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'The struggle [against tuberculosis] has caught hold along the whole line and enthusiasm for the lofty aim runs so high that a slackening is no longer to be feared. If [...], Tuberculosis (TB) is an ancient disease, but not a disease of the past. After disappearing from the world public health agenda in the 1960s and 1970s, TB returned in the early 1990s for several reasons, including the emergence of the HIV/AIDS pandemic and increases in drug resistance. More than 100 years after the discovery of the tubercle bacillus by Robert Koch, what is the status of TB control worldwide? Here, we review the evolution of global TB control policies, including DOTS (directly observed therapy, short course) and the Stop TB Strategy, and assess whether the challenges and obstacles faced by the public health community worldwide in developing and implementing this strategy can aid future action towards the elimination of TB.

The article discusses the critical factors impeding the control of multidrug-resistant tuberculosis and the solutions required to address such factors. Critical weaknesses have been encountered in current approaches to the treatment and control of tuberculosis and attempts are being to address the same globally.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2009.03.041 Byline: Knut Lonnroth, Ernesto Jaramillo, Brian G. Williams, Christopher Dye, Mario Raviglione Abstract: The main thrust of the World Health Organization's global tuberculosis (TB) control strategy is to ensure effective and equitable delivery of quality assured diagnosis and treatment of TB. Options for including preventive efforts have not yet been fully considered. This paper presents a narrative review of the historical and recent progress in TB control and the role of TB risk factors and social determinants. The review was conducted with a view to assess the prospects of effectively controlling TB under the current strategy, and the potential to increase epidemiological impact through additional preventive interventions. The review suggests that, while the current strategy is effective in curing patients and saving lives, the epidemiological impact has so far been less than predicted. In order to reach long-term epidemiological targets for global TB control, additional interventions to reduce peoples' vulnerability for TB may therefore be required. Risk factors that seem to be of importance at the population level include poor living and working conditions associated with high risk of TB transmission, and factors that impair the host's defence against TB infection and disease, such as HIV infection, malnutrition, smoking, diabetes, alcohol abuse, and indoor air pollution. Preventive interventions may target these factors directly or via their underlying social determinants. The identification of risk groups also helps to target strategies for early detection of people in need of TB treatment. More research is needed on the suitability, feasibility and cost-effectiveness of these intervention options. Author Affiliation: World Health Organization, Geneva, Switzerland

Introduction 'When the elephants fight, the grass gets trampled'--this aphorism exemplifies the vigorous debate over the best approach to planning for development. The debate positions Jeffrey Sachs, (1) a proponent [...], The Global Plan to Stop TB 2006-2015 is a road map for policy-makers and managers of national programmes. It sets out the key actions needed to achieve the targets of the Millennium Development Goals relating to tuberculosis (TB): to halve the prevalence and deaths by 2015 relative to 1990 levels and to save 14 million lives. Developed by a broad coalition of partners, the plan presents a model approach combining interventions that can feasibly be supplied on the ground. The main areas of activity set out in the plan are: scaling up interventions to control tuberculosis; promoting the research and development of improved diagnostics, drugs and vaccines; and engaging in related activities for advocacy, communications and social mobilization. Scenarios for the planning process were developed; these looked at issues both globally and in seven epidemiological regions. The scenarios made ambitious but realistic assumptions about the pace of scale-up and implementation coverage of the activities. A mathematical model was used to estimate the impact of scaling up current interventions based on data from studies of tuberculosis biology and from experience with tuberculosis control in diverse settings. The estimated costs of the activities set out in the Global Plan were based on implementing interventions and researching and developing drugs, diagnostics and vaccines; these costs were US$ 56 billion over 10 years. When translated into cost per disability adjusted life year averted, these costs compare favourably with those of other public health interventions. This approach to planning for global tuberculosis control is a valuable example of developing plans to improve global health that has relevance for other health issues. Resume Le plan mondial Halte a la tuberculose 2006-2015 fournit des lignes directrices aux decideurs politiques et aux directeurs de programmes nationaux. Il presente les interventions cles necessaires a la realisation des objectifs du Millenaire pour le developpement concernant la tuberculose (TB), a savoir faire baisser de moitie, entre 1990 et 2015, la prevalence de cette maladie et la mortalite lui etant imputable et epargner 14 millions de vies. Mis au point par un vaste groupement de partenaires, le plan propose un modele de strategie associant des interventions faciles a mettre en oeuvre sur le terrain. Les principaux domaines d'activite prevus sont : Le passage a l'echelle superieure des interventions de lutte antituberculeuse, la promotion des travaux de recherche et developpement concernant des outils diagnostiques, des medicaments et des vaccins plus performants et l'engagement dans des activites connexes de plaidoyer, de communication et de mobilisation sociale. Des scenarios ont ete developpes pour aider au processus de planification : ils considerent les problemes a l'echelle mondiale et dans sept regions epidemiologiques. Ces scenarios reposent sur des hypotheses ambitieuses, mais realistes, quant au rythme de passage a l'echelle superieure et de developpement de la couverture des activites. Un modele mathematique a ete utilise pour evaluer l'impact du passage a l'echelle superieure des interventions en cours a partir de donnees d'etudes biologiques sur la tuberculose et de l'experience acquise dans divers contextes en matiere de lutte antituberculeuse. Les estimations de couts pour les activites prevues par le Plan mondial correspondent a la mise en oeuvre des interventions et aux travaux de recherche et developpement de medicaments, d'outils diagnostiques et de vaccins ameliores ; elles se montent a US$ 56 milliard sur 10 ans. Une fois convertis en couts par annee de vie corrigee de l'incapacite (DALY), ces chiffres supportent favorablement la comparaison avec ceux d'autres interventions de sante publique. Cette strategie de planification de la lutte contre la tuberculose au niveau mondial est un exemple utile de programme de developpement pour l'amelioration de la sante dans le monde, qui interesse d'autres problemes sanitaires. Resumen El Plan Mundial para Detener la Tuberculosis 2006-2015 es una hoja de ruta para instancias normativas y gestores de programas nacionales. En el se establecen las principales intervenciones necesarias para alcanzar las metas de los Objetivos de Desarrollo del Milenio relacionadas con la tuberculosis: reducir a la mitad la prevalencia de esta enfermedad y la mortalidad por esa causa para 2015 en comparacion con los niveles de 1990 y salvar asi 14 millones de vidas. Elaborado por una amplia coalicion de asociados, el plan presenta un modelo que combina diversas intervenciones que pueden aplicarse de forma viable sobre el terreno. Las areas principales de actividad contempladas en el plan son las siguientes: expansion de las intervenciones de lucha antituberculosa; promocion de la investigacion y el desarrollo de mejores medios diagnosticos, medicamentos y vacunas; y participacion en las actividades relacionadas con la promocion, las comunicaciones y la movilizacion social. Se desarrollaron distintos escenarios para el proceso de planificacion, considerando los problemas a nivel mundial y en siete regiones epidemiologicas. Los escenarios partian de hipotesis ambiciosas pero realistas sobre el ritmo de expansion y la cobertura de aplicacion de las actividades. Se utilizo un modelo matematico para estimar la repercusion de la expansion de las intervenciones actuales sobre la base de datos procedentes de estudios de la biologia de la tuberculosis y de la experiencia de la lucha antituberculosa en diversos entornos. Los costos estimados de las actividades establecidas en el Plan Mundial -correspondientes a la ejecucion de las intervenciones y la investigacion y el desarrollo de medicamentos, medios de diagnostico y vacunas- ascendian a US$ 56 000 millones a lo largo de 10 anos. Traducidos al costo por AVAD (anos de vida ajustados en funcion de la discapacidad) evitado, la cifra es mas baja que la de otras intervenciones de salud publica. Este metodo de planificacion del control mundial de la tuberculosis brinda un valioso ejemplo para elaborar planes de mejora de la salud mundial que revistan interes para otros problemas sanitarios. [TEXT NOT REPRODUCIBLE IN ASCI.]

