INT J TUBERC LUNG DIS 7(8):828–836© 2003 IUATLD

The new National Tuberculosis Control Programmein 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,

S U M M A R Y

Jerusalem, § Centre for Lung Disease, Clalit Health Services, Haifa, Israel

SETTING: Israel has implemented a new tuberculosis(TB) control programme in response to the rise in theincidence of tuberculosis due to immigration in the lastdecade. It complies with World Health Organizationguidelines, and also includes specific measures address-ing the needs of immigrants. We describe the new pro-gramme and compare the outcome of treatment priorand after its realisation.METHODS: Each component of the new strategy wasscrutinised, aspects that did not function well were iden-tified and how we contended with these issues isdescribed. Analysis of outcome of treatment was accord-ing to WHO/IUATLD definitions.RESULTS: Better and clearer organisation of TB treat-

ment in all its aspects, including cultural sensitivity, hasbeen obtained. Compliance improved from less than27% for successful outcome before the new programmeto more than 75% after. In addition to the improvementin completion rates, the universal use of directly observedtreatment has ensured enhanced adherence.CONCLUSION: Using legislative, administrative and bud-getary measures, as well as clinical guidelines publishedby the Ministry of Health, the TB infrastructure in Israelhas been successfully reorganised. The decision to do sowas not only clinically and organisationally justifiable, itis also economically viable.KEY WORDS: Israel; treatment policy; tuberculosis epi-demiology; DOTS; immigration

BETWEEN 1989 and 1995, the population of Israel,a low tuberculosis (TB) prevalence country, rose from4.5 to 5.6 million,1 mainly due to mass immigrationfrom 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 thepremature dismantling of the TB treatment infra-structure that occurred during the 1980s,3 as else-where,4 there were not enough health-care workersexperienced in managing TB.5,6 Patient care lackedexpertise, had become disjointed, was not supervisedand was further confounded by the cultural gapbetween health workers and the immigrants.7 In addi-tion, under a new National Health Insurance Law(NHIL), the responsibility for TB shifted from the Min-istry of Health (MOH) to four Israeli Health Mainte-nance Organisations (HMOs), further fragmentingand weakening TB care. Laboratory services were notwell defined, and testing for drug susceptibility wasnot done routinely. Drug supplies were erratic, andsecond-line drugs to deal with a rising incidence of TBdrug resistance were virtually non-existent.

We found that 40% of active TB cases were lost tofollow-up before the end of their treatment, and that‘successful treatment’ was related to the organisation

of TB services; larger TB clinics, although far fromperfect, had better treatment outcomes.5,6

Consequently, in 1995, a new National Tuberculo-sis Programme (NTP) was recommended, and waslaunched in April 1997.8 As in other NTPs,9 the newprogramme incorporates the five elements of theDOTS strategy recommended by the World HealthOrganization (WHO):10 1) political commitment; 2)laboratory diagnostic facilities; 3) directly observedtreatment (DOT); 4) a consistent drug supply, and 5)a permanent reporting system. It also has four uniquefeatures: 1) DOT is universally applied, with abso-lutely no exceptions and for the full duration of treat-ment; 2) DOT is administered using a community-based strategy supported by the MOH at central andlocal level;* 3) unique screening procedures, caseinvestigation and treatment of latent infection areperformed routinely, particularly for the new immi-grant population, and 4) original research was con-

* In public health administrative terminology this implies the in-corporation of ‘horizontal’ (primary care community clinics andlocal District Health Offices) and ‘vertical’ (dedicated structuresfrom the MOH at the top down through TB centres and hospitalwards and the two TB laboratories) organisational structures.

Correspondence to: Daniel Chemtob, MD, MPH, DEA, Director, Department of Tuberculosis and AIDS, Manager, NationalTuberculosis Programme, Ministry of Health, P O Box 1176, Jerusalem 91010, Israel. Tel: (�972 2) 672 8112. Fax: (�9722) 672 5568. e-mail: daniel.chemtob@moh.health.gov.ilArticle submitted 16 June 2002. Final version accepted 25 February 2003.

