Alarming levels of multidrug-resistant tuberculosis in Ukraine: results from the first national survey.

SETTING: The true prevalence of multidrug-resistant tuberculosis (MDR-TB) in Ukraine is not known. Available data are a decade old and limited to only one province. OBJECTIVE: To determine the prevalence of MDR-TB among new and previously treated TB cases in Ukraine and explore the risk factors associated with drug resistance. METHODS: A total of 1550 sputum smear-positive pulmonary TB patients were recruited from 40 clusters throughout Ukraine. Sputum specimens were examined using culture, drug susceptibility testing and pncA gene sequencing. RESULTS: The proportion of MDR-TB among new and previously treated TB cases was respectively 24.1% (95%CI 20.7-27.6) and 58.1% (95%CI 52.1-64.1). More than one third (38.0%) of MDR-TB or rifampicin (RMP) resistant cases showed resistance to either a fluoroquinolone (FQ) or a second-line injectable agent or both. Resistance to pyrazinamide and FQs was low in patients with RMP-susceptible TB. Among new TB cases, the odds of MDR-TB were higher among patients who were younger, female and living in south-eastern provinces, as well as among human immunodeficiency virus-positive patients who belonged to a low socio-economic group. CONCLUSIONS: Our study showed that the burden of MDR-TB in Ukraine was much greater than previously assumed. Urgent actions are needed to prevent further spread of drug-resistant TB in Ukraine.

Social determinants and risk factors for tuberculosis in national surveillance systems in Europe.

SETTING: National tuberculosis programmes (NTPs) of the 53 Member States of the World Health Organization (WHO) European Region. OBJECTIVES: To identify the social determinants and underlying risk factors for tuberculosis (TB) as routinely monitored by NTPs and to identify those feasible and appropriate to be included in the annual reporting to the joint European Centre for Disease Prevention and Control (ECDC) WHO reporting platform. DESIGN: A semi-structured questionnaire sent to 53 national TB surveillance correspondents. RESULTS: A total of 47 countries submitted questionnaires; most of the countries collect a number of social determinants and risk factors that are not requested for reporting to the Joint ECDC-WHO Reporting Platform. Occupation/employment, homelessness, diabetes mellitus and use of alcohol are collected by the majority of countries, but without standardised definitions. CONCLUSIONS: Four social determinants/risk factors are already included in the national TB surveillance systems of the majority of countries and could be incorporated in the annual reporting to the Joint ECDC/WHO Reporting Platform. Standardised epidemiological case definitions need to be adopted.

Contexte : Programmes nationaux contre la tuberculose (PNT) des 53 états membres de la région Europe de l'Organisation Mondiale de la Santé (OMS).Objectifs: Identifier les déterminants sociaux et les facteurs de risque sous-jacents de la tuberculose (TB) tels qu'ils sont suivis en routine par les PNT et identifier ceux qui sont faciles à recueillir et appropriés pour les inclure dans le rapport annuel à la plate-forme conjointe du Centre européen de prévention et contrôle des maladies (CEPCM) et l'OMS.Schéma : Un questionnaire semi-structuré a été envoyé à 53 correspondants des programmes nationaux de surveillance de la TB.Résultats : Au total, 47 pays ont soumis leurs questionnaires ; la plupart des pays recueillent un certain nombre de déterminants sociaux et de facteurs de risque qui ne sont pas exigés dans les rapports destinés à la plate-forme conjointe CEPCM-OMS. Profession, absence de domicile fixe, diabète et consommation d'alcool sont recueillis par la majorité des pays, mais sans définitions standardisées.Conclusions : Quatre déterminants sociaux/facteurs de risque sont déjà inclus dans le système national de surveillance de la TB dans la majorité des pays et pourraient être incorporés dans le rapport annuel à la plate-forme conjointe CEPCM/OMS. Mais il faut adopter des définitions de cas épidémiologiques standardisées.

