July 2002 issue of the Stop TB Communiqué
STOP TB COMMUNIQUE
Issue 22, July 2002
1. General Stop TB Awareness News
a. An expanded DOTS framework for effective tuberculosis control
Several challenges impede sustainable implementation and expansion of TB control activities. Many of these stem from a weak political will failing to elicit the required health system and societal response to control TB. General public health services need to enhance their capacity to sustain and expand DOTS implementation without compromising the quality of case detection and treatment. Community involvement in TB care and a patient-centred approach need emphasis and promotion to improve both access to and utilisation of health services. Collaboration and synergy among the public, private, and voluntary sectors are essential to ensure accessible and quality-assured TB diagnosis and treatment. The increasing impact of HIV on the incidence of TB especially in Sub-Saharan Africa calls for new partnerships and approaches. A surge in drug-resistant forms of TB in the former Soviet Union and several other parts of the world requires effective implementation of the DOTS strategy to prevent occurrence of new multi drug-resistant (MDR-TB) cases as well as measures to cure existing MDR-TB cases. Sustaining DOTS programmes will also entail their integration into primary health care and adaptation to ongoing reforms within health sectors worldwide.
In view of the above challenges and
experiences of about a decade of DOTS implementation – achievements and constraints
– Stop TB department of WHO, Geneva recently published "An expanded framework
for effective tuberculosis control". To access the entire document, please click on
the following hyperlink:
http://www.who.int/gtb/dots/index.htm
The expanded strategy lays equal emphasis on technical, managerial, social and political dimensions of DOTS. It acknowledges access to TB care as a human right and recognises TB control as a social good with large benefits to society. It underscores the contribution TB control makes to poverty alleviation by reducing the great socio-economic burden that the disease inflicts on the poor.
The expanded framework reinforces the five essential elements of the DOTS strategy. It applies to HIV-related and drug-resistant forms of TB as well. The five elements of the expanded framework are:
a. Sustained political
commitment to increase human and financial resources and make TB control a nation-wide
activity integral to national health system; The DOTS programme should be made an integral
health system activity with nation-wide coverage that anchors TB activities throughout the
health system at all levels, including peripheral health facilities and the community.
b. Access to quality-assured TB sputum microscopy for case detection
among persons presenting with, or found through screening to have, symptoms of TB (most
importantly prolonged cough). Special attention is necessary for case detection among
HIV-infected people and other high-risk groups e.g. people in institutions.
c. Standardised short-course chemotherapy to all cases of TB under proper
case-management conditions including direct observation of treatment – proper case
management conditions imply technically sound and socially supportive treatment services.
The added components under this element include harnessing community contribution to TB
care, involving private and voluntary health care providers and addressing the issue of
MDR-TB where appropriate
d. Uninterrupted supply of quality-assured drugs with reliable drug
procurement and distribution systems. Anti-TB drugs should be available free of charge to
all TB patients since curing TB patients is beneficial to society at large. Their proper
utilisation in practice should be strictly monitored. Use of fixed dose combinations
should be encouraged.
e. Recording and reporting system enabling outcome assessment of each and
every patient and assessment of the overall programme performance. Local capacity to
analyse and use routinely collected data should be strengthened.
The expanded framework also incorporates additional key operational elements like information, education, communication and social mobilisation; economic analysis and financial planning and programme-based, problem solving operational research.
b. Call for participants—Workshop for TB and HIV patient community representatives
A one-day intensive educational workshop for TB and HIV patient community representatives to learn the basics of TB/HIV coinfection, including epidemiology, diagnosis, care, and treatment, will be held during the 33rd IUATLD World Conference on Lung Health, 4-5 October 2002. It is planned as a Satellite Workshop with follow-up 6-9 October 2002, Montréal, Québec sponsored by Treatment Action Group (TAG). International patient community representatives will then attend IUATLD conference sessions and meet daily for an open discussion, with time for question and answers. Researchers, NTP officers, and WHO regional officers also will meet and interact with patient community representatives.
We are currently identifying workshop participants. If you know of people who can put us in touch with potential candidates, please contact us and find more information at: http://www.aidsinfonyc.org/tag/comp/tbworkshop.html
If you have any suggestions for names please reply before the 12 August.
