The Directly Observed Therapy Short-Course (DOTS) strategy in Samara Oblast, Russian Federation

Telenursing Intervention for Pulmonary Tuberculosis Patients - A Scoping Review

Management of care for people with Pulmonary TB at home using Information and Communication Technology (ICT) tools and innovative approaches, such as tools for telecommunications online education. In the nursing sector, the use of telecommunications is called telenursing. The purpose of this study is to determine the types of telecommunications-based interventions, especially telenursing, in monitoring the level of treatment adherence in patients with pulmonary TB. This study used a scoping review method approach to determine the type of telecommunications-based interventions, especially telenursing, in monitoring the level of treatment adherence in patients with pulmonary TB. Literature distribution using several sources, namely EBSCOhost, Scopus (Elsevier), and PubMed. To facilitate obtaining appropriate literature, PICO techniques are used in conducting literature searches, P (population/problem/patient), I (intervention, prognostic factor, exposure), C (comparison, control), and O (outcome). Keywords used in English "Tuberculosis OR Pulmonary Tuberculosis AND Telehealth OR Telehealth Nursing AND Medication Adherence OR Medication Compliance OR Behavior". In total from the 13 articles obtained, the articles used several telehealth to pulmonary TB patients with various implementations, such as the Directly Observed Therapy, Short Course (DOTS) (n = 7). These four implementations have the same goal and support adherence to taking medication and daily recovery in pulmonary TB patients. Overall characteristics of pulmonary TB patients in the reviewed articles are pediatric TB patients (0-14 years), adult TB (18-30 years). A total of 9 studies used a sample population of adult TB patients (18-30 years), TB undergoing Directly Observed Treatment Short-course (DOTS), TB receiving medical care and TB patients actively receiving treatment. The most influential effectiveness of telehealth in helping the treatment process of Pulmonary TB patients is Directly Observed Treatment Short-course (DOTS) because the main focus of the DOTS strategy is patient discovery and cure, priority is given to infectious TB patients without ruling out other types of TB.

Factors associated with unfavorable outcome of tuberculosis treatment in people deprived of liberty: a systematic review

OBJECTIVE

to analyze factors associated with unfavorable outcome of tuberculosis treatment in people deprived of liberty.

METHOD

systematic review, carried out in March 2021 in seven databases, with no delimitation of period of publication. The selection process of publications and data extraction was carried out by two independent reviewers.

RESULTS

a total of 1,448 publications was identified and nine were included in the study. Unfavorable outcome was higher among those who were men; had low level of education; were living in a rural area before detention; had longer prison time; received occasional visits; had been transferred between prisons; with no sputum smear microscopy or with a positive result at the diagnosis; with no follow-up sputum smear microscopy, previous history of tuberculosis; having both clinical forms of the disease, HIV/AIDS; alcoholics; smokers; low body weight; and self-administered treatment. Treatment default was associated with young people and death with older people.

CONCLUSION

prison health managers and professionals are expected to establish mechanisms of surveillance and health actions innovation aimed at the population deprived of liberty, making efforts to reduce the unfavorable outcomes of tuberculosis treatment.

A systematic review of tuberculosis detection and prevention studies in prisons

Many studies have demonstrated that prisons are hotspots of tuberculosis disease and transmission. Despite this, it remains unclear which interventions are most effective at controlling tuberculosis in prisons. The objective was to determine the study designs used to investigate tuberculosis control in prisons, and the efficacy of interventions undertaken. This systematic review included published studies which had the aim of reducing TB incidence or prevalence, or increasing the number of people screened for active pulmonary tuberculosis in incarcerated populations. 2,429 records were identified, 178 full-text articles were screened, and 17 studies included. The majority of reports were before/after or prospective non-comparative studies. The median study duration was 23 months (range 5-144). The most common intervention was the introduction of active case finding (10/17 studies) but the timing and methods varied. Comparable pre- and post intervention outcome values were infrequently reported; therefore, it was not possible to quantify the efficacy of interventions. Data from studies of tuberculosis control in prisons is limited by a lack of: controlled interventions, reporting of pre-intervention methods, and comparable pre- and post-intervention outcomes. Prospective comparative trials of adequate duration to determine trends in incidence are necessary to understand which interventions are effective in prisons.