Israel’s National Tuberculosis Control Programme 829

ducted into the cultural-anthropological needs of theimmigrants from Ethiopia and the relevant findingswere applied in the NTP.7

We feel that our experience might benefit other lowprevalence countries, particularly those where TB isinfluenced by immigration. We also present datashowing the dramatic increase in successful treatmentoutcomes under DOT that followed the implementa-tion of the new NTP.

METHODS

The content of the new NTP

Political commitment and administrative/budgeting measuresThe political will to implement the NTP is evidencedby law, new administrative directives and medicalguidelines8 and the establishment of a National TBUnit (the Department of Tuberculosis and AIDS, DTA),which initiated, coordinated, and implemented all themeasures described. Under section 20 of the PublicHealth Ordinance, TB was declared a ‘dangerousinfectious disease’,11 empowering the MOH to limitthe treatment of tuberculosis to nine designated cen-tres using only DOT.12

Four HMOs fund the programme, except for thoseinvestments funded by the MOH. They participatedin evaluating the cost of the NTP, which came to someUS $9668 per ambulatory patient, based on a mix ofcases, simple and complicated.13 Each HMO appointeda senior official responsible for TB and AIDS withinthe organisation who liaises with the DTA on allissues pertaining to TB and AIDS.

Laboratory diagnostic facilitiesTwo regional laboratories, one of which is also theNational Reference Laboratory, process all specimensfrom patients followed at the TB centres. Smears andcultures for in-patients are done only in hospital lab-oratories with a minimum turnover of specimens.Positive isolates from hospital laboratories are sent tothe two regional laboratories. Only the National Ref-erence Laboratory14 performs drug susceptibility test-ing (DST) for second-line drugs. All isolates in thecountry are stored here and restriction fragment lengthpolymorphism (RFLP) analysis is performed for epi-demiological investigations15 and for clinical applica-tion when needed.

Directly observed treatment (DOT)All ambulatory TB patients are followed at one of thenine TB centres. These are located to enable conve-nient access for most patients. Wherever possible weavoided TB centres in hospitals, as hospital physi-cians are often late for out-patient clinics and willoften have something more urgent to deal with thanTB patients. This is not conducive to compliance withprolonged TB treatment.

Treatment is by DOT for the entire duration oftreatment, and not only for the initial 2-monthperiod, as frequently done elsewhere.9 We use stan-dard regimens such as 2HRZ/4HR, 2EHRZ/4HR,2SHRZ/4HR, 2E3H3R3Z3/4H3R3,*8 and DOT is usu-ally administered at the primary care communityHMO clinic that is most convenient for the patient.Limiting treatment to only a few centres assures a criti-cal mass of TB cases, which in turn allows for the accu-mulation of the experience and motivation needed forefficiently treating difficult patients,16 such as multidrug-resistant (MDR) patients, patients requiring custom-tailored DOT with daily or more home visits, anddifficult-to-reach patients such as new immigrants7 andthe homeless, drug addicts, alcoholics and other patientswith socio-economic or psycho-social problems.17

The district health offices (DHOs), answerable tothe DTA, supervise the TB centres through regularmeetings. In order to be reimbursed by the HMO, theTB centre has to provide 90% fulfilment of the drugregimen on DOT each month. Less than 90% resultsin repetition of that month’s treatment at the centre’sexpense.8

The NHIL provides full coverage of treatment ofall TB patients for Israeli residents, while the MOHcovers uninsured tourists, foreign workers and theirfamilies.8. In the interests of expertise in treatmentand to allow concentration of resources, hospitalisa-tion is confined to two wards, one in the north andone near Tel Aviv. These have been equipped with airsterilisation and other measures, in accordance withthe guidelines of the Centers for Disease Control andPrevention,18 to ensure the safety of the staff and ofthe other patients. Our policy is to reduce hospitalisa-tion of TB patients to a minimum. The main indica-tion for hospitalisation is difficulty in ambulatorycare due to severe social problems; medical indica-tions are severity of disease and the need to adjusttreatment regimens due to drug reactions or drugresistance. Continuity of care at the time of dischargefrom hospital to the community is a particularlyimportant aspect of our programme. We try to ensurethat all aspects of DOT in the community arearranged so that at discharge the patient finds a med-ical team in the community familiar with his case,with all medications ready to continue treatment.Discharge from hospital prior to setting up ambula-tory DOT is not permitted (Table 1).

