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Introduction: The Republic of Moldova is among the 18 high priority countries for tuberculosis (TB) in Europe. This study compared adherence and short and long-term TB treatment outcomes for TB patients who experienced asynchronous Video Observed Treatment (aVOT) during three months of outpatient treatment versus Directly Observed Treatment (DOT) in operational conditions in 2016-2017 in Chisinau. Methodology: We used secondary data from the 2016-2017 Randomized Clinical Trial (RCT) that piloted the aVOT Strategy in Chisinau and data from the national TB register. Relative risk was selected as a measure of association in analysis of treatment strategies (aVOT and DOT under operational conditions) and short and long-term treatment outcomes. Results: From 647 TB patients included in the study, 169 followed the treatment strategy in the RCT (83 in aVOT and 86 in DOT) and 478 were on DOT in operational conditions. Those in aVOT were more likely to have favourable short-term outcome than patients with DOT in operational conditions (RR 0.07; p < 0.001). TB recurrence as an indicator for the long-term outcome, was observed in group with DOT in operational conditions (40 cases, p = 0.006). Conclusions: This study demonstrated that the aVOT treatment strategy was associated with better adherence and both short and long-term TB treatment favourable outcomes. aVOT as a new patient-centred approach supporting TB patients on improving treatment adherence and outcomes might be recommended as an alternative to DOT strategy in the Republic of Moldova.

Background/objectiveRefugees and migrants to the World Health Organization (WHO) European Region are disproportionately affected by infections, including tuberculosis (TB), human immunodeficiency virus (HIV) and hepatitis B and C (HBV/HCV) compared with the host population. There are inequities in the accessibility and quality of health services available to refugees and migrants in the Region. This has consequences for health outcomes and will ultimately impact the ability to meet Regional infection elimination targets.MethodsWe reviewed academic and grey literature to identify national policies and guidelines for TB/HIV/HBV/HCV specific to refugees and migrants in the Member States of the WHO European Region and to identify: (i) evidence informing policy and (ii) barriers and facilitators to policy implementation.ResultsRelatively few primary national policy/guideline documents were identified which related to refugees and migrants and TB [14 of 53 Member States (26%), HIV (n = 15, 28%) and HBV/HCV (n = 3, 6%)], which often did not align with the WHO recommendations, and for some countries, violated refugees' and migrants’ human rights. We found extreme heterogeneity in the implementation of the WHO- and European Centre for Disease Prevention and Control (ECDC)-advocated policies and recommendations on the prevention, diagnosis, treatment and care of TB/HIV/HBV/HCV infection among migrants across the Member States of the WHO European Region.There is great heterogeneity in implementation of WHO- and ECDC-advocated policies on the prevention, diagnosis, treatment and care of TB/HIV/HBV/HCV infection in refugees and migrants across the Member States in the Region.ConclusionMore transparent and accessible reporting of national policies and guidelines are required, together with the evidence base upon which these policy decisions are based. Political engagement is essential to drive the changes in national legislation to ensure equitable and universal access to the diagnosis and care for infectious diseases.

A single paragraph of about 200 words maximum. For research articles, abstracts should give a pertinent overview of the work. We strongly encourage authors to use the following style of structured abstracts, but without headings: (1) Background: Place the question addressed in a broad context and highlight the purpose of the study; (2) Methods: briefly describe the main methods or treatments applied; (3) Results: summarize the article’s main findings; (4) Conclusions: indicate the main conclusions or interpretations. The abstract should be an objective representation of the article and it must not contain results that are not presented and substantiated in the main text and should not exaggerate the main conclusions.

Setting: Tuberculosis (TB) morbidity in penitentiary sectors is one of the major barriers to ending TB in the World Health Organization (WHO) European Region. Objectives and design: a comparative analysis of TB notification rates during 2014–2018 and of treatment outcomes in the civilian and penitentiary sectors in the WHO European Region, with an assessment of risks of developing TB among people experience incarceration. Results: in the WHO European Region, incident TB rates in inmates were 4–24 times higher than in the civilian population. In 12 eastern Europe and central Asia (EECA) countries, inmates compared to civilians had higher relative risks of developing TB (RR = 25) than in the rest of the region (RR = 11), with the highest rates reported in inmates in Azerbaijan, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, and Ukraine. The average annual change in TB notification rates between 2014 and 2018 was −7.0% in the civilian sector and −10.9% in the penitentiary sector. A total of 15 countries achieved treatment success rates of over 85% for new penitentiary sector TB patients, the target for the WHO European Region. In 10 countries, there were no significant differences in treatment outcomes between civilian and penitentiary sectors. Conclusion: 42 out of 53 (79%) WHO European Region countries reported TB data for the selected time periods. Most countries in the region achieved a substantial decline in TB burden in prisons, which indicates the effectiveness of recent interventions in correctional institutions. Nevertheless, people who experience incarceration remain an at-risk population for acquiring infection, developing active disease and unfavourable treatment outcomes. Therefore, TB prevention and care practices in inmates need to be improved.

People living with the human immunodeficiency virus (PLHIV) have a higher risk of developing active tuberculosis (TB) disease, and TB remains a major cause of death in PLHIV. Uzbekistan is facing a substantial TB epidemic, which increases the risk of PLHIV developing active TB. Our retrospective cohort study aimed to evaluate the incidence rate and assess the risk factors for developing active TB among PLHIV. We collected secondary data extracted from medical charts of all patients, newly diagnosed at the AIDS Center in Tashkent, during the period of 2015–2017. The incidence rate of TB among PLHIV was 5.1 (95% CI: 4.5–6.0) per 1000 person/month. Adjusted regression analysis showed three major risk factors for TB, namely, being less than 15 years old (hazard ratio (HR) 5.83, 95% CI: 3.24–10.50, p value = 0.001),low CD4 count (adjusted hazard ratio(aHR) 21.0, 95% CI: 9.25–47.7, p value &lt, 0.001), and antiretroviral therapy (ART) interruption/not receiving ART (aHR 5.57, 95% CI: 3.46–8.97 and aHR 6.2, 95% CI: 3.75–10.24, p value &lt, 0.001, respectively) were significantly associated with developing active TB among PLHIV. Our findings indicate that taking prescribed ART without interruptions and maintaining CD4cell counts higher than 320 cells/μL are essential to prevent the development of active TB among PLHIV.

