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STRATEGIES IN TB CONTROL DOTS

STRATEGIES IN TB CONTROL DOTS. Lucica Ditiu, Antalya, April 2005. The DOTS Strategy (1995). Government commitment to TB control Diagnosis by smear microscopy mostly on self-reporting symptomatic patients Standardised SCC under proper case management conditions, including DOT

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STRATEGIES IN TB CONTROL DOTS

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  1. STRATEGIES IN TB CONTROL DOTS Lucica Ditiu, Antalya, April 2005

  2. The DOTS Strategy (1995) • Government commitment to TB control • Diagnosis by smear microscopy mostly on self-reporting symptomatic patients • Standardised SCC under proper case management conditions, including DOT • Efficient system of drug supply • Efficient recording and reporting system with assessment of treatment results

  3. Evolution of WHO's TB Control Strategy • DOTS launched in 1995 and promoted for a decade with great success (182 countries!) • DOTS expansion nearly completed with most designated public services "covered" (>80% of world population) • DOTS is the sine qua non for TB control, an enlarged approach is necessary to achieve MDGs by 2015 • Requires: adaptation to special settings; engagement of all health sectors; advocacy and social mobilisation; new tools

  4. Consolidate DOTS: Optimise, sustain and measure achievements, through a patient-centered approach, by building capacity and mobilising human and financial resources within strengthened health systems • Adapt DOTS: Address TB/HIV, MDR-TB and other special situations • Engage all Providers: Ensure all care givers, public and private, use the international standard of TB care, making it accessible to all patients, especially the poor • Mobilise Communities: Promote community participation and engage societies to increase demand for, and contribute to, proper care • Promote R&D for new Tools: Support efforts by public and private enterprises to develop better tools for TB diagnosis, treatment and prevention Stop TB Department

  5. Diagnosis • Should be evaluated: persons with otherwise unexplained cough lasting for 2-3 weeks or more. • Microbiological evaluation (smear + culture) is essential (including children extra-pulmonary, and persons with radiographic abnormalities) • Specific criteria for smear-negative cases • Assessment for HIV infection in persons at risk (based on epidemiological circumstances, risk group, or clinical findings)

  6. Microbiological evaluation (smear + culture) is essential for all patients (including children, extra-pulmonary, and persons with radiographic abnormalities) • Microscopy – methods to increase the positivity rate – concentration, fluorescence • Culture – increase the case detection. Ideally can be used for at least initial specimens of all patients plus those with suspect DR. - in case definitions and treatment follow up - depends on financial resources (5-10 times more expensive than microscopy), trained personnel and availability of reagents, equipment and infrastructure

  7. No radiographic pattern is diagnostic of TB!

  8. Errors – under, over-reading • Treating persons with images/shadows - treat too many unnecessarily or wrong! • X-ray should be part of the diagnostic algorithm in the diagnosis of smear negative TB cases: • At least 3 sputum smear negative • X-ray findings consistent with TB • Lack to response to antimicrobial agents (excepting anti TB drugs and quinolones)

  9. TREATMENT • Provider is responsible for prescribing an adequate regimen and ensuring adherence • Preferred regimen: 6 months with RIF throughout • A patient-centered approach should be developed for all patients: a treatment supporter to ensure supervision • Patients to be monitored for response to therapy • HIV testing for all patients and ARVs if indicated • Assessment of likelihood of drug resistance/consultation for patients at risk of having disease caused by resistant M TB

  10. A patient-centered, approach to treatment should be developed for all patients. • A central element is support for adherence, including direct observation by a treatment supporter

  11. Adherence • Socio-economic factors – living conditions, high costs, gender, age • Health care factors – underdevelopment, lack of access, poor relationship with health care providers, lack of training, motivation • Patient factors – forget, other diseases, depression, stress • Disease factors –complex treatment regimens, side effects

  12. Patient monitoring and treatment supervision • Sputum smear microscopy is the most effective • Clinical and radiological assessment -unreliable and misleading • Record and report the data of the patients, drugs given, side effects, results of bacteriological examination

  13. Public Health • Requirement to see that high-risk contacts are evaluated • Requirement for reporting cases and treatment outcome

  14. Requirement to analyze and use the data

  15. Top Priority 2005: Consolidate DOTS • Political commitment with long-term planning, adequate human resources and sustainable financing to reach WHA and MDG targets • Diagnosis through bacteriology (microscopy first, and culture/DST) and establishment of an effective laboratory network to facilitate detection of SS+, SS- and DR- TB cases • Standardized treatment under proper case management conditions, including DOT, and full patient support for all TB cases • An effective drug supply system • An adequate recording and reporting of cases and outcomes

  16. Focus on Quality TB care for all: • Patient care to cure and prevent TB is the ultimate goal of DOTS and any TB control effort • The foundation of DOTS is effective patient care which alleviates suffering, and controls and prevents TB in a community • A standard of care for TB exists within DOTS, but needs further promotion among all care providers • Simply, each care provider, public or private, should: 1- Diagnose TB quickly (i.e., bacteriological confirmation) 2- Treat TB properly (i.e., SCC and treatment support) 3- Report TB cases and treatment outcomes

  17. International Standards for Tuberculosis Care • Standards apply to all providers in all sectors regardless of circumstances • Standards apply to all patients of all ages, smear positive and negative, extra-pulmonary, MDR, TB/HIV • All providers must recognize that they are assuming a public health function with a high degree of responsibility to the community and to the patient • Consistent with existing international guidelines

  18. Tesekkur ederim!

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