Global survey of national tuberculosis drug policies.

SETTING: National tuberculosis (TB) programmes (NTPs) in 100 countries. OBJECTIVES: To evaluate the relationship between the estimated prevalence of multidrug resistance in previously untreated TB cases and policies regarding sales and distribution of TB drugs, particularly rifampicin (RMP). DESIGN: Questionnaire survey of national TB drug control policies, completed by NTP managers. Results were correlated with recent World Health Organization estimates of prevalence of drug resistance in new cases of TB. RESULTS: Questionnaires were received from 100 countries, including 88 low- and middle-income countries (LMICs) and 17 of the 22 high-burden countries. Current policies were considered adequate in only 40 of the 88 LMICs (45%). A higher prevalence of multidrug resistance was associated with fewer years of free availability of TB drugs from the NTP (P = 0.02) and more years of availability of RMP from providers or pharmacies outside the NTP (P = 0.02). Eleven of the 20 countries with the highest prevalence of multidrug resistance had inadequate policies governing sales and distribution of TB drugs. CONCLUSIONS: These findings suggest that policies regarding sales and distribution of TB drugs should receive more emphasis as part of the global strategy to control drug resistance.

Harmonisation of TB control in the WHO European region: the history of the Wolfheze Workshops.

In 1990 a workshop was organised in the village of Wolfheze (the Netherlands), where experts discussed the critical interventions that would foster elimination of TB in Europe. This event has been followed by several more over the following two decades to become known as the "Wolfheze Workshops". This article provides a brief overview of the history and the impact the Wolfheze Workshops have had on the commitment of European governments to standardise definitions, recording and reporting systems and, thus, permitted comparison of interventions and improving TB control across borders. The Wolfheze Workshops have been and still are an essential platform for this exchange of experiences, promoting common approaches.

[Berlin Declaration on Tuberculosis: High Level Follow-Up of High Priority Countries for TB Control in the WHO-EURO Region 'Double Trouble or Double Success? Bringing Together Diseases and Programs' - a symposium report]. / Berlin Declaration on Tuberculosis: High Level Follow-Up of High Priority Countries for TB Control in the WHO-EURO Region 'Double Trouble or Double Success? Bringing Together Diseases and Programs' - ein Symposiumsbericht.

The global tuberculosis (TB) situation has deteriorated dramatically since the beginning of the 1990s. In 2007, the WHO identified 18 countries of the WHO European Region as 'high priority countries' and introduced a plan for these countries to improve the situation. To further promote solutions a WHO European Ministerial Forum 'All against Tuberculosis' took place in Berlin in 2007 and resulted in the 'Berlin Declaration' which was commonly endorsed. In October 2009 a meeting was organized by the German Ministry of Health under the title "Berlin Declaration on Tuberculosis: High Level Follow-Up of High Priority Countries for TB Control in the WHO-EURO Region 'Double Trouble or Double Success? Bringing together Diseases and Programs'". This article summarizes the symposium. Besides reporting on the recent epidemiological situation of the WHO-EURO Region (with partly dramatically developments) presentations on psychosocial issues, the role of the EU and the 'Global Fund to Fight AIDS, Tuberculosis and Malaria', the importance of new tools for the fight against tuberculosis and the need for further political commitment were given.

Adjunctive resectional lung surgery for extensively drug-resistant tuberculosis.

Extensively drug-resistant (XDR) tuberculosis (TB) poses significant management challenges as there are limited pharmacological treatment options for cure. Adjunctive resectional lung surgery decreases case-fatality rates for some patients with multidrug-resistant tuberculosis (MDR-TB), but its use has not been well documented for patients with XDR-TB. We describe 17 XDR-TB patients treated with surgery as part of their case management in Latvia during 1999-2005. One patient had no previous TB treatment history, 10 were previously treated for drug-susceptible TB and six were previously treated for MDR-TB. Mycobacterium tuberculosis isolates from the 17 patients were resistant to a mean of 9.2 drugs. Due to failure of pharmacological therapy, one due to a large cavity and one due to pulmonary haemorrhage, 15 patients were treated with surgery. Despite failure of pharmacological treatment in 15 out of 17 patients, eight (47%) were cured with adjunctive surgical treatment. Surgery should be explored as a possible treatment option for patients with XDR-TB.

Reforming tuberculosis control in Ukraine: results of pilot projects and implications for the national scale-up of DOTS.

The period of economic transition has had severe consequences for health and health systems in Ukraine. The tuberculosis (TB) situation illustrates this. The strategy recommended by the World Health Organization (WHO) for TB, directly observed treatment short-course (DOTS), has the potential to provide real improvements in TB services, forming the basis of the response to the growing epidemic. In 2002, Ukraine, financially supported by USAID and the European Community (EC), began to introduce DOTS through pilot projects in Mariupol and Kyiv City. The aim of this study is to assess the feasibility, effectiveness, health service cost, patient cost, and the cost-effectiveness of these pilots, in order to inform the national scale-up of DOTS. The study finds that DOTS is feasible and has the potential to be both effective and cost-effective in Ukraine. Following this study, Ukraine adopted DOTS as a national TB control strategy in 2005. However, the pilots also found that there are several evidence-related concerns and perverse economic incentives to both providers and patients that will need to be addressed if national scale-up is to be successful. These include concerns related to the treatment of MDR-TB, economic benefits to some patients to remain hospitalized, and payments to providers and health facilities that support current practices. These will need to be addressed if Ukraine is to develop an effective response to its emerging TB epidemic.

