[Practical approach to lung health strategy in Algeria]. / L'approche pratique de la santé respiratoire en algérie.

SETTING: A total of 77 health care facilities in 10 provinces. OBJECTIVE: To perform a feasibility study before the extension of the Practical Approach to Lung (PAL) health strategy. METHOD: A cross-sectional study comparing before and after findings of a training course for general practitioners. RESULTS: Respiratory symptoms were the main reason for attending the primary health care services, accounting for 31.6% and 31.1% in the two periods studied. Acute respiratory infections constituted 70% of all respiratory disorders identified during the two periods. Chronic respiratory disorders, particularly asthma, were diagnosed more frequently after the training course (15.9% vs. 10.9%). Tuberculosis (TB) suspects accounted for only a minority of patients seeking health care and were more easily identified post-training. Treatment recommendations were more rational after training, which led to a reduction in prescription costs. CONCLUSIONS: The adoption of the PAL strategy by general practitioners led to an improvement in the quality of diagnosis of respiratory disorders and TB, fewer secondary investigations, less patient travel and an increase in the efficiency of medical practice by lowering prescription costs.

Implementation of fixed-dose combinations in tuberculosis control: outline of responsibilities.

Fixed-dose combinations (FDCs) of antituberculosis drugs have been available on the world market for more than forty years. For more than twenty years rifampicin-containing FDCs have become increasingly visible on the market in combinations of two, three and even four fixed-dose combinations, but in different dosages depending on the country and the region. As a result, instead of simplifying tuberculosis treatment and the application of standardised chemotherapy regimens, the situation has become progressively more complicated, and at the same time neither bioavailability nor patients' safety is guaranteed. It is time to rationalise and extend the use of FDCs in national tuberculosis programmes. International, supranational and national responsibilities must be clearly defined in this process.

Global surveillance for antituberculosis-drug resistance, 1994-1997. World Health Organization-International Union against Tuberculosis and Lung Disease Working Group on Anti-Tuberculosis Drug Resistance Surveillance.

BACKGROUND: Drug-resistant tuberculosis threatens efforts to control the disease. This report describes the prevalence of resistance to four first-line drugs in 35 countries participating in the World Health Organization-International Union against Tuberculosis and Lung Disease Global Project on Anti-Tuberculosis Drug Resistance Surveillance between 1994 and 1997. METHODS: The data are from cross-sectional surveys and surveillance reports. Participating countries followed guidelines to ensure the use of representative samples, accurate histories of treatment, standardized laboratory methods, and common definitions. A network of reference laboratories provided quality assurance. The median number of patients studied in each country or region was 555 (range, 59 to 14,344). RESULTS: Among patients with no prior treatment, a median of 9.9 percent of Mycobacterium tuberculosis strains were resistant to at least one drug (range, 2 to 41 percent); resistance to isoniazid (7.3 percent) or streptomycin (6.5 percent) was more common than resistance to rifampin (1.8 percent) or ethambutol (1.0 percent). The prevalence of primary multidrug resistance was 1.4 percent (range, 0 to 14.4 percent). Among patients with histories of treatment for one month or more [corrected], the prevalence of resistance to any of the four drugs was 36.0 percent (range, 5.3 to 100 percent), and the prevalence of multidrug resistance was 13 percent (range, 0 to 54 percent). The overall prevalences were 12.6 percent for resistance to any of the four drugs [corrected] (range, 2.3 to 42.4 percent) and 2.2 percent for multidrug resistance (range, 0 to 22.1 percent). Particularly high prevalences of multidrug resistance were found in the former Soviet Union, Asia, the Dominican Republic, and Argentina. CONCLUSIONS: Resistance to antituberculosis drugs was found in all 35 countries and regions surveyed, suggesting that it is a global problem.

After health sector reform, whither lung health?

