Framework and Standards for

Effective TB Control

Module 3 – March 2010

Project Partners

Funded by the Health Resources and Services Administration (HRSA)

STOP TB!

Module Overview

The Stop TB Strategy

International Standards for Tuberculosis Care (ISTC)

National Tuberculosis Program (NTP)

Learning Objectives

Objectives: At the end of this presentation,participants will be able to:

Describe the components of the DOTS Strategy and the Stop TB Strategy

Describe the purpose and content areas of the International Standards for Tuberculosis Care (ISTC)

Describe the structure of the National TB Program (NTP) and potential areas for collaboration with the National HIV/AIDS Program (NAP)

The Global Emergency

In 1993, the WHO declared TB a global emergency due to it’s increasing importance as a public health problem

Contributing Factors:• Poverty• Population growth• Migration

• Concurrent HIV epidemic

The Directly Observed Treatment Short-course (DOTS) Strategy was developed as a response to the global emergency

The Stop TB Strategy

In 2001, the first Global Plan to Stop TB was launched through the Stop TB Partnership

This Strategy serves as a roadmap for reaching the Millennium Development Goals (MDG)

The objectives are to:

• achieve universal access to high-quality diagnosis and patient-centered treatment

• reduce human suffering and socio-economic burden associated with TB

• protect poor and vulnerable populations from TB, TB/HIV and MDR-TB

• support the development and use of new tools

Stop TB: Critical Components1. Pursue high-quality DOTS expansion and enhancement Secure political commitment, with adequate and sustained financing Ensure early case detection and diagnosis through quality-assured bacteriology Provide standardized treatment with supervision, and patient drug supply system and

management Monitor and evaluate performance and impact

2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations

Scale-up collaborative TB/HIV activities Scale-up prevention and management of multidrug-resistant TB Address the needs of TB contacts, and poor and vulnerable populations

3. Contribute to health system strengthening based on primary health care

Help improve health policies, human resource development, financing, supplies, service delivery and information

Strengthen infection control in health services, other congregate settings and households

Upgrade laboratory networks, and implement the Practical Approach to Lung Health Adapt successful approaches from other fields and sectors, and foster action on the

social determinants of health

Stop TB: Critical Components (2)

4. Engage all care providers Involve all public, voluntary, corporate and private providers through Public- Private

Mix approaches Promote use of the International Standards for Tuberculosis Care (ISTC)

5. Empower people with TB, and communities through partnership

Pursue advocacy, communication and social mobilization Foster community participation in TB care, prevention and health promotion Promote us of the Patients’ Charter for Tuberculosis Care (PCTC)

6. Enable and promote research Conduct program-based operational research, and introduce new tools into practice Advocate for and participate in research to develop new diagnostics, drugs, and

vaccines

Millennium Development Goal (MDG)

Targets: MDG 6, Target 8; halt and begin to reverse the

incidence of TB by 2015 Epidemiological targets linked to the MDGs

and endorsed by Stop TB Partnership:• by 2005, detect at least 70% of infectious (sputum

smear-positive) TB cases and cure at least 85% of these cases

• by 2015, reduce TB prevalence and death due to TB by 50% relative to 1990 levels

• by 2050, eliminate TB as a public health problem (i.e., <1 case/million population per year)

www.istcweb.org

(ISTC)

International Standards for Tuberculosis Care (ISTC)

These 21 standards of TB care pull together research findings and clinical expertise to provide guidance based on evidence and experience over time

ISTC companion documents include:• Patients’ Charter for Tuberculosis Care

(PCTC)• Handbook for using the International

Standards for Tuberculosis Care• ISTC Tuberculosis Training Modules and

Facilitator’s Guide

ISTC Collaborators

International Standards for TB Care

Diagnosis Standards – ISTC #’s 1 – 6 Treatment Standards – ISTC #’s 7 – 13 HIV and other Co-morbid Conditions

Standards – ISTC #’s 14 – 17 Public Health Standards – ISTC #’s 18 – 21

CAREC’s Response

Grouping CMCs according to TB burden Development of policies and guidelines Networking with regional and international

partners (PAHO; CARICOM; WHO; CDC; Health Canada)

Training of laboratory staff and other National Tuberculosis Program (NTP) personnel

TB/HIV collaborative efforts

National TB Program (NTP)

The aim of the NTP is to reduce morbidity, mortality, and disease transmission, while preventing the development of drug resistance

In settings with high HIV and AIDS prevalence, TB prevention and control strategies should be coordinated with those of the National AIDS Program (NAP)

National TB Program (2)

The short-term program targets are:• To achieve a cure rate of 85% among new

sputum smear-positive tuberculosis patients

• To detect 70% of existing cases of sputum smear-positive tuberculosis

• To prevent the emergence of acquired drug-resistant M. tuberculosis

Essential Components of the NTP

Activity

NTP: Key Features

A project development strategic plan, with budget details, funding sources and responsibilities

A central unit NTP manual available at the level of the

periphery A tuberculosis management information system

using standardized registers A nationwide network of quality assured

microscopy services in close contact with primary health care (PHC) services and subject to regular quality control

