Stop TB Strategy: implementation and planning (2005–2007)
The information on implementing and planning the Stop TB Strategy presented and analysed in this report reflects activities mostly carried out in the 2005–2006 fiscal year and planned for the 2006–2007 fiscal year (see also Financing TB control). For this report, HBC activities and plans were monitored mainly through a questionnaire on Stop TB Strategy implementation sent by WHO to NTP managers of the 22 HBCs in May 2006. The questionnaire1 was structured around the components of the Stop TB Strategy and included questions on: DOTS expansion and enhancement; laboratory and diagnostic services; human resource development; drug management; monitoring and evaluation system, and impact measurement; collaborative TB/HIV activities; drug-resistant TB; special populations and other high-risk groups; health system strengthening and TB control; Practical Approach to Lung Health (PAL); public–public and public–private mix (PPM) approaches; International Standards for Tuberculosis Care;2 advocacy, communication and social mobilization (ACSM); community TB care; Patients’ Charter for Tuberculosis Care;3 operational research; Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM); and technical and financial partners.
Other mechanisms were used to clarify or complement responses provided in the questionnaire. These mechanisms included direct discussion with NTP managers, e-mail and telephone communication with NTPs, consultation with international technical agencies, monitoring missions, comprehensive programme reviews, applications to the GFATM, regional NTP managers’ meetings, and the annual meeting of the DOTS Expansion, TB/HIV and MDR-TB working groups of the Stop TB Partnership.
Implementation of the Stop TB Strategy in non-HBCs was monitored through analysis of the responses to the Stop TB Strategy questions in the standard data collection form (see Monitoring progress in TB control) sent by WHO to all countries. Each component of the Stop TB Strategy was covered in the data collection form but in less detail than the questionnaire.
In developing the country profiles (Annex 1), WHO staff worked closely with NTP managers of the 22 HBCs to:
- assess the main national TB control activities carried out and planned, focusing on improving political commitment, expanding access to DOTS, strengthening laboratory and diagnostic services, ensuring human resource development, strengthening drug management, and improving programme monitoring and supervision;
- summarize progress made by the end of 2006 in implementing, or scaling up, national plans for DOTS expansion;
- identify challenges to reaching the targets for case detection and treatment success;
- determine the status of collaborative TB/HIV activities;
- assess levels of drug resistance and activities planned to address MDR-TB, including mechanisms of drug-resistance surveillance, MDR-TB diagnosis and treatment policies, and the availability of second-line anti-TB drugs;
- identify action plans of the NTP for high-risk groups and special populations;
- describe the contribution of TB control activities to the strengthening of health systems;
- determine the status of additional strategies to expand DOTS, including community participation in TB care, ACSM strategies, and PPM approaches;
- describe the level of operational research carried out and reported;
- review and revise the list of partners supporting DOTS implementation and expansion.
Addressing TB/HIV, MDR-TB and other challenges
Collaborative TB/HIV activities
The WHO policy on collaborative TB/HIV activities4 emphasizes three areas. First, organizational structures should be put in place to plan and manage collaborative TB/HIV activities. Second, people should be screened for TB when they test positive for HIV and again whenever they attend the health services. If they have active TB they should be treated; if they have latent infection but not active TB they should be given isoniazid preventive therapy (IPT). Third, all TB patients should be given counselling about HIV and encouraged to have an HIV test; if they are HIV positive they should be offered co-trimoxazole preventive therapy (CPT) and should be assessed for, and started on, antiretroviral therapy (ART) as soon as possible.
