WHO target product profiles for TB preventive treatment

BACKGROUND: The WHO has developed target product profiles (TPPs) describing the most appropriate qualities for future TPT regimens to assist developers in aligning the characteristics of new treatments with programmatic requirements.METHODS: A technical consultation group was convened by the WHO to determine regimen attributes with greatest potential impact for patients (i.e., improved risk/benefit profile) and populations (i.e., reduction in transmission and TB prevalence). The group categorised regimen attributes as 'priority´ or 'desirable´; and defined for each attribute the minimum requirements and optimal targets.RESULTS: Nine priority attributes were defined, including efficacy, treatment duration, safety, drug-drug interactions, barrier to emergence of drug resistance, target population, formulation, dosage, frequency and route of administration, stability and shelf life. Regimens meeting optimal targets were characterised, for example, as having superior efficacy, treatment duration of ≤2 weeks, and improved tolerability and safety profile compared with current regimens. The four desirable attributes included regimen cost, safety in special populations, treatment adherence and need for drug susceptibility testing in the index patient.DISCUSSION: It may be difficult for a single regimen to satisfy all characteristics so regimen developers may have to consider trade-offs. Additional operational aspects may be relevant to the feasibility and public health impact of new TPT regimens.

TB preventive treatment in high- and intermediate-incidence countries: research needs for scale-up

BACKGROUND: In 2018, the WHO Member States committed to providing TB preventive treatment (TPT) to at least 30 million people by 2022. However, only 6.3 million people had initiated TPT by the end of 2019. Major knowledge gaps and research needs in diagnosis, treatment and the programmatic management of TPT (PMTPT) require to be addressed urgently.METHODS: In September 2019, a group of stakeholders involved in PMTPT in high TB burden countries met to develop an action agenda to support the global expansion of PMTPT.RESULTS: Barriers at the health system level, and priorities for research to overcome these, were identified for each step of the PMTPT cascade. The need for data on TPT financing, gaps and coverage under national health insurance schemes, as well as the need for mathematical and cost-effectiveness modelling of the impact of TPT on TB incidence and mortality were highlighted. Specific research needs were identified for high-risk populations such as household contacts of any age and people living with HIV, as well as other people at risk.CONCLUSIONS: The meeting facilitated agreement on a set of actions needed to ensure that PMTPT continues to expand to achieve the End TB Strategy targets.

Urgent need to address the slow scale-up of TB preventive treatment in the WHO South-East Asia Region

In September 2018, all countries made a commitment at the first ever United Nations High-Level Meeting (UNHLM) on TB, to provide TB preventive treatment (TPT) to at least 30 million people at high-risk of TB disease between 2018 and 2022. In the WHO South-East Asia Region (SEA Region), which accounts for 44% of the global TB burden, only 1.2 million high-risk individuals (household contacts and people living with HIV) were provided TPT (11% of the 10.8 million regional UNHLM TPT target) in 2018 and 2019. By 2020, almost all 11 countries of the SEA Region had revised their policies on TPT target groups and criteria to assess TPT eligibility, and had adopted at least one shorter TPT regimen recommended in the latest WHO TPT guidelines. The major challenges for TPT scale-up in the SEA Region are resource shortages, knowledge and service delivery/uptake gaps among providers and service recipients, and the lack of adequate quantities of rifapentine for use in shorter TPT regimens. There are several regional opportunities to address these gaps and countries of the SEA Region must make use of these opportunities to scale up TPT services rapidly to reduce the TB burden in the SEA Region.

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.

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 2010–2011, 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: 1.45–3.45), imprisonment (1.93; 95% CI: 1.01–3.70), previous treatment (4.45; 95% CI: 2.66–7.43), and not owning a home (1.79; 95% CI: 1.01–3.16). 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.

Multidrug resistance in new tuberculosis patients: burden and implications

In 2010, 30 countries with anti-tuberculosis drug resistance surveillance data were each estimated to have more than 700 multidrug-resistant tuberculosis (MDR-TB) cases among their notified TB cases. New TB patients comprised a median of 54% (interquartile range 45-67) of the MDR-TB cases. The occurrence of MDR-TB in a new TB patient is a warning sign that MDR-TB is spreading in a community. While MDR-TB case-finding efforts should first prioritize previously treated patients, reaching universal access requires rapidly adding other risk groups, and then all new TB patients. Epidemiological data as presented in this paper can help inform country scale-up plans.

