Module 3 – March 2010
Framework and
Standards for
Effective TB Control
Project Partners
Funded by the Health Resources and Services Administration (HRSA)
Module Overview
 STOP TB!
 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 Shortcourse (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 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

Stop TB: Critical Components (2)
4. Engage all care providers
 Involve all public, voluntary, corporate and private providers through PublicPrivate 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)
(ISTC)
www.istcweb.org
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 drugresistant 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 diagnostic
materials 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
TB/HIV
TB
DOTS
+VCT
+Condoms
+HIV
surveillance
Intensified
case-finding
Isoniazid
preventive
therapy
Co-trimoxazole preventive therapy
Home- and community-based care
General Health Services
HIV
VCT + TB
screening
IEC
STIs
ARVs
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