To the Editor:
As part of the 2012–2013 European Respiratory Society (ERS) Presidential plan, the ERS/World Health Organization (WHO) Tuberculosis (TB) Consilium was implemented as a novel high priority initiative to face the growing global multidrug-resistant (MDR) TB pandemic, which is also very much a European problem [1–3].
This priority is largely due to the alarming rates of MDR-TB (i.e. active TB cases infected by Mycobacterium tuberculosis strains that are resistant to isoniazid and rifampicin) and extensively drug-resistant (XDR) TB (i.e. TB caused by strains that are resistant to at least one fluoroquinolone and one injectable second-line anti-TB drug, in addition to isoniazid and rifampicin) [4–7]. MDR/XDR-TB are considered serious threats for TB control and elimination in Europe as their clinical outcomes are largely suboptimal, as the regimens are very toxic and expensive and taken for much longer [6–9]. The largest available meta-analysis, assessing 9153 MDR-TB cases, has shown treatment success as low as 54% (with 15% dying, 8% failing/relapsing and 23% defaulting). In cases whose disease is caused by M. tuberculosis strains with resistance patterns beyond XDR-TB the outcomes are much lower: treatment success ranges from 19% to 40%, failure/relapse from 15% to 54% and death from 15% to 35% [6, 7].
Due to the clinical complexity (frequent occurrence of adverse events, lack of clinical experience, limited availability of adequate diagnostics and second-line anti-TB drugs in some countries), the real risk for acquiring further resistance and problems in patients’ adherence to treatment, clinicians face a greater challenge to successfully manage their patients. The ERS and the WHO Regional Office for Europe implemented a consultation body (the ERS/WHO TB Consilium) in late April 2013 [1, 2]. Clinicians can upload a case description via the website (www.tbconsilium.org). The case is then sent to two experts belonging to the Consilium roster, who are expected to respond within a few days. The aim of the present article is to evaluate the e-platform’s functionality after it has supported the clinical management of the first 10 cases as of July 15, 2013.
The following parameters have been taken into consideration in this first report of evaluated cases: the origin of the expert consultants request (country generating the request and patients’ country of birth); clinical questions and clinical features of the case; performance of the platform (time taken to load the case, response time, the need for an additional request for details, any problems encountered, etc.); and client satisfaction (evaluated through a structured questionnaire). The results are summarised in table 1.
Based on the initial experience with the ERS/WHO TB Consilium, the following issues were found to be of relevance.
1) The need for clinical advice is global. Requests came mainly from Europe, with the UK being predominant (five out of 10 cases), but also from India and Vietnam.
2) Seven out of the 10 cases were born in Moldova and/or in India.
3) More female patients are represented (seven out of 10 cases).
4) The patients are young (mean age: 27.9 years; range: 12–40 years), two out of 10 cases were paediatric (both females, a 14 year-old from Vietnam and a 12 year-old from India).
5) Out of the 10 cases, one is susceptible and nine are MDR-TB, of whom two are XDR-TB and one is pre-XDR-TB (i.e. MDR-TB with additional resistance to a fluoroquinolone or aminoglycoside).
6) Interestingly, while six cases were pulmonary, three were extrapulmonary and one was both pulmonary and extrapulmonary. This proportion exceeds the general proportion of notified extrapulmonary cases in the global context [3]. They are all bacteriologically confirmed, in contrast to what is usually reported through surveillance systems.
7) In all cases, the clinical question was related to the treatment regimen. In seven cases, the question specifically focused on the drug choice, the validation of the treatment regimen prescribed and treatment duration. In one case from the UK, the clinical question was more complicated, including a request for expert opinion on the management of cachexia, muscle wasting and possible surgery. In other cases, specific guidance on possible drug interactions was requested. In one of the extrapulmonary cases, the question was a specific request regarding how to monitor the response to treatment and when to stop it.
8) The time taken for the clinician to load the case onto the electronic platform was <30 min, with a mean value of 20 min. No clinician reported problems in using the system.
9) The average response time was 40 h, although in eight cases it was within 24 h, in one case 48 h, and in a single case 6 days as one of the two experts, after accepting the request, temporarily had no access to an internet connection and needed some time to complete the report. In two cases the experts asked the clinician to provide further details in order to finalise their report. The mail exchange was rapid and did not delay the time to the final answer.
10) All clinicians reported they were satisfied with the experts’ advice.
11) No problems were reported by the experts, who provided useful comments for improving the system functionality. All these suggestions were captured by the Consilium coordinators. The main suggestions were aimed at improving reporting of new diagnostics and radiological findings, and a better location for the spaces where the clinician is allowed to add descriptive clinical details.
12) The coordinators identified a need to allow consolidation of the two experts’ reports, in order to provide the clinician with a perspective for the best interpretation and use of the experts’ reports. In addition the client satisfaction survey was added, together with the option to invite a third expert, if necessary, or to disengage an expert not providing a rapid reply. The reviewer pop-up directory was improved, making further details available to facilitate the choice of expert, for example language spoken and speciality (HIV, paediatrician, surgeon etc.).
Preliminary analysis indicates that 2 months after its launch, the e-platform has achieved a satisfactory functionality, thanks to adequate pretesting. Useful operational conclusions can be drawn from this initial analysis, including: 1) regimen selection appears to be the predominant query from clinicians, vis-à-vis the need for rational prescribing of regimens with maximised clinical effectiveness; and 2) extrapulmonary and paediatric TB cases raise questions regarding both management and monitoring of therapy.
A rapid response to each request is possible if the Consilium director and area coordinator provide an immediate reaction following the upload of a case into the system. Next steps will include the full activation of the Russian translation of the system interface, which will be followed by translation into Spanish, Portuguese and French.
In addition to providing clinical advice, the system also allows monitoring and evaluation of the adherence to existing guidelines [10], as well as the transborder follow-up of TB cases throughout Europe [10]. An ad hoc analysis will be planned when a sufficient number of cases have been stored in the database, under the stringent rules of the Swiss legislation with regard to confidentiality and data protection (the server is hosted by the ERS in Lausanne).
The ERS Consilium platform aims to provide clinicians world-wide with a tool that assists care providers in formulating individualised treatment plans for their MDR-TB patients, hence guaranteeing better guideline adherence, improved treatment success rates, tolerability and prevention of further resistance.
Footnotes
Conflict of interest: S. Dupasquier is an employee of the European Respiratory Society.
- Received July 23, 2013.
- Accepted August 21, 2013.
- ©ERS 2014