Predictors of In-Hospital Mortality among Patients with Pulmonary Tuberculosis: A Systematic Review and Meta-analysis

Background: There is uncertainty regarding which factors are associated with in-hospital mortality among patients with pulmonary TB (PTB). The aim of this systematic review and meta-analysis is to identify predictors of in-hospital mortality among patients with PTB. Methods: We searched MEDLINE, EMBASE, and Global Health, for cohort and case-control studies that reported risk factors for in-hospital mortality in PTB. We pooled all factors that were assessed for an association, and presented relative associations as pooled odds ratios (ORs). Results: We identified 2,969 records, of which we retrieved 51 in full text; 11 cohort studies that evaluated 5,468 patients proved eligible. Moderate quality evidence suggested an association with co-morbid malignancy and in-hospital mortality (OR 1.85; 95% CI 1.01–3.40). Low quality evidence showed no association with positive sputum smear (OR 0.99; 95% CI 0.40–2.48), or male sex (OR 1.09, 95% CI 0.84–1.41), and very low quality evidence showed no association with diabetes mellitus (OR 1.31, 95% IC 0.38–4.46), and previous TB infection (OR 2.66, 95% CI 0.48–14.87). Conclusion: Co-morbid malignancy was associated with increased risk of in-hospital death among pulmonary TB patients. There is insufficient evidence to confirm positive sputum smear, male sex, diabetes mellitus, and previous TB infection as predictors of in-hospital mortality in TB patients.

Underweight increases the risk of early death in tuberculosis patients

Evidence regarding the association between BMI and mortality in tuberculosis (TB) patients is limited and inconsistent. We investigated the impact of BMI on TB-specific and non-TB-specific mortality with respect to different timing of death. All Taiwanese adults with TB in Taipei were included in a retrospective cohort study in 2012-2014. Multinomial Cox proportional hazards regression was used to evaluate the associations between BMI, cause-specific mortality and timing of death. Of 2410 eligible patients, 86·0 % (2061) were successfully treated, and TB-specific and non-TB-specific mortality occurred for 2·2 % (54) and 13·9 % (335), respectively. After controlling for potential confounders, underweight was significantly associated with a higher risk of all-cause mortality (adjusted hazard ratio (AHR) 1·57; 95 % CI 1·26, 1·95), whereas overweight was not. When cause-specific death was considered, underweight was associated with an increased risk of either TB-specific (AHR 1·85; 95 % CI 1·03, 3·33) or non-TB-specific death (AHR 1·52; 95 % CI 1·19, 1·95) during treatment. With joint consideration of cause-specific and timing of death, underweight only significantly increased the risk of TB-specific (AHR 2·23; 95 % CI 1·09, 4·59) and non-TB-specific mortality (AHR 1·81; 95 % CI 1·29, 2·55) within the first 8 weeks of treatment. This study suggests that underweight increases the risk of early death in TB patients during treatment.

Multidrug resistant tuberculosis in prisons located in former Soviet countries: A systematic review

Background

A systematic literature review was performed to investigate the occurrence of multidrug-resistant tuberculosis (MDR TB) in prisons located in countries formerly part of the Soviet Union.

Methods

A systematic search of published studies reporting MDR TB occurrence in prisons located in former Soviet countries was conducted by probing PubMed and Cumulative Index Nursing and Allied Health Literature for articles that met predetermined inclusion criteria.

Results

Seventeen studies were identified for systematic review. Studies were conducted in six different countries. Overall, prevalence of MDR TB among prisoners varied greatly between studies. Our findings suggest a high prevalence of MDR TB in prisons of Post-Soviet states with percentages as high as 16 times more than the worldwide prevalence estimated by the WHO in 2014.

Conclusion

All studies suggested a high prevalence of MDR TB in prison populations in Post-Soviet states.