Tuberculosis (TB) pleural effusion (TPE) is the second most common manifestation of extrapulmonary TB (EPTB), which remains a great diagnostic challenge worldwide. In Uzbekistan, there has been no formal evaluation of the actual practices of diagnosing and treating TPE. Our cohort study therefore aimed to describe the frequency and types of different diagnostic procedures of TPE during 2017–2018 and assess the association of baseline characteristics and establish diagnostic methods with TB treatment outcomes. In total, 187 patients with presumptive TPE were assessed, and 149 had a confirmed diagnosis of TPE (other diagnoses included cancer n = 8, pneumonia n = 17, and 13 cases were unspecified). TB was bacteriologically confirmed in 22 (14.8%), cytologically confirmed in 64 (43.0%), and histologically confirmed in 16 (10.7%) patients. Hepatitis was the only co-morbidity significantly associated with unsuccessful treatment outcomes (RR 4.8, 95%CI: 1.44–15.98, p value 0.011). Multivariable regression analysis showed that drug-resistant TB was independently associated with unsuccessful TB treatment outcome. (RR 3.83, 95%CI: 1.05–14.02, p value 0.04). Multidisciplinary approaches are required to maximize the diagnostic accuracy of TPE and minimize the chances of misdiagnosis. TPE patients with co-infections and those with drug resistance should be more closely monitored to try and ensure successful TB treatment outcomes.

The European Region of the World Health Organization (WHO) incorporates 53 Member States with reported rates of tuberculosis (TB) incidence ranging from near elimination to rates exceeding 100 per 100,000 population. Top 9 of the 30 countries with the higher multidrug-resistant TB (MDR-TB) burden globally are in the WHO European Region. Outdated tools to prevent, detect and treat tuberculosis limit health systems in the region to provide equitable and equable TB care provision.

Mental health comorbidities are common among tuberculosis patients, with higher prevalence among people with rifampicin-resistant/multidrug-resistant (RR/MDR) tuberculosis. TB and depression share common risk factors adding to the overall disease burden. There is limited evidence about prevalence of depression and anxiety symptoms among tuberculosis patients in Romania. We assessed the prevalence of depression and anxiety symptoms and their evolution over the course of the treatment in RR/MDR-TB patients receiving in-patient care at the National Institute of Pneumonology (NIP) “Marius Nasta” in Romania during May-September 2020. We conducted a cohort study and used the Hospital Anxiety and Depression Scale (HADS) to assess the prevalence of depression and anxiety (defined as score≥ 8) symptoms at admission (baseline) and the second month of in-patient treatment (follow-up). Difference between baseline and follow-up depression and anxiety symptoms were assessed using McNemar test. Binary logistic regression was used to evaluate the association between sociodemographic and clinical characteristics with the presence of depression and anxiety symptoms at baseline. The cohort included 46 patients, 63% were male, mean age was 46 (±13.3) years. The prevalence of depression and anxiety in our cohort was 46% and 43% at baseline respectively, and 50% and 39%, at the follow-up respectively. About one third (7/25) of patients who had normal HADS depression score at baseline, had an increase above the threshold at the second month of treatment. No statistical difference in prevalence of depression or anxiety was found between the baseline and second month of treatment. Unadjusted analysis showed that odds of depression at baseline was lower in patients with education above 8th grade compared to patients with education below 8th grade (odds ratio=0.2, 95% confidence interval: 0.1,0.8, p=0.026). The study revealed high prevalence of depression and anxiety among RR/MDR-TB patients admitted to the NIP, underlining the necessity of evaluating the mental health of TB patients and linking them to appropriate care.

Rifampicin-Resistant/Multidrug-Resistant Tuberculosis (RR/MDR-TB) is recognized as a major public health concern globally. In Armenia, the proportion of RR/MDR-TB is increasing among all people affected with TB. We conducted a nationwide cohort study involving analysis of programmatic data to investigate the rates of and factors associated with unfavourable treatment outcomes among patients with RR/MDR-TB registered by the national TB programme from 2014 to 2017 in Armenia. We used Cox regression to identify factors associated with the outcome. Among 451 RR/MDR-TB patients, 80% were men and median age was 46 years. Of them, 53 (11.8%) had Extensively Drug-Resistant Tuberculosis (XDR-TB) and 132 (29.3%) had pre-XDR-TB. Almost half (224, 49.7%) of the patients had unfavourable treatment outcome, which included 26.8% Loss To Follow-Up (LTFU), 13.3% failures and 9.5% deaths. In multivariable analysis, people with pre-XDR-TB [adjusted Hazard Ratio [aHR] 3.13, 95% confidence intervals [CI] 2.16-4.55] and XDR-TB (aHR 4.08, 95% CI 2.45-6.79) had a higher risk of unfavourable outcomes. Patients receiving home-based treatment (71/451, 15.7%) and treatment with new drugs (172/451, 38.1%) had significantly lower risk (aHR 0.45, 95% CI 0.28-0.72 and aHR 0.26, 95% CI 0.18-0.39) of unfavourable treatment outcome. The proportion of MDR-TB patients reaching favourable treatment outcome in Armenia was substantially lower than the recommended level (75%). The most common treatment outcome was LTFU indicating the need for further assessment of underlying determinants. Home-based treatment looks promising and future studies are required to see if expanding it to all RR/MDR-TB patients is feasible and cost-effective.

