INT J TUBERC LUNG DIS 7(8):828–836
© 2003 IUATLD
The new National Tuberculosis Control Programme
in Israel, a country of high immigration
D. Chemtob,*† A. Leventhal,† Y. Berlowitz,‡ D. Weiler-Ravell*†§
* Department of Tuberculosis and AIDS, † Public Health Services and ‡ Deputy Director General, Ministry of Health,
Jerusalem, § Centre for Lung Disease, Clalit Health Services, Haifa, Israel
SUMMARY
SETTING:
Israel has implemented a new tuberculosis
(TB) control programme in response to the rise in the
incidence of tuberculosis due to immigration in the last
decade. It complies with World Health Organization
guidelines, and also includes specific measures addressing the needs of immigrants. We describe the new programme and compare the outcome of treatment prior
and after its realisation.
M E T H O D S : Each component of the new strategy was
scrutinised, aspects that did not function well were identified and how we contended with these issues is
described. Analysis of outcome of treatment was according to WHO/IUATLD definitions.
R E S U L T S : Better and clearer organisation of TB treat-
ment in all its aspects, including cultural sensitivity, has
been obtained. Compliance improved from less than
27% for successful outcome before the new programme
to more than 75% after. In addition to the improvement
in completion rates, the universal use of directly observed
treatment has ensured enhanced adherence.
C O N C L U S I O N : Using legislative, administrative and budgetary measures, as well as clinical guidelines published
by the Ministry of Health, the TB infrastructure in Israel
has been successfully reorganised. The decision to do so
was not only clinically and organisationally justifiable, it
is also economically viable.
K E Y W O R D S : Israel; treatment policy; tuberculosis epidemiology; DOTS; immigration
BETWEEN 1989 and 1995, the population of Israel,
a low tuberculosis (TB) prevalence country, rose from
4.5 to 5.6 million,1 mainly due to mass immigration
from high and moderate TB prevalence countries.
The absolute number of patients almost quadrupled,
from 133 cases in 1989 to 500 in 1991.2 Due to the
premature dismantling of the TB treatment infrastructure that occurred during the 1980s,3 as elsewhere,4 there were not enough health-care workers
experienced in managing TB.5,6 Patient care lacked
expertise, had become disjointed, was not supervised
and was further confounded by the cultural gap
between health workers and the immigrants.7 In addition, under a new National Health Insurance Law
(NHIL), the responsibility for TB shifted from the Ministry of Health (MOH) to four Israeli Health Maintenance Organisations (HMOs), further fragmenting
and weakening TB care. Laboratory services were not
well defined, and testing for drug susceptibility was
not done routinely. Drug supplies were erratic, and
second-line drugs to deal with a rising incidence of TB
drug resistance were virtually non-existent.
We found that 40% of active TB cases were lost to
follow-up before the end of their treatment, and that
‘successful treatment’ was related to the organisation
of TB services; larger TB clinics, although far from
perfect, had better treatment outcomes.5,6
Consequently, in 1995, a new National Tuberculosis Programme (NTP) was recommended, and was
launched in April 1997.8 As in other NTPs,9 the new
programme incorporates the five elements of the
DOTS strategy recommended by the World Health
Organization (WHO):10 1) political commitment; 2)
laboratory diagnostic facilities; 3) directly observed
treatment (DOT); 4) a consistent drug supply, and 5)
a permanent reporting system. It also has four unique
features: 1) DOT is universally applied, with absolutely no exceptions and for the full duration of treatment; 2) DOT is administered using a communitybased strategy supported by the MOH at central and
local level;* 3) unique screening procedures, case
investigation and treatment of latent infection are
performed routinely, particularly for the new immigrant population, and 4) original research was con* In public health administrative terminology this implies the incorporation of ‘horizontal’ (primary care community clinics and
local District Health Offices) and ‘vertical’ (dedicated structures
from the MOH at the top down through TB centres and hospital
wards and the two TB laboratories) organisational structures.
Correspondence to: Daniel Chemtob, MD, MPH, DEA, Director, Department of Tuberculosis and AIDS, Manager, National
Tuberculosis Programme, Ministry of Health, P O Box 1176, Jerusalem 91010, Israel. Tel: (⫹972 2) 672 8112. Fax: (⫹972
2) 672 5568. e-mail: daniel.chemtob@moh.health.gov.il
Article submitted 16 June 2002. Final version accepted 25 February 2003.
Israel’s National Tuberculosis Control Programme
ducted into the cultural-anthropological needs of the
immigrants from Ethiopia and the relevant findings
were applied in the NTP.7
We feel that our experience might benefit other low
prevalence countries, particularly those where TB is
influenced by immigration. We also present data
showing the dramatic increase in successful treatment
outcomes under DOT that followed the implementation of the new NTP.
