[e-drug] WHO's TB control strategy said to be insufficient

["E-Drug" <e-drug@healthnet.org>]

E-DRUG: WHO's TB control strategy said to be insufficient
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[If you like the Lancet, and work a lot with infectious diseases, have a look at the The Lancet Infectious Diseases, a monthly journal with quite a lot of relevance for developing countries and essential drugs.
Most "third world" content is freely downloadable at http://infection.thelancet.com/journal

We haven't had much debate in E-drug about the pro's and con's of WHO's TB strategy (read: DOTS). TB is getting out of hand, and it is getting increasingly difficult to treat. The debate is open what to do with TB: to DOTS or not to DOTS? 

To start the debate, here an article from the latest issue of the Lancet Infectious Diseases.

The original article is at http://jech.bmjjournals.com/cgi/content/abstract/58/10/822
E-druggers from developing countries with a GDP < USD 1000 have free full-text access! See http://www.bmjjournals.com/subscriptions/countries.shtml for a list of countries and procedure to follow.
WB]

http://infection.thelancet.com/journal/vol4/iss11/full/laid.4.11.newsdesk.31018.1

WHO's tuberculosis control strategy said to be insufficient
Roxanne Nelson 

WHO is not doing enough to control rising levels of tuberculosis, according to researchers at Harvard University, MA, USA. Despite almost 10 years of Directly Observed Treatment, Short-course (DOTS), WHO's main strategy for treating active tuberculosis infections and reducing its prevalence, most of the world remains no closer to controlling this disease (J Epidemiol Community Health 2004; 58: 82225).

The DOTS programme detects tuberculosis by sputum-smear microscopy then administers standard short-course chemotherapy under a directly observed therapy approach. WHO's goal is to identify 70% of patients with positive smears, and to cure 85% of them by the end of 2005. But this tactic, says author Timothy Brewer, is likely to have only a modest effect on population-based tuberculosis control.

Clinical trials have repeatedly shown that treatment of latent infection is very effective at preventing active disease among individuals at high risk for developing tuberculosis, says Brewer. Computer simulation models suggest that combinations of prevention and treatment strategies are more effective at controlling tuberculosis in populations than treatment strategies alone. The current WHO strategy does very little to prevent tuberculosis from developing in people at high risk for this disease, despite the availability of effective prevention.

Treatment needs to be targeted at individuals infected with HIV, and at household contacts of patients with latent tuberculosis infection. In HIV-endemic countries in sub-Saharan Africa with well run DOTS programmes, tuberculosis cases have increased by 200% or more over the past 10 years, says Brewer.

The report was contested by Mario Raviglione, director of WHO's Stop TB Department, who noted that DOTS has been successful in controlling tuberculosis in several countries, including Chile, Cuba, Uruguay, and Peru. In areas of China using the DOTS programme, the prevalence of tuberculosis was reduced up to 40%, compared with areas not using it, says Raviglione.

The paper has minimalised the achievements of DOTS in a very unfair way, and a non-evidenced based way, he says. We have been improving surveillance for 10 years, and now we can count detection rates, cure rates, and so on. It's not always easy in developing nations, but the paper says we need to do a better job. It would be nice if it offered a practical suggestion for improving surveillance.

Raviglione also points out that for chemoprophylaxis to really have a benefit, we will have to treat hundreds of millions because two billion people are infected. And that really isn't very feasible, he says.