr" rid="CR5">5</xref>]. Resistance profiles to first- and second-line drugs were performed at MRC Unit, The Gambia, and isolates were archived in a biobank.</p></sec><sec id="Sec5"><title>First- and second-line drug susceptibility testing</title><p>Drug susceptibility testing (DST) was performed to determine the resistance pattern of isolates to first- and second-line anti-TB drugs. The standard protocol for DST for the first-line drugs streptomycin (STR, 1 μg/mL), isoniazid (INH, 0.1 μg/mL), rifampicin (RIF, 1 μg/mL) and ethambutol (EMB, 5 μg/mL) in MGIT 960 (Becton Dickinson, Oxford Science Park, Oxford, UK) was followed according to the manufacturer’s instructions [<xref ref-type="bibr" rid="CR6">6</xref>]. Phenotypic DST for second-line drugs was performed on identified MDR isolates in MGIT 960 (Becton Dickinson, Oxford Science Park, Oxford, UK) using kanamycin (KAN, 2.5 μg/mL) capreomycin (CAP, 2.5 μg/mL), ofloxacin (OFX, 2 μg/mL) and ethionamide (ETH, 5 μg/mL) (Sigma-Aldrich, St. Louis, Mo, USA) [<xref ref-type="bibr" rid="CR7">7</xref>].</p></sec><sec id="Sec6"><title>Quality assurance</title><p>To assure accuracy of DST results, the MRC TB Diagnostics Laboratory participates in external quality assurance from the National External Quality Assessment Service (NEQAS), UK (<ext-link ext-link-type="uri" xlink:href="http://www.ukneqas.org.uk/">http://www.ukneqas.org.uk/</ext-link>). A blinded panel provided by WHO through the National Mycobacterium Reference Laboratory in the UK (<ext-link ext-link-type="uri" xlink:href="https://www.gov.uk/government/collections/national-mycobacterium-reference-laboratory-nmrl">https://www.gov.uk/government/collections/national-mycobacterium-reference-laboratory-nmrl</ext-link>) was analysed for quality assurance of speciation and first- and second-line DST. In addition, a standardised susceptible H37Rv (ATCC 27249) laboratory strain was included in each batch. The MRC Diagnostics laboratories’ first- and second-line DST together with other diagnostic assays achieved ISO15189:2012 accreditation in July 2015.</p></sec><sec id="Sec7"><title>Data management and statistical analysis</title><p>Sample data were entered in real time at MRC Unit, The Gambia, into a custom-built Structured Query Language (SQL) database with an Access front end. Data were checked thoroughly for consistency before the database was locked in June 2015. The extracted data were analysed using Stata/SE v12.1 (2011, Stata Statistical Software: Release 12, StataCorp LP, College Station, TX, USA). Categorical data were summarised using appropriate descriptive count and percentage statistics. To achieve appropriate coverage, confidence intervals were constructed using the Wilson interval. All analyses were split by site and treatment history status (new and retreatment).</p></sec></sec><sec id="Sec8"><title>Results</title><sec id="Sec9"><title>Drug resistance in West Africa</title><sec id="Sec10"><title>Mycobacterial collection and patient characteristics</title><p>Isolates were collected from new and retreatment patients from each of the study sites, analysed and then archived for future research in a newly founded biobank at MRC Unit, The Gambia. A total of 1568 isolates were collected across the nine study sites and sent to MRC Unit, The Gambia. Out of 1462 that were processed, 9 % were contaminated and 25 % were non-viable following the shipment. In total, 974 isolates (66 %) were included in the drug resistance survey and stored at –70 °C (see Fig. <xref rid="Fig2" ref-type="fig">2</xref>). For an overview of patient demographics, including treatment history, sex, age and HIV status, see Table <xref rid="Tab2" ref-type="table">2</xref>.<fig id="Fig2"><label>Fig. 2</label><caption><p>Flowchart of collected, shipped and processed samples included in the present study</p></caption><graphic xlink:href="12916_2016_704_Fig2_HTML" id="MO2"></graphic></fig><table-wrap id="Tab2"><label>Table 2</label><caption><p>Patient characteristics of study population at individual WANETAM study sites</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2" colspan="2"></th><th colspan="2">Burkina Faso</th><th colspan="2">The Gambia</th><th colspan="2">Ghana</th><th colspan="2">Guinea-Bissau</th><th colspan="2">Mali</th><th colspan="2">Nigeria Ibadan</th><th colspan="2">Nigeria Lagos</th><th colspan="2">Senegal</th><th colspan="2">Togo</th><th colspan="2">All study sites</th></tr><tr><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th></tr></thead><tbody><tr><td colspan="2">Total</td><td>27</td><td>(3)</td><td>104</td><td>(11)</td><td>127</td><td>(13)</td><td>44</td><td>(5)</td><td>208</td><td>(21)</td><td>57</td><td>(6)</td><td>120</td><td>(12)</td><td>75</td><td>(8)</td><td>212</td><td>(21)</td><td>974</td><td>(100)</td></tr><tr><td rowspan="3">Treatment history</td><td>New</td><td>20</td><td>(74)</td><td>9</td><td>(9)</td><td>15</td><td>(12)</td><td>32</td><td>(73)</td><td>150</td><td>(72)</td><td>13</td><td>(23)</td><td>28</td><td>(23)</td><td>55</td><td>(73)</td><td>94</td><td>(44)</td><td>416</td><td>(43)</td></tr><tr><td>Retreatment</td><td>1</td><td>(4)</td><td>95</td><td>(91)</td><td>112</td><td>(88)</td><td>4</td><td>(9)</td><td>58</td><td>(28)</td><td>44</td><td>(77)</td><td>88</td><td>(73)</td><td>20</td><td>(27)</td><td>112</td><td>(53)</td><td>534</td><td>(55)</td></tr><tr><td>Unknown</td><td>6</td><td>(22)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>8</td><td>(18)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>4</td><td>(3)</td><td>0</td><td>(0)</td><td>6</td><td>(3)</td><td>24</td><td>(2)</td></tr><tr><td rowspan="8">Age</td><td>0–14</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>1</td><td>(1)</td><td>1</td><td>(3)</td><td>4</td><td>(2)</td><td>3</td><td>(5)</td><td>1</td><td>(1)</td><td>4</td><td>(5)</td><td>3</td><td>(1)</td><td>17</td><td>(2)</td></tr><tr><td>15–24</td><td>3</td><td>(14)</td><td>31</td><td>(30)</td><td>16</td><td>(13)</td><td>10</td><td>(26)</td><td>50</td><td>(24)</td><td>6</td><td>(10)</td><td>16</td><td>(14)</td><td>12</td><td>(16)</td><td>27</td><td>(13)</td><td>171</td><td>(18)</td></tr><tr><td>25–34</td><td>3</td><td>(14)</td><td>31</td><td>(30)</td><td>35</td><td>(29)</td><td>12</td><td>(31)</td><td>78</td><td>(38)</td><td>21</td><td>(37)</td><td>45</td><td>(39)</td><td>25</td><td>(34)</td><td>57</td><td>(27)</td><td>307</td><td>(31)</td></tr><tr><td>35–44</td><td>8</td><td>(38)</td><td>20</td><td>(20)</td><td>32</td><td>(26)</td><td>7</td><td>(18)</td><td>38</td><td>(18)</td><td>15</td><td>(26)</td><td>32</td><td>(28)</td><td>14</td><td>(19)</td><td>57</td><td>(27)</td><td>223</td><td>(23)</td></tr><tr><td>45–54</td><td>3</td><td>(14)</td><td>10</td><td>(10)</td><td>26</td><td>(21)</td><td>6</td><td>(15)</td><td>21</td><td>(10)</td><td>8</td><td>(14)</td><td>12</td><td>(10)</td><td>7</td><td>(9)</td><td>42</td><td>(20)</td><td>135</td><td>(14)</td></tr><tr><td>55–64</td><td>2</td><td>(10)</td><td>7</td><td>(7)</td><td>4</td><td>(3)</td><td>1</td><td>(3)</td><td>11</td><td>(5)</td><td>2</td><td>(4)</td><td>9</td><td>(8)</td><td>5</td><td>(7)</td><td>13</td><td>(6)</td><td>54</td><td>(5)</td></tr><tr><td>65+</td><td>2</td><td>(10)</td><td>3</td><td>(3)</td><td>8</td><td>(7)</td><td>2</td><td>(5)</td><td>6</td><td>(3)</td><td>2</td><td>(4)</td><td>1</td><td>(1)</td><td>7</td><td>(9)</td><td>9</td><td>(4)</td><td>40</td><td>(4)</td></tr><tr><td>Unknown</td><td>6</td><td>–</td><td>2</td><td>-</td><td>5</td><td>-</td><td>5</td><td>–</td><td>0</td><td>–</td><td>0</td><td>–</td><td>4</td><td>–</td><td>1</td><td>–</td><td>4</td><td>–</td><td>27</td><td>(3)</td></tr><tr><td