METHODS
The content of the new NTP
Political commitment and administrative/
budgeting measures
The political will to implement the NTP is evidenced
by law, new administrative directives and medical
guidelines8 and the establishment of a National TB
Unit (the Department of Tuberculosis and AIDS, DTA),
which initiated, coordinated, and implemented all the
measures described. Under section 20 of the Public
Health Ordinance, TB was declared a ‘dangerous
infectious disease’,11 empowering the MOH to limit
the treatment of tuberculosis to nine designated centres using only DOT.12
Four HMOs fund the programme, except for those
investments funded by the MOH. They participated
in evaluating the cost of the NTP, which came to some
US $9668 per ambulatory patient, based on a mix of
cases, simple and complicated.13 Each HMO appointed
a senior official responsible for TB and AIDS within
the organisation who liaises with the DTA on all
issues pertaining to TB and AIDS.
Laboratory diagnostic facilities
Two regional laboratories, one of which is also the
National Reference Laboratory, process all specimens
from patients followed at the TB centres. Smears and
cultures for in-patients are done only in hospital laboratories with a minimum turnover of specimens.
Positive isolates from hospital laboratories are sent to
the two regional laboratories. Only the National Reference Laboratory14 performs drug susceptibility testing (DST) for second-line drugs. All isolates in the
country are stored here and restriction fragment length
polymorphism (RFLP) analysis is performed for epidemiological investigations15 and for clinical application when needed.
Directly observed treatment (DOT)
All ambulatory TB patients are followed at one of the
nine TB centres. These are located to enable convenient access for most patients. Wherever possible we
avoided TB centres in hospitals, as hospital physicians are often late for out-patient clinics and will
often have something more urgent to deal with than
TB patients. This is not conducive to compliance with
prolonged TB treatment.
829
Treatment is by DOT for the entire duration of
treatment, and not only for the initial 2-month
period, as frequently done elsewhere.9 We use standard regimens such as 2HRZ/4HR, 2EHRZ/4HR,
2SHRZ/4HR, 2E3H3R3Z3/4H3R3,*8 and DOT is usually administered at the primary care community
HMO clinic that is most convenient for the patient.
Limiting treatment to only a few centres assures a critical mass of TB cases, which in turn allows for the accumulation of the experience and motivation needed for
efficiently treating difficult patients,16 such as multidrugresistant (MDR) patients, patients requiring customtailored DOT with daily or more home visits, and
difficult-to-reach patients such as new immigrants7 and
the homeless, drug addicts, alcoholics and other patients
with socio-economic or psycho-social problems.17
The district health offices (DHOs), answerable to
the DTA, supervise the TB centres through regular
meetings. In order to be reimbursed by the HMO, the
TB centre has to provide 90% fulfilment of the drug
regimen on DOT each month. Less than 90% results
in repetition of that month’s treatment at the centre’s
expense.8
The NHIL provides full coverage of treatment of
all TB patients for Israeli residents, while the MOH
covers uninsured tourists, foreign workers and their
families.8. In the interests of expertise in treatment
and to allow concentration of resources, hospitalisation is confined to two wards, one in the north and
one near Tel Aviv. These have been equipped with air
sterilisation and other measures, in accordance with
the guidelines of the Centers for Disease Control and
Prevention,18 to ensure the safety of the staff and of
the other patients. Our policy is to reduce hospitalisation of TB patients to a minimum. The main indication for hospitalisation is difficulty in ambulatory
care due to severe social problems; medical indications are severity of disease and the need to adjust
treatment regimens due to drug reactions or drug
resistance. Continuity of care at the time of discharge
from hospital to the community is a particularly
important aspect of our programme. We try to ensure
that all aspects of DOT in the community are
arranged so that at discharge the patient finds a medical team in the community familiar with his case,
with all medications ready to continue treatment.
Discharge from hospital prior to setting up ambulatory DOT is not permitted (Table 1).
Regular drug supplies
Regular drug supplies were problematic at the onset
of the NTP. With only about 400–600 new cases of
TB a year, the expense of registering new drugs
* H ⫽ isoniazid; R ⫽ rifampicin; Z ⫽ pyrazinamide; E ⫽ ethambutol; S ⫽ streptomycin. Numbers before the letters indicate the
duration of the treatment phase in months. Numbers in subscript
indicate the number of times the drug is given per week.
830
Table 1
The International Journal of Tuberculosis and Lung Disease
Outline of the new Israeli NTP
Core (WHO recommendations)
Political commitment of Ministry of Health: legislating new TB regulations and establishing a dedicated National TB Department in the
MOH, with an independent budget.
