Methods: Planning and DOTS implementation
The information on strategic planning presented in this report reflects activities during 2003, including some activities that began in 2002. The Global DOTS Expansion Plan (GDEP) is monitored through several mechanisms including direct discussions with NTP managers, collaboration with international technical agencies, monitoring missions, comprehensive programme reviews, GFATM applications, regional NTP managers' meetings, and the annual meeting of the DOTS Expansion Working Group (DEWG). In writing this report, WHO staff worked with NTP managers of the 22 HBCs to:
- Assess national TB control activities planned and carried out during 2003, focusing on activities to improve political commitment, expand access to DOTS, strengthen diagnosis, improve treatment outcomes, ensure adequate staffing, improve programme monitoring and supervision, and implement additional strategies.
- Update the country profiles5 to summarize progress made by the end of 2003 in implementing, or scaling up, national plans for DOTS expansion.
- Analyse constraints to reaching the targets for detection and treatment success.
- Review and revise the list of partners operating in, or on behalf of, each country.
- Assess levels of drug resistance and planning activities to address MDR-TB.
- Determine the status of collaborative TB/HIV activities.
Planning activities carried out in 2003
In preparation for the 4th DEWG meeting (The Hague, Netherlands, 7-8 October 2003), NTP managers for the 22 HBCs were asked to summarize what activities had been planned for implementation during 2002, which of those activities were implemented and which were not, why planned activities were not implemented, and what corrective actions were taken so that these activities could be implemented in 2003 (objective 1). WHO country staff then determined which of the activities planned for 2003 were actually implemented. The information from these DEWG summary tables, supplemented with additional information provided by WHO staff, is incorporated into the country profiles.
Update of country profiles
Country profiles were updated (objective 2) by incorporating information from the following sources: summary tables prepared for the 4th DEWG; country posters presented by the 22 HBCs at the DEWG meeting; and consultations with, and reviews of the country profiles by, NTP staff and collaborating technical agencies. Each country profile in Annex 1 contains the 5 sections shown in Table 3 .
Constraints and remedial actions
Following last year's analysis of constraints to DOTS expansion and remedial actions proposed,5 this year's report provides an update (objective 3). Constraints and remedial actions were assessed with information provided at the DEWG meeting, and through personal communications with NTP managers and staff.
Partnerships and coordination
The list of donors and collaborating organizations was updated in consultation with NTP managers, WHO regional offices, and partners (objective 4). Major technical agencies, along with financial partners, are listed in each country profile. The coordination of these numerous agencies is vital for the efficient use of limited resources within countries, and is facilitated through a formal coordination mechanism, such as the NICC.
Planning for MDR-TB control
The status of plans to address MDR-TB (objective 5) was assessed through personal communication with the NTPs of 9 HBCs (China, India, Kenya, Nigeria, the Russian Federation, South Africa, Tanzania, the Philippines, Viet Nam). These countries either have high rates of MDR-TB, or high absolute numbers of MDR-TB cases. Some have started DOTS-Plus pilot projects, approved by the Green Light Committee (GLC), to manage drug resistance (the Philippines, the Russian Federation), some have applications under review by the GLC (India, Kenya), and some are preparing applications to the GLC (Tanzania, Viet Nam, and possibly South Africa).
In 1994, due to the lack of standardized data on anti-TB drug resistance, and in an effort to assess the geographical distribution of drug resistance, WHO, IUATLD, and other partners developed the Global Project on Anti-tuberculosis Drug Resistance Surveillance (DRS). The project assembled a network of supranational laboratories to aid national reference laboratories in conducting drug susceptibility testing to international standards, in conjunction with national or local surveys of anti-TB drug resistance. We report here some of the results of the 3rd global review of anti-TB drug resistance, which will appear in full in a separate report to be published in 2004.6 The country profiles contain MDR-TB survey data for those countries participating in the WHO/IUATLD surveillance project, and which could provide new information by January 2004. These new data supplement earlier estimates of MDR-TB rates,15 which are also given in the tables at Annex 1.
Collaborative TB/HIV activities
HIV fuels the TB epidemic and collaboration between TB and HIV control programmes will be vital to address this growing problem. A rapid assessment was undertaken to determine the extent to which the 22 HBCs are implementing collaborative TB/HIV activities (objective 6). A simple questionnaire was developed for interviewing NTP managers during the 4th DEWG meeting. Respondents were asked whether the following 12 collaborative activities (outlined in WHO's interim policy on collaborative TB/HIV activities16) are carried out in the country: establishment of TB/HIV collaborating bodies; HIV surveillance in TB patients; joint TB/HIV planning; TB/HIV monitoring and evaluation; intensified TB case finding in people infected with HIV; isoniazid preventive therapy; TB infection control in health facilities and congregate settings (e.g. prisons, workers' hostels, police and military barracks); HIV testing of TB patients; TB patients provided with HIV prevention methods; cotrimoxazole preventive therapy; HIV care and support for TB patients; and ART for HIV-infected TB patients. Any collaborative programme services or pilot projects implemented in any scale by the MoH, NGOs, or research organizations were included in the survey.
15 Dye C, Espinal MA, Watt C, Mbiaga C, Williams BG. Worldwide incidence of multidrug-resistant tuberculosis. Journal of Infectious Diseases 2002; 185: 1197–1202.
16 WHO. Interim Policy on Collaborative TB/HIV Activities. Geneva, WHO/HTM/TB/2004.330 and WHO/HTM/HIV/2004.1.