INT J TUBERC LUNG DIS 18(3):253 © 2014 The Union http://dx.doi.org/10.5588/ijtld.14.0035
EDITORIAL
Updating the International Standards for Tuberculosis Care THE FIRST EDITION of the International Standards for Tuberculosis Care (ISTC), published in 2006, states, ‘The Standards should be viewed as a living document that will be revised as technology, resources, and circumstances change.’1 In line with this philosophy, a second edition was produced in 2009. In the 5 years since the second edition there have been substantial changes in technology and circumstances. Thus, to be consistent with the concept of a ‘living document’ the ISTC has been updated, with a third edition being issued this month. The availability and increasing utilization of rapid molecular testing, together with substantial guidance from the World Health Organization (WHO), have highlighted the need for updating the ISTC.2,3 Consequently, the largest number of changes in the ISTC is in the standards for diagnosis. Rapid molecular testing using devices that have excellent performance characteristics for detecting Mycobacterium tuberculosis and rifampicin resistance and are practical and affordable for use in decentralized facilities in lowresource settings are now widely available. Used appropriately, these devices can provide a confirmed diagnosis and a determination of rifampicin resistance within a few hours. In addition to new technologic approaches, circumstances have changed. The DOTS strategy is widely implemented and highly successful.4,5 The global tuberculosis case rate is declining, although the decline, at approximately 2% per year, is far too slow. The success of DOTS in the diagnosis and treatment of ‘usual’ tuberculosis now enables an intensified focus on the problem areas that remain: improving the speed and completeness of case detection, thereby reducing transmission of M. tuberculosis; addressing drug-resistant tuberculosis; effectively managing tuberculosis in persons with co-morbidities, especially human immunodeficiency virus (HIV) infection; and developing approaches to tuberculosis detection and prevention in groups at increased risk of the disease.6 In addition, it is recognized that DOTS implementation by only the public sector of the health care system is insufficient to bring about true tuberculosis control and that new, broader-based approaches must be implemented in both the public and the private sectors. Consequently, in addition to the incorporation of new information and recommendations regarding diagnostic test technology, additional important changes in this third edition include: emphasis
on the recognition of groups at increased risk of tuberculosis and considerations for screening within such groups; updating the standard on antiretroviral treatment to indicate that treatment should be initiated promptly for any person with tuberculosis and HIV infection; and revising the standard on treating multidrug-resistant tuberculosis, to be consistent with the 2011 WHO update.7 A major aim of all three editions of the ISTC is promoting engagement of all care providers, especially those in the private sector, in low- and middle-income countries, in delivering highquality services for tuberculosis; thus, no change is required in the ISTC to be consistent with the increasing private sector focus. It should be emphasized that the basic principles that underlie the ISTC have not changed. Case detection and curative treatment remain the cornerstones of tuberculosis care and control, and the fundamental public health responsibilities of providers are unchanged. Philip C. Hopewell Curry International Tuberculosis Center University of California, San Francisco Division of Pulmonary and Critical Care Medicine San Francisco General Hospital San Francisco, California, USA e-mail: [email protected] References 1 Tuberculosis Coalition for Technical Assistance. International standards for tuberculosis care (ISTC). The Hague, The Netherlands: TBCTA, 2006. 2 World Health Organization. Rapid implementation of the Xpert MTB/RIF diagnostic test: technical and operational ‘how-to’: practical considerations. Geneva, Switzerland: WHO, 2011. 3 Steingart K, Sohn H, Schiller I, et al. Xpert® MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults. Cochrane Database Syst Rev 2013; 1: CD009593 4 Lonnroth K, Raviglione M C. Global epidemiology of tuberculosis: prospects for control. Sem Respir Crit Care Med 2008; 29: 481–491. 5 World Health Organization. Global tuberculosis report, 2013. WHO/HTM/TB/2013.11. Geneva, Switzerland: WHO, 2013. 6 World Health Organization. Systematic screening for active tuberculosis: principles and recommendations. Geneva, Switzerland: WHO, 2013. 7 World Health Organization. Guidelines for the programmatic management of drug-resistant tuberculosis: a 2011 update. WHO/ HTM/TB/2011.6. Geneva, Switzerland: WHO, 2011.