Adequate laboratory diagnostic facilities by limiting laboratory involvement mainly to two regional TB laboratories, with adequate
facilities.
Standardised short-course chemotherapy, free of charge, under proper case management conditions, including DOT.
Consistent drug supplies (centralised purchasing and supply of drugs).
Permanent reporting system, with supervision and monitoring through District Health Offices of the MOH by the National TB
Department. In addition, an on-line computerised TB database will be accessible to clinicians and public health personnel.
Enhancing features
Use of existing health care networks with specific additions.
Involvement of the primary health providers (HMOs) in planning, execution, monitoring and ongoing evaluation; consensus on costs.
Treatment under the responsibility of a limited number of regional TB centres (geographical accessibility, critical mass of patients, building
a new cadre of TB expertise), and the involvement of the primary health care system for supervised treatment.
DOT for all and for the total period of treatment.
Built-in liaison between TB centres and DHO supervisors: a team management approach.
Screening immigrants from endemic areas and treatment of latent infection.
Cultural sensitivity—training immigrant health workers to bridge cultural gaps between immigrants and health professionals.
Regular training programme for clinical and public health personnel.
Incentives for completion of treatment for both patient and TB centre.
Legal sanctions for absconders.
Limitation of hospitalisation to two regional centres.
Built-in ongoing evaluation (both process and outcome).
NTP ⫽ National Tuberculosis Programme; MOH ⫽ Ministry of Health; DOT ⫽ directly observed treatment; HMO ⫽ Health Maintenance Organisation; DHO ⫽
District Health Office.
deterred private importation of anti-tuberculosis medications, particularly of second-line drugs. Except for
isoniazid 300 mg (only 50 mg tablets were initially
available, but a local company was eventually persuaded to produce a 300 mg tablet), first-line drugs
were obtainable, but all the second line drugs, including ethionamide, cycloserine, capreomycin and others,
had to be ordered using special procedures. A central
supply agency now delivers a regular supply of TB
drugs, and the DTA maintains a reserve cache of all
drugs to ensure non-interruption of supplies.
Permanent reporting system
TB notification to the MOH is mandatory for both
physicians and laboratories. Individualised data on
Figure 1
TB notification and DST reports are reported at district and national levels. The annual incidence of
tuberculosis for the years 1974–2001 is shown in
Figure 1. Outcome of treatment reports are aggregated at the district level according to directives
issued by the DTA, in accordance with WHO/IUATLD
recommendations.19 A goal of the programme is to
have on-line computerised TB data for epidemiological, clinical and laboratory services available for
all TB partners.20
Unique features of the programme
The universal use of DOT for the full period of treatment
and the provision of DOT by primary care community
clinics without extraordinary resources are unique.
Incidence of tuberculosis in Israel, 1974–2001 (per 100 000 population).
Israel’s National Tuberculosis Control Programme
Screening procedures, contact investigation
and treatment of latent infection
We follow accepted guidelines regarding contact
investigation, case finding and treatment of latent
infection.21 Immigrants from Ethiopia are screened
on arrival by skin testing and radiography when
appropriate. Among this high-risk population, children up to 5 years of age with negative skin tests are
vaccinated with BCG, and those up to the age of 18
who test positive receive DOT for latent infection.
Many adults with positive skin tests also get their
medication under direct observation. This is possible because new immigrants often stay together in
absorption centres for several months before relocation to a permanent home. Since 1991 we have
emphasised human immunodeficiency virus (HIV)
co-morbidity among new immigrants from subSaharan Africa,22 through HIV and TB active case
finding.23
Cultural sensitivity: an important element for
TB control in migrant populations
Israel is a country of immigration,24 as illustrated in
Figure 2. Some 85% of TB cases are foreign-born,
mainly Israeli citizens from the Former Soviet Union
(FSU) and from Ethiopia. Addressing the difference
between Ethiopian and Israeli life styles, we used
anthropological tools to evaluate the needs of Ethiopian immigrants and health professionals dealing
with them, and to train Ethiopian health workers to
assist the DHOs and the TB clinics in bridging the
831
culture gap with the immigrants, as described in
detail elsewhere.7
Methods for outcome of treatment evaluation
We compare treatment outcome before and after
implementation of the new NTP. In 1998, new definitions on treatment outcome were adopted by a
working group of the WHO and the European
Region of the IUATLD,19 analysing treatment outcome by annual cohort. In order to be able to compare the two periods (before vs. after the new NTP),
we re-analysed treatment outcome according to the
outcome classification recommended by the working group.6 For data for the period January 1990–
September 1992, we used ‘a proxy’ outcome analysis
based on the main categories defined by the working
group. We defined two mutually exclusive groups,
‘new cases’ and ‘re-treatment cases’;6 the analysis was
performed in both groups according to three mutually exclusive categories: ‘successful outcome’, ‘death’,
and ‘potentially unsatisfactory outcome’. ‘Successful
outcome’ was applied according to the WHO/
IUATLD definition (within 12 months after the start
of treatment).19 All the other notified cases, with the
exception of those known to have died during treatment, were defined as ‘potentially unsatisfactory outcome’, irrespective of whether any follow-up information was available. Since the cohort of 1999, our
outcome analysis is based exactly on the WHO/
IUATLD definition,19 in which seven mutually exclusive categories are used for culture-positive pulmonary
Figure 2 Tuberculosis cases according to population groups, by percentage of the annual total
absolute numbers, Israel 1989–2001.
