Standards For Tuberculosis Care Research Articles

Recommendations for Use of Video Directly Observed Therapy During Tuberculosis Treatment - United States, 2023.

U.S. clinical practice guidelines recommend directly observed therapy (DOT) as the standard of care for tuberculosis (TB) treatment (1). DOT, during which a health care worker observes a patient ingesting the TB medications, has typically been conducted in person. Video DOT (vDOT) uses video-enabled devices to facilitate remote interactions between patients and health care workers to promote medication adherence and clinical monitoring. Published systematic reviews, a published meta-analysis, and a literature search through 2022 demonstrate that vDOT is associated with a higher proportion of medication doses being observed and similar proportions of cases with treatment completion and microbiologic resolution when compared with in-person DOT (2-5). Based on this evidence, CDC has updated the recommendation for DOT during TB treatment to include vDOT as an equivalent alternative to in-person DOT. vDOT can assist health department TB programs meet the U.S. standard of care for patients undergoing TB treatment, while using resources efficiently.

TB management in the European Union/European Economic Area: a multi-centre survey.

SUMMARYBACKGROUND:Essential TB care in the European Union/European Economic Area (EU/EEA) comprises 21 standards for the diagnosis, treatment and prevention of TB that constitute the European Union Standards for Tuberculosis Care (ESTC).METHODS:In 2017, we conducted an audit on TB management and infection control measures against the ESTC standards. TB reference centres in five EU/EEA countries were purposely selected to represent the heterogeneous European TB burden and examine geographic variability.RESULTS:Data from 122 patients, diagnosed between 2012 and 2015 with multidrug-resistant TB (n = 49), extensively drug-resistant TB (XDR-TB) (n = 11), pre-XDR-TB (n = 29) and drug-susceptible TB (n = 33), showed that TB diagnosis and treatment practices were in general in agreement with the ESTC.CONCLUSION:Overall, TB management and infection control practices were in agreement with the ESTC in the selected EU/EEA reference centres. Areas for improvement include strengthening of integrated care services and further implementation of patient-centred approaches.

Variation in tuberculosis treatment outcomes and treatment supervision practices in Uganda

BackgroundVariation in healthcare delivery is increasingly recognized as an important metric of healthcare quality. Directly observed therapy (DOT) has been the standard of care for tuberculosis (TB) treatment supervision for decades based on World Health Organization (WHO) guidelines. However, variation in implementation of DOT and associated TB treatment supervision practices remains poorly defined. MethodsWe collected individual patient data from TB treatment registers at 18 TB treatment units in Uganda including District Health Centers, District Hospitals, and Regional Referral Hospitals. We also administered a survey and did observations of TB treatment supervision practices by health workers at each site. We describe variation in TB treatment outcomes and TB treatment supervision practices. ResultsOf 2767 patients treated for TB across the 18 clinical sites between January 1 and December 31, 2017, 1740 (62.9%) were men, most were of working age (median 35 years, interquartile range [IQR] 27 – 46), 2546 (92.0%) had a new TB diagnosis, and nearly half (45.9%, n = 1283) were HIV positive. The pooled treatment success proportion was 69.4% (95% confidence interval [CI] 67.8 – 71.1) but there was substantial variation across sites (range 42.6 – 87.6%, I-squared 92.7%, p < 0.001). The survey and observation of TB treatment practices revealed that the majority of sites practice community-based DOT (66.7%, n = 12) and request a family member, who receives no additional training or supervision, to serve as a treatment supporter (77.8%, n = 14). At TB medication refill visits, all sites screen for side effects and most assess adherence via self-report (83.3%, n = 15). Only 7 (38.9%) sites followed-up patients who missed appointments using either phone calls (22.2%, n = 4/7) or community health workers (16.7%, n = 3/7). All 18 sites counseled patients at treatment initiation, but none provided additional counseling at refill visits other than addressing poor adherence or missed appointments. ConclusionThere was substantial variation in implementation of DOT, including observation and documentation of daily dosing, training and supervision of treatment supporters, and follow-up for missed clinic visits. Identifying best practices and reducing uncontrolled variation in the delivery of TB treatment is critical to improving treatment outcomes.

