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The World Health Organization has developed target product profiles containing minimum and optimum targets for key characteristics for tests for tuberculosis treatment monitoring and optimization. Tuberculosis treatment optimization refers to initiating or switching to an effective tuberculosis treatment regimen that results in a high likelihood of a good treatment outcome. The target product profiles also cover tests of cure conducted at the end of treatment. The development of the target product profiles was informed by a stakeholder survey, a cost-effectiveness analysis and a patient-care pathway analysis. Additional feedback from stakeholders was obtained by means of a Delphi-like process, a technical consultation and a call for public comment on a draft document. A scientific development group agreed on the final targets in a consensus meeting. For characteristics rated of highest importance, the document lists: (i) high diagnostic accuracy (sensitivity and specificity); (ii) time to result of optimally [less than or equal to] 2 hours and no more than 1 day; (iii) required sample type to be minimally invasive, easily obtainable, such as urine, breath, or capillary blood, or a respiratory sample that goes beyond sputum; (iv) ideally the test could be placed at a peripheral-level health facility without a laboratory; and (v) the test should be affordable to low- and middle-income countries, and allow wide and equitable access and scale-up. Use of these target product profiles should facilitate the development of new tuberculosis treatment monitoring and optimization tests that are accurate and accessible for all people being treated for tuberculosis. L'Organisation mondiale de la sante a elabore des profils de produits cibles contenant des cibles minimales et optimales pour les caracteristiques principales des essais destines au suivi et a l'optimisation du traitement de la tuberculose. L'optimisation du traitement de la tuberculose fait reference a l'instauration d'un regime de traitement efficace de la tuberculose ou a l'adoption d'un tel regime, avec une probabilite elevee d'obtenir de bons resultats therapeutiques. Les profils de produits cibles couvrent egalement les essais de guerison effectues a l'issue du traitement. Les profils de produits cibles ont ete elabores sur la base d'un sondage aupres des parties prenantes, d'une analyse cout-efficacite et d'une analyse du parcours de soins du patient. Des retours supplementaires des parties prenantes ont ete obtenus au moyen d'un processus cree selon la methode Delphi, d'une consultation technique et d'un appel a commentaires publics sur un projet de document. Un groupe d'elaboration scientifique s'est mis d'accord sur les objectifs finaux lors d'une reunion de concertation. En ce qui concerne les caracteristiques jugees les plus importantes, le document enumere ce qui suit: (i) une grande precision diagnostique (sensibilite et specificite); (ii) un delai ideal d'obtention des resultats [less than or equal to] 2 heures et au maximum de 1 jour; (iii) le type d'echantillon requis doit etre peu invasif et facile a obtenir, comme l'urine, l'haleine ou le sang capillaire, ou bien un echantillon respiratoire au-dela des expectorations; (iv) idealement, l'essai pourrait avoir lieu dans un etablissement de sante peripherique sans laboratoire ; et (v) l'essai devrait etre abordable pour les pays a revenu faible et intermediaire et permettre un acces large et equitable ainsi qu'une mise a l'echelle. L'utilisation de ces profils de produits cibles devrait faciliter la mise au point de nouveaux essais de surveillance et d'optimisation du traitement de la tuberculose qui soient precis et accessibles a toutes les personnes suivant un traitement pour la tuberculose. La Organizacion Mundial de la Salud ha elaborado perfiles de productos objetivo que contienen objetivos minimos y optimos para las caracteristicas principales de las pruebas de seguimiento y optimizacion del tratamiento de la tuberculosis. La optimizacion del tratamiento de la tuberculosis consiste en iniciar o cambiar a un regimen eficaz de tratamiento de la tuberculosis que ofrezca una alta probabilidad de un buen resultado terapeutico. Los perfiles de productos objetivo tambien abarcan las pruebas de curacion realizadas al final del tratamiento. La elaboracion de los perfiles de los productos objetivo se baso en una encuesta a las partes interesadas, un analisis de rentabilidad y un analisis de la via de atencion al paciente. Se obtuvo informacion adicional de las partes interesadas mediante un proceso tipo Delphi, una consulta tecnica y una convocatoria de comentarios publicos sobre un borrador del documento. Un grupo de desarrollo cientifico acordo los objetivos finales en una reunion de consenso. Para las caracteristicas clasificadas de mayor importancia, el documento enumera: (i) alta precision diagnostica (sensibilidad y especificidad); (ii) tiempo hasta el resultado de optimamente [less than or equal to] 2 horas y no mas de 1 dia; (iii) el tipo de muestra requerida debe ser minimamente invasiva, facil de obtener, como orina, aliento o sangre capilar, o una muestra respiratoria que vaya mas alla del esputo; (iv) idealmente la prueba podria realizarse en un centro sanitario periferico sin laboratorio; y (v) la prueba debe ser asequible para los paises de ingresos bajos y medios y permitir un acceso amplio y equitativo y su expansion. El uso de estos perfiles de producto objetivo deberia facilitar el desarrollo de pruebas nuevas de seguimiento y optimizacion del tratamiento de la tuberculosis que sean precisas y accesibles para todas las personas que reciben tratamiento antituberculoso. [phrase omitted], Introduction Tuberculosis continues to be a major cause of morbidity and mortality globally, despite being curable and preventable. In 2021, an estimated 10.6 million people had tuberculosis disease and 1.6 [...]

BackgroundTreatment of multidrug-resistant tuberculosis requires long-term therapy with a combination of multiple second-line drugs. These drugs are associated with numerous adverse events that can cause severe morbidity, such as deafness, and in some instances can lead to death. Our aim was to estimate the absolute and relative frequency of adverse events associated with different tuberculosis drugs to provide useful information for clinicians and tuberculosis programmes in selecting optimal treatment regimens.MethodsWe did a meta-analysis using individual-level patient data that were obtained from studies that reported adverse events that resulted in permanent discontinuation of anti-tuberculosis medications. We used a database created for our previous meta-analysis of multidrug-resistant tuberculosis treatment and outcomes, for which we did a systematic review of literature published between Jan 1, 2009, and Aug 31, 2015 (updated April 15, 2016), and requested individual patient-level information from authors. We also considered for this analysis studies contributing patient-level data in response to a public call made by WHO in 2018. Meta-analysis for proportions and arm-based network meta-analysis were done to estimate the incidence of adverse events for each tuberculosis drug.Findings58 studies were identified, including 50 studies from the updated individual patient data meta-analysis for multidrug-resistant tuberculosis treatment. 35 of these studies, with 9178 patients, were included in our analysis. Using meta-analysis of proportions, drugs with low risks of adverse event occurrence leading to permanent discontinuation included levofloxacin (1·3% [95% CI 0·3-5·0]), moxifloxacin (2·9% [1·6-5·0]), bedaquiline (1·7% [0·7-4·2]), and clofazimine (1·6% [0·5-5·3]). Relatively high incidence of adverse events leading to permanent discontinuation was seen with three second-line injectable drugs (amikacin: 10·2% [6·3-16·0]; kanamycin: 7·5% [4·6-11·9]; capreomycin: 8·2% [6·3-10·7]), aminosalicylic acid (11·6% [7·1-18·3]), and linezolid (14·1% [9·9-19·6]). Risk of bias in selection of studies was judged to be low because there were no important differences between included and excluded studies. Variability between studies was significant for most outcomes analysed.InterpretationFluoroquinolones, clofazimine, and bedaquiline had the lowest incidence of adverse events leading to permanent drug discontinuation, whereas second-line injectable drugs, aminosalicylic acid, and linezolid had the highest incidence. These results suggest that close monitoring of adverse events is important for patients being treated for multidrug-resistant tuberculosis. Our results also underscore the urgent need for safer and better-tolerated drugs to reduce morbidity from treatment itself for patients with multidrug-resistant tuberculosis.FundingCanadian Institutes of Health Research, Centers for Disease Control and Prevention (USA), American Thoracic Society, European Respiratory Society, and Infectious Diseases Society of America.

