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

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

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

4. «  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 )

5. 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.

6. 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

7. 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

8. Distribution of respiratory symptomatics
in health services ( )
Guinea Morocco Kirghzistan Thaïland Total
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

9. 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

10. 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)

11. 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

12. 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)

13. 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

14. 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.

15. 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)