RESUMO
Multidrug-resistant tuberculosis (MDR-TB) (resistance to at least isoniazid and rifampicin) will influence the future of global TB control. 88% of estimated MDR-TB cases occur in middle- or high-income countries, and 60% occur in Brazil, China, India, the Russian Federation and South Africa. The World Health Organization collects country data annually to monitor the response to MDR-TB. Notification, treatment enrolment and outcome data were summarised for 30 countries, accounting for >90% of the estimated MDR-TB cases among notified TB cases worldwide. In 2012, a median of 14% (interquartile range 6-50%) of estimated MDR-TB cases were notified in the 30 countries studied. In 15 of the 30 countries, the number of patients treated for MDR-TB in 2012 (71 681) was >50% higher than in 2011. Median treatment success was 53% (interquartile range 40-70%) in the 25 countries reporting data for 30 021 MDR-TB cases who started treatment in 2010. Although progress has been noted in the expansion of MDR-TB care, urgent efforts are required in order to provide wider access to diagnosis and treatment in most countries with the highest burden of MDR-TB.
Assuntos
Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Antituberculosos/uso terapêutico , Brasil , China , Controle de Doenças Transmissíveis , Coleta de Dados , Saúde Global , Humanos , Índia , Isoniazida/uso terapêutico , Pobreza , Rifampina/uso terapêutico , Federação Russa , África do Sul , Resultado do Tratamento , Organização Mundial da SaúdeRESUMO
BACKGROUND: The prospects for global tuberculosis control in the near future will be determined by the effectiveness of the response of countries to their burden of multidrug-resistant (MDR; resistance to, at least, isoniazid and rifampicin) tuberculosis. During the 2009 World Health Assembly, countries committed to achieve universal access to MDR-tuberculosis care by 2015. We assessed the progress towards the 2015 targets achieved by countries accounting for 90% of the estimated MDR-tuberculosis cases in the world in 2011. METHODS: We analysed data reported to WHO by 30 countries expected to have more than 1000 MDR-tuberculosis cases among notified patients with pulmonary tuberculosis in 2011. FINDINGS: In the 30 countries, 18% of the estimated MDR-tuberculosis cases were enrolled on treatment in 2011. Belarus, Brazil, Kazakhstan, Peru, South Africa, and Ukraine each detected and enrolled on treatment more than 50% of their estimated cases of MDR-tuberculosis. In Ethiopia, India, Indonesia, the Philippines, and Russia, enrolments increased steadily between 2009 and 2011 with a mean yearly change greater than 50%: however, in these countries enrolment in 2011 was low, ranging from 4% to 43% of the estimated cases. In the remaining countries (Afghanistan, Angola, Azerbaijan, Bangladesh, China, Democratic Republic of the Congo, Kenya, Kyrgyzstan, Moldova, Mozambique, Burma, Nepal, Nigeria, North Korea, Pakistan, South Korea, Thailand, Uzbekistan, and Vietnam) progress in detection and enrolment was slower. In 23 countries, a median of 53% (IQR 41-71) patients with MDR-tuberculosis successfully completed their treatment after starting it in 2008-09. INTERPRETATION: Six countries (Belarus, Brazil, Kazakhstan, Peru, South Africa, and Ukraine) can achieve universal access to MDR-tuberculosis care by 2015 should they sustain their current pace of progress. In other countries a radical scale-up will be needed for them to have an effect on their MDR-tuberculosis burden. Unless barriers to diagnosis and successful treatment are urgently overcome, and new technologies in diagnostics and treatment effectively implemented, the global targets for 2015 are unlikely be achieved. FUNDING: WHO.
Assuntos
Saúde Global , Vigilância da População , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , África , Antituberculosos/provisão & distribuição , Sudeste Asiático , Ásia Ocidental , Brasil , Europa Oriental , Ásia Oriental , Objetivos , Acessibilidade aos Serviços de Saúde , Humanos , Peru , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Tuberculose Resistente a Múltiplos Medicamentos/prevenção & controleRESUMO
AIM: To describe the incidence of extensive drug-resistant tuberculosis (XDR-TB) reported in the Peruvian National multidrug-resistant tuberculosis (MDR-TB) registry over a period of more than ten years and present the treatment outcomes for a cohort of these patients. METHODS: From the Peruvian MDR-TB registry we extracted all entries that were approved for second-line anti-TB treatment between January 1997 and June of 2007 and that had Drug Susceptibility Test (DST) results indicating resistance to both rifampicin and isoniazid (i.e. MDR-TB) in addition to results for at least one fluoroquinolone and one second-line injectable (amikacin, capreomycin and kanamycin). RESULTS: Of 1,989 confirmed MDR-TB cases with second-line DSTs, 119(6.0%) XDR-TB cases were detected between January 1997 and June of 2007. Lima and its metropolitan area account for 91% of cases, a distribution statistically similar to that of MDR-TB. A total of 43 XDR-TB cases were included in the cohort analysis, 37 of them received ITR. Of these, 17(46%) were cured, 8(22%) died and 11(30%) either failed or defaulted treatment. Of the 14 XDR-TB patients diagnosed as such before ITR treatment initiation, 10 (71%) were cured and the median conversion time was 2 months. CONCLUSION: In the Peruvian context, with long experience in treating MDR-TB and low HIV burden, although the overall cure rate was poor, a large proportion of XDR-TB patients can be cured if DST to second-line drugs is performed early and treatment is delivered according to the WHO Guidelines.