BackgroundIncomplete adherence to tuberculosis (TB) treatment increases the risk of delayed culture conversion with continued transmission in the community, as well as treatment failure, relapse, and development or amplification of drug resistance. We conducted a systematic review and meta-analysis of adherence interventions, including directly observed therapy (DOT), to determine which approaches lead to improved TB treatment outcomes.Methods and findingsWe systematically reviewed Medline as well as the references of published review articles for relevant studies of adherence to multidrug treatment of both drug-susceptible and drug-resistant TB through February 3, 2018. We included randomized controlled trials (RCTs) as well as prospective and retrospective cohort studies (CSs) with an internal or external control group that evaluated any adherence intervention and conducted a meta-analysis of their impact on TB treatment outcomes. Our search identified 7,729 articles, of which 129 met the inclusion criteria for quantitative analysis. Seven adherence categories were identified, including DOT offered by different providers and at various locations, reminders and tracers, incentives and enablers, patient education, digital technologies (short message services [SMSs] via mobile phones and video-observed therapy [VOT]), staff education, and combinations of these interventions. When compared with DOT alone, self-administered therapy (SAT) was associated with lower rates of treatment success (CS: risk ratio [RR] 0.81, 95% CI 0.73-0.89; RCT: RR 0.94, 95% CI 0.89-0.98), adherence (CS: RR 0.83, 95% CI 0.75-0.93), and sputum smear conversion (RCT: RR 0.92, 95% CI 0.87-0.98) as well as higher rates of development of drug resistance (CS: RR 4.19, 95% CI 2.34-7.49). When compared to DOT provided by healthcare providers, DOT provided by family members was associated with a lower rate of adherence (CS: RR 0.86, 95% CI 0.79-0.94). DOT delivery in the community versus at the clinic was associated with a higher rate of treatment success (CS: RR 1.08, 95% CI 1.01-1.15) and sputum conversion at the end of two months (CS: RR 1.05, 95% CI 1.02-1.08) as well as lower rates of treatment failure (CS: RR 0.56, 95% CI 0.33-0.95) and loss to follow-up (CS: RR 0.63, 95% CI 0.40-0.98). Medication monitors improved adherence and treatment success and VOT was comparable with DOT. SMS reminders led to a higher treatment completion rate in one RCT and were associated with higher rates of cure and sputum conversion when used in combination with medication monitors. TB treatment outcomes improved when patient education, healthcare provider education, incentives and enablers, psychological interventions, reminders and tracers, or mobile digital technologies were employed. Our findings are limited by the heterogeneity of the included studies and lack of standardized research methodology on adherence interventions.ConclusionTB treatment outcomes are improved with the use of adherence interventions, such as patient education and counseling, incentives and enablers, psychological interventions, reminders and tracers, and digital health technologies. Trained healthcare providers as well as community delivery provides patient-centered DOT options that both enhance adherence and improve treatment outcomes as compared to unsupervised, SAT alone.

BackgroundIsoniazid-resistant, rifampicin-susceptible (INH-R) tuberculosis is the most common form of drug resistance, and is associated with failure, relapse, and acquired rifampicin resistance if treated with first-line anti-tuberculosis drugs. The aim of the study was to compare success, mortality, and acquired rifampicin resistance in patients with INH-R pulmonary tuberculosis given different durations of rifampicin, ethambutol, and pyrazinamide (REZ); a fluoroquinolone plus 6 months or more of REZ; and streptomycin plus a core regimen of REZ.MethodsStudies with regimens and outcomes known for individual patients with INH-R tuberculosis were eligible, irrespective of the number of patients if randomised trials, or with at least 20 participants if a cohort study. Studies were identified from two relevant systematic reviews, an updated search of one of the systematic reviews (for papers published between April 1, 2015, and Feb 10, 2016), and personal communications. Individual patient data were obtained from authors of eligible studies. The individual patient data meta-analysis was performed with propensity score matched logistic regression to estimate adjusted odds ratios (aOR) and risk differences of treatment success (cure or treatment completion), death during treatment, and acquired rifampicin resistance. Outcomes were measured across different treatment regimens to assess the effects of: different durations of REZ (≤6 months vs >6 months); addition of a fluoroquinolone to REZ (fluoroquinolone plus 6 months or more of REZ vs 6 months or more of REZ); and addition of streptomycin to REZ (streptomycin plus 6 months of rifampicin and ethambutol and 1-3 months of pyrazinamide vs 6 months or more of REZ). The overall quality of the evidence was assessed using GRADE methodology.FindingsIndividual patient data were requested for 57 cohort studies and 17 randomised trials including 8089 patients with INH-R tuberculosis. We received 33 datasets with 6424 patients, of which 3923 patients in 23 studies received regimens related to the study objectives. Compared with a daily regimen of 6 months of (H)REZ (REZ with or without isoniazid), extending the duration to 8-9 months had similar outcomes; as such, 6 months or more of (H)REZ was used for subsequent comparisons. Addition of a fluoroquinolone to 6 months or more of (H)REZ was associated with significantly greater treatment success (aOR 2·8, 95% CI 1·1-7·3), but no significant effect on mortality (aOR 0·7, 0·4-1·1) or acquired rifampicin resistance (aOR 0·1, 0·0-1·2). Compared with 6 months or more of (H)REZ, the standardised retreatment regimen (2 months of streptomycin, 3 months of pyrazinamide, and 8 months of isoniazid, rifampicin, and ethambutol) was associated with significantly worse treatment success (aOR 0·4, 0·2-0·7). The quality of the evidence was very low for all outcomes and treatment regimens assessed, owing to the observational nature of most of the data, the diverse settings, and the imprecision of estimates.InterpretationIn patients with INH-R tuberculosis, compared with treatment with at least 6 months of daily REZ, addition of a fluoroquinolone was associated with better treatment success, whereas addition of streptomycin was associated with less treatment success; however, the quality of the evidence was very low. These results support the conduct of randomised trials to identify the optimum regimen for this important and common form of drug-resistant tuberculosis.FundingWorld Health Organization and Canadian Institutes of Health Research.

