23165 TB Control at a glance Why tackle tuberculosis? than to any other opportunistic infection. Up to 60% of TB patients are HIV-positive in some Sub-Saharan Tuberculosis (TB), a public health threat for thousands African countries and the proportion is rising in Asia. of years, remains a top killer worldwide despite the discovery 50 years ago of drugs that can cure this Poor prescribing, inadequate drug supply, erratic pill- infectious disease. 8.5 million new TB cases taking and self-medication all have contributed to the developed in 2002 and over 2 million men and emergence of drug-resistant TB. Recent standardized women died, most 15-45 years old. 95% of cases national surveys have documented multi-drug resistant and 98% of deaths occurred in the developing world. TB (MDR-TB) strains across the globe. Patients with Africa faces the highest TB rates (per population), but MDR-TB face more complex, high-cost and toxic Asia carries the greatest absolute burden and the treatment, and a higher risk of death. epidemic is worsening in other regions as well. As seen in the former Soviet republics, economic and As TB crosses all borders and market failures reduce social crises can quickly exacerbate the TB epidemic. the probability of effective treatment, TB treatment and control carries significant positive externalities. One third of the world's population is infected by Increased international cooperation is urgently Mycobacterium tuberculosis (M.tb). By coughing and needed to reverse the epidemic, and move towards sneezing, persons with infectious TB spread TB elimination of this ancient killer. through the air to people nearby, especially in crowded or poorly ventilated settings. In general, What to do about tuberculosis: 90% of infected individuals harbor the bacteria but DOTS never develop disease. 10% fall ill, either soon after infection, or later in life as their immune systems The World Health Organization recommends the become impaired or when burdened by physical or DOTS Strategy as the foundation for TB control emotional stress. Without any treatment, half of those worldwide. Over 155 countries have adopted it. It who fall ill will die. People with pulmonary TB1 can aims to reduce morbidity, mortality and transmission. have a range of symptoms, the most frequent of DOTS includes five core interventions (see table which are productive cough, fever and night sweats. below). Large-scale implementation in low-income Due to cultural, access and knowledge constraints, countries (e.g., China, India, Tanzania, Nicaragua, patients may delay seeking care and providers may Vietnam, Kenya and Peru) has shown DOTS to be fail to detect or treat the disease quickly, increasing highly cost-effective (US$3-7/DALY saved), and the likelihood of transmitting disease, developing adaptable within primary care systems. Some complications and death. countries facing high levels of drug-resistant disease or HIV/AIDS will need to supplement this strategy, as As with HIV/AIDS and malaria, the social and will low-burden countries aiming to eliminate the economic burden from TB on ill people, and on their disease as a public health threat. The table lists families and communities, is enormous. Poor people specific strategies in each setting. High-burden are especially vulnerable to TB because of their countries are working with partners to increase underlying health status, living conditions, and their financing to enable scale-up of these interventions limited access to treatment. People who suffer from and sharing of best practices. malnutrition or diseases such as HIV/AIDS or diabetes are at greater risk given their impaired 1 About half of pulmonary cases present with infectious disease ability to fight off infection and illness. Over 12 identifiable in sputum examined under a microscope. About million persons are dually infected with M.tb and HIV 10-12% of all TB cases present with disease in other body organs worldwide. More HIV-infected persons die due to TB (so-called extra-pulmonary disease). November 2003 This table summarizes the core elements of the DOTS strategy and related interventions for TB control, their intended beneficiaries, and performance indicators Beneficiaries/ Objectives Core Interventions Target Groups Indicators Core DOTS interventions (all countries) Reduce morbidity, mortality A cohesive and cost-effective package of interventions Persons ill with disease, Targets: and disease transmission specified below that is accessible through primary health especially the poor who By the year 2005: under DOTS successfully treat at least such that TB no longer poses care services are at high risk and face 85% of new infectious cases detected, and detect at the greatest barriers to least 70% of infectious cases existing in the community a threat