PENGARUH PERAN PENGAWAS MENELAN OBAT (PMO) TERHADAP KEPATUHAN PENDERITA TUBERKULOSIS DALAM MENGIKUTI PROGRAM PENGOBATAN DOTS (DIRECTLY OBSERVED TREATMENT SHORTCOUSE)

Background: Tuberculosis (TBC) treatment regimens require the introduction of PMO (Drugs Swallowing Drug) standardized on International Standards for Tuberculosis Care (ISTC) with DOTS strategy (Directly Observed Treatment Shortcouse). The goal of controlling new challenges such as TB/HIV co-infection, Multi Drug Resistance (MDR), Extensively Drug Resistance (XDR) and Loss to follow-up.&#x0D; Objective: Type of cross sectional study. Population 35 PMO using saturated samples. Methods: The instruments used are questionnaires and in-depth interviews. Data analysis is univariate, bivariate and multivariate.&#x0D; Results: The result of the study was the relationship between the role of PMO from family members in the supervision of taking medicine (p=0,024), there was a relationship between the role of PMO from family members in drug taking assistance in Fasyankes (p=0,002) and there was relationship between the influence of PMO role from family member accompaniment of sputum checks in Fasyankes (p=0,005) to TBC patient compliance.&#x0D; Conclusion: There is a statistical correlation between the roles of PMO from the family towards adherence to tuberculosis patients. Suggestion of research is given to related parties be reformed TBC control policy related to election criteria of PMO coming from family member in Semarang regency.

Quality of Inpatient Tuberculosis Health Care in High-Burden Resource-Limited Settings: Protocol for a Comprehensive Mixed Methods Assessment Study

BackgroundThe quality of care for tuberculosis (TB) is deficient in high-burden countries and urgently needs improvement. However, comprehensively identifying the required improvements is challenging. Providing high-quality TB care is an important step toward improving patients’ quality of life and decreasing TB morbidity and mortality. Effective tools for assessing the quality of TB services using international standards and guidelines can identify existing gaps in services and inform improvements to ensure high-quality inpatient TB services.ObjectiveThis study aimed to develop evaluation instruments for defining the quality of provision of TB services.MethodsTo assess quality of services in the largest TB hospital in Armenia, we developed instruments based on the Joint Commission International Accreditation Standards for Hospitals, International Standards for TB Care, TB Laboratories Bio-Safety Standards, and the World Health Organization framework for conducting TB program reviews. A mixed methods approach was utilized, triangulating quantitative (checklists) and qualitative (in-depth interviews) results. A scoring system and strengths, weaknesses, opportunities, and treats analysis was applied to detail results for each of the 122 standards assessed. A scaling approach was used to present overall performances of inpatient services for eight patient-centered functions and five organization management functions.ResultsOverall, 40 in-depth interviews and 91 checklists (21 observations, 16 policy papers, 20 staff qualification documents, and 34 medical records) were developed, utilized, and analyzed to explore practices of health care professionals, assess inpatient treatment experience of patients and their family members, evaluate facility environmental conditions, and define the degree of compliance to standards.ConclusionsThe effective comprehensive evaluation instruments and methods developed in this study for quality of inpatient TB services support the implementation of similar effective assessments in other countries. It may also become a platform to develop similar approaches for assessing ambulatory TB services in resource-limited countries.International Registered Report Identifier (IRRID)DERR1-10.2196/13903