Determinants of mortality in elderly patients with tuberculosis: a population-based follow-up study

Elderly individuals with tuberculosis (TB) are more likely to have a non-specific clinical presentation of TB and high mortality. However, factors associated with mortality in elderly TB patients have not been extensively studied. This retrospective cohort study aimed to identify factors associated with death among elderly Taiwanese with TB. All elderly patients with TB from 2006 to 2014 in Taipei, Taiwan, were included in a study. Multiple logistic regression was used to identify the factors associated with death in elderly TB patients. The mean age of the 5011 patients was 79·7 years; 74·1% were men; 32·7% had mortality during the study follow-up period. After controlling for potential confounders, age ⩾75 years (reference: 65-74 years), male sex, end-stage renal disease (ESRD), malignancy, acid-fast bacilli-smear positivity, TB-culture positivity, pleural effusion on chest radiograph and notification by an ordinary ward or intensive care unit were associated with a higher risk of all-cause death; while high school, and university or higher education, cavity on chest radiograph and directly observed therapy were associated with a lower risk of all-cause death. This study found that the proportion of death among elderly patients with TB in Taipei, Taiwan, was high. To improve TB treatment outcomes, future control programmes should particularly target individuals with comorbidities (e.g. ESRD and malignancy) and those with a lower socio-economic status (e.g. not educated).

Association of Body Mass Index With Tuberculosis Mortality: A Population-Based Follow-Up Study

Evidence regarding the association between body mass index (BMI) and mortality in TB patients is limited and inconsistent. We investigated the effect of BMI on TB-specific and non-TB-specific mortality in TB patients. All adult Taiwanese with TB in Taipei, Taiwan, during 2011 to 2012 were included in this retrospective cohort study. Multinomial logistic regression was used to evaluate associations of BMI with cause of death in TB patients. Of the 1608 eligible patients, 83.6% (1345) were successfully treated, 3.3% (53) died of TB-specific causes, and 13.1% (210) died of non-TB-specific causes. Mean age was 64.6 years, and 67.5% of patients were male. After controlling for potential confounders, underweight was significantly associated with higher risks of all-cause mortality (adjusted odds ratio [AOR], 1.66; 95% confidence interval [CI], 1.21-2.30), TB-specific mortality (AOR, 2.14; 95% CI, 1.18-3.89), and non-TB-specific mortality (AOR, 1.58; 95% CI, 1.11-2.25) during TB treatment, while overweight was not. When gender differences on the association of BMI with mortality were considered, underweight only significantly increased risks of TB-specific (AOR, 2.37; 95% CI, 1.19-4.72) and non-TB-specific mortality (AOR, 1.58; 95% CI, 1.05-2.37) during treatment in male patients, but not female subjects.T he present findings indicate that underweight was associated with higher risks of TB-specific and non-TB-specific mortality during TB treatment, particularly in male patients.

Directly observed treatment short-course (DOTS) for treatment of new tuberculosis cases in Somali Regional State, Eastern Ethiopia: ten years retrospective study

Background

A third of the world population is infected with tuberculosis (TB) bacilli. TB accounts for 25 % of all avoidable deaths in developing countries. The objective of the study was to assess impact of directly observed treatment short-course (DOTS) strategy on new tuberculosis case finding and treatment outcomes in Somali Regional State, Ethiopia from 2003 up to 2012 and from 2004 up to 2013, respectively.

Methods

A health facility based retrospective study was employed. Quarterly reports were collected using World Health Organization (WHO) reporting format for TB case finding and treatment outcome from all zones in the region to the Federal Ministry of Health.

Results

A total of 31, 198 all types of new TB cases were registered and reported during the period from 2003 up to 2012, in the region. Out of these, smear positive pulmonary TB cases were 12,466 (40 %), and 10,537 (33.8 %) and 8195 (26.2 %) for smear negative pulmonary TB and extra-pulmonary TB cases, respectively. An average case detection rate (CDR) of 19.1 % (SD 3.6) and treatment success rate (TSR) of 85.5 % (SD 5.0) for smear positive pulmonary TB were reported for the specified years period. For the overall study period, trend chi-squire analysis for CDR was X² = 2.1; P > 0.05 and X² = 5.64; P < 0.05 for TSR.