Introduction Private health care providers play a prominent role in delivering curative services in the majority of low-income countries. (l-5) They are often the first point of contact for a [...], Over the past decade, there has been a rapid increase in the number of initiatives involving 'for-profit' private health care providers in national tuberculosis (TB) control efforts. We reviewed 15 such initiatives with respect to contractual arrangements, quality of care and success achieved in TB control. In seven initiatives, the National TB Programme (NTP) interacted directly with for-profit providers; while in the remaining eight, the NTP collaborated with for-profit providers through intermediary hot-for-profit nongovernmental organizations. All but one of the initiatives used relational 'drugs-for-performance contracts' to engage for-profit providers, i.e. drugs were provided free of charge by the NTP emphasizing that providers dispense them free of charge to patients and follow national guidelines for diagnosis and treatment. We found that 90% (range 61-96%) of new smear-positive pulmonary TB cases were successfully treated across all initiatives and TB case detection rates increased between 10% and 36%. We conclude that for-profit providers can be effectively involved in TB control through informal, but well defined drugs-for- performance contracts. The contracting party should be able to reach a common understanding concerning goals and role division with for-profit providers and monitor them for content and quality. Relational drugs-for-performance contracts minimize the need for handling the legal and financial aspects of classical contracting. We opine that further analysis is required to assess if such 'soft' contracts are sufficient to scale up private for-profit provider involvement in TB control and other priority health interventions. Engagement productif des prestateurs prives dans la lutte antituberculeuse : des benefices bien reels sans contrat Ieonin Au cours de la derniere decennie, on a observe une rapide augmentation du nombre d'initiatives impliquant des prestateurs de soins de sante prives (<>) dans les efforts de lutte contre la tuberculose. Nous avons analyse 15 de ces initiatives sous l'angle des dispositions contractuelles, de la qualite des soins et des succes obtenus dans la lutte antituberculeuse. Dans le cas de 7 d'entre elles, le programme national de lutte contre la tuberculose (PNT) traitait directement avec des prestateurs exercant une activite lucrative, tandis que dans le cadre des 8 autres, le PNT collaborait avec des prestateurs a but lucratif, par l'intermediaire d'organisations non gouvernementales a but non lucratif. Toutes ces initiatives sauf une faisaient appel aux prestateurs a but lucratif en passant avec eux des contrats relationnels << Medicaments contre prestations >>, c'est-a-dire que les medicaments leur etaient fournis gratuitement par le PNT a la condition explicite qu'ils les distribuent gratuitement aux patients et qu'ils respectent les directives nationales en matiere de diagnostic et de traitement. Nous avons constate que, pour l'ensemble des initiatives, 90% (plage de variation : 61 - 96 %) des nouveaux cas de tuberculose pulmonaire a frottis positif avaient ete traites avec succes et que le taux de detection de la tuberculose aurait augmente de 10 a 36 %. Nous avons conclu que les prestateurs a but lucratif pouvaient participer efficacement a la lutte antituberculeuse par l'intermediaire de contrats informels, mais bien definis sous l'angle de la condition : medicaments contre prestations. La partie contractante doit etre en mesure de parvenir a un accord concernant les buts et la repartition des roles avec les prestateurs a but lucratif et de surveiller le contenu et la qualite de leurs prestations. Les contrats relationnels de type Medicaments contre prestations n'exigent qu'une prise en compte minimale des aspects juridiques et financiers couverts par les contrats classiques. Nous sommes d'avis qu'une analyse plus poussee s'impose pour evaluer si ces contrats <> suffisent pour elargir la participation des prestateurs prives a but lucratif a la lutte antituberculeuse et a Ventajas de los contratos relacionales: contratacion productiva de proveedores privados en la lucha contra la tuberculosis En el ultimo decenio han proliferado rapidamente las iniciativas que recurren a proveedores de atencion sanitaria privados con animo de lucro en las actividades nacionales de lucha contra la tuberculosis. Examinamos los acuerdos contractuales, la calidad de la asistencia prestada y los resultados obtenidos en la lucha contra dicha enfermedad en 15 iniciativas de ese tipo. En siete de ellas, el Programa Nacional contra la Tuberculosis trabajaba directamente con proveedores con animo de lucro, y en las ocho restantes colaboraba con proveedores con animo de lucro a traves de organizaciones no gubernamentales no lucrativas. Exceptuando un caso, en todas las iniciativas se recurrio a <> para hacer participar a los proveedores con animo de lucro, esto es, el Programa les proporcionaba los medicamentos de forma gratuita, pero insistiendo en que se dispensaran tambien gratuitamente a los pacientes y con arreglo a las directrices nacionales en materia de diagnostico y tratamiento. Observamos que en todas las iniciativas el 90% (intervalo: 61%-96%) de los nuevos casos baciliferos de tuberculosis pulmonar habian sido tratados satisfactoriamente, y que las tasas de deteccion de casos aumentaron entre el 10% y el 36%. Nuestra conclusion es que los proveedores con animo de lucro pueden participar de forma eficaz en la lucha antituberculosa mediante contratos informales, pero bien definidos, de medicamentos por prestaciones. La parte contratante debe poder llegar a un consenso sobre los objetivos y el reparto de las funciones con esos proveedores, y vigilar el contenido y la calidad de sus servicios. Los contratos de medicamentos por prestaciones reducen al minimo la necesidad de ocuparse de los aspectos juridicos y financieros de los contratos ordinarios. Consideramos que es conveniente realizar un analisis en mayor profundidad para determinar si esos contratos simplificados bastan para extender masivamente la participacion de los proveedores privados con animo de lucro en la lucha contra la tuberculosis y en otras intervenciones de salud prioritarias. [TEXT NOT REPRODUCIBLE IN ASCII.]