to the public's health This is the minimum that must be provided, with other care supplementary activities possible (see other sections 2015 Millenium Development Goal: halve the below) The overall population prevalence of infectious TB as well as TB-attributable through reduced risk of mortality, and begin to reduce incidence exposure and burden 1. Mobilize resources and 1. Government commitment to sustained TB control Same as above 1. Existence of central TB unit, national TB control capacity to pursue TB activities manual, and resources for core functions control within general health (training, supervision, drugs, etc.) system development and with community involvement 2. Provide timely diagnosis of 2. Case detection by sputum-smear microscopy among The approach taken to 2. % of smear-positive cases among all detected cases at least sputum-smear symptomatic patients self-reporting to health services pursue 2 and 3 will vary (over 50% in high burden countries) positive (infectious) TB depending on available patients (those most at risk infrastructure and the of death and transmitting target group (e.g., urban disease) or rural population; 3. Provide treatment to cure at 3. Standardized treatment regimen of 6-8 months for at persons in congregate 3. % of detected TB cases treated under DOTS strategy least infectious cases least all confirmed sputum smear positive cases, with settings or living under proper case management, including direct observation, particularly strained for at least the initial 2 months conditions, such as 4. Ensure no patient goes 4. A system for regular, uninterrupted supply of all prisoners or refugees) 4. % of administrative units reporting stock-outs of TB without medicines and essential anti-TB drugs drugs within a year reduce risk of drug resistance 5. Track the epidemic, motivate 5. A standardized recording and reporting system that 5. % of administrative units reporting regularly on case providers and hold them allows assessment of individual patient treatment detection and treatment accountable for their results, as well as overall coverage and quality of the patients' care control program Beneficiaries/ Objectives Core Interventions Target Groups Indicators Strategy to harmonize/mainstream TB prevention and care into HIV/AIDS program operations and HIV/AIDS prevention and care in TB program operations Reduce the burden of TB and 1. Conduct surveillance of HIV in patients with TB Persons dually infected 1. # and % of TB patients infected with HIV HIV/AIDS in the community, 2. Offer routine HIV testing and counselling to TB patients with HIV and TB, and 2. # and % of TB patients being counselled and HIV and increase quality of life and when HIV prevalence is 5% or higher those with AIDS and/or tested life expectancy, in the 3. Conduct active case-finding for TB disease among active TB 3. # and % of VCT clients screened for TB disease, and population dually infected and PLWHA in VCT centres, clinics and hospitals; and % diagnosed with active TB affected by TB and HIV/AIDS. populations at high-risk of TB and HIV The overall community 4. # and % of HIV+ VCT clients started and completed 4. Organize a continuum of prevention and care for preventive TB treatment PLWHA and PLWTB, including involvement of 5. # and % of TB patients started on preventive community health care workers treatment for Opportunistic Infections. 5. Provide education and communication to communities 6. # of HIV+ TB patients also treated with ART and patients on TB, HIV and their link "DOTS-Plus" Strategy for areas where drug-resistant disease is prevalent (strategy being piloted) Identify populations where 1. Create reference laboratory capacity for drug Drug-resistant patients in Under development, may include: drug-resistant TB is already a susceptibility testing general population and 1. Proportion of detected cases with access to drug major threat and ensure early 2. Conduct standardized surveillance for drug-resistance groups with high risk of susceptibility testing when Rx regimens fail diagnosis and treatment for among new and retreated TB patients developing drug-resistance 2. Existence of drug resistance surveillance studies and patients suffering from multi- 3. Provide standardized or individualized treatment, using (may include marginalized analysis of trends drug resistant disease, as part second-line drugs, for diagnosed drug-resistant cases populations and prisoners) 3. Results of treatment of multi-drug resistent cases of overall DOTS programs (those resistent to at least rifampicin and isoniazid Overall population in all countries aiming to prevent spread of drug-resistance Enhanced TB prevention and control efforts in low-prevalence countries (TB incidence under about 20-25/100,000) Increase the speed of 1. Identify high-risk