Regular drug suppliesRegular drug supplies were problematic at the onsetof the NTP. With only about 400–600 new cases ofTB a year, the expense of registering new drugs

* H � isoniazid; R � rifampicin; Z � pyrazinamide; E � etham-butol; S � streptomycin. Numbers before the letters indicate theduration of the treatment phase in months. Numbers in subscriptindicate the number of times the drug is given per week.

830 The International Journal of Tuberculosis and Lung Disease

deterred private importation of anti-tuberculosis med-ications, particularly of second-line drugs. Except forisoniazid 300 mg (only 50 mg tablets were initiallyavailable, but a local company was eventually per-suaded to produce a 300 mg tablet), first-line drugswere obtainable, but all the second line drugs, includ-ing ethionamide, cycloserine, capreomycin and others,had to be ordered using special procedures. A centralsupply agency now delivers a regular supply of TBdrugs, and the DTA maintains a reserve cache of alldrugs to ensure non-interruption of supplies.

Permanent reporting systemTB notification to the MOH is mandatory for bothphysicians and laboratories. Individualised data on

TB notification and DST reports are reported at dis-trict and national levels. The annual incidence oftuberculosis for the years 1974–2001 is shown inFigure 1. Outcome of treatment reports are aggre-gated at the district level according to directivesissued by the DTA, in accordance with WHO/IUATLDrecommendations.19 A goal of the programme is tohave on-line computerised TB data for epidemio-logical, clinical and laboratory services available forall TB partners.20

Unique features of the programmeThe universal use of DOT for the full period of treatmentand the provision of DOT by primary care communityclinics without extraordinary resources are unique.

Table 1 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 featuresUse 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.

Figure 1 Incidence of tuberculosis in Israel, 1974–2001 (per 100 000 population).

Israel’s National Tuberculosis Control Programme 831

Screening procedures, contact investigationand treatment of latent infectionWe follow accepted guidelines regarding contactinvestigation, case finding and treatment of latentinfection.21 Immigrants from Ethiopia are screenedon arrival by skin testing and radiography whenappropriate. Among this high-risk population, chil-dren up to 5 years of age with negative skin tests arevaccinated with BCG, and those up to the age of 18who test positive receive DOT for latent infection.Many adults with positive skin tests also get theirmedication under direct observation. This is pos-sible because new immigrants often stay together inabsorption centres for several months before reloca-tion to a permanent home. Since 1991 we haveemphasised human immunodeficiency virus (HIV)co-morbidity among new immigrants from sub-Saharan Africa,22 through HIV and TB active casefinding.23

Cultural sensitivity: an important element forTB control in migrant populationsIsrael is a country of immigration,24 as illustrated inFigure 2. Some 85% of TB cases are foreign-born,mainly Israeli citizens from the Former Soviet Union(FSU) and from Ethiopia. Addressing the differencebetween Ethiopian and Israeli life styles, we usedanthropological tools to evaluate the needs of Ethio-pian immigrants and health professionals dealingwith them, and to train Ethiopian health workers toassist the DHOs and the TB clinics in bridging the

