Tuberculosis care and control in refugee and displaced populations
An interagency field manual
This manual is intended to inform humanitarian agencies, including nongovernmental organizations, United Nations organizations and donors, of the issues relating to the care and control of tuberculosis (TB) in refugee and displaced populations. The manual will serve as a tool for health coordinators at the field level for the implementation, monitoring and evaluation of TB programmes in these settings. The main targets are those agencies providing health care to refugee and displaced populations, ministries of health or United Nations organizations coordinating these services and donor agencies providing financial support.
Recent field experience has demonstrated that a TB programme can be implemented effectively and produce good treatment outcomes, in appropriately chosen refugee and displaced population settings. TB care and control is not a priority in the acute phase of an emergency when mortality rates are high due to acute respiratory infections, diarrhoeal diseases, measles, malaria in endemic areas, and malnutrition. The priorities during this phase are the provision of adequate food, water, shelter, sanitation, basic drugs and the control of common acute communicable diseases. A TB programme should not be initiated until death rates have been reduced to less than 1 per 10 000 population per day, basic needs are provided, and essential clinical services and supplies are available.
A TB programme should be implemented only if the security situation is sufficiently stable to enable implementation of activities and if no major movements of the camp or the population served are anticipated in the near future. At a minimum, programme funding should be sufficient to enrol patients for 12 months and complete the treatment of all members of this cohort—a minimum of 18 months.
Whenever possible, the national TB control programme (NTP) of the host country should be involved in the development of the TB programme. The policies of the NTP in the country of origin should also be taken into consideration if refugees are likely to be repatriated. Coordination with UNHCR in the planning stage is critical in order to minimize the risk of patients interrupting treatment when camps or populations are moved.
The priorities of a TB programme are first to identify and treat infectious TB patients with smear positive pulmonary TB and those with severe forms of the disease. Cure of infectious patients is the most effective means of reducing TB transmission in the family and community. However, the impact of TB treatment on a population may be demonstrable only after a number of years of programme operation—longer than the likely span of many emergency programmes. TB treatment can be justified in these settings on the basis of the humanitarian benefit to individual patients. Once the programme is established, it is appropriate to treat other forms of TB, as many as possible if resources permit.
The recommended strategy to control TB is the WHO Stop TB Strategy (Appendix 1). This new strategy has six components, one of which ("pursuing high-quality STOP TB expansion and enhancement") includes five basic key elements – the most relevant in refugee and displaced populations:
- political commitment and sustained financing
- case detection through quality-assured bacteriology
- standardized short-course chemotherapy with supervision and patient support
- an effective drug supply and management system
- monitoring and evaluation system, and impact measurement.
Quality-controlled smear microscopy for TB diagnosis and treatment should be provided free of charge and integrated into the primary health care services for refugee and displaced populations.
Many refugees and displaced persons may come from, or seek refuge in, countries with a high prevalence of infection with human immunodeficiency virus (HIV). Hence TB/HIV coinfection may be prevalent in these populations. A high rate of HIV should be considered a factor increasing the priority of TB treatment and control. TB patients coinfected with HIV respond well to standard TB treatment. TB and HIV programmes should therefore be closely coordinated.
Provision of food may be important in TB programmes in malnourished populations and can serve a useful function as an incentive, but food supplementation is not routinely necessary for successful TB treatment.