The Republic of Moldova is among the 30 Rifampicin-Resistant and/or Multidrug-Resistant (RR/MDR) Tuberculosis (TB) high burden countries in the world. Despite free TB diagnostics and treatment, TB patients face substantial economic losses and this may impact overall treatment outcomes. We assessed if there is an association between TB-related catastrophic costs and TB treatment outcomes. We conducted a cohort study using data from patient records and a survey that quantified catastrophic costs among RR/MDR-TB affected households in the Republic of Moldova in 2016. We included adult patients (age ≥18 years) with RR/MDR-TB who had been in inpatient (intensive phase) or outpatient (continuous phase) treatment for at least 2 months. Unfavourable treatment outcome, such as failure, death or lost to follow-up, was the primary outcome variable. The definition of catastrophic TB-related costs followed the World Health Organisation (WHO) guidelines: costs due to TB ≥20% of annual household income. Log-binomial regression was used to assess association between the outcome and catastrophic TB-related costs adjusting for other socio-demographic, behavioural and clinical covariates. In total 287 RR/MDR-TB patients (78% males, mean age 42 years) were included. Of them, 30% experienced catastrophic TB-related costs. Overall, one in five patients (21%) had unfavourable treatment outcome, such as treatment failure (5%), death (8%) or lost to follow-up (8%). The experience of catastrophic TB-related costs was not associated with unfavourable treatment outcome [adjusted relative risk (aRR)=0.88, 95% CI: 0.50–1.50]. Major factors independently associated with unfavourable TB treatment outcomes were poverty (aRR=2.07; 95% CI: 1.06-4.07), urban residence (aRR=1.99; 95% CI: 1.12-3.52) and positive HIV (Human Immunodeficiency Virus) status (aRR=2.61; 95% CI: 1.31-4.89). As a result, we failed to find an association between catastrophic costs and treatment outcomes of RR/MDR-TB patients in the Republic of Moldova. However, we found that patients from poor households and urban areas were twice more likely to achieve unfavourable TB treatment outcomes disregarding whether they experienced catastrophic costs or not. Also, TB/HIV patients and urban residents were identified as the most vulnerable groups with higher risk of unfavourable treatment outcome and TB-related costs.

Setting The true prevalence of multidrug-resistant tuberculosis (MDR-TB) in Ukraine is not known. Available data are a decade old and limited to only one province. Objective To determine the prevalence of MDR-TB among new and previously treated TB cases in Ukraine and explore the risk factors associated with drug resistance. Methods A total of 1550 sputum smear-positive pulmonary TB patients were recruited from 40 clusters throughout Ukraine. Sputum specimens were examined using culture, drug susceptibility testing and pncA gene sequencing. Results The proportion of MDR-TB among new and previously treated TB cases was respectively 24.1% (95%CI 20.7-27.6) and 58.1% (95%CI 52.1-64.1). More than one third (38.0%) of MDR-TB or rifampicin (RMP) resistant cases showed resistance to either a fluoroquinolone (FQ) or a second-line injectable agent or both. Resistance to pyrazinamide and FQs was low in patients with RMP-susceptible TB. Among new TB cases, the odds of MDR-TB were higher among patients who were younger, female and living in south-eastern provinces, as well as among human immunodeficiency virus-positive patients who belonged to a low socio-economic group. Conclusions Our study showed that the burden of MDR-TB in Ukraine was much greater than previously assumed. Urgent actions are needed to prevent further spread of drug-resistant TB in Ukraine.

Background In many countries, regular monitoring of the emergence of resistance to anti-tuberculosis drugs is hampered by the limitations of phenotypic testing for drug susceptibility. We therefore evaluated the use of genetic sequencing for surveillance of drug resistance in tuberculosis. Methods Population-level surveys were done in hospitals and clinics in seven countries (Azerbaijan, Bangladesh, Belarus, Pakistan, Philippines, South Africa, and Ukraine) to evaluate the use of genetic sequencing to estimate the resistance of Mycobacterium tuberculosis isolates to rifampicin, isoniazid, ofloxacin, moxifloxacin, pyrazinamide, kanamycin, amikacin, and capreomycin. For each drug, we assessed the accuracy of genetic sequencing by a comparison of the adjusted prevalence of resistance, measured by genetic sequencing, with the true prevalence of resistance, determined by phenotypic testing. Findings Isolates were taken from 7094 patients with tuberculosis who were enrolled in the study between November, 2009, and May, 2014. In all tuberculosis cases, the overall pooled sensitivity values for predicting resistance by genetic sequencing were 91% (95% CI 87-94) for rpoB (rifampicin resistance), 86% (74-93) for katG, inhA, andfabG promoter combined (isoniazid resistance), 54% (39-68) for pucA (pyrazinamide resistance), 85% (77-91) for gyrA and gyrB combined (ofloxacin resistance), and 88% (81-92) for gyrA and gyrB combined (moxifloxacin resistance). For nearly all drugs and in most settings, there was a large overlap in the estimated prevalence of drug resistance by genetic sequencing and the estimated prevalence by phenotypic testing. Interpretation Genetic sequencing can be a valuable tool for surveillance of drug resistance, providing new opportunities to monitor drug resistance in tuberculosis in resource-poor countries. Before its widespread adoption for surveillance purposes, there is a need to standardise DNA extraction methods, recording and reporting nomenclature, and data interpretation. Copyright (C) 2018 World Health Organization; licensee Elsevier. This is an Open Access article published under the CC BY 3.0 IGO license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

© 2016, Centers for Disease Control and Prevention (CDC). All rights reserved. A recent innovation to help patients adhere to daily tuberculosis (TB) treatment over many months is video (or virtually) observed therapy (VOT). VOT is becoming increasingly feasible as mobile telephone applications and tablet computers become more widely available. Studies of the effectiveness of VOT in improving TB patient outcomes are being conducted.

Background and Aims: Directly observed treatment is recommended to improve adherence to tuberculosis (TB) treatment. However, daily treatment observation presents challenges for both patients and health care staff. Video observed treatment (VOT) can help bridge the gap between patients and health services and promote adherence. In 2015 the Ministry of Health of Belarus, with support from the World Health Organization (WHO), piloted VOT for TB patients in the capital, Minsk. The intervention was aligned to the digital health target product profiles developed by WHO/ERS (2015) with aim of testing the feasibility and performance of VOT in a programme setting. Methods: A smartphone application was created and linked to the national electronic TB register. Patients were provided with smartphones with internet access, and shown how to record and transmit video files to trained clinic staff. Following an initial pilot project VOT was expanded countrywide with Global Fund support. Results: Between 1 January 2016 and 1 February 2017, 105 patients were recruited: median age 32 years (range:18-67); 68% male; 62% multidrug- or extensively-drug resistant TB. Of 4,797 VOT episodes registered, 94% were of good quality. No smartphone was lost; 14 of 15 (93%) patients who completed treatment for drug-susceptible TB had a successful outcome. Conclusions: Preliminary data demonstrate high levels of patient acceptability and treatment adherence using VOT among a diverse mix of TB patients and staff in all six regions of Belarus. The experience gained can promote this patient-centered approach for TB patients with comorbidities (e.g. HIV, substance abuse) and complex social issues.