Drug resistance beyond extensively drug-resistant tuberculosis: individual patient data meta-analysis

The broadest pattern of tuberculosis (TB) drug resistance for which a consensus definition exists is extensively drug-resistant (XDR)-TB. It is not known if additional drug resistance portends worsened patient outcomes. This study compares treatment outcomes of XDR-TB patients with and without additional resistance in order to explore the need for a new definition. Individual patient data on XDR-TB outcomes were included in a meta-analysis comparing outcomes between XDR alone and three nonmutually exclusive XDR-TB patient groups: XDR plus resistance to all the second-line injectables (sli) and capreomycin and kanamycin/amikacin (XDR+2sli) XDR plus resistance to second-line injectables and to more than one group 4 drug, i.e. ethionamide/protionamide, cycloserine/terizidone or para-aminosalicylic acid (XDR+sliG4) and XDR+sliG4 plus resistance to ethambutol and/or pyrazinamide (XDR+sliG4EZ). Of 405 XDR-TB cases, 301 were XDR alone, 68 XDR+2sli, 48 XDR+sliG4 and 42 XDR+sliG4EZ. In multivariate analysis, the odds of cure were significantly lower in XDR+2sli (adjusted OR 0.4, 95% CI 0.2-0.8) compared to XDR alone, while odds of failure and death were higher in all XDR patients with additional resistance (adjusted OR 2.6-2.8). Patients with additional resistance beyond XDR-TB showed poorer outcomes. Limitations in availability, accuracy and reproducibility of current drug susceptibility testing methods preclude the adoption of a useful definition beyond the one currently used for XDR-TB.

Predictors of sputum culture conversion among patients treated for multidrug-resistant tuberculosis

OBJECTIVE

To identify predictors of initial sputum culture conversion, estimate the usefulness of persistent positive cultures at different time points in predicting treatment failure, and evaluate different definitions of culture conversion for predicting failure among patients with multidrug-resistant tuberculosis (MDR-TB) in five countries, 2000-2004.

METHODS

Predictors of time to conversion were identified using multivariate Cox proportional hazards regression modeling. Receiver operating characteristic curves were plotted to visualize the effect of using different definitions of 'culture conversion' on the balance between sensitivity and specificity.

RESULTS

Overall, 1209/1416 (85%) of patients with baseline positive cultures converted in a median of 3.0 months (interquartile range 2.0-5.0). Independent predictors of less likely conversion included baseline positive smear (hazard ratio [HR] 0.60, 95%CI 0.53-0.68), resistance to pyrazinamide (HR 0.82, 95%CI 0.70-0.96), fluoroquinolones (FQs; HR 0.65, 95%CI 0.51-0.83) or thioamide (HR 0.83, 95%CI 0.71-0.96), previous use of FQs (HR 0.71, 95%CI 0.60-0.83), poor outcome of previous anti-tuberculosis treatment (HR 0.69, 95%CI 0.54-0.88) and alcoholism (HR 0.74, 95%CI 0.63-0.87). The maximum combined sensitivity (84%) and specificity (94%) in predicting treatment failure was based on lack of culture conversion at month 9 of treatment, assuming conversion is defined as five consecutive negative cultures.

CONCLUSION

Patients with identified risk factors were less likely to achieve sputum culture conversion during MDR-TB treatment.

Frequency and type of microbiological monitoring of multidrug-resistant tuberculosis treatment

Monthly culture is usually recommended to monitor treatment of multidrug-resistant tuberculosis (MDR-TB). As mycobacterial laboratory capacity is limited in many settings, TB programs need evidence to decide whether monthly cultures are necessary compared to other approaches. We simulated three alternative monitoring strategies (culture every 2 or 3 months, and monthly smears alone) in a cohort of MDR-TB patients in Estonia, Latvia, Philippines, Russia and Peru from 2000 to 2004. This retrospective analysis illustrated that less frequent testing delays confirmation of bacteriological conversion. This would prolong intensive treatment, hospitalization and respiratory isolation, increasing cost and toxicity. After conversion, less frequent testing could delay diagnosis of possible treatment failure.

