TB prevention activities in the WHO European Region.

BACKGROUND: TB preventive treatment (TPT) is the primary available healthcare intervention to reduce the risk of progression from TB infection to TB disease. The WHO Regional Office for Europe established the European Prevention and Systematic Screening Initiative to End TB (PASS) to scale up activities related to the programmatic management of TPT. In the absence of a system to measure and monitor preventive activities, a baseline assessment survey was carried out to provide a reference to monitor the scale-up of the intervention. METHODS: This was a semi-structured survey including 52 questions that was developed, implemented in the WHO-hosted LimeSurvey data form and sent to focal points in the 55 countries and territories in the European Region between September and October 2023. The questions covered TPT, systematic screening and infection prevention and control. RESULTS: A total of 28 questionnaires were returned, corresponding to an overall 51% response rate. Most national policies for TPT and TB screening are in line with the latest WHO guidelines. However, implementation of TB screening, prevention, and infection control activities is lagging. Results are presented separately for high-priority and low-priority countries. CONCLUSION: The survey identified several important areas that the PASS initiative will focus on to accelerate efforts towards reaching the targets set at the 2027 UN High-Level Meeting on TB for preventive therapy in the European Region. This will require a massive scale-up of efforts and larger investments, as well as coordinated approaches and interventions across the 'cascade' of prevention, from the identification of target populations to the completion of treatment.

CONTEXTE: Le traitement préventif de la TB (TPT) est une intervention majeure en santé publique pour réduire le risque de progression de l'infection TB vers la maladie TB. L'initiative européenne de prévention et de dépistage systématique pour mettre fin à la TB (PASS) a été lancée par le bureau régional de l'OMS pour l'Europe afin de renforcer les activités liées à la gestion programmatique du traitement préventif de la TB. Une enquête d'évaluation de base a été menée en l'absence d'un système de mesure et de suivi des activités de prévention, afin de fournir une référence pour suivre l'intensification de l'intervention. MÉTHODES: Il s'agit d'une enquête semi-structurée composée de 52 questions, conçue, mise en place dans le formulaire de données LimeSurvey hébergé par l'OMS, et envoyée aux points focaux dans les 55 pays et territoires de la Région européenne entre septembre et octobre 2023. Les questions abordaient le TPT, le dépistage systématique, ainsi que la prévention et le contrôle des infections. RÉSULTATS: Au total, 28 questionnaires ont été retournés, ce qui équivaut à un taux de réponse global de 51%. La plupart des politiques nationales en matière de TPT et de dépistage de la TB sont conformes aux dernières directives de l'OMS. Cependant, la mise en œuvre des activités de dépistage de la TB, de prévention et de lutte contre l'infection est en retard. Les résultats de l'initiative PASS sont présentés de manière distincte pour les pays hautement prioritaires et les pays faiblement prioritaires. CONCLUSION: L'enquête a révélé plusieurs domaines clés sur lesquels l'initiative PASS se concentrera pour accélérer les efforts visant à atteindre les objectifs de 2027 de l'UN High-Level Meeting en matière de traitement préventif dans la Région européenne. Cela exigera une intensification massive des efforts et des investissements accrus, ainsi que des approches et des interventions coordonnées tout au long de la « cascade ¼ de la prévention, depuis l'identification des populations cibles jusqu'à l'achèvement du traitement.

TB and poverty: the effect of rifampicin-resistant TB on household income.

SETTING: The Republic of Moldova, one of Europe's poorest countries, also bears one of the highest burdens of rifampicin-resistant TB (RR-TB). OBJECTIVES: To trace the patients' journey through TB in terms of the relationship with poverty and assess its determinants. DESIGN: This cross-sectional study used secondary data from a survey assessing catastrophic costs in RR-TB-affected households. RESULTS: Data were obtained from 430 RR-TB patients. The percentage of poor TB-affected households rose from 65% prior to TB to 86% after TB treatment completion (P < 0.001). Social factors leading to poverty were identified for each stage: diagnostic period (history of incarceration: cOR 2.3, 95% CI 1.1-5.2); treatment period (being unemployed or unofficially employed: cOR 6.7, 95% CI 4.3-10.0); and post-treatment (being married or cohabiting: cOR 5.7, 95% CI 2.9-11.0). Participants who had ≥3 members in their households were more likely to be poor at all TB stages: diagnostic period (cOR 5.7, 95% CI 3.7-8.8), treatment period (cOR 3.8, 95% CI 2.5-5.6) and post-treatment (cOR 7.2, 95% CI 3.6-14.3). CONCLUSION: The study identified risk factors associated with poverty at each stage of TB. These findings outline that innovative social protection policies are required to protect TB patients against poverty.

