STRATEGIES IN TB CONTROL DOTS

1. STRATEGIES IN TB CONTROL DOTS Lucica Ditiu, Antalya, April 2005

2. The DOTS Strategy (1995) • Government commitment to TB control • Diagnosis by smear microscopy mostly on self-reporting symptomatic patients • Standardised SCC under proper case management conditions, including DOT • Efficient system of drug supply • Efficient recording and reporting system with assessment of treatment results

3. Evolution of WHO's TB Control Strategy • DOTS launched in 1995 and promoted for a decade with great success (182 countries!) • DOTS expansion nearly completed with most designated public services "covered" (>80% of world population) • DOTS is the sine qua non for TB control, an enlarged approach is necessary to achieve MDGs by 2015 • Requires: adaptation to special settings; engagement of all health sectors; advocacy and social mobilisation; new tools

4. Consolidate DOTS: Optimise, sustain and measure achievements, through a patient-centered approach, by building capacity and mobilising human and financial resources within strengthened health systems • Adapt DOTS: Address TB/HIV, MDR-TB and other special situations • Engage all Providers: Ensure all care givers, public and private, use the international standard of TB care, making it accessible to all patients, especially the poor • Mobilise Communities: Promote community participation and engage societies to increase demand for, and contribute to, proper care • Promote R&D for new Tools: Support efforts by public and private enterprises to develop better tools for TB diagnosis, treatment and prevention Stop TB Department

5. Diagnosis • Should be evaluated: persons with otherwise unexplained cough lasting for 2-3 weeks or more. • Microbiological evaluation (smear + culture) is essential (including children extra-pulmonary, and persons with radiographic abnormalities) • Specific criteria for smear-negative cases • Assessment for HIV infection in persons at risk (based on epidemiological circumstances, risk group, or clinical findings)

6. Microbiological evaluation (smear + culture) is essential for all patients (including children, extra-pulmonary, and persons with radiographic abnormalities) • Microscopy – methods to increase the positivity rate – concentration, fluorescence • Culture – increase the case detection. Ideally can be used for at least initial specimens of all patients plus those with suspect DR. - in case definitions and treatment follow up - depends on financial resources (5-10 times more expensive than microscopy), trained personnel and availability of reagents, equipment and infrastructure

7. No radiographic pattern is diagnostic of TB!

8. Errors – under, over-reading • Treating persons with images/shadows - treat too many unnecessarily or wrong! • X-ray should be part of the diagnostic algorithm in the diagnosis of smear negative TB cases: • At least 3 sputum smear negative • X-ray findings consistent with TB • Lack to response to antimicrobial agents (excepting anti TB drugs and quinolones)

9. TREATMENT • Provider is responsible for prescribing an adequate regimen and ensuring adherence • Preferred regimen: 6 months with RIF throughout • A patient-centered approach should be developed for all patients: a treatment supporter to ensure supervision • Patients to be monitored for response to therapy • HIV testing for all patients and ARVs if indicated • Assessment of likelihood of drug resistance/consultation for patients at risk of having disease caused by resistant M TB

10. A patient-centered, approach to treatment should be developed for all patients. • A central element is support for adherence, including direct observation by a treatment supporter

11. Adherence • Socio-economic factors – living conditions, high costs, gender, age • Health care factors – underdevelopment, lack of access, poor relationship with health care providers, lack of training, motivation • Patient factors – forget, other diseases, depression, stress • Disease factors –complex treatment regimens, side effects

12. Patient monitoring and treatment supervision • Sputum smear microscopy is the most effective • Clinical and radiological assessment -unreliable and misleading • Record and report the data of the patients, drugs given, side effects, results of bacteriological examination

13. Public Health • Requirement to see that high-risk contacts are evaluated • Requirement for reporting cases and treatment outcome

14. Requirement to analyze and use the data

15. Top Priority 2005: Consolidate DOTS • Political commitment with long-term planning, adequate human resources and sustainable financing to reach WHA and MDG targets • Diagnosis through bacteriology (microscopy first, and culture/DST) and establishment of an effective laboratory network to facilitate detection of SS+, SS- and DR- TB cases • Standardized treatment under proper case management conditions, including DOT, and full patient support for all TB cases • An effective drug supply system • An adequate recording and reporting of cases and outcomes

16. Focus on Quality TB care for all: • Patient care to cure and prevent TB is the ultimate goal of DOTS and any TB control effort • The foundation of DOTS is effective patient care which alleviates suffering, and controls and prevents TB in a community • A standard of care for TB exists within DOTS, but needs further promotion among all care providers • Simply, each care provider, public or private, should: 1- Diagnose TB quickly (i.e., bacteriological confirmation) 2- Treat TB properly (i.e., SCC and treatment support) 3- Report TB cases and treatment outcomes

17. International Standards for Tuberculosis Care • Standards apply to all providers in all sectors regardless of circumstances • Standards apply to all patients of all ages, smear positive and negative, extra-pulmonary, MDR, TB/HIV • All providers must recognize that they are assuming a public health function with a high degree of responsibility to the community and to the patient • Consistent with existing international guidelines

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