culture gap with the immigrants, as described indetail elsewhere.7

Methods for outcome of treatment evaluationWe compare treatment outcome before and afterimplementation of the new NTP. In 1998, new defi-nitions on treatment outcome were adopted by aworking group of the WHO and the EuropeanRegion of the IUATLD,19 analysing treatment out-come by annual cohort. In order to be able to com-pare the two periods (before vs. after the new NTP),we re-analysed treatment outcome according to theoutcome classification recommended by the work-ing group.6 For data for the period January 1990–September 1992, we used ‘a proxy’ outcome analysisbased on the main categories defined by the workinggroup. We defined two mutually exclusive groups,‘new cases’ and ‘re-treatment cases’;6 the analysis wasperformed in both groups according to three mutu-ally exclusive categories: ‘successful outcome’, ‘death’,and ‘potentially unsatisfactory outcome’. ‘Successfuloutcome’ was applied according to the WHO/IUATLD definition (within 12 months after the startof treatment).19 All the other notified cases, with theexception of those known to have died during treat-ment, were defined as ‘potentially unsatisfactory out-come’, irrespective of whether any follow-up infor-mation was available. Since the cohort of 1999, ouroutcome analysis is based exactly on the WHO/IUATLD definition,19 in which seven mutually exclu-sive categories are used for culture-positive pulmonary

Figure 2 Tuberculosis cases according to population groups, by percentage of the annual totalabsolute 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 measuresMost of the proposed changes described were imple-mented according to the new NTP regulations. As aresult, better and clearer organisation of TB treat-ment in almost all the aspects has been achieved.

In this section, we address those aspects of the pro-gramme that did not function in a satisfactory man-ner, and describe how we contended with these issues.

Laboratory diagnostic facilitiesCentralised bacteriology, in the interests of efficiency,centralisation of data and the possibility of introduc-ing new and expensive technologies to serve the entirehealth community, has proved difficult to implement.Hospitals conduct their own TB diagnostic proce-dures and do not always transfer isolates to the cen-tral laboratories.25 This causes delays in obtainingDST results for second-line drugs, and sometimes delaysthe results of DST for first-line drugs. We modified theprior recommendations and used financial incentivesto improve compliance: we requested the hospital lab-oratories to forward isolates promptly to the regionalTB laboratories, after identification of Mycobacteriumtuberculosis complex, and not to do further bacterio-logical testing. We also asked the regional laborato-ries to invoice the TB centres directly. As a result weshifted all the costs for strain identification and DSTto the TB centres from the hospital laboratory thatfirst diagnosed the case, as an incentive to limit in-house laboratory testing to a minimum.

DOTDOT worked very well for most of the TB cases, inparticular for those with no or a moderate level ofsocial difficulties. However, when analysing all TBpatients under treatment in 1999, some 12% weredefined as complex TB cases, mostly for social rea-sons, and their compliance was poor, despite all thesupport they received.26 We are in the process ofaddressing this problem by adding a network of socialworkers to the staff of the TB centres, to deal specifi-cally with complex TB patients.

Regular drug suppliesFull cooperation with this aspect of the NTP has notbeen forthcoming from the HMO that operates threeof the nine TB centres. This has sometimes causeddelays in drug supplies for these centres, but theyhave always been able to obtain drugs from the MOHsupplier on request.

Permanent reporting systemand process evaluationLinking TB notification and monthly evaluation ofthe DOT by the DHO to reimbursement of the TBcentre by the HMO has been an incentive for goodnotification and an important tool for supervision ofthe TB centres.

Ongoing process evaluation27 has already enabled usto detect and correct some of the weaknesses of the newNTP. This overall supervision will be facilitated by theon-line computerisation of the medical-epidemiologicalfile between all TB partners.20

TB incidence and outcome of treatment resultsSince the late 1980s, TB incidence has risen from 3.5cases per 100 000 population in 1989, before thestart of mass immigration from the FSU, to some 11/100 000 in 1998 (Figure 1). This rise is generally con-comitant with immigration from endemic countries.24

In recent years, some 80–85% of TB cases are foreign-born, mostly naturalised Israeli citizens from Ethi-opia or from the FSU. In Figure 2, we can see how,during the last decade, incidence is related to thecountry of origin: Ethiopia or the FSU. In 1991, some54% of new TB cases were from Ethiopia; as thedecade progressed, more cases came from the FSU.There is also a rise in the last years in TB diagnosedamong non-Israelis—foreign workers or tourists;around 7–9% of total TB cases.24