[TEXT NOT REPRODUCIBLE IN ASCII] Introduction Globally, there are almost nine million new cases of tuberculosis (TB) each year, two million of which result in death. More than one-third of [...], Objective To assess the cost and cost-effectiveness of the Public-Private Mix DOTS (PPM-DOTS) strategy for tuberculosis (TB) control in India. Methods We collected data on the costs and effects of pilot PPM-DOTS projects in Delhi and Hyderabad using documentary data and interviews. The cost of PPM-DOTS was compared with public sector DOTS (i.e. DOTS delivered through public sector facilities only) and non-DOTS treatment in the private sector. Costs for 2002 in US$ were assessed for the public sector, private practitioners, and patients/attendants. Effectiveness was measured as the number of cases successfully treated. Findings The average cost per patient treated was US$111-123 for PPM-DOTS and public sector DOTS, and US$111-172 for non-DOTS treatment in the private sector. From the public sector's perspective, the cost per patient treated was lower in PPM-DOTS projects than in public sector DOTS programmes (US$ 24-33 versus US$ 63). DOTS implementation in either the public or private sectors improved treatment outcomes and substantially lowered costs incurred by patients and their attendants, compared to non-DOTS treatment in the private sector (US$ 50-60 for DOTS compared to over US$100 for non-DOTS). The average cost-effectiveness of PPM-DOTS and public sector DOTS was similar, at US$120-140 per patient successfully treated, compared to US$ 218-338 for non-DOTS private sector treatment. Incremental cost-effectiveness analysis showed that PPM-DOTS can improve effectiveness while also lowering costs. Conclusion PPM-DOTS can be an affordable and cost-effective approach to improving TB control in India, and can substantially lower the economic burden of TB for patients. Resume Cout et rapport cout/efficacite de la strategie PPM-DOTS dans la lutte contre la tuberculose: resultats obtenus en Inde Objectif Evaluer le cout et le rapport cout/efficacite de la strategie DOTS mixte, associant secteurs public et prive, dans la lutte contre la tuberculose (TB) en Inde. Methodes Des donnees relatives aux coots et aux effets de projets pilotes PPM-DOTS menes a Delhi et a Hyderabad ont ete rassemblees a partir de l'analyse de documents et d'entretiens. Le coot des projets PPM-DOTS a ete compare a celui de l'application de la strategie DOTS par le secteur public (c'est-a-dire la delivrance des prestations DOTS par des etablissements publics uniquement) et a celui d'un traitement non DOTS mis en oeuvre par le secteur prive. Les coots en US $ pour 2002 ont ete evalues pour le secteur public, les praticiens prives et les malades/les personnes qui les soignent. L'efficacite a ete mesuree par le nombre de cas traites avec succes. Resultats Le cout moyen par malade traite se montait a US $ 111-123 pour la strategie PPM-DOTS et les prestations de type DOTS par le secteur public et a US $111-172 pour le traitement non DOTS pratique par le secteur prive. Du point de vue du secteur public, le cout par malade traite eteit plus faible pour les projets PPM-DOTS que pour les programmes DOTS mis en oeuvre par le secteur public (US $ 24-33 contre US $ 63). Qu'elle soit appliquee par le secteur public ou prive, la strategie DOTS permet d'ameliorer les resultats therapeutiques et de reduire considerablement les coots supportes par les malades et les personnes qui les soignent par comparaison avec le traitement non DOTS applique par le secteur prive (US $ 50-60 pour la strategie DOTS contre plus de US $100 pour le traitement non DOTS). Les rapports cout/efficacite moyens pour la strategie PPM-DOTS et pour la strategie DOTS appliquee par le secteur public etaient similaires : US $120-140 par malade traite avec succes, a comparer a la valeur de US $ 218-338 obtenue pour le traitement non DOTS. Une analyse differentielle du rapport cout/efficacite a montre que la strategie PPM-DOTS permettait d'ameliorer l'efficacite tout en abaissant les couts. Conclusion La strategie PPM-DOTS est une approche peu onereuse et d'un bon rapport cout/efficacite pour faire progresser la lutte contre la tuberculose en Inde. Elle permet de reduire substantiellement la charge economique qu'impose aux malades cette pathologie. Resumen Costo y costoeficacia de la DOTS-PP contra la tuberculosis: datos de la India Objetivo Evaluar el costo y la costoeficacia de la estrategia DOTS publicoprivada (DOTS-PP) como medio de control de la tuberculosis en la India. Metodos Reunimos datos sobre los costos y los efectos de proyectos piloto de DOTS-PP llevados a cabo en Delhi y Hyderabad, utilizando para ello informacion documental y entrevistas. El costo de la DOTS-PP se comparo con el de la DOTS del sector publico (es decir, el tratamiento DOTS aplicado solo a traves de establecimientos del sector publico) y el del tratamiento distinto del DOTS en el sector privado. Se evaluaron los costos en US$ correspondientes a 2002 para el sector publico, los medicos particulares, y los pacientes/lasistentes, y la eficacia se midio como el numero de casos tratados satisfactoriamente. Resultados El costo medio pot paciente tratado fue de US$ 111-123 para la DOTS-PP y la DOTS del sector publico, y de US$ 111-172 para el tratamiento distinto del DOTS administrado en el sector privado. Desde la perspectiva del sector publico, en los proyectos DOTS-PP el costo por paciente tratado fue menor que en los programas DOTS del sector publico (US$ 24-33 frente a US$ 63). Tanto en el sector publico como en el privado, la aplicacion de la DOTS mejoro los resultados terapeuticos y redujo sustancialmente los costos para los pacientes y sus asistentes en comparacion con el tratamiento distinto del DOTS en el sector privado (US$ 50-60 para el DOTS, frente a mas de US$100 en el otro caso). La costoeficacia media del DOTS-PP y el DOTS del sector publico fue semejante, de US$ 120-140 por paciente tratado satisfactoriamente, frente a US$ 218-338 para el tratamiento no DOTS en el sector privado. El analisis de la costoeficacia marginal demostro que el DOTS-PP puede mejorar la eficacia reduciendo al mismo tiempo los costos. Conclusion El DOTS-PP puede ser una alternativa asequible y costoeficaz para mejorar el control de la tuberculosis en la India, y reducir sustancialmente la carga economica que acarrea la tuberculosis para los pacientes.