Marco de referencia: Los programas nacionales contra la tuberculosis (PNT) de los 53 Estados Miembros de la Región Europea de la Organización Mundial de la Salud (OMS)Objetivos: Encontrar los determinantes sociales y los factores de riesgo subyacentes de contraer la tuberculosis (TB), como se recogen de manera sistemática en la vigilancia de los PNT y escoger los determinantes cuya recogida es factible y es apropiado incluirlos en el informe anual que se presenta a la plataforma de notificación conjunta del Centro Europeo para la Prevención y el Control de las Enfermedades (CEPCE) y la OMS.Métodos: Se envió un cuestionario semiestructurado a 53 corresponsales nacionales de la vigilancia de la TB.Resultados: Se recibieron cuestionarios de 47 países; la mayoría de países recoge una serie de determinantes sociales y factores de riesgo cuya notificación no se exige en el informe a la plataforma conjunta de notificación del CEPCE y la OMS. La mayor parte de los países obtiene información sobre los siguientes determinantes: ocupación o empleo, falta de vivienda, diabetes y consumo de alcohol, sin definiciones normalizadas.Conclusión: El sistema de vigilancia de la TB de la mayoría de los países incluye ya cuatro determinantes sociales o factores de riesgo de padecer la enfermedad que se podrían incorporar a la plataforma de notificación conjunta del CEPCE y la OMS. Es preciso adoptar definiciones de caso epidemiológicas normalizadas.

Poor treatment outcomes among multidrug-resistant tuberculosis patients in Gomel Region, Republic of Belarus.

SETTINGS: Tuberculosis (TB) health facilities in the Gomel Region, Republic of Belarus-settings with a high burden of multidrug-resistant TB (MDR-TB) and human immunodeficiency virus (HIV) infection. OBJECTIVE: To determine treatment outcomes among MDR-TB patients diagnosed in 2009-2010 and factors associated with unsuccessful outcomes (death, failure and loss to follow-up). DESIGN: Retrospective cohort study involving a review of an electronic patient database maintained under the National Tuberculosis Control Programme. RESULTS: Of 517 patients diagnosed, 78 (15%) did not start treatment. Among 439 patients who started treatment (84% males, median age 45 years, 15% HIV-infected), 291 (66%) had unsuccessful outcomes (35% deaths, 18% treatment failure and 13% lost to follow-up). Multivariate regression analysis showed that patients aged ⩾45 years (aRR 1.2, 95%CI 1.1-1.3), HIV-infected patients and those not receiving antiretroviral therapy (ART) (aRR 1.5, 95%CI 1.4-1.6) and those with a previous history of anti-tuberculosis treatment (aRR 1.2, 95%CI 1.1-1.4) had significantly higher risk of unsuccessful outcomes. CONCLUSION: Treatment outcomes among MDR-TB patients were poor, with high rates of death, failure and loss to follow-up (including pre-treatment loss to follow-up). Urgent measures to increase ART uptake among HIV-infected MDR-TB patients, improved access to second-line anti-tuberculosis drug susceptibility testing and comprehensive patient support measures are required to address this grim situation.

Risk factors associated with loss to follow-up among multidrug-resistant tuberculosis patients in Georgia.

SETTING: Georgia, a country with a high-burden of multi-drug-resistant tuberculosis (MDR-TB). OBJECTIVE: To determine the proportion of loss to follow-up (LFU) among MDR-TB patients treated nationwide from 2009 to 2011, and associated risk factors. DESIGN: Retrospective cohort study involving a review of the National Tuberculosis Programme electronic surveillance database. A Cox proportional hazards model was used to assess risk factors for time to LFU. RESULTS: Among 1593 patients, 458 (29%) were lost to follow-up. A total of 1240 MDR-TB patients were included in the final analysis (845 treatment success, 395 LFU). Over 40% of LFU occurred during the first 8 months of MDR-TB treatment; 40% of patients had not achieved culture conversion at the time of LFU. In multivariate analysis, the factors associated with LFU included male sex, illicit drug use, tobacco use, history of previous anti-tuberculosis treatment, site of TB disease, and place and year of initiating treatment. CONCLUSION: LFU was high among MDR-TB patients in Georgia and posed a significant public health risk, as many were culture-positive at the time of LFU. A multi-pronged approach is needed to address the various patient- and treatment-related characteristics associated with LFU.

Treatment outcomes among drug-susceptible tuberculosis patients in Latvia, 2006-2010.