Drug-resistant tuberculosis and HIV in Ukraine: a threatening convergence of two epidemics?

OBJECTIVE: To investigate anti-tuberculosis (TB) drug resistance rates in Donetsk Oblast, Ukraine, and to explore the association between the epidemics of human immunodeficiency virus (HIV) and multidrug-resistant TB (MDR-TB). METHODS: All consecutive newly diagnosed and previously treated patients with sputum smear-positive TB presenting to all TB units in Donetsk Oblast over 12 months were invited to take part in the study. A total of 1293 and 203 patients with TB were tested for HIV and MDR-TB in the civilian and penitentiary sectors, respectively. RESULTS: Of those enrolled for the study, 307 were HIV-positive, 379 had MDR-TB, and 97 had MDR-TB and HIV co-infection. MDR-TB rates in the civilian sector were respectively 15.5% (95%CI 13.1-17.8) and 41.5% (95%CI 36.4-46.5) in newly diagnosed and previously treated TB patients. Among prisoners, MDR-TB rates were 21.8% (95%CI 12.4-31.2) in new cases and 52.8% (95%CI 43.9-61.7) in previously treated TB cases. HIV status was significantly associated with MDR-TB (OR 1.7, 95%CI 1.3-2.3). CONCLUSIONS: High MDR-TB rates and a positive association between MDR-TB and HIV epidemics were found in Donetsk Oblast. Urgent measures to improve HIV prevention, control of drug-resistant TB and collaboration between HIV and TB control activities need to be implemented without further delay.

Under-reporting of HIV infection among cohorts of TB patients in the WHO European Region, 2003-2004.

SETTING: The World Health Organization (WHO) European Region, which includes 52 countries. OBJECTIVE: To assess an epidemiological data collection tool implemented in 2004 for recording human immunodeficiency virus (HIV) status among tuberculosis (TB) patients. DESIGN: Based on WHO estimates, the reported number of TB patients with HIV was compared with the number expected. The analysis included all forms of TB and was restricted to adults, wherever possible. The numbers of TB patients detected from HIV/acquired immune-deficiency syndrome (AIDS) programmes (NAPs) were also assessed. RESULTS: In 2003, 20 (38%) National TB Programmes (NTPs) reported 4602 (35%) HIV-infected TB cases of 13117 expected; in 2004, 23 (44%) NTPs reported 5902 (42%) cases of 13901 expected. In 2003, 47 (90%) NAPs reported 3575 (27%) TB cases as a new AIDS diagnosis, while in 2004, 40 (77%) NAPs reported 3901 (28%) TB cases. Those countries that did report, reported on average 60-65% of expected cases, irrespective of the kind of programme and the year. CONCLUSION: Most NTPs did not report TB cases with HIV infection. Overall, the number of cases reported in countries that reported data from either NTPs or NAPs was significantly lower than expected. Improved surveillance requires concerted efforts from both NTPs and NAPs.

Tuberculosis in European cities: establishment of a patient monitoring system over 10 years in Paris, France.

BACKGROUND: Tuberculosis (TB) is a persistent public health problem in European cities. France has been unable to report on treatment outcomes until now, and it is not known whether the World Health Organization (WHO) target cure rate of 85% has been met. METHODS: All patients placed under treatment in four hospitals and five out-patient Social Medical Centres in Paris were followed up between 1996 and 2005. Patient monitoring and evaluation were performed using a new software programme, TB-INFO. RESULTS: In a cohort of 1127 patients, 76% had pulmonary TB, of whom 39% were smear-positive, 81% were foreign-born and 9.3% were human immunodeficiency virus positive. At the end of the follow-up, 16% were cured and 54% had completed treatment. Among the 1118 non-multidrug-resistant patients, these percentages were 17% and 46%, respectively, for smear-positive pulmonary patients. Some patients died (1.9%) or failed treatment (0.1%), but many more defaulted (20.5%) as they interrupted treatment (1.5%), were lost to follow-up (19.5%) or were transferred out (7.9%). CONCLUSIONS: This 10-year follow-up of TB patients, managed with TB-INFO software, shows that a patient monitoring system can be implemented in France, providing essential information. Treatment success in this cohort of patients was far below the WHO target.

European framework to decrease the burden of TB/HIV.

Tuberculosis (TB) in Europe is declining in countries in western and central Europe, but the burden is still high and increasing in eastern Europe. HIV/AIDS is increasing dramatically in eastern Europe. HIV-related tuberculosis (TB/HIV) morbidity and mortality are expected to accelerate significantly in the future. This framework aims to guide European countries in developing their national plan for reducing TB/HIV morbidity and mortality. It results from an extensive consultation process undertaken by the World Health Organization Regional Office for Europe and by those responsible for HIV/AIDS and TB programmes and their partners. It builds on strategies developed globally and in Europe for TB control and for HIV/AIDS prevention and care. This framework sets out the rationale for effective collaboration between HIV/AIDS and tuberculosis national programmes. It identifies five strategic components (political commitment, collaborative prevention, intensified case-finding, coordinated treatment and strengthened surveillance) and eight key operations (central coordination, policy development, surveillance, training, supply management, service delivery, health promotion and research).