Assuntos
Antituberculosos/uso terapêutico , Farmacorresistência Bacteriana/efeitos dos fármacos , Resistência a Múltiplos Medicamentos , Tuberculose/tratamento farmacológico , Antituberculosos/classificação , Estudos de Coortes , Quimioterapia Combinada , Humanos , Peru , Estudos Retrospectivos , Falha de Tratamento , Resultado do Tratamento , Tuberculose/classificaçãoAssuntos
Tuberculose Extensivamente Resistente a Medicamentos , Saúde Pública , Antituberculosos/uso terapêutico , Desenho de Fármacos , Tuberculose Extensivamente Resistente a Medicamentos/diagnóstico , Tuberculose Extensivamente Resistente a Medicamentos/epidemiologia , Tuberculose Extensivamente Resistente a Medicamentos/prevenção & controle , Tuberculose Extensivamente Resistente a Medicamentos/terapia , Humanos , Saúde Pública/economiaRESUMO
Evidence of successful management of multidrug-resistant tuberculosis (MDRTB) is mainly generated from referral hospitals in high-income countries. We evaluate the management of MDRTB in 5 resource-limited countries: Estonia, Latvia, Peru, the Philippines, and the Russian Federation. All projects were approved by the Green Light Committee for access to quality-assured second-line drugs provided at reduced price for MDRTB management. Of 1047 MDRTB patients evaluated, 119 (11%) were new, and 928 (89%) had received treatment previously. More than 50% of previously treated patients had received both first- and second-line drugs, and 65% of all patients had infections that were resistant to both first- and second-line drugs. Treatment was successful in 70% of all patients, but success rate was higher among new (77%) than among previously treated patients (69%). In resource-limited settings, treatment of MDRTB provided through, or in collaboration with, national TB programs can yield results similar to those from wealthier settings.
Assuntos
Antituberculosos , Países em Desenvolvimento , Programas Governamentais , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/prevenção & controle , Antituberculosos/administração & dosagem , Antituberculosos/uso terapêutico , Controle de Doenças Transmissíveis/métodos , Esquema de Medicação , Estônia/epidemiologia , Humanos , Letônia/epidemiologia , Peru/epidemiologia , Filipinas/epidemiologia , Avaliação de Programas e Projetos de Saúde , Federação Russa/epidemiologia , Resultado do Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/microbiologiaRESUMO
INTRODUCTION: Ethics committees are a necessary resource to guarantee ethical integrity in human research; they must apply international standards in their ethical evaluation of research projects involving human subjects. OBJECTIVE: The ethics committees for human research of Colombia were characterized, and recommendations for strengthening them were formulated. MATERIALS AND METHODS: In 2003, 280 groups with research projects involving human subjects were selected from a list of research groups which form part of the science and technology network of Colciencias. (Colciencias is the Colombian national agency that promotes and funds science and technology.) Eighty percent (224) of the projects were associated with 40 institutions, consisting of universities, hospitals, and public or private research centers. Thirty of these institutions had at least one ethics committee for evaluating use of human subjects. A questionnaire was mailed to each of these Committees, requesting information concerning its their compostition, regulations, multidisciplinarity, plurality, representativity and independence. The World Health Organization's Operational Guidelines for Ethic Committees that Evaluate Biomedical Research (TDR/PRD/ETHICS/2000) was used as reference for the analysis. In 5 of the cities, supplemental information was obtained by direct discussions with members of the ethics committees. RESULTS: Twenty-six committees responded to the questionnaire. The results indicated that 47% of the committee members were physicians, but only 23% of the committees had representatives from the community. In 60% of the Committees, members were not independent from the organization in which it was based. Seventy percent had established operating procedures. Lack of national regulations and limited education in research ethics were mentioned as the main drawbacks in providing effective guidance. CONCLUSIONS: These observations led to the conclusion that national guidelines must be established for ethics committees that correspond to international standards. Committee members must be trained before accepting committee responsibilities. Finally, new committees must be created along with the improvement of the currently existing committees for reinforcing and promoting the importance of ethical integrity in research.