AN EXTINCT CURE FOR AN ANCIENT DISEASE: RECOGNIZING PLOMBAGE

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Despite advances in the treatment of pulmonary tuberculosis (TB) in the last century tuberculosis remains one of the top ten causes of death worldwide [1]. Antibiotic therapy has supplanted surgical treatment and it is unusual to recognize patients with previous surgical treatments. We review the case of a patient with a history of TB who presented with a lung mass. Our goal is to reinforce awareness of an outdated TB treatment and to emphasize the importance of thorough history-taking in reaching the correct diagnosis. CASE PRESENTATION: A 71-year-old lady was referred to our service for evaluation of a left upper lobe mass. She reported no respiratory symptoms, but confirmed an abnormal sensation and a stabbing pain from her fingers radiating up her arm and across her chest. Given her suspicious arm pain a shoulder and spine x-ray were ordered which showed a large calcified mass in the left lung apex and volume loss in the left lung. She revealed that she grew up in an orphanage in Columbia . When specifically questioned, she recalls being diagnosed with TB and treated with surgery as a teenager in 1961 eight years before immigrating to the United States. Physical exam was significant for a left posterior thoracotomy scar and equal bronchovesicular breath sounds. All other components of the physical exam were within normal limits. A subsequent CT scan showed a non-enhancing 12 cm heavily ossified septated left upper thorax mass possibly arising from an upper left ribs. The mass contains chondroid matrix and peripherally high-density septations throughout with a low-density center. Brachial plexus involvement cannot be excluded. The mass was consistent with plombage treatment for TB and biopsy was not recommended. DISCUSSION: During the 1930s-1950s the standard of care for TB involved surgical collapse of the lung; a treatment called, “plombage”. A shift toward antibiotic treatment was made with the development of streptomycin in 1946, which was found to have curative effects [2]. Inert plombage materials included mineral oil, air, paraffin wax, and polymethyl-methacrylate (Lucite) balls [3]. Upon insertion into the chest cavity, the affected lobe would collapse, decreasing ventilation to the region and starving the aerobic bacteria of oxygen. As antibiotics to TB were developed plombage treatment fell out of favor in most parts of the world. Late complications of plombage can include hemorrhage, infection, chest wall deformities, fistulization to bronchi, great vessels in the thoracic cavity, and esophagus or brachial plexopathy. CONCLUSIONS: Obtaining the patient’s complete history particularly of tuberculosis treated in her native country in 1961 became central to the diagnosis of retained calcified Plombage material.It is important for physicians to move beyond the most likely diagnosis and rely on thorough history-taking skills to arrive at the correct diagnosis. Reference #1: 1. Mathers et al (2009). “Global and Regional Causes of Death” British Medical Journal Reference #2: 2. D'Arcy Hart P (August 1999). "A change in scientific approach: from alternation to randomised allocation in clinical trials in the 1940s". British Medical Journal. Reference #3: 3. Historical TB treatment – Plombage; QJM: An International Journal of Medicine, 2017 DISCLOSURES: No relevant relationships by Kristin Fless, source=Web Response no disclosure on file for Nirav Mistry; No relevant relationships by Mihir Odak, source=Web Response No relevant relationships by Vagram Ovnanian, source=Web Response No relevant relationships by Killol Patel, source=Web Response No relevant relationships by Fariborz Rezai, source=Web Response No relevant relationships by Paul Yodice, source=Web Response

Smartphone-enabled video-observed versus directly observed treatment for tuberculosis: a multicentre, analyst-blinded, randomised, controlled superiority trial

SummaryBackgroundDirectly observed treatment (DOT) has been the standard of care for tuberculosis since the early 1990s, but it is inconvenient for patients and service providers. Video-observed therapy (VOT) has been conditionally recommended by WHO as an alternative to DOT. We tested whether levels of treatment observation were improved with VOT.MethodsWe did a multicentre, analyst-blinded, randomised controlled superiority trial in 22 clinics in England (UK). Eligible participants were patients aged at least 16 years with active pulmonary or non-pulmonary tuberculosis who were eligible for DOT according to local guidance. Exclusion criteria included patients who did not have access to charging a smartphone. We randomly assigned participants to either VOT (daily remote observation using a smartphone app) or DOT (observations done three to five times per week in the home, community, or clinic settings). Randomisation was done by the SealedEnvelope service using minimisation. DOT involved treatment observation by a health-care or lay worker, with any remaining daily doses self-administered. VOT was provided by a centralised service in London. Patients were trained to record and send videos of every dose ingested 7 days per week using a smartphone app. Trained treatment observers viewed these videos through a password-protected website. Patients were also encouraged to report adverse drug events on the videos. Smartphones and data plans were provided free of charge by study investigators. DOT or VOT observation records were completed by observers until treatment or study end. The primary outcome was completion of 80% or more scheduled treatment observations over the first 2 months following enrolment. Intention-to-treat (ITT) and restricted (including only patients completing at least 1 week of observation on allocated arm) analyses were done. Superiority was determined by a 15% difference in the proportion of patients with the primary outcome (60% vs 75%). This trial is registered with the International Standard Randomised Controlled Trials Number registry, number ISRCTN26184967.FindingsBetween Sept 1, 2014, and Oct 1, 2016, we randomly assigned 226 patients; 112 to VOT and 114 to DOT. Overall, 131 (58%) patients had a history of homelessness, imprisonment, drug use, alcohol problems or mental health problems. In the ITT analysis, 78 (70%) of 112 patients on VOT achieved ≥80% scheduled observations successfully completed during the first 2 months compared with 35 (31%) of 114 on DOT (adjusted odds ratio [OR] 5·48, 95% CI 3·10–9·68; p<0·0001). In the restricted analysis, 78 (77%) of 101 patients on VOT achieved the primary outcome compared with 35 (63%) of 56 on DOT (adjusted OR 2·52; 95% CI 1·17–5·54; p=0·017). Stomach pain, nausea, and vomiting were the most common adverse events reported (in 16 [14%] of 112 on VOT and nine [8%] of 114 on DOT).InterpretationVOT was a more effective approach to observation of tuberculosis treatment than DOT. VOT is likely to be preferable to DOT for many patients across a broad range of settings, providing a more acceptable, effective, and cheaper option for supervision of daily and multiple daily doses than DOT.FundingNational Institute for Health Research.

