Moving Forward in Diagnosis of Infectious Diseasesin Developing Countries: A Focus on Tuberculosis

Les Pensièrs, Veyrier-du-Lac, France8 – 9 May 2008y

Contemporary diagnosis for all TB patients:p y g pInternational Standards for TB Care

Karin WeyerOn behalf of ISTC Steering Committee

Organizations responsible for ISTC

ISTC development process• Funded (Oct 1, 2004) by USAID via TBCTA

• Steering Committee: 28 members / 14 countries

• Co-chairs: M Raviglione (WHO) & P Hopewell (ATS)Co c a s a g o e ( O) & ope e ( S)

• Process coordinated by ATS

• Evidence-based with six systematic reviews

• Ten drafts prior to finalp

• Final document December 2005

C f C• Patients’ Charter for Tuberculosis Care developed in tandem

• Launched on World TB Day (Mar 24, 2006)

• 2008 revision in preparation

The New Global Strategy to Stop TB

Introduction

Introduction: Key points• Purpose: to describe a widely accepted level of

care that all practitioners should seek to achieve in managing all patients

• Audience: all health care practitioners, public and privatep

• Scope: diagnosis, treatment, and public health responsibilities; intended to complement local andresponsibilities; intended to complement local and national guidelinesRationale: sound tuberculosis control requires• Rationale: sound tuberculosis control requires the effective engagement all providers in providing high quality care and in collaboratingproviding high quality care and in collaborating with tuberculosis control programmes

17 Standards for TB Care

• Six Standards for Diagnosis– All highlighting the need for microbiological investigations– Covering HIV-associated and drug-resistant TB

• Nine Standards for Treatment– Four dependent on microbiological investigations

• Two Standards for Public Health

Standards for Diagnosis

Diagnosis: Key points

D ib d f t i ti f• Describes need for sputum examination of patients with cough for 2-3 weeks or more

• Emphasizes requirement for microbiological evaluation for suspected pulmonary and extra

l i d h i di hpulmonary sites; de-emphasizes radiography as a single tool for diagnosis

• Describes a rigorous approach to diagnosis of smear-negative tuberculosis (including g ( gchildren)

• Describes a rigorous approach to diagnosis ofDescribes a rigorous approach to diagnosis of drug-resistant tuberculosis

Standards for Treatment

Treatment: Key points

• Emphasizes public health responsibility: prescribe regimen• Emphasizes public health responsibility: prescribe regimen, assess adherence, and address poor adherence

• Stresses use of internationally accepted regimen(s)

• Focuses on a mutually acceptable patient-centered approach tailored to patient’s circumstances

• Describes need for recording and monitoring of treatmentDescribes need for recording and monitoring of treatment

• Presents indications for HIV testing of tuberculosis patients and for ARV treatmentand for ARV treatment

• Presents situations in which drug susceptibility is indicated and describes appropriate regimens

Standards for Public Health

Public Health: Key Points

• Describes need for investigation of high-risk contacts (children <5 years and HIV infected persons)

• Emphasizes need for reporting to public• Emphasizes need for reporting to public health authorities

Research Needs

ISTC: Test Sites

• Indonesia• Indonesia

• Kenya

• Tanzania

• MexicoMexico

I di• India

ISTC: Pilot Sites

• Indonesia• Indonesia– Situation analysis of the constraints to y

full implementation at provincial level in collaboration with PDPI

– Coordinated professional society campaign with Indonesian Medicalcampaign with Indonesian Medical SocietyDissemination & ed cation acti ities– Dissemination & education activities

– Patients Charter activities

Professional society endorsements: Indonesiae do se e ts do es a

ISTC implementation: role of professional societiesprofessional societies

Professional societies as valuableProfessional societies as valuable collaborators with public health programmes

• Serving as conduits to their private sector• Serving as conduits to their private sector membersGi i dibili bli h l h• Giving credibility to public health programmes

• Providing technical assistance to programmesg p g• Conducting training activities

E ti• Exerting peer pressure• Advocating for appropriate resources and g pp p

policies

ISTC: Pilot sites, India

Used for PPM training by RNTCP/IMAUsed for PPM training by RNTCP/IMA

ISTC: IndiaIMPACT

Indian Medical Professional Associations Coalition against Tuberculosis

• Indian Medical Association• Association of Physicians of India• Indian Chest SocietyIndian Chest Society• National College of Chest Physicians (India)• Indian Academy of Paediatrics• Indian Academy of Paediatrics• Federation of Family Physicians Associations

of Indiaof India

ISTC Pilot Sites

• Kenya – Coordinated professional society campaign with

KAPTLD– Dissemination & education activities

• TanzaniaDeveloping coordinated curriculum for medical– Developing coordinated curriculum for medical students at all schools in the country

• MexicoAd i l l i f i l i i– Adaptation at state level via professional societies and national/local control programmes

ISTC: Languages

• English • Indonesian• English• French

• Indonesian• Vietnamese

• Spanish• Russian

• Japanese• Khmer• Russian

• Chinese• Khmer• Thai

Editorial: Lancet Infectious Diseases, November 2006November 2006

‘In this month's issue of The Lancet Infectious Diseases we publish the pInternational Standards for Tuberculosis Care. When national tuberculosis control programmes and individual clinicians apply these t d d tl ltid i t tstandards correctly, multidrug-resistant

tuberculosis and—the recently d fi d t i l d i t tdefined—extensively drug-resistant (XDR) tuberculosis should not develop’

ISTC Steering CommitteegEdith Alarcon (nurse, international technical agency, NGO)R. V. Asokan (professional society)Jaap Broekmans (international technical agency, NGO)Jaap Broekmans (international technical agency, NGO)Jose Caminero (academic institution, care provider)Kenneth Castro (national tuberculosis programme director)Lakbir Singh Chauhan (national tuberculosis programme director)David Coetzee (TB/HIV care provider)David Coetzee (TB/HIV care provider)Sandra Dudereva (medical student)Saidi Egwaga (national tuberculosis programme director)Paula Fujiwara (international technical agency, NGO)Robert Gie (paediatrics, care provider)Robert Gie (paediatrics, care provider)Case Gordon (patient advocate)Philip Hopewell, Co-Chair (professional society, academic institution, care provider)Umesh Lalloo (academic institution, care provider)Dermot Maher (global tuberculosis control)Dermot Maher (global tuberculosis control)GB Migliori (professional society)Richard O’Brien (new tools development, private foundation)Mario Raviglione, Co-Chair (global tuberculosis control)D’Arcy Richardson (nurse, funding agency)cy c a dso ( u se, u d g age cy)Papa Salif Sow (HIV care provider)Thelma Tupasi (multidrug drug-resistant tuberculosis, private sector, care provider)Mukund Uplekar (global tuberculosis control)Diana Weil (global tuberculosis control)(g )Charles Wells (technical agency, national tuberculosis program)Karin Weyer (laboratory, academic institution)Wang Xie Xiu (national public health agency)