Pierpaolo de Colombani

Multidrug-resistant tuberculosis in Belarus: the size of the problem and associated risk factors

OBJECTIVE To assess the problem of multidrug-resistant tuberculosis (MDR-TB) throughout Belarus and investigate the associated risk factors. METHODS In a nationwide survey in 2010-2011, 1420 tuberculosis (TB) patients were screened and 934 new and 410 previously treated cases of TB were found to meet the inclusion criteria. Isolates of Mycobacterium tuberculosis from each eligible patient were tested for susceptibility to anti-TB drugs. Sociobehavioural information was gathered in interviews based on a structured questionnaire. FINDINGS MDR-TB was found in 32.3% and 75.6% of the new and previously treated patients, respectively, and, 11.9% of the 612 patients found to have MDR-TB had extensively drug-resistant TB (XDR-TB). A history of previous treatment for TB was the strongest independent risk factor for MDR-TB (odds ratio, OR: 6.1; 95% confidence interval, CI: 4.8-7.7). The other independent risk factors were human immunodeficiency virus (HIV) infection (OR: 2.2; 95% CI: 1.4-3.5), age < 35 years (OR: 1.4; 95% CI: 1.0-1.8), history of imprisonment (OR: 1.5; 95% CI: 1.1-2.0), disability sufficient to prevent work (OR: 1.9; 95% CI: 1.2-3.0), alcohol abuse (OR: 1.3; 95% CI: 1.0-1.8) and smoking (OR: 1.5; 95% CI: 1.1-2.0). CONCLUSION MDR-TB is very common among TB patients throughout Belarus. The numerous risk factors identified for MDR-TB and the convergence of the epidemics of MDR-TB and HIV infection call not only for stronger collaboration between TB and HIV control programmes, but also for the implementation of innovative measures to accelerate the detection of TB resistance and improve treatment adherence.

Minimum package for cross-border TB control and care in the WHO European region: a Wolfheze consensus statement

The World Health Organization (WHO) European region estimates that more than 400,000 tuberculosis (TB) cases occur in Europe, a large proportion of them among migrants. A coordinated public health mechanism to guarantee TB prevention, diagnosis, treatment and care across borders is not in place. A consensus paper describing the minimum package of cross-border TB control and care was prepared by a task force following a literature review, and with input from the national TB control programme managers of the WHO European region and the Wolfheze 2011 conference. A literature review focused on the subject of TB in migrants was carried out, selecting documents published during the 11-yr period 2001–2011. Several issues were identified in cross-border TB control and care, varying from the limited access to early TB diagnosis, to the lack of continuity of care and information during migration, and the availability of, and access to, health services in the new country. The recommended minimum package addresses the current shortcomings and intends to improve the situation by covering several areas: political commitment (including the implementation of a legal framework for TB cross-border collaboration), financial mechanisms and adequate health service delivery (prevention, infection control, contact management, diagnosis and treatment, and psychosocial support).

Multidrug-resistant tuberculosis in Eastern Europe: still on the increase?

The recently published World Health Organization (WHO) 2011 Global Report [1] provides important new information on the status of the tuberculosis (TB) epidemic and better estimates are now available on different indicators of TB control. These were possible thanks to new methodologies used to measure the disease, producing more precise figures on mortality, number of children orphaned by TB, budget needs and financial gaps. Overall, a clearer picture of TB in general, and multidrug-resistant (MDR)- and extensively drug-resistant (XDR)-TB in particular, is now available to guide the necessary national and international public health response [1–4]. A major response to this is that of the WHO Regional Office for Europe (Copenhagen, Denmark), which has recently prioritised MDR-TB prevention and control by developing a consolidated 5-yr action plan. The action plan and its resolution were endorsed at the 61st Regional Committee in Baku, Azerbaijan in September 2011. The plan envisages identifying and addressing the causes leading to emergence of drug-resistant TB in the region [5]. A complex interplay of factors, such as irrational drug policies, and social and clinical determinants ( e.g. HIV infection, imprisonment, migration and socioeconomic factors), are driving the emergence and the spread of MDR-TB and XDR-TB [6, 7]. Surveillance of drug resistance is a major tool to document the situation at the national level, and the trends in performance of TB care and control efforts, as long as three simple …

Factors Associated with Unfavorable Treatment Outcomes in New and Previously Treated TB Patients in Uzbekistan: A Five Year Countrywide Study

