Planning and DOTS implementation
Planning activities carried out in 2003
In preparation for the 5th DEWG meeting (Paris, France, 27–28 October 2004), NTP managers for the 22 HBCs were asked to summarize what activities had been planned for implementation during 2003, which of those activities were implemented, which were not and why, and what corrective actions were taken so that these activities could be implemented in 2004. The information from these DEWG summary tables, supplemented with additional information provided by NTP managers and by WHO staff, is incorporated into the country profiles (Annex 1).
Update of country profiles
Country profiles (Annex 1) were updated by incorporating information from the following sources: summary tables prepared for the 5th DEWG; country posters presented by the 22 HBCs at the DEWG meeting; questionnaires submitted by the 22 HBCs; and consultations with, and reviews of, the country profiles by NTP staff and collaborating technical agencies.
Constraints and remedial actions
Following the previous analysis of constraints to DOTS expansion and remedial actions proposed, 13 this year’s report provides an update. Constraints and remedial actions were assessed with information provided at the DEWG meeting, and through personal communications with NTP managers and staff. Special attention was devoted to constraints related to laboratory services and human resources.
Partnerships and coordination
The list of donors and collaborating organizations was updated in consultation with NTP managers, WHO regional and country offices and partners. 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 national interagency coordinating committee (NICC).
Management of drug resistance
Data on the prevalence of drug resistance are collected through the WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance (DRS), which began in 1994, and which published its third report in 2004. 8 Profiles of the 22 HBCs contain estimates of the national prevalence of MDR-TB among previously untreated TB patients based on survey data for those countries participating in the WHO/IUATLD project. For those countries that have not carried out surveys, figures given in the country profiles are estimates.
WHO develops global policy on the management of MDR-TB and facilitates access to second-line drugs through the Green Light Committee (GLC). 14 As part of this process, and under the continuous monitoring of the GLC, several DOTS-Plus pilot projects are evaluating the feasibility and cost-effectiveness of using second-line drugs for managing MDR-TB in countries with limited resources. Projects approved by the GLC have access to quality-assured, second-line drugs at reduced prices and benefit from technical support and external monitoring. This report summarizes the number and status of GLC-approved DOTS-Plus projects that had been established by 2004.
Collaborative TB/HIV activities
WHO has published an interim policy on collaborative TB/HIV activities 15 that outlines the methods and benefits of collaboration between HIV and TB programmes. Three main areas of collaboration are recommended. First, organizational structures should be set up to plan and manage collaborative TB/HIV activities. Second, people infected with HIV should be screened for TB, treated if they have active disease, and offered isoniazid preventive therapy as needed. Third, TB patients should be offered voluntary counselling and testing for HIV infection (VCT); if positive, they should be offered co-trimoxazole preventive therapy and, wherever possible, ART. WHO has also developed a guide for monitoring and evaluating collaborative TB/HIV activities that defines indicators for each of the key activities recommended in the interim policy. 16
To investigate progress in implementing the recommended collaborative TB/HIV activities, countries were asked, via the standard WHO data collection form, to report on the extent to which TB patients were tested for HIV, assessed for ART and provided with ART during 2003. A supplementary questionnaire (available at www.who.int/tb) was sent to the 41 countries that have the highest incidence rates of TB with HIV coinfection. This questionnaire asked specifically about policy developments between 2002 and 2003. The data obtained from both forms were reviewed at WHO regional offices and headquarters, and any inconsistencies or missing data were discussed with the national correspondent before being included in the analysis.
Additional strategies for DOTS expansion
This report covers three areas:
- PPM initiatives that aim to bring a greater diversity of health-care providers into DOTS programmes, promoting the essential package of patient care and improving reporting and monitoring procedures;
- community participation that improves access to care and fosters a patient-centered approach to the management of TB. While the type and scope of community involvement depends upon location and context, many HBCs regard civil society as an essential partner in providing support to patients and their families;
- the feasibility of implementing the Practical Approach to Lung Health (PAL), which several countries are examining, and assessing its potential impact on TB case detection and on the rationalization of drug prescriptions.
In addition to the findings presented in this report, further details of PPM, TB/HIV, PAL and other projects can be found at www.who.int/tb.
8 Anti-tuberculosis drug resistance in the world. Report No.3. WHO/IUATLD Global Project on Anti-Tuberculosis Drug Resistance Surveillance. Geneva, World Health Organization, 2004 (WHO/HTM/TB/2004.343).
13 Global tuberculosis control: surveillance, planning, financing. WHO report 2004. Geneva, World Health Organization (WHO/HTM/TB/2004.331).
14 Gupta R et al. Increasing transparency in partnerships for health – introducing the Green Light Committee. Tropical Medicine and International Health, 2002, 7:970–976.
15 Interim policy on collaborative TB/HIV activities. Geneva, World Health Organization, 2004 (WHO/HTM/TB/2004.330; WHO/HTM/HIV/2004.1).
16 A guide to monitoring and evaluation for collaborative TB/HIV activities. Geneva, World Health Organization, 2004 (WHO/HTM/TB/2004.342; WHO/HIV/2004.09).