The impact and cost-effectiveness of strategies to detect drug-resistant tuberculosis

Drug-resistant tuberculosis (TB) is a serious emerging problem in many low-resource countries. TB control programmes are uncertain of which drug susceptibility tests (DSTs) to use and when to test patients. We predicted the potential cost-effectiveness of different DST strategies, in settings with varying prevalence of drug resistance. Using decision analysis, we assessed the cost-effectiveness of conventional and rapid DSTs for previously diagnosed smear-positive TB cases. Five different time-points were considered for administering DSTs. Different initial drug resistance and HIV scenarios were also considered. All DST scenarios in the wide range of settings considered were found to be cost-effective. The strategy of performing a rapid DST that detects any form of isoniazid (INH) and rifampicin (RIF) resistance for all patients before the initiation of treatment was predicted to be the most cost-effective strategy. In a setting with moderate drug resistance, the cost per disability-adjusted life year gained was as low as US$744. Our findings support the roll-out of rapid drug susceptibility testing at the moment of diagnosis to detect any form of INH and RIF resistance in all countries with moderate or greater burdens of drug-resistant TB.

WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update

The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥ 20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens.

Harmonisation of TB control in the WHO European region: the history of the Wolfheze Workshops

In 1990 a workshop was organised in the village of Wolfheze (the Netherlands), where experts discussed the critical interventions that would foster elimination of TB in Europe. This event has been followed by several more over the following two decades to become known as the "Wolfheze Workshops". This article provides a brief overview of the history and the impact the Wolfheze Workshops have had on the commitment of European governments to standardise definitions, recording and reporting systems and, thus, permitted comparison of interventions and improving TB control across borders. The Wolfheze Workshops have been and still are an essential platform for this exchange of experiences, promoting common approaches.

Risk factors for death among tuberculosis cases: analysis of European surveillance data

The proportion of tuberculosis (TB) patients in the European Union (EU) who die remains high (8% overall). The aim of the present study was to quantify the risk of dying associated with demographic and clinical factors. Case-based data on 39,566 TB patients notified by 15 EU countries during 2002-2004 were analysed using logistic regression. It was observed that advancing age and resistance to isoniazid and rifampicin were the strongest determinants of death, while male sex, European origin, pulmonary site of disease and previous anti-TB treatment were weaker predictors. Risk varied between reporting countries, presumably reflecting differences in patient profiles, reporting practices and programme effectiveness. In conclusion, earlier suspicion, diagnosis and treatment may reduce deaths, particularly among the elderly. Special attention is needed to avert the development and transmission of multidrug-resistant tuberculosis.

Stopping TB in Europe: some progress but still not there

Overview of the epidemiological situation in 2006. The latest available information from countries in the World Health Organization (WHO) European Region carries important signals about the tuberculosis (TB) situation in this part of the world [1]. The total number of TB cases reported in the Region was slightly lower in 2006 than in 2005 (422,830 versus 426,457), reflecting a decrease in three-fourths of the reporting countries. Most TB cases in 2006 (73%) were reported by 12 former Soviet Union republics in the East, 21% by the European Union and West (EU and West) and 6% by the remaining countries in the Balkans (Table 1; for the composition of geographical areas see Box). National TB notification rates ranged from 4 to 282 per 100,000 population. The total TB notification rate for the whole Region has increased very slightly between 2002 and 2006, from 46 to 48 cases per 100,000, although rates of previously untreated TB cases appear to be on the decrease in both the East and West (Figure 1). We describe the main epidemiological features of TB cases notified in each of the abovementioned areas using surveillance data reported by the countries themselves.

