TUBERCULOSIS

:: Box 5.1
Enablers for establishing effective monitoring and evaluation of treatment for LTBI
In April 2016, WHO in collaboration with the Republic of
Korea’s Centers for Disease Control and Prevention, and
International Tuberculosis Research Center organized a
global consultation on the programmatic management of
LTBI. This was the first such consultation in the era of the
End TB Strategy, and brought together participants from
both high and low TB burden countries to discuss and
identify challenges, opportunities and best practices in the
programmatic management of LTBI.
Barriers to monitoring and evaluation of the provision of
treatment for LTBI that were identified included the nonnotifiable
status of LTBI in many countries, the existence of
multiple paper-based registers for recording of treatment,
fragmentation due to the involvement of multiple service
providers and lack of regulation of the private sector.
Examples of approaches that can facilitate effective
monitoring and evaluation system were shared. These
included:
incorporating treatment of LTBI in the routine surveillance
system for TB by making LTBI a notifiable condition (Japan);
improving data management, including by using an
electronic web-based register (the Netherlands) and linking
data from multiple electronic databases (Norway); and
establishing better relationships with the private sector
(Republic of Korea), especially to improve the reporting of
preventive treatment for people in clinical risk groups.
the WHO African Region (Fig. 5.2). In 2015, a total of 57
countries (representing 61% of the estimated global burden
of HIV-associated TB) reported providing preventive
TB treatment to people newly enrolled in HIV care, up from
49 countries in 2014. The total number of people started
on preventive treatment globally was 910 124, similar to the
level of 2014 and up from the very low levels in 2005 when
WHO first requested data. Most of this progress has occurred
since 2010, following definition of a four-symptom
algorithm for screening for TB among people living with
HIV and associated WHO guidance. 1,2
As in previous years, South Africa accounted for the
largest proportion (45%) of the global total in 2015 (Fig.
5.2), followed by Malawi, Mozambique and Kenya (Table
5.2). Ten countries reported data for the first time, including
Kenya, and several other countries in the WHO African
Region reported higher numbers in 2015 compared with
2014 (e.g. Ethiopia, Mozambique, Nigeria and Zimbabwe).
Despite this progress, much more remains to be done.
Of the 30 high TB/HIV burden countries, 21 did not report
any provision of preventive treatment in 2015, and in the
nine that did report data, coverage among people newly
enrolled in HIV care ranged from 2% in Indonesia to 79%
in Malawi (Table 5.2).
1
Getahun H, Kittikraisak W, Heilig CM, Corbett EL, Ayles H, Cain KP et
al. Development of a standardized screening rule for tuberculosis in
people living with HIV in resource-constrained settings: individual
participant data meta-analysis of observational studies. PLoS Med.
2011;8(1):e1000391 (http://www.ncbi.nlm.nih.gov/
pubmed/21267059, accessed 30 August 2016).
2
World Health Organization. Guidelines for intensified tuberculosis
case-finding and isoniazid preventive therapy for people living with
HIV in resource-constrained settings. Geneva: WHO; 2015 (http://
apps.who.int/iris/bitstream/10665/44472/1/9789241500708_eng.
pdf, accessed 31 August 2016).
5.1.3 Other at-risk populations
Data on provision of preventive treatment to other at-risk
populations were reported by seven countries: France, Japan,
the Netherlands, Norway, Portugal, Republic of Korea
and Slovakia (Table 5.3). Only four countries could report
denominators, and then only for a subset of risk groups. All
seven countries reported providing preventive treatment to
adult contacts, and coverage was more than 50% in the
four countries that reported denominators. Data for clinical
risk groups such as patients starting anti-tumour necrosis
factor (TNF) therapy and those preparing for transplantation
were reported by Norway, Portugal and Slovakia. The
lack of routinely reported data, particularly for clinical risk
groups, makes it difficult to monitor coverage levels. Better
monitoring mechanisms need to be established; examples
of how to do this are provided in Box 5.1.
5.2 TB infection control
TB infection control is one of the key components of the
second pillar of the End TB Strategy (Chapter 2) and is also
one of the collaborative TB/HIV activities that falls under
pillar one. The risk of TB transmission is high in health-care
and other congregate settings. This puts health-care workers
at greater risk of TB infection and disease, and nosocomial
outbreaks of multidrug-resistant TB (MDR-TB) and
extensively drug-resistant TB (XDR-TB) among people living
with HIV have been documented in the literature. 3,4
TB infection control should be part of national infection
3
Gandhi NR, Weissman D, Moodley P, Ramathal M, Elson I, Kreiswirth
BN et al. Nosocomial transmission of extensively drug-resistant
tuberculosis in a rural hospital in South Africa. J Infec Dis.
2013;207(1):9–17.
4
Moro ML, Gori A, Errante I, Infuso A, Franzetti F, Sodano L et al. An
outbreak of multidrug-resistant tuberculosis involving HIV-infected
patients of two hospitals in Milan, Italy. AIDS. 1998;12(9):1095–1102.
86 :: GLOBAL TUBERCULOSIS REPORT 2016