rowspan="3">Sex</td><td>Female</td><td>7</td><td>(33)</td><td>31</td><td>(30)</td><td>29</td><td>(24)</td><td>18</td><td>(44)</td><td>51</td><td>(25)</td><td>23</td><td>(40)</td><td>54</td><td>(46)</td><td>17</td><td>(23)</td><td>76</td><td>(36)</td><td>306</td><td>(31)</td></tr><tr><td>Male</td><td>14</td><td>(67)</td><td>73</td><td>(70)</td><td>93</td><td>(76)</td><td>23</td><td>(56)</td><td>157</td><td>(75)</td><td>34</td><td>(60)</td><td>63</td><td>(54)</td><td>58</td><td>(77)</td><td>136</td><td>(64)</td><td>650</td><td>(67)</td></tr><tr><td>Unknown</td><td>6</td><td>–</td><td>0</td><td>-</td><td>5</td><td>-</td><td>3</td><td>–</td><td>0</td><td>–</td><td>0</td><td>–</td><td>3</td><td>–</td><td>0</td><td>–</td><td>1</td><td>–</td><td>18</td><td>(2)</td></tr><tr><td rowspan="3">HIV</td><td>Negative</td><td>0</td><td>(0)</td><td>56</td><td>(54)</td><td>25</td><td>(20)</td><td>0</td><td>(0)</td><td>172</td><td>(83)</td><td>42</td><td>(74)</td><td>46</td><td>(38)</td><td>15</td><td>(20)</td><td>115</td><td>(54)</td><td>471</td><td>(48)</td></tr><tr><td>Positive</td><td>0</td><td>(0)</td><td>5</td><td>(5)</td><td>3</td><td>(2)</td><td>12</td><td>(27)</td><td>29</td><td>(14)</td><td>4</td><td>(7)</td><td>27</td><td>(23)</td><td>12</td><td>(16)</td><td>36</td><td>(17)</td><td>128</td><td>(14)</td></tr><tr><td>Unknown</td><td>27</td><td>(100)</td><td>43</td><td>(41)</td><td>99</td><td>(78)</td><td>32</td><td>(73)</td><td>7</td><td>(3)</td><td>11</td><td>(19)</td><td>47</td><td>(39)</td><td>48</td><td>(64)</td><td>61</td><td>(29)</td><td>375</td><td>(38)</td></tr></tbody></table></table-wrap></p></sec><sec id="Sec11"><title>Resistance to first-line drugs and MDR</title><p>In total, 39 % of all isolates were resistant to at least one first-line drug, and MDR isolates were found at all sites (Table <xref rid="Tab3" ref-type="table">3</xref> and Fig. <xref rid="Fig3" ref-type="fig">3</xref>). Consistent with previous studies, we found that bacteria isolated from retreatment patients were more than four times more likely to be resistant to one or more first-line drugs when compared to mycobacteria from new patients (OR 4.4 [95 % CI 3.3–5.9]).<table-wrap id="Tab3"><label>Table 3</label><caption><p>First-line drug resistance by study site and treatment history</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="3">Study site</th><th rowspan="3" colspan="2">Treatment history</th><th colspan="4">First-line drug resistance</th><th rowspan="3">Total</th><th colspan="12">DST profiles of resistant isolates</th></tr><tr><th colspan="2">Pan susceptible</th><th colspan="2">Any resistance</th><th colspan="2">RMP mono</th><th colspan="2">INH mono</th><th colspan="2">SM mono</th><th colspan="2">EMB mono</th><th colspan="2">PDR</th><th colspan="2">MDR</th></tr><tr><th><italic>N</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>N</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>N</italic></th><th>%</th><th><italic>n</italic></th><th>%</th></tr></thead><tbody><tr><td rowspan="4">Burkina Faso</td><td rowspan="4">All</td><td></td><td>18</td><td>(67)</td><td>9</td><td>(33)</td><td>27</td><td>0</td><td>(0)</td><td>2</td><td>(7)</td><td>1</td><td>(4)</td><td>0</td><td>(0)</td><td>4</td><td>(15)</td><td>2</td><td>(7)</td></tr><tr><td>New</td><td>13</td><td>(65)</td><td>7</td><td>(35)</td><td>20</td><td>0</td><td>(0)</td><td>2</td><td>(10)</td><td>1</td><td>(5)</td><td>0</td><td>(0)</td><td>3</td><td>(15)</td><td>1</td><td>(5)</td></tr><tr><td>Retreatment</td><td>0</td><td>(0)</td><td>1</td><td>(100)</td><td>1</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>1</td><td>(100)</td></tr><tr><td>Unknown</td><td>5</td><td>(83)</td><td>1</td><td>(17)</td><td>6</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>1</td><td>(17)</td><td>0</td><td>(0)</td></tr><tr><td rowspan="3">The Gambia</td><td rowspan="3">All</td><td></td><td>80</td><td>(77)</td><td>24</td><td>(23)</td><td>104</td><td>1</td><td>(1)</td><td>4</td><td>(4)</td><td>6</td><td>(6)</td><td>0</td><td>(0)</td><td>1</td><td>(1)</td><td>12</td><td>(11)</td></tr><tr><td>New</td><td>7</td><td>(78)</td><td>2</td><td>(22)</td><td>9</td><td>0</td><td>(0)</td><td>1</td><td>(11)</td><td>1</td><td>(11)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>Retreatment</td><td>73</td><td>(77)</td><td>22</td><td>(23)</td><td>95</td><td>1</td><td>(1)</td><td>3</td><td>(3)</td><td>5</td><td>(5)</td><td>0</td><td>(0)</td><td>1</td><td>(1)</td><td>12</td><td>(13)</td></tr><tr><td rowspan="3">Ghana</td><td rowspan="3">All</td><td></td><td>64</td><td>(50)</td><td>63</td><td>(50)</td><td>127</td><td>1</td><td>(0)</td><td>7</td><td>(5)</td><td>13</td><td>(10)</td><td>0</td><td>(0)</td><td>9</td><td>(7)</td><td>33</td><td>(26)</td></tr><tr><td>New</td><td>11</td><td>(73)</td><td>4</td><td>(27)</td><td>15</td><td>0</td><td>(0)</td><td>1</td><td>(7)</td><td>1</td><td>(7)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>2</td><td>(13)</td></tr><tr><td>Retreatment</td><td>53</td><td>(47)</td><td>59</td><td>(53)</td><td>112</td><td>1</td><td>(1)</td><td>6</td><td>(5)</td><td>12</td><td>(11)</td><td>0</td><td>(0)</td><td>9</td><td>(8)</td><td>31</td><td>(28)</td></tr><tr><td rowspan="4">Guinea-Bissau</td><td rowspan="4">All</td><td></td><td>34</td><td>(77)</td><td>10</td><td>(23)</td><td>44</td><td>2</td><td>(4)</td><td>1</td><td>(2)</td><td>1</td><td>(2)</td><td>1</td><td>(2)</td><td>2</td><td>(5)</td><td>3</td><td>(7)</td></tr><tr><td>New</td><td>24</td><td>(75)</td><td>8</td><td>(25)</td><td>32</td><td>2</td><td>(6)</td><td>1</td><td>(3)</td><td>1</td><td>(3)</td><td>1</td><td>(3)</td><td>2</td><td>(6)</td><td>1</td><td>(3)</td></tr><tr><td>Retreatment</td><td>2</td><td>(50)</td><td>2</td><td>(50)</td><td>4</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>2</td><td>(50)</td></tr><tr><td>Unknown</td><td>8</td><td>(100)</td><td>0</td><td>(0)</td><td>8</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td rowspan="3">Mali</td><td rowspan="3">All</td><td></td><td>143</td><td>(69)</td><td>65</td><td>(31)</td><td>208</td><td>1</td><td>(0)</td><td>7</td><td>(3)</td><td>7</td><td>(3)</td><td>0</td><td>(0)</td><td>11</td><td>(5)</td><td>39</td><td>(19)</td></tr><tr><td>New</td><td>127</td><td>(85)</td><td>23</td><td>(15)</td><td>150</td><td>1</td><td>(1)</td><td>7</td><td>(5)</td><td>6</td><td>(4)</td><td>0</td><td>(0)</td><td>4</td><td>(3)</td><td>5</td><td>(3)</td></tr><tr><td>Retreatment</td><td>16</td><td>(28)</td><td>42</td><td>(72)</td><td>58</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>1</td><td>(2)</td><td>0</td><td>(0)</td><td>7</td><td>(12)</td><td>34</td><td>(59)</td></tr><tr><td rowspan="3">Nigeria/Ibadan</td><td rowspan="3">All</td><td></td><td>31</td><td>(54)</td><td>26</td><td>(46)</td><td>57</td><td>1</td><td>(2)</td><td>1</td><td>(2)</td><td>4</td><td>(7)</td><td>0</td><td>(0)</td><td>3</td><td>(5)</td><td>17</td><td>(30)</td></tr><tr><td>New</td><td>11</td><td>(85)</td><td>2</td><td>(15)</td><td>13</td><td>0</td><td>(0)</td><td>1</td><td>(8)</td><td>1</td><td>(8)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>Retreatment</td><td>20</td><td>(45)</td><td>24</td><td>(55)</td><td>44</td><td>1</td><td>(2)</td><td>0</td><td>(0)</td><td>3</td><td>(7)</td><td>0</td><td>(0)</td><td>3</td><td>(7)</td><td>17</td><td>(39)</td></tr><tr><td