Variations in the quality of tuberculosis care in urban India: A cross-sectional, standardized patient study in two cities.

BackgroundIndia has the highest burden of tuberculosis (TB). Although most patients with TB in India seek care from the private sector, there is limited evidence on quality of TB care or its correlates. Following our validation study on the standardized patient (SP) method for TB, we utilized SPs to examine quality of adult TB care among health providers with different qualifications in 2 Indian cities.Methods and findingsDuring 2014–2017, pilot programs engaged the private health sector to improve TB management in Mumbai and Patna. Nested within these projects, to obtain representative, baseline measures of quality of TB care at the city level, we recruited 24 adults to be SPs. They were trained to portray 4 TB “case scenarios” representing various stages of disease and diagnostic progression. Between November 2014 and August 2015, the SPs visited representatively sampled private providers stratified by qualification: (1) allopathic providers with Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees or higher and (2) non-MBBS providers with alternative medicine, minimal, or no qualifications.Our main outcome was case-specific correct management benchmarked against the Standards for TB Care in India (STCI). Using ANOVA, we assessed variation in correct management and quality outcomes across (a) cities, (b) qualifications, and (c) case scenarios. Additionally, 2 micro-experiments identified sources of variation: first, quality in the presence of diagnostic test results certainty and second, provider consistency for different patients presenting the same case.A total of 2,652 SP–provider interactions across 1,203 health facilities were analyzed. Based on our sampling strategy and after removing 50 micro-experiment interactions, 2,602 interactions were weighted for city-representative interpretation. After weighting, the 473 Patna providers receiving SPs represent 3,179 eligible providers in Patna; in Mumbai, the 730 providers represent 7,115 eligible providers. Correct management was observed in 959 out of 2,602 interactions (37%; 35% weighted; 95% CI 32%–37%), primarily from referrals and ordering chest X-rays (CXRs). Unnecessary medicines were given to nearly all SPs, and antibiotic use was common. Anti-TB drugs were prescribed in 118 interactions (4.5%; 5% weighted), of which 45 were given in the case in which such treatment is considered correct management.MBBS and more qualified providers had higher odds of correctly managing cases than non-MBBS providers (odds ratio [OR] 2.80; 95% CI 2.05–3.82; p < 0.0001). Mumbai non-MBBS providers had higher odds of correct management than non-MBBS in Patna (OR 1.79; 95% CI 1.06–3.03), and MBBS providers’ quality of care did not vary between cities (OR 1.15; 95% CI 0.79–1.68; p = 0.4642). In the micro-experiments, improving diagnostic certainty had a positive effect on correct management but not across all quality dimensions. Also, providers delivered idiosyncratically consistent care, repeating all observed actions, including mistakes, approximately 75% of the time. The SP method has limitations: it cannot account for patient mix or care-management practices reflecting more than one patient–provider interaction.ConclusionsQuality of TB care is suboptimal and variable in urban India’s private health sector. Addressing this is critical for India’s plans to end TB by 2025. For the first time, we have rich measures on representative levels of care quality from 2 cities, which can inform private-sector TB interventions and quality-improvement efforts.

Adherence of Physicians-in-Training to the 2009 International Standards for Tuberculosis Care (ISTC) at the University of the Philippines- Philippine General Hospital