SETTING: Latvia, an Eastern European country with a high burden of tuberculosis (TB). OBJECTIVE: To describe treatment outcomes among new drug-susceptible TB patients and assess the association of treatment outcomes with selected social determinants and risk factors. DESIGN: A retrospective cohort study of patients aged ⩾15 years registered during 2006-2010, with a review of records in the National Tuberculosis Registry. RESULTS: Of 2476 patients, 1704 (69%) were male; the median age was 42 years. About two thirds of patients were unemployed or retired, 7% were human immunodeficiency virus (HIV) positive and 35% had a history of alcohol use. Treatment success was achieved in 2167 (88%) patients. Older age, unemployment, HIV infection and alcohol use were found to be independently associated with unsuccessful treatment (death, loss to follow-up, failure, transfer out and other). For many variables, including HIV infection, diabetes mellitus and tobacco use, it was not possible to distinguish between 'not recorded' and 'not present' in the registry. CONCLUSION: The treatment success rate among new drug-susceptible TB patients exceeded the 85% global target for TB control. Additional attention and support is required for most vulnerable patients, such as those who are unemployed or retired, HIV infected and alcohol users. The National TB Registry should be revised to improve definitions and staff should be trained for proper data collection and recording.

Do incentives improve tuberculosis treatment outcomes in the Republic of Moldova?

SETTING: Tuberculosis (TB) health facilities in the Republic of Moldova, where various incentives were provided to TB patients to improve treatment outcomes. OBJECTIVE: To compare treatment outcomes among new drug-susceptible TB patients registered for treatment before (2008) and after (2011) introduction of incentives. DESIGN: Retrospective cohort study using data from the national electronic patient database and incentive registers. RESULTS: Of 2378 patients registered in 2011, 1895 (80%) received incentives (cash, food vouchers, travel reimbursement). Compared to 2008 (no incentives, n = 2492), the patients registered with incentives in 2011 had higher treatment success (88% vs. 79%, P < 0.001) and lower proportions of unsuccessful outcomes: loss to follow-up (5% vs. 10%, P < 0.001), death (5% vs. 6%, P = 0.03) and failure (2% vs. 5%, P < 0.001). In multivariate analysis (log-binomial regression) using the intention-to-treat approach, provision of incentives was independently associated with an overall reduction in unsuccessful outcomes of 50% (RR 0.5, 95%CI 0.45-0.62, P < 0.001), after adjusting for other confounders such as sex, age, education, occupation, residence, homelessness, type of TB and human immunodeficiency virus status. CONCLUSION: Provision of incentives to TB patients significantly improved treatment success rates and needs to continue. Treatment retention increased, thus potentially preventing drug resistance, a serious problem in the Republic of Moldova.

High time to use rapid tests to detect multidrug resistance in sputum smear-negative tuberculosis in Belarus.

SETTING: Belarus (Eastern Europe) is facing an epidemic of multidrug-resistant tuberculosis (MDR-TB). In 2012, rapid molecular diagnostics were prioritised for sputum smear-positive pulmonary tuberculosis (PTB) patients to diagnose MDR-TB, while pulmonary sputum smear-negative pulmonary TB (SN-PTB) patients were investigated using conventional methods, often delaying the diagnosis of MDR-TB by 2-4 months. OBJECTIVE: To determine the proportion of MDR-TB among SN-PTB patients registered in 2012 and associated clinical and demographic factors. DESIGN: Retrospective cohort study using countrywide data from the national electronic TB register. RESULTS: Of the 5377 TB cases registered, 2960 (55%) were SN-PTB. Of the latter, 1639 (55%) were culture-positive, of whom 768 (47%) had MDR-TB: 33% (363/1084) were new and 73% (405/555) previously treated patients. Previous history of treatment, age, region, urban residence, human immunodeficiency virus (HIV) status and being a pensioner were independently associated with MDR-TB. CONCLUSION: About half of culture-positive SN-PTB patients have MDR-TB and this rises to over 7/10 for retreatment cases. A national policy decision to extend rapid molecular diagnostics universally to all PTB patients, including SN-PTB, seems justified. Steps need to be taken to ensure implementation of this urgent priority, given the patient and public health implications of delayed diagnosis.