Demographic features and trends in tuberculosis cases in the European Region, 1995-2005

In 2005, 426,457 tuberculosis (TB) cases were notified in the World Health Organization (WHO) European Region, with a wide variation and an incremental west-to-east gradient in notification rates also reflected in TB mortality rates. In the enlarged European Union ('EU-27') and other western countries--where 19% of cases were of foreign origin in 2005 (>50% in 13 countries)--overall TB notification rates decreased by 2.4% yearly between 2000 and 2005, compared to 1.6% in 1995-2000, reflecting a declining incidence in all age groups and in most countries. Half the cases notified by the 12 ex-republics of the former Soviet Union in the East in 2005 were reported by the Russian Federation. In the East, the mean annual increase in 1995-2000 (10.0%) was higher than in 2000-2005 (3.9%), and in recent years the number of new cases stabilised while previously treated cases have increased. Efforts are still needed to improve and standardise TB surveillance across the Region. The collection of additional data on risk factors of TB may be useful for surveillance and control.

Tuberculosis: still a concern for all countries in Europe

Tuberculosis (TB) is a matter of concern for all countries in the World Health Organization European Region, although the epidemiological situation of the disease varies widely between countries. To mark World TB Day on 24 March 2007, the European Centre for Disease Prevention and Control (ECDC) will hold a scientific seminar at the European Parliament on 22 March (http://www.ecdc.eu.int/tbseminar) to increase awareness and share views and knowledge about the importance of TB control in Europe. Data from a newly published report from EuroTB (a collaborating centre of WHO for the surveillance of TB) on cases of the disease notified during 2005 will be presented.

In the European Union, TB patients from former Soviet countries have a high risk of multidrug resistance

SETTING

Fourteen countries of the European Union (EU).

OBJECTIVE

To explore determinants of resistance to isoniazid and rifampicin (multidrug-resistant tuberculosis [MDR-TB]) among tuberculosis (TB) patients in the EU.

DESIGN

Pooled TB case notification data for 2003 from the-Baltic States (Estonia, Latvia, Lithuania) and Austria, Belgium, the Czech Republic, Denmark, Finland, Germany, Luxembourg, The Netherlands, Slovenia, Sweden and the UK were investigated using bivariate and multivariable analysis.

RESULTS

Of 12,109 cases with data, MDR-TB occurred in 709 cases, 91% of whom were from countries of the former Soviet Union (FSU), including the Baltic States. At multivariable analysis, MDR-TB was strongly associated with previous treatment in both Baltic and non-Baltic countries (adjusted OR 9.5 and 6.4, respectively), and inversely related to age >64 years (OR 0.4 and 0.2). In non-Baltic countries, MDR-TB was more strongly related to origin from the FSU (OR 19.7, reference non-Baltic EU) than from other regions (up to OR 2.3). Among cases pooled from all countries, provenance from the FSU was very strongly linked to MDR-TB in both previously untreated (OR 24.9) and previously treated (OR 53.7) cases.

CONCLUSION

Within a context of increasing mobility, public health workers should be aware of a higher risk for MDR-TB among patients from the FSU as well as among patients previously treated for TB.

Tuberculosis and air travel: towards improved control

The first reports of tuberculosis (TB) transmission linked to air travel in the early 1990s came at a time when TB

World TB day: European countries report over 400,000 tuberculosis cases in 2004

In 2004, 414 163 tuberculosis cases were notified by 51 of the 52 countries of the World Health Organization European Region, representing 8% of notifications to WHO worldwide in the same year. Seventy per cent of all TB cases in the region were in the 12 countries of the Former Soviet Union

European survey of BCG vaccination policies and surveillance in children, 2005

In 2005, all 25 EU countries, as well as Andorra, Bulgaria, Norway, Romania and Switzerland, participated in a survey on BCG vaccination in children. BCG was recommended nationally for children under 12 months in 12 countries, in older children in five countries and in children at risk (from origin, contact or travel) in 10 countries. Seven countries did not use BCG systematically. Revaccination was practised in four countries. In countries with universal vaccination, BCG coverage was high (83.0% to 99.8%). TB cases commonly occurred in vaccinated children (at least 30%-98% in five countries using universal or high-risk approach). Disseminated infection due to BCG was rarely reported in recent years (0-1/100 000 vaccinated). There is a wide variation among BCG recommendations in Europe, and nearly half the countries surveyed were considering revisions, at a time when the European Centre for Disease Prevention and Control (ECDC) is advocating for harmonised vaccine strategies. Data on monitoring of BCG coverage in target groups is important but often lacking in Europe. Information on BCG status and eligibility should be collected routinely through TB case notification. The incidence of severe adverse effects of BCG in children should be monitored. Given lack of evidence to its efficacy, revaccination should be discontinued.