Conclusions

The recommended TSR set by WHO was achieved (85.5 %) and the CDR reported was far below (19.1 %) from the recommended target. Extensive efforts should be established to maintain the achieved TSR and to increase the low CDR for the smear positive pulmonary TB cases through implementing alternative case finding strategies.

[Analysis of the implementation of the Tuberculosis Control Program in Brazilian prisons]

Tuberculosis control measures in Brazil's prison population have been regulated for ten years under the National Prison Health System Plan. Brazilian states have different organizational models for the Tuberculosis Control Program (TCP) in their prison systems. This study evaluated TCP implementation in prisons in two Brazilian states, using a multiple case study design with a qualitative approach and a log-frame analysis and assessment. According to predefined criteria, two state cases were selected, with two analytical units for each case and one prison hospital in Case 2. We identified partial program implementation in the Case 1 prisons and prison hospital and low implementation in non-hospital prison health services in Case 2. Lack of financial investment and resources, lack of integration between the courts and law enforcement system and health institutions, and poor access to health services in prisons were adverse factors for program implementation.

Directly observed therapy reduces tuberculosis-specific mortality: a population-based follow-up study in Taipei, Taiwan

Objectives

To determine the effect of directly observed therapy (DOT) on tuberculosis-specific mortality and non-TB-specific mortality and identify prognostic factors associated with mortality among adults with culture-positive pulmonary TB (PTB).

Methods

All adult Taiwanese with PTB in Taipei, Taiwan were included in a retrospective cohort study in 2006–2010. Backward stepwise multinomial logistic regression was used to identify risk factors associated with each mortality outcome.

Results

Mean age of the 3,487 patients was 64.2 years and 70.4% were male. Among 2471 patients on DOT, 4.2% (105) died of TB-specific causes and 15.4% (381) died of non-TB-specific causes. Among 1016 patients on SAT, 4.4% (45) died of TB-specific causes and 11.8% (120) died of non-TB-specific causes. , After adjustment for potential confounders, the odds ratio for TB-specific mortality was 0.45 (95% CI: 0.30–0.69) among patients treated with DOT as compared with those on self-administered treatment. Independent predictors of TB-specific and non-TB-specific mortality included older age (ie, 65–79 and ≥80 years vs. 18–49 years), being unemployed, a positive sputum smear for acid-fast bacilli, and TB notification from a general ward or intensive care unit (reference: outpatient services). Male sex, end-stage renal disease requiring dialysis, malignancy, and pleural effusion on chest radiography were associated with increased risk of non-TB-specific mortality, while presence of lung cavities on chest radiography was associated with lower risk.

Conclusions

DOT reduced TB-specific mortality by 55% among patients with PTB, after controlling for confounders. DOT should be given to all TB patients to further reduce TB-specific mortality.

Implementing the global plan to stop TB, 2011-2015--optimizing allocations and the Global Fund's contribution: a scenario projections study

Background

The Global Plan to Stop TB estimates funding required in low- and middle-income countries to achieve TB control targets set by the Stop TB Partnership within the context of the Millennium Development Goals. We estimate the contribution and impact of Global Fund investments under various scenarios of allocations across interventions and regions.

Methodology/Principal Findings

Using Global Plan assumptions on expected cases and mortality, we estimate treatment costs and mortality impact for diagnosis and treatment for drug-sensitive and multidrug-resistant TB (MDR-TB), including antiretroviral treatment (ART) during DOTS for HIV-co-infected patients, for four country groups, overall and for the Global Fund investments. In 2015, China and India account for 24% of funding need, Eastern Europe and Central Asia (EECA) for 33%, sub-Saharan Africa (SSA) for 20%, and other low- and middle-income countries for 24%. Scale-up of MDR-TB treatment, especially in EECA, drives an increasing global TB funding need – an essential investment to contain the mortality burden associated with MDR-TB and future disease costs. Funding needs rise fastest in SSA, reflecting increasing coverage need of improved TB/HIV management, which saves most lives per dollar spent in the short term. The Global Fund is expected to finance 8–12% of Global Plan implementation costs annually. Lives saved through Global Fund TB support within the available funding envelope could increase 37% if allocations shifted from current regional demand patterns to a prioritized scale-up of improved TB/HIV treatment and secondly DOTS, both mainly in Africa − with EECA region, which has disproportionately high per-patient costs, funded from alternative resources.