[TEXT NOT REPRODUCIBLE IN ASCII] Introduction Bangladesh ranks fifth among the 22 highest tuberculosis-burden countries in the world with an estimated tuberculosis (TB) incidence rate of 246 cases per 100 [...], In 1998, the Damien Foundation Bangladesh invited semi-qualified, private 'gram dakter' (Bangla for 'village doctors') to participate in tuberculosis (TB) programmes in a population of 26 million people in rural Bangladesh. The organization trained 12 525 village doctors to not only refer suspected TB cases for free diagnosis but also to provide directly observed treatment (DOT) free of charge. Source of referral and place of DOT was recorded as part of the standardized TB recording and reporting system, which enabled us to quantify the contribution of village doctors to case detection rates and also allowed disaggregated cohort analysis of treatment outcome. During 2002 and 2003, 11% of all TB cases with positive sputum smears in the study area had been referred by village doctors; the rate of positive tests in patients referred by village doctors was 14.4%. 18 792 patients received DOT from village doctors, accounting for between 20% and 45% of patients on treatment during the 1998-2003 period. The treatment success rate was about 90% throughout the period. Urine samples taken during random checks of treatment compliance were positive for isoniazid in 98% of patients treated by village doctors. Within the framework of Public-Private Mix DOTS, services provided by semi-qualified private health care providers are a feasible and effective way to improve access to affordable high quality TB treatment in poor rural populations. The large informal health workforce that exists in resource poor countries can be used to achieve public health goals. Involvement of village doctors in TB control has now become national policy in Bangladesh. Resume Medecine informelle et lutte contre la tuberculose au Bangladesh ou comment transformer en ressources des elements consideres comme des handicaps En 1998, la Fondation Damien au Bangladesh a invite des <> (terme local designant les <>) partiellement qualifies et prives a participer aux programmes de lutte contre la tuberculose (TB) dont beneficient 26 millions d'habitants des zones rurales du Bangladesh. Cette organisation a forme 12 525 medecins de village non seulement a orienter les cas suspects de TB vers un diagnostic gratuit, mais egalement a delivrer un traitement sous observation directe (DOT) gratuit egalement. La source de la notification et le lieu d'administration du traitement DOT ont ete enregistres dans le cadre du systeme standardise d'enregistrement et de notification des cas de TB, ce qui a permis de quantifier la contribution en pourcentage des medecins de village a la detection des cas et de realiser une analyse desagregee des resultats du traitement au sein de la cohorte. De 2002 a 2003, les medecins de village avaient notifie 11% de l'ensemble des cas de TB a frottis positif recenses dans la zone etudiee et dirige 14,4 % des patients presentant un test positif vers un specialiste. Ces medecins avaient egalement delivre un traitement DOT a 18 792 malades, soit une proportion de 20 a 45 % des malades sous traitement pendant la periode 1998-2003. Le taux de succes du traitement etait de 90% pour cette meme periode. Des echantillons d'urine preleves au hasard pour controler l'observance du traitement etaient positifs pour l'isoniazide chez 98 % des malades traites par des medecins de village. Dans le cadre des programmes DOTS mixtes public/prive, les services fournis par les dispensateurs de soins de sante partiellement qualifies et prives offrent aux populations rurales demunies un moyen efficace pour acceder plus facilement a un traitement antituberculeux de qualite. Il est donc possible de faire appel aux importants moyens humains de la medecine informelle dans les pays pauvres pour realiser les objectifs de sante publique. La participation des medecins de village a la lutte contre la TB fait maintenant partie de la politique nationale du Bangladesh. Resumen Aprovechar al maximo los recursos: medicos de aldea informales y control de la tuberculosis en Bangladesh En 1998, la Fundacion Damien de Bangladesh invito a <> (<> en bangla) privados semicualificados a participar en programas de tuberculosis para una poblacion de 26 millones de personas del Bangladesh rural. La organizacion capacito a 12 525 medicos de aldea no solo para derivar los casos sospechosos de tuberculosis a servicios de diagnostico gratuito, sino tambien para proporcionar gratuitamente tratamiento bajo observacion directa (DOT). La fuente de derivacion y el lugar de administracion del DOT se registraron como parte del sistema normalizado de registro y notificacion de la tuberculosis, lo que nos permitio cuantificar la contribucion de los medicos de aldea a las tasas de deteccion de casos y, ademas, efectuar analisis de cohortes desglosados de los resultados terapeuticos. Durante 2002 y 2003, el 11% de todos los casos de tuberculosis con baciloscopia de esputo positiva en el area de estudio fueron derivados por medicos de aldea; la tasa de pruebas positivas entre los pacientes derivados pot esos medicos fue del 14,4%. 18 792 pacientes recibieron DOT de los medicos ae aldea, lo que supone un 20%-45% de los pacientes sometidos a tratamiento durante 1998-2003. La tasa de exito terapeutico fue de alrededor del 90% durante el periodo considerado. Las muestras de orina obtenidas en los controles aleatorios del cumplimiento del tratamiento fueron positivas a la isoniazida en el 98% de los pacientes tratados por los medicos de aldea. En el marco de la DOTS publicoprivada, los servicios ofrecidos por dispensadores de atencion sanitaria privados semicualificados son una opcion viable y eficaz para mejorar el acceso a un tratamiento antituberculoso asequible y de calidad en las poblaciones rurales pobres. La amplia fuerza laboral sanitaria informal existente en los paises con pocos recursos puede ser aprovechada para alcanzar metas de salud publica. La participacion de medicos de aldea en la lucha contra la tuberculosis ha pasado a format parte de la politica nacional en Bangladesh.

