Framework and Standards for Effective TB Control

1. Module 3 – March 2010 Framework and Standards for Effective TB Control

2. Project Partners Funded by the Health Resources and Services Administration (HRSA)

3. Module Overview • The Stop TB Strategy • International Standards for Tuberculosis Care (ISTC) • National Tuberculosis Program (NTP) STOP TB!

4. 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)

5. 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

6. 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

7. Stop TB: Critical Components 1. 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 

8. 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

9. 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)

10. (ISTC) www.istcweb.org

11. 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

12. ISTC Collaborators

13. 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

14. 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

15. 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)

16. 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

17. Essential Components of the NTP Activity

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Collaboration Goal and Objectives Goal: To decrease the burden of TB and HIV in dually affected populations Objectives: • To establish the mechanisms for collaboration between TB and HIV/AIDS programs • To decrease the burden of TB among people living with HIV/AIDS • To decrease the burden of HIV in tuberculosis patients

28. TB/HIV Objectives and Activities • 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

29. TB/HIV Objectives and Activities (2) • 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

30. TB/HIV Objectives and Activities (3) • 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

31. Joint TB/HIV Activities TB TB/HIV HIV DOTS +VCT +Condoms +HIV surveillance VCT + TB screening IEC STIs ARVs Intensified case-finding Isoniazid preventive therapy Co-trimoxazole preventive therapy Home- and community-based care General Health Services

32. 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

33. 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

34. 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

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

36. 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