Conclusions/Significance

These findings, alongside country funding gaps, domestic funding and implementation capacity and equity considerations, should inform strategies and policies for international donors, national governments and disease control programs to implement a more optimal investment approach focusing on highest-impact populations and interventions.

Screening and rapid molecular diagnosis of tuberculosis in prisons in Russia and Eastern Europe: a cost-effectiveness analysis

BACKGROUND

Prisons of the former Soviet Union (FSU) have high rates of multidrug-resistant tuberculosis (MDR-TB) and are thought to drive general population tuberculosis (TB) epidemics. Effective prison case detection, though employing more expensive technologies, may reduce long-term treatment costs and slow MDR-TB transmission.

METHODS AND FINDINGS

We developed a dynamic transmission model of TB and drug resistance matched to the epidemiology and costs in FSU prisons. We evaluated eight strategies for TB screening and diagnosis involving, alone or in combination, self-referral, symptom screening, mass miniature radiography (MMR), and sputum PCR with probes for rifampin resistance (Xpert MTB/RIF). Over a 10-y horizon, we projected costs, quality-adjusted life years (QALYs), and TB and MDR-TB prevalence. Using sputum PCR as an annual primary screening tool among the general prison population most effectively reduced overall TB prevalence (from 2.78% to 2.31%) and MDR-TB prevalence (from 0.74% to 0.63%), and cost US$543/QALY for additional QALYs gained compared to MMR screening with sputum PCR reserved for rapid detection of MDR-TB. Adding sputum PCR to the currently used strategy of annual MMR screening was cost-saving over 10 y compared to MMR screening alone, but produced only a modest reduction in MDR-TB prevalence (from 0.74% to 0.69%) and had minimal effect on overall TB prevalence (from 2.78% to 2.74%). Strategies based on symptom screening alone were less effective and more expensive than MMR-based strategies. Study limitations included scarce primary TB time-series data in FSU prisons and uncertainties regarding screening test characteristics.

CONCLUSIONS

In prisons of the FSU, annual screening of the general inmate population with sputum PCR most effectively reduces TB and MDR-TB prevalence, doing so cost-effectively. If this approach is not feasible, the current strategy of annual MMR is both more effective and less expensive than strategies using self-referral or symptom screening alone, and the addition of sputum PCR for rapid MDR-TB detection may be cost-saving over time.

Survival of civilian and prisoner drug-sensitive, multi- and extensive drug- resistant tuberculosis cohorts prospectively followed in Russia

Objective and Methods

A long-term observational study was conducted in Samara, Russia to assess the survival and risk factors for death of a cohort of non-multidrug resistant tuberculosis (non-MDRTB) and multidrug resistant tuberculosis (MDRTB) civilian and prison patients and a civilian extensive drug-resistant tuberculosis (XDRTB) cohort.

Results

MDRTB and XDRTB rates of 54.8% and 11.1% were identified in the region. Half (50%) of MDRTB patients and the majority of non-MDRTB patients (71%) were still alive at 5 years. Over half (58%) of the patients died within two years of establishing a diagnosis of XDRTB. In the multivariate analysis, retreatment (HR = 1.61, 95%CI 1.04, 2.49) and MDRTB (HR = 1.67, 95%CI 1.17, 2.39) were significantly associated with death within the non-MDR/MDRTB cohort. The effect of age on survival was relatively small (HR = 1.01, 95%CI 1.00, 1.02). No specific factor affected survival of XDRTB patients although median survival time for HIV-infected versus HIV-negative patients from this group was shorter (185 versus 496 days). The majority of MDRTB and XDRTB strains (84% and 92% respectively) strains belonged to the Beijing family. Mutations in the rpoB (codon 531 in 81/92; 88.8%), katG (mutation S315T in 91/92, 98.9%) and inhA genes accounted for most rifampin and isoniazid resistance respectively, mutations in the QRDR region of gyrA for most fluroquinolone resistance (68/92; 73.5%).