Introduction: The international standards for tuberculosis care (ISTC) was published to provide widely accepted level of care that all practitioners should follow in managing confirmed TB or suspected TB patients. Various initiatives were started in order to reinforce the standards embodied in the ISTC since 2006. Hence the investigators would like to evaluate the adherence of third year residents - in - training (Internal Medicine and Family Medicine from University of the Philippines, Philippine General Hospital (UP-PGH), 2012-2013) to the ISTC 2009 guidelines. Methodology: This study was done through review of randomly selected 59 outpatient records from January 2012 to December 2013 of TB patients seen by all third year residents from Internal Medicine and Family Medicine in UP-PGH. Outcome variables were the number of residents-in-training following the selected ISTC core standards: Standards for: Diagnosis (2,3); Treatment (8,10,13); HIV Infection and other Co-morbid Conditions (14); and Public Health and Prevention (21). Results: Standards 2 (at least 2 sputum specimens), 17 (thorough assessment of co-morbidities), and 8 (use of 1st line treatment regimen) were noted with higher number of residents adhering with 88.1% (52/59), 76.3% (45/59) and 64.4% (38/59) respectively. Standard 14 (HIV testing among TB patients) was only documented in 15.2% (9/59) residents. Conclusion: Standards 2, 17, and 8 were the most adhered ISTC guideline while standard 14 was least adhered to. Reinforcements are needed to provide updates to scale up TB management of residents-in-training based on international standard through regular continuing medical educations (CMEs), forums and/or seminars and feedbacks. Mechanisms and infrastructures should be in place to facilitate adherence to the ISTC.

Use of standardised patients to assess quality of tuberculosis care: a pilot, cross-sectional study

Existing studies of the quality of tuberculosis care have relied on recall-based patient surveys, questionnaire surveys of knowledge, and prescription or medical record analysis, and the results mostly show the health-care provider's knowledge rather than actual practice. No study has used standardised patients to assess clinical practice. Therefore we aimed to assess quality of care for tuberculosis using such patients. We did a pilot, cross-sectional validation study of a convenience sample of consenting private health-care providers in low-income and middle-income areas of Delhi, India. We recruited standardised patients in apparently good health from the local community to present four cases (two of presumed tuberculosis and one each of confirmed tuberculosis and suspected multidrug-resistant tuberculosis) to a randomly allocated health-care provider. The key objective was to validate the standardised-patient method using three criteria: negligible risk and ability to avoid adverse events for providers and standardised patients, low detection rates of standardised patients by providers, and data accuracy across standardised patients and audio verification of standardised-patient recall. We also used medical vignettes to assess providers' knowledge of presumed tuberculosis. Correct case management was benchmarked using Standards for Tuberculosis Care in India (STCI). Between Feb 2, and March 28, 2014, we recruited and trained 17 standardised patients who had 250 interactions with 100 health-care providers, 29 of whom were qualified in allopathic medicine (ie, they had a Bachelor of Medicine & Surgery [MBBS] degree), 40 of whom practised alternative medicine, and 31 of whom were informal health-care providers with few or no qualifications. The interactions took place between April 1, and April 23, 2014. The proportion of detected standardised patients was low (11 [5%] detected out of 232 interactions among providers who completed the follow-up survey), and standardised patients' recall correlated highly with audio recordings (r=0·63 [95% CI 0·53-0·79]), with no safety concerns reported. The mean consultation length was 6 min (95% CI 5·5-6·6) with a mean of 6·18 (5·72-6·64) questions or examinations completed, representing 35% (33-38) of essential checklist items. Across all cases, only 52 (21% [16-26]) of 250 were correctly managed. Correct management was higher among MBBS-qualified doctors than other types of health-care provider (adjusted odds ratio 2·41 [95% CI 1·17-4·93]; p=0·0166). Of the 69 providers who completed the vignette, knowledge in the vignettes was more consistent with STCI than their actual clinical practice-eg, 50 (73%) ordered a chest radiograph or sputum test during the vignette compared with seven (10%) during the standardised-patient interaction; OR 0·04 (95% CI 0·02-0·11); p<0·0001. Standardised patients can be successfully implemented to assess tuberculosis care. Our data suggest a big gap between private provider knowledge and practice. Additional work is needed to substantiate our pilot data, understand the know-do gap in provider behaviour, and to identify the best approach to measure and improve the quality of tuberculosis care in India. Grand Challenges Canada, the Bill & Melinda Gates Foundation, Knowledge for Change Program, and the World Bank Development Research Group.

Costs and Consequences of Using Interferon-γ Release Assays for the Diagnosis of Active Tuberculosis in India.