CONTEXTE: La République de Moldavie est l'un des pays les plus pauvres d'Europe et l'un des plus touchés par la TB résistante à la rifampicine (RR-TB). OBJECTIFS: Nous avons cartographié le parcours des patients atteints de TB en lien avec la pauvreté et évalué les déterminants associés. MÉTHODE: Cette étude transversale a analysé des données secondaires issues d'une enquête évaluant les coûts catastrophiques supportés par les ménages touchés par la RR-TB. RÉSULTATS: Des données ont été recueillies auprès de 430 patients atteints de RR-TB. Le taux de ménages pauvres touchés par la TB est passé de 65% avant le traitement à 86% après la fin du traitement de la TB (P < 0,001). Pour chaque stade de la TB, les facteurs sociaux conduisant à la pauvreté ont été identifiés : période de diagnostic (antécédents d'emprisonnement : rapport de cotes brut (cOR) 2,3, IC à 95% 1,1­5,2) ; période de traitement (être au chômage ou employé officieux : cOR 6,7 ; IC 95% 4,3­10,0) ; et post-traitement (être marié ou cohabitant : cOR 5,7, IC 95% 2,9­11,0). Les participants dont le ménage comptait ≥3 membres étaient plus susceptibles d'être pauvres à tous les stades de la TB : période de diagnostic (cOR 5,7 ; IC à 95% 3,7­8,8), période de traitement (cOR 3,8 ; IC à 95% 2,5­5,6) et post-traitement (cOR 7,2 ; IC à 95% 3,6­14,3). CONCLUSION: L'étude a permis d'identifier des facteurs de risque liés à la pauvreté à toutes les étapes de la TB. Ces résultats soulignent l'importance de mettre en place des politiques de protection sociale novatrices pour prévenir l'appauvrissement des patients atteints de TB.

Determinant of catastrophic costs associated with treatment for rifampicin-resistant TB in households in the Republic of Moldova.

SETTING: The Republic of Moldova is a lower-middle-income country. Patients with TB face some barriers to accessing TB services. Welfare benefits are available during TB treatment. OBJECTIVES: We aimed to determine the proportion of rifampicin-resistant TB (RR-TB) households that experienced catastrophic costs due to TB at a threshold of ≥20% of household income and investigate the associated risk factors. DESIGN: A cross-sectional countrywide study comprised 430 patients with RR-TB who had received TB treatment as an inpatient or outpatient for at least 2 months. RESULTS: RR-TB patients lost 30% of their household income in inpatient and 70% in outpatient TB care. TB-related costs were associated with being unofficially employed or unemployed (aOR 1.9, 95% CI 1.1-3.3), having fewer household members (aOR 2.1, 95% CI 1.3-3.5), having an income that accounted for over 50% of household income (aOR 2.4, 95% CI 1.5-3.8), and being a poor household (aOR 2.2, 95% CI 1.2-3.9). CONCLUSION: Although TB health services are provided to patients free of charge, 26% of RR-TB households experienced catastrophic TB costs. The associated factors should be considered to improve patient-centred TB care, especially in vulnerable groups. Welfare payments mitigate TB costs.