Assuntos
Comitês de Ética em Pesquisa , Ética em Pesquisa , Pesquisa Biomédica , Colômbia , Guias como Assunto , Experimentação Humana , Humanos , Internacionalidade , Inquéritos e QuestionáriosRESUMO
Introducción. Los comités de ética de investigación en humanos que aplican los estándares internacionales en la evaluación ética de proyectos de investigación son un recurso indispensable para garantizar la integridad ética de la investigación en humanos. Objetivo. El presente trabajo se propuso conocer las características de los comités de ética de investigación en humanos y sus necesidades con miras a su fortalecimiento en Colombia. Materiales y métodos. En el 2003, se seleccionaron 280 grupos de investigación en humanos de un listado de grupos de investigación que acudieron a la convocatoria del año 2002 de la Red de Ciencia y Tecnología de Colciencias. El 80 por ciento de estos grupos pertenecía a 40 instituciones entre universidades, hospitales y centros de investigación públicos y privados. Treinta de 40 instituciones tenían comité de ética. Se les envió un cuestionario que indagaba sobre la constitución, reglamentación, composición multidisciplinaria, pluralidad, representatividad e independencia de los comités. Las respuestas se analizaron utilizando como referencia las Guías operacionales para comités de ética de investigación biomédica (TDR/PRD/ETHICS/2000). Se complementó la información obtenida mediante discusiones con miembros de estos comités en cinco ciudades del país. Resultados. Veintiséis comités respondieron la encuesta. El 47 por ciento de los miembros eran médicos, 23 por ciento de los comités tenía un miembro representante de la comunidad, 40 por ciento tenía un miembro independiente, 70 por ciento tenía manual de operaciones. Mencionaron la necesidad de mejorar la constitución de los comités, la capacitación de sus miembros, la regulación y las guías nacionales. Conclusión. Es urgente que en Colombia se elaboren guías nacionales para los comités de ética de investigación basados en estándares internacionales, se capacite a sus miembros y se promueva la integridad ética de la investigación.
Assuntos
Comitês de Ética em Pesquisa , Ética em Pesquisa , Experimentação Humana , Pesquisa BiomédicaRESUMO
La tasa de notificación de tuberculosis pulmonar bacilífera en 2001 en Buenaventura, Colombia, fue de 66 por 100.000 habitantes. El pobre control de la tuberculosis en este municipio durante los últimos 10 años y el uso inadecuado de medicamentos de primera línea hace sospechar una elevada resistencia a estas drogas antituberculosas. En este artículo se presentan y discuten los resultados de dos encuestas de resistencia inicial a drogas antituberculosas de primera línea en personas con tuberculosis pulmonar realizadas en Buenaventura entre el 1° de agosto de 1997 y el 31 de enero de 1998, y entre el 15 de noviembre de 2000 y el 15 de noviembre de 2001, con un intervalo de dos años y nueve meses. En las dos encuestas se utilizó el método de proporciones múltiples. Se logró aislar Mycobacterium tuberculosis en 93% y 55% de los casos nuevos de tuberculosis pulmonar diagnosticados en cada uno de los periodos estudiados. La resistencia inicial a cualquier medicamento antituberculoso fue de 25% (9/36) y 32% (23/72) en la primera y segunda encuesta, respectivamente. La multirresistencia inicial (definida como resistencia, al menos, a isoniacida y rifampicina) fue de 6% en ambas encuestas. Este porcentaje de resistencia encontrado demuestra la diseminación de cepas multirresistentes y destaca a la vigilancia epidemiológica de la resistencia a drogas antituberculosas como un componente esencial en el control de la enfermedad, por lo menos, en las zonas en las que el programa ha sido errático en el pasado. De esta manera, se podrán identificar las áreas en las que la estrategia DOTS deba ser reforzada con el uso de drogas de segunda línea (DOTS-plus).
In 2001, Buenaventura, Colombia, the rate of smear-positive pulmonary tuberculosis was of 66 per 100.000 inhabitants. The poor control of the tuberculosis in this city during the last 10 years and the inadequate use of first-line anti-tuberculosis drugs was an opportune situation for the development of high resistance to these drugs. Two surveys of initial resistance to first-line antituberculosis drugs were conducted in new cases of pulmonary TB, in the city of Buenaventura-the first from August 1, of 1997 to January 31 of 1998 and the second from November 15, of 2000 to November 15, 2001. The method of multiple proportions was used to determine drug susceptibility. Mycobacterium tuberculosis was isolated in 93% and 55% of the new cases of lung TB during each respective period. The initial resistance to at least one drug was 25% (9/ 36) and 32% (23/72), respectively. The initial multi-drug resistance (defined as resistance to at least isoniazid and rifampicin) was 6% for both surveys. This demonstrates the dissemination of multidrug-resistant bacilli and shows the need for surveillance of resistance to antituberculosis drugs in control of the disease, particularly in those areas where the TB control program has been erratically applied. In areas where multi-drug resistant TB occurs, the control strategy should be enhanced with the careful introduction of second-line drugs.