In order to assess the extent to which collaborative TB/HIV activities are being implemented, NTP managers were asked if they had a national policy of testing TB patients for HIV in 2005 and to report on the number that were tested for HIV, the number that tested positive, the number that started CPT and ART in 2004 and 2005, and the number that are expected to be started on ART in 2006 and 2007. In the 63 countries that account for 98% of the total number of HIV-infected TB cases, NTP managers were also asked for information about their policy on TB/HIV management, and for data on screening for TB and the provision of IPT to people with HIV in 2005. These countries included 58 for which the estimated HIV prevalence in adults aged 15–49 years was greater than 1% in 2004,5 plus Brazil, India, Indonesia, the Russian Federation and Viet Nam, which are among the 41 countries with the highest numbers of HIV-infected TB patients.6
The data were reviewed at WHO regional offices and at headquarters, and an attempt was made to resolve inconsistencies and to obtain missing data in discussions with NTP managers. Because data have now been collected since 2002, time trends in TB/HIV activities are also discussed. Indicators for monitoring and evaluating collaborative TB/HIV activities are available from WHO.7
MDR-TB surveillance and control
In 2006, the standard data collection form asked for the following information on MDR-TB surveillance and control:
- whether the management of MDR-TB patients is among the activities of the NTP;
- if practice follows WHO guidelines on the management of drug-resistant TB and, if not, whether the NTP plans to start treating MDR-TB patients in the next two years;
- the number of new and re-treatment patients registered in 2005 who received drug susceptibility testing (DST) at the start of treatment;
- the number of laboratory-confirmed cases of MDR-TB identified among new and re-treatment patients in whom TB was diagnosed in 2005;
- the number of MDR-TB patients expected to be treated in 2006 and 2007;
- treatment outcomes among new, re-treatment and other MDR-TB patients registered in 2002 in GLC-approved and non-GLC approved countries or areas.
In addition to the standard data collection form, the questionnaire on implementation of the Stop TB Strategy sent to HBCs provided further information on plans for drug resistance surveillance (DRS) and MDR-TB diagnosis and treatment, and identified the principal obstacles to implementing these activities.
Besides this information, this report includes data on the prevalence of drug resistance among TB patients collected through the WHO/IUATLD Global Project on Antituberculosis Drug Resistance Surveillance (Global DRS Project), which began in 1994.8 The project carries out surveys of drug resistance, using established and agreed methods, among patients who present to clinics, hospitals and other health institutions. The fourth report on the global magnitude and trends of drug resistant TB will be published by mid-2007. The profiles of the 22 HBCs (Annex 1) contain estimates of the national prevalence of MDR-TB among both new and previously treated TB patients, based on survey data for those countries participating in the Global DRS Project and for which data are considered reliable. For those countries that have not carried out surveys, or that do not have representative data on new or previously-treated cases, the figures given in the country profiles are estimates based on a regression model described in detail elsewhere.9
This report also summarizes the projects approved by the Green Light Committee (GLC) in 2006 for access to quality-assured, second-line anti-TB drugs at reduced prices and independent external monitoring.
1 Posted at www.who.int/tb/country/en/
2 Hopewell PC et al. International standards for tuberculosis care. Lancet Infectious Diseases, 2006, 6:710-725.
3 Posted at www.who.int/tb/publications/2006/istc/en/index.html
4 Interim policy on collaborative TB/HIV activities. Geneva, World Health Organization, 2004 (WHO/HTM/TB/2004.330; WHO/HTM/HIV/2004.1; available at whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.330.pdf).
5 HIV prevalence estimates for 2004 (unpublished data). Geneva, UNAIDS.
6 Questionnaires are available at www.who.int/tb/country/en/
7 A guide to monitoring and evaluation for collaborative TB/HIV activities. Geneva, World Health Organization, 2004 (WHO/HTM/TB/2004.342 and WHO/HIV/2004.09; available at whqlibdoc.who.int/hq/2004/WHO_HTM/TB_2004.342.pdf).
8 The WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance. Anti-tuberculosis drug resistance in the world. Third global report. Geneva, World Health Organization, 2003 (WHO/HTM/TB/2004.343; more information about the project can be found at www.who.int/tb/dots/dotsplus/surveillance/en/index.html).
9 Zignol M et al. Global incidence of multidrug-resistant tuberculosis. Journal of Infectious Diseases, 2006, 194: 479-485.