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Background: The Millennium Development Goals (MDG) provide targets for 2015. MDG 6 includes a target to reduce the tuberculosis (TB) death rate by 50% compared with 1990. We aimed to assess whether this target was reached by the European Union (EU) and European Economic Area countries.Methods: We used Eurostat causes of death data to assess whether the target was reached in the EU. We calculated the reduction in reported and adjusted death rates and the annual average percentage decline based on the available data.Results: Between 1999 and 2014, the TB death rate decreased by 50%, the adjusted death rate by 56% and the annual average percentage decline was 5.43% (95% confidence interval 4.94-6.74) for the EU. Twenty of 26 countries reporting >5 TB deaths in the first reporting year reached the target of 50% reduction in adjusted death rate.Conclusions: The EU reached the MDG target of a 50% reduction of the TB death rate and also the annual average percentage decline was larger than the 2.73% needed to reach the target. The World Health Organization 'End TB Strategy' requires a further reduction of the number of TB deaths of 35% by 2020 compared to 2015, which will challenge TB prevention and care services in the EU. [ABSTRACT FROM AUTHOR]

Background: In the European Union and European Economic Area only 38% of multidrug-resistant tuberculosis patients notified in 2011 completed treatment successfully at 24 months' evaluation. Socio-economic factors and patient factors such as demographic characteristics, behaviour and attitudes are associated with treatment outcomes. Characteristics of healthcare systems also affect health outcomes. This study was conducted to identify and better understand the contribution of health system components to successful treatment of multidrug-resistant tuberculosis.Methods: We selected four European Union countries to provide for a broad range of geographical locations and levels of treatment success rates of the multidrug-resistant tuberculosis cohort in 2009. We conducted semi-structured interviews following a conceptual framework with representatives from policy and planning authorities, healthcare providers and civil society organisations. Responses were organised according to the six building blocks of the World Health Organization health systems framework.Results: In the four included countries, Austria, Bulgaria, Spain, and the United Kingdom, the following healthcare system factors were perceived as key to achieving good treatment results for patients with multidrug-resistant tuberculosis: timely diagnosis of drug-resistant tuberculosis; financial systems that ensure access to a full course of treatment and support for multidrug-resistant tuberculosis patients; patient-centred approaches with strong intersectoral collaboration that address patients' emotional and social needs; motivated and dedicated healthcare workers with sufficient mandate and means to support patients; and cross-border management of multidrug-resistant tuberculosis to secure continuum of care between countries.Conclusion: We suggest that the following actions may improve the success of treatment for multidrug-resistant tuberculosis patients: deployment of rapid molecular diagnostic tests; development of context-specific treatment guidance and criteria for hospital admission and discharge in the European context; strengthening patient-centred approaches; development of collaborative mechanisms to ensure cross-border care, and development of long-term sustainable financing strategies. [ABSTRACT FROM AUTHOR]

Background: Latent tuberculosis infection (LTBI) control relies on high initiation and completion rates of preventive treatment to preclude progression to tuberculosis disease. Specific interventions may improve initiation and completion rates. The objective was to systematically review data on determinants of initiation, adherence and completion of LTBI treatment, and on interventions to improve initiation and completion.Methods: A systematic review of the literature (PubMed, Embase) published up to February 2014 was performed. Relevant prospective intervention studies were assessed using GRADE.Results: Sixty-two articles reporting on determinants of treatment initiation and completion were included and 23 articles on interventions. Determinants of LTBI treatment completion include shorter treatment regimen and directly observed treatment (DOT, positive association), adverse events and alcohol use (negative association), and specific populations with LTBI (both positive and negative associations). A positive effect on completion was noted in intervention studies that used short regimens and social interventions; mixed results were found for intervention studies that used DOT or incentives.Conclusion: LTBI treatment completion can be improved by using shorter regimens and social interventions. Specific needs of the different populations with LTBI should be addressed taking into consideration the setting and condition in which the LTBI treatment programme is implemented. [ABSTRACT FROM AUTHOR]