Contexte : Le Belarus (Europe de l'Est) est confronté à une épidémie de tuberculose multirésistante (TB-MDR). En 2012, les patients atteints de tuberculose pulmonaire (TBP) à frottis positif ont bénéficié en priorité de diagnostics moléculaires pour confirmer une TB-MDR, tandis que les patients atteints de TBP à frottis négatif (SN-PTB) ont bénéficié de méthodes conventionnelles qui retardaient souvent le diagnostic de TB-MDR de 2 à 4 mois.Objectif : Déterminer la proportion de TB-MDR parmi les patients SN-PTB enregistrés en 2012, ainsi que les facteurs cliniques et démographiques associés.Schéma : Etude de cohorte rétrospective basée sur des données émanant de tout le pays grâce au registre électronique national de la TB.Résultats : Sur 5377 cas de TB enregistrés, 2960 (55%) étaient des SN-PTB. Parmi ces derniers, 1639 (55%) avaient une culture positive, dont 768 (47%) avaient une TB-MDR : 33% (363/1084) nouveaux cas et 73% (405/555) patients déjà traités préalablement. La notion de traitement antérieur, l'âge, la région, la résidence en milieu urbain, le statut à l'égard du virus de l'immunodéficience humaine et le fait d'être retraité étaient indépendamment associés à la TB-MDR.Conclusion : Près de la moitié des patients SN-PTB à culture positive ont une TB-MDR, et dans les cas de retraitement, on arrive à plus de sept patients sur dix. La décision politique nationale d'extension des diagnostics moléculaires rapides à tous les patients TBP, y compris les patients SN-PTB, semble donc justifiée. Il est nécessaire de prendre des mesures afin d'assurer la mise en œuvre de cette priorité urgente, en raison des implications d'un diagnostic retardé à la fois pour les patients et en termes de santé publique.

Marco de referencia: El país de Bielorrusia, en Europa oriental, afronta una epidemia de tuberculosis multidrogorresistente (TB-MDR). En el 2012, se privilegió la práctica de las pruebas moleculares rápidas con el fin de diagnosticar la TB-MDR en los pacientes con TB pulmonar (TBP) y baciloscopia positiva y los casos con baciloscopia negativa (SN-PTB) se investigaron mediante los métodos clásicos, lo cual solía retardar de dos a cuatro meses el diagnóstico de la TB-MDR.Objetivo: Determinar en los pacientes SN-PTB registrados en el 2012, la proporción de casos TB-MDR y examinar los factores clínicos y demográficos que se asociaban con este diagnóstico.Método: Un estudio retrospectivo de cohortes a partir de los datos del Registro Nacional Informatizado de Tuberculosis.Resultados: De los 5377 casos de TB registrados, 2960 correspondían a SN-PTB (55%). De estos pacientes, 1639 presentaron un cultivo positivo (55%) y en 768 casos se diagnosticó TB-MDR (47%). De los pacientes con diagnóstico de TB-MDR, el 33% correspondió a casos nuevos (363/1084) y el 73% consistió en pacientes previamente tratados (405/555). Los factores que se asociaron de manera independiente con el diagnóstico de TB-MDR fueron el antecedente de tratamiento antituberculoso, la edad, el domicilio en zona urbana, la situación frente al virus de la inmunodeficiencia humana y el hecho de ser jubilado.Conclusión: Cerca de la mitad de los pacientes con SN-PTB presentó TB-MDR. Esta proporción llegó a ser siete de cada 10 de los casos en retratamiento. Con base en estos resultados, está justificada una decisión política a escala nacional de ampliación del uso de las pruebas rápidas de diagnóstico molecular de manera universal a todos los pacientes con TBP, incluidos los pacientes con SN-PTB. Es necesario tomar medidas encaminadas a fomentar la ejecución de esta prioridad urgente, dadas las repercusiones que un diagnóstico tardío impone a los pacientes y al sistema de salud pública.

Multidrug-resistant tuberculosis in Uzbekistan: results of a nationwide survey, 2010 to 2011.

Multidrug-resistant tuberculosis (MDR-TB; resistance to at least rifampicin and isoniazid) is a global public health concern. In 2010­2011, Uzbekistan, in central Asia, conducted its first countrywide survey to determine the prevalence of MDR-TB among TB patients. The proportion of MDR-TB among new and previously treated TB patients throughout the country was measured and risk factors for MDR-TB explored. A total of 1,037 patients were included. MDR-TB was detected in 165 treatment-naïve (23.2%; 95% confidence interval (CI) 17.8%­29.5%) and 207 previously treated (62.0%; 95% CI: 52.5%­70.7%) patients. In 5.3% (95% CI: 3.1%­8.4%) of MDR-TB cases, resistance to fluoroquinolones and second-line injectable drugs (extensively drug resistant TB; XDR-TB) was detected. MDR-TB was significantly associated with age under 45 years (adjusted odds ratio: 2.24; 95% CI: 1.45­3.45), imprisonment (1.93; 95% CI: 1.01­3.70), previous treatment (4.45; 95% CI: 2.66­7.43), and not owning a home (1.79; 95% CI: 1.01­3.16). MDR-TB estimates for Uzbekistan are among the highest reported in former Soviet Union countries. Efforts to diagnose, treat and prevent spread of MDR-TB need scaling up.