The cohort analysis of outcome of treatment forthe years 1999–2000 of culture-positive pulmonaryTB cases is seen in Table 2. There is a real improve-ment 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 ‘transferredcases’ in 1999 and 2000, and respectively 4.3% and1.2% were ‘failed cases’. Lastly, 10% of TB cases died,compared to some 5% prior to the new NTP. Whenfurther analysing the cause of death, not all cases dieddue to TB but rather with TB (18% and 25% of deathsin 1999 and 2000, respectively). Concerning deathsdue to TB, diagnosis was made less than 1 week beforedeath in 10% of cases, and after death in 25% and12% of cases in respectively 1999 and 2000.

Reported completion of treatmentvs. fully supervised treatmentIn addition to the improvement in successful outcomeof treatment since the new NTP, another majorimprovement is fully supervised treatment. Under thenew programme with universal DOT, treatment com-pletion includes adherence, whereas before comple-tion did not ensure adherence.

Cost-effectiveness analysisCost-effectiveness analysis is beyond the scope of thispaper. However, before starting the new NTP, a cost-

Israel’s National Tuberculosis Control Programme 833

effectiveness analysis was done13 and it was estimatedthat despite the additional costs for infrastructure,Israel would save between US $3.46 and $4.20 mil-lion in resources if 600 new TB cases needed treat-ment annually.

DISCUSSION

The rationale for a new NTP in a low prevalencecountry was the concern that with the rise in the case-load and the depletion of anti-tuberculosis resources,events might overtake Israel as they did in New YorkCity.16 Israel provides full medical coverage to all res-idents using a patient approach, as in other Bismarck-ian Health Systems.28 However, contact investigationand follow-up of treatment adherence, a major publichealth problem,4,9,10,29 is best dealt with by a commu-nity approach,30 and by a single entity, not by fourdifferent HMOs.

Our public health service is community-oriented,with a DHO for each region. We used this system andthe network of primary care community clinics runby the HMOs to construct a new entity in TB controland care. This incorporates the principal of verticaland horizontal structures in implementing a healthprogramme. The vertical element runs from the DTAthrough the DHO and regional TB centres, and endswith reimbursement of the TB centres by the HMOs foreach individual treated in the programme. We had toovercome the resistance of the HMOs to take on activi-ties related to TB, which they perceived as public healthmeasures. Working on the problem together with themand allowing transparency of all financial aspects of theprogramme finally overcame this resistance.

The new NTP has rejuvenated clinical expertise inthe field of TB management. This has benefited clini-

cal and public health nurses and physicians in bothfields, and the laboratory services: without central-ised laboratory services there would have been greatdifficulty in mastering modern mycobacteriology,14

including rapid, accurate susceptibility testing andmolecular biology, in a satisfactory manner.15 It hasalso ensured close cooperation between clinicians andlaboratory personnel.

The horizontal element of the programme is inthe MOH and in the clinical part of the NTP. In theMOH, the DHOs interact with each other and withthe TB centres in a horizontal manner. On anotherlevel, both the TB centres and the DHOs interact withthe community clinics in a similar manner. Likewise,the two regional laboratories interact in a horizontalfashion with each other and with the TB centres.Using the existing infrastructure of primary healthcare clinics, run by the different HMOs but united bythe conceptual and practical acceptance of the NTP,has led to considerable savings,13 and easy access forthe patients treated in the community with DOTS.

The reimbursement of the centres is paid out of theglobal budget of each HMO. Using a flat rate fortreatment has provided an incentive for the TB cen-tres to complete treatment expeditiously. This is aclassic case of the ‘money follows the patient’31 prin-ciple of health economics, whereby the more patientsand contacts the TB centre treats, and treats well, themore efficient the operation becomes.