rowspan="4">Nigeria/Lagos</td><td rowspan="4">All</td><td></td><td>27</td><td>(22)</td><td>93</td><td>(78)</td><td>120</td><td>0</td><td>(0)</td><td>6</td><td>(5)</td><td>11</td><td>(9)</td><td>0</td><td>(0)</td><td>5</td><td>(4)</td><td>71</td><td>(59)</td></tr><tr><td>New</td><td>11</td><td>(40)</td><td>17</td><td>(61)</td><td>28</td><td>0</td><td>(0)</td><td>1</td><td>(4)</td><td>5</td><td>(18)</td><td>0</td><td>(0)</td><td>2</td><td>(7)</td><td>9</td><td>(32)</td></tr><tr><td>Retreatment</td><td>16</td><td>(18)</td><td>72</td><td>(82)</td><td>88</td><td>0</td><td>(0)</td><td>5</td><td>(6)</td><td>6</td><td>(7)</td><td>0</td><td>(0)</td><td>3</td><td>(3)</td><td>58</td><td>(66)</td></tr><tr><td>Unknown</td><td>0</td><td>(0)</td><td>4</td><td>(100)</td><td>4</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>4</td><td>(100)</td></tr><tr><td rowspan="3">Senegal</td><td rowspan="3">All</td><td></td><td>60</td><td>(80)</td><td>15</td><td>(20)</td><td>75</td><td>0</td><td>(0)</td><td>3</td><td>(4)</td><td>1</td><td>(1)</td><td>0</td><td>(0)</td><td>3</td><td>(4)</td><td>8</td><td>(11)</td></tr><tr><td>New</td><td>49</td><td>(90)</td><td>6</td><td>(11)</td><td>55</td><td>0</td><td>(0)</td><td>1</td><td>(2)</td><td>1</td><td>(2)</td><td>0</td><td>(0)</td><td>1</td><td>(2)</td><td>3</td><td>(5)</td></tr><tr><td>Retreatment</td><td>11</td><td>(55)</td><td>9</td><td>(45)</td><td>20</td><td>0</td><td>(0)</td><td>2</td><td>(10)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>2</td><td>(10)</td><td>5</td><td>(25)</td></tr><tr><td rowspan="4">Togo</td><td rowspan="4">All</td><td></td><td>142</td><td>(67)</td><td>70</td><td>(33)</td><td>212</td><td>4</td><td>(2)</td><td>14</td><td>(7)</td><td>16</td><td>(7)</td><td>1</td><td>(0)</td><td>5</td><td>(2)</td><td>30</td><td>(14)</td></tr><tr><td>New</td><td>79</td><td>(84)</td><td>15</td><td>(16)</td><td>94</td><td>1</td><td>(1)</td><td>1</td><td>(1)</td><td>7</td><td>(7)</td><td>0</td><td>(0)</td><td>1</td><td>(1)</td><td>5</td><td>(5)</td></tr><tr><td>Retreatment</td><td>62</td><td>(55)</td><td>50</td><td>(45)</td><td>112</td><td>3</td><td>(3)</td><td>13</td><td>(12)</td><td>8</td><td>(7)</td><td>1</td><td>(1)</td><td>3</td><td>(3)</td><td>22</td><td>(20)</td></tr><tr><td>Unknown</td><td>1</td><td>(17)</td><td>5</td><td>(83)</td><td>6</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>1</td><td>(17)</td><td>0</td><td>(0)</td><td>1</td><td>(17)</td><td>3</td><td>(50)</td></tr><tr><td rowspan="4">All study sites</td><td rowspan="4">All</td><td></td><td>599</td><td>(61)</td><td>375</td><td>(39)</td><td>974</td><td>10</td><td>(1)</td><td>45</td><td>(5)</td><td>60</td><td>(6)</td><td>2</td><td>(0)</td><td>43</td><td>(4)</td><td>215</td><td>(22)</td></tr><tr><td>New</td><td>332</td><td>(80)</td><td>84</td><td>(20)</td><td>416</td><td>4</td><td>(1)</td><td>16</td><td>(4)</td><td>24</td><td>(6)</td><td>1</td><td>(0)</td><td>13</td><td>(3)</td><td>26</td><td>(6)</td></tr><tr><td>Retreatment</td><td>253</td><td>(47)</td><td>281</td><td>(53)</td><td>534</td><td>6</td><td>(1)</td><td>29</td><td>(5)</td><td>35</td><td>(7)</td><td>1</td><td>(0)</td><td>28</td><td>(5)</td><td>182</td><td>(34)</td></tr><tr><td>Unknown</td><td>14</td><td>(58)</td><td>10</td><td>(42)</td><td>24</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>1</td><td>(4)</td><td>0</td><td>(0)</td><td>2</td><td>(8)</td><td>7</td><td>(29)</td></tr></tbody></table><table-wrap-foot><p>The overall proportion of resistance to any drug is displayed as well as a detailed description of resistant isolates and their resistant patterns, stratified by mono-resistance to rifampicin (<italic>RMP</italic>), isoniazid (<italic>INH</italic>), streptomycin (<italic>SM</italic>), ethambutol (<italic>EMB</italic>), poly-drug-resistance (<italic>PDR</italic>, resistance to a combination of any two first-line drugs except for MDR) and multi-drug-resistance (<italic>MDR</italic>, resistance to at least both RMP and INH)</p></table-wrap-foot></table-wrap><fig id="Fig3"><label>Fig. 3</label><caption><p>Geographical distribution and prevalence of drug-resistant <italic>M. tuberculosis</italic> complex isolates in WANETAM study sites. The proportions of resistant strains within the total bacterial population per country are mapped (for Nigeria the average of the two study sites, Lagos and Ibadan, is displayed). The maps are stratified by new (<italic>left column</italic>) and retreatment patients (<italic>right column</italic>). The <italic>upper panel</italic> shows geographical distribution of the proportion of isolates with any first-line drug resistance. The <italic>centre panel</italic> shows the proportion of MDR amongst the total bacterial population. The <italic>lower panel</italic> shows the proportional geographical distribution of pre-XDR within the total population of MDR isolates. The sample sizes for each country are as follows (country name [<italic>n</italic> = new patients/<italic>n</italic> = retreatment patients]): Burkina Faso [20/1], The Gambia [9/95], Ghana [15/112], Guinea-Bissau [32/4], Mali [150/58], Nigeria [41/132] (Lagos and Ibadan combined), Senegal [55/20], Togo [94/112] (for further details see Tables <xref rid="Tab3" ref-type="table">3</xref> and <xref rid="Tab4" ref-type="table">4</xref>)</p></caption><graphic xlink:href="12916_2016_704_Fig3_HTML" id="MO3"></graphic></fig></p><p>Amongst retreatment patients, Mali (59 %) and the Nigerian study sites in Lagos (66 %) and Ibadan (39 %) had the highest percentages of MDR-TB. All other study sites had high numbers of MDR amongst retreatment patients with The Gambia at 13 % being the lowest. With the exception of The Gambia and Nigeria/Ibadan, the majority of countries identified MDR isolates from new patients, with Nigeria/Lagos (32 %) and Ghana (13 %) reporting the largest proportions (Table <xref rid="Tab3" ref-type="table">3</xref>).</p></sec><sec id="Sec12"><title>Resistance to second-line drugs and XDR/pre-XDR</title><p>Amongst all MDR strains tested for second-line drug resistance, no XDR was found (see Table <xref rid="Tab4" ref-type="table">4</xref>). However 41 (21 %) pre-XDR strains resistant to OFX or KAN and/or CAP were found in 199 MDR isolates. Interestingly, only Ghana and Togo reported pre-XDR strains from new patients, whereas pre-XDR from retreatment patients was found in The Gambia, Ghana, Mali, Nigeria (Ibadan/Lagos) and Togo (see Table <xref rid="Tab4" ref-type="table">4</xref>, Fig. <xref rid="Fig3" ref-type="fig">3</xref>).