832
The International Journal of Tuberculosis and Lung Disease
TB cases: cured, completed, died, failed, defaulted,
transferred and not evaluated.
RESULTS
The new TB infrastructure
Political commitment and administrative/
budgeting measures
Most of the proposed changes described were implemented according to the new NTP regulations. As a
result, better and clearer organisation of TB treatment in almost all the aspects has been achieved.
In this section, we address those aspects of the programme that did not function in a satisfactory manner, and describe how we contended with these issues.
Laboratory diagnostic facilities
Centralised bacteriology, in the interests of efficiency,
centralisation of data and the possibility of introducing new and expensive technologies to serve the entire
health community, has proved difficult to implement.
Hospitals conduct their own TB diagnostic procedures and do not always transfer isolates to the central laboratories.25 This causes delays in obtaining
DST results for second-line drugs, and sometimes delays
the results of DST for first-line drugs. We modified the
prior recommendations and used financial incentives
to improve compliance: we requested the hospital laboratories to forward isolates promptly to the regional
TB laboratories, after identification of Mycobacterium
tuberculosis complex, and not to do further bacteriological testing. We also asked the regional laboratories to invoice the TB centres directly. As a result we
shifted all the costs for strain identification and DST
to the TB centres from the hospital laboratory that
first diagnosed the case, as an incentive to limit inhouse laboratory testing to a minimum.
DOT
DOT worked very well for most of the TB cases, in
particular for those with no or a moderate level of
social difficulties. However, when analysing all TB
patients under treatment in 1999, some 12% were
defined as complex TB cases, mostly for social reasons, and their compliance was poor, despite all the
support they received.26 We are in the process of
addressing this problem by adding a network of social
workers to the staff of the TB centres, to deal specifically with complex TB patients.
Regular drug supplies
Full cooperation with this aspect of the NTP has not
been forthcoming from the HMO that operates three
of the nine TB centres. This has sometimes caused
delays in drug supplies for these centres, but they
have always been able to obtain drugs from the MOH
supplier on request.
Permanent reporting system
and process evaluation
Linking TB notification and monthly evaluation of
the DOT by the DHO to reimbursement of the TB
centre by the HMO has been an incentive for good
notification and an important tool for supervision of
the TB centres.
Ongoing process evaluation27 has already enabled us
to detect and correct some of the weaknesses of the new
NTP. This overall supervision will be facilitated by the
on-line computerisation of the medical-epidemiological
file between all TB partners.20
TB incidence and outcome of treatment results
Since the late 1980s, TB incidence has risen from 3.5
cases per 100 000 population in 1989, before the
start of mass immigration from the FSU, to some 11/
100 000 in 1998 (Figure 1). This rise is generally concomitant with immigration from endemic countries.24
In recent years, some 80–85% of TB cases are foreignborn, mostly naturalised Israeli citizens from Ethiopia or from the FSU. In Figure 2, we can see how,
during the last decade, incidence is related to the
country of origin: Ethiopia or the FSU. In 1991, some
54% of new TB cases were from Ethiopia; as the
decade progressed, more cases came from the FSU.
There is also a rise in the last years in TB diagnosed
among non-Israelis—foreign workers or tourists;
around 7–9% of total TB cases.24
The cohort analysis of outcome of treatment for
the years 1999–2000 of culture-positive pulmonary
TB cases is seen in Table 2. There is a real improvement in treatment outcome, from less than 27%
before the new NTP to more than 75% of ‘cured’ or
‘completed’ cases after. In addition, respectively 2.4%
and 6.9% of the outcome were among ‘transferred
cases’ in 1999 and 2000, and respectively 4.3% and
1.2% were ‘failed cases’. Lastly, 10% of TB cases died,
compared to some 5% prior to the new NTP. When
further analysing the cause of death, not all cases died
due to TB but rather with TB (18% and 25% of deaths
in 1999 and 2000, respectively). Concerning deaths
due to TB, diagnosis was made less than 1 week before
death in 10% of cases, and after death in 25% and
12% of cases in respectively 1999 and 2000.