NTP: Key Features (2)

Treatment services within the PHC system, with priority for directly observed short-course chemotherapy

Uninterrupted supply of quality assured drugs and diagnosticmaterials with reliable procurement and distribution systems

Plan of supervision

NTP: Key Features (3)

A training program covering all aspects of the NTP policy package

Mechanisms for stakeholder and health service collaboration with special attention to TB and HIV operations

Advocacy, communication and social mobilization to empower patients and communities

NTP: Activities

Early detection of TB suspects in health facilities and communities

Early and intensified TB case-finding supported by:• Voluntary counselling and testing, or• Provider-initiated testing for HIV detection

Diagnosis through smear and/or culture Administration of adequate treatment to

achieve cure under DOT supervision

NTP: Structure

NTP activities should be integrated into the existing health care services

Health care workers of the general services health unit must be aware of the mechanisms for case-finding and treatment• Shared responsibility and assistance facilitating

and implementing the control measures

Managerial and supervisory staff should be responsible for TB specific technical competence of all health care workers involved in the program

NTP: Structure (2)

The NTP structure must also reflect:• The multi-disciplinary approach to surveillance and

case management

• The mechanisms for implementing TB and HIV collaboration

Headed by a program manager responsible for:• Planning the work of the program

• Collaborating with health care staff in the periphery

Regional/District/Parish level coordinators assist with supervising TB control activities at their level

Collaboration Between TB and HIV/AIDS Program

Guiding principles for collaboration: Prevention of HIV should be a priority for TB

control given the impact HIV has on TB morbidity and mortality

TB care and prevention should be a priority for HIV/AIDS programs given the high morbidity and mortality from TB among people with HIV

Joint TB/HIV program planning, implementation and coordination of activities is critical to the successful control of both diseases

Areas for Collaboration

Areas for potential TB and HIV/AIDS collaboration:• Advocacy, communication and social

mobilization (ACSM) strategies

• Policy consensus

• Training activities

• Procurement and distribution of drugs, consumables, laboratory reagents

• Monitoring and evaluation

TB

Areas for Collaboration (2)

Areas for potential TB and HIV/AIDS collaboration (continued):• Information systems

• Surveillance and referral

• Counseling and testing services

• Provision of preventive therapy

• Provision and supervision of Antiretroviral Therapy (ART) and TB treatment

TB

Collaboration Goal and Objectives

Goal:To decrease the burden of TB and HIV in dually affected populations

Objectives:A.To establish the mechanisms for collaboration between TB and HIV/AIDS programs

B.To decrease the burden of TB among people living with HIV/AIDS

C.To decrease the burden of HIV in tuberculosis patients

TB/HIV Objectives and Activities

A. Establish the mechanisms for collaboration Set up a coordinating body for TB/HIV

activities Conduct surveillance of HIV prevalence

among TB patients Carry out joint TB/HIV planning Conduct monitoring and evaluation

TB/HIV Objectives and Activities (2)

B. Decrease the burden of TB in people living with HIV/AIDS Establish intensified tuberculosis case-finding Introduce isoniazid preventive therapy Ensure TB infection control in health care

and congregate settings

TB/HIV Objectives and Activities (3)

C. Decrease the burden of HIV in tuberculosis patients Provide HIV testing and counselling Introduce HIV prevention methods Introduce co-trimoxazole preventive therapy Ensure HIV care and support Introduce anti-retroviral drugs

Joint TB/HIV Activities

TBTB HIVHIV

General Health Services

Intensified case-finding

Isoniazid preventive

therapy

TB/HIVTB/HIV

Home- and community-based care

VCT + TB screening

IECSTIsARVs

DOTS+VCT

+Condoms+HIV

surveillance

Co-trimoxazole preventive therapy

Health Promotion, Communication, and Education

Formulate health Public Policy:• Promote health as a strategic input and

priority outcome of Public Policy development

 Re-orient health services through:• Response to needs of individuals and

communities

• Health professional’s recognition of partnership with communities and individuals

• Promote curative and preventive patient centered care

Health Promotion, Communication, and Education (2)

Empower communities to achieve well-being through:• Collaboration within

communities to determine priorities

• Facilitate and support community action plans

• Provide information and skills for community to take action

Health Promotion, Communication, and Education (3)

Build alliances within the community: • Special emphasis on media collaboration

• Access and pool resources from all sectors for the promotion of health

• Form alliances with other government sectors: education, social and community development, culture, gender affairs, youth and sports organizations

• Include Non-Governmental Organizations, faith- based organizations, service clubs, and NAPs

What Health Promotion, Communication, and Education activities have you been involved with?

Summary

The Stop TB Strategy and the ISTC are key responses to addressing the high global TB prevalence

While NTP structure varies by country, a cohesive and well organized program is essential for effective TB prevention and control

Health promotion, communication, and education are necessary for patients, staff, and the community

Collaboration between TB and HIV/AIDS programs can greatly improve the effectiveness of both the NTP and NAP