Background TB is one of the main health priorities in Uzbekistan and relatively high rates of unfavorable treatment outcomes have recently been reported. This requires closer analysis to explain the reasons and recommend interventions to improve the situation. Thus, by using countrywide data this study sought to determine trends in unfavorable outcomes (lost-to-follow-ups, deaths and treatment failures) and describe their associations with socio-demographic and clinical factors. Method A countrywide retrospective cohort study of all new and previously treated TB patients registered in the National Tuberculosis programme between January 2006 and December 2010. Results Among 107,380 registered patients, 67% were adults, with smaller proportions of children (10%), adolescents (4%) and elderly patients (19%). Sixty per cent were male, 66% lived in rural areas, 1% were HIV-infected and 1% had a history of imprisonment. Pulmonary TB (PTB) was present in 77%, of which 43% were smear-positive and 53% were smear-negative. Overall, 83% of patients were successfully treated, 6% died, 6% were lost-to-follow-up, 3% failed treatment and 2% transferred out. Factors associated with death included being above 55 years of age, HIV-positive, sputum smear positive, previously treated, jobless and living in certain provinces. Factors associated with lost-to-follow-up were being male, previously treated, jobless, living in an urban area, and living in certain provinces. Having smear-positive PTB, being an adolescent, being urban population, being HIV-negative, previously treated, jobless and residing in particular provinces were associated with treatment failure. Conclusion Overall, 83% treatment success rate was achieved. However, our study findings highlight the need to improve TB services for certain vulnerable groups and in specific areas of the country. They also emphasize the need to develop unified monitoring and evaluation tools for drug-susceptible and drug-resistant TB, and call for better TB surveillance and coordination between provinces and neighbouring countries.

Video-observed treatment for tuberculosis patients in Belarus: findings from the first programmatic experience

The treatment of tuberculosis requires daily intake of multiple medications for between 6 months and 2 years, or more [1, 2]. This long duration predisposes to the interruption of medications with the risk of the emergence of drug resistance, death, disease persistence and continued transmission of tuberculosis in the community. Directly observed treatment, together with patient support, has been recommended to improve adherence [3]. However, daily treatment observation presents challenges for both patients and observers, which have limited its implementation [4]. Digital technologies, like video (or virtually)-observed treatment (VOT) can help bridge the gap between patients and health services and promote adherence [5]. VOT usually requires patients to film themselves taking medications on a computer or mobile device and then transmit these images to a remote observer via the internet [6–9]. Video technology has been available for more than a decade, but the increasing availability of smartphones and broadband internet is making VOT practical to implement even in resource-constrained settings. Belarus has started implementing video-observed treatment for patients with tuberculosis using smartphones http://ow.ly/q1dM307W7hC

Low HIV infection rates among tuberculosis patients in Dhaka, Bangladesh.

The association of tuberculosis (TB) with HIV infection is well established with TB being one of the common manifestations of AIDS. The proportion of TB cases with HIV infection has been rising and the global prevalence of TB/HIV coinfection among adults aged 15–49 years is 0.36%. India has the largest number of co-infected individuals. Bangladesh ranks fifth among the countries with the highest burden of TB but fortunately HIV prevalence in Bangladesh is still low. However recent data from surveillance show that Bangladesh is at the brink of a concentrated epidemic in injecting drug users. The country has 363 people with HIV/AIDS (PHA) identified through passive case reporting as announced by the National AIDS/STD Programme of the Government of Bangladesh on 1 December 2003. Of 67 PHA who visited the Voluntary Counselling and Testing (VCT) Unit of ICDDRB between April 2003 and June 2004 47 had opportunistic infections of whom six had TB (M M Parvez ICDDRB personal communication). (excerpt)

Framework for Selecting Best Practices in Public Health: A Systematic Literature Review.

Evidence-based public health has commonly relied on findings from empirical studies, or research-based evidence. However, this paper advocates that practice-based evidence derived from programmes implemented in real-life settings is likely to be a more suitable source of evidence for inspiring and guiding public health programmes. Selection of best practices from the array of implemented programmes is one way of generating such practice-based evidence. Yet the lack of consensus on the definition and criteria for practice-based evidence and best practices has limited their application in public health so far. To address the gap in literature on practice-based evidence, this paper hence proposes measures of success for public health interventions by developing an evaluation framework for selection of best practices. The proposed framework was synthesised from a systematic literature review of peer-reviewed and grey literature on existing evaluation frameworks for public health programmes as well as processes employed by health-related organisations when selecting best practices. A best practice is firstly defined as an intervention that has shown evidence of effectiveness in a particular setting and is likely to be replicable to other situations. Regardless of the area of public health, interventions should be evaluated by their context, process and outcomes. A best practice should hence meet most, if not all, of eight identified evaluation criteria: relevance, community participation, stakeholder collaboration, ethical soundness, replicability, effectiveness, efficiency and sustainability. Ultimately, a standardised framework for selection of best practices will improve the usefulness and credibility of practice-based evidence in informing evidence-based public health interventions. Significance for public health Best practices are a valuable source of practice-based evidence on effective public health interventions implemented in real-life settings. Yet, despite the frequent branding of interventions as best practices or good practices, there is no consensus on the definition and desirable characteristics of such best practices. Hence, this is likely to be the first systematic review on the topic of best practices in public health. Having a single widely accepted framework for selecting best practices will ensure that the selection processes by different agencies are fair and comparable, as well as enable public health workers to better appreciate and adopt best practices in different settings. Ultimately, standardisation will improve the credibility and usefulness of practice-based evidence to that of research-based evidence.