Framework and Standards for Effective TB Control Module 3 – March 2010

Framework and Standards for Effective TB Control Module 3 – March 2010
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Module Version Module 3 – March 2010 Framework and Standards for Effective TB Control Instructor’s Notes Module 3: Framework and Standards for Effective TB Control Module Time: Approximately 75 minutes This module has been divided into the following sections: Overview/Introduction (slides 2-5) – 5 min. Stop TB Strategy and the International Standards for TB Care (slides 6-13) – 10 min. Essential NTP Components (slides 14-23) – 38 min. (includes a 30 min. activity on slide 17) TB and HIV Program Collaboration (slides 24-30) – 14 min. Health Promotion, Communication, and Education and Summary (slides 32–36) – 8 min. Resource documents: Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV (CTBG) Chapter 3 Interactive options: Ideas for interactive discussions are offered on many of the slides in this module. Participant discussion can enhance active learning, but will add more time to the lecture and must be planned for. Evaluation questions may be attached or inserted within presentation for discussion purposes, or alternatively, combined with questions from other modules to produce evaluation tool. Additional Material: Slides containing related material may be found in the following modules: 5, 7A and 7B, 9A and 9B, and 13.

Funded by the Health Resources and Services Administration (HRSA)
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Project Partners Module Version Overview/Introduction (slides 2-5) – 5 min. Funded by the Health Resources and Services Administration (HRSA)

 STOP TB! Module Overview The Stop TB Strategy
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Module Overview Module Version The Stop TB Strategy International Standards for Tuberculosis Care (ISTC) National Tuberculosis Program (NTP) Overview: [Review the slide content] [Image credit: Lung Health Image Library/Pierre Virot]  STOP TB!

Learning Objectives Objectives: At the end of this presentation,
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Learning Objectives Module Version Objectives: At the end of this presentation, participants will be able to: Describe the components of the DOTS Strategy and the Stop TB Strategy Describe the purpose and content areas of the International Standards for Tuberculosis Care (ISTC) Describe the structure of the National TB Program (NTP) and potential areas for collaboration with the National HIV/AIDS Program (NAP) [Review objectives from the slide content]

Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV
The Global Emergency Module Version In 1993, the WHO declared TB a global emergency due to it’s increasing importance as a public health problem Contributing Factors: Poverty Population growth Migration Concurrent HIV epidemic The Directly Observed Treatment Short-course (DOTS) Strategy was developed as a response to the global emergency [Review the slide content] Mention that in addition to these contributing factors, the persistence of TB is also due to: Failure to ensure accessible diagnosis and treatment services, including directly observed treatment (DOT) Inadequate treatment regimens and failure to use standardized treatment regimens Lack of program supervision and use of an information management system to ensure rigorous evaluation of treatment outcomes of TB patients Misguided policies for health sector reform, with cuts in health care budgets and resultant reduction in financial support to peripheral health services The five elements of DOTS Strategy have now become the first component of the current TB control strategy which is called the Stop TB Strategy [Image Credit: Microsoft Word clip art 2007]

The Stop TB Strategy Module Version In 2001, the first Global Plan to Stop TB was launched through the Stop TB Partnership This Strategy serves as a roadmap for reaching the Millennium Development Goals (MDG) The objectives are to: achieve universal access to high-quality diagnosis and patient-centered treatment reduce human suffering and socio-economic burden associated with TB protect poor and vulnerable populations from TB, TB/HIV and MDR-TB support the development and use of new tools Stop TB Strategy and the International Standards for TB Care (slides 6- 13) – 10 min. [Review the slide content] Can refer participants to Chapter 3 (pages 11-12) of the Caribbean TB Guidelines for further detail on the Stop TB Strategy and Millennium Development Goals

Stop TB: Critical Components
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Stop TB: Critical Components Module Version 1. Pursue high-quality DOTS expansion and enhancement Secure political commitment, with adequate and sustained financing Ensure early case detection and diagnosis through quality-assured bacteriology Provide standardized treatment with supervision, and patient drug supply system and management Monitor and evaluate performance and impact 2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations Scale-up collaborative TB/HIV activities Scale-up prevention and management of multidrug-resistant TB Address the needs of TB contacts, and poor and vulnerable populations 3. Contribute to health system strengthening based on primary health care Help improve health policies, human resource development, financing, supplies, service delivery and information Strengthen infection control in health services, other congregate settings and households Upgrade laboratory networks, and implement the Practical Approach to Lung Health Adapt successful approaches from other fields and sectors, and foster action on the social determinants of health [Review the 6 critical components of the Stop TB Strategy] 

Stop TB: Critical Components (2)
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Stop TB: Critical Components (2) Module Version 4. Engage all care providers Involve all public, voluntary, corporate and private providers through Public- Private Mix approaches Promote use of the International Standards for Tuberculosis Care (ISTC) 5. Empower people with TB, and communities through partnership Pursue advocacy, communication and social mobilization Foster community participation in TB care, prevention and health promotion Promote us of the Patients’ Charter for Tuberculosis Care (PCTC) 6. Enable and promote research Conduct program-based operational research, and introduce new tools into practice Advocate for and participate in research to develop new diagnostics, drugs, and vaccines [Continue review of the 6 critical components of the Stop TB Strategy]

Millennium Development Goal (MDG)
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Millennium Development Goal (MDG) Module Version Targets: MDG 6, Target 8; halt and begin to reverse the incidence of TB by 2015 Epidemiological targets linked to the MDGs and endorsed by Stop TB Partnership: by 2005, detect at least 70% of infectious (sputum smear-positive) TB cases and cure at least 85% of these cases by 2015, reduce TB prevalence and death due to TB by 50% relative to 1990 levels by 2050, eliminate TB as a public health problem (i.e., <1 case/million population per year) [Review the slide content] These are the targets of the Stop TB Strategy to be accomplished via the critical components l It is important for us to assess where we are at in relation to achieving these targets While the goal to eliminate TB as a public health problem by 2050 is a more distant goal, it is important to ensure that we have outlined the steps we will take toward achieving it

Module Version (ISTC) Another important document to NTPs is The International Standards for Tuberculosis Care (ISTC) which was first published in The ISTC were revised and the second edition was released in December The ISTC second edition has 21 standards rather than the original 17 and many of the original standards were revised or renumbered This document was developed with the intention to unify approaches to diagnosis and treatment of TB in the private and public sectors Designed to be a complement to local and national TB control policies and are consistent with WHO recommendations Note that all the ISTC documents and several versions of the translations are available at the website noted at the bottom right of the slide [Image credit: Lung Health Image Library]

International Standards for Tuberculosis Care (ISTC)
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV International Standards for Tuberculosis Care (ISTC) Module Version These 21 standards of TB care pull together research findings and clinical expertise to provide guidance based on evidence and experience over time ISTC companion documents include: Patients’ Charter for Tuberculosis Care (PCTC) Handbook for using the International Standards for Tuberculosis Care ISTC Tuberculosis Training Modules and Facilitator’s Guide This document outlines 21 standards of tuberculosis care related to diagnosis, treatment, HIV infection and other co-morbid conditions and public health responsibility [Review the slide content] The Patient’s Charter was developed to promote a “patient-centered” approach to tuberculosis care and it outlines the rights and responsibilities of people with TB and serves as a resource for addressing the fifth element of the “Stop TB Strategy” The Handbook was produced in late 2007 to present suggestions and guidance for using the ISTC as a tool to foster and guide the delivery of high-quality care by all practitioners providing TB services and can be used as a resource to accomplish the fourth element of the “Stop TB Strategy” The Tuberculosis Training Modules and Facilitator’s Guide were created in 2008 and were updated in 2009 to reflect the ISTC 2nd edition. Several new modules were also created in 2009 for a total of 13 modules plus 2 summary slide sets. The Facilitator’s Guide was also updated in 2009 Can refer participants to Chapter 3 (pages 12-13) of the Caribbean TB Guidelines for further detail

ISTC Collaborators Module Version The ISTC were developed by: [Review the slide content] The Standards augment existing guidelines because they describe what should be done whereas guidelines describe how Note that these standards have been included throughout the Caribbean TB Guidelines and this series of training modules to reinforce the guideline content relevant to each of the 21 standards of TB care

International Standards for TB Care
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Module Version Diagnosis Standards – ISTC #’s 1 – 6 Treatment Standards – ISTC #’s 7 – 13 HIV and other Co-morbid Conditions Standards – ISTC #’s 14 – 17 Public Health Standards – ISTC #’s 18 – 21 Standards 1-6 are related to the diagnosis of tuberculosis Standards 7-13 are related to the treatment of tuberculosis Standards are related to HIV infection and other co-morbid conditions Standards are related to public health issues pertaining to tuberculosis [Image credit: Lung Health Image Library]

CAREC’s Response Grouping CMCs according to TB burden
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV CAREC’s Response Module Version Grouping CMCs according to TB burden Development of policies and guidelines Networking with regional and international partners (PAHO; CARICOM; WHO; CDC; Health Canada) Training of laboratory staff and other National Tuberculosis Program (NTP) personnel TB/HIV collaborative efforts Essential NTP Components (Slides 14-23) – 38 minutes (includes 30 minute activity on slide 17) Following the declaration of TB as global emergency on tuberculosis, CARECs response included: [Review slide content]

National TB Program (NTP)
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV National TB Program (NTP) Module Version The aim of the NTP is to reduce morbidity, mortality, and disease transmission, while preventing the development of drug resistance In settings with high HIV and AIDS prevalence, TB prevention and control strategies should be coordinated with those of the National AIDS Program (NAP) [Review the slide content]

National TB Program (2) The short-term program targets are:
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV National TB Program (2) Module Version The short-term program targets are: To achieve a cure rate of 85% among new sputum smear-positive tuberculosis patients To detect 70% of existing cases of sputum smear-positive tuberculosis To prevent the emergence of acquired drug-resistant M. tuberculosis These NTP objectives come from the Stop TB Strategy

Activity Essential Components of the NTP
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Module Version Essential Components of the NTP Activity This activity will take approximately 30 minutes Divide into four small groups Each group will have 10 minutes to discuss one of the following as assigned: What is the ideal structure of the NTP? What are the key features/activities of the NTP? Describe TB and HIV Program Collaborative Activities Describe Health Promotion Activities of the NTP After 10 minutes, have each small group report back to the large group a 3-5 minute summary of their discussion

NTP: Key Features Module Version A project development strategic plan, with budget details, funding sources and responsibilities A central unit NTP manual available at the level of the periphery A tuberculosis management information system using standardized registers A nationwide network of quality assured microscopy services in close contact with primary health care (PHC) services and subject to regular quality control As the small group activity will have covered some of the material on the next 9 slides, it may be sufficient to highlight just the points not covered by small group reports The structure of the NTP varies in the CAREC Member Countries (CMC) with both centralized and decentralized systems. There are key features that should exist in every NTP to ensure effectiveness and accountability: [Review any content on slide not mentioned in small group report backs]

NTP: Key Features (2) Module Version Treatment services within the PHC system, with priority for directly observed short-course chemotherapy Uninterrupted supply of quality assured drugs and diagnostic materials with reliable procurement and distribution systems Plan of supervision Treatment services within the Primary Health Care system, with priority for directly observed short-course chemotherapy. This may require that there be a designated position (e.g., TB Coordinator) within the NTP and NAP that would server as a liaison to the PHC to ensure standards of care are being followed [Review any content on slide not mentioned in small group report backs] [Image credit: Lung Health Image Library/Virginia Arnold]

NTP: Key Features (3) Module Version A training program covering all aspects of the NTP policy package Mechanisms for stakeholder and health service collaboration with special attention to TB and HIV operations Advocacy, communication and social mobilization to empower patients and communities Other important features may include: [Review any content on slide not mentioned in small group report backs]

NTP: Activities Module Version Early detection of TB suspects in health facilities and communities Early and intensified TB case-finding supported by: Voluntary counselling and testing, or Provider-initiated testing for HIV detection Diagnosis through smear and/or culture Administration of adequate treatment to achieve cure under DOT supervision A number of supporting activities are needed to accomplish these major NTP activities. The supporting activities are listed below and on page 14 of the Caribbean TB Guidelines: [Review any content on slide not mentioned in small group report backs]

NTP: Structure Module Version NTP activities should be integrated into the existing health care services Health care workers of the general services health unit must be aware of the mechanisms for case-finding and treatment Shared responsibility and assistance facilitating and implementing the control measures Managerial and supervisory staff should be responsible for TB specific technical competence of all health care workers involved in the program [Review any content on slide not mentioned in small group report backs] [When presenting this content to a single country audience, it may be useful to insert an organigram that shows the different positions/staff within the NTP and NAP including laboratory services and how these programs (including laboratory services) fit under an organigram of the Ministry of Health]

NTP: Structure (2) The NTP structure must also reflect:
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV NTP: Structure (2) Module Version The NTP structure must also reflect: The multi-disciplinary approach to surveillance and case management The mechanisms for implementing TB and HIV collaboration Headed by a program manager responsible for: Planning the work of the program Collaborating with health care staff in the periphery Regional/District/Parish level coordinators assist with supervising TB control activities at their level [Review any content/points on slide not mentioned in small group report backs] Headed by a program manager responsible for: Planning the work of the program Collaborating with health care staff in the periphery The program manager is preferably a medical officer with specialization in infectious diseases, epidemiology or public health. This individual should be responsible to the Chief Medical Officer of Health in the Ministry of Health The manager must work closely with the national coordinator and other key individuals such as the pharmacist, senior microbiologist, and the lead person in the National AIDS Program (NAP) Regional/District/Parish level coordinators assist with supervising TB control activities at their level The regional coordinator is a key worker, liaising with the health care workers in the field and the national TB Program Manager A very important role of the national TB program manager is to SUPERVISE the general health staff in TB case-finding and treatment as well as provide education for the health care workers and the general public The collection, processing, reading, recording and reporting of sputum at Centers with AFB microscopy must also be supervised The purpose of supervision is to enable continuing improvement in the performance of staff. It plays a major role in staff management. Can refer also to Appendix D pages of the Caribbean TB Guidelines which covers Supervision

Collaboration Between TB and HIV/AIDS Program
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Collaboration Between TB and HIV/AIDS Program Module Version Guiding principles for collaboration: Prevention of HIV should be a priority for TB control given the impact HIV has on TB morbidity and mortality TB care and prevention should be a priority for HIV/AIDS programs given the high morbidity and mortality from TB among people with HIV Joint TB/HIV program planning, implementation and coordination of activities is critical to the successful control of both diseases TB and HIV Program Collaboration (Slides 24-30) – 14 min. Tuberculosis is a global public health problem and continues to be a significant health threat in some Caribbean countries Untreated HIV infection leads to progressive immunodeficiency and increased susceptibility to infections, including TB For many years, the efforts to tackle TB and HIV/AIDS have been largely separate, despite the overlapping epidemiology. However, it is now increasingly recognized that only through combined and coordinated efforts for both TB and HIV/AIDS can this dual epidemic be halted The following are the guiding principles for collaboration between NTPs and NAPs: [Review any content on slide not mentioned in small group report backs]

Areas for Collaboration
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Areas for Collaboration Module Version Areas for potential TB and HIV/AIDS collaboration: Advocacy, communication and social mobilization (ACSM) strategies Policy consensus Training activities Procurement and distribution of drugs, consumables, laboratory reagents Monitoring and evaluation Joint Activities should focus on areas of mutual interest. The following are some of the areas that should be considered when developing a policy document for collaborative TB and HIV/AIDS activities: [Review any content on slide not mentioned in small group report backs] [Image Credit: Microsoft Word clip art 2007] TB

Areas for Collaboration (2)
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Areas for Collaboration (2) Module Version Areas for potential TB and HIV/AIDS collaboration (continued): Information systems Surveillance and referral Counseling and testing services Provision of preventive therapy Provision and supervision of Antiretroviral Therapy (ART) and TB treatment Additional areas for potential collaboration are: [Review any content on slide not mentioned in small group report backs] [Image Credit: Microsoft Word clip art 2007] TB

Collaboration Goal and Objectives
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Module Version Goal: To decrease the burden of TB and HIV in dually affected populations Objectives: To establish the mechanisms for collaboration between TB and HIV/AIDS programs To decrease the burden of TB among people living with HIV/AIDS To decrease the burden of HIV in tuberculosis patients The TB/HIV collaboration policy goal is to decrease the burden of tuberculosis and HIV in populations affected by both diseases [Click: Slide Animation]

TB/HIV Objectives and Activities
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV TB/HIV Objectives and Activities Module Version Establish the mechanisms for collaboration Set up a coordinating body for TB/HIV activities Conduct surveillance of HIV prevalence among TB patients Carry out joint TB/HIV planning Conduct monitoring and evaluation Under objective 1, the recommended TB/HIV activities include: [Review the slide content] Following along the same lines of ensuring that surveillance of HIV prevalence among TB patients occurs, ensuring processes are in place to conduct surveillance of TB among HIV patients is also important Good coordination and management of joint activities between the two programs is critical to ensure a continuum of quality care for people with, or at risk of, tuberculosis and HIV More information on TB and HIV/AIDS collaborative activities and co-management can be found in Chapter 9 of the Caribbean TB Guidelines and training modules 9A and 9B

TB/HIV Objectives and Activities (2)
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Module Version Decrease the burden of TB in people living with HIV/AIDS Establish intensified tuberculosis case-finding Introduce isoniazid preventive therapy Ensure TB infection control in health care and congregate settings Recommended TB and HIV/AIDS activities related to decreasing the burden of TB in PLWHA include the three :I’s: [Review the slide content]

TB/HIV Objectives and Activities (3)
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Module Version Decrease the burden of HIV in tuberculosis patients Provide HIV testing and counselling Introduce HIV prevention methods Introduce co-trimoxazole preventive therapy Ensure HIV care and support Introduce anti-retroviral drugs The recommended TB and HIV/AIDS activities pertaining to decreasing the burden of HIV in patients with tuberculosis include: [Review the slide content]

Joint TB/HIV Activities
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Joint TB/HIV Activities Module Version TB TB/HIV HIV DOTS +VCT +Condoms +HIV surveillance VCT + TB screening IEC STIs ARVs Intensified case-finding Isoniazid preventive therapy There are a number of areas where TB and HIV/AIDS programs can maximize their outreach efforts through collaboration This figure presents a model highlighting program activities where both TB and HIV/AIDS Programs might collaborate [Slide source: Adapted from WHO. Management of collaborative TB/HIV activities: Training for managers at the national and subnational levels. 2005] Co-trimoxazole preventive therapy Home- and community-based care General Health Services

Health Promotion, Communication, and Education
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Health Promotion, Communication, and Education Module Version Formulate health Public Policy: Promote health as a strategic input and priority outcome of Public Policy development Re-orient health services through: Response to needs of individuals and communities Health professional’s recognition of partnership with communities and individuals Promote curative and preventive patient centered care Health Promotion, Communication, and Education and Summary (slides 32-36) – 8 minutes Health promotion, communication, and education are an integral part of the “Stop TB Strategy” and a key activity of a successful NTP. Must incorporate a commitment to: Communities participation Inter-sectoral action Maintaining the skills and knowledge of staff NTP’s should actively work toward achieving the following: [Review the slide content]

Health Promotion, Communication, and Education (2)
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Health Promotion, Communication, and Education (2) Module Version Empower communities to achieve well-being through: Collaboration within communities to determine priorities Facilitate and support community action plans Provide information and skills for community to take action [Review the slide content] [Image Credit: FJ Curry National Tuberculosis Center/Ann Raftery]

Health Promotion, Communication, and Education (3)
Caribbean Guidelines for the Prevention, Treatment, Care, and Control of Tuberculosis and TB/HIV Health Promotion, Communication, and Education (3) Module Version Build alliances within the community: Special emphasis on media collaboration Access and pool resources from all sectors for the promotion of health Form alliances with other government sectors: education, social and community development, culture, gender affairs, youth and sports organizations Include Non-Governmental Organizations, faith- based organizations, service clubs, and NAPs [Review the slide content] In addition, the health care worker (HCW) has an important role in direct patient education. HCWs must clearly and effectively instruct and educate the patient about the curability of the disease and that treatment must be regular, adequate, and for a sufficient period of time Client and communities must understand the following: What tuberculosis is What TB/HIV co-infection is How the disease is spread What can be done to limit the spread of the disease When, where and how to access care The curability of the disease What medications are used and for how long How the treatment is to be followed The side-effects to be expected Adequate training and continuing education opportunities for all TB program staff are needed to ensure that accurate and appropriate information is delivered to the patients, community members, and media

Module Version What Health Promotion, Communication, and Education activities have you been involved with? [Interactive Option: Ask participants to share activities that they have been involved with related to TB health promotion, communication, and education. Ask them to describe at least 1 component that they liked about the event/activity and why as well as at least one component that they would have liked to improve and how]

Summary Module Version The Stop TB Strategy and the ISTC are key responses to addressing the high global TB prevalence While NTP structure varies by country, a cohesive and well organized program is essential for effective TB prevention and control Health promotion, communication, and education are necessary for patients, staff, and the community Collaboration between TB and HIV/AIDS programs can greatly improve the effectiveness of both the NTP and NAP [Review the slide content]

Framework and Standards for Effective TB Control Module 3 – March 2010

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Framework and Standards for Effective TB Control Module 3 – March 2010

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