BackgroundThere is growing concern that interferon-γ release assays (IGRAs) are being used off-label for the diagnosis of active tuberculosis (TB) disease in many high-burden settings, including India, where the background prevalence of latent TB infection is high. We analyzed the costs and consequences of using IGRAs for the diagnosis of active TB in India from the perspective of the Indian TB control sector.Methods and FindingsWe constructed a decision analytic model to estimate the incremental cost and effectiveness of IGRAs for the diagnosis of active TB in India. We compared a reference scenario of clinical examination and non-microbiological tests against scenarios in which clinical diagnosis was augmented by the addition of either sputum smear microscopy, IGRA, or Xpert MTB/RIF. We examined costs (in 2013 US dollars) and consequences from the perspective of the Indian healthcare sector. Relative to sputum smear microscopy, use of IGRA for active TB resulted in 23,700 (95% uncertainty range, UR: 3,800 – 38,300) additional true-positive diagnoses, but at the expense of 315,700 (95% UR: 118,300 – 388,400) additional false-positive diagnoses and an incremental cost of US$49.3 million (95% UR: $34.9 – $58.0 million) (2.9 billion Indian Rupees). Relative to Xpert MTB/RIF (including the cost of treatment for drug resistant TB), use of IGRA led to 400 additional TB cases treated (95% UR: [-8,000] – 16,200), 370,600 (95% UR: 252,200 – 441,700) more false-positive diagnoses, 70,400 (95% UR: [-7,900] – 247,200) fewer disability-adjusted life years averted, and US$14.6 million (95%UR: [-$7.2] – $28.7 million) (854 million Indian Rupees) in additional costs.ConclusionUsing IGRAs for diagnosis of active TB in a setting like India results in tremendous overtreatment of people without TB, and substantial incremental cost with little gain in health. These results support the policies by WHO and Standards for TB Care in India, which discourage the use of IGRAs for the diagnosis of active TB in India and similar settings.

Quality of diagnosis and monitoring of tuberculosis in Northern Ethiopia: medical records-based retrospective study.

To determine quality of diagnosis and monitoring of treatment response of patients with smear-negative pulmonary tuberculosis (TB) compared with smear-positive cases in Ethiopia. A retrospective analysis of medical records of newly diagnosed pulmonary TB cases that were registered for taking anti-TB medication and had completed treatment between 2010 and 2012. We evaluated the percentage of cases that were managed according to the International Standards of Tuberculosis Care (ISTC) and compared smear-negative with smear-positive cases. We analysed 1168 cases of which 742 (64%) were sputum smear-negative cases. Chest radiography examination at diagnosis and microbiological testing at the end of the intensive phase of treatment was performed in a smaller proportion than in smear-positive TB cases (70% vs. 79%, P value <0.001) and (70% vs. 95%, P value <0.001), respectively. Clinical actions recommended in the ISTC are of greatest importance in minimising pitfalls in care of smear-negative TB yet were performed less often in smear-negative than smear-positive TB cases.

Diagnosis and Treatment of Childhood Pulmonary Tuberculosis: A Cross-Sectional Study of Practices among Paediatricians in Private Sector, Mumbai.

Majority of children with tuberculosis are treated in private sector in India with no available data on management practices. The study assessed diagnostic and treatment practices related to childhood pulmonary tuberculosis among paediatricians in Mumbai's private sector in comparison with International Standards for Tuberculosis Care (ISTC) 2009. In this cross-sectional study, 64 paediatricians from private sector filled self-administered questionnaires. Cough was reported as a symptom of childhood TB by 77.8% of respondents. 38.1% request sputum smear or culture for diagnosis and fewer (32.8%) use it for patients positive on chest radiographs and 32.8% induce sputum for those unable to produce it. Sputum negative TB suspect is always tested with X-ray or tuberculin skin test. 61.4% prescribe regimen as recommended in ISTC and all monitor progress to treatment clinically. Drug-resistance at beginning of treatment is suspected for child in contact with a drug-resistant patient (67.7%) and with prior history of antitubercular treatment (12.9%). About half of them (48%) request drug-resistance test for rifampicin in case of nonresponse after two to three months of therapy and regimen prescribed by 41.7% for multidrug-resistant TB was as per ISTC. The study highlights inappropriate diagnostic and treatment practices for managing childhood pulmonary TB among paediatricians in private sector.

What's in a name? The future of drug-resistant tuberculosis classification

Due to a recent resurgence in tuberculosis research focused on drug development, several new antituberculosis drugs are in the pipeline, and the standard of care for tuberculosis might soon change. If new drugs replace the current first-line treatment, then existing classifications of resistance, including multidrug-resistant and extensively drug-resistant tuberculosis, might become less relevant. When much needed new drugs reach the market, a new classification system for resistance might need to be devised to describe resistance to these novel agents. Many options for such a system exist, each with its own inherent benefits and challenges. The adoption of new terminology for resistance should be guided by outcomes data from clinical trials in progress, and should be accompanied by increased support for drug susceptibility testing in developing countries to be clinically useful. Consideration of these issues now will hopefully help foster an informed approach to the classification of drug-resistant tuberculosis in the era of new drugs.