The concept of DOTS for all, not on a basis ofpatients perceived (often erroneously) to be difficultcases, but across the board, has significantly improvedthe outcome of treatment (Table 2). The actual figuresmay be better because some of the ‘defaulted’ and‘transferred’ cases notified in an aggregate manner arequite likely ‘cured’ or ‘completed cases’. At present,

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)

Pulmonaryculture-positivecases

n

Outcome of treatment %

Period Died Not evaluated

Successful outcome Potentially unsatisfactory outcome

January 1990–September 1992New cases 196 24.5 5.6 69.9Retreated cases 10 70.0 10.0 20.0

Total 206 26.7 5.8 67.5

Cured Completed Failed Defaulted Transferred

1999New cases 289 73.0 9.0 10.4 2.1 2.8 1.7 0.1Retreated cases 36 50.0 0 11.1 22.3 8.3 8.3 0

Total 325 78.5 10.5 4.3 3.4 2.4 0.9

2000New cases 320 67.2 10.3 10.6 0.9 2.8 6.9 1.3Retreated cases 26 23.1 46.1 3.8 3.8 3.8 7.9 11.5

Total 346 76.9 10.1 1.2 2.9 6.9 2.0

834 The International Journal of Tuberculosis and Lung Disease

we do not have individualised data for outcome oftreatment at a central level to enable us to confirmthis. Whether the increase in death rates after theimplementation of the new programme is a true phe-nomenon or due to an increase in the awareness of TBremains to be seen.

The use of DOTS elsewhere is increasing (21 coun-tries implemented DOTS in 2000, bringing the totalto 148/210),29 but it is still a controversial issue, par-ticularly in low-incidence countries. In the WHOEuropean Region only 17* countries (out of 51) areusing DOTS nationwide (out of 95 countries glo-bally).29 Of the 23 countries in the West WHO Euro-pean Region (WWER), only seven countries haveadopted DOTS fully (Andorra, Austria, Israel, Malta,the Netherlands, Norway and Portugal), and Italy hasapplied DOTS in an expansion phase.29

In the WWER, TB incidence is low (an average of12.6/100 000 in 1999), consistent with the finding32

of a reduction or stabilisation in TB incidence inWestern Europe since the late 1980s.33 This analysisdoes not reflect the impact of the immigrant popula-tion in Western Europe. In the WWER, 27% of noti-fied cases in 1999 were of foreign origin; in ninecountries this figure was more than 50%; the highestrate, 86.2%, was in Israel.33

The last WHO global report includes outcome oftreatment for 1999 according to WHO/IUATLDdefinitions19 for only seven countries (Andorra, Austria,Italy, Malta, the Netherlands, Norway and Portugal).†29

In this paper, we present data on treatment out-come for Israel for 1999–2000. The successful out-come for pulmonary culture-positive cases in Israel issimilar to that reported for 1999 among smear-positivecases by the Netherlands, Norway and Portugal (allimplement full coverage of DOTS) and the USA.29

Nevertheless, it remains to be seen whether treat-ment outcome in low incidence countries that arenot using DOTS, especially those where the rate ofTB among foreign born is high, will be worse than insimilar countries that have adopted this WHO-recommended strategy.

DOTS alone, however, is probably not the onlyreason for the improvements in treatment outcome inIsrael. As described elsewhere,9 other complementaryfactors (integration of vertical and horizontal struc-tures, cultural sensitivity, staff training and motivation,incentives, defaulter tracing) are important elements ofthe programme. Our use of existing resources in thecommunity rather than additional expenditure forDOTS, and our approach to Ethiopian immigrants,are examples of additional elements in the programme

* In the 2002 WHO Report,29 Israel was mistakenly not registeredas a country with full DOTS coverage.† Data on outcome for Israel are not in this report29 because, as rec-ommended,19 we classified outcome of treatment according to cul-ture rather than according to smear.

that might benefit other low TB prevalence coun-tries, particularly those where TB is influenced byimmigration.

