International Standards for Tuberculosis Care published

Led by the American Thoracic Society (ATS) and the World Health Organization (WHO), a consortium of international health agencies today published on the World Wide Web the first International Standards for Tuberculosis Care (ISTC).

"The purpose of the ISTC," said Philip C. Hopewell, M.D., who co-chaired the committee that produced the standards and who is a past president of the ATS, "is to establish a widely accepted level of care that all practitioners, public and private, should achieve in managing patients who have, or are suspected of having, tuberculosis."

The committee met under the auspices of the Tuberculosis Coalition for Technical Assistance (TBCTA). In addition to the ATS and WHO, the TBCTA includes the Dutch Tuberculosis Foundation (KNCV), the International Union Against Tuberculosis and Lung Disease (the UNION), and the U.S. Centers for Disease Control and Prevention (CDC). The United States Agency for International Development (USAID) funded the development and dissemination of the ISTC.

The ISTC is part of the WHO's new Stop TB Strategy and the Global Plan to Stop TB 2006-2015 developed by the Stop TB Partnership. The Stop TB Partnership consists of more than 300 organizations worldwide that are concerned with tuberculosis care and control.

The number of new cases of tuberculosis continues to grow: Each year, between 8 and 9 million new cases occur worldwide. Though curable, two million people die from the disease each year.

The burden of tuberculosis prevalence and mortality falls disproportionately on the world's poorest countries. Ninety-five percent of those infected live in the developing world, and case rates are especially high in parts of the world where HIV infection is highly prevalent.

The ISTC is designed to address the care of patients of all ages with any manifestation of the disease, including multi-drug resistant and extra-pulmonary tuberculosis and tuberculosis combined with HIV infection. The ISTC is also designed to guide providers everywhere, regardless of the circumstances of their practice.

The committee, however, was especially concerned about reaching healthcare providers working outside national and local tuberculosis control programs. These providers, according to Dr. Hopewell, are less likely than their government counterparts to follow proven methods for evaluating and treating patients with tuberculosis.

According to the committee writing the standards, private physicians rely too heavily on chest x-rays and too little on sputum microscopy in making diagnoses, often use incorrect drug regimens and can fail to supervise adherence to treatment, which can lead to drug-resistant forms of the disease.

Private healthcare professionals are also less likely than providers in government programs to assume responsibility for controlling the spread of the tuberculosis.

"In caring for patients with tuberculosis, providers assume an important public health function," said Dr. Hopewell. "Providers have a responsibility to their patients and to the community."

The standards address this concern by requiring providers to evaluate all those who have come into contact with the patient and to report new cases of tuberculosis and the outcome of existing cases to local public health authorities.

According to Dr. Hopewell, fulfilling these public health responsibilities is a big challenge for physicians practicing in the developing world. Most work in hospitals during the day and see private patients during the evening, with little time left for completing important public health documents.

The ATS has begun to address this problem by piloting an implementation program in Indonesia, where providers have been given a copy of the standards in their native language. Working with local medical societies, Dr. Hopewell has begun collaborations in Indonesia to evaluate methods to ensure that the ISTC has its intended impact. Similar evaluations are planned in Kenya and two other countries to be determined.

Twenty-eight members participated on the committee that formulated the ISTC. The members represented physicians, nurses, medical students, patients, patient advocates and public and private agencies dedicated to tuberculosis control in 14 countries.

As an outgrowth of the process of developing the ISTC, the World Care Council, a patient advocacy group, developed a companion document, "The Patients' Charter for Tuberculosis Care." The charter specifies patients' rights and responsibilities.