Reported completion of treatment
vs. fully supervised treatment
In addition to the improvement in successful outcome
of treatment since the new NTP, another major
improvement is fully supervised treatment. Under the
new programme with universal DOT, treatment completion includes adherence, whereas before completion did not ensure adherence.
Cost-effectiveness analysis
Cost-effectiveness analysis is beyond the scope of this
paper. However, before starting the new NTP, a cost-
Israel’s National Tuberculosis Control Programme
833
Table 2 Trends in treatment outcome for pulmonary culture-positive cases only, before and after implementation of the new NTP,
according to WHO/IUATLD definitions19 (and their proxy for the period January 1990 to September 1992)
Period
Pulmonary
culturepositive
cases
n
Outcome of treatment %
Died
Successful outcome
January 1990–September 1992
New cases
Retreated cases
Total
1999
New cases
Retreated cases
Total
2000
New cases
Retreated cases
Total
196
10
206
24.5
70.0
26.7
Not evaluated
Potentially unsatisfactory outcome
5.6
10.0
5.8
69.9
20.0
67.5
Cured
Completed
289
36
325
73.0
50.0
78.5
9.0
0
10.4
11.1
10.5
2.1
22.3
4.3
2.8
8.3
3.4
1.7
8.3
2.4
0.1
0
0.9
320
26
346
67.2
23.1
76.9
10.3
46.1
10.6
3.8
10.1
0.9
3.8
1.2
2.8
3.8
2.9
6.9
7.9
6.9
1.3
11.5
2.0
effectiveness analysis was done13 and it was estimated
that despite the additional costs for infrastructure,
Israel would save between US $3.46 and $4.20 million in resources if 600 new TB cases needed treatment annually.
DISCUSSION
The rationale for a new NTP in a low prevalence
country was the concern that with the rise in the caseload and the depletion of anti-tuberculosis resources,
events might overtake Israel as they did in New York
City.16 Israel provides full medical coverage to all residents using a patient approach, as in other Bismarckian Health Systems.28 However, contact investigation
and follow-up of treatment adherence, a major public
health problem,4,9,10,29 is best dealt with by a community approach,30 and by a single entity, not by four
different HMOs.
Our public health service is community-oriented,
with a DHO for each region. We used this system and
the network of primary care community clinics run
by the HMOs to construct a new entity in TB control
and care. This incorporates the principal of vertical
and horizontal structures in implementing a health
programme. The vertical element runs from the DTA
through the DHO and regional TB centres, and ends
with reimbursement of the TB centres by the HMOs for
each individual treated in the programme. We had to
overcome the resistance of the HMOs to take on activities related to TB, which they perceived as public health
measures. Working on the problem together with them
and allowing transparency of all financial aspects of the
programme finally overcame this resistance.
The new NTP has rejuvenated clinical expertise in
the field of TB management. This has benefited clini-
Failed
Defaulted Transferred
cal and public health nurses and physicians in both
fields, and the laboratory services: without centralised laboratory services there would have been great
difficulty in mastering modern mycobacteriology,14
including rapid, accurate susceptibility testing and
molecular biology, in a satisfactory manner.15 It has
also ensured close cooperation between clinicians and
laboratory personnel.
The horizontal element of the programme is in
the MOH and in the clinical part of the NTP. In the
MOH, the DHOs interact with each other and with
the TB centres in a horizontal manner. On another
level, both the TB centres and the DHOs interact with
the community clinics in a similar manner. Likewise,
the two regional laboratories interact in a horizontal
fashion with each other and with the TB centres.
Using the existing infrastructure of primary health
care clinics, run by the different HMOs but united by
the conceptual and practical acceptance of the NTP,
has led to considerable savings,13 and easy access for
the patients treated in the community with DOTS.
The reimbursement of the centres is paid out of the
global budget of each HMO. Using a flat rate for
treatment has provided an incentive for the TB centres to complete treatment expeditiously. This is a
classic case of the ‘money follows the patient’31 principle of health economics, whereby the more patients
and contacts the TB centre treats, and treats well, the
more efficient the operation becomes.