Health sector reform, which is currently taking place in low or middle income countries following the implementation of structural adjustment programmes, advocates the use of rational measures aimed at increasing the efficiency of the health services. These measures are being applied unevenly. Cuts in governments' social budgets have had the effect of favouring the development of the private medical and pharmaceutical sector, rather than rationalising the choice of priorities. The emphasis on cost recovery in basic health services is penalising the poorest and most vulnerable groups. In developing countries, a managerial approach that does not take into account the socio-political structures of these countries and the priorities of health policies only serves to aggravate the inequalities inherent in obtaining access to health care. Under these circumstances, the promotion of lung health runs the risk of being forgotten or compromised. The persisting or worsening weaknesses of the basic health services do not facilitate the application of an integrated approach to respiratory diseases (including tuberculosis), nor the support of a minimum package of health activities to offer to the population. Environmental factors affecting respiratory health (such as smoking and air pollution) are not taken into account in health sector reform, even though they constitute an obvious threat and demand urgent, widespread action. It is a new challenge for health personnel to promote and guarantee lung health.

El control de la tuberculosis en refugiados y desplazados / Tuberculosis control in refugees and displaced persons

As a result of national and international conflicts, the number of refugees and displaced persons in various countries of the world is increasing. The complex and protracted nature of these conflicts often forces refugees to remain away from their countries for long periods, living in refugee camps. Many refugees come from countries where tuberculosis is endemic and, once the immediate problems of establishing a camp are overcome, this disease becomes the principal problem affecting refugee camps. In order to advise the persons in charge of refugee camps on how to set up tuberculosis control programs, this document details the general requirements and specific recommendations of WHO for the implementation of such programs, as well as guidelines for their evalutation and monitoring, including criteria that would justify camp closure

As a result of national and international conflicts, the number of refugees and displaced persons in various countries of the world is increasing. The complex and protracted nature of these conflicts often forces refugees to remain away from their countries for long periods, living in refugee camps. Many refugees come from countries where tuberculosis is endemic and, once the immediate problems of establishing a camp are overcome, this disease becomes the principal problem affecting refugee camps. In order to advise the persons in charge of refugee camps on how to set up tuberculosis control programs, this document details the general requirements and specific recommendations of WHO for the implementation of such programs, as well as guidelines for their evaluation and monitoring, including criteria that would justify camp closure

[Control of tuberculosis in refugees and displaced]. / El control de la tuberculosis en refugiados y desplazados.

As a result of national and international conflicts, the number of refugees and displaced persons in various countries of the world is increasing. The complex and protracted nature of these conflicts often forces refugees to remain away from their countries for long periods, living in refugee camps. Many refugees come from countries where tuberculosis is endemic and, once the immediate problems of establishing a camp are overcome, this disease becomes the principal problem affecting refugee camps. In order to advise the persons in charge of refugee camps on how to set up tuberculosis control programs, this document details the general requirements and specific recommendations of WHO for the implementation of such programs, as well as guidelines for their evaluation and monitoring, including criteria that would justify camp closure.

The campaign against TB: governments must commit themselves. TB in Africa.

PIP: This article presents an interview with Pierre Chaulet on the campaign against tuberculosis (TB) in Africa. Chaulet noted during the 9th IUATLD Conference of the Africa Region that the national TB control programs have taken on a new commitment in Africa since the declaration of TB as a global emergency in the 1990s. The TB control program package consists of five principal components: 1) political will of the government and its commitment to support the program; 2) case detection; 3) initiation of short course chemotherapy among detected cases; 4) ensuring the regular supply of essential anti-TB drugs; and 5) establishing a registry and reporting system for program monitoring and evaluation. Of the 40 African countries participating in the conference, 30 have efficient programs. Comparing the management of National TB Control Programs in Francophone and Anglophone Africa, it is noted that both are complementary, although generally, public health issues are more easily integrated into the medical training in the Anglophone countries than they are in the Francophone. Anglophone uses a more comprehensive approach to public health while countries in the Francophone practiced a more traditional university centralization. Finally, Chaulet gives his comment on the role of WHO in addressing concerns over the financial issues involved in TB Control Programs, particularly in the mobilization of resources from nongovernmental organizations and international institutions.^ieng

Surveillance of drug resistance for tuberculosis control: why and how?

The resistance of Mycobacterium tuberculosis to antibiotics, which reflects the quality of the chemotherapy applied in the community, is one of the elements of epidemiological surveillance used in national tuberculosis programmes. Measurement of drug resistance poses problems for biologists in standardization of laboratory methods and quality control. The definition of rates of acquired and primary drug resistance also necessitates standardization in the methods used to collect information transmitted by clinicians. Finally, the significance of the rates calculated depends on the choice of the patients sample on which sensitivity tests have been performed. National surveys of drug resistance therefore require multidisciplinary participation in order to select the only useful indicators: rates of primary resistance and of acquired resistance. These indicators, gathered in representative groups of patients over a long period, are a measurement of the impact of modern chemotherapy regimens on bacterial ecology.

[Clinical trial of a combination of three drugs in fixed proportions in the treatment of tuberculosis. Groupe de Travail sur la Chimiothérapie de la Tuberculose]. / Essai clinique d'une combinaison en proportions fixes de trois medicaments dans le traitement de la tuberculose. Groupe de Travail sur la Chimiothérapie de la Tuberculose.

SETTING: The Matiben Chest Clinic at the West Algiers University Teaching Hospital, and 3 outpatient clinics specializing in tuberculosis and lung disease in Algiers. OBJECTIVE: To determine the tolerance and efficacy of a fixed proportion combination of 3 antituberculosis drugs (per tablet: 50 mg isoniazid + 120 mg rifampicin + 300 mg pyrazinamide) given during the first 2 months of a daily 6-month chemotherapy regimen. DESIGN: Random prospective treatment trial comparing a group of 124 patients receiving the triple combination with another group of 126 patients receiving the 3 drugs separately during the initial treatment phase. The continuation phase was identical for the 2 groups. Comparison of tolerance in the first 2 months, and of the failure and relapse rates (respectively at the end of treatment and 24 months after the end of treatment). RESULTS: During the first 2 months side-effects were significantly more common in the group receiving the drugs separately. At the end of treatment and during the following 24 months there were no significant differences in the cumulative rates of observed failures and relapses (2% and 1%). CONCLUSION: The triple combination studied could replace the separate drugs in the initial treatment phase in countries where the bioavailability of the drugs used has been proven.

The supply of antituberculosis drugs: price evolution.

The cost of antituberculosis drugs and chemotherapy regimens has fallen sharply in the last 2 years. This evolution in the international market, although attenuated by local currency devaluation, should encourage the directors of national tuberculosis programmes to quantify their needs more clearly and to organise centralised purchasing of antituberculosis drugs from non-profitmaking suppliers offering quality controlled generic drugs at the lowest prices.

[Curative treatment of tuberculosis in the world]. / Le traitement curatif de la tuberculose dans le monde.

Recent WHO recommendations for the treatment of tuberculosis have emphasized the need for simplicity and standardization of short term chemotherapy regims which can be applied in all forms of tuberculosis, including both pulmonary and extrapulmonary forms. But in order for the recommended chemotherapy regimes to be effective, there is a need for precise organization. Patient care must begin with the first consultation, dosage must be adapted to patient weight, drug intake must, at least during the initial phase of treatment, be supervised and patients who are absent or irregular should be recalled, surveillance and correction of rare side effects should be recorded, global consideration of the patient's medical and social problems and laboratory (and clinical) check-ups at the end of the initial phase of treatment and again at the end of treatment. Together, the aim of these technical and organizational measures is the limit the development bacterial resistance both to isoniazid and to rifampicin. In countries with limited financial resources, where the majority of the tuberculosis population lives, a reliable network of laboratories equipped with microscopes and a permanent anti-tuberculosis supply organization are required for any and all treatment programmes. In all countries, the evaluation of results using representative cohorts and surveillance of bacterial resistance provide evidence that such policies are successful.

The supply of antituberculosis drugs and national drugs policies.

The money necessary for purchasing antituberculosis drugs in a national programme comes from the Public Health Services budget, funds from the health insurance scheme (when it exists) and household budgets. The Public Health Services budget is on average $2-23 US per year and per person in low or middle income countries. Average drug consumption in these groups of countries was from $2-26 US per person in 1990. The number of patients to be treated depends on the annual risk of tuberculous infection (ARTI) and the case detection rate: it is the same when the ARTI is 1% and the detection rate 100%, and when the ARTI is 2% and the detection rate 50% of cases. The supply of antituberculosis drugs has a real cost representing around 3% of global drug consumption in low income countries and is always less than 1% of global drug consumption in middle income countries. In most developing countries it could be covered with the aid of national financial resources, on condition that it is integrated into a coherent national drugs policy aimed at guaranteeing the continued availability of essential drugs.

Treatment of tuberculosis in children.