<table-wrap id="Tab4"><label>Table 4</label><caption><p>Second-line drug resistance by study site and treatment history</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="4">Study site</th><th rowspan="4" colspan="2">Treatment history</th><th colspan="4">Second-line drug resistance amongst MDR</th><th rowspan="4">Total MDR with second-line DST done</th><th colspan="8">Pre-XDR drug resistance profiles of MDR isolates</th></tr><tr><th rowspan="2" colspan="2">Susceptible</th><th rowspan="2" colspan="2">Pre-XDR</th><th colspan="2">Fluoroquinolones</th><th colspan="6">Injectables</th></tr><tr><th colspan="2">OFX</th><th colspan="2">KAN</th><th colspan="2">CAP</th><th colspan="2">KAN/CAP</th></tr><tr><th><italic>N</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th><th><italic>n</italic></th><th>%</th></tr></thead><tbody><tr><td rowspan="3">Burkina Faso</td><td rowspan="3">All</td><td></td><td>1</td><td>(100)</td><td>0</td><td>(0)</td><td>1</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>New</td><td>–</td><td>–</td><td>–</td><td>–</td><td>0</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td></tr><tr><td>Retreatment</td><td>1</td><td>(100)</td><td>0</td><td>(0)</td><td>1</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td rowspan="3">The Gambia</td><td rowspan="3">All</td><td></td><td>9</td><td>(75)</td><td>3</td><td>(25)</td><td>12</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>2</td><td>(17)</td><td>1</td><td>(8)</td></tr><tr><td>New</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>Retreatment</td><td>9</td><td>(75)</td><td>3</td><td>(25)</td><td>12</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>2</td><td>(17)</td><td>1</td><td>(8)</td></tr><tr><td rowspan="3">Ghana</td><td rowspan="3">All</td><td></td><td>20</td><td>(61)</td><td>13</td><td>(39)</td><td>33</td><td>3</td><td>(9)</td><td>2</td><td>(6)</td><td>7</td><td>(21)</td><td>1</td><td>(3)</td></tr><tr><td>New</td><td>0</td><td>(0)</td><td>2</td><td>(100)</td><td>2</td><td>0</td><td>(0)</td><td>2</td><td>(100)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>Retreatment</td><td>20</td><td>(65)</td><td>11</td><td>(35)</td><td>31</td><td>3</td><td>(10)</td><td>0</td><td>(0)</td><td>7</td><td>(23)</td><td>1</td><td>(3)</td></tr><tr><td rowspan="3">Guinea-Bissau</td><td rowspan="3">All</td><td></td><td>1</td><td>(100)</td><td>0</td><td>(0)</td><td>1</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>New</td><td>1</td><td>(100)</td><td>0</td><td>(0)</td><td>1</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>Retreatment</td><td>–</td><td>–</td><td>–</td><td>–</td><td>0</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td></tr><tr><td rowspan="3">Mali</td><td rowspan="3">All</td><td></td><td>30</td><td>(79)</td><td>8</td><td>(21)</td><td>38</td><td>1</td><td>(3)</td><td>1</td><td>(3)</td><td>5</td><td>(13)</td><td>1</td><td>(3)</td></tr><tr><td>New</td><td>5</td><td>(100)</td><td>0</td><td>(0)</td><td>5</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>Retreatment</td><td>25</td><td>(76)</td><td>8</td><td>(24)</td><td>33</td><td>1</td><td>(3)</td><td>1</td><td>(3)</td><td>5</td><td>(16)</td><td>1</td><td>(3)</td></tr><tr><td rowspan="3">Nigeria/Ibadan</td><td rowspan="3">All</td><td></td><td>13</td><td>(76)</td><td>4</td><td>(23)</td><td>17</td><td>2</td><td>(12)</td><td>0</td><td>(0)</td><td>2</td><td>(12)</td><td>0</td><td>(0)</td></tr><tr><td>New</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>Retreatment</td><td>13</td><td>(76)</td><td>4</td><td>(23)</td><td>17</td><td>2</td><td>(12)</td><td>0</td><td>(0)</td><td>2</td><td>(12)</td><td>0</td><td>(0)</td></tr><tr><td rowspan="3">Nigeria/Lagos</td><td rowspan="3">All</td><td></td><td>59</td><td>(91)</td><td>6</td><td>(9)</td><td>65</td><td>6</td><td>(9)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>New</td><td>8</td><td>(100)</td><td>0</td><td>(0)</td><td>8</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>Retreatment</td><td>51</td><td>(89)</td><td>6</td><td>(11)</td><td>57</td><td>6</td><td>(10)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td rowspan="3">Senegal</td><td rowspan="3">All</td><td></td><td>5</td><td>(100)</td><td>0</td><td>(0)</td><td>5</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>New</td><td>2</td><td>(100)</td><td>0</td><td>(0)</td><td>2</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td>Retreatment</td><td>3</td><td>(100)</td><td>0</td><td>(0)</td><td>3</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td><td>0</td><td>(0)</td></tr><tr><td rowspan="3">Togo</td><td rowspan="3">All</td><td></td><td>20</td><td>(74)</td><td>7</td><td>(26)</td><td>27</td><td>1</td><td>(4)</td><td>1</td><td>(4)</td><td>3</td><td>(11)</td><td>2</td><td>(7)</td></tr><tr><td>New</td><td>2</td><td>(40)</td><td>3</td><td>(60)</td><td>5</td><td>1</td><td>(20)</td><td>0</td><td>(0)</td><td>1</td><td>(20)</td><td>1</td><td>(20)</td></tr><tr><td>Retreatment</td><td>18</td><td>(82)</td><td>4</td><td>(18)</td><td>22</td><td>0</td><td>(0)</td><td>1</td><td>(4)</td><td>2</td><td>(9)</td><td>1</td><td>(4)</td></tr><tr><td rowspan="3">All study sites</td><td rowspan="3">All</td><td></td><td>158</td><td>(79)</td><td>41</td><td>(21)</td><td>199</td><td>12</td><td>(6)</td><td>4</td><td>(2)</td><td>19</td><td>(9)</td><td>6</td><td>(3)</td></tr><tr><td>New</td><td>18</td><td>(78)</td><td>5</td><td>(22)</td><td>23</td><td>1</td><td>(4)</td><td>2</td><td>(9)</td><td>1</td><td>(4)</td><td>1</td><td>(4)</td></tr><tr><td>Retreatment</td><td>140</td><td>(80)</td><td>36</td><td>(20)</td><td>176</td><td>11</td><td>(6)</td><td>2</td><td>(1)</td><td>18</td><td>(10)</td><td>5</td><td>(3)</td></tr></tbody></table><table-wrap-foot><p>No extensively drug-resistant isolates (<italic>XDR</italic>) were found in the survey. The proportion of pre-XDR within the population of MDR isolates is displayed as well as a detailed description of pre-XDR isolates and their resistance patterns, stratified by mono-resistance to ofloxacin (<italic>OFX</italic>), kanamycin (<italic>KAN</italic>) and capreomycin (<italic>CAP</italic>) and the combination of the latter two (<italic>KAN/CAP</italic>)</p></table-wrap-foot></table-wrap></p></sec></sec></sec><sec id="Sec13"><title>Discussion</title><p>Due to scanty data, most of West Africa remains a ‘blank’ or is classified as ‘no data’ on drug resistance figures in WHO TB reports [<xref ref-type="bibr" rid="CR3">3</xref>]. According to the WHO, lack of laboratory infrastructure is responsible for this shortcoming, and this urgently needs to be overcome [<xref ref-type="bibr" rid="CR3">3</xref>]. A prerequisite for conducting TB drug surveys, and a necessity for any clinical TB trial, is the ability to successfully perform smear microscopy in combination with mycobacterial cultures, both of which were established at the West African study sites within the WANETAM network. In recently designed surveys, such as the one in Senegal, the primary screen for rifampicin resistance is based on the GeneXpert MTB/RIF, followed by culture and DST for rifampicin-resistant sputa and a sub-set of the sensitive ones. Following common SOPs, the nine WANETAM study sites collected sputa and isolated mycobacteria using solid or liquid cultures. Ultimately we described a comprehensive overview of drug resistance in West Africa for the first time.