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

Encouragingly, global rates of new tuberculosis (TB) cases have been falling since 2005, in line with the Millennium Development Goal targets; however, cases of multidrug-resistant (MDR-) and extensively drug-resistant TB (XDR-TB) have been increasing. Fifteen of the world's 27 high MDR- and XDR-TB burden countries are in the World Health Organization (WHO) European Region, of which 10 are in Eastern Europe (including Baltic and Caucasus countries). To address the MDR- and XDR-TB situation in the WHO European Region, a Consolidated Action Plan to Prevent and Combat M/XDR-TB (2011–2015) was developed for all 53 Member States and implemented in 2011. Since the implementation of the Action Plan, the proportion of MDR-TB appears largely to have levelled off among bacteriologically confirmed TB cases in high-burden countries with universal or near universal (>95%) first-line drug susceptibility testing (DST). The treatment success rate, however, continues to decrease. A contributing factor is the substantial proportion of MDR-TB cases that are additionally resistant to either a fluoroquinolone, a second-line injectable agent or both (XDR-TB); high-burden country proportions range from 12.6% to 80.4%. Proportions of XDR-TB range from 5% to 24.8%. Despite much progress in Eastern Europe, critical challenges remain as regards access to appropriate treatment regimens; patient hospitalisation; scale-up of laboratory capacity, including the use of rapid diagnostics and second-line DST; vulnerable populations; human resources; and financing. Solutions to these challenges are aligned with the Post-2015 Global TB strategy. As a first step, the global strategy should be adapted at regional and country levels to serve as a framework for immediate actions as well as longer-term ways forward.

Outcomes of treatment for multidrug-resistant tuberculosis (MDR-TB) remain poor worldwide. In MDR-TB patients starting treatment in 2012 in Belarus, only 54% completed it successfully while in 22% treatment failed, 11% died and 13% were lost to follow up or unevaluated. The Ministry of Health has introduced new and repurposed drugs in MDR-TB treatment regimens to improve outcomes. We describe how active TB drug-safety monitoring and management (aDSM) is being implemented to reduce harms in MDR-TB patients on linezolid and bedaquiline. The NTP and the pharmacovigilance centre of the Ministry of Health use standard questionnaires to monitor safety and effectiveness of regimens containing linezolid and bedaquiline, in line with the WHO recommendations. Clinical, laboratory and microbiological data are collected at start, during treatment and follow-up. Data has now been collected from 205 patients on linezolid (since its introduction in June 2014) and 133 patients on bedaquiline (since June 2015). These medicines were used along with 5-7 other second-line TB drugs. 124 patients received both drugs. Among patients on linezolid, 78.1% developed 1 or more adverse events (AEs) attributable to TB treatment and 4.8% had serious AEs requiring withdrawal or reduction of dose of medicines.Among patients on bedaquiline, 72% had one or more AEs attributed to TB treatment and 3.9% had serious AEs requiring withdrawal or reduction of dose of medicines. There were no deaths as a result of serious AEs of from the two medicines. aDSM adds value to the other monitoring activities aimed at improving outcomes of TB patients on novel medicines and regimens.

Background: Practical Approach to Lung Health (PAL) is a patient-centred approach to improving the quality of diagnosis and treatment of common respiratory illnesses (including TB) in primary health care (PHC) settings. PAL training of 20 PHC physicians in one region of Belarus was shown to improve rational antibiotic prescription for pneumonia, awareness of airborne infection control, counselling in smoking cessation and nicotine-replacement therapy (NRT). The Ministry of Health of Belarus developed the National PAL Guidelines in 2014 with the assistance of World Health Organization Regional Office for Europe. We describe how these guidelines were converted into an electronic format for wider dissemination. Methods: A software application for Android operating system smartphones and tablets based on the National PAL Guidelines was developed by a local company in 2015. This project was supported by WHO and European Respiratory Society (ERS). The app conforms to the digital health target product profiles developed by the WHO/ERS for TB/tobacco. Results: The first version of the application for Android devices contains the following features: i) enhanced access to the guidelines text which adapts to screen-size; ii) follow-up e-mails to patients in support of smoking-cessation and NRT); iii) forwarding of guidelines text to patients via e-mail to strengthen knowledge; iv) automated issuing of medical prescriptions. Conclusion: Initial findings show positive user reactions to the mobile app. Its use will be formally evaluated. The app could be of use in Russian-speaking countries other than Belarus.

Tuberculosis (TB) patients in Eastern Europe & Central Asia have the highest risk worldwide for rifampicin-resistance (RR-TB), which is less amenable to treatment than drug-susceptible TB. Detection and treatment of RR-TB requires public investment in diagnostics, infrastructure and human resources. We discuss progress in 9 countries with the topmost burden of RR-TB in the WHO European Region to align to the 2011 European “Roadmap to prevent and combat drug-resistant tuberculosis”. We use aggregated surveillance data reported by countries to WHO and compared detection and enrolment indicators to the estimated burden. Enrolment on treatment increased in all countries between 2009 and 2014;case detection has fluctuated but increased overall to ∼55% of the estimated caseload of RR-TB in these countries. In some countries enrolment now exceeds detection (Belarus, Kazakhstan, Russian Fed.) while in others the two trends are converging (Moldova Rep, Tajikistan). While some countries are coordinating action to detect RR-TB patients and treat them, disparities may indicate delays in starting treatment, shortages in second-line drugs, poor recording, incomplete reporting, and treatment of patients without laboratory confirmation. These challenges could be addressed through improved data management, reporting skills, diagnostic coverage and capacity to treat patients rapidly and effectively. Country studies to find appropriate solutions would be useful.