groups for TB infection and disease TB-infected persons; Depends on: elimination of TB as a public 2. Expand access to culture for early detection and persons at high risk of the populations at risk and their distribution (such as health threat through treatment of disease exposure to disease; the contacts of infectious cases ­ including health workers, interventions that increase early 3. Provide treatment to prevent development of disease general population persons living in congregate settings, family members detection of disease, and among those infected, often linked to other social of TB cases etc.); immigrants from high-burden prevent disease among infected services required for high-risk groups countries; and resources available to expand persons 4. Investigate outbreaks and reduce associated risks of interventions exposure to disease Patients with disease; Where to start DO expect reported incidence to rise with improved case detection before it gradually begins Throughout the developing world, successful TB control to fall. programs have emerged where committed policy- DON'T use technology improperly or inefficiently makers, public health leaders and communities: (1) (especially radiology, specialized laboratory develop well-defined strategic plans that (2) begin with testing, reserve "second-line" TB drugs, or demonstration areas and (3) expand as trained hospitalization). manpower and inputs (drugs, microscopes etc.) are DON'T expand case detection if cure rates remain available and documented good results are shared. low. The first priority for public safety and program Good treatment success rates (80% or more) and quality is to ensure effective treatment before detection of a majority of estimated cases in demon- generating more demand. stration areas is needed, before attempting expansion. DO promote coverage of BCG vaccine (Bacille Demonstrating good performance can help to mobilize Calmette-Guerin) within immunization programs in support to scale up and to attract those who are ill. At moderate and high TB burden countries, but not as the same time, nation-wide efforts need to be made to a TB control tool. It is effective in preventing reduce harm from dangerous current practices (e.g., dangerous forms of childhood TB, but children ensuring that no patient begins therapy without all rarely develop infectious disease. needed drugs secured, and that ineffective and DON'T expect a reversal in the epidemic overnight wasteful practices are stopped (see Lessons learned). ­ TB control requires a long-term agenda and commitment. How to adapt DOTS to local conditions Key documents DOTS is a basic template that is adapted depending WHO, Global Tuberculosis Control, 2003 Report, on a range of variables, including: Geneva. WHO/CDS/TB/2003.316 The level and distribution of TB, HIV/AIDS, multi-drug WHO, An Expanded DOTS Framework for Effective resistant disease, etc. Tuberculosis Control, 2002. WHO/CDS/TB/2002.297 WHO, Tuberculosis Handbook, Geneva, 1998. Health system organization (including the degree of WHO/TB/98.253 decentralization, nature of financing, administrative International Union against TB and Lung Disease capacity at each level, logistical systems, etc.). (IUATLD), Epidemiologic Basis of Tuberculosis Control, Distribution of health infrastructure, staff, and unused First Edition, Paris, IUATLD, 1999. capacity, e.g., laboratories, health centers, hospitals, http://www.who.int/gtb for additional references on community health workers, referral services and TB/HIV and MDR-TB specialists, NGOs, private providers or other interested parties. Key web sites http://www.worldbank.org/tuberculosis Lessons learned http://www.who.int/gtb http://www.iuatld.org DO develop delivery strategies that put the patients http://www.cdc.gov and their needs first. http://www.stoptb.org The Stop TB Initiative is an DO pursue DOTS principles within the general international partnership of high TB burden governments, framework of primary health care sector programs international and national agencies, NGOs and and/or poverty reduction strategies. researchers. Stop TB aims to facilitate rapid scale-up of DOTS, and the development of new tools and DO harness all stakeholders: government health approaches to battle TB disease, drug resistance and services, private sector, NGOs, employers, HIV-associated TB. community groups, civic leaders, patients and their families. For further information, contact Robert Hecht DO provide in-service training and regular (Rhecht@worldbank.org) or Diana Weil supervision to motivate staff, validate results and (Dweil@worldbank.org). ensure quality. Expanded versions of the "at a glance" series, with e-linkages to resources and more information, are available on the World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp