1. Global TB Programme, World Health Organization, Geneva, Switzerland 2. U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, U.S.A. 3. Rotterdam Public Health Service, Rotterdam, the Netherlands 4. National Tuberculosis Programme, Islamabad, Pakistan 5. National Tuberculosis Programme, Hanoi, Viet Nam 6. Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France 7. European Centre for Disease Prevention and Control, Stockholm, Sweden 8. Global Alliance for TB drug development, New York, NY, USA 9. US Agency for International Development, Washington DC, USA 10. Public Health England, Colindale, UK 11. University College London, London, UK

SETTING:All 11 tuberculosis (TB) diagnostic and treatment units in Kyankwanzi and Kiboga Districts in Uganda. OBJECTIVES:To determine the frequency of, factors associated with and barriers related to incomplete anti-tuberculosis treatment sputum monitoring. DESIGN:Data were abstracted from anti-tuberculosis treatment and laboratory registers of sputum smear-positive patients who started treatment between January 2009 and December 2011 in the study districts. Patients missing documentation for any smear results at 2 or 3, 5, and 6 or 8 months were classified as having incomplete monitoring. Health providers and patients were interviewed about barriers to sputum monitoring. RESULTS:Overall, 272 (55%) of 492 patients had incomplete monitoring: 16% (78/492) at 2 or 3 months, 39% (181/465) at 5 months and 28% (119/428) at 6 or 8 months of treatment. More sputum results were recorded in laboratory than in TB treatment registers. Incomplete monitoring was significantly associated with being male, living in Kyankwanzi District and not receiving directly observed treatment. Patients' inability to produce sputum, long laboratory waiting times, and insufficient patient and provider education were primary reasons for incomplete monitoring. CONCLUSION:Over half of patients missed at least one smear result during treatment, which has implications for treatment monitoring and treatment outcomes in Uganda.

BACKGROUND Although an estimated three million tuberculosis (TB) cases worldwide are missed by national TB programs annually, the level of under-reporting of diagnosed cases in high TB burden settings is largely unknown. OBJECTIVE To quantify and describe under-reporting of sputum smear-positive TB cases in Kenya. DESIGN A national-level retrospective TB inventory study was conducted. All sputum smear-positive TB cases diagnosed by public or private laboratories during 1 April-30 June 2013 were extracted from laboratory registers in 73 randomly sampled subcounties and matched to TB cases in the national TB surveillance system (TIBU). Bivariate and multivariate analyses were conducted. RESULTS In the subcounties sampled, 715 of 3409 smear-positive TB cases in laboratory registers were not found in TIBU. The estimated level of under-reporting of smear-positive TB cases in Kenya was 20.7% (95%CI 18.4-23.0). Under-reporting was greatest in subcounties with a high TB burden. Unreported cases were more likely to be patients aged ⩾55 years, have scanty smear results, and be diagnosed at large facilities, private facilities, and facilities in high TB burden regions. CONCLUSION In Kenya, one fifth of smear-positive TB cases diagnosed during the study period went unreported, suggesting that the true TB burden is higher than reported. TB surveillance in Kenya should be strengthened to ensure all diagnosed TB cases are reported.

BACKGROUND: The burden of tuberculosis (TB) in the estimated 370 million indigenous peoples worldwide is unknown.OBJECTIVE: To conduct a literature review to summarize the TB burden in indigenous peoples, identify gaps in current knowledge, and provide the foundation for a research agenda prioritizing indigenous health within TB control.METHODS: A systematic literature review identified articles published between January 1990 and November 2011 quantifying TB disease burden in indigenous populations worldwide.RESULTS: Among the 91 articles from 19 countries included in the review, only 56 were from outside Australia, Canada, New Zealand and the United States. The majority of the studies showed higher TB rates among indigenous groups than non-indigenous groups. Studies from the Amazon generally reported the highest TB prevalence and incidence, but select populations from South-East Asia and Africa were found to have similarly high rates of TB. In North America, the Inuit had the highest reported TB incidence (156/100000), whereas the Metis of Canada and American Indians/Alaska Natives experienced rates of <10/100000. New Zealand's Maori and Pacific Islanders had higher TB incidence rates than Australian Aborigines, but all were at greater risk of developing TB than non-indigenous groups.CONCLUSION: Where data exist, indigenous peoples were generally found to have higher rates of TB disease than non-indigenous peoples; however, this burden varied greatly. The paucity of published information on TB burden among indigenous peoples highlights the need to implement and improve TB surveillance to better measure and understand global disparities in TB rates.