The concept of DOTS for all, not on a basis of
patients perceived (often erroneously) to be difficult
cases, but across the board, has significantly improved
the outcome of treatment (Table 2). The actual figures
may be better because some of the ‘defaulted’ and
‘transferred’ cases notified in an aggregate manner are
quite likely ‘cured’ or ‘completed cases’. At present,
834
The International Journal of Tuberculosis and Lung Disease
we do not have individualised data for outcome of
treatment at a central level to enable us to confirm
this. Whether the increase in death rates after the
implementation of the new programme is a true phenomenon or due to an increase in the awareness of TB
remains to be seen.
The use of DOTS elsewhere is increasing (21 countries implemented DOTS in 2000, bringing the total
to 148/210),29 but it is still a controversial issue, particularly in low-incidence countries. In the WHO
European Region only 17* countries (out of 51) are
using DOTS nationwide (out of 95 countries globally).29 Of the 23 countries in the West WHO European Region (WWER), only seven countries have
adopted DOTS fully (Andorra, Austria, Israel, Malta,
the Netherlands, Norway and Portugal), and Italy has
applied DOTS in an expansion phase.29
In the WWER, TB incidence is low (an average of
12.6/100 000 in 1999), consistent with the finding32
of a reduction or stabilisation in TB incidence in
Western Europe since the late 1980s.33 This analysis
does not reflect the impact of the immigrant population in Western Europe. In the WWER, 27% of notified cases in 1999 were of foreign origin; in nine
countries this figure was more than 50%; the highest
rate, 86.2%, was in Israel.33
The last WHO global report includes outcome of
treatment for 1999 according to WHO/IUATLD
definitions19 for only seven countries (Andorra, Austria,
Italy, Malta, the Netherlands, Norway and Portugal).†29
In this paper, we present data on treatment outcome for Israel for 1999–2000. The successful outcome for pulmonary culture-positive cases in Israel is
similar to that reported for 1999 among smear-positive
cases by the Netherlands, Norway and Portugal (all
implement full coverage of DOTS) and the USA.29
Nevertheless, it remains to be seen whether treatment outcome in low incidence countries that are
not using DOTS, especially those where the rate of
TB among foreign born is high, will be worse than in
similar countries that have adopted this WHOrecommended strategy.
DOTS alone, however, is probably not the only
reason for the improvements in treatment outcome in
Israel. As described elsewhere,9 other complementary
factors (integration of vertical and horizontal structures, cultural sensitivity, staff training and motivation,
incentives, defaulter tracing) are important elements of
the programme. Our use of existing resources in the
community rather than additional expenditure for
DOTS, and our approach to Ethiopian immigrants,
are examples of additional elements in the programme
* In the 2002 WHO Report,29 Israel was mistakenly not registered
as a country with full DOTS coverage.
† Data on outcome for Israel are not in this report29 because, as recommended,19 we classified outcome of treatment according to culture rather than according to smear.
that might benefit other low TB prevalence countries, particularly those where TB is influenced by
immigration.
Acknowledgements
We gratefully acknowledge the health care professionals who are
implementing this new TB programme with so much energy and
devotion, on behalf of their TB patients and families. Not to be forgotten is the role of the members of the Advisory Committee on TB
to the Ministry of Health, for their contribution to the planning of
this programme. Finally, we gratefully acknowledge the role of
Professor G Barbash, then Director General of the MOH, whose
intervention made the programme a reality.
Members of the initial MOH TB Advisory Committee: Baum
G, Chemtob D, Efrat M, Gabbay D, Lavy A, Lidji M, Marcus J,
Rishpon S, Schwarz T, Wartski S, Weiler-Ravell D (Chairman).
The opinions expressed in this article are those of the authors
and do not purport to represent the opinions of the agencies with
which they are associated.
Part of this paper was presented in abstract form in Paris at the
Conference on Global Lung Health and the 1997 Annual Meeting
of the IUATLD in Paris.
References
1 Central Bureau of Statistics. Statistical Abstract of Israel, No.
53. Jerusalem: Central Bureau of Statistics, 2002.
2 Chemtob D. Tuberculosis in Israel—epidemiological data
1993. Jerusalem: Ministry of Health, 1994.
3 Wartski S A. Epidemiology and control of tuberculosis in Israel. Public Health Rev 1995; 23: 297–341.
4 Reichman L B. Fear, embarrassment, and relief: the tuberculosis epidemic and public health. Am J Public Health 1993; 83:
639–641.
5 Chemtob D. Completion of Tuberculosis treatment in Ethiopian immigrants compared to other population groups, Israel
1990–1992. Dissertation for the degree of Masters in Public
Health (MPH). Jerusalem, Israel: Hebrew University of Jerusalem, 1995.