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).

Tuberculosis and patient gender in Bangladesh: sex differences in diagnosis and treatment outcome.

SETTING: The public health sector of Bangladesh. OBJECTIVE: To assess gender differences in access to tuberculosis diagnosis and in tuberculosis treatment outcome in Bangladesh. METHODS: Information on the age and sex of a sample of patients in 1997 was collected from out-patient registers and tuberculosis laboratory and treatment registers in 59 thanas in three divisions in Bangladesh. RESULTS: The female/male ratio was 0.79 among 42,877 out-patients with respiratory complaints, 0.51 among 5,665 tuberculosis suspects undergoing sputum smear microscopy, 0.36 among 869 tuberculosis suspects with positive sputum smears, and 0.35 among 5,632 patients registered for tuberculosis treatment. Treatment was successful (cured or treatment completed) in 86% of female and 84% of male patients. CONCLUSION: Women in Bangladesh appear to have less access to public out-patient clinics than men, and if they present with respiratory symptoms they are less likely to undergo sputum smear examination. If examined, women are less likely than men to be smear-positive. No gender bias was observed in tuberculosis treatment outcome. It is recommended to focus further research on exploration of sex differences in the incidence of respiratory conditions, identification of constraints among women in accessing out-patient clinics and verification of the quality of sputum submitted by women for examination.

Tuberculosis and health sector reform in Bangladesh.

In 1998 the Government of Bangladesh changed its health and population sector strategy from a project-oriented approach (the Fourth Population and Health Project--FPHP) to sector-wide management (the Fifth Health and Population Sector Programme--HPSP). This article describes the development and achievements of the tuberculosis programme during the FPHP, and discusses the potential opportunities and challenges anticipated by the programme from the reformed health service delivery of the HPSP. 'Further strengthening of tuberculosis and leprosy control services' was one of the 66 projects of the FPHP. As part of the FPHP, the National Tuberculosis Programme policy was revised in 1992 and the project was implemented in phases. By mid 1998, 90% of the population was covered, and more than 200,000 tuberculosis cases had been diagnosed and treated with 80% success. We describe the reasons for this success and analyse the pitfalls of the project. The objective of the reforms in HPSP is to provide cost-effective, sustainable, quality services to those in need through an essential service package that includes control of communicable diseases such as tuberculosis and leprosy. Tuberculosis services will become more accessible as community clinics deliver essential health services for every 6000 population. Non-public health care providers, who contribute significantly to health services in the country, will be involved in service delivery. The main challenge is to maintain the quality of successful projects, such as tuberculosis control, during the transition period.

Review of national tuberculosis programmes: the experience in Bangladesh.

Tuberculosis control efforts should be evaluated periodically to assess progress made by national programmes and to plan for the future. Simple and reliable tools are required for such assessments. This paper summarises the methodology and results of the review of the national tuberculosis programme in Bangladesh conducted in 1997. The authors conclude that similar reviews would not only help to verify the reports from the routine recording system, but would also assist policy development and future planning.

Post-emergency epidemiological surveillance in Iraqi-Kurdish refugee camps in Iran.

In 1991 a computerized, comprehensive epidemiological surveillance system was developed to monitor health trends in approximately 25,000 acutely displaced Kurds in Nowsood and Saryas refugee camps, Bakhtaran region, Northwestern Iran. In addition, community-based surveys offered information unobtainable from health facilities. Weekly population movements, attack rates, point-prevalence estimates, and case fatality ratios were calculated, and the data were analysed and compared. The overall crude mortality rate (CMR) in the camps under study was still 9 times higher than the reported CMR for Iraq. Health problems with very low rates (less than 1.0/1,000 population/week) included the triad of measles, meningitis and tetanus. However, morbidity for the most common conditions (acute respiratory infections, diarrhoea, skin infections, eye diseases and, finally, typhoid fever) was shown to increase at the end of the intervention, highlighting that the pressure of repatriation on refugees made them progressively worse. This article concludes that epidemiological surveillance systems should be implemented during mass-migrations in developing countries also in post-emergency settings. Furthermore, surveillance appears to be indispensable in order for the international agencies to keep abreast of events and to safeguard human rights when international attention subsides.