DOTS EXPANSION AND BEYOND DOTS World Health Organization PRACTICAL APPROACH TO LUNG HEALTH (PAL STRATEGY) World Health Organization 2002

GLOBAL BURDEN OF DISEASE 2000 Injuries 12,4 % Non Communicable diseases 41 % TB and respiratory diseases 17,2 % Communicable disease 29,4 %

Global mortality 2000 Communicable diseases 19,9% diseases Non communicable diseases 50,4 % Injuries 9,1 % TB and respiratory diseases 20,6 %

«  Standardized practice guidelines for those providing care of respiratory diseases may improve case detection among patients with respiratory symptoms, increase quality of TB diagnosis and strengthen the ownership of TB control activities by general health care providers. » ( An expanded DOTS framework for effective tuberculosis control – WHO – Geneva 2002 )

PAL : A NEW STRATEGY TO IMPROVE TB CONTROL As a part of « essential package of clinical services » Integrated into PHC services Standardisation of management of patients presenting respiratory symptoms Combined management of TB, ARI, CRD. Coordination between PHC level and first referal level, PHC department and NTP.

A PARADOX TB : 1-2% of patients with respiratory symptoms Management of TB is standardized, supervised and evaluated ARI : 70-80% of patients with respiratory symptoms Management of ARI standardized in children under 5 (IMCI) Management of ARI not standardized in adults (some national consensus, without systematic registration and evaluation) CRD : 10-20% of patients with respiratory symptoms Some consensus for asthma (children and adults) Some consensus in COPD (adults only) Without standardisation, registration and evaluation

PAL Strategy : objectives Improvement of quality of respiratory care - improvement of tuberculosis detection - integrated care for ARI ( in children, in adults, in HIV positive) ,and for CRD (asthma, COPD) improvement of efficiency in service delivery - rationalisation of drug prescription (ED) - rationalisation of referral and counter-referral - improvement of planning and ressource management

Distribution of respiratory symptomatics in health services (1997-2001) Guinea Morocco Kirghzistan Thaïland Total 2564 3625 1637 2047 21580 81,2 10,6 8,2 8,2 10,6 86 6,4 7,6 69,4 25 5,6 84,4 11,5 4,1 81 14,6 4,4 86 81,2 ARI CRD TB suspects

PTB CASES AMONG TB SUSPECTS 496 943 11,3 0,2 23,6 7 11,5 30,6 PTB + PTB - PHC Services First referal level

PAL IMPLEMENTATION SCENARIOS EPIDEMIOLOGICAL TRANSITION ACCORDING TO THE EPIDEMIOLOGICAL TRANSITION Before transition low HIV prevalence (Nepal) high HIV prevalence (South africa) In transition (Morocco) After transition (Chile)

PAL IMPLEMENTAION SCENARIOS « NEPALI MODEL » High TB prevalence, ARI important in children and youth, CRD undetected Priorities Case management of ARI Detection and treatment of Sm+PTB Standardisation of case management of ARI and PTB Strenghten NTP PAL as operational research

PAL IMPLEMENTAION SCENARIOS « SOUTH AFRICAN MODEL » High TB prevalence, high HIV prevalence, ARI important In children and adults, CRD increasing PRIORITIES Standardized case management of ARI and smear+ PTB, in HIV- and HIV+ Improve and maintain TB treatment gains Concerted managment of TB, TB/HIV and TB/AIDS PAL : Coordination between levels of care and between programmes (NTP ans AIDS programmes)

PAL IMPLEMENTAION SCENARIOS « MOROCCAN MODEL » Intermediate TB prevalence ARI important in children, youth and adults, CRD increasing (asthma mainly) PRIORITIES Maintain TB control gains Standardized case management of PTB (SM+ and SM-), ARI, CRD Guideline at two levels : PHC level ans first referral level Coordination between PHC department and TB / respiratory disease Department at central level Use of simple indicators for standardised evaluation at two levels

PAL IMPLEMENTAION SCENARIOS « CHILEAN MODEL » Low TB prevalence, ARI (pneumonia) important in elderly, CRD important (COPD mainly) PRIORITIES ARI Case management at two levels : evaluation accross severity, drug use, and hospitalisation PTB case management (reduction PTB smear negative) CRD case management at two levels drug use , exacerbation, hospitalisation  Combined programmes evaluation.

CONCLUSIONS PAL strategy is applicable in all settings - high or low TB prevalence - high or low HIV prevalence - in public sector as in a private practice PAL strategy needs to be adapted to country’s priorities - first step : operational research - extension phase : permanent evaluation through appropriate indicators PAL strategy guidelines should be used for training - in-service training - pre-service training (medical schools, nursing schools)