6 Chemtob D, Epstein L, Slater P E, Weiler-Ravell D. Epidemiological analysis of tuberculosis treatment outcome as a tool for
changing tuberculosis control policy in Israel. Israel Med Assoc
J 2001; 3: 479–483.
7 Chemtob D, Weiser S, Yitzhak I, Weiler-Ravell D. Medical
anthropology—an important adjunct to international TB control. In: Reichman L B, Hershfield E S, eds. Tuberculosis: A
Comprehensive International Approach. 2nd ed. New York:
Marcel Dekker, 2000: pp 745–770.
8 Israeli Ministry of Health. National Program for the Elimination of Tuberculosis. Circular No. 3/97 of the Director General, 30/03/97, and circular No. 7/98, 12/05/98, Jerusalem:
Israeli Ministry of Health. [in Hebrew].
9 Volmink J, Matchaba P, Garner P. Directly observed therapy
and treatment adherence. Lancet 2000; 355: 1345–1350.
10 World Health Organization. WHO Tuberculosis Programme:
framework for effective tuberculosis control. WHO/TB/94.
Geneva: WHO, 1994.
11 State of Israel. Law Amendment: ‘Considering Tuberculosis as
a dangerous infectious disease’. Gazette 4427, 14/07/1996, (in
Hebrew).
12 Weiler-Ravell D, Chemtob D, Leventhal A. The mandatory
hospitalization of recalcitrant contagious TB patients in Israel.
Int J Tuberc Lung Dis 1997; 1 (Suppl 1): S85.
13 Chemtob D, Ginsberg G M, Weiler-Ravell D. Cost-effectiveness
analysis of a new national TB policy in Israel. Int J Tuberc
Lung Dis 1997; 1 (Suppl 1): S137.
14 Mates A, Weiler-Ravell D, Chemtob D. Regulation of laboratory testing for Mycobacterium tuberculosis in a new National
Israel’s National Tuberculosis Control Programme
15
16
17
18
19
20
21
22
23
TB Program in Israel. Int J Tuberc Lung Dis 1997; 1 (Suppl 1):
S148–S149.
Weiler-Ravell D, Chemtob D, Volovik I et al. Concomitant use
of classic and molecular epidemiology (RFLP & spoligotyping)
for investigating TB outbreaks in Israeli boarding schools. Eur
Respir J 2000; 16 (Suppl 31): S296.
Frieden T R, Fujiwara P I, Washko R M, Hamburg M A.
Tuberculosis in New York City—turning the tide. N Engl J
Med 1995; 333: 229–233.
Sumartojo E. When tuberculosis treatment fails. A social behavioural account of patient adherence. Am Rev Respir Dis
1993; 147: 1311–1320.
Centers for Disease Control and Prevention. Guidelines for
preventing the transmission of Mycobacterium tuberculosis in
health care facilities, 1994. MMWR 1994; 43(RR-13): 1–132.
Veen J, Raviglione M C, Rieder H L et al. Standardized tuberculosis treatment outcome monitoring in Europe. Recommendations of a working group of the WHO and the European
Region of the International Union Against Tuberculosis and
Lung Disease (IUATLD) for uniform reporting by cohort analysis of treatment outcome of tuberculosis patients. Eur Respir
J 1998; 12: 505–510.
Chemtob D, Weiler-Ravell D, Wallach G. Computerization of
a new TB control program in Israel. Int J Tuberc Lung Dis
1999; 3 (Suppl 1): S167.
American Thoracic Society, Centers for Disease Control. Treatment of tuberculosis and tuberculosis infection in adults and
children. Am J Respir Crit Care Med 1994; 149: 1359–1374.
Chemtob D, Weiler-Ravell D. Tuberculosis associated with
AIDS in Israel, 1981–1998. Budapest, Hungary: First Congress
of the IUATLD, Europe Region, 2000: 131.
Wartski S A. Tuberculosis case finding and treatment in Ethiopian immigrants to Israel, 1989–1991. Isr J Med Sci 1993; 29:
376–380.
835
24 Chemtob D, Leventhal A, Weiler-Ravell D. Screening and management of tuberculosis in immigrants: the challenge beyond
professional competence. Int J Tuberc Lung Dis 2003 (in press).
25 Chemtob D, Weiler-Ravell D. Incorrect estimation of TB drug
resistance in Israel, probably due to recruitment and collection
biases. Int J Tuberc Lung Dis 2000; 4: 990–991.
26 Chemtob D, Damelin B, Ben Shachar I, et al. The impact of intervention by welfare social workers on TB patients’ adherence, as assessed by TB nurses in Israel. Int J Tuberc Lung Dis
2001; 5 (Suppl 1): S170.
