National Tuberculosis Management Guidelines 2008 NATIONAL TUBERCULOSIS MANAGEMENT GUIDELINES 2008 PREFACE Tracking epidemiological trends and the extent to which TB targets have been reached provides an indication of progress in TB control. Two key targets had been set by the World Health Assembly in 1991: to detect 70% and to cure 85% of smear-positive clients by the year 2000. These targets were based on epidemiological modelling which suggested that this would reduce the prevalence of infectious TB cases, the number of infected contacts, and the incidence of infectious cases. It was estimated that in the absence of HIV co-infection, the annual incidence of TB could be reduced by 7- 12%. The DOTS strategy was in support of these goals. The Millennium Development Goals (MDG) set by the United Nations frames TB control within the developmental context of reducing poverty and improving the health of the poor. The Millennium Development Goal 6 - “To combat HIV and AIDS, malaria and other diseases” has a target to “have halted by 2015 and begun to reverse the incidence of malaria and other major diseases”. The Stop TB Partnership has endorsed two targets linked to the MDG: To detect at least 70% of new sputum smear-positive TB cases and cure at least 85% of these cases By 2015, to reduce TB prevalence and death rates by 50% relative to 1990 levels The new Stop TB Strategy builds on current achievements of the DOTS strategy, but calls for additional strategies to effectively address constraints and challenges in TB control including efforts to strengthen health systems, alleviate poverty and advance human rights. Specific local aspects include ensuring equitable access to services, improving continuity of care and improving the care of those co-infected with TB and HIV. The National TB Strategic Plan for 2007-2011 aims to intensify TB activities towards the attainment of the MDG TB targets. This plan aims to ensure that everyone has access to good quality TB services whilst also providing an environment that is conducive to health, free of infection. It highlights the need for availability of skilled human resources, sustained adequate funding, partnership building, mobilising communities and fighting poverty to accelerate economic and social growth is critical for the success of this plan. The targets set in plan for 2011 are: Case detection rate 70% Cure Rate 85% Treatment Success rate >85% The basis for this being that it is with sustained high case detection and cure rates over time that an impact on the prevalence of TB can be made. These guidelines therefore aim to provide guidance to primary health care personnel and managers in addressing the challenges of TB control and successfully managing all clients presenting with TB, including those co-infected with HIV as well as early detection of drug resistant TB. 1 NATIONAL TUBERCULOSIS MANAGEMENT GUIDELINES 2008 ACKNOWLEDGEMENTS The National Department of Health would like to acknowledge the technical inputs provided by all those who participated in the development of these guidelines. Our gratitude goes to the University Research Corporation who provided the financial support for the development of these guidelines. 2 NATIONAL TUBERCULOSIS MANAGEMENT GUIDELINES 2008 List of abbreviations AFB Acid-Alcohol Fast Bacilli AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Therapy BCG Bacille Calmette - Guerin CBO Community Based Organisation CHW Community Health Worker DOH Department of Health DOT Directly-Observed Treatment DOTS Directly-Observed Treatment, Short course E Ethambutol ETR Electronic TB Register H Isoniazid HIV Human Immunodeficiency Virus HR Isoniazid/ Rifampicin MDG Millennium Development Goals MDR-TB Multidrug-Resistant Tuberculosis NGO Non-Governmental Organisation TB National Tuberculosis Control Programme PROGRAMME PHC Primary Health Care PN Professional Nurse PMTCT Prevention of Mother-to-Child HIV Transmission QA Quality Assurance R Rifampicin RSA Republic of South Africa S Streptomycin SHR Streptomycin/ Isoniazid/ Rifampicin Streptomycin/ Isoniazid/ Rifampicin/ Pyrazinamide/ SHRZE Ethambutol STI Sexually Transmitted Infections TB Tuberculosis VCT Voluntary Counselling and Testing WHO World Health Organisation XDR-TB Extensively drug-resistant TB Z Pyrazinamide 3 NATIONAL TUBERCULOSIS MANAGEMENT GUIDELINES 2008 CONTENTS PREFACE........................................................................................................................................................................... 1 ACKNOWLEDGEMENTS................................................................................................................................................... 2 1 INTRODUCTION......................................................................................................................................................... 9 1.1 Global epidemiology and burden of disease ...................................................................................................... 9 1.2 TB control in South Africa.................................................................................................................................... 9 1.3 Challenges to TB control.................................................................................................................................... 10 2 THE NATIONAL TUBERCULOSIS CONTROL PROGRAMME............................................................................... 11 2.1 The mission, strategic objectives and targets for TB control ......................................................................... 11 2.2 The structure of The National TB Control Programme .................................................................................... 12 2.2.1 Core activities at the national level............................................................................................................ 13 2.2.2 Core activities at the provincial level ........................................................................................................ 13 2.2.3 Core activities at the district level ............................................................................................................. 14 2.2.4 Core activities at PHC facility level ………………………………………………………………………………….14 2.2.5 Core activities at community level …………………………………………………………………………………..14 3 TRANSMISSION AND PATHOGENESIS OF TB..................................................................................................... 15 3.1 Transmission of tuberculosis ............................................................................................................................ 15 3.2 Pathogenesis of tuberculosis ............................................................................................................................ 16 3.3 Primary infection................................................................................................................................................. 16 3.4 Post-primary TB / Secondary TB ....................................................................................................................... 17 4 DIAGNOSIS OF TB .................................................................................................................................................. 18 4.1 Symptoms and signs of TB ................................................................................................................................ 18 4.2 How is the diagnosis of tuberculosis confirmed?............................................................................................ 18 4.2.1 Smear and culture evaluation of a TB suspect pre-treatment................................................................. 18 4.2.2 Sputum smears ........................................................................................................................................... 19 4.2.3 Sputum culture and drug susceptibility testing ....................................................................................... 22 4.2.4 Chest x-rays................................................................................................................................................. 23 4.2.5 Tuberculin skin test .................................................................................................................................... 23 4.3 The seriously ill TB-suspect............................................................................................................................... 23 4.4 Algorithm for TB diagnosis in a new case ........................................................................................................ 24 4.5 Algorithm for TB diagnosis in high risk TB suspects and retreatment cases............................................... 25 5 TB CASE DEFINITIONS........................................................................................................................................... 26 5.1 Why case definitions? ........................................................................................................................................ 26 5.2 Why match treatment to standardised category? ............................................................................................ 26 5.3 What determines case definitions? ................................................................................................................... 26 5.3.1 Site of TB disease - pulmonary or extra-pulmonary ...............................................................................