At this stage, the countries we are most interested in contacting are:
Botswana, Brazil, Burundi, Cambodia, Central African Republic, China, Côte d'Ivoire, Dominican Republic, DR Congo, Ethiopia, Guyana, Haiti, India, Kenya, Lesotho, Malawi, Mozambique, Myanmar, Namibia, Nigeria, Peru, the Philippines, Russian Federation, Rwanda, South Africa, Swaziland, Tanzania, Thailand, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe.
Further information is available from Daniel Raymond: daniel.raymond@verizon.net
c. "Stop TB, fight
Poverty":
Satellite symposium on TB and Poverty, Montréal 11th October 2002
The theme for the Satellite Symposium builds on World TB Day 2002: "Stop TB, fight poverty". It is suggested that tackling TB, one of several illnesses that affect the poor, is one way of achieving greater global prosperity.
TB is among the top causes of avoidable death in many countries. Only one in four TB patients is treated with DOTS, and the poor are under-represented in this group. As part of this year’s theme, this symposium will build on the co-ordination work of the Stop TB Partnership Secretariat through the TB and Poverty Advisory Committee and the subsequent in-depth studies.
Objectives of Meeting:
Please contact the TB Equity Knowledge programme of the Liverpool School of Tropical Medicine (att. Bertie Squire and/or Rachael Fletcher) for further details.
S.B.Squire@liverpool.ac.uk, R.Fletcher@liverpool.ac.uk; tel. +44.151.7053101 or +44.151.7089393
2. News from the Stop TB Partnership Secretariat
Advocacy and Communications
Country Level Social Mobilisation
The Stop TB Partnership is currently planning new social mobilisation initiatives to support DOTS expansion in the 22 High TB Burden Countries (HBCs) during the period 2002-2005. Their principal objective will be to rapidly accelerate case detection in the HBCs in order to reach the global 2005 targets of 70% case detection and 85% cure rates for detected cases.
The first three countries of focus will be Bangladesh, India and Kenya, a selection made by the Stop TB Task Force on Advocacy and Communications at its last meeting in Newark (USA) in late April 2002. The main criteria for selection were countries with high DOTS coverage and low detection rates, but with good infrastructures in place to implement social mobilisation activities. The planning work is being done in cooperation with WHO's Social Mobilisation Team (SMT) and employs the COMBI (Communications for Behavioural Impact) method, which will focus on inducing people who exhibit symptoms of active TB to report themselves to a clinic for screening and treatment. The field research and draft plan for Bangladesh has already been completed, with Kenya to follow in August and India in September. Implementation of COMBI activities should be underway in all three countries before the end of the year.
At the same time, Stop TB has developed critical analyses of communications and advocacy capacities in the other 19 HBCs as a tool for identifying deficiencies that can be improved and advance work that can be done prior to planning and implementing social mobilisation initiatives. The analyses were developed by Stop TB in cooperation with Scott McCoy of CDC, a member of the Task Force who visited Geneva for 3 weeks in July.
3. News from the Stop TB Working
Groups
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Working Group on TB/HIV
a. The 2nd Global TB/HIV Working Group (WG) Meeting
Date and venue: June 14-16 2002, Durban
At the end of the International Union Against Tuberculosis and Lung Disease (IUATLD) Africa Region meeting, 130 participants met in the Durban International Conference Centre for the 2nd TB/HIV WG Meeting. The aim of the conference was to shift focus from the global level strategy development of last year to address the opportunities and constraints that confront people working on joint TB and HIV programme activities at country level. In response to popular demand, the over-packed agenda was quickly revised on the Friday night to include more break-out sessions and discussion time.
The meeting reviewed the year’s progress which included:
Participants reviewed this material and
approved the guidelines, recommending that they be shortened and edited. Dr Marco Vittoria
presented such remarkable data from Sao Paolo, Brazil on the impact of triple
anti-retroviral therapy on reducing the incidence of TB, that participants requested WHO
and other agencies to review all existing data on the impact of anti-retroviral therapy on
TB and include it as soon as possible as part of the phased implementation of joint TB and
HIV activities. The World Health Assembly was asked to prepare a resolution on TB/HIV to
encourage countries to develop HIV/AIDS care strategies linked with TB control. Countries
were urged to establish TB/HIV technical groups or organising committees under the
Ministry of Health, and to strengthen both National TB and AIDS Control Programmes. All
participating agencies were asked to address the fundamental problem of the shortage of
human resources. The agenda and presentations are already available at http://www.who.int/gtb/whats-new/durban/index.htm
and the first draft of the report has been dispatched to the participants for their
comments.