</p><p>We found a high proportion of isolates that were resistant to one or more first-line drugs (39 %) across the West African sites. In addition almost a quarter (22 %) of all isolates tested showed MDR phenotypes and are therefore unlikely to respond to first-line drug therapy or even to the standardised retreatment (category II) regimen that adds only streptomycin as the new drug to the first-line therapy. These infections require specific future TB control measures such as adequate diagnostics and availability of effective therapy based on DST results. Although high rates of MDR in retreatment patients are systematically found across all WANETAM study sites, the situation appears especially alarming in Nigeria (Lagos 66 %, Ibadan 39 %) and Mali (59 %). In Lagos, for instance, 32 % of all new patients with their first ever episode of TB were already presenting with widely circulating MDR isolates. Our findings support previous publications from Nigeria [<xref ref-type="bibr" rid="CR8">8</xref>–<xref ref-type="bibr" rid="CR12">12</xref>] and Burkina Faso [<xref ref-type="bibr" rid="CR13">13</xref>, <xref ref-type="bibr" rid="CR14">14</xref>]; however, variations in the respective MDR prevalence estimates of these publications are considerable, due to differences in sampling strategy, collection time points and location, making an overall comparison difficult. Burkina Faso, Nigeria and Niger were the only WANETAM countries that previously reported XDR isolates [<xref ref-type="bibr" rid="CR3">3</xref>, <xref ref-type="bibr" rid="CR15">15</xref>]. Although we did not identify any XDR isolates in our set of samples, six countries demonstrated the emergence of pre-XDR strains. Despite having the highest MDR prevalence, it was not the site in Lagos, Nigeria but Ghana that yielded the highest proportion of pre-XDR isolates in 11 % and 35 %, respectively, within their MDR population of new and retreatment patients. Overall, 21 % of all MDR strains were pre-XDR across all WANETAM sites combined. As second-line treatment of these strains will be impaired due to lack of susceptibility to either fluoroquinolones or injectable drugs, these pre-XDR bacteria are on the verge of developing the full XDR phenotype if no effective interventions are instituted, and they constitute a major public health threat in the region. Of further concern is that Ghana and Togo, independently from each other, identified pre-XDR amongst new patients. This suggests that these strains have started spreading within the general population of these two neighbouring West African countries, although confirmation by molecular fingerprinting methods of circulating isolates is needed.</p><p>To put the WANETAM results in context, we compared our estimates with the latest data from the WHO Global Tuberculosis Report 2014 (Fig. <xref rid="Fig4" ref-type="fig">4</xref>) [<xref ref-type="bibr" rid="CR3">3</xref>]. To date only three WANETAM countries conducted previous drug-resistance surveys. While a Senegalese survey is presently on-going and Nigeria completed a survey in between 2009–2010 [<xref ref-type="bibr" rid="CR16">16</xref>], data from The Gambia was collected more than a decade ago in 1999 [<xref ref-type="bibr" rid="CR17">17</xref>]. As no previous data existed for several countries in 2013, WHO reports a common MDR estimate (new patient: 1.9 % [0.1 –5.3 %], retreatment: 20 % [0.1–40 %]) for Mali, Guinea-Bissau, Ghana and Burkina Faso.<fig id="Fig4"><label>Fig. 4</label><caption><p>Comparison between WANETAM (<italic>blue</italic>) and WHO Global TB report, 2014 (<italic>red</italic>) MDR prevalence estimates. The country-specific WHO estimates were retrieved from the recent Global TB report, 2014, at <ext-link ext-link-type="uri" xlink:href="http://www.who.int/tb/country/data/profiles/en/">http://www.who.int/tb/country/data/profiles/en/</ext-link> (accessed 11.08.2015). The mean (<italic>triangle</italic>) percentage of MDR per all TB isolates is given for each country/study site and Africa, together with the respective 95 % CI. The <italic>upper panel</italic> shows results for new patients, the <italic>lower panel</italic> retreatment patients. The <italic>shaded areas</italic> display the global average (<italic>dotted line</italic>), including the range from the lower to upper limit of the 95 % CI. Note that in case of a potential strong selection bias, a limitation of the present study, the confidence intervals around the WANETAM mean might still reflect an overestimate of the true prevalence</p></caption><graphic xlink:href="12916_2016_704_Fig4_HTML" id="MO4"></graphic></fig></p><p>Our results allow us to update and complement previous and/or missing data reported to WHO from these eight WANETAM countries (see Fig. <xref rid="Fig4" ref-type="fig">4</xref>). While our estimates are in concordance for Togo and Senegal, we found significantly higher MDR prevalence in retreatment patients in the Nigerian and Malian sites when compared with the WHO estimated data [<xref ref-type="bibr" rid="CR3">3</xref>]. This is not surprising, especially in Nigeria, where a 2012 nationwide TB prevalence survey found WHO estimates were 50 % of the true TB burden [<xref ref-type="bibr" rid="CR16">16</xref>]. In contrast to the WHO estimates, none of the confidence intervals from our nine study sites included zero (in retreatment patients), providing strong evidence that MDR isolates are truly prevalent at all sites (Fig. <xref rid="Fig4" ref-type="fig">4</xref>). WANETAM data tend to be higher than WHO prevalences, highlighting the possibility that drug resistance in West Africa is currently underestimated (see Fig. <xref rid="Fig4" ref-type="fig">4</xref>). For instance, amongst new and retreatment patients, respectively, five out of nine and seven out of nine WANETAM sites were above the global TB prevalence average, and seven out of nine and eight out of nine WANETAM sites were above the estimated African MDR prevalence average.</p><p>Our study has limitations. First of all, sample collection in Burkina Faso and Guinea-Bissau was limited, and therefore the sample sizes were relatively small. We accounted for that by displaying 95 % CI for all study sites wherever appropriate. Secondly, selection bias based on the ‘catchment’ populations of the participating sites is likely to contribute to the high resistance rates, especially at NIMR in Lagos, which included a referral population who had been identified as resistant elsewhere. Also, despite thorough training, we cannot exclude the potential misclassification of treatment history (new versus retreatment) or infer the missing treatment history data. As no HIV status data were available for the majority of the patients, we were not able to investigate the role of HIV co-infection on MDR rates in our study. Finally, we did not include amikacin in the second-line DST, as it was not sustainably available in West Africa at the time of the initiation of the WANETAM network in 2009.</p><p>The presented MDR data, together with the documented emerging spread of pre-XDR in Ghana and Togo, indicate that the drug-resistance problem in West Africa may be greater than currently assumed, highlighting the urgent need for countrywide drug resistance surveys according to WHO guidelines. While awaiting such robust and unbiased results, our data should already prompt the implementation of continuous surveillance of all retreatment patients in participating countries. Such a system is ideally based on molecular screens, such as with the GeneXpert MTB/RIF, followed by additional molecular and phenotypic testing at the National Reference Laboratories. Moreover, the increasing detection of patients with MDR-TB stresses the need for the wider availability of effective treatment. Such efforts are already on-going, such as the roll-out of the 9-month short-course MDR regimen [<xref ref-type="bibr" rid="CR18">18</xref>] in West and Central African countries with support from the International Union Against Tuberculosis and Lung Disease (IUTLD), beyond Niger, Benin and Cameroon [<xref ref-type="bibr" rid="CR19">19</xref>, <xref ref-type="bibr" rid="CR20">20</xref>], which were early adopters of this regimen and report high rates of treatment success. As demonstrated, the WANETAM network has established essential laboratory capacity to conduct future clinical TB trials. A major challenge, however, for any successful network is its capability to function sustainably and independently. Encouragingly, WANETAM’s capacity building efforts have already had several positive consequences for member states beyond the initially defined network activities. For instance, the National TB Program of The Gambia recently conducted the first Gambian TB prevalence study, The Gambian Survey of Tuberculosis Prevalence (GAMSTEP). Similarly, the Chest Clinic Laboratory at the Korle-Bu Teaching Hospital in Ghana, which did not perform culture in the past, was accredited as the country’s National TB Reference Laboratory in the course of the WANETAM project. SEREFO in Bamako was selected as the diagnostic laboratory during the Malian response to the Ebola epidemic in 2014. During the same outbreak, IATA certified shippers in multiple countries, trained by WANETAM, were often the only staff available to send clinical samples of Ebola patients to respective reference laboratories. Most encouragingly, Senegal, Mali and Benin have hosted their own regional workshops in which both WANETAM member and non-member states, such as Chad, Rwanda or Democratic Republic of Congo (amongst others), were trained in classical microbiological and molecular methods.