27 Damelin B, Chemtob D, Shmulovich L, Weiler-Ravell D. Process Evaluation of a new TB program in Israel. Int J Tuberc
Lung Dis 1999; 3 (Suppl 1): S167.
28 Vienonen M. Health care reforms in Europe: evolutions, revolution or seesaw. In: Shemer J, Vienonen M, eds. Reform
Health Care Systems. Jerusalem: Gefen Publishing House,
1995.
29 World Health Organization. Global tuberculosis control: surveillance, planning, financing. WHO Report 2002. WHO/
CDS/TB/2002.295. Geneva: WHO, 2002.
30 Kark S L. Epidemiology and community health. New York:
Appelton Century Crofts, 1974.
31 Ham Cris. Health care reforms in the UK: lessons from experience in governments and health systems: implications for different involvements. In: Chinitz D, Cohen J, eds. London: John
Wiley & Sons, 1998.
32 Raviglione M C, Sudre P, Rieder H L, Spinaci S, Kochi A. Secular trends of tuberculosis in Western Europe. Bull World
Health Organ 1993; 71: 297–306.
33 EuroTB (InVS/KNCV) and the national coordinators for
tuberculosis surveillance in the WHO European Region. Surveillance of Tuberculosis in Europe. Report on tuberculosis
cases notified in 1999. France: EuroTB, March 2002.
RÉSUMÉ
C A D R E : Israël
a mis en œuvre un nouveau programme de
lutte contre la tuberculose (TB) à la suite de l’augmentation d’incidence de la TB, due à l’immigration au cours
de la dernière décennie. Il est en conformité avec les
directives de l’OMS et inclut, par ailleurs, des mesures
spécifiques répondant aux besoins des immigrants.
Nous décrivons le nouveau programme et comparons le
résultat du traitement avant et après sa mise en place.
M É T H O D E S : Nous examinons en détail chaque composante de la nouvelle stratégie et insistons sur les
aspects qui ne fonctionnaient pas correctement, ainsi
que sur la manière dont nous avons fait face à ces
problèmes. L’analyse du résultat du traitement a été conduite selon les définitions de l’OMS/UICTMR.
R É S U L T A T S : Nous avons clarifié et amélioré l’organisa-
tion du traitement de la tuberculose dans tous ses
aspects, y compris ceux ayant trait aux différences culturelles. L’adhésion s’est améliorée : de 27% de « résultats favorables » avant le nouveau programme a plus de
75% après sa mise en place. Outre l’amélioration du
taux d’achèvement du traitement, l’utilisation généralisée du DOT a assuré un renforcement de l’adhésion.
C O N C L U S I O N : Grâce a des mesures législatives, administratives et budgétaires, ainsi qu’aux directives cliniques
publiées par le Ministère de la Santé, l’infrastructure TB
en Israël a été réorganisée avec succès. L’application de
ce programme s’est avérée justifiée non seulement du
point de vue clinique et organisationnel, mais aussi sur le
plan économique.
RESUMEN
Israel ha implementado un
nuevo programa de control de la tuberculosis (TB), como
consecuencia de un aumento de la incidencia de TB, debido
a la inmigración en la última década. Este programa sigue
las directrices de la OMS y además incluye medidas específicas en relación con las necesidades de los inmigrantes. Se
describe el nuevo programa y se compara el resultado del
tratamiento antes y después de su implementación.
MARCO DE REFERENCIA :
Se examinó a fondo cada componente de la
nueva estrategia y se puso énfasis en los aspectos que no
funcionaban correctamente y en la manera como se
habían enfrentado estos problemas. El análisis de los
resultados del tratamiento se efectuó según las definiciones de la OMS y de la UICTER.
R E S U L T A D O S : Se obtuvo una mejor y más clara organización del tratamiento de la TB en todos sus aspectos,
MÉTODO :
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The International Journal of Tuberculosis and Lung Disease
incluyendo aquéllos relacionados con las diferencias culturales. El cumplimiento del tratamiento mejoró de
menos de 27% de ‘resultados exitosos’ antes del nuevo
programa a más de 75% después de su implementación.
Además del mejoramiento de las tasas de cumplimiento,
el uso generalizado del DOT ha asegurado un refuerzo
de la adhesión.
C O N C L U S I Ó N : La infraestructura de la TB en Israel ha
sido reorganizada con éxito poniendo en práctica medidas legislativas, administrativas y presupuestarias, así
como directrices clínicas publicadas por el Ministerio de
la Salud. La aplicación de este programa se justificaba
no solamente desde el punto de vista clínico y organizativo, sino que también fue económicamente viable.