Academic journal article Bulletin of the World Health Organization

Low Access to a Highly Effective Therapy: A Challenge for International Tuberculosis Control

Academic journal article Bulletin of the World Health Organization

Low Access to a Highly Effective Therapy: A Challenge for International Tuberculosis Control

Article excerpt

Voir page 443 le resume en francais. En la pagina 443 figura un resumen en espanol.

Introduction

The past two years have been remarkable for the way in which the international Stop TB Partnership has coalesced behind an agreed plan, with agreed funding needs, to reach agreed global targets. This is the fruit of work that took the TB control community from the Amsterdam Declaration (March 2000) to the Washington Commitment (October 2001). Between those two events were launched the Global Plan to Stop TB (GPSTB), the Global Drug Facility (GDF), and the Global DOTS Expansion Plan (GDEP). The estimated financial need for GDEP--approximately US$ 1.2 billion per year from 2002 to 2005 (1)--was echoed in the 2001 report of the Commission on Macroeconomics and Health (2). With this unprecedented unanimity of purpose, the Stop TB Partnership can claim to represent a new movement for global TB control.

The Stop TB Partners' Forum in Washington, USA, reaffirmed its commitment to reaching the WHO target of detecting 70% of new smear-positive cases under DOTS by 2005 and of successfully treating 85% of these patients. WHO's monitoring and surveillance project is primarily a mechanism for assessing trends in TB incidence, and tracking progress towards these targets. The project has recorded 68 million TB cases since 1980, and 10 million new smear-positive cases since 1993, of which 7 million were monitored for treatment outcome. WHO data suggest that the 10 millionth TB patient will be treated under DOTS sometime during 2002.

In this paper we summarize the most recent findings of the surveillance project, focusing on progress towards the 2005 targets for case detection and treatment success. We present data for the world as a whole, for different regions, and for a selection of countries and territories that carry the highest burden of TB (22 countries account for about 80% of all new TB cases arising annually). A more comprehensive analysis of the latest data is provided elsewhere (3).

Interventions against TB and targets for control

Notwithstanding widespread BCG vaccination (4, 5), and a growing interest in the treatment of latent TB infection (6), the principal method of TB control is prompt treatment of symptomatic cases with short-course chemotherapy, administered as the DOTS strategy (7). The strategy has five elements: political commitment; case detection by sputum smear microscopy mostly among self-referring symptomatic patients; standard short-course chemotherapy administered under proper case management conditions including directly observed therapy; a system to ensure regular drug supplies; and a standard recording and reporting system including the evaluation of treatment outcomes. Standard short-course regimens can cure over 90% of new, drug-susceptible TB cases, and high cure rates should be a prerequisite for expanding case finding. In areas with high rates of drug resistance, especially multiple drug resistance, cure rates are typically lower (8). WHO recommends that all countries implement the DOTS strategy in full and that DOTS should be the basis of more complex strategies (e.g. DOTS-Plus) for TB control where rates of drug resistance or HIV infection are high.

Table 1 sets out the global targets for TB control under DOTS, here expressed within the framework of the United Nations Millennium Development Goals. The objectives (usually referred to as "targets" by WHO) of 70% case detection (24a) and 85% cure (24b)--the main concern in this paper--were ratified by the World Health Assembly, originally for the year 2000 (11), but were then deferred to 2005 (12). The additional objectives of halving TB prevalence (23a) and deaths (23b) were proposed at the 2000 G8 summit in Okinawa, Japan. Although the objectives for implementation (24a, 24b) are global, they are commonly used within countries and WHO regions. Two of WHO's six regional offices (the WHO Regional Office for the Western Pacific and the WHO Regional Office for the Eastern Mediterranean) have formally adopted the 2010 impact objectives (23a, 23b). …

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