Objectives: Diabetes is a risk factor for active tuberculosis (TB). Data are limited regarding the association between diabetes and TB drug resistance and treatment outcomes. We examined characteristics of TB patients with and without diabetes in a Peruvian cohort at high risk for drug-resistant TB. Among TB patients with diabetes (TB-DM), we studied the association between diabetes clinical/management characteristics and TB drug resistance and treatment outcomes.Methods: During 2005-2008, adults with suspected TB with respiratory symptoms in Lima, Peru, who received rapid drug susceptibility testing (DST), were prospectively enrolled and followed during treatment. Bivariate and Kaplan-Meier analyses were used to examine the relationships of diabetes characteristics with drug-resistant TB and TB outcomes.Results: Of 1671 adult TB patients enrolled, 186 (11.1%) had diabetes. TB-DM patients were significantly more likely than TB patients without diabetes to be older, have had no previous TB treatment, and to have a body mass index (BMI) > 18.5 kg/m(2) (p < 0.05). In patients without and with previous TB treatment, the prevalence of multidrug-resistant TB was 23% and 26%, respectively, among patients without diabetes, and 12% and 28%, respectively, among TB-DM patients. Among 149 TB-DM patients with DST results, 104 (69.8%) had drug-susceptible TB and 45 (30.2%) had drug-resistant TB, of whom 29 had multidrug-resistant TB. There was no association between diabetes characteristics and drug-resistant TB. Of 136 TB-DM patients with outcome information, 107 (78.7%) had a favorable TB outcome; active diabetes management was associated with a favorable outcome.Conclusions: Diabetes was common in a cohort of TB patients at high risk for drug-resistant TB. Despite prevalent multidrug-resistant TB among TB-DM patients, the majority had a favorable TB treatment outcome. (C) 2013 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

An unprecedented number of nationwide tuberculosis (TB) prevalence surveys will be implemented between 2010 and 2015, to better estimate the burden of disease caused by TB and assess whether global targets for TB control set for 2015 are achieved. It is crucial that results are analysed using best-practice methods.

In Botswana, where one quarter of the adult population is infected with the human immunodeficiency virus and the annual tuberculosis (TB) incidence is among the highest globally, intensified TB case finding is needed in health care facilities to detect and treat TB cases early and prevent transmission. During August-December 2009, TB screening was implemented among adults at patient intake in five clinics in Francistown. Among 11 779 TB screenings at intake, 926 were positive. Nineteen patients were diagnosed with TB. Routine TB screening at intake was operationally feasible, but had low yield. Innovative case-finding strategies are needed in Botswana.

SETTING Directly observed therapy (DOT) is a core element of tuberculosis (TB) care and control efforts. In Taiwan, DOT was implemented in 2006, when the Stop TB Strategy was adopted as a national policy. OBJECTIVE To quantify DOT among patients on anti-tuberculosis treatment and measure the association between proportion of DOT and TB treatment outcomes at a national level in Taiwan. DESIGN We analyzed data prospectively collected on all new pulmonary TB cases reported to the national web-based registry between 1 January 2007 and 30 June 2008. We compared treatment outcomes and proportion of DOT in multivariable analyses. RESULTS Among 11,528 patients initiating anti-tuberculosis treatment, the proportion of days during which an official DOT observer witnessed treatment was >60% for 5150 (45%) patients and ≤60% for 4601 (40%) patients, whereas for 1777 (15%) patients no days of DOT were recorded. Being older, male, having positive bacteriology results and a non-World Health Organization recommended treatment regimen at baseline were independently related to unsuccessful treatment outcomes and mortality. A dose-response effect was found between proportion of DOT and these outcomes. CONCLUSION These findings highlight the importance of ensuring universal DOT in improving treatment outcomes among new pulmonary TB patients.

SETTING: Latvia has one of the highest rates of multidrug-resistant tuberculosis (MDR-TB) globally. Clinical management of MDR-TB requires lengthy multidrug regimens that often cause adverse events.DESIGN: We retrospectively reviewed records of patients who began MDR-TB treatment between 2000 and 2004. Treatment-related adverse events and factors associated with experiencing adverse events were evaluated. We also examined the frequency of and reasons for changing drug regimens.RESULTS: Among 1027 cases, 807 (79%) experienced at least one adverse event, with a median of three events per case. The most commonly reported events were nausea (58%), vomiting (39%) and abdominal pain (24%). More serious events, such as psychiatric episodes (13%), hepatitis (9%) and renal failure (4%), were relatively frequent. A change in drug dose due to an adverse event occurred in 201 (20%) cases, while 661 (64%) had at least one drug discontinued temporarily or permanently. Being older, female, having bilateral lung cavities and a greater number of TB symptoms at baseline were associated with an increased number of events.CONCLUSION: Adverse events were prevalent among MDR-TB cases treated in Latvia, with over two thirds requiring discontinuation of at least one drug. MDR-TB patients who are female, older or have severe TB disease should be closely monitored for treatment-related adverse events.

BACKGROUND:The World Health Organization recommends that national tuberculosis (TB) programs encourage public and private providers to follow the 'International standards for tuberculosis care'. We assessed services and treatment outcomes in TB patients in public and private facilities to inform public-private mix scale-up in Thailand.METHODS:We prospectively collected data on TB patients in four provinces and the national infectious diseases hospital during 2004-2006. We analyzed services and outcomes among new pulmonary TB patients according to facility type.RESULTS:Of 7526 patients, 4539 (60%) were treated in small public facilities, 2275 (30%) in large public facilities and 712 (10%) in private facilities. Compared with the private sector, more public sector patients had at least two sputum smears examined, were prescribed a standard anti-tuberculosis regimen and received directly observed therapy; however, public sector facilities also performed suboptimally. Treatment outcomes were unsuccessful for 237 (33%) patients in private facilities, and for respectively 1018 (23%) and 655 (29%) patients in small and large public facilities.CONCLUSIONS:TB diagnostic and treatment services and outcomes should be enhanced in both public and private facilities in Thailand. Initiatives are needed to improve treatment outcomes and increase the use of microscopy, standardized TB regimens, and directly observed therapy in the public and private sectors.