WHO has declared that TB is a global emergency, because TB is out of control in many parts of the world.The following are the main reasons why TB is out of control:
a) governments in many parts of the world have neglected the disease;
b) inadequate TB control programmes have led to an increased burden of disease (inadequately treated TB patients live longer with chronic disease and infect other people) and the emergence of drug-resistant TB;
c) high rates of population growth have contributed to an increased number of TB cases;
d) the HIV epidemic has led to an enormous increase in the number of TB cases, in places where HIV and TB are both common.
WHO has expanded the framework for TB control in order to reflect experience gained since the development of the original framework in l994.The expanded framework is relevant in all settings, including where HIV is common. Successful TB control depends on health care workers treating TB patients within this framework in a national TB programme (NTP). Full implementation of the DOTS strategy remains the priority. This means ensuring the accurate diagnosis and effective treatment of all TB patients.
In addition TB and HIV/AIDS programmes must collaborate to counteract the impact of HIV on TB.This depends on implementation of the DOTS strategy and other interventions. In addition to effective TB case-finding and cure, these interventions include: measures to decrease HIV transmission (e.g. promotion of condoms, treatment of sexually transmitted infections); highly active antiretroviral therapy (HAART);TB preventive treatment; and antibiotic prophylaxis against HIV-related bacterial infections.
COMPONENTS OF EXPANDED TB CONTROL FRAMEWORK
The expanded framework consists of the following:
1. Goals of TB control.
2. Targets for TB control.
3. TB control policy package.
4. Key operations for DOTS implemantation.
5. Indicators to measure NTP progress in TB control.
The goals of TB control are to reduce mortality, morbidity and disease transmission (while preventing drug resistance) until TB no longer poses a threat to public health.The aim is also to reduce human suffering and the social and economic burden on families and communities as a consequence of TB. In order to achieve this, it is necessary to ensure access to diagnosis, treatment and cure for each patient.
12.2.2 | Targets for TB control (cure and case detection)
a) To cure 85% of the sputum smear-positive PTB cases detected.
A national TB programme that achieves at least an 85% cure rate in patients with sputum smear-positive PTB has the following impact on TB:
i) TB prevalence,TB mortality and rate of TB transmission decrease rapidly;
ii) TB incidence decreases gradually;
iii) there is less drug resistance (which makes future treatment of TB easier and more affordable).
Achieving high cure rates is the highest priority.TB programmes with high cure rates rapidly reduce disease transmission.They are likely to attract the majority of existing cases in the community.
b) To detect 70% of existing cases of sputum smear-positive PTB.
It is important to expand case-finding only when the national TB programme has achieved a high cure rate.A national TB programme that has a low cure rate makes the TB problem worse:
i) there are more cases of sputum smear-positive PTB treatment failure;
ii) transmission of drug resistance increases.
A treatable epidemic becomes an untreatable epidemic.
An effective NTP has a high cure rate and a low level of drug resistance.
Provided that a high cure rate is achieved, increased case detection of sputum smear-positive PTB cases will decrease TB transmission.
2.2.3 TB control policy package (the DOTS strategy)
NTPs face new challenges. They need significant strengthening in order to achieve the targets for TB control.
° General public health services need to increase their capacity to sustain and expand DOTS implementation. At the same time they must maintain the quality of case detection and treatment.
° Promoting a patient-centred approach and community involvement in TB care can improve both access to and utilization of health services.
° Collaboration is essential between the public, private, and voluntary sectors to ensure accessible and quality-assured TB diagnosis and treatment.
° The increasing impact of HIV on the incidence of TB requires new approaches and partnerships.
° A high prevalence of drug-resistant TB requires two complementary approaches: NTPs need to cure existing multidrug-resistant (MDR) TB cases as well as prevent new cases (through the DOTS strategy).
