Publicação: 18 de dezembro de 2018
THE TB TREATMENT OUTCOMES in the Piedmont area in Italy, described in this issue of the Journal, illustrate that TB control in low-incidence countries continues to pose signifi cant problems.1 The low reported treatment success rate of 56.5% in new pulmonary cases is far below the targets set by the World Health Organization of 85% […]
THE TB TREATMENT OUTCOMES in the Piedmont area in Italy, described in this issue of the Journal, illustrate that TB control in low-incidence countries continues to pose signifi cant problems.1 The low reported treatment success rate of 56.5% in new pulmonary cases is far below the targets set by the World Health Organization of 85% cure, while the staggeringly high level of unsuccessful outcome, 36.8%, is unacceptable and may create subsequent problems with drug resistance, which was not studied in this report. For Western European countries, the respective outcome results are on average 78% and 19% (of which 3% are still on treatment).2 It is time that Italy—and others not included in the EuroTB report—heed the call to report their outcomes. Poor outcomes across Western Europe are generally associated with a loss to follow-up in excess of 10%, especially among patients of foreign origin, and elderly patients, who are more frequent in the national population.2 A nomogram has now been proposed to predict those at risk of unfavourable outcome.
Treatment outcome monitoring is a public health strategy for evaluating the effi cacy of the set of interventions that contribute to a successful outcome of case management. Some clinicians justify the failure to report outcomes on the basis that non-standardised treatment has been used. As it is important to include all cases in outcome monitoring, even those who have not been treated, such as those diagnosed post mortem, ‘case management monitoring’ would have been a better label.
Successful TB case management is the result of a combination of interventions aimed at patient-, providerand system-related problems. The Piedmont ‘nomogram’ using patient- and system-related risk factors, which may predict the individual probability of an unfavourable outcome, still cannot identify which specific individual is at risk. It is thus absolutely essential that every case be supervised.
An important provider-related risk factor in lowincidence countries is the loss of TB expertise, which may lead to under-diagnosis, incorrect treatment and erroneous reporting. How to maintain expertise is a challenge. Concentration of expertise seems a logical approach, but a Finnish study has suggested that outcomes would not improve by concentrating treatment in fewer units with more patients.3 A nomogram may help alert the clinician to the fact that the patient may be at increased risk if treatment is not completed, but unless there is a solid, sustained public health infrastructure to support and supervise follow-up of the individual case, the alert itself is meaningless.
Uniform systematic surveillance data on outcomes in European countries have been collected for several years now, but not all countries report their data. To improve outcome success, some low-incidence countries in Western Europe need to invest more in creating a national coherent infrastructure for diagnosis, treatment, follow-up and surveillance, including outcome monitoring. Supervision of patients by a case manager who coordinates the activities of different services and supervises treatment adherence (by directly observed or self-administered treatment) is a critical part of the system. This manager, usually a public health TB nurse, provides support to the patient, feedback to the clinical services and standardised information to the public health system. Countries on the verge of eliminating TB cannot afford to be complacent.
TB Control Advisor
1 Baussano I, Pivetta E, Vizzini L, Abbona F, Bugiani M. Predicting tuberculosis treatment outcome in a low-incidence area. Int J Tuberc Lung Dis 2008; 12: 1441–1448.
2 EuroTB and the national coordinators for tuberculosis surveillance in the WHO European Region. Surveillance of tuberculosis in Europe. Report on tuberculosis cases notifi ed in 2005. Saint- Maurice, France: Institut de Veille sanitaire, March 2007.
3 Vasankari T, Holmstrom P, Ollgren J, Liippo K, Kokki M, Ruutu P. Risk factors for poor tuberculosis treatment outcome in Finland: a cohort study. BMC Public Health 2007, 7: 291. www. biomedcentral.com/1471-2458/7/291 Accessed August 2008.