Key Point

The Stop TB Strategy and the ISTC were recently developed to help prevent, manage, and control tuberculosis.

GENEVA AND NEW YORK CITYWith concern growing about the possibility of an avian influenza pandemic, we are hearing less about other matters, including tuberculosis. Nonetheless, important work in the prevention and management of the disease has continued internationally.

Recently, the World Health Organization (WHO) released its new Stop TB Strategy, with its stated goal of dramatically reducing the global burden of tuberculosis.¹ A tuberculosis-free world is the strategy’s ultimate vision.

WHO and the American Thoracic Society also oversaw development of the new International Standards for Tuberculosis Care (ISTC).² That document’s purpose is to describe a level of care that all practitioners should seek to achieve in managing patients with confirmed or suspected tuberculosis.

BUILDING ON THE SUCCESS OF DOTS

For more than a decade the core focus of the tuberculosis control community has been DOTS, the internationally agreed-upon framework for controlling the disease. DOTS has five important elements, with directly observed therapy being one of them. The impact on tuberculosis through DOTS cannot be understated. More than 22 million patients have been treated since its launch in 1995. But despite its enormous strengths, it had some limitations that needed to be addressed. "New challenges have arisen since DOTS was created, so we needed to modernize and expand it," Mario Raviglione, MD, Director of WHO’s Stop TB Department, told Pulmonary Reviews. Hence the development of the new Stop TB Strategy.

A main goal of the strategy is to halt and begin reversing tuberculosis incidence by 2015. At that point, the WHO would also like to see reductions in tuberculosis prevalence and mortality of 50% relative to 1990. By 2050, the aim is a case rate of less than one per million, effectively eliminating tuberculosis as a public health problem.

There are six components of the Stop TB Strategy:

Pursue high-quality expansion and enhancement of DOTS. DOTS remains central to the new Stop TB Strategy. Political commitment with increased and sustained financing, case detection through quality-assured bacteriology, standardized treatment with supervision and patient support, an effective drug supply and management system, and a monitoring and evaluation system and impact measurement remain firmly in place.

Address tuberculosis/HIV, multidrug-resistant tuberculosis (MDR-TB), and other challenges. HIV and tuberculosis programs must increase collaboration, and MDR-TB management should become an integral part of national tuberculosis control.

Contribute to health system strengthening. Policies, human resources, management, financing, service delivery, and information systems must be aligned and improved. Innovative implementation strategies should be designed, adapted, and shared.

Engage all care providers. Increased efforts to include public and private providers in the elimination of tuberculosis will help to increase case detection, standardize case management, reduce costs, and improve access and equity in care provision.

Empower people with tuberculosis and communities. People and communities can share in key tasks in tuberculosis control with guidance from local health services.

Enable and promote research. "We are not going to eliminate tuberculosis with the current tools," asserted Dr. Raviglione. "The only way is to develop the necessary tools through research."

THE ISTC

The ISTC, stressed the authors, is a living document that will be revised with changes in technology, resources, and circumstances. It is "presented within a context of what is generally considered to be feasible now or in the near future," they added.

The document contains 17 standards, which are summarized here:

Standard 1. All persons with otherwise unexplained productive cough lasting at least two to three weeks should be evaluated for tuberculosis.

Standard 2. All patients with suspected pulmonary tuberculosis should have at least two, and preferably three, sputum specimens examined microscopically.

Standard 3. In all patients with suspected extrapulmonary tuberculosis, specimens from the suspected sites of involvement should be obtained for microscopy and for culture and histopathology.

Standard 4. All persons with chest radiographic findings suggesting tuberculosis should have sputum specimens submitted for microbiologic examination.

Standard 5. Sputum smear–negative pulmonary tuberculosis should be diagnosed if at least three sputum smears are negative, chest radiography findings suggest tuberculosis, and there is no response to a trial of broad-spectrum antimicrobials.

Standard 6. Intrathoracic tuberculosis should be diagnosed in symptomatic children with negative sputum smears if chest radiography suggests tuberculosis and there is either a history of tuberculosis exposure or evidence of tuberculosis infection.

Standard 7. Practitioners who treat tuberculosis must not only prescribe appropriate therapy but also assess patient adherence and address poor adherence when it occurs.

Standard 8. All patients who have not been treated for tuberculosis previously should receive an internationally accepted first-line treatment regimen.

Standard 9. Practitioners should take a patient-centered approach to treatment.

Standard 10. In patients with pulmonary tuberculosis, the response to therapy is best judged with sputum microscopy. Response is best assessed clinically in extrapulmonary tuberculosis and in children.

Standard 11. A record of all medications, bacteriologic response, and adverse reactions should be maintained for all patients.

Standard 12. Where HIV rates are high and tuberculosis and HIV are likely to coexist, routine HIV testing and counseling are indicated for all tuberculosis patients. Where HIV rates are lower, testing and counseling are indicated.

Standard 13. In all patients with tuberculosis and HIV, it should be determined if antiretroviral therapy is indicated during tuberculosis treatment.

Standard 14. All patients with tuberculosis should be assessed for drug resistance based on prior treatment, exposure to an individual who may have resistant tuberculosis, and the prevalence of drug resistance.

Standard 15. Drug-resistant tuberculosis warrants a specialized regimen containing second-line antituberculosis drugs.

Standard 16. Evaluation and management according to international recommendations should be ensured for individuals in close contact with patients.

Standard 17. Care providers must report new and recurrent tuberculosis cases and treatment outcomes to local public health authorities.

—Timothy Begany

References
1. World Health Organization. WHO launches new Stop TB Strategy to fight the global tuberculosis epidemic. Press release available at: www.who.int/mediacentre/ news/releases/2006/pr12/en/index.html. Accessed May 1, 2006.
2. Tuberculosis Coalition for Technical Assistance. International Standards for Tuberculosis Care (ISTC). The Hague: Tuberculosis Coalition for Technical Assistance; 2006.

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