The expanded DOTS framework reinforces the five essential elements of the DOTS strategy:
a. Sustained political commitment to increase human and financial resources and make TB control a nationwide activity integral to the national health system.
b. Access to quality-assured TB sputum microscopy for case detection among persons presenting with, or found through screening to have, symptoms of TB (most importantly prolonged cough). Special attention to case detection is necessary among HIV-infected people and other high-risk groups, e.g. people in institutions.
c. Standardized short-course chemotherapy (SCC) for all cases of TB under proper case-management conditions including direct observation of treatment. Proper case management conditions imply technically sound and socially supportive treatment services.
d. Uninterrupted supply of quality-assured drugs with reliable drug procurement and distribution systems.
e. Recording and reporting system enabling outcome assessment of every patient and assessment of the overall programme performance.
12.2.4 I Key operations for DOTS implementation
° Establish a national TB programme (NTP) with a central unit.
° Prepare a programme development plan.
° Prepare the NTP manual and make it available at district level.
° Establish a recording and reporting system using standardized material allowing categorizaton of cases registered and cohort analysis for treatment outcomes.
° Plan and initiate a training programme covering all aspects of the policy package.
° Establish a microscopy services network in close contact with primary health care (PHC) services and subject to regular quality control.
° Establish treatment services within the PHC system where directly observed short-course chemotherapy is given priority and patient education is provided.Treatment services should achieve total geographical and patient coverage.
° Secure a regular supply of drugs and diagnostic material based on previous case notification data.
° Design a plan of supervision of the key operations at the intermediate and district level to be implemented from the start of the programme.
° Undertake social mobilization through information, education and communication activities, in order to mobilize and sustain support for TB control.
° Involve all health care providers, e.g. private and voluntary health care providers, nongovernmental organizations (NGOs), religious organizations and employers.
° Undertake economic analysis and financial planning to ensure that the NTP is on a sound financial footing.
° Undertake operational research as an integral component of DOTS implementation to improve NTP performance.
2.2.5 Indicators to measure NTP progress in TB control
° National TB control policies, as set out in the NTP manual, consistent with the DOTS strategy.
° The number of administrative areas in the country that are implementing the DOTS strategy.
° The cure rate in new smear-positive cases.
° The case detection rate.
The WHO document, "An expanded DOTS framework for effective tuberculosis control" (WHO/CDS/TB/2002.297), provides a full list of indicators.
directly observed treatment
What is directly observed treatment?
Patient adherence to treatment is necessary to ensure that the treatment cures the patient. Patient adherence to SCC means the patient takes every dose of the recommended treatment regimen. It may be difficult for a patient to adhere to anti-TB treatment for 6 to 8 months. It is difficult to predict which TB patients will adhere to self-administered treatment. One certain way to ensure patient adherence to treatment is direct observation of treatment. This means that someone supports the patient during the course of treatment and watches the patient swallow the tablets. The NTP coordinates the training of patient supporters and monitors their effectiveness in ensuring treatment adherence.
Directly observed treatment as close to the patient's home as possible
TB patients are unlikely to adhere to treatment if they have far to go for treatment. One of the aims of a TB programme is to organize TB services so that patients have treatment as close to home as possible.A TB programme brings treatment to patients wherever they live. Many TB patients live close to a health facility (e.g. health centre, district hospital).
For these patients, the treatment supporter who directly observes treatment could be one of the health staff in the health facility. Some TB patients live far away from a health facility. For these patients, the supervisor may be a trained local community member or a health outreach worker. Family members who provide health care support can also be trained as TB treatment supporters. Some areas have HIV/AIDS community care schemes. With suitable training and supervision, the HIV/AIDS home care providers can support TB patients, including directly observing treatment.
Integration of TB treatment services with general health services
In the past, some TB programmes have relied on special TB hospitals and clinics, separate from the general health service.The problem with that system is that many TB patients live far from a TB hospital or clinic. One reason why TB is out of control in many countries is that TB patients do not have access to TB diagnosis and treatment services. A successful NTP brings TB diagnosis and treatment services to the TB patients.This is why TB treatment services are integrated with existing general health services.