Conclusions

Alarmingly high rates of XDRTB exist. Previous TB treatment cycles and MDR were significant risk factors for mortality. XDRTB patients' survival is short especially for HIV-infected patients. Beijing family strains comprise the majority of drug-resistant strains.

Risk factors for non-cure among new sputum smear positive tuberculosis patients treated in tuberculosis dispensaries in Yunnan, China

Background

Yunnan province in China has a high tuberculosis (TB) burden. Cure rates in general are high, but they were below the target of 85% in 26 out of 129 counties in 2005. In these 26 counties we assessed which patient-related and treatment-related factors were associated with non-cure.

Methods

We conducted a prospective cohort study. Smear positive pulmonary TB patients treated at the local Center for Disease Control and Prevention (CDC) were interviewed before start of treatment and during the fifth month of treatment using structured questionnaires. Information on treatment outcome was extracted from patient records. Patients cured at the end of treatment were compared to patients with unsuccessful treatment outcomes (failure, default, and death).

Results

A total of 841 patients were registered between January-June 2007 of which 792 (94%) were cured. Independent risk factors for non-cure were having a low income (<3000 RMB per year), not having medical insurance, a delay in health care seeking >30 days, a positive smear test result two months after start of treatment, not being aware of the need to go to the CDC for medical follow up during treatment, and not seeing the need for treatment observation.

Conclusion

Reducing the financial burden of TB disease and providing health education to improve compliance with treatment could increase the proportion of patients with successful treatment outcomes.

Mortality among patients with tuberculosis requiring intensive care: a retrospective cohort study

Background

To describe the characteristics of patients with tuberculosis (TB) requiring intensive care and to identify the factors that predicts in-hospital mortality in a city of a developing country with intermediate-to-high TB endemicity.

Methods

We conducted a retrospective, cohort study, between November 2005 and November 2007. The patients with TB requiring intensive care were included. Predictors of mortality were assessed. The primary outcome was the in-hospital mortality.

Results

During the study period, 67 patients with TB required intensive care. Of them, 62 (92.5%) had acute respiratory failure and required mechanical ventilation. Forty-four (65.7%) patients died. Coinfection with human immunodeficiency virus was present in 46 (68.7%) patients. Early intensive care unit admission and ventilator-associated pneumonia were independently associated with the in-hospital mortality.

Conclusions

In this study we found a high mortality rate in TB patients requiring intensive care, especially in those with an early ICU admission.

Mycobacterium tuberculosis genotype and case notification rates, rural Vietnam, 2003-2006

Young adults may be introducing Beijing strains.

Tuberculosis case notification rates (CNRs) for young adults in Vietnam are increasing. To determine whether this finding could reflect emergence of Mycobacterium tuberculosis Beijing genotype, we studied all new sputum smear–positive pulmonary tuberculosis patients registered for treatment in 3 rural districts in Vietnam during 2003–2006. Beijing strain infections were more frequent in younger patients (15–24 years of age, 53%) than in older patients (31%; p<0.001). The increase in CNRs for youngest patients was larger for disease caused by the Beijing genotype than by other genotypes, but the difference was not significant. For patients 15–24 years of age, 85% of fluctuations in CNRs between years was caused by fluctuations in Beijing genotype infections compared with 53% and 23% in the groups 25–64 and >65 years of age, respectively (p<0.001). These findings suggest that young adults may be responsible for introducing Beijing strains into rural Vietnam.

An integrated approach to rapid diagnosis of tuberculosis and multidrug resistance using liquid culture and molecular methods in Russia

OBJECTIVE

To analyse the feasibility, cost and performance of rapid tuberculosis (TB) molecular and culture systems, in a high multidrug-resistant TB (MDR TB) middle-income region (Samara, Russia) and provide evidence for WHO policy change.