Digital technologies are increasingly harnessed to support treatment of persons with tuberculosis (TB). Since in-person directly observed treatment (DOT) can be resource intensive and challenging to implement, these technologies may have the potential to improve adherence and clinical outcomes. We reviewed the effect of these technologies on TB treatment adherence and patient outcomes.We searched several bibliographical databases for studies reporting the effect of digital interventions, including short message service (SMS), video-observed therapy (VOT) and medication monitors (MMs), to support treatment for active TB. Only studies with a control group and which reported effect estimates were included.Four trials showed no statistically significant effect on treatment completion when SMS was added to standard care. Two observational studies of VOT reported comparable treatment completion rates when compared with in-person DOT. MMs increased the probability of cure (RR 2.3, 95% CI 1.6-3.4) in one observational study, and one trial reported a statistically significant reduction in missed treatment doses relative to standard care (adjusted means ratio 0.58, 95% CI 0.42-0.79).Evidence of the effect of digital technologies to improve TB care remains limited. More studies of better quality are needed to determine how such technologies can enhance programme performance.

In 2014, the World Health Organization (WHO) developed the End TB Strategy in response to a World Health Assembly Resolution requesting Member States to end the worldwide epidemic of tuberculosis (TB) by 2035. For the strategy's objectives to be realised, the next 20 years will need novel solutions to address the challenges posed by TB to health professionals, and to affected people and communities. Information and communication technology presents opportunities for innovative approaches to support TB efforts in patient care, surveillance, programme management and electronic learning. The effective application of digital health products at a large scale and their continued development need the engagement of TB patients and their caregivers, innovators, funders, policy-makers, advocacy groups, and affected communities.In April 2015, WHO established its Global Task Force on Digital Health for TB to advocate and support the development of digital health innovations in global efforts to improve TB care and prevention. We outline the group's approach to stewarding this process in alignment with the three pillars of the End TB Strategy. The supplementary material of this article includes target product profiles, as developed by early 2016, defining nine priority digital health concepts and products that are strategically positioned to enhance TB action at the country level.

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.

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.

A meta-analysis for response to treatment was undertaken using individual data of multidrug-resistant tuberculosis (MDR-TB) (resistance to isoniazid and rifampicin) patients from 26 centres. The analysis assessed the impact of additional resistance to fluoroquinolones and/or second-line injectable drugs on treatment outcome. Compared with treatment failure, relapse and death, treatment success was higher in MDR-TB patients infected with strains without additional resistance (n=4763; 64%, 95% CI 57-72%) or with resistance to second-line injectable drugs only (n=1130; 56%, 95% CI 45-66%), than in those having resistance to fluoroquinolones alone (n=426; 48%, 95% CI 36-60%) or to fluoroquinolones plus second-line injectable drugs (extensively drug resistant (XDR)-TB) (n=405; 40%, 95% CI 27-53%). In XDR-TB patients, treatment success was highest if at least six drugs were used in the intensive phase (adjusted OR 4.9, 95% CI 1.4-16.6; reference fewer than three drugs) and four in the continuation phase (OR 6.1, 95% CI 1.4-26.3). The odds of success in XDR-TB patients was maximised when the intensive phase reached 6.6-9.0 months duration and the total duration of treatment 20.1-25.0 months. In XDR-TB patients, regimens containing more drugs than those recommended in MDR-TB but given for a similar duration were associated with the highest odds of success. All data were from observational studies and methodologies varied between centres, therefore, the bias may be substantial. Better quality evidence is needed to optimise regimens.

