Drug-resistant tuberculosis in Eastern Europe: challenges and ways forward

Abstract

Encouragingly, global rates of new tuberculosis (TB) cases have been falling since 2005, in line with the Millennium Development Goal targets; however, cases of multidrug-resistant (MDR-) and extensively drug-resistant TB (XDR-TB) have been increasing. Fifteen of the world's 27 high MDR- and XDR-TB burden countries are in the World Health Organization (WHO) European Region, of which 10 are in Eastern Europe (including Baltic and Caucasus countries). To address the MDR- and XDR-TB situation in the WHO European Region, a Consolidated Action Plan to Prevent and Combat M/XDR-TB (2011-2015) was developed for all 53 Member States and implemented in 2011. Since the implementation of the Action Plan, the proportion of MDR-TB appears largely to have levelled off among bacteriologically confirmed TB cases in high-burden countries with universal or near universal (>95%) first-line drug susceptibility testing (DST). The treatment success rate, however, continues to decrease. A contributing factor is the substantial proportion of MDR-TB cases that are additionally resistant to either a fluoroquinolone, a second-line injectable agent or both (XDR-TB); high-burden country proportions range from 12.6% to 80.4%. Proportions of XDR-TB range from 5% to 24.8%. Despite much progress in Eastern Europe, critical challenges remain as regards access to appropriate treatment regimens; patient hospitalisation; scale-up of laboratory capacity, including the use of rapid diagnostics and second-line DST; vulnerable populations; human resources; and financing. Solutions to these challenges are aligned with the Post-2015 Global TB strategy. As a first step, the global strategy should be adapted at regional and country levels to serve as a framework for immediate actions as well as longer-term ways forward.

Keywords: European Region; MDR-TB; WHO; XDR-TB; epidemiology; review.

FIGURE 1

Notification rates of MDR-TB cases/100 000 population, European Region, 2012 (reproduced with permission from Tuberculosis Surveillance and Monitoring in Europe 201411). MDR-TB = multidrug-resistant tuberculosis.

FIGURE 2

TB notification rate and estimated incidence in the WHO European Region, 1980–2012. MS = Member States (53 in the WHO European Region); HPC = high-priority countries (i.e., high MDR- and XDR-TB burden countries in the WHO European Region, plus Bulgaria, Romania, Turkey and Turkmenistan); EU = European Union; EEA = European Economic Area; MDR-TB = multidrug-resistant tuberculosis; XDR-TB = extensively drug-resistant TB.

FIGURE 3

Proportion of MDR-TB among all notified TB cases with first-line DST and treatment success rates in countries in Eastern Europe, 2009–2012. Note: Trend-line not drawn where fewer than 4 data points are available. x-axis = year; y-axis = proportion; ♦ = proportion of MDR-TB among all notified TB cases with first-line DST; ▪ = proportion of all notified MDR-TB cases with a successful treatment outcome for that year. MDR-TB = multidrug-resistant tuberculosis; DST = drug susceptibility testing.