Background: Control of latent tuberculosis infection (LTBI) is an important step towards tuberculosis elimination. Preventive treatment will prevent the development of disease in most cases diagnosed with LTBI. However, low initiation and completion rates affect the effectiveness of preventive treatment. The objective was to systematically review data on initiation rates and completion rates for LTBI treatment regimens in the general population and specific populations with LTBI.Methods: A systematic review of the literature (PubMed, Embase) published up to February 2014 was performed.Results: Forty-five studies on initiation rates and 83 studies on completion rates of LTBI treatment were found. These studies provided initiation rates (IR) and completion rates (CR) in people with LTBI among the general population (IR 26-99 %, CR 39-96 %), case contacts (IR 40-95 %, CR 48-82 %), healthcare workers (IR 47-98 %, CR 17-79 %), the homeless (IR 34-90 %, CR 23-71 %), people who inject drugs (IR 52-91 %, CR 38-89 %), HIV-infected individuals (IR 67-92 %, CR 55-95 %), inmates (IR 7-90 %, CR 4-100 %), immigrants (IR 23-97 %, CR 7-86 %), and patients with comorbidities (IR 82-93 %, CR 75-92 %). Generally, completion rates were higher for short than for long LTBI treatment regimens.Conclusion: Initiation and completion rates for LTBI treatment regimens were frequently suboptimal and varied greatly within and across different populations. [ABSTRACT FROM AUTHOR]

Background Since non-tuberculous mycobacteria (NTM) disease is not notifiable in most European Union (EU) and European Economic Area (EEA) countries, the epidemiological situation of the >150 NTM species is largely unknown. We aimed to collect data on the frequency of NTM detection and NTM species types in EU/EEA countries. Methods Officially nominated national tuberculosis reference laboratories of all EU/EEA countries were asked to provide information on: laboratory routines for detection and identification of NTM, including drug sensitivity testing (DST) methods; data on the number and type of NTM species identified; coverage and completeness of the provided data on NTM; type and number of human specimens tested for NTM; and number of specimens tested for Mycobacterium tuberculosis complex and NTM. This information was summarized and the main results are described. Results In total, 99 different NTM species were identified with M. avium, M. gordonae, M. xenopi , M. intracellulare, and M. fortuitum identified most frequently. Seven percent of the NTM species could not be identified. NTM was cultured from between 0.4-2.0% of the specimens (data from four countries). The laboratories use culturing methods optimised for M. tuberculosis complex. Identification is mainly carried out by a commercial line probe assay supplemented with sequencing. Most laboratories carried out DST for rapid growers and only at the explicit clinical request for slow growers. Conclusion It is likely that the prevalence of NTM is underestimated because diagnostic procedures are not optimized specifically for NTM and isolates may not be referred to the national reference laboratory for identification. Due to the diagnostic challenges and the need to establish the clinical relevance of NTM, we recommend that countries should concentrate detection and identification in only few laboratories. [ABSTRACT FROM AUTHOR]

Background: Yunnan province in China has a high tuberculosis (TB) burden. Cure rates in general are high, but they were below the target of 85% in 26 out of 129 counties in 2005. In these 26 counties we assessed which patient-related and treatment-related factors were associated with non-cure. Methods: We conducted a prospective cohort study. Smear positive pulmonary TB patients treated at the local Center for Disease Control and Prevention (CDC) were interviewed before start of treatment and during the fifth month of treatment using structured questionnaires. Information on treatment outcome was extracted from patient records. Patients cured at the end of treatment were compared to patients with unsuccessful treatment outcomes (failure, default, and death). Results: A total of 841 patients were registered between January-June 2007 of which 792 (94%) were cured. Independent risk factors for non-cure were having a low income (<3000 RMB per year), not having medical insurance, a delay in health care seeking >30 days, a positive smear test result two months after start of treatment, not being aware of the need to go to the CDC for medical follow up during treatment, and not seeing the need for treatment observation. Conclusion: Reducing the financial burden of TB disease and providing health education to improve compliance with treatment could increase the proportion of patients with successful treatment outcomes. [ABSTRACT FROM AUTHOR]

Background: Cooperation between different public and private health institutes involved in tuberculosis (TB) control has proven to enhance TB control in different settings. In China, such a mechanism has not been set up yet between Centers for Disease Control (CDCs) and university hospitals despite an increased TB incidence among students. This study aims to improve arrival of TB suspects identified by universities at the CDCs in order to manage them under standardized, directly observed treatment-short course (DOTS) conditions according to the National Tuberculosis Programme (NTP) guidelines. Methods: Five matched pairs of universities were randomly assigned to the control and intervention group. After a baseline survey, a cooperation mechanism between local CDCs and university hospitals was set up in the intervention group. The effects on referral of TB suspects to the local CDC, tracing by the local CDC, and arrival at the local CDCs were assessed. Differences were tested by means of the chi-square test. Results: During the baseline survey, the referral, tracing and arrival rates were between 37% and 46%. After implementation of the cooperation mechanism, these rates had not changed in the control group but increased significantly in the intervention group: the referral, tracing and arrival rates were 97%, 95%, and 93%, respectively. Conclusions: It is feasible and effective to set up cooperation between CDCs and university hospitals to increase the number of TB suspects examined by CDCs and increase the number of TB patients treated under DOTS conditions. These public-public mix (PPM) activities should be expanded to cover all other university hospitals in China. [ABSTRACT FROM AUTHOR]