Author(s): Grania Brigden 1,*, Nguyen Viet Nhung 2, Alena Skrahina 3, Norbert Ndjeka 4, Dennis Falzon 5, Matteo Zignol 5 Summary points The World Health Organization (WHO) plays an important [...]

Background An estimated 32,000 children develop multidrug-resistant tuberculosis (MDR-TB; Mycobacterium tuberculosis resistant to isoniazid and rifampin) each year. Little is known about the optimal treatment for these children. Methods and findings To inform the pediatric aspects of the revised World Health Organization (WHO) MDR-TB treatment guidelines, we performed a systematic review and individual patient data (IPD) meta-analysis, describing treatment outcomes in children treated for MDR-TB. To identify eligible reports we searched PubMed, LILACS, Embase, The Cochrane Library, PsychINFO, and BioMedCentral databases through 1 October 2014. To identify unpublished data, we reviewed conference abstracts, contacted experts in the field, and requested data through other routes, including at national and international conferences and through organizations working in pediatric MDR-TB. A cohort was eligible for inclusion if it included a minimum of three children (aged Conclusions This study suggests that children respond favorably to MDR-TB treatment. The low success rate in children infected with HIV who did not receive ART during their MDR-TB treatment highlights the need for ART in these children. Our findings of individual drug effects on treatment outcome should be further evaluated., Author(s): Elizabeth P. Harausz 1,2,*, Anthony J. Garcia-Prats 1, Stephanie Law 3, H. Simon Schaaf 1, Tamara Kredo 4, James A. Seddon 5, Dick Menzies 3, Anna Turkova 6, Jay [...]