Setting Global survey among low tuberculosis (TB) burden countries, which are primary target countries for the World Health Organization (WHO) guidelines on the programmatic management of latent tuberculous infection (LTBI). Objective To perform a baseline assessment of policies and practices for the programmatic management of LTBI. Design Online and paper-based pre-tested questionnaire filled out by national TB programme managers or their equivalents from 108 countries. Results Of 74 respondent countries, 75.7% (56/74) had a national policy on LTBI. The majority of the countries (67/74, 90.5%) provided LTBI testing and treatment for child contacts of TB cases, while almost two thirds (49/74, 66%) reported provision of LTBI testing and treatment to people living with the human immunodeficiency virus (PLHIV). Six countries (8.1%) did not report providing LTBI management to child contacts and PLHIV. Among countries that reported both the availability of policy and practice of testing and treatment of LTBI for at-risk populations, a system for recording and reporting data was available in 62% (33/53) for child contacts and in 53% (21/40) for PLHIV. Conclusion Countries need to ensure that national LTBI policies and a standardised monitoring and evaluation system are in place to promote the programmatic management of LTBI.

Summary Background Pyrazinamide and fluoroquinolones are essential antituberculosis drugs in new rifampicin-sparing regimens. However, little information about the extent of resistance to these drugs at the population level is available. Methods In a molecular epidemiology analysis, we used population-based surveys from Azerbaijan, Bangladesh, Belarus, Pakistan, and South Africa to investigate resistance to pyrazinamide and fluoroquinolones among patients with tuberculosis. Resistance to pyrazinamide was assessed by gene sequencing with the detection of resistance-conferring mutations in the pncA gene, and susceptibility testing to fluoroquinolones was conducted using the MGIT system. Findings Pyrazinamide resistance was assessed in 4972 patients. Levels of resistance varied substantially in the surveyed settings (3·0–42·1%). In all settings, pyrazinamide resistance was significantly associated with rifampicin resistance. Among 5015 patients who underwent susceptibility testing to fluoroquinolones, proportions of resistance ranged from 1·0–16·6% for ofloxacin, to 0·5–12·4% for levofloxacin, and 0·9–14·6% for moxifloxacin when tested at 0·5 μg/mL. High levels of ofloxacin resistance were detected in Pakistan. Resistance to moxifloxacin and gatifloxacin when tested at 2 μg/mL was low in all countries. Interpretation Although pyrazinamide resistance was significantly associated with rifampicin resistance, this drug may still be effective in 19–63% of patients with rifampicin-resistant tuberculosis. Even though the high level of resistance to ofloxacin found in Pakistan is worrisome because it might be the expression of extensive and unregulated use of fluoroquinolones in some parts of Asia, the negligible levels of resistance to fourth-generation fluoroquinolones documented in all survey sites is an encouraging finding. Rational use of this class of antibiotics should therefore be ensured to preserve its effectiveness. Funding Bill & Melinda Gates Foundation, United States Agency for International Development, Global Alliance for Tuberculosis Drug Development.

Purpose To provide an overview of the tuberculosis (TB) and multi-drug resistant tuberculosis (MDR-TB) in the WHO European Region and evolution of public health response with focus on extra-pulmonary tuberculosis and Pott’s disease. Methods Authors reviewed regional strategic documents related to TB. The epidemiologic data were reviewed and analyzed. Results In the absence of associated pulmonary TB, Pott’s disease is reported as extra-pulmonary TB (up to 47 % of all TB cases in some settings). Due to limitations of the surveillance system, the epidemiology of Pott’s disease and its treatment success are unknown. The Stop TB Strategy and Consolidated Action Plan to Prevent and Combat M/XDR-TB provide comprehensive roadmaps to address all types of TB. Conclusions There is a need to further analyze country data to document the extent of Pott’s disease and develop specific guidelines for timely diagnosis and treatment of Pott’s disease.

Background We explored host-related factors associated with the site of tuberculosis (TB) disease using variables routinely collected by the 31 EU/EEA countries for national surveillance. Methods Logistic regression models were fitted to case-based surveillance data reported to the European Centre for Disease Prevention and Control for TB cases notified from 2003 to 2014. Missing data on HIV infection and on susceptibility to isoniazid and rifampicin for many patients precluded the inclusion of these variables in the analysis. Records from Finland, Lithuania, Spain and the United Kingdom were excluded for lack of exact details of disease localisation; other records without one or more variable (e.g. previous treatment history, geographical origin) or who had mixed pulmonary and extrapulmonary disease or more than one form of extrapulmonary disease were also removed (total exclusion = 38% of 913,637 notifications). Results 564,916 TB cases reported by 27 EU/EEA countries had exclusive pulmonary (PTB; 83%) or extrapulmonary (EPTB; 17%) disease. EPTB was associated with age 3.7), and age

Background: In Belarus, care for multidrug-resistant tuberculosis (strains resistant to at least isoniazid and rifampicin, MDR-TB) patients has been effectively implemented since 2008. Outcomes however remain unsatisfactory: among patients starting treatment in 2011, 10% interrupted medication, in 24% treatment failed and 11% died. Adverse drug reactions (ADR) are likely to contribute to these negative outcomes. Introduction of new or repurposed drugs in MDR-TB regimens could provoke previously unrecognised ADRs. Methods: We describe how active pharmacovigilance (cohort event monitoring) was used to improve the detection of drug-related harms in MDR-TB patients treated with Linezolid. Results: Standard questionnaires were developed by the TB programme and the pharmacovigilance centre of the Ministry of Health to capture data on the safety and effectiveness of Linezolid-containing regimens in accordance with the recommendations of the World Health Organization (WHO). Health care staff collected clinical, laboratory and microbiology data at the start, during and after end of treatment. Between 6 June 2014 and 31 January 2015, 58 MDR-TB patients had Linezolid added for up to 8 months to regimens containing 5-7 other second-line TB medicines. Forty-six (79%) had deranged laboratory test results or other ADRs attributable to anti-TB treatment (various organ systems involved, including blood, metabolic, renal, hepato-biliary and neurological), and 3 (5%) developed serious ADRs requiring withdrawal or reduction of dose. Conclusion: active pharmacovigilance adds value to other monitoring activities geared to improve outcomes in TB patients on new medicines and regimens.