CADRE: La République de Moldova est un pays à revenu intermédiaire de la tranche inférieure. Les patients atteints de TB se heurtent à certains obstacles pour accéder aux services de lutte contre la TB. Des prestations sociales sont disponibles pendant le traitement de la TB. OBJECTIFS: Nous avons cherché à déterminer la proportion de ménages atteints de TB résistant à la rifampicine (RR-TB) qui ont subi des coûts catastrophiques dus à la TB à un seuil de ≥20% du revenu du ménage et à étudier les facteurs de risque associés. MÉTHODE: Une étude transversale à l'échelle nationale a porté sur 430 patients atteints de RR-TB qui avaient reçu un traitement antituberculeux en hospitalisation ou en consultation externe pendant au moins 2 mois. RÉSULTATS: Les patients atteints de RR-TB ont perdu 30% du revenu de leur ménage en hospitalisation et 70% en soins ambulatoires. Les coûts liés à la TB étaient associés au fait d'avoir un emploi non officiel ou un chômeur (OR ajusté [ORa] 1,9 ; IC à 95% 1,1 à 3,3), d'avoir moins de membres du ménage (ORa 2,1 ; IC à 95% 1,3 à 3,5), d'avoir un revenu représentant plus de 50 % du revenu du ménage (ORa 2,4 ; IC à 95% 1,5 à 3,8) et d'être un ménage pauvre (ORa 2,2 ; IC à 95% 1,2 à 3,9). CONCLUSION: Bien que les services de santé liés à la TB soient fournis gratuitement aux patients, 26% des ménages atteints de RR-TB ont subi des coûts catastrophiques. Les facteurs associés doivent être pris en compte pour améliorer les soins de la TB centrés sur le patient, en particulier dans les groupes vulnérables. Les prestations sociales atténuent les coûts de la TB.

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.

Policies and practices on the programmatic management of latent tuberculous infection: global survey.

SETTING: Global survey among low tuberculosis (TB) burden countries, which are primary target countries for the World Health Organization (WHO) guidelines on the programmatic management of latent tuberculous infection (LTBI). OBJECTIVE: To perform a baseline assessment of policies and practices for the programmatic management of LTBI. DESIGN: Online and paper-based pre-tested questionnaire filled out by national TB programme managers or their equivalents from 108 countries. RESULTS: Of 74 respondent countries, 75.7% (56/74) had a national policy on LTBI. The majority of the countries (67/74, 90.5%) provided LTBI testing and treatment for child contacts of TB cases, while almost two thirds (49/74, 66%) reported provision of LTBI testing and treatment to people living with the human immunodeficiency virus (PLHIV). Six countries (8.1%) did not report providing LTBI management to child contacts and PLHIV. Among countries that reported both the availability of policy and practice of testing and treatment of LTBI for at-risk populations, a system for recording and reporting data was available in 62% (33/53) for child contacts and in 53% (21/40) for PLHIV. CONCLUSION: Countries need to ensure that national LTBI policies and a standardised monitoring and evaluation system are in place to promote the programmatic management of LTBI.

First national survey of anti-tuberculosis drug resistance in Azerbaijan and risk factors analysis.

SETTING: Civilian population of the Republic of Azerbaijan. OBJECTIVES: To determine patterns of anti-tuberculosis drug resistance among new and previously treated pulmonary tuberculosis (TB) cases, and explore their association with socio-demographic and clinical characteristics. DESIGN: National cross-sectional survey conducted in 2012-2013. RESULTS: Of 789 patients (549 new and 240 previously treated) who met the enrolment criteria, 231 (42%) new and 146 (61%) previously treated patients were resistant to any anti-tuberculosis drug; 72 (13%) new and 66 (28%) previously treated patients had multidrug-resistant TB (MDR-TB). Among MDR-TB cases, 38% of new and 46% of previously treated cases had pre-extensively drug-resistant TB (pre-XDR-TB) or XDR-TB. In previously treated cases, 51% of those who had failed treatment had MDR-TB, which was 15 times higher than in relapse cases (OR 15.2, 95%CI 6-39). The only characteristic significantly associated with MDR-TB was a history of previous treatment (OR 3.1, 95%CI 2.1-4.7); for this group, history of incarceration was an additional risk factor for MDR-TB (OR 2.8, 95%CI 1.1-7.4). CONCLUSION: Azerbaijan remains a high MDR-TB burden country. There is a need to implement countrywide control and innovative measures to accelerate early diagnosis of drug resistance in individual patients, improve treatment adherence and strengthen routine surveillance of drug resistance.

Drug-resistant tuberculosis in Eastern Europe: challenges and ways forward.