Objective To present a global update of drug-resistant tuberculosis (TB) and explore trends in 1994-2010. Methods Data on drug resistance among new and previously treated TB patients, as reported by countries to the World Health Organization, were analysed. Such data are collected through surveys of a representative sample of TB patients or surveillance systems based on routine drug susceptibility testing. Associations between multidrug-resistant TB (MDR-TB) and human immunodeficiency virus (HIV) infection and sex were explored through logistic regression. Findings In 2007-2010, 80 countries and 8 territories reported surveillance data. MDR-TB among new and previously treated cases was highest in the Russian Federation (Murmansk oblast, 28.9%) and the Republic of Moldova (65.1%), respectively. In three former Soviet Union countries and South Africa, more than 10% of the cases of MDR-TB were extensively drug-resistant. Globally, in 1994 to 2010 multidrug resistance was observed in 3.4% (95% confidence interval, CI: 1.9-5.0) of all new TB cases and in 19.8% (95% CI: 14.4-25.1) of previously treated TB cases. No overall associations between MDR-TB and HIV infection (odds ratio, OR: 1.4; 95% CI: 0.7-3.0) or sex (OR: 1.1; 95% CI: 0.8-1.4) were found. Between 1994 and 2010, MDR-TB rates in the general population increased in Botswana, Peru, the Republic of Korea and declined in Estonia, Latvia and the United States of America. Conclusion The highest global rates of MDR-TB ever reported were documented in 2009 and 2010. Trends in MDR-TB are still unclear in most settings. Better surveillance or survey data are required, especially from Africa and India. [TEXT NOT REPRODUCIBLE IN ASCII.] Surveillance de la resistance aux medicaments antituberculeux dans le monde: une analyse actualisee, 2007-2010 Objectif Presenter une mise a jour globale de la tuberculose (TB) pharmacoresistante et explorer les tendances de 1994 a 2010. Methodes Les donnees relatives a la resistance aux medicaments des nouveaux patients de TB et de ceux traites anterieurement, telles que rapportees par les pays a l'Organisation mondiale de la Sante, ont ete analysees. Ces donnees sont recueillies par des enquetes representatives aupres des patients ou des systemes de surveillance bases sur des tests systematiques de sensibilite. Les associations entre la tuberculose ultraresistante (TB-UR), le virus de l'immunodeficience humaine (VIH) et le sexe ont ete explorees par regression logistique. Resultats En 2007-2010, 80 pays et 8 territoires ont fourni des donnees de surveillance. Parmi les cas nouveaux et traites a nterieurement, la TB-UR etait la plus elevee dans la Federation de Russie (oblast de Mourmansk, 28,9%) et la Republique de Moldavie (65,1%), respectivement. Dans trois pays de l'ex-Union sovietique et en Afrique du Sud, plus de 10% des cas deTB-UR etaient ultra-resistants. Globalement, en 1994-2010, la multiresistance aux medicaments a ete observee chez 3,4% (intervalle de confiance 95%, IC: 1,9 a 5,0) de tous les nouveaux cas de TB et 19,8% (IC 95%: 14,4 a 25,1) des cas de TB traites anterieurement. Aucune association generale entre la TB-UR et l'infection au VIH (rapports de cotes, OR: 1,4, IC 95%: 0,7 a 3,0) ou le sexe (OR: 1,1, IC 95%: 0,8 a 1,4) n'a ete trouvee. Entre 1994 et 2010, les taux de TB-UR dans la population generale ont augmente au Botswana, en Republique de Coree et au Perou et diminue en Estonie, Lettonie et aux Etats-Unis d'Amerique. Conclusion Les taux mondiaux les plus eleves jamais signales de TBUR ont ete documentes en 2009 et 2010. Les tendances de la TB-UR sont encore peu claires dans la plupart des parametres. De meilleures donnees de surveillance ou d'enquete sont necessaires, surtout en provenance d'Afrique et d'Inde. [TEXT NOT REPRODUCIBLE IN ASCII.] Vigilancia de la resistencia a los medicamentos contra la tuberculosis en todo el mundo: analisis actualizado, 2007-2010 Objetivo Presentar una actualizacion global de la situacion de la tuberculosis (TB) resistente a los medicamentos y analizar las tendencias entre 1994 y 2010. Metodo Se analizaron los datos sobre la resistencia a los medicamentos entre los pacientes recien diagnosticados con TB y los que habian recibido tratamiento con anterioridad, en base a los informes que los paises remitieron a la Organizacion Mundial de la Salud. Dichos datos se recopilaron a traves de encuestas representativas a pacientes o mediante sistemas de vigilancia basados en pruebas rutinarias de sensibilidad a los medicamentos. A traves de una regresion logistica se analizaron las asociaciones existentes entre la tuberculosis multirresistente (TB-MDR), el virus de la inmunodeficiencia humana y el sexo. Resultados Entre 2007 y 2010, 80 paises y 8 territorios facilitaron sus datos de vigilancia. Los niveles mas elevados de TB-MDR entre los casos recien diagnosticados y previamente tratados se registraron en la Federacion de Rusia (Murmansk oblast, 28,9%) y la Republica de Moldova (65,1%), respectivamente. En tres de los paises de la antigua Union Sovietica y en Sudafrica, mas de un 10% de los casos de TB-MDR fueron extremadamente resistentes. Entre 1994 y 2010 se observo en todo el mundo una multirresistencia de un 3,4% (95% de intervalo de confianza, IC: 1,9-5,0) en todos los casos nuevos de TB y de un 19,8% (95% IC: 14,4-25,1) en los casos de TB previamente tratados. No se observaron asociaciones globales entre la TB-MDR y la infeccion por el VIH (cociente de posibilidades, OR: 1,4; IC del 95%: 0,7-3,0) ni con el sexo (OR: 1,1; IC del 95%: 0,8-1,4). Entre los anos 1994 y 2010, las tasas de TB-MDR en la poblacion general aumentaron en Botswana, la Republica de Corea y Peru y descendieron en Estonia, Letonia y Estados Unidos de America. Conclusion En 2009 y 2010 se registraron las tasas globales de MDR-TB mas altas de la historia. Las tendencias de TB-MDR siguen sin quedar claras en la mayoria de los entornos. Es necesaria una mejor vigilancia o mas datos procedentes de encuestas, especialmente en los casos de africa e India., Introduction Surveillance of resistance to drugs against tuberculosis (TB) is a cornerstone of any TB control programme. Surveillance data on drug resistance are needed to track the effectiveness of TB [...]