METHODS

Performance and cost evaluation was conducted to compare the BACTEC MGIT 960 system for culture and drug susceptibility testing (DST) and molecular systems for TB diagnosis, resistance to isoniazid and rifampin, and MDR TB identification compared to conventional Lowenstein-Jensen culture assays.

FINDINGS

698 consecutive patients (2487 sputum samples) with risk factors for drug-resistant tuberculosis were recruited. Overall M. tuberculosis complex culture positivity rates were 31.6% (787/2487) in MGIT and 27.1% (675/2487) in LJ (90.5% and 83.2% for smear-positive specimens). In total, 809 cultures of M. tuberculosis complex were isolated by any method. Median time to detection was 14 days for MGIT and 36 days for LJ (10 and 33 days for smear positive specimens) and indirect DST in MGIT took 9 days compared to 21 days on LJ. There was good concordance between DST on LJ and MGIT (96.8% for rifampin and 95.6% for isoniazid). Both molecular hybridization assay results correlated well with MGIT DST results, although molecular assays generally yielded higher rates of resistance (by approximately 3% for both isoniazid and rifampin).

CONCLUSION

With effective planning and logistics, the MGIT 960 and molecular based methodologies can be successfully introduced into a reference laboratory setting in a middle incidence country. High rates of MDR TB in the Russian Federation make the introduction of such assays particularly useful.

Epidemiology and treatment of multidrug resistant tuberculosis

Multidrug resistant tuberculosis is now thought to afflict between 1 and 2 million patients annually. Although significant regional variability in the distribution of disease has been recorded, surveillance data are limited by several factors. The true burden of disease is likely underestimated. Nevertheless, the estimated burden is substantial enough to warrant concerted action. A range of approaches is possible, but all appropriate interventions require scale-up of laboratories and early treatment with regimens containing a sufficient number of second-line drugs. Ambulatory treatment for most patients, and improved infection control, can facilitate scale-up with decreased risk of nosocomial transmission. Several obstacles have been considered to preclude worldwide scale-up of treatment, mostly attributable to inadequate human, drug, and financial resources. Further delays in scale-up, however, risk continued generation and transmission of resistant tuberculosis, as well as associated morbidity and mortality.

Default from tuberculosis treatment in Tashkent, Uzbekistan; who are these defaulters and why do they default?

Background

In Tashkent (Uzbekistan), TB treatment is provided in accordance with the DOTS strategy. Of 1087 pulmonary TB patients started on treatment in 2005, 228 (21%) defaulted. This study investigates who the defaulters in Tashkent are, when they default and why they default.

Methods

We reviewed the records of 126 defaulters (cases) and 132 controls and collected information on time of default, demographic factors, social factors, potential risk factors for default, characteristics of treatment and recorded reasons for default.

Results

Unemployment, being a pensioner, alcoholism and homelessness were associated with default. Patients defaulted mostly during the intensive phase, while they were hospitalized (61%), or just before they were to start the continuation phase (26%). Reasons for default listed in the records were various, 'Refusal of further treatment' (27%) and 'Violation of hospital rules' (18%) were most frequently recorded. One third of the recorded defaulters did not really default but continued treatment under 'non-DOTS' conditions.

Conclusion

Whereas patient factors such as unemployment, being a pensioner, alcoholism and homelessness play a role, there are also system factors that need to be addressed to reduce default. Such system factors include the obligatory admission in TB hospitals and the inadequately organized transition from hospitalized to ambulatory treatment.