Tuberculosis outcome monitoring – is it time to update European recommendations?

We discuss tuberculosis treatment outcome monitoring and the adherence of countries in the WHO European Region to modifications introduced in 2001 to enhance inter-country comparability. Outcomes for definite pulmonary tuberculosis cases were compared for cases reported in 2001 and 2000. Reporting was considered complete if 98% or more of cases originally notified had outcome reported. In both years, maximal period of observation was 12 months from start of treatment. In 2000, countries reported outcome as ‘cured’, ‘completed’, ‘died’, ‘failed’, ‘defaulted’, ‘transferred’ and ‘other, not evaluated’ for cohorts of new and retreated cases. In 2001, following changes, countries were also requested to monitor cases with unknown treatment history and two outcome categories were added – ‘still on treatment’ and ‘unknown’. Of 42 countries reporting outcomes in 2001, 74% (31) had nationwide, complete data, up from 50% (19/38) in 2000. Twelve of 21 countries that reported on observation period complied with that recommended. ‘Defaulted’ and ‘transferred’ were applied interchangeably with ‘unknown’. Among new cases, ‘still on treatment’ was used by 15/31 countries (range: 1%-15%). ‘Failed’ was rarely recorded in western European countries (<1%). European tuberculosis outcome monitoring should include all definite pulmonary cases, applying the standard period of observation and revised categories, and preferably reported using individual data.

Tuberculosis outcome monitoring--is it time to update European recommendations?

We discuss tuberculosis treatment outcome monitoring and the adherence of countries in the WHO European Region to modifications introduced in 2001 to enhance inter-country comparability. Outcomes for definite pulmonary tuberculosis cases were compared for cases reported in 2001 and 2000. Reporting was considered complete if 98% or more of cases originally notified had outcome reported. In both years, maximal period of observation was 12 months from start of treatment. In 2000, countries reported outcome as 'cured', 'completed', 'died', 'failed', 'defaulted', 'transferred' and 'other, not evaluated' for cohorts of new and retreated cases. In 2001, following changes, countries were also requested to monitor cases with unknown treatment history and two outcome categories were added--'still on treatment' and 'unknown'. Of 42 countries reporting outcomes in 2001, 74% (31) had nationwide, complete data, up from 50% (19/38) in 2000. Twelve of 21 countries that reported on observation period complied with that recommended. 'Defaulted' and 'transferred' were applied interchangeably with 'unknown'. Among new cases, 'still on treatment' was used by 15/31 countries (range: 1%-15%). 'Failed' was rarely recorded in western European countries (<1%). European tuberculosis outcome monitoring should include all definite pulmonary cases, applying the standard period of observation and revised categories, and preferably reported using individual data.

European survey of BCG vaccination policies and surveillance in children, 2005

In 2005, all 25 EU countries, as well as Andorra, Bulgaria, Norway, Romania and Switzerland, participated in a survey on BCG vaccination in children. BCG was recommended nationally for children under 12 months in 12 countries, in older children in five countries and in children at risk (from origin, contact or travel) in 10 countries. Seven countries did not use BCG systematically. Revaccination was practised in four countries. In countries with universal vaccination, BCG coverage was high (83.0% to 99.8%). TB cases commonly occurred in vaccinated children (at least 30%-98% in five countries using universal or high-risk approach). Disseminated infection due to BCG was rarely reported in recent years (0-1/100 000 vaccinated). There is a wide variation among BCG recommendations in Europe, and nearly half the countries surveyed were considering revisions, at a time when the European Centre for Disease Prevention and Control (ECDC) is advocating for harmonised vaccine strategies. Data on monitoring of BCG coverage in target groups is important but often lacking in Europe. Information on BCG status and eligibility should be collected routinely through TB case notification. The incidence of severe adverse effects of BCG in children should be monitored. Given lack of evidence to its efficacy, revaccination should be discontinued.

Exploring the determinants of treatment success for tuberculosis cases in Europe

SETTING

Pooled tuberculosis (TB) notifications from 13 European countries.

OBJECTIVE

To analyse the determinants of TB treatment success in different countries using individual data.