</p></sec><sec id="Sec14"><title>Conclusion</title><p>WANETAM accomplished the first steps in producing regional TB research of public health relevance in West Africa. As the established TB network is entirely based on South-South collaborations, partners face both similar and unique challenges, and can reach out across the region for further training exchanges and research collaborations. WANETAM is a crucial stepping stone in moving West Africa forward towards independent and internationally competitive TB research, for both the individual institutes and for multi-centred TB trials across the whole sub-region.</p><p>One of the most important achievements of WANETAM so far is the finding that drug-resistant TB could become a serious public health problem in West Africa if required control measures are not taken. This is not only because of high drug-resistant TB rates amongst retreatment patients but especially amongst new patients, showing that on-going transmission is currently insufficiently controlled. As the problem of emerging drug resistance is multi-facetted and sub-regional, control strategies need to improve on various levels and between countries. Implementing required quality standards (SOPs and GCLP) and laboratory infrastructure, as done by WANETAM, can therefore only be a first step in the successful control of drug-resistant TB in West Africa. We hope that our data could serve as a foundation for common West African guidelines and policies, jointly developed by the individual National TB Programs (NTPs) under the guidance of the West African Health Organisation (WAHO). Those guidelines are needed to ultimately tackle the challenges the sub-region is facing. Ideally, scientific networks, such as WANETAM, should consequently be maintained as powerful platforms that would have the capacity to bring the various stakeholders together and facilitate such a process. Therefore, we encourage international donors, such as EDCTP or WHO, to provide further future funds to allow the creation of new and continuation of already existing scientific networks in Africa and the developing world.</p></sec></body><back><glossary><title>Abbreviations</title><def-list><def-item><term>CAP</term><def><p>Capreomycin</p></def></def-item><def-item><term>DST</term><def><p>Drug susceptibility testing</p></def></def-item><def-item><term>EDCTP</term><def><p>European and Developing Countries Clinical Trials Partnership</p></def></def-item><def-item><term>EMB</term><def><p>Ethambutol</p></def></def-item><def-item><term>ETH</term><def><p>Ethionamide</p></def></def-item><def-item><term>GCLP</term><def><p>Good Clinical Laboratory Practice</p></def></def-item><def-item><term>HIV</term><def><p>Human immunodeficiency virus</p></def></def-item><def-item><term>IATA</term><def><p>International Air Transport Association</p></def></def-item><def-item><term>INH</term><def><p>Isoniazid</p></def></def-item><def-item><term>MDR</term><def><p>Multi-drug-resistant</p></def></def-item><def-item><term>NEQAS</term><def><p>National External Quality Assessment Service</p></def></def-item><def-item><term>NoE</term><def><p>Node of Excellence</p></def></def-item><def-item><term>NTP</term><def><p>National TB Program</p></def></def-item><def-item><term>OFX</term><def><p>Ofloxacin</p></def></def-item><def-item><term>OR</term><def><p>Odds ratio</p></def></def-item><def-item><term>Pre-XDR</term><def><p>Pre-extensively drug-resistant</p></def></def-item><def-item><term>RIF</term><def><p>Rifampicin</p></def></def-item><def-item><term>SOP</term><def><p>Standard Operating Procedure</p></def></def-item><def-item><term>STR</term><def><p>Streptomycin</p></def></def-item><def-item><term>TB</term><def><p>Tuberculosis</p></def></def-item><def-item><term>WAHO</term><def><p>West African Health Organisation</p></def></def-item><def-item><term>WANETAM</term><def><p>West African Network of Excellence for Tuberculosis, AIDS and Malaria</p></def></def-item><def-item><term>WHO</term><def><p>World Health Organisation</p></def></def-item><def-item><term>XDR</term><def><p>Extensively drug-resistant</p></def></def-item></def-list></glossary><ack><title>Acknowledgements</title><p>The study was funded by the EDCTP, MRC (UK). We thank the WANETAM Secretariat led by Souleymane Mboup (Bactériologie-Virologie CHU Aristide Le Dantec Dakar, Sénégal) for coordination, advice and support throughout the project. We thank the study participants and their families throughout West Africa and the staff members and students at the WANETAM host institutions for study recruitment and sample collection.</p><sec id="FPar1"><title>Funding</title><p>WANETAM and the study are supported by the European & Developing Countries Clinical Trials Partnership (EDCTP) Grant No. CB. 2007. 41700.007</p></sec><sec id="FPar2"><title>Availability of data and materials</title><p>The datasets supporting the conclusions of this article are included within the article.</p></sec><sec id="FPar3"><title>Authors’ contributions</title><p>MA, BdJ, RA, SM and TC proposed the study idea and established the WANETAM consortium. MA supervised the overall TB package of WANETAM including setting-up the sentinel surveillance system. AF, SKudzawu, AKwara, OA, KS, IB, AJallow, MJ, KD, AJ, SC, KE, EI, CO, NO, ADagnra, TFJ, PR, MM, MS, BD, SC, and AJallow clinically investigated and recruited the patients at the sentinel sites, collected demographic data and Mtb. SK, OA, KS, IB, AJallow, ABD, MJ, KD, KE, EI, NO, AJ, PR, MM, MSanogo and SA performed smear microscopy and Mtb culture at sentinel sites and shipped Mtb to MRC Unit The Gambia. JO performed DST at MRC Unit, The Gambia supervised by MA. MA supervised the overall Mycobacteriology work at The MRC Unit The Gambia. UD and TC provided institutional support whilst SM and AJaye provided WANETAM Secretariat support. BK provided Theme support at MRC Unit, The Gambia. MA, FG and BdJ developed the analysis plan and LK performed the statistical analysis FG, JO, LK, BdJ and MA drafted the paper. All authors contributed to the interpretation of the findings and the writing of the final manuscript.</p></sec><sec id="FPar4"><title>Competing interests</title><p>The authors declare that they have no competing interests.