Background: Hospitals with inadequate infection control are risky environments for the emergence and transmission of tuberculosis (TB). We evaluated TB infection control practices, and the prevalence of latent TB infection (LTBI) and TB disease and risk factors in health care workers (HCW) in TB centers in Henan province in China. Methods: A cross-sectional survey was conducted in 2005. To assess TB infection control practices in TB centers, checklists were used. HCW were tuberculin skin tested (TST) to measure LTBI prevalence, and were asked for sputum smears and chest X-rays to detect TB disease, and questionnaires to assess risk factors. Differences between groups for categorical variables were analyzed by binary logistic regression. The clustered design of the study was taken into account by using a multilevel logistic model. Results: The assessment of infection control practices showed that only in a minority of the centers the patient consultation areas and X-ray areas were separated from the waiting areas and administrative areas. Mechanical ventilation was not available in any of the TB centers. N95 respirators were not available for HCW and surgical masks were not available for TB patients and suspects. The LTBI prevalence of HCW with and without BCG scar was 55.6% (432/777) and 49.0% (674/1376), respectively (P = 0.003). Older HCW, HCW with longer duration of employment, and HCW who worked in departments with increased contact with TB patients had a higher prevalence of LTBI. HCW who work in TB centers at the prefecture level, or with an inpatient ward also had a higher prevalence of LTBI. Twenty cases of pulmonary TB were detected among 3746 HCW. The TB prevalence was 6.7/1000 among medical staff and 2.5/1000 among administrative/logistic staff. Conclusion: TB infection control in TB centers in Henan, China, appears to be inadequate and the prevalence of LTBI and TB disease among HCW was high. TB infection control practices in TB centers should be strengthened in China, including administrative measures, renovation of buildings, and use of respirators and masks. Regular screening of HCW for TB disease and LTBI needs to be considered, offering preventive therapy to those with TST conversions. [ABSTRACT FROM AUTHOR]

Background: The directly observed therapy-short course (DOTS) strategy was introduced in Shaanxi province, China to improve tuberculosis (TB) control by means of improved case detection (target: > = 70%) and treatment success rates (target: > = 85%) in new smear positive (SS+) TB patients. At a provincial level the targets were both reached in 2005. However in 30 (28%) out of 107 counties of Shaanxi province the cure rate was below 85%. This study aimed to investigate patient and treatment characteristics associated with non-cure after tuberculosis (TB) treatment in these counties. Methods: In this case-control study, new smear positive TB cases in 30 counties with a cure rate <85% were included. Cured patients were compared to non-cured patients using logistic regression analysis to assess determinants for non-cure. Results: Of the 659 patients included, 153 (23.2%) did not have cure as treatment outcome. Interruption of treatment was most strongly associated with non-cure (OR = 8.7, 95% CI 3.9-18.4). Other independent risk factors were co-morbidity, low education level, lack of appetite as an initial symptom of TB disease, diagnosis of TB outside of the government TB control institutes, missing sputum re-examinations during treatment, and not having a treatment observer. Twenty-six percent of patients did not have a treatment observer. The non-cure rate was better for those with a doctor (odds ratio (OR) 0.38, 95% confidence interval (CI) 0.17-0.88) as treatment observer than for those with a family member (OR 0.62, 95%CI 0.37-1.03). The main reason for interrupted treatment mentioned by patients was presence of adverse effects during treatment (46.5%). Conclusions: Interruption of treatment was most strongly associated with non-cure. Although treatment observation by medical staff is preferred, in order to diminish the proportion of patients who do not have a treatment observer and thereby reduce the proportion of patients who interrupt treatment, we suggest making it possible for family members, after sufficient training, to be treatment observers in remote areas where it is logistically difficult to have village doctors observe treatment for all patients. [ABSTRACT FROM AUTHOR]

Background: Sputum smear microscopy is the standard diagnostic method for detection of smear positive pulmonary tuberculosis (TB). Insufficient quality of sputum might result in missing cases. In this study we aimed at assessing the quality of sputum in a district in Central Java and determining patient and health worker factors associated with submission of three good quality sputum samples. Methods: In 16 health centers information was collected on the quality of sputum submitted by TB suspects, i.e. volume, color, and viscosity. TB suspects were interviewed to assess their knowledge of TB, motivation to provide sputum and whether they were informed why and how to produce a sputum sample. Health workers were interviewed to assess what information they provided to TB suspects about the reason for sputum examination, methods to produce sputum and characteristics of a good quality sputum sample. All health worker and patient factors were evaluated for association with sputum quality. Results: Of 387 TB suspects, 294 (76.0%) could be traced and interviewed, and of 272 (70.3%) information about sputum quality was available. Of those 203 (74.6%) submitted three samples, 90 (33.1%) provided at least one good sample, and 37 (13.6%) provided three good quality sputum samples. Of the 272 TB suspects, 168 (61.8%) mentioned that information on the reason for sputum examination was provided, 66 (24.3%) remembered that they were informed about how to produce sputum and 40 (14.7%) recalled being informed about the characteristics of good quality sputum. Paramedics reported to provide often/always information on the importance of sputum examination, and when to produce sputum. Information on how to produce sputum and characteristics of a good sputum sample was less often provided. None of the studied patient characteristics or health worker factors was associated with providing good quality sputum. Conclusion: A considerable number of TB suspects did not provide three sputum samples and a large number of sputum samples were of insufficient quality. Training of health workers in providing health education to the TB suspect about the reason for sputum examination and how to produce a good quality sputum sample should be a priority of the TB program. [ABSTRACT FROM AUTHOR]

Background: In Tashkent (Uzbekistan), TB treatment is provided in accordance with the DOTS strategy. Of 1087 pulmonary TB patients started on treatment in 2005, 228 (21%) defaulted. This study investigates who the defaulters in Tashkent are, when they default and why they default. Methods: We reviewed the records of 126 defaulters (cases) and 132 controls and collected information on time of default, demographic factors, social factors, potential risk factors for default, characteristics of treatment and recorded reasons for default. Results: Unemployment, being a pensioner, alcoholism and homelessness were associated with default. Patients defaulted mostly during the intensive phase, while they were hospitalized (61%), or just before they were to start the continuation phase (26%). Reasons for default listed in the records were various, 'Refusal of further treatment' (27%) and 'Violation of hospital rules' (18%) were most frequently recorded. One third of the recorded defaulters did not really default but continued treatment under 'non-DOTS' conditions. Conclusion: Whereas patient factors such as unemployment, being a pensioner, alcoholism and homelessness play a role, there are also system factors that need to be addressed to reduce default. Such system factors include the obligatory admission in TB hospitals and the inadequately organized transition from hospitalized to ambulatory treatment. [ABSTRACT FROM AUTHOR]

Background: The emergence of drug-resistant tuberculosis (TB) hampers TB control. Ten provinces in China performed drug resistance surveys among tuberculosis (TB) patients in 1996-2004 to assess levels of drug resistance.Methods: Provincial drug resistance surveys included all isolates from newly diagnosed, smear-positive TB patients. Drug susceptibility testing (DST) against isoniazid, rifampicin, streptomycin and ethambutol was carried out in the provincial laboratories. For purposes of quality assurance, a random sample (11.6%) was re-tested by the national reference laboratory (NRL).Results: Of 14,059 patients tested 11,052 (79%) were new TB cases. The weighted mean prevalence of multi-drug resistant tuberculosis (MDR-TB) among all cases was 9.3% (range 2.2%-10.4%); 5.4% (range 2.1% - 10.4%) among new cases and 25.6% (range 11.7%-36.9%) among previously treated cases. Adjusting the drug resistance proportions using the re-testing results did not change the estimated national mean prevalence significantly. However, in some individual provinces the estimated resistance proportions were greatly influenced, especially among re-treatment patients.Conclusion: MDR-TB levels varied greatly between provinces in China, but on average were high compared to the global estimated average of 4.8%. This study shows the importance of quality-assured laboratory performance. Programmatic management of drug-resistant TB, including high quality DST for patients at high risk of resistance and treatment with second-line drugs, should become the standard, especially in high MDR-TB settings. [ABSTRACT FROM AUTHOR]