Encouragingly, global rates of new tuberculosis (TB) cases have been falling since 2005, in line with the Millennium Development Goal targets; however, cases of multidrug-resistant (MDR-) and extensively drug-resistant TB (XDR-TB) have been increasing. Fifteen of the world's 27 high MDR- and XDR-TB burden countries are in the World Health Organization (WHO) European Region, of which 10 are in Eastern Europe (including Baltic and Caucasus countries). To address the MDR- and XDR-TB situation in the WHO European Region, a Consolidated Action Plan to Prevent and Combat M/XDR-TB (2011-2015) was developed for all 53 Member States and implemented in 2011. Since the implementation of the Action Plan, the proportion of MDR-TB appears largely to have levelled off among bacteriologically confirmed TB cases in high-burden countries with universal or near universal (>95%) first-line drug susceptibility testing (DST). The treatment success rate, however, continues to decrease. A contributing factor is the substantial proportion of MDR-TB cases that are additionally resistant to either a fluoroquinolone, a second-line injectable agent or both (XDR-TB); high-burden country proportions range from 12.6% to 80.4%. Proportions of XDR-TB range from 5% to 24.8%. Despite much progress in Eastern Europe, critical challenges remain as regards access to appropriate treatment regimens; patient hospitalisation; scale-up of laboratory capacity, including the use of rapid diagnostics and second-line DST; vulnerable populations; human resources; and financing. Solutions to these challenges are aligned with the Post-2015 Global TB strategy. As a first step, the global strategy should be adapted at regional and country levels to serve as a framework for immediate actions as well as longer-term ways forward.

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.

Progress toward tuberculosis control and determinants of treatment outcomes--Kazakhstan, 2000-2002.

INTRODUCTION: In Kazakhstan, during 1995-2002, the annual notification rate per 100,000 population for new cases of tuberculosis (TB) increased from 67.1 to 165.1. Beginning in 1998, public health authorities have used the national case management strategy (DOTS) promulgated by the World Health Organization (WHO) to control TB. Intended goals of DOTS include achieving a cure rate of >85% for persons with newly detected pulmonary TB sputum-smear-positive (PTB+) cases and having PTB+ represent >65% of all PTB cases among adults. Surveillance data collected during 2000-2002 were analyzed to evaluate progress toward achieving these goals and identify factors associated with specific treatment outcomes. METHODS: Surveillance data included the following nonidentifiable information on persons with newly reported cases of PTB: dates of disease onset and treatment initiation; methods of diagnosis; treatment outcomes; HIV status; and selected demographic, socioeconomic, and behavioral characteristics. Cure rates and proportions of PTB+ cases were calculated on the basis of the TB case definition and treatment outcome classification format outlined in DOTS guidelines issued by WHO. Denominator data to calculate rates were obtained from the National Census Office of Kazakhstan. Logistic regression was employed to investigate factors associated with treatment outcomes using Epi Info version 3.2. RESULTS: During 2000-2002, a total of 65,011 new cases of PTB were detected in Kazakhstan. The average annual countrywide notification rate per 100,000 population was 146.0; provincial notification rates varied (range: 65.1-274.0). The countrywide cure rate for newly detected PTB+ was 72.2%; provincial rates varied (range: 65%-81%). Of 59,905 cases of PTB among adults during 2000-2002, a total of 26,804 (44.7%) were PTB+. Unfavorable treatment outcome of new PTB+ cases was associated with alcohol abuse, homelessness, and previous incarceration. CONCLUSION: The cure rate for new PTB+ cases and the proportion of cases of PTB+ among all adults with PTB were below targeted goals. This might, in part, be explained by the 1998 adoption of DOTS. Improving program indicators requires evaluation of detection efforts, laboratory diagnostic capabilities, and adherence to treatment regimens, especially in provinces in which rates are high and among persons at high risk for unfavorable treatment outcomes.

Hepatitis E virus antibody prevalence among persons who work with swine.

Prevalence of antibody and risk factors to hepatitis E virus (HEV) infection were determined in a cross-sectional study of 2 group-matched populations: swine farmers (n=264) and persons without occupational exposure to swine (n=255) in Moldova, a country without reported cases of hepatitis E. The prevalence of HEV infection was higher among swine farmers than among the comparison group (51.1% vs. 24.7%; prevalence ratio, 2.07; 95% confidence interval [CI], 1.62-2.64). In multivariate analysis, HEV infection was associated with an occupational history of cleaning barns or assisting sows at birth (odds ratio [OR], 2.46; 95% CI, 1.52-4.01), years of occupational exposure (OR, 1.04 per year; 95% CI, 1.01-1.07), and a history of drinking raw milk (OR, 1.61; 95% CI, 1.08-2.40). HEV infection was not associated with civilian travel abroad or having piped water in the household. The increased prevalence of HEV infection among persons with occupational exposure to swine suggests animal-to-human transmission of this infection.