PIP: Treatment guidelines for tuberculosis in children, issued by the International Union against Tuberculosis and Lung Diseases in 1987 and 1990 and the World Health Organization Tuberculosis Unit for the Treatment of Tuberculosis in Adults and Children in 1991, are explained. The combination drug treatments are similar to those recommended for adults, except that ethambutol is not normally given to children too young to have vision tests. Another difference is that the 2 or 3 times weekly dosing schedules are not usually followed in young children, because they cannot take so many tablets orally. The treatment schedule involves an initial intensive phase with 4 drugs, isoniazid, rifampicin, pyrazinamide, and streptomycin, followed by a consolidation phase lasting 6-8 months without pyrazinamide. Alternatively, a longer regimen without isoniazid taken for 4-8 months, can be used for the more common paucibacillary forms. In case of suspected cure failure or relapse, another regimen of 5 drugs must be restarted, including isoniazid, rifampicin, ethambutol, pyrazinamide, and streptomycin for 8 months. These multi-drug regimens are continued until definitive testing shows the TB is not resistant, when some drugs may be dropped. Aspects of management of the child's care are reviewed, such as types of clinical exams; family education; dosage; giving prednisone in cases of meningitis; miliary tuberculosis; serosis; or lobar, segmental, or bronchial involvement. Recommendations are given for supervision and delegation of drug administration; follow-up visits; treatment of localized TB in joints, pleura, or pericardium, and the importance of notification of childhood TB. These drug regimens, if followed, correctly, will cure TB in 100% of children, but the sequelae will depend on the extent of initial infection.^ieng

Prevention of tuberculosis in children. Detection and chemotherapy of infectious cases of tuberculosis.

PIP: Prevention of tuberculosis (TB) in children in developing countries involves 3 interventions: detection and treatment of sources of infection, i.e., adults with pulmonary TB; BCG vaccination of newborns to prevent primary infection and its complications; and prophylactic treatment of newly infected infants. The first element of prevention is reviewed here. In less developed areas, detection and diagnosis of TB entails education of the public and of health providers so that people with chronic cough have sputum sent to regional laboratories for microscopic examination. Rarely, x-ray facilities may also be used. Quality control of laboratory work and universal coverage are essential. The proportion of actual cases of TB diagnosed by microscopy ranges from 5 to 10% in African and Latin American countries to 25% in Asian countries, depending on the prevalence of TB, the age structure of the population, and the quality of the laboratories. Calculated rates of detection are 60-90% however. There are 3 types of infectious TB cases; new cases with smear-positive pulmonary TB (80-90%), previously treated cases who are true or false failures or relapses, and chronic TB cases who probably have resistant organisms. In developing countries, the last group will probably not receive second-line drugs because of the cost, but will be treated with isoniazid alone and are considered unlikely to recover. At the end of standardized treatment, there are 6 classes of patients: cured cases, probable cures, failures or relapses, decreased, lost to follow-up, and move to another district for care. World Health Organization objectives for rate of cure will probably be modified in given countries due to financial limitations.^ieng

Chemoprophylaxis of tuberculosis in children.

PIP: The situations when prophylactic antibiotics should be given to children in developing countries where BCG vaccination is common are explained. In most countries, 80-90% of children have been vaccinated with BCG by the age of 1. Since BCG makes a tuberculin (PPD) test moot, because all BCG-vaccinated persons have positive PPD tests, the only children in developing countries who can be diagnoses with TB are those who are vaccinated and live in close contact with a TB infected person. The only prophylactic medication recommended for children is daily isoniazid, 5 mg/kg for 6 months. Preventive medication is never given to healthy BCG-vaccinated children. The multi-drug regimen is not appropriate because young children have relatively few Mycobacterium bacilli, and developing countries cannot even afford to treat infected adults with these regimens. The only situations for treating children prophylactically are: 1) healthy children, under 5, not BCG vaccinated, and tuberculin positive; 2) healthy children, age 5-14, tuberculin positive with documented negative PPD test within 2 years, and 3) age 1, not BCG vaccinated, recently diagnosed as tuberculin positive. In an infant living in close contact with an infected source, a PPD test is done after 3 months of treatment with isoniazid, and if positive, treatment is continued for another 3 months. If the PPD test is still negative, the BCG vaccination is given.^ieng