Resume Partenariat public-prive pour la mise en ouvre de la strategie DOTS : quels sont les facteurs de succes? Objectif Comparer les processus de developpement et de realisation et les [...], Objective To compare processes and outcomes of four public-private mix (PPM) projects on DOTS implementation for tuberculosis (TB) control in New Delhi, India; Ho Chi Minh City, Viet Nam; Nairobi, Kenya; and Pune, India. Methods Cross-project analysis of secondary data from separate project evaluations was used. Differences among PPM project sites in impact on TB control (change in case detection, treatment outcomes and equity in access) were correlated with differences in chosen intervention strategies and structural conditions. Findings The analysis suggests that an effective intervention package should include the following provider-side components: (1) orienting private providers (PPs) and the staff of the national TB programme (NTP); (2) improving the referral and information system through simple practical tools; (3) the NTP adequately supervising and monitoring PPs; and (4) the NTP providing free anti-TB drugs to patients treated in the private sector. Conclusion Getting such an intervention package to work requires that the NTP be strongly committed to supporting, supervising and evaluating PPM projects. Further, using a local nongovernmental organization or a medical association as an intermediary may facilitate collaboration. Investing time and effort to ensure that sufficient dialogue takes place among all stakeholders is important to help build trust and achieve a high level of agreement. Keywords Tuberculosis Pulmonary/drug therapy; Antitubercular agents/supply and distribution; Private sector/utilization; Public sector; Directly observed therapy/utilization; National health programs/organization and administration; Health plan implementation; Intersectoral cooperation; Outcome and process assessment (Health care); Comparative study; India; Kenya; Viet Nam (source: MESH, NLM). Mots cles Tuberculose pulmonaire/chimiotherapie; Antituberculeux/ressources et distribution; Secteur prive/utilisation; Secteur public; Therapie sous observation directe/utilisation; Programme national sante/organisation et administration; Mise en oeuvre plan sanitaire; Cooperation intersectorielle; Evaluation resultats et methodes (Soins); Etude comparative; Inde; Kenya; Viet Nam (source: MESH, INSERM). Palabras clave Tuberculosis pulmonar/quimioterapia; Agentes antituberculosos/provision y distribucion; Sector privado/utilizacion; Sector publico; Terapia por observacion directa/utilizacion; Programas nacionales de salud/organizacion y administracion; Implementacion de plan de salud; Cooperacion intersectorial; Evaluacion de procesos y resultados (Atencion de salud); Estudio comparativo; India; Kenya; Viet Nam (fuente: DeCS, BIREME). [TEXT NOT REPRODUCIBLE IN ASCII.]

This paper is part of the PLOS Universal Health Coverage Collection. Universal Access and Social Protection in the Post-2015 Global TB Strategy The WHO has developed a post-2015 global tuberculosis [...], Tuberculosis (TB) remains a major global public health problem. In all societies, the disease affects the poorest individuals the worst. A new post-2015 global TB strategy has been developed by WHO, which explicitly highlights the key role of universal health coverage (UHC) and social protection. One of the proposed targets is that 'No TB affected families experience catastrophic costs due to TB.' High direct and indirect costs of care hamper access, increase the risk of poor TB treatment outcomes, exacerbate poverty, and contribute to sustaining TB transmission. UHC, conventionally defined as access to health care without risk of financial hardship due to out-of-pocket health care expenditures, is essential but not sufficient for effective and equitable TB care and prevention. Social protection interventions that prevent or mitigate other financial risks associated with TB, including income losses and non-medical expenditures such as on transport and food, are also important. We propose a framework for monitoring both health and social protection coverage, and their impact on TB epidemiology. We describe key indicators and review methodological considerations. We show that while monitoring of general health care access will be important to track the health system environment within which TB services are delivered, specific indicators on TB access, quality, and financial risk protection can also serve as equity-sensitive tracers for progress towards and achievement of overall access and social protection.

Introduction Tuberculosis (TB) disease kills 1.4 million per year and remains a major global health problem [1]. Many low- and middle-income countries are unlikely to meet the Millennium Development Goals [...], Background: Even when tuberculosis (TB) treatment is free, hidden costs incurred by patients and their households (TB- affected households) may worsen poverty and health. Extreme TB-associated costs have been termed 'catastrophic' but are poorly defined. We studied TB-affected households' hidden costs and their association with adverse TB outcome to create a clinically relevant definition of catastrophic costs. Methods and Findings: From 26 October 2002 to 30 November 2009, TB patients (n = 876, 11% with multi-drug-resistant [MDR] TB) and healthy controls (n = 487) were recruited to a prospective cohort study in shantytowns in Lima, Peru. Patients were interviewed prior to and every 2-4 wk throughout treatment, recording direct (household expenses) and indirect (lost income) TB-related costs. Costs were expressed as a proportion of the household's annual income. In poorer households, costs were lower but constituted a higher proportion of the household's annual income: 27% (95% CI = 20%-43%) in the least-poor houses versus 48% (95% CI = 36%-50%) in the poorest. Adverse TB outcome was defined as death, treatment abandonment or treatment failure during therapy, or recurrence within 2 y. 23% (166/725) of patients with a defined treatment outcome had an adverse outcome. Total costs $20% of household annual income was defined as catastrophic because this threshold was most strongly associated with adverse TB outcome. Catastrophic costs were incurred by 345 households (39%). Having MDR TB was associated with a higher likelihood of incurring catastrophic costs (54% [95% CI = 43%-61%] versus 38% [95% CI = 34%-41%], p < 0.003). Adverse outcome was independently associated with MDR TB (odds ratio [OR] = 8.4 [95% CI = 4.7-15], p < 0.001), previous TB (OR = 2.1 [95% CI = 1.3-3.5], p = 0.005), days too unwell to work pre-treatment (OR = 1.01 [95% CI = 1.00-1.01], p = 0.02), and catastrophic costs (OR =1.7 [95% CI = 1.1-2.6], p = 0.01). The adjusted population attributable fraction of adverse outcomes explained by catastrophic costs was 18% (95% CI = 6.9%-28%), similar to that of MDR TB (20% [95% CI = 14%-25%]). Sensitivity analyses demonstrated that existing catastrophic costs thresholds (≥ 10% or [greater than or equal to] 15% of household annual income) were not associated with adverse outcome in our setting. Study limitations included not measuring certain 'dis-saving' variables (including selling household items) and gathering only 6 mo of costs-specific follow-up data for MDR TB patients. Conclusions: Despite free TB care, having TB disease was expensive for impoverished TB patients in Peru. Incurring higher relative costs was associated with adverse TB outcome. The population attributable fraction indicated that catastrophic costs and MDR TB were associated with similar proportions of adverse outcomes. Thus TB is a socioeconomic as well as infectious problem, and TB control interventions should address both the economic and clinical aspects of this disease. Please see later in the article for the Editors' Summary.