Towards the development of EU/EEA Standards for Tuberculosis Care (ESTC)

Tuberculosis (TB) continues to pose a public-health threat to the people of the member states of the European Union (EU) and European Economic Area (EEA). EU/EEA countries comprise Austria, Belgium, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, the Republic of Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden and the UK. In 2009, almost 80,000 TB cases were notified in the EU/EEA, and while several countries are progressing towards achieving and sustaining low levels of TB incidence, the contrasts in TB disease burden remain great within the EU/EEA [1]. Some countries are faced with a significant burden of drug-resistant TB, and multidrug-resistant (MDR)-TB. In 2009, 5.3% of all active TB cases reported in the EU/EEA were MDR-TB, and 14.1% were resistant to any of the first-line TB drugs [1]. HIV co-infection is still low, with an overall proportion of 2.3% of TB cases being HIV-seropositive, although accurate surveillance data reporting is suboptimal in many countries [1–3]. The EU/EEA member states were proactive in adopting the existing global strategies for TB control, including Directly Observed Treatment Short Course (DOTS) and the Stop TB Strategy [4]. The stepwise adoption of these principles was facilitated by the development of a set of European-specific, consensus-based documents born within the Wolfheze initiative [5]. A European group of experts, country representatives and international organisations (World Health Organization (WHO), International Union Against Tuberculosis and Lung Disease (IUATLD) and the KNCV Tuberculosis Foundation) developed guidance and policy documents on TB control and elimination, surveillance, screening and management of immigrants, treatment outcome monitoring, drug susceptibility testing [6–10] and, more recently, contact tracing [11]. The whole package …

DOT — Not Worth the Effort in Treatment-Naive HIV Patients

Directly observed therapy (DOT) is the standard of care for tuberculosis (TB). Preliminary studies, mostly in small cohorts and in supervised settings

International Standards for Tuberculosis Care: revisiting the cornerstones of tuberculosis care and control

Tuberculosis (TB) remains an enormous global health problem. There are 8–9 million new cases and 2 million deaths from TB annually. Despite the overwhelming burden of disease, the basic principles of care for persons with, or suspected of having, TB are the same worldwide: a diagnosis should be established promptly and accurately, standardized treatment regimens of proven efficacy should be used together with appropriate treatment support and supervision, the response to treatment should be monitored, and the essential public health responsibilities must be carried out. As an approach to improving the care of patients with TB, an evidence-based document, the International Standards for Tuberculosis Care (ISTC) was developed and has been endorsed by more than 30 international and national agencies. This special report introduces the ISTC and discusses the fact that accurate diagnosis and effective treatment are not only essential for good patient care, they are the key elements in the public health response to TB and are the cornerstone of TB control. With the recent emergence of extensively drug-resistant TB, there is an urgent need to ensure globally that standards of TB care are based on rigorous scientific findings, are clear and well understood, and are accessible to and applied by all types of healthcare providers in all corners of the world.