Setting: Civilian population of the Republic of Azerbaijan. Objectives: To determine patterns of anti-tuberculosis drug resistance among new and previously treated pulmonary tuberculosis (TB) cases, and explore their association with socio-demographic and clinical characteristics. Design: National cross-sectional survey conducted in 2012–2013. Results: Of 789 patients (549 new and 240 previously treated) who met the enrolment criteria, 231 (42%) new and 146 (61%) previously treated patients were resistant to any anti-tuberculosis drug; 72 (13%) new and 66 (28%) previously treated patients had multidrug-resistant TB (MDR-TB). Among MDR-TB cases, 38% of new and 46% of previously treated cases had pre-extensively drug-resistant TB (pre-XDR-TB) or XDR-TB. In previously treated cases, 51% of those who had failed treatment had MDR-TB, which was 15 times higher than in relapse cases (OR 15.2, 95%CI 6–39). The only characteristic significantly associated with MDR-TB was a history of previous treatment (OR 3.1, 95%CI 2.1–4.7); for this group, history of incarceration was an additional risk factor for MDR-TB (OR 2.8, 95%CI 1.1–7.4). Conclusion: Azerbaijan remains a high MDR-TB burden country. There is a need to implement countrywide control and innovative measures to accelerate early diagnosis of drug resistance in individual patients, improve treatment adherence and strengthen routine surveillance of drug resistance.

To review the latest information about levels of anti-tuberculosis (TB) drug resistance in the European Region of the World Health Organization (WHO) and time-trends in multidrug-resistant TB (resistance to isoniazid and rifampicin; MDR-TB) over the past fifteen years.We analysed data on drug resistance among new and previously treated TB cases reported from 1997 to 2012. Data are collected in surveys of representative samples of TB patients or from surveillance systems based on diagnostic drug susceptibility testing.A total of 15.7% (95% confidence limits (CI): 9.5–21.9) of new and 45.3% (95%CI: 39.2–51.5) of previously treated TB cases are estimated to have MDR-TB in the Region. Extensively drug-resistant TB (MDR-TB and resistance to fluoroquinolones and second-line injectables; XDR-TB) had been reported by 38 of the 53 countries of the region (72%). The proportion of MDR-TB cases with XDR-TB is 11.4% (95%CI: 8.6–14.2). Between 1997 and 2012, population rates of MDR-TB declined in Estonia, Latvia and Germany and increased in the United Kingdom, Sweden and Tomsk Oblasts of the Russian Federation.Surveillance of drug resistance has been strengthened in the WHO European Region, which has the highest proportions of MDR-TB and XDR-TB ever reported globally. More complete data are needed particularly from the Russian Federation.

Multidrug-resistant tuberculosis (MDR-TB; resistance to at least rifampicin and isoniazid) is a global public health concern. In 2010–2011, Uzbekistan, in central Asia, conducted its first countrywide survey to determine the prevalence of MDR-TB among TB patients. The proportion of MDR-TB among new and previously treated TB patients throughout the country was measured and risk factors for MDR-TB explored. A total of 1,037 patients were included. MDR-TB was detected in 165 treatment-naive (23.2%; 95% confidence interval (CI) 17.8%–29.5%) and 207 previously treated (62.0%; 95% CI: 52.5%–70.7%) patients. In 5.3% (95% CI: 3.1%–8.4%) of MDR-TB cases, resistance to fluoroquinolones and second-line injectable drugs (extensively drug resistant TB; XDR-TB) was detected. MDR-TB was significantly associated with age under 45 years (adjusted odds ratio: 2.24; 95% CI: 1.45–3.45), imprisonment (1.93; 95% CI: 1.01–3.70), previous treatment (4.45; 95% CI: 2.66–7.43), and not owning a home (1.79; 95% CI: 1.01–3.16). MDR-TB estimates for Uzbekistan are among the highest reported in former Soviet Union countries. Efforts to diagnose, treat and prevent spread of MDR-TB need scaling up.

Multidrug-resistant tuberculosis (MDR-TB) is a major concern in countries of the former Soviet Union. The reported risk of resistance among tuberculosis (TB) cases in the Republic of Moldova is among the highest in the world. We aimed to produce high-resolution spatial maps of MDR-TB risk and burden in this setting. We analysed national TB surveillance data collected between 2007 and 2010 in Moldova. High drug susceptibility testing coverage and detailed location data permitted identification of subregional areas of higher MDR-TB risk. We investigated whether the distribution of cases with MDR-TB risk factors could explain this observed spatial variation in MDR-TB. 3447 MDR-TB cases were notified during this period; 24% of new and 62% of previously treated patients had MDR-TB. Nationally, the estimated annual MDR-TB incidence was 54 cases per 100 000 persons and1000 cases per 100 000 persons within penitentiaries. We identified substantial geographical variation in MDR-TB burden and hotspots of MDR-TB. Locations with a higher percentage of previously incarcerated TB cases were at greater risk of being MDR-TB hotspots. Spatial analyses revealed striking geographical heterogeneity of MDR-TB. Methods to identify locations of high MDR-TB risk and burden should allow for better resource allocation and more appropriate targeting of studies to understand local mechanisms driving resistance.

To assess the problem of multidrug-resistant tuberculosis (MDR-TB) throughout Belarus and investigate the associated risk factors.In a nationwide survey in 2010-2011, 1420 tuberculosis (TB) patients were screened and 934 new and 410 previously treated cases of TB were found to meet the inclusion criteria. Isolates of Mycobacterium tuberculosis from each eligible patient were tested for susceptibility to anti-TB drugs. Sociobehavioural information was gathered in interviews based on a structured questionnaire.MDR-TB was found in 32.3% and 75.6% of the new and previously treated patients, respectively, and, 11.9% of the 612 patients found to have MDR-TB had extensively drug-resistant TB (XDR-TB). A history of previous treatment for TB was the strongest independent risk factor for MDR-TB (odds ratio, OR: 6.1; 95% confidence interval, CI: 4.8-7.7). The other independent risk factors were human immunodeficiency virus (HIV) infection (OR: 2.2; 95% CI: 1.4-3.5), age 35 years (OR: 1.4; 95% CI: 1.0-1.8), history of imprisonment (OR: 1.5; 95% CI: 1.1-2.0), disability sufficient to prevent work (OR: 1.9; 95% CI: 1.2-3.0), alcohol abuse (OR: 1.3; 95% CI: 1.0-1.8) and smoking (OR: 1.5; 95% CI: 1.1-2.0).MDR-TB is very common among TB patients throughout Belarus. The numerous risk factors identified for MDR-TB and the convergence of the epidemics of MDR-TB and HIV infection call not only for stronger collaboration between TB and HIV control programmes, but also for the implementation of innovative measures to accelerate the detection of TB resistance and improve treatment adherence.Résumé OBJECTIF: Évaluer le problème de la tuberculose multirésistante (TB-MR) sur le territoire biélorusse et explorer les facteurs de risque associés. MÉTHODES: Au cours d'une enquête nationale menée en 2010-2011, 1420 cas de tuberculose (TB) ont été dépistés et 934 cas nouveaux ainsi que 410 cas précédemment traités ont été jugés conformes aux critères d'inclusion. Des isolats de Mycobacterium tuberculosis provenant de chaque patient admissible ont été testés pour leur sensibilité envers les médicaments antituberculeux. Des informations sociocomportementales ont été recueillies lors d'entretiens basés sur un questionnaire structuré. RÉSULTATS: La TB-MR a été détectée dans respectivement 32,3% et 75,6% des cas nouveaux et des cas traités antérieurement, et 11,9% des 612 patients porteurs de la TB-MR présentaient une forme de tuberculose ultrarésistante (TB-UR). Un historique de traitement antérieur pour la TB représentait le principal facteur de risque indépendant pour la TB-MR (rapport des cotes, RC: 6,1; intervalle de confiance à 95%, IC: 4,8 à 7,7). Les autres facteurs de risque indépendants comprenaient l'infection par le virus d'immunodéficience humaine (VIH) (RC: 2,2; IC à 95%: 1,4 à 3,5), l’âge35 ans (RC: 1,4 ; IC à 95%: 1,0 à 1,8), un historique d'emprisonnement (RC: 1,5; IC à 95%: 1,1 à 2,0), une invalidité suffisante pour empêcher le travail (RC: 1,9 ; IC à 95%: 1,2 à 3,0), l’alcoolisme (RC: 1,3; IC à 95%: 1,0 à 1,8) et le tabagisme (RC: 1,5; IC à 95%: 1,1 à 2,0). CONCLUSION: La TB-MR est très fréquente chez les patients atteints de tuberculose en Bélarus. Les nombreux facteurs de risque identifiés pour la TB-MR et la convergence entre l’épidémie de TB-MR et l'infection par le VIH exigent non seulement de renforcer la collaboration entre les programmes antituberculeux et de lutte contre le VIH, mais aussi la mise en œuvre de mesures innovantes pour accélérer la détection de la résistance à la tuberculose et améliorer l'observance du traitement.Resumen OBJETIVO: Evaluar el problema de la tuberculosis multirresistente (TB-MR) en Bielorrusia e investigar los factores de riesgo asociados. MÉTODOS: En una encuesta a nivel nacional llevada a cabo entre 2010 y 2011, se evaluó a 1420 pacientes con tuberculosis (TB) y se consideró que 934 nuevos casos de TB y 410 casos de TB previamente tratados reunían los criterios de inclusión. Se analizaron cepas de Mycobacterium tuberculosis de cada paciente elegible con el fin de determinar la susceptibilidad a los fármacos antituberculosos. Se recopiló información socioconductual mediante entrevistas basadas en un cuestionario estructurado. RESULTADOS: Se detectó TB-MR en el 32,3% y el 75,6% de los pacientes de nuevo diagnóstico y tratados previamente, respectivamente, y se observó que el 11,9% de los 612 pacientes con TB-MR presentaba tuberculosis ultrarresistente (TB-XR). Los antecedentes de tratamiento previo de la TB resultaron ser el factor de riesgo independiente que más predispone a sufrir TB-MR (razón de posibilidades, OR: 6,1; intervalo de confianza del 95%, IC: 4,8–7,7). Los demás factores de riesgo independientes fueron el virus de la inmunodeficiencia humana (VIH) (OR: 2,2; IC del 95%: 1,4–3,5), edad 35 años (OR: 1,4; IC del 95%: 1,0–1,8), antecedentes de encarcelamiento (OR: 1,5; IC del 95%: 1,1–2,0), incapacidad suficiente para impedir el trabajo (OR: 1,9; IC del 95%: 1,2–3,0), alcoholismo (OR: 1,3; IC del 95%: 1,0–1,8) y tabaquismo (OR: 1,5; IC del 95%: 1,1–2,0). CONCLUSIÓN: La TB.MR es muy frecuente entre los pacientes con tuberculosis en Bielorrusia. Los numerosos factores de riesgo identificados para la TB-MR, unidos a la convergencia de las epidemias de TB-MR y la infección por el VIH, exigen no solo una mayor colaboración entre los programas de control de la TB y del VIH, sino también la aplicación de medidas innovadoras destinadas a acelerar la detección de la resistencia a la TB y mejorar el cumplimiento terapéutico.ملخص الغرض : تقييم مشكلة السل المقاوم للأدوية المتعددة (MDR-TB) في جميع أنحاء بيلاروس وتحري عوامل الاختطار ذات الصلة. الطريقة : من خلال دراسة استقصائية على الصعيد الوطني في الفترة من 2010 إلى 2011، تم فحص 1420 مريضاً بمرض السل وتبين تلبية معايير الإدراج لدى 934 حالة إصابة جديدة بالسل و410 حالة خضعت للعلاج في السابق. وتم اختبار المستفردات الخاصة بالبكتريا المتفطرة السليّة من كل مريض مؤهل من أجل حساسية الأدوية المقاومة للسل. وتم جمع المعلومات الاجتماعية والسلوكية في مقابلات استندت على دراسة استقصائية منظمة. النتائج : تبين إصابة 32.3 % و75.6 % من المرضى الجدد والذين خضعوا للعلاج في السابق بالسل المقاوم للأدوية المتعددة، على التوالي، وأن 11.9 % من 612 مريضاً الذين تبين إصابتهم بالسل المقاوم للأدوية المتعددة أصيبوا بالسل الشديد المقاوم للأدوية. وكان تاريخ العلاج السابق للسل أقوى عامل اختطار مستقل للسل المقاوم للأدوية المتعددة (نسبة الاحتمال: 6.1؛ فاصل الثقة 95 %: من 4.8 إلى 7.7). وكانت عوامل الاختطار المستقلة الأخرى هي عدوى فيروس العوز المناعي البشري (نسبة الاحتمال: 2.2؛ فاصل الثقة 95 %: من 1.4 إلى 3.5)، السن أقل من 35 سنة (نسبة الاحتمال: 1.4؛ فاصل الثقة 95 %: من 1.0 إلى 1.8)، تاريخ السجن (نسبة الاحتمال: 1.5؛ فاصل الثقة 95 %: من 1.1 إلى 2.0)، والإعاقة الكافية للحيلولة دون العمل (نسبة الاحتمال: 1.9؛ فاصل الثقة 95 %: من 1.2 إلى 3.0)، وإساءة استعمال الكحوليات (نسبة الاحتمال: 1.3؛ فاصل الثقة 95 %: من 1.0 إلى 1.8) والتدخين (نسبة الاحتمال: 1.5؛ فاصل الثقة 95 %: من 1.1 إلى 2.0). الاستنتاج : السل المقاوم للأدوية المتعددة شائع جداً بين مرضى السل في أنحاء بيلاروس. ولا تتطلب عوامل الاختطار العديدة التي تم تحديدها بخصوص السل المقاوم للأدوية المتعددة وتلاقي أوبئة السل المقاوم للأدوية المتعددة وعدوى فيروس العوز المناعي البشري درجة أقوى من التعاون بين برامج مكافحة السل وفيروس العوز المناعي البشري فحسب، ولكنها تتطلب أيضاً تنفيذ تدابير ابتكارية من أجل تسريع كشف مقاومة السل وتحسين الالتزام بالعلاج.摘要 目的: 评估整个白俄罗斯耐多药结核病（MDR-TB）的问题并调查相关的风险因素。 方法: 在2010-2011 年全国范围的调查中对1420 位结核病（TB）患者进行筛选，发现其中934 个新的和410 个既往接受过治疗的结核病患者符合纳入标准。检测每个符合资格的患者的结核杆菌菌株的抗结核药物的敏感性。在基于结构性问卷的访谈中收集社会行为信息。 结果: 在新的和既往接受过治疗的患者中分别在32.3%和75.6%的患者中发现MDR-TB，612 名发现有MDR-TB的患者中有11.9%为广泛耐药结核病（XDR-TB）。TB既往治疗史是MDR-TB最强的独立风险因素（优势比，OR：6.1；95%置信区间，CI：4.8-7.7）。其他的独立风险因素是艾滋病病毒（HIV）感染（OR：2.2；95% CI：1.4-3.5）、年龄35岁（OR：1.4；95% CI：1.0-1.8）、羁押史（OR：1.5，95% CI：1.1-2.0）、足以妨碍工作的残疾（OR：1.9；95% CI：1.2-3.0）、酗酒（OR：1.3，95% CI：1.0-1.8）和吸烟（OR：1.5，95% CI：1.1-2.0）。 结论: 在整个白俄罗斯的结核病患者中MDR-TB十分常见。所确定的众多MDR-TB的风险因素以及MDR-TB和艾滋病毒感染同时流行，不仅亟需加强结核病和艾滋病控制计划之间的合作，同时也迫切需要实施创新措施，加快结核病抗性的检测，改善治疗依从性。Резюме Цель: Оценить проблему туберкулеза со множественной лекарственной устойчивостью (МЛУ-ТБ) на всей территории Беларуси и исследовать связанные с ней факторы риска. Методы: В ходе общенационального обследования в 2010-2011 годах был проведен скрининг 1420 пациентов, больных туберкулезом (ТБ), и было выявлено 934 новых случаев заболевания ТБ и 410 случая с проведенным ранее лечением, которые были признаны отвечающими критериям включения. Изоляты Mycobacterium tuberculosis, полученные от каждого удовлетворяющего критериям пациента, были протестированы на чувствительность к противотуберкулезным лекарственным средствам. Социоповеденческая информация была собрана в ходе собеседования на основе структурированного вопросника. Результаты: МЛУ-ТБ был обнаружен у 32,3% новых и 75,6% ранее лечившихся пациентов, а у 11,9% из 612 пациентов был выявлен МЛУ-ТБ с широкой лекарственной устойчивостью (ШЛУ-ТБ). История предыдущего лечения ТБ является самым важным независимым фактором риска для МЛУ-ТБ (отношение шансов, ОШ: 6,1, 95% доверительный интервал (ДИ) – 4,8-7,7). К числу других независимых факторов риска относились: инфицирование вирусом иммунодефицита человека (ВИЧ) (ОШ: 2,2; 95% ДИ: 1,4-3,5), возраст35 лет (ОШ: 1,4; 95% ДИ: 1,0-1,8), предыдущее пребывание в местах лишения свободы (ОШ: 1,5; 95% ДИ: 1,1-2,0), инвалидность, обуславливающая невозможность трудоустройства (ОШ: 1,9; 95% ДИ: 1,2-3,0), злоупотребление алкоголем (ОШ: 1,3; 95% ДИ: 1,0-1,8) и курение (ОШ: 1,5; 95% ДИ: 1,1-2,0). Вывод: МЛУ-ТБ широко распространен среди больных туберкулезом на всей территории Беларуси. Были выявлены многочисленные факторы риска МЛУ-ТБ, а сочетание эпидемии МЛУ-ТБ и ВИЧ-инфекции требует не только большей скоординированности программ борьбы с ТБ и ВИЧ, но и реализации новаторских мер для более быстрого выявления резистентности ТБ и более тщательного соблюдения назначенного лечения.

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

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

Prevalence of antibody and risk factors to hepatitis E virus (HEV) infection were determined in a cross-sectional study of 2 group-matched populations: swine farmers (n=264) and persons without occupational exposure to swine (n=255) in Moldova, a country without reported cases of hepatitis E. The prevalence of HEV infection was higher among swine farmers than among the comparison group (51.1% vs. 24.7%; prevalence ratio, 2.07; 95% confidence interval [CI], 1.62-2.64). In multivariate analysis, HEV infection was associated with an occupational history of cleaning barns or assisting sows at birth (odds ratio [OR], 2.46; 95% CI, 1.52-4.01), years of occupational exposure (OR, 1.04 per year; 95% CI, 1.01-1.07), and a history of drinking raw milk (OR, 1.61; 95% CI, 1.08-2.40). HEV infection was not associated with civilian travel abroad or having piped water in the household. The increased prevalence of HEV infection among persons with occupational exposure to swine suggests animal-to-human transmission of this infection.