ArticlesAssessment of worldwide tuberculosis control
Introduction
Tuberculosis (TB) has been neglected as a publichealth issue for many years by many countries and remains the major cause of death from a single infectious agent among adults in developing countries. There has been a resurgence of TB in industrialised countries.1: Several factors, most notably a lack of resources and government commitment, have prevented adequate implementation of control measures. In many countries of Africa and southeast Asia, infection with HIV has further increased TB morbidity and mortality.2, 3, 4 In several formerly socialist countries, TB morbidity and mortality continue to rise because of the deterioration of public-health systems.5 Finally, in many industrialised countries the recent increase of TB, which is due largely to cases among immigrants from other countries,6, 7, 8 is the direct consequence of worldwide neglect. In 1993, WHO declared TB to be a global emergency.1 The exact burden of disease, however, is not known and the worldwide achievements of national TB control programmes in terms of diagnosis and treatment results have not been analysed.
The key to controlling TB is rapid detection and cure of infectious cases by TB control programmes. In 1991, the World Health Assembly recommended that national TB programmes should work towards two objectives by the year 2000: to treat successfully 85% and to detect 70% of smear-positive cases9 by the introduction of an effective approach to TB control. The WHO TB control strategy (directly observed treatment, short course) is defined by five elements: government commitment to TB control; case detection focusing on patients with symptoms self-reporting to health services and use of sputum-smear microscopy; administration of short-course chemotherapy in a standard way throughout the country with direct observation of treatment during, at least, the first 2 months of treatment; a regular supply of all essential antituberculosis drugs; and a standard recording and reporting system that allows assessment of treatment results.10
To assess the achievements of TB control, WHO set up a worldwide surveillance and monitoring project in 1995. We present the first results, focusing on the extent of implementation of the WHO strategy and the
performance of national TB programmes, and attempt to compare areas that have and have not adopted the WHO strategy.
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Methods
In early 1996, we developed two data-collection forms requesting information on TB-control policy, cases reported for 1995, and treatment outcomes among patients registered during 1994. The first form asked questions in the standard format proposed by WHO10 for countries or areas within countries where the WHO strategy was implemented. The second form was designed for countries and areas where the WHO strategy had not been implemented and did not request certain data-for example, re-treatment
Results
By 1 July, 1997, WHO had received data from 180 countries, areas, and territories (83% of the 216 surveyed, 98% of the worldwide population). Of these, 84 (47%) areas had not yet accepted the WHO strategy, 75 (42%) had implemented the strategy (39 in >90% of the population), and 21 (12%) had a casenotification rate of less than ten per 100 000 population (table 1). 2% of the worldwide population lived in countries that did not report to WHO, 27% in countries where the WHO strategy was not
Discussion
The main purposes of this study were to assess the extent of implementation of the WHO strategy worldwide, the achievements of national TB programmes, and the progress towards the achievements of the two WHO targets set by the World Health Assembly in 1991.9 Of the 216 countries, areas, and territories surveyed, 83% replied to WHO.
By the end of 1995, the WHO strategy had been accepted in 75 countries (35%) of the 216 surveyed), but only 39 countries had implemented the strategy countrywide. The
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