DESIGN

We asked 18 European countries with both outcome data and individual TB records to code outcomes for cases notified in 2000 and/or 2001. Cases completing treatment regardless of bacteriological proof of cure were considered successful.

RESULTS

Ten European Union countries and Iceland, Norway and Romania participated (72% response). Among 24 660 TB cases (Romania excluded), 'success' was reported in 69% (country range 60-88%), 9% (0-11%) died, 1% (0-5%) failed, 4% defaulted or transferred (2-15%) and 12% (0-23%) were 'unknown'. On logistic regression among cases with drug susceptibility results (n = 10 303), 'success' was associated with younger age (>74 years: reference; 55-74 years: OR = 2.0, 95%CI 1.8-2.4; 35-54 years: 3.0, 95%CI 2.6-3.5; 15-34 years: 3.7, 95%CI 3.2-4.4; <15 years: 4.4, 95%CI 2.9-6.7), female sex (1.4, 95%CI 1.3-1.6), and no polyresistance (9.2, 95%CI 6.8-12.4). The Netherlands (1.6, 95%CI 1.3-2.0) and Slovakia (1.8, 95%CI 1.4-2.2) had higher success than Estonia (reference: lowest percentage success), while Austria was lower (0.64, 95%CI 0.52-0.78).

CONCLUSION

Preventing drug resistance, increasing adherence and improving care in the elderly should be priorities. Inter-country variations in treatment success suggest differences in the completeness of monitoring data and in the efficacy of national control programmes.

Surveillance européenne de la tuberculose : description du réseau et résultats récents

A network for the surveillance of tuberculosis covering the WHO European Region was set up in 1996. It aims to improve the contribution of surveillance to TB control, promoting standardised methods to compare countries. Standardized individual or aggregate data on notified TB cases is provided annually from national surveillance institutions. In the enlarged European Union (EU), overall TB notification rates decreased in recent years (14/100 000 in 2002), but leveled off in some countries including France and the United Kingdom, partly due to increasing numbers of patients from high TB incidence areas (30% in 2002). Multidrug resistance (MDR) was much more frequent in the Baltic States (21% in 2002) than in other countries (1.7%; range: 0-3.7%). Treatment of new pulmonary TB cases notified in 2001 was completed within 12 months in 74% of cases, ongoing in 3%, interrupted due to death in 7%, and interrupted for other reasons or unknown in 15%. In the Balkans and Turkey, notification rates ranged between 20 and 62 per 100 000 in 2002, and decreasing or stable except for Romania (153 in 2002). In the East (former Soviet Union), TB surveillance data, although incomplete, shows an increasing incidence (97/100 000 in 2002), high prevalence of primary MDR (14% in Kazakhstan), and frequent treatment failures (10% in new cases). At the time of EU enlargement, European TB surveillance covering the whole WHO European Region should continue, with support of TB control in the East as a regional priority.

Surveillance of anti-tuberculosis drug resistance in Europe, 1999

With the exception of Israel, representative data from Western and Central Europe indicate consistently low levels of resistance to isoniazid (0-9,3%) or rifampicin (0-2,1%) and of multidrug resistance (0-2,1%) among new tuberculosis (TB) cases. Resistance is more frequent among previously treated cases, but comparisons of data should be done cautiously, as criteria for inclusion in TB notifications may vary across countries. In Western Europe, drug resistance is more frequent among cases of foreign origin, a group with high TB incidence. In 1999, cases of foreign origin accounted for over 90% of the MDR cases in the West, and for all MDR cases notified in Israel. The majority of foreign born cases notified originated from Africa or Asia. In the East, representative data from the Baltic States show that overall, 15% of TB cases notified in 1999 were MDR, among the highest proportion worldwide and indicating inadequacies in previous treatment programmes. In the other countries of the former Soviet Union, non-representative data show high levels of resistance which, along with data from the Baltic states and results of surveys, are very alarming.

SRSV-1 gastroenteritis in Malta - 1995

Small round structured viruses (SRSV) are known to cause epidemic gastroenteritis in institutions and account for 54% of person to person outbreaks and 6% of foodborne outbreaks in England and Wales. Infection is commonly transmitted from person to person