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.

Successful management of multidrug-resistant tuberculosis under programme conditions in the Dominican Republic.

SETTING: The Dominican Republic is a high-incidence area for multidrug-resistant tuberculosis (MDR-TB; 6.6% of initial cases). Standardised treatment regimens for MDR-TB may be a potential solution. OBJECTIVE: To present the effectiveness of standard regimens under routine national conditions. DESIGN: We reviewed all MDR-TB patients treated under routine conditions from 29 August 2006 to 30 June 2010, showing interim and final outcomes. Patients were treated with regimens that were standardised or individualised based on previously received second-line anti-tuberculosis drugs. RESULTS: Population description and culture conversion data are reported for the 289 MDR-TB patients. The median patient age was 31 years. Most had failed first-line treatment (72.6%). Culture negativity was obtained within 4 months (median 2 months) in 78.6%. Among the 150 patients treated between 2006 and 2008, 74% had favourable results on standardised and 66% on individualised regimens (P = 0.211). The efficacy of the standardised and individualised regimens was respectively 92.8% and 81% (P = 0.056). The relapse rate was approximately 1%. A median of five drug side effects occurred per patient. More than 2 months to culture conversion and bilateral cavitation on chest X-ray were found to be unfavourable outcome risk factors. CONCLUSIONS: Standardised MDR-TB regimens may be effective at the national level, even in resource-poor settings.

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.

Epidemiology of tuberculosis in the Americas: the Stop TB strategy and the millennium development goals.

BACKGROUND: Tuberculosis (TB), a preventable and curable disease, remains a major public health threat in the poorest regions of the Americas. The DOTS strategy was implemented to control TB in the region in 1993, and the new Stop TB strategy, emphasizing high-quality DOTS expansion, in 2006. OBJECTIVES: To describe TB epidemiology in the region of the Americas from 1994 to 2005 and to analyze the progress made towards and prospects for achieving Goal 6 of the Millennium Development Goals (MDGs) by 2015. METHODS: TB incidence, mortality and prevalence rates as well as DOTS coverage and DOTS treatment success rates were collated from the World Health Organization (WHO) databases from 1994 to 2005. RESULTS: DOTS coverage and DOTS treatment success rates rose steadily from 1994 to 2005, with 88% of the population covered under DOTS by 2005, and an 80% success rate by the end of 2004. The TB incidence, prevalence and mortality rates have also decreased steadily from 1994 to date, but differ with respect to the various scenarios. CONCLUSIONS: With the exception of some countries, further reduction in TB incidence, prevalence and deaths by 2015 is possible. Widespread implementation of DOTS should continue in order to meet WHO targets and attain the MDGs.

Scaling up collaborative TB-HIV activities in Latin America.

TB-HIV collaborative activities are one of the cornerstones of TB control in the Stop TB strategy. Since 2003, most countries in Latin America and the Caribbean have been gradually implementing TB-HIV collaborative activities; however, limited information is currently available on the degree of implementation. This study is therefore aimed at describing to what degree TB-HIV collaborative activities are being implemented in 17 countries selected for the study. These countries were asked to complete a semi-structured questionnaire. An analysis of this questionnaire revealed that the challenges for TB-HIV collaboration lie in the fields of human resources, surveillance and HIV testing of TB patients.

Results of PAL feasibility test in primary health care facilities in four regions of Bolivia.

SETTING: Primary health care (PHC) centres in four Bolivian regions. OBJECTIVES: To test the feasibility and impact of training general practitioners (GPs) in standard case management of respiratory conditions in patients aged > or =5 years. DESIGN: Comparison of the results of two surveys: the baseline survey before training and the impact survey after training on standard guidelines on case management of respiratory conditions. RESULTS: A total of 78 GPs working in 65 health centres participated in both surveys. The baseline survey registered 1033 respiratory patients and the impact survey 1154. The patients were comparable in sex distribution, previous visits, duration of symptoms and clinical diagnoses. The differences were significant in age distribution, concomitant diseases and risk factors. As a result of training, referrals to a higher level decreased by 34.6% and the proportion of tuberculosis (TB) suspects identified increased by 30%. The number of drugs prescribed per patient decreased by 16.2%. The average cost of prescription of any drug per patient dropped by 32.3%. CONCLUSION: Training in the standard practical approach to lung health guidelines improved the quality and reduced the cost of treatment of respiratory diseases at PHC units. Training should be an integral part of a comprehensive managerial approach for the implementation of case management guidelines.