TB and HIV are closely interlinked.TB is a leading cause of HIV-related morbidity and mortality. HIV is the most important factor fuelling the TB epidemic in populations with a high HIV prevalence. The WHO global strategic framework to control TB/HIV represents a coordinated response to the joint epidemics of TB and HIV. Collaboration between TB and HIV/AIDS programmes is crucial in supporting general health service providers. These providers need support in delivering the full range of HIV and TB prevention and care interventions. To counteract the impact of HIV on TB, other interventions are required apart from effective TB case-finding and cure.These interventions include
° measures to decrease HIV transmission (e.g. promotion of condoms, treatment of sexually transmitted infections, voluntary counselling and HIV testing, safe intravenous drug use, reduction in the number of sexual partners, prevention of mother-to-child HIV transmission, HIV screening of blood for transfusion, and application of universal HIV precautions by health care workers); ° antiretroviral therapy (ART) (to improve or maintain immune function in people living with HIV infection); ° care for people living with HIV infection (e.g.treatment of HIV-related diseases, prevention of HIV-related infections,TB prevention, palliative care and nutritional support).
High levels of multidrug-resistant TB (MDR-TB) in some areas threaten TB control efforts. MDR-TB is TB that is resistant to at least isoniazid and rifampicin. DOTS-Plus for MDR-TB is a comprehensive management initiative, built upon the five elements of the DOTS strategy. However, DOTS-Plus also takes into account specific issues, such as the use of second-line anti-TB drugs.The goal of DOTS-Plus is to prevent further development and spread of MDR-TB. DOTS-Plus is not intended for universal application, and is not required in all settings. The aim of implementation of DOTS-Plus in selected areas with significant levels of MDR-TB is to combat an emerging epidemic.The underlying principle is that the first step in controlling MDR-TB is prevention by full implementation of DOTS. An effective DOTS-based TB control programme is a prerequisite for implementation of DOTS-Plus.
I I SUGGESTIONS FOR FURTHER READING I I
International Union Against Tuberculosis and Lung Disease. Tuberculosis guide for low income countries. Fifth edition. Paris, 2000.
Maher D, van Gorkom JLC, Gondrie P Raviglione MC. Community contribution to tuberculosis care in countries with high tuberculosis prevalence: past, present and future. International journal of tuberculosis and lung disease, 1999, 3: 762-768.
World Health Organization. Guidelines for the management of drug-resistant Tuberculosis. Geneva, 1997, (WHO/TB/96.210 - Rev.1).
World Health Organization. What is DOTS? A guide to understanding the WHO-recommended TB control strategy known as DOTS. Geneva, 1999, (WH0/CDS/CPC/TB/99.270).
World Health Organization. Anti-tuberculosis drug resistance in the world. Report No.2. Prevalence and trends. Geneva, 2000 (WHO/CDS/TB/2000.278).
World Health Organization. The WHO/IUATLD Global Project on anti-tuberculosis drug resistance surveillance. Geneva, 2000.
World Health Organization. Guidelines for establishing DOTS-Plus pilot projects for the management of multidrug-resistant TB. Geneva, 2000 (WHO/CDS/TB/2000.279).
World Health Organisation. An expanded DOTS framework for effective tuberculosis control. Geneva, 2002, (WHO/CDS/TB/2002.297).
World Health Organization. A strategic framework to decrease the burden of TB/HIV. Geneva, 2002, (WH0/CDS/TB/2002.296).
World Health Organisation. Treatment of tuberculosis: guidelines for national programmes. Third edition. Geneva, 2003, (wHO/CDS/TB/2003.313).
World Health Organization. Community contribution to TB care: practice and policy. Geneva, 2003, (WHO/CDS/TB/2003.3 12).
World Health Organization. Guidelines for collaborative TB and HIV programme activities. Geneva, 2003, (WHO/CDS/TB/2003.319, WHO/HIV/2003.01).
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