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Journal of Tropical Pediatrics. 2007 Jun; 53(3):147-149.Tuberculosis (TB) kills about 2 million adults and around 100 000 children every year. One-third of the world's population are currently infected with Mycobacterium tuberculosis and many have active disease. In Europe TB emerged as a major disease in the latter part of the 14th century. The industrial revolution saw rapid growth of urban centres where overcrowding with poor living conditions provided ideal circumstances for the spread of the disease. Great impact was made by streptomycin and isoniazid, so that by the 1970s TB was no longer being considered a problem in the developed world. But beginning in the 1980s the number of new cases of TB in USA and across Europe rose sharply. The pattern was repeated in many countries and worldwide throughout the 1990s and into the new millennium. The incidence of TB climbed to over 9 million cases every year. In 1993 the World Health Organization (WHO) declared TB as a global emergency. During the 1990s multidrug resistant tuberculosis (MDR-TB), defined as resistance to at least isoniazid and rifampicin, emerged as a threat to TB control. MDR-TB requires the use of second line drugs that are less effective, more toxic and costlier. In a global survey of 17 690 TB isolates during 2000-04, 20% were MDR and 2% were extremely drug resistant (XDR). XDR-TB is defined as MDR plus resistance to any fluoroquinolones and at least one of three injectable second line drugs kanamycin and amikacin, or capreomycin or both. Currently one in ten new infections is resistant to at least one antituberculosis drug. (excerpt)
Bulletin of the World Health Organization. 2007 May; 85(5):325-420.In 1991, the 44th World Health Assembly set two key targets for global tuberculosis (TB) control to be reached by 2000: 70% case detection of acid-fast bacilli smear-positive TB patients under the DOTS strategy recommended by WHO and 85% treatment success of those detected. This paper describes how TB control was scaled up to achieve these targets; it also considers the barriers encountered in reaching the targets, with a particular focus on how HIV infection affects TB control. Strong TB control will be facilitated by scaling-up WHO-recommended TB/HIV collaborative activities and by improving coordination between HIV and TB control programmes; in particular, to ensure control of drug-resistant TB. Required activities include more HIV counselling and testing of TB patients, greater use and acceptance of isoniazid as a preventive treatment in HIV-infected individuals, screening for active TB in HIV-care settings, and provision of universal access to antiretroviral treatment for all HIV-infected individuals eligible for such treatment. Integration of TB and HIV services in all facilities (i.e. in HIV-care settings and in TB clinics), especially at the periphery, is needed to effectively treat those infected with both diseases, to prolong their survival and to maximize limited human resources. Global TB targets can be met, particularly if there is renewed attention to TB/HIV collaborative activities combined with tremendous political commitment and will. (author's)
The Global Drug Facility: a unique, holistic and pioneering approach to drug procurement and management.
Bulletin of the World Health Organization. 2007 May; 85(5):325-420.In January 2006, the Stop TB Partnership launched the Global Plan to Stop TB 2006-2015, which describes the actions and resources needed to reduce tuberculosis (TB) incidence, prevalence and deaths. A fundamental aim of the Global Plan is to expand equitable access to affordable high-quality anti-tuberculous drugs and diagnostics. A principal tool developed by the Stop TB Partnership to achieve this is the Global Drug Facility (GDF). This paper demonstrates the GDF's unique, holistic and pioneering approach to drug procurement and management by analysing its key achievements. One of these has been to provide 9 million patient-treatments to 78 countries in its first 6 years of operation. The GDF recognized that the incentives provided by free or affordable anti-tuberculosis drugs are not sufficient to induce governments to improve their programmes' standards and coverage, nor does the provision of free or affordable drugs guarantee that there is broad access to, and use of, drug treatment in cases where procurement systems are weak, regulatory hurdles exist or there are unreliable distribution and storage systems. Thus, the paper also illustrates how the GDF has contributed towards making sustained improvements in the capacity of countries worldwide to properly manage their anti-TB drugs. This paper also assesses some of the limitations, shortcomings and risks associated with the model. The paper concludes by examining the GDF's key plans and strategies for the future, and the challenges associated with implementation. (author's)
Bulletin of the World Health Organization. 2007 May; 85(5):325-420.Laboratories and laboratory networks are a fundamental component of tuberculosis (TB) control, providing testing for diagnosis, surveillance and treatment monitoring at every level of the health-care system. New initiatives and resources to strengthen laboratory capacity and implement rapid and new diagnostic tests for TB will require recognition that laboratories are systems that require quality standards, appropriate human resources, and attention to safety in addition to supplies and equipment. To prepare the laboratory networks for new diagnostics and expanded capacity, we need to focus efforts on strengthening quality management systems (QMS) through additional resources for external quality assessment programmes for microscopy, culture, drug susceptibility testing (DST) and molecular diagnostics. QMS should also promote development of accreditation programmes to ensure adherence to standards to improve both the quality and credibility of the laboratory system within TB programmes. Corresponding attention must be given to addressing human resources at every level of the laboratory, with special consideration being given to new programmes for laboratory management and leadership skills. Strengthening laboratory networks will also involve setting up partnerships between TB programmes and those seeking to control other diseases in order to pool resources and to promote advocacy for quality standards, to develop strategies to integrate laboratories' functions and to extend control programme activities to the private sector. Improving the laboratory system will assure that increased resources, in the form of supplies, equipment and facilities, will be invested in networks that are capable of providing effective testing to meet the goals of the Global Plan to Stop TB. (author's)