</p></sec><sec id="FPar5"><title>Ethics approval and consent to participate</title><p>The partnering sites in Guinea-Bissau, The Gambia, Mali, Burkina Faso, Ghana, Nigeria/Ibadan and Nigeria/Lagos obtained ethical approval through their local ethics boards, including:<list list-type="order"><list-item><p>Comité Nacional de Ética na Saúde/National Ethic Committe for Health, Guinea-Bissau</p></list-item><list-item><p>Joint Gambia Government/MRC Ethics Committee, The Gambia</p></list-item><list-item><p>Ethics Committee of the Faculty of Medicine, Pharmacy and Dentistry of Bamako, Mali;</p></list-item><list-item><p>Comité d’Ethique pour la Recherche en Santé (CERS/MESSRS)/Burkina Faso</p></list-item><list-item><p>University of Ghana Medical School Ethics and Protocol Review Committee, Ghana</p></list-item><list-item><p>University of Ibadan and University College Hospital, Ibadan joint ethical review Committees, Ibadan, Nigeria</p></list-item><list-item><p>Nigerian Institute of Medical Research, institutional board, Lagos, Nigeria.</p></list-item></list></p><p>However, for the sites in Togo and Senegal, ethical approval was not a requirement, as drug susceptibility testing of collected isolates is approved within the routine TB diagnostic algorithm. Additionally, the study received overarching ethical approval (SCC1255) by the joint MRC/The Gambia Government ethics board that allowed the analysis of collected West African isolates at MRC Unit, The Gambia.</p></sec></ack><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Roca</surname><given-names>A</given-names></name><name><surname>Afolabi</surname><given-names>MO</given-names></name><name><surname>Saidu</surname><given-names>Y</given-names></name><name><surname>Kampmann</surname><given-names>B</given-names></name></person-group><article-title>Ebola: a holistic approach is required to achieve effective management and control</article-title><source>J Allergy Clin Immunol.</source><year>2015</year><volume>135</volume><fpage>856</fpage><lpage>67</lpage><pub-id pub-id-type="doi">10.1016/j.jaci.2015.02.015</pub-id><pub-id pub-id-type="pmid">25843598</pub-id></element-citation></ref><ref id="CR2"><label>2.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Miiro</surname><given-names>GM</given-names></name><name><surname>Oukem-Boyer</surname><given-names>OO</given-names></name><name><surname>Sarr</surname><given-names>O</given-names></name><name><surname>Rahmani</surname><given-names>M</given-names></name><name><surname>Ntoumi</surname><given-names>F</given-names></name><etal></etal></person-group><article-title>EDCTP regional networks of excellence: initial merits for planned clinical trials in Africa</article-title><source>BMC Public Health.</source><year>2013</year><volume>13</volume><fpage>258</fpage><pub-id pub-id-type="doi">10.1186/1471-2458-13-258</pub-id><pub-id pub-id-type="pmid">23517572</pub-id></element-citation></ref><ref id="CR3"><label>3.</label><element-citation publication-type="book"><person-group person-group-type="author"><collab>World Health Organization</collab></person-group><source>WHO report, global tuberculosis report</source><year>2014</year><publisher-loc>Geneva</publisher-loc><publisher-name>World Health Organization</publisher-name></element-citation></ref><ref id="CR4"><label>4.</label><element-citation publication-type="book"><person-group person-group-type="author"><collab>World Health Organization</collab></person-group><source>Multidrug-resistant tuberculosis (MDR-TB), 2014 update</source><year>2014</year><publisher-loc>Geneva</publisher-loc><publisher-name>World Health Organization</publisher-name></element-citation></ref><ref id="CR5"><label>5.</label><element-citation publication-type="book"><person-group person-group-type="author"><collab>International Air Transport Association</collab></person-group><source>Infectious substances shipping guidelines — The complete reference guide for pharmaceutical & health professionals</source><year>2013</year><edition>12</edition><publisher-loc>Montreal</publisher-loc><publisher-name>IATA</publisher-name></element-citation></ref><ref id="CR6"><label>6.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ardito</surname><given-names>F</given-names></name><name><surname>Posteraro</surname><given-names>B</given-names></name><name><surname>Sanguinetti</surname><given-names>M</given-names></name><name><surname>Zanetti</surname><given-names>S</given-names></name><name><surname>Fadda</surname><given-names>G</given-names></name></person-group><article-title>Evaluation of BACTEC Mycobacteria Growth Indicator Tube (MGIT 960) automated system for drug susceptibility testing of <italic>Mycobacterium tuberculosis</italic></article-title><source>J Clin Microbiol.</source><year>2001</year><volume>39</volume><fpage>4440</fpage><lpage>4</lpage><pub-id pub-id-type="doi">10.1128/JCM.39.12.4440-4444.2001</pub-id><pub-id pub-id-type="pmid">11724858</pub-id></element-citation></ref><ref id="CR7"><label>7.</label><element-citation publication-type="book"><person-group person-group-type="author"><collab>World Health Organization</collab></person-group><source>The Stop TB Department. Policy guidance on drug-susceptibility testing (DST) of second-line antituberculosis drugs</source><year>2008</year><publisher-loc>Geneva</publisher-loc><publisher-name>World Health Organization</publisher-name></element-citation></ref><ref id="CR8"><label>8.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ani</surname><given-names>AE</given-names></name><name><surname>Idoko</surname><given-names>J</given-names></name><name><surname>Dalyop</surname><given-names>YB</given-names></name><name><surname>Pitmang</surname><given-names>SL</given-names></name></person-group><article-title>Drug resistance profile of <italic>Mycobacterium tuberculosis</italic> isolates from pulmonary tuberculosis patients in Jos, Nigeria</article-title><source>Trans R Soc Trop Med Hyg.</source><year>2009</year><volume>103</volume><fpage>67</fpage><lpage>71</lpage><pub-id pub-id-type="doi">10.1016/j.trstmh.2008.08.004</pub-id><pub-id pub-id-type="pmid">18789463</pub-id></element-citation></ref><ref id="CR9"><label>9.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Daniel</surname><given-names>O</given-names></name><name><surname>Osman</surname><given-names>E</given-names></name></person-group><article-title>Prevalence and risk factors associated with drug resistant TB in South West, Nigeria</article-title><source>Asian Pac J Trop Med.</source><year>2011</year><volume>4</volume><fpage>148</fpage><lpage>51</lpage><pub-id pub-id-type="doi">10.1016/S1995-7645(11)60057-6</pub-id><pub-id pub-id-type="pmid">21771441</pub-id></element-citation></ref><ref id="CR10"><label>10.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kehinde</surname><given-names>AO</given-names></name><name><surname>Adebiyi</surname><given-names>EO</given-names></name></person-group><article-title>Molecular diagnosis of MDR-TB using GenoType MTBDRplus 96 assay in Ibadan, Nigeria</article-title><source>Niger J Physiol Sci.</source><year>2013</year><volume>28</volume><fpage>187</fpage><lpage>91</lpage><pub-id pub-id-type="pmid">24937395</pub-id></element-citation></ref><ref id="CR11"><label>11.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Lawson</surname><given-names>L</given-names></name><name><surname>Yassin</surname><given-names>MA</given-names></name><name><surname>Abdurrahman</surname><given-names>ST</given-names></name><name><surname>Parry</surname><given-names>CM</given-names></name><name><surname>Dacombe</surname><given-names>R</given-names></name><etal></etal></person-group><article-title>Resistance to first-line tuberculosis drugs in three cities of Nigeria</article-title><source>Trop Med Int Health.