Introducing the Sixth Edition of theCanadian Tuberculosis Standards

The sixth edition of the Canadian Tuberculosis Standards will soon be available in hard copy through the offices of the Canadian Lung Association (CLA), and the individual provincial and territorial lung associations, and in PDF format at . Historically, the Standards became important when effective treatment of tuberculosis became available and sanatoria closed. In contrast to the first (1972), second (1981), third (1988) and fourth (1996) editions, which were products of the Canadian Thoracic Society (CTS)/CLA alone, the fifth (2000) and sixth editions of the Standards were jointly produced by the CTS/CLA and Health Canada (fifth), and the Public Health Agency of Canada (PHAC) (sixth). The evolution of the Standards as a document dependent on the CTS for medical and scientific input, and on the PHAC for public health and policy input, was part of a broader shift from nongovernmental to governmental organization of tuberculosis prevention and control activity in Canada. The Tuberculosis Prevention and Control Program of the PHAC is the sponsor of the Canadian Tuberculosis Committee, a national committee with representation from each province and territory, Citizenship and Immigration Canada, First Nations and Inuit Health Branch of Health Canada, Correctional Service Canada, Canadian Public Health Laboratory Network, Association of Medical Microbiology and Infectious Disease, CLA, CTS and PHAC (both the National Microbiology Laboratory and the Tuberculosis Prevention and Control Program). It also houses the Canadian Tuberculosis Surveillance System and the Canadian Tuberculosis Laboratory Surveillance System, as well as represents Canada internationally. The major role of the Tuberculosis Committee of the CTS is now the preparation of the Standards. In fact, the membership of the CTS Tuberculosis Committee and the editorial committee of the Standards are one and the same; the editors of the Standards are the Chair of the CTS Tuberculosis Committee and the Manager of the Tuberculosis Prevention and Control Program of the PHAC. The sixth edition of the Standards is a substantial revision to its predecessor the fifth edition (see below). Chapters or appendixes already in the fifth edition were redacted, and new chapters and appendixes were added (Chapters 14, 15 and 18; Appendixes D, E, F, G, H and J) after a systematic survey of end-user satisfaction with the fifth edition undertaken by the CTS. In addition to the chapter-specific table of contents and expanded bibliographies, the text is populated with a series of Web resources that will be regularly updated by PHAC and other agencies. As in the fifth edition, treatment recommendations are rated using a roman numeral (I, II or III), which indicates the quality of evidence supporting the recommendation (1). The Standards are meant to be a definitive resource on issues pertaining to tuberculosis prevention and control in Canada. In contrast to provincial and territorial guidelines, which describe how an action is to be accomplished and how the structure of care is framed, the Canadian Tuberculosis Standards, like the International Standards for Tuberculosis Care (available at ), provide the foundation on which care can be based, presenting what should be done.

Introducing the Sixth Edition of theCanadian tuberculosis standards

The sixth edition of the Canadian Tuberculosis Standards will soon be available in hard copy through the offices of the Canadian Lung Association (CLA), and the individual provincial and territorial lung associations, and in PDF format at . Historically, the Standards became important when effective treatment of tuberculosis became available and sanatoria closed. In contrast to the first (1972), second (1981), third (1988) and fourth (1996) editions, which were products of the Canadian Thoracic Society (CTS)/CLA alone, the fifth (2000) and sixth editions of the Standards were jointly produced by the CTS/CLA and Health Canada (fifth), and the Public Health Agency of Canada (PHAC) (sixth). The evolution of the Standards as a document dependent on the CTS for medical and scientific input, and on the PHAC for public health and policy input, was part of a broader shift from nongovernmental to governmental organization of tuberculosis prevention and control activity in Canada. The Tuberculosis Prevention and Control Program of the PHAC is the sponsor of the Canadian Tuberculosis Committee, a national committee with representation from each province and territory, Citizenship and Immigration Canada, First Nations and Inuit Health Branch of Health Canada, Correctional Service Canada, Canadian Public Health Laboratory Network, Association of Medical Microbiology and Infectious Disease, CLA, CTS and PHAC (both the National Microbiology Laboratory and the Tuberculosis Prevention and Control Program). It also houses the Canadian Tuberculosis Surveillance System and the Canadian Tuberculosis Laboratory Surveillance System, as well as represents Canada internationally. The major role of the Tuberculosis Committee of the CTS is now the preparation of the Standards. In fact, the membership of the CTS Tuberculosis Committee and the editorial committee of the Standards are one and the same; the editors of the Standards are the Chair of the CTS Tuberculosis Committee and the Manager of the Tuberculosis Prevention and Control Program of the PHAC. The sixth edition of the Standards is a substantial revision to its predecessor the fifth edition (see below). Chapters or appendixes already in the fifth edition were redacted, and new chapters and appendixes were added (Chapters 14, 15 and 18; Appendixes D, E, F, G, H and J) after a systematic survey of end-user satisfaction with the fifth edition undertaken by the CTS. In addition to the chapter-specific table of contents and expanded bibliographies, the text is populated with a series of Web resources that will be regularly updated by PHAC and other agencies. As in the fifth edition, treatment recommendations are rated using a roman numeral (I, II or III), which indicates the quality of evidence supporting the recommendation (1). The Standards are meant to be a definitive resource on issues pertaining to tuberculosis prevention and control in Canada. In contrast to provincial and territorial guidelines, which describe how an action is to be accomplished and how the structure of care is framed, the Canadian Tuberculosis Standards, like the International Standards for Tuberculosis Care (available at ), provide the foundation on which care can be based, presenting what should be done.