The stage has been set for an expansion of the work of the Working Group, and for the stimulation and facilitation of country level action against the joint scourge of TB and HIV. Plans are being prepared now and will be reviewed by the core group on September 24-25 in Geneva.
b. Report on TB/HIV at the XIV International AIDS Conference
Date and venue: July 7-12 2002, Barcelona
The two main messages from the conference were:
1. It is a scandal that so
few people with HIV in developing countries are receiving anti-retroviral treatment;
2. It is a scandal that developed countries have not so far contributed
the funds they have promised to support anti-retroviral treatment in developing countries.
The earlier AIDS conferences emphasised HIV prevention, and the conferences since Vancouver in 1996 have emphasised anti-retroviral treatment. The treatment of HIV-related illnesses has fallen between the cracks. The extent to which TB/HIV features at the International AIDS Conferences increases with each Conference, but still did not achieve a profile in the Barcelona conference commensurate with the importance of TB as a leading cause of HIV-related illness and death.
There were two satellite symposia on TB/HIV, one organised by the International Union Against TB and Lung Disease (IUATLD) and one organised by WHO (jointly by the Stop TB and HIV/AIDS Departments), that attracted reasonable numbers of participants considering the large number of competing events. These two symposia covered the spectrum of clinical science, epidemiology, public health interventions, operational research and policy. In the main conference programme there were two sessions on TB/HIV: one oral abstract session (with heavy coverage of research from South Africa on TB in miners) and one bridging session (with coverage mainly of issues in low HIV prevalence countries). Further advocacy is necessary to encourage submissions on TB/HIV and to promote the cause of TB/HIV among the members of the conference organising and scientific committees.
A press conference on TB/HIV featured Dr JW Lee (Director, Stop TB Department, WHO), Dr B Schwartlander (Director, HIV/AIDS Department, WHO), Dr Helene Gayle (Director HIV/AIDS and TB, Gates Foundation) and Dr E McCray (Director of the Global AIDS Programme of the USA Centers for Disease Control and Prevention). Louise Berry (Health Development Network) reported that the attendance by only a handful of journalists was indicative of the low profile of TB in the HIV policy field and among the media and advocacy groups. One correspondent asked Dr Gayle why she thought the press conference was badly attended. She replied "TB is not perceived in the same sensationalist way as HIV, which conjures up associations with sex, death, and illicit activities…TB, is seen as an "old disease" and most people in the west have no idea of its extent and impact in the world".
Louise also commented that change can be frustratingly slow, but deepening commitment to tackle TB/HIV is emerging in a variety of spheres from the global TB/HIV policy, to national and grassroots levels. Through the TB/HIV Working Group, the StopTB Partnership will be assisting high countries badly affected by TB/HIV countries to develop national plans to translate the global TB/HIV strategic framework into action. Public pressure on governments to adopt this kind of approach is necessary. The need for mainstreaming TB into the HIV agenda at an activism level was described as essential by Helene Gayle. Michael Marco of the US-based HIV Treatment Action Group stated that we "need to get a groundswell of people behind the TB issue…let’s treat TB now so we don’t make the HIV worse than it needs to be". The treatment Action Group plans to hold a TB/HIV coinfection and mobilisation workshop at the next International Union of Tuberculosis and Lung Disease (IUATLD) conference in Montréal this October, in order to empower patient community representatives to mobilise and disseminate information to their local communities. The workshop will also introduce patient community representatives to country NTP program officers, WHO, CDC, and regional officers so that they may work together to implement future TB/HIV initiatives and will oversee the creation of an ad hoc international TB/HIV community advisory board.
With the long overdue mobilisation of community TB activism and the marriage of HIV and TB health services, perhaps there is still hope for what Dr JW Lee has called "a divorce of the TB and HIV epidemics".
4. News from the Global TB Drug FacilityGDF Applications/Review Update:
Activity |
To date |
| Rounds of applications and review | 3 |
| Number of counties applying for GDF support | 38 |
| Number of countries approved for support | 25 |
| Drug orders placed | 19 |
| Number of patient treatments approved (inc. buffer stocks) | 1,150,780 |
| Number of countries which have received drug deliveries | 11 |
5. CALENDAR OF EVENTS
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2002
2003