Resistance to implementing policy change: the case of Ukraine

Tuberculosis (TB) is a major public health problem in eastern Europe. Since 1990, the incidence rates of TB have continued to increase in Belarus, the Russian Federation, the Ukraine and the central Asian republics of Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan. Eastern Europe, and in particular the Russian Federation and the Ukraine, also face the public health challenge of an escalating multidrug-resistant tuberculosis (MDR-TB) epidemic. Of the 17 283 global MDR-TB cases reported in 2004, over 60% (10 595) were from the European region and the vast majority of these from eastern Europe, including the Baltic states of Estonia, Latvia and Lithuania. Of particular concern is the fact that, along with Africa, treatment success for DOTS in eastern Europe is substantially below average when compared with other regions of the world, and DOTS coverage and smear-positive case detection rate remain the lowest in the world. Collectively, along with Africa, these problems in eastern Europe remain the principal obstacle to meeting the Millennium Development Goals for TB in Europe. The Ukraine has worsening epidemics of TB, MDR-TB and HIV, against a background of epidemics of sexually transmitted illness (STI) and injecting drug users (IDUs). The TB and HIV epidemics are converging. In spite of attempts, the Ukraine has failed to implement DOTS policy due to health systems organization, financing and provider payment systems that created disincentives to change while opposition by policy-makers and clinicians to DOTS strategy hindered implementation efforts.

The impact of social factors on tuberculosis management

AIM

This paper is a report of a study to examine the impact of social factors on the management of tuberculosis including engagement with services, hospitalization and extended treatment.

BACKGROUND

Rates of tuberculosis in major European cities have increased greatly in the last 10 years. The changing epidemiology of the disease, concentrated in marginalized groups, presents new challenges to the control of tuberculosis.

METHODS

A prospective cohort study of 250 newly diagnosed tuberculosis patients was conducted in London between January 2003 and January 2005. Data were collected by means of a risk assessment tool and from medical records. Outcome measures included missed appointments, frequency and duration of hospitalization and length of treatment.

RESULTS

The median age of the study sample was 33.82 (range 16.4-92.5) and 56.8% were male. Thirty-two per cent were hostel/street homeless or temporarily sharing accommodation with friends or relatives. Thirty-nine per cent were in receipt of welfare benefits and 13.2% had no income. Over a third anticipated difficulties taking their medicines and 30.3% had noone to remind them of this. Increased hospitalization was associated with hostel/street homelessness, drug or alcohol use and having noone to remind them to take their medicines (all P <or= 0.01). Missed appointments were associated with drug/alcohol use and previous tuberculosis treatment. Extended treatment was also associated with drug/alcohol use; previous tuberculosis treatment, drug resistance and those anticipating difficulties taking medication (all P <or= 0.001).

CONCLUSIONS

The development of a social outreach model of care with an emphasis on prevention and support is an essential aspect of modern, international tuberculosis care.

Risk factors for developing tuberculosis in remand prisons in St. Petersburg, Russia - a case-control study

BACKGROUND

Detainees have a substantial risk to develop tuberculosis (TB) due to a higher incidence of TB in remand prison compared to the civil community. They develop TB during incarceration not only due to poor living conditions in remand prison, but also due to some factors affecting their life before imprisonment. Prevention measures against TB spread from penitentiary institutions to society include study of factors, which contribute to TB development. Current study aims at identification of important risk factors of TB development in remand prison in St. Petersburg, Russia.

METHODS

A retrospective matched case-control study was performed from May 2002 to May 2003 in two remand prisons in St. Petersburg. One hundred and fourteen prisoners (57 cases, 57 controls) were interviewed by using standardised questionnaire. Logistic regression analysis was performed to identify risk factors.

RESULTS

Six factors were significantly linked to the risk of developing TB: narcotic drug use (odds ratio (OR): 2.6, 95% confidence interval (CI): 1.0-6.9), low income (OR: 3.2, CI: 1.2-8.6), high ratio of prisoners per available bed (OR: 4.0, CI: 1.1-15.0), not having own bed clothes (OR: 13.0, CI: 2.7-61.6), and little time outdoors (OR: 3.3, CI: 1.3-8.5). However, good housing before imprisonment (OR: 4.2, CI: 1.1-15.7) was a separate risk factor for TB.

CONCLUSIONS

Three of the risk factors (high number of prisoners per bed, not having own bed clothes, and little time outdoors) are certainly possible to approach by improvement of conditions in remand prisons. The remaining three factors (narcotic drug use, good housing before imprisonment, and low income) provide knowledge about study population, but cannot be intervened by prison's medical staff.