Background. In Sudan, tuberculosis diagnosis largely relies on clinical symptoms and smear microscopy as in many other low- and middle-income countries. The aim of this study was to investigate the positive predictive value of a positive sputum smear in patients investigated for pulmonary tuberculosis in Eastern Sudan. Methods. Two sputum samples from patients presenting with symptoms suggestive of tuberculosis were investigated using direct Ziehl-Neelsen (ZN) staining and light microscopy between June to October 2014 and January to July 2016. If one of the samples was smear positive, both samples were pooled, stored at −20°C, and sent to the National Reference Laboratory (NRL), Germany. Following decontamination, samples underwent repeat microscopy and culture. Culture negative/contaminated samples were investigated using polymerase chain reaction (PCR). Results. A total of 383 samples were investigated. Repeat microscopy categorized 123 (32.1%) as negative, among which 31 were culture positive. This increased to 80 when PCR and culture results were considered together. A total of 196 samples were culture positive, of which 171 (87.3%), 14 (7.1%), and 11 (5.6%) were M. tuberculosis, M. intracellulare, and mixed species. Overall, 15.6% (57/365) of the samples had no evidence of M. tuberculosis, resulting in a positive predictive value of 84.4%. Conclusions. There was a discordance between the results of smear microscopy performed at local laboratories in the Sudan and at the NRL, Germany; besides, a considerable number of samples had no evidence of M. tuberculosis. Improved quality control for smear microscopy and more specific diagnostics are crucial to avoid possible overtreatment. [ABSTRACT FROM AUTHOR]

We welcome the commentary 'Addressing Smoking Cessation in Tuberculosis Control' responding to the Bulletin theme issue on tuberculosis (May 2007), and thank the authors for raising this important issue. If [...]

Editor--Mahendradhata & Utarini rightly call for a an urgent move from feasibility studies of public-private collaboration in tuberculosis (TB) control to studies that analyse success factors as well as the [...]

Introduction The sequelae of multidrug-resistant tuberculosis (MDR-TB) are poorly understood and inconsistently reported. We will aim to assess the existing evidence for the clinical, psychological, social and economic sequelae of MDR-TB and to assess the health-related quality of life in patients with MDR-TB. Methods and analysis We will perform a systematic review and meta-analysis of published studies reporting sequelae of MDR-TB. We will search PubMed, SCOPUS, ProQuest, Web of Science and PsychINFO databases up to 5 September 2017. MDR-TB sequelae will include any clinical, psychological, social and economic effects as well as health-related quality of life that occur after MDR-TB treatment or illness. Two researchers will screen the titles and abstracts of all citations identified in our search, extract data, and assess the scientific quality using standardised formats. Providing there is appropriate comparability in the studies, we will use a random-effects meta-analysis model to produce pooled estimates of MDRTB sequelae from the included studies. We will stratify the analyses based on treatment regimen, comorbidities (such as HIV status and diabetes mellitus), previous TB treatment history and study setting. Ethics and dissemination As this study will be based on published data, ethical approval is not required. The final report will be disseminated through publication in a peer-reviewed scientific journal and will also be presented at relevant conferences. PROSPERO registration number CRD42017073182. [ABSTRACT FROM AUTHOR]

Background: Meticulous identification and investigation of patients presenting with tuberculosis (TB) suggestive symptoms rarely happen in crowded outpatient departments (OPDs). Making health providers in OPDs diligently follow screening procedures may help increase TB case detection. From July 2010 to December 2013, two symptom based TB screening approaches of varying cough duration were used to screen and test for TB among general outpatients, PLHIV, diabetics and contacts in Accra, Ghana.Methods: This study was a retrospective analysis comparing the yield of TB cases using two different screening approaches, allocated to selected public health facilities. In the first approach, the conventional 2 weeks cough duration with or without other TB suggestive symptoms was the criterion to test for TB in attendants of 7 general OPDs. In the second approach the screening criteria cough of >24 hours, as well as a history of at least one of the following symptoms: fever, weight loss and drenching night sweats were used to screen and test for TB among attendants of 3 general OPDs, 7 HIV clinics and 2 diabetes clinics. Contact investigation was initiated for index TB patients. The facilities documented the number of patients verbally screened, with presumptive TB, tested using smear microscopy and those diagnosed with TB in order to calculate the yield and number needed to screen (NNS) to find one TB case. Case notification trends in Accra were compared to those of a control area.Results: In the approach using >24-hour cough, significantly more presumptive TB cases were identified among outpatients (0.82% versus 0.63%), more were tested (90.1% versus 86.7%), but less smear positive patients were identified among those tested (8.0% versus 9.4%). Overall, all forms of TB cases identified per 100,000 screened were significantly higher in the >24-hour cough approach at OPD (92.7 for cough >24 hour versus 82.7 for cough >2 weeks ), and even higher in diabetics (364), among contacts (693) and PLHIV (995). NNS (95% Confidence Interval) varied from 100 (93-109) for PLHIV, 144 (112-202) for contacts, 275 (197-451) for diabetics and 1144 (1101-1190) for OPD attendants. About 80% of the TB cases were detected in general OPDs. Despite the intervention, notifications trends were similar in the intervention and control areas.Conclusion: The >24-hour cough approach yielded more TB cases though required TB testing for a larger number of patients. The yield of TB cases per 100,000 population screened was highest among PLHIV, contacts, and diabetics, but the majority of cases were detected in general OPDs. The intervention had no discernible impact on general case notification. [ABSTRACT FROM AUTHOR]