EDITORIAL
Updating the International Standards for Tuberculosis Care THE FIRST EDITION of the International Standards for Tuberculosis Care (ISTC), published in 2006, states, ‘The Standards should be viewed as a living document that will be revised as technology, resources, and circumstances change.’1 In line with this philosophy, a second edition was produced in 2009. In the 5 years since the second edition there have been substantial changes in technology and circumstances. Thus, to be consistent with the concept of a ‘living document’ the ISTC has been updated, with a third edition being issued this month. The availability and increasing utilization of rapid molecular testing, together with substantial guidance from the World Health Organization (WHO), have highlighted the need for updating the ISTC.2,3 Consequently, the largest number of changes in the ISTC is in the standards for diagnosis. Rapid molecular testing using devices that have excellent performance characteristics for detecting Mycobacterium tuberculosis and rifampicin resistance and are practical and affordable for use in decentralized facilities in lowresource settings are now widely available. Used appropriately, these devices can provide a confirmed diagnosis and a determination of rifampicin resistance within a few hours. In addition to new technologic approaches, circumstances have changed. The DOTS strategy is widely implemented and highly successful.4,5 The global tuberculosis case rate is declining, although the decline, at approximately 2% per year, is far too slow. The success of DOTS in the diagnosis and treatment of ‘usual’ tuberculosis now enables an intensified focus on the problem areas that remain: improving the speed and completeness of case detection, thereby reducing transmission of M. tuberculosis; addressing drug-resistant tuberculosis; effectively managing tuberculosis in persons with co-morbidities, especially human immunodeficiency virus (HIV) infection; and developing approaches to tuberculosis detection and prevention in groups at increased risk of the disease.6 In addition, it is recognized that DOTS implementation by only the public sector of the health care system is insufficient to bring about true tuberculosis control and that new, broader-based approaches must be implemented in both the public and the private sectors. Consequently, in addition to the incorporation of new information and recommendations regarding diagnostic test technology, additional important changes in this third edition include: emphasis
on the recognition of groups at increased risk of tuberculosis and considerations for screening within such groups; updating the standard on antiretroviral treatment to indicate that treatment should be initiated promptly for any person with tuberculosis and HIV infection; and revising the standard on treating multidrug-resistant tuberculosis, to be consistent with the 2011 WHO update.7 A major aim of all three editions of the ISTC is promoting engagement of all care providers, especially those in the private sector, in low- and middle-income countries, in delivering highquality services for tuberculosis; thus, no change is required in the ISTC to be consistent with the increasing private sector focus. It should be emphasized that the basic principles that underlie the ISTC have not changed. Case detection and curative treatment remain the cornerstones of tuberculosis care and control, and the fundamental public health responsibilities of providers are unchanged. Philip C. Hopewell Curry International Tuberculosis Center University of California, San Francisco Division of Pulmonary and Critical Care Medicine San Francisco General Hospital San Francisco, California, USA e-mail: [email protected] References 1 Tuberculosis Coalition for Technical Assistance. International standards for tuberculosis care (ISTC). The Hague, The Netherlands: TBCTA, 2006. 2 World Health Organization. Rapid implementation of the Xpert MTB/RIF diagnostic test: technical and operational ‘how-to’: practical considerations. Geneva, Switzerland: WHO, 2011. 3 Steingart K, Sohn H, Schiller I, et al. Xpert® MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults. Cochrane Database Syst Rev 2013; 1: CD009593 4 Lonnroth K, Raviglione M C. Global epidemiology of tuberculosis: prospects for control. Sem Respir Crit Care Med 2008; 29: 481–491. 5 World Health Organization. Global tuberculosis report, 2013. WHO/HTM/TB/2013.11. Geneva, Switzerland: WHO, 2013. 6 World Health Organization. Systematic screening for active tuberculosis: principles and recommendations. Geneva, Switzerland: WHO, 2013. 7 World Health Organization. Guidelines for the programmatic management of drug-resistant tuberculosis: a 2011 update. WHO/ HTM/TB/2011.6. Geneva, Switzerland: WHO, 2011.