</source><year>2011</year><volume>16</volume><fpage>974</fpage><lpage>80</lpage><pub-id pub-id-type="doi">10.1111/j.1365-3156.2011.02792.x</pub-id><pub-id pub-id-type="pmid">21564425</pub-id></element-citation></ref><ref id="CR12"><label>12.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Otu</surname><given-names>A</given-names></name><name><surname>Umoh</surname><given-names>V</given-names></name><name><surname>Habib</surname><given-names>A</given-names></name><name><surname>Ansa</surname><given-names>V</given-names></name></person-group><article-title>Prevalence and clinical predictors of drug-resistant tuberculosis in three clinical settings in Calabar, Nigeria</article-title><source>Clin Respir J.</source><year>2014</year><volume>8</volume><fpage>234</fpage><lpage>9</lpage><pub-id pub-id-type="doi">10.1111/crj.12065</pub-id><pub-id pub-id-type="pmid">24131513</pub-id></element-citation></ref><ref id="CR13"><label>13.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sangare</surname><given-names>L</given-names></name><name><surname>Diande</surname><given-names>S</given-names></name><name><surname>Badoum</surname><given-names>G</given-names></name><name><surname>Dingtoumda</surname><given-names>B</given-names></name><name><surname>Traore</surname><given-names>AS</given-names></name></person-group><article-title>Anti-tuberculosis drug resistance in new and previously treated pulmonary tuberculosis cases in Burkina Faso</article-title><source>Int J Tuberc Lung Dis.</source><year>2010</year><volume>14</volume><fpage>1424</fpage><lpage>9</lpage><pub-id pub-id-type="pmid">20937182</pub-id></element-citation></ref><ref id="CR14"><label>14.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sangare</surname><given-names>L</given-names></name><name><surname>Diande</surname><given-names>S</given-names></name><name><surname>Kouanda</surname><given-names>S</given-names></name><name><surname>Dingtoumda</surname><given-names>BI</given-names></name><name><surname>Mourfou</surname><given-names>A</given-names></name><etal></etal></person-group><article-title><italic>Mycobacterium tuberculosis</italic> drug-resistance in previously treated patients in Ouagadougou, Burkina Faso</article-title><source>Ann Afr Med.</source><year>2010</year><volume>9</volume><fpage>15</fpage><lpage>9</lpage><pub-id pub-id-type="doi">10.4103/1596-3519.62619</pub-id><pub-id pub-id-type="pmid">20418644</pub-id></element-citation></ref><ref id="CR15"><label>15.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Saleri</surname><given-names>N</given-names></name><name><surname>Badoum</surname><given-names>G</given-names></name><name><surname>Ouedraogo</surname><given-names>M</given-names></name><name><surname>Dembele</surname><given-names>SM</given-names></name><name><surname>Nacanabo</surname><given-names>R</given-names></name><etal></etal></person-group><article-title>Extensively drug-resistant tuberculosis, Burkina Faso</article-title><source>Emerg Infect Dis.</source><year>2010</year><volume>16</volume><fpage>840</fpage><lpage>2</lpage><pub-id pub-id-type="doi">10.3201/eid1605.091262</pub-id><pub-id pub-id-type="pmid">20409379</pub-id></element-citation></ref><ref id="CR16"><label>16.</label><mixed-citation publication-type="other">Sebastian V. From facility to finding drug resistance mutations: drug resistance survey in Nigeria. 45th Union World Conference on Lung Health. Barcelona; 2014. p. 57.</mixed-citation></ref><ref id="CR17"><label>17.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Adegbola</surname><given-names>RA</given-names></name><name><surname>Hill</surname><given-names>P</given-names></name><name><surname>Baldeh</surname><given-names>I</given-names></name><name><surname>Otu</surname><given-names>J</given-names></name><name><surname>Sarr</surname><given-names>R</given-names></name><etal></etal></person-group><article-title>Surveillance of drug-resistant <italic>Mycobacterium tuberculosis</italic> in The Gambia</article-title><source>Int J Tuberc Lung Dis.</source><year>2003</year><volume>7</volume><fpage>390</fpage><lpage>3</lpage><pub-id pub-id-type="pmid">12729346</pub-id></element-citation></ref><ref id="CR18"><label>18.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Van Deun</surname><given-names>A</given-names></name><name><surname>Maug</surname><given-names>AK</given-names></name><name><surname>Salim</surname><given-names>MA</given-names></name><name><surname>Das</surname><given-names>PK</given-names></name><name><surname>Sarker</surname><given-names>MR</given-names></name><etal></etal></person-group><article-title>Short, highly effective, and inexpensive standardized treatment of multidrug-resistant tuberculosis</article-title><source>Am J Respir Crit Care Med.</source><year>2010</year><volume>182</volume><fpage>684</fpage><lpage>92</lpage><pub-id pub-id-type="doi">10.1164/rccm.201001-0077OC</pub-id><pub-id pub-id-type="pmid">20442432</pub-id></element-citation></ref><ref id="CR19"><label>19.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kuaban</surname><given-names>C</given-names></name><name><surname>Noeske</surname><given-names>J</given-names></name><name><surname>Rieder</surname><given-names>HL</given-names></name><name><surname>Ait-Khaled</surname><given-names>N</given-names></name><name><surname>Abena Foe</surname><given-names>JL</given-names></name><etal></etal></person-group><article-title>High effectiveness of a 12-month regimen for MDR-TB patients in Cameroon</article-title><source>Int J Tuberc Lung Dis.</source><year>2015</year><volume>19</volume><fpage>517</fpage><lpage>24</lpage><pub-id pub-id-type="doi">10.5588/ijtld.14.0535</pub-id><pub-id pub-id-type="pmid">25868018</pub-id></element-citation></ref><ref id="CR20"><label>20.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Piubello</surname><given-names>A</given-names></name><name><surname>Harouna</surname><given-names>SH</given-names></name><name><surname>Souleymane</surname><given-names>MB</given-names></name><name><surname>Boukary</surname><given-names>I</given-names></name><name><surname>Morou</surname><given-names>S</given-names></name><etal></etal></person-group><article-title>High cure rate with standardised short-course multidrug-resistant tuberculosis treatment in Niger: no relapses</article-title><source>Int J Tuberc Lung Dis.</source><year>2014</year><volume>18</volume><fpage>1188</fpage><lpage>94</lpage><pub-id pub-id-type="doi">10.5588/ijtld.13.0075</pub-id><pub-id pub-id-type="pmid">25216832</pub-id></element-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
EXPLOR_STEP=$WICRI_ROOT/Wicri/Sante/explor/SidaGhanaV1/Data/Pmc/Corpus
HfdSelect -h $EXPLOR_STEP/biblio.hfd -nk 000102 | SxmlIndent | more
Ou
HfdSelect -h $EXPLOR_AREA/Data/Pmc/Corpus/biblio.hfd -nk 000102 | SxmlIndent | more
Pour mettre un lien sur cette page dans le réseau Wicri
{{Explor lien
|wiki= Wicri/Sante
|area= SidaGhanaV1
|flux= Pmc
|étape= Corpus
|type= RBID
|clé= PMC:5094099
|texte= The emerging threat of pre-extensively drug-resistant tuberculosis in West Africa: preparing for large-scale tuberculosis research and drug resistance surveillance
}}
Pour générer des pages wiki
HfdIndexSelect -h $EXPLOR_AREA/Data/Pmc/Corpus/RBID.i -Sk "pubmed:27806714" \
| HfdSelect -Kh $EXPLOR_AREA/Data/Pmc/Corpus/biblio.hfd \
| NlmPubMed2Wicri -a SidaGhanaV1
| This area was generated with Dilib version V0.6.31. |  |