Objective To assess the design, delivery and outcomes of interventions to improve adherence to treatment for paediatric tuberculosis in low- and middle-income countries and develop a contextual framework for such interventions. Methods We searched PubMed and Cochrane databases for reports published between 1 January 2003 and 1 December 2013 on interventions to improve adherence to treatment for tuberculosis that included patients younger than 20 years who lived in a low- or middle-income country. For potentially relevant articles that lacked paediatric outcomes, we contacted the authors of the studies. We assessed heterogeneity and risk of bias. To evaluate treatment success -- i.e. the combination of treatment completion and cure -- we performed random-effects meta-analysis. We identified areas of need for improved intervention practices. Findings We included 15 studies in 11 countries for the qualitative analysis and of these studies, 11 qualified for the meta-analysis -- representing 1279 children. Of the interventions described in the 15 studies, two focused on education, one on psychosocial support, seven on care delivery, four on health systems and one on financial provisions. The children in intervention arms had higher rates of treatment success, compared with those in control groups (odds ratio: 3.02; 95% confidence interval: 2.19-4.15). Using the results of our analyses, we developed a framework around factors that promoted or threatened treatment completion. Conclusion Various interventions to improve adherence to treatment for paediatric tuberculosis appear both feasible and effective in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Background: Currently three hospital and tuberculosis (TB) collaboration models exist in China: the dispensary model where TB has to be diagnosed and treated in TB dispensaries, the specialist model where TB specialist hospital also treat TB patients, and the integrated model where TB diagnosis and treatment is integrated into a general hospital. The study compared effects of the three models through exploring patient experience in TB diagnosis and treatment. Methods: We selected two sites in each model of TB service in four provinces of China. In each site, 50 patients were selected from TB patient registries for a structured questionnaire survey, with a total of 293 patients recruited. All participants were newly registered uncomplicated TB cases without any major complications or resistance to first-line anti-TB drugs, and having successfully completed treatment. Diagnostic and treatment procedures were reviewed from medical charts of the surveyed patients to compare with national guidelines. Results: Specialist sites had the highest patient expenditure, hospitalization rates and mostly used second-line anti-TB drugs, while the integrated model reported the opposite. The median health expenditure was USD 1,499 for the specialist sites and USD 306 for the integrated sites, with 83% and 15% patients respectively having unnecessary hospitalization. 74% of the specialist sites and 19% of the integrated sites used second-line anti-TB drugs. Mixed results were identified in the two dispensary sites. One site had median health expenditure of USD 138 with 12% of patients hospitalized, while the other had USD 912 and 65% respectively. Conclusion: The study observed prohibitive financial expenditure and a high level of deviation from national guidelines in all sites, which may be related to the profit-seeking behavior of public hospitals. The study supports the integrated model as the better policy option for future TB health reform in China. [ABSTRACT FROM AUTHOR]

The article discusses issues related to the planned control and elimination of tuberculosis from 2010 to 2050. The global control of tuberculosis faces several challenges, including the emergence of roughly 9.4 million new cases in 2008, as well as multidrug-resistant tuberculosis. An overview of the Stop TB Strategy is presented. The article also enumerates possible strategies to reduce costs for patients with tuberculosis and their families and emphasizes the need to intensify research on new medical technologies for prevention, diagnosis, and treatment.

Explores health-seeking behavior among people with tuberculosis (TB), focused on reasons for choices of private versus public health care providers. Characteristics of private tuberculosis care; Argument that the use of rigid approaches to TV control which ignores the needs of individuals may be counterproductive for public health.

Background: To inform the choice of an appropriate screening and diagnostic algorithm for tuberculosis (TB) screening initiatives in different epidemiological settings, we compare algorithms composed of currently available methods.Methods: Of twelve algorithms composed of screening for symptoms (prolonged cough or any TB symptom) and/or chest radiography abnormalities, and either sputum-smear microscopy (SSM) or Xpert MTB/RIF (XP) as confirmatory test we model algorithm outcomes and summarize the yield, number needed to screen (NNS) and positive predictive value (PPV) for different levels of TB prevalence.Results: Screening for prolonged cough has low yield, 22% if confirmatory testing is by SSM and 32% if XP, and a high NNS, exceeding 1000 if TB prevalence is ≤0.5%. Due to low specificity the PPV of screening for any TB symptom followed by SSM is less than 50%, even if TB prevalence is 2%. CXR screening for TB abnormalities followed by XP has the highest case detection (87%) and lowest NNS, but is resource intensive. CXR as a second screen for symptom screen positives improves efficiency.Conclusions: The ideal algorithm does not exist. The choice will be setting specific, for which this study provides guidance. Generally an algorithm composed of CXR screening followed by confirmatory testing with XP can achieve the lowest NNS and highest PPV, and is the least amenable to setting-specific variation. However resource requirements for tests and equipment may be prohibitive in some settings and a reason to opt for symptom screening and SSM. To better inform disease control programs we need empirical data to confirm the modeled yield, cost-effectiveness studies, transmission models and a better screening test. [ABSTRACT FROM AUTHOR]