AcknowledgementsWe gratefully acknowledge the health care professionals who areimplementing this new TB programme with so much energy anddevotion, on behalf of their TB patients and families. Not to be for-gotten is the role of the members of the Advisory Committee on TBto the Ministry of Health, for their contribution to the planning ofthis programme. Finally, we gratefully acknowledge the role ofProfessor G Barbash, then Director General of the MOH, whoseintervention made the programme a reality.

Members of the initial MOH TB Advisory Committee: BaumG, 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 authorsand do not purport to represent the opinions of the agencies withwhich they are associated.

Part of this paper was presented in abstract form in Paris at theConference on Global Lung Health and the 1997 Annual Meetingof the IUATLD in Paris.

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29 World Health Organization. Global tuberculosis control: sur-veillance, planning, financing. WHO Report 2002. WHO/CDS/TB/2002.295. Geneva: WHO, 2002.

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R É S U M É

CADRE : Israël a mis en œuvre un nouveau programme delutte contre la tuberculose (TB) à la suite de l’augmenta-tion d’incidence de la TB, due à l’immigration au coursde la dernière décennie. Il est en conformité avec lesdirectives de l’OMS et inclut, par ailleurs, des mesuresspécifiques répondant aux besoins des immigrants.Nous décrivons le nouveau programme et comparons lerésultat du traitement avant et après sa mise en place.MÉTHODES : Nous examinons en détail chaque com-posante de la nouvelle stratégie et insistons sur lesaspects qui ne fonctionnaient pas correctement, ainsique sur la manière dont nous avons fait face à cesproblèmes. L’analyse du résultat du traitement a été con-duite selon les définitions de l’OMS/UICTMR.RÉSULTATS : Nous avons clarifié et amélioré l’organisa-

tion du traitement de la tuberculose dans tous sesaspects, y compris ceux ayant trait aux différences cul-turelles. L’adhésion s’est améliorée : de 27% de « résul-tats favorables » avant le nouveau programme a plus de75% après sa mise en place. Outre l’amélioration dutaux d’achèvement du traitement, l’utilisation généra-lisée du DOT a assuré un renforcement de l’adhésion.CONCLUSION : Grâce a des mesures législatives, admin-istratives et budgétaires, ainsi qu’aux directives cliniquespubliées par le Ministère de la Santé, l’infrastructure TBen Israël a été réorganisée avec succès. L’application dece programme s’est avérée justifiée non seulement dupoint de vue clinique et organisationnel, mais aussi sur leplan économique.

R E S U M E N

MARCO DE REFERENCIA : Israel ha implementado unnuevo programa de control de la tuberculosis (TB), comoconsecuencia de un aumento de la incidencia de TB, debidoa la inmigración en la última década. Este programa siguelas directrices de la OMS y además incluye medidas especí-ficas en relación con las necesidades de los inmigrantes. Sedescribe el nuevo programa y se compara el resultado deltratamiento antes y después de su implementación.

MÉTODO : Se examinó a fondo cada componente de lanueva estrategia y se puso énfasis en los aspectos que nofuncionaban correctamente y en la manera como sehabían enfrentado estos problemas. El análisis de losresultados del tratamiento se efectuó según las defini-ciones de la OMS y de la UICTER.RESULTADOS : Se obtuvo una mejor y más clara orga-nización del tratamiento de la TB en todos sus aspectos,

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incluyendo aquéllos relacionados con las diferencias cul-turales. El cumplimiento del tratamiento mejoró demenos de 27% de ‘resultados exitosos’ antes del nuevoprograma a más de 75% después de su implementación.Además del mejoramiento de las tasas de cumplimiento,el uso generalizado del DOT ha asegurado un refuerzode la adhesión.

CONCLUSIÓN : La infraestructura de la TB en Israel hasido reorganizada con éxito poniendo en práctica medi-das legislativas, administrativas y presupuestarias, asícomo directrices clínicas publicadas por el Ministerio dela Salud. La aplicación de este programa se justificabano solamente desde el punto de vista clínico y organiza-tivo, sino que también fue económicamente viable.