Is DOTS-Plus a Feasible and Cost-Effective Strategy?

Paul Garner and colleagues discuss the implications of the pilot study by Katherine Floyd and colleagues of the DOTS-Plus project for tuberculosis control in the Philippines

New Measurable Indicator for Tuberculosis Case Detection

Conducting prevalence surveys at 5- to 10-year intervals would allow countries to determine their case detection performance

Epidemiology of Tuberculosis in a High HIV Prevalence Population Provided with Enhanced Diagnosis of Symptomatic Disease

BACKGROUND: Directly observed treatment short course (DOTS), the global control strategy aimed at controlling tuberculosis (TB) transmission through prompt diagnosis of symptomatic smear-positive disease, has failed to prevent rising tuberculosis incidence rates in Africa brought about by the HIV epidemic. However, rising incidence does not necessarily imply failure to control tuberculosis transmission, which is primarily driven by prevalent infectious disease. We investigated the epidemiology of prevalent and incident TB in a high HIV prevalence population provided with enhanced primary health care. METHODS AND FINDINGS: Twenty-two businesses in Harare, Zimbabwe, were provided with free smear- and culture-based investigation of TB symptoms through occupational clinics. Anonymised HIV tests were requested from all employees. After 2 y of follow-up for incident TB, a culture-based survey for undiagnosed prevalent TB was conducted. A total of 6,440 of 7,478 eligible employees participated. HIV prevalence was 19%. For HIV-positive and -negative participants, the incidence of culture-positive tuberculosis was 25.3 and 1.3 per 1,000 person-years, respectively (adjusted incidence rate ratio = 18.8; 95% confidence interval [CI] = 10.3 to 34.5: population attributable fraction = 78%), and point prevalence after 2 y was 5.7 and 2.6 per 1,000 population (adjusted odds ratio = 1.7; 95% CI = 0.5 to 6.8: population attributable fraction = 14%). Most patients with prevalent culture-positive TB had subclinical disease when first detected. CONCLUSIONS: Strategies based on prompt investigation of TB symptoms, such as DOTS, may be an effective way of controlling prevalent TB in high HIV prevalence populations. This may translate into effective control of TB transmission despite high TB incidence rates and a period of subclinical infectiousness in some patients

Prevalence of Antimicrobial Resistance in Haemophilus influenzae and Streptococcus pneumoniae : Comparison of Clinical Isolates of Japan and The Philippines

For clinical isolates of Haemophilus influenzae and Streptococcus pneumoniae in Japan (356 and 179 strains, respectively) and in the Philippines (98 and 59 strains, respectively), minimum inhibitory concentrations (MICs) of ampicillin, cefazolin, cefotiam, ceftizoxim, ofloxacin, erythromycin, and minocycline were examined. The rates of β-lactamase producing H. influenzae were 17.7% (63/356) in Japan and 2.0% (2/98) in the Philippines, and all of these strains were ampicillin MICs 〓1.56 ugml^. In addition, 5 strains in Japan that lacked β-lactamase activity were also less susceptible to ampicillin. Among the antimicrobials tested, ceftizoxim was the most active against H. influenzae in both countries (MICs 〓0.2 ugml^). Five strains of S. pneumoniae in Japan were relatively resistant to ampicillin (MIC=0.1 ugml^), whereas there were no such strains among isolates in the Philippines. Forty strains (22.3%) and 108 strains (60.3%) among S. pneumoniae in Japan exhibited erythromycin MICs 〓0.2 ugml^ and minocycline MICs 〓1.56 ugml^, respectively. In contrast, all isolates in the Philippines were erythromycin MICs 〓0.05 ugml^ and minocycline MICs 〓0.39 ugml^. Present study indicates that H. influenzae and S. pneumoniae in the Philippines remained still susceptible to the antimicrobials tested except for 2 β-lactamase-positive, ampicillin-resistant H. influenzae, whereas ampicillin-resistant H. influenzae mediated by β-lactamase or non-β-lactamase mechanisms and ampicillin-, erythromycin- or minocycline-resistant S. pneumoniae were included among isolates in Japan

Randomized Trials to Optimize Treatment of Multidrug-Resistant Tuberculosis: The time for action is now

The time is now right for randomized trials of MDR-TB, say the authors, as the expansion of MDR-TB programs provides the setting in which trials can be implemented

Rifampicin for Continuation Phase Tuberculosis Treatment in Uganda: A Cost-Effectiveness Analysis

In Uganda, isoniazid plus ethambutol is used for 6 months (6HE) during the continuation treatment phase of new tuberculosis (TB) cases. However, the World Health Organization (WHO) recommends using isoniazid plus rifampicin for 4 months (4HR) instead of 6HE. We compared the impact of a continuation phase using 6HE or 4HR on total cost and expected mortality from the perspective of the Ugandan national health system.Treatment costs and outcomes were determined by decision analysis. Median daily drug price was US$0.115 for HR and US$0.069 for HE. TB treatment failure or relapse and mortality rates associated with 6HE vs. 4HR were obtained from randomized trials and systematic reviews for HIV-negative (46% of TB cases; failure/relapse -6HE: 10.4% vs. 4HR: 5.2%; mortality -6HE: 5.6% vs. 4HR: 3.5%) and HIV-positive patients (54% of TB cases; failure or relapse -6HE: 13.7% vs. 4HR: 12.4%; mortality -6HE: 16.6% vs. 4HR: 10.5%). When the initial treatment is not successful, retreatment involves an additional 8-month drug-regimen at a cost of $110.70. The model predicted a mortality rate of 13.3$26.07 for 6HE and $23.64 for 4HR. These results were robust to the inclusion of MDR-TB as an additional outcome after treatment failure or relapse.Combination therapy with 4HR in the continuation phase dominates 6HE as it is associated with both lower expected costs and lower expected mortality. These data support the WHO recommendation to transition to a continuation phase comprising 4HR

High Prevalence of Tuberculosis in Previously Treated Patients, Cape Town, South Africa

More than half of smear-positive case-patients had previously undergone treatment