Background: TB is concentrated in populations with complex health and social issues, including alcohol use disorders (AUD). We describe treatment adherence and outcomes in a person-centred, multidisciplinary, psychosocial support and harm reduction intervention for people with multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB) with harmful alcohol use., Methods: An observational cohort study, including multilevel mixed-effects logistic regression and survival analysis with people living in Minsk admitted with MDR/RR-TB and AUD during January 2019-November 2021 who received this person-centred, multidisciplinary, psychosocial support and harm reduction intervention, was conducted., Results: There were 89 participants enrolled in the intervention, with a median follow-up of 12.2 (IQR: 8.1-20.5) mo. The majority (n=80; 89.9%) of participants had AUD, 11 (12.4%) also had a dependence on other substances, six (6.7%) a dependence on opioids and three (3.4%) a personality disorder. Fifty-eight had a history of past incarceration (65.2%), homelessness (n=9; 10.1%) or unemployment (n=55; 61.8%). Median adherence was 95.4% (IQR: 90.4-99.6%) and outpatient adherence was 91.2% (IQR: 65.1-97.0%). Lower adherence was associated with hepatitis C, alcohol plus other substance use and outpatient facility-based treatment, rather than video-observed treatment, home-based or inpatient treatment support., Conclusions: This intervention led to good adherence to MDR/RR-TB treatment in people with harmful use of alcohol, a group usually at risk of poor outcomes. Poor outcomes were associated with hepatitis C, other substance misuse and outpatient facility-based treatment support., (© The Author(s) 2024. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

BACKGROUND:  The World Health Organization's End TB (tuberculosis) Strategy advocates social and economic support for TB-affected households but evidence from low-income settings is scarce. We will evaluate the feasibility and acceptability of a locally-appropriate socioeconomic support intervention for TB-affected households in Nepal. METHODS:  We will conduct a pilot randomised-controlled trial with mixed-methods process evaluation in four TB-endemic, impoverished districts of Nepal: Pyuthan, Chitwan, Mahottari, and Morang. We will recruit 128 people with TB notified to the Nepal National TB Program (NTP) and 40 multisectoral stakeholders including NTP staff, civil-society members, policy-makers, and ASCOT (Addressing the Social Determinants and Consequences of Tuberculosis) team members. People with TB will be randomised 1:1:1:1 to four study arms (n=32 each): control; social support; economic support; and combined social and economic (socioeconomic) support. Social support will be TB education and peer-led mutual-support TB Clubs providing TB education and stigma-reduction counselling. Economic support will be monthly unconditional cash transfers during TB treatment with expectations (not conditions) of meeting NTP goals. At 0, 2, and 6 months following TB treatment initiation, participants will be asked to complete a survey detailing the social determinants and consequences of TB and their feedback on ASCOT. Complementary process evaluation will use focus group discussions (FGD), key informant interviews (KII), and a workshop with multi-sectoral stakeholders to consider the challenges to ASCOT's implementation and scale-up. A sample of ~100 people with TB is recommended to estimate TB-related costs. Information power is estimated to be reached with approximately 25 FGD and 15 KII participants. CONCLUSIONS:  The ASCOT pilot trial will both generate robust evidence on a locally-appropriate, socioeconomic support intervention for TB-affected households in Nepal and inform a large-scale future ASCOT trial, which will evaluate the intervention's impact on catastrophic costs mitigation and TB outcomes. The trial is registered with the ISRCTN ( ISRCTN17025974)., Competing Interests: No competing interests were disclosed., (Copyright: © 2022 Rai B et al.)

Under-detection and -reporting in the private sector constitute a major barrier in Viet Nam's fight to end tuberculosis (TB). Effective private-sector engagement requires innovative approaches. We established an intermediary agency that incentivized private providers in two districts of Ho Chi Minh City to refer persons with presumptive TB and share data of unreported TB treatment from July 2017 to March 2019. We subsidized chest x-ray screening and Xpert MTB/RIF testing, and supported test logistics, recording, and reporting. Among 393 participating private providers, 32.1% (126/393) referred at least one symptomatic person, and 3.6% (14/393) reported TB patients treated in their practice. In total, the study identified 1203 people with TB through private provider engagement. Of these, 7.6% (91/1203) were referred for treatment in government facilities. The referrals led to a post-intervention increase of +8.5% in All Forms TB notifications in the intervention districts. The remaining 92.4% (1112/1203) of identified people with TB elected private-sector treatment and were not notified to the NTP. Had this private TB treatment been included in official notifications, the increase in All Forms TB notifications would have been +68.3%. Our evaluation showed that an intermediary agency model can potentially engage private providers in Viet Nam to notify many people with TB who are not being captured by the current system. This could have a substantial impact on transparency into disease burden and contribute significantly to the progress towards ending TB.

Background:  WHO's 2015 End TB Strategy advocates social and economic (socioeconomic) support for TB-affected households to improve TB control. However, evidence concerning socioeconomic support for TB-affected households remains limited, especially in low-income countries. Protocol:  This mixed-methods study in Nepal will: evaluate the socioeconomic impact of accessing TB diagnosis and care (Project 1); and create a shortlist of feasible, locally-appropriate interventions to mitigate this impact (Project 2). The study will be conducted in the Chitwan, Mahottari, Makawanpur, and Dhanusha districts of Nepal, which have frequent TB and poverty. The study population will include: approximately 200 people with TB (Cases) starting TB treatment with Nepal's National TB Program and 100 randomly-selected people without TB (Controls) in the same sites (Project 1); and approximately 40 key in-country stakeholders from Nepal including people with TB, community leaders, and TB healthcare professionals (Project 2). During Project 1, visits will be made to people with TB's households during months 3 and 6 of TB treatment, and a single visit made to Control households. During visits, participants will be asked about: TB-related costs (if receiving treatment), food insecurity, stigma; TB-related knowledge; household poverty level; social capital; and quality of life. During Project 2, stakeholders will be invited to participate in: a survey and focus group discussion (FGD) to characterise socioeconomic impact, barriers and facilitators to accessing and engaging with TB care in Nepal; and a one-day workshop to review FGD findings and suggest interventions to mitigate the barriers identified. Ethics and dissemination:  The study has received ethical approval. Results will be disseminated through scientific meetings, open access publications, and a national workshop in Nepal.  Conclusions:  This research will strengthen understanding of the socioeconomic impact of TB in Nepal and generate a shortlist of feasible and locally-appropriate socioeconomic interventions for TB-affected households for trial evaluation., Competing Interests: No competing interests were disclosed., (Copyright: © 2020 Dixit K et al.)