Professional Documents
Culture Documents
The Stop TB Strategy launched by the World Health Organization in 2006 describes the recommended interventions that should be implemented to achieve the targets for global TB control
that have been established within the context of the Millennium Development Goals. See Raviglione MC, Uplekar MW. WHOs new Stop TB Strategy. Lancet, 2006, 367:952955.
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Guidelines for the programmatic management of drug-resistant tuberculosis. Geneva, World Health
Organization, 2006 (WHO/HTM/TB/2006.361).
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The key changes for the emergency update 2008 are summarized below.
Chapter
Key recommendations
Key changes
(* indicates updated recommendation)
Chapter 1
Not applicable
Target audience is defined.
Background
Development of guidelines is
information on described.
drug-resistant
Stop TB Strategy is
tuberculosis summarized.
New data are provided from
the WHO/IUATLD Global
Project on Antituberculosis
Drug Resistance
Surveillance.
Updated information is
provided from a survey of the
network of supranational
reference laboratories to
determine the prevalence of
XDR-TB among strains sent
for drug susceptibility testing
(DST).
Definition of XDR-TB is
Chapter 4
Not applicable
Definitions: case introduced.
registration,
Concise instructions for
bacteriology and registration of new cases of
treatment XDR-TB are provided.
outcomes
Chapter 5
All patients at increased risk
Stronger emphasis is placed
Case-finding for MDR-TB should be screened on the recommendation that
strategies for drug resistance.* all patients at increased risk
Patients infected with HIV for MDR-TB should receive
should receive DST at the start DST, with the goal of
of anti-TB therapy to avoid universal access to DST for
mortality caused by all that need it.
unrecognized MDR-TB.*
The use of rapid DST in all
Rapid DST should be used for HIV-infected patients who are
the initial screening of MDR-TB smear-positive is highly
whenever possible. encouraged, and it is
Patients at increased risk for recommended that all
XDR-TB should receive DST of HIV-infected patients at
isoniazid, rifampicin, second- moderate to high risk be
line injectable agents and a screened for resistance in
fluoroquinolone.* order to avoid the high
mortality associated with
unrecognized MDR-TB.
An algorithm for the use of
rapid drug-resistance testing
is introduced.
The use of DST for second line drugs in case-finding for
XDR-TB is introduced, and
risk factors for XDR-TB are
described.
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Executive summary
Chapter
Key recommendations
Key changes
(* indicates updated recommendation)
Chapter 6
All patients with suspected
Definitions of common terms
Laboratory MDR-TB or XDR-TB need access used in laboratory issues are
aspects to laboratory services for provided at the start of the
adequate and timely diagnosis. chapter.
Laboratories should be tested New recommendations for
for proficiency and quality DST to second-line drugs are
assured externally to perform proposed based on recent
DST.* WHO policy guidance;
Laboratories should perform
References for regulations on
DST for the fluoroquinolones how to transport infectious
and second-line injectable specimens internationally are
agents where adequate capacity provided.
and expertise exists.*
DR-TB strains can be
transported safely across
international borders if inter national procedures and guide lines are followed.*
Laboratories must follow all
standardized protocols for
infection control and biosafety.
Quality control and quality
assurance should be in place
for microscopy, culture and DST.
Links with supranational
reference laboratories are
strongly encouraged.
Chapter 7
Design regimens with a
The five groups of anti-TB
Treatment consistent approach based on drugs are re-defined.
strategies for the hierarchy of the five groups Thioacetazone is placed in
MDR-TB of anti-TB drugs. Group 5. High-dose isoniazid
Promptly diagnose MDR-TB and and imipenem are added to
initiate appropriate therapy. Group 5.
Use at least four drugs with
Ciprofloxacin is removed as
either certain, or almost certain, an anti-TB agent because of
effectiveness. its weak efficacy compared
DST should generally be used to with other fluoroquinolones.
guide therapy; however, do not Strong caution is warranted
depend on DST of ethambutol for any programme that uses
or pyrazinamide in individual gatifloxacin given the rare but
regimen design, pyrazinamide, dangerous adverse effects of
Group 4 and 5 drugs. dysglycaemia associated
Do not use ciprofloxacin as an with this drug.
anti-TB agent in management A new review of DST of
of DR-TB.** second-line drugs has
Design a programme strategy resulted in strong caution
that takes into consideration against basing the design of
access to quality-assured DST, individual regimens on
rates of DR-TB, HIV prevalence, results of DST of ethambutol,
technical capacity and financial pyrazinamide, or Group 4 and
resources. 5 drugs.
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Chapter
Key recommendations
Key changes
(* indicates updated recommendation)
Chapter 7
Treat MDR-TB patients for
Table 7.2 is new and
(continued) 18 months past the date of summarizes programme
culture conversion. strategies accepted by the
Use adjunct therapies including Green Light Committee that
surgery and nutritional or social take into consideration
support. quality of DST, rates of
Treat XDR-TB aggressively DR-TB, technical capacity
whenever possible. and financial resources.
Treat adverse effects
The management of XDR-TB
immediately and adequately. is introduced.
Perform provider-initiated HIV
Stronger emphasis is placed
Chapter 10
HIV infection testing and counselling in all on performing DST of
and MDR-TB TB suspects.* HIV-infected individuals at
Use standard algorithms to the start of anti-TB therapy in
diagnose pulmonary and extra- areas of moderate or high
pulmonary TB. MDR-TB prevalence. This
Use mycobacterial cultures and, subject is also introduced in
where available, newer more Chapter 5 as a key change.
rapid methods of diagnosis.
Greater detail is provided on
Determine the extent (or the concomitant treatment of
prevalence) of anti-TB drug HIV and MDR-TB, including
resistance in patients with HIV. discussion of immune
Introduce antiretroviral therapy reconstitution inflammatory
(ART) promptly in MDR-TB or syndrome.
XDR-TB /HIV patients.
Table 10.3 provides a list of
Consider empirical therapy with potential overlapping and
second-line anti-TB drugs.* additive toxicities of ART and
Provide co-trimoxazole anti-TB therapy.
preventive therapy (CPT) as part
of a comprehensive package of
HIV care to patients with active
TB and HIV.*
Arrange treatment follow-up by
a specialized team.
Implement additional nutritional
and socioeconomic support.
Ensure effective infection
control.
Involve key stakeholders in
MDR-TB/HIV activities.
Monitor overlying toxicity with
ART and DR-TB therapy.
xiv
Executive summary
Chapter
Key recommendations
Key changes
(* indicates updated recommendation)
Chapter 11
Standard monitoring should be New recommendations for
Initial evaluation, implemented for all patients on monitoring the response to
monitoring of MDR-TB treatment. treatment are described.
treatment and
Results both of sputum smear Laboratory monitoring for
management of and culture should be monitored patients receiving both ART
adverse effects monthly to evaluate treatment and MDR-TB therapy is added
response.* to Table 11.1.
Increased monitoring is
required in HIV cases and for
patients on ART.*
Health-care workers in MDR-TB
control programmes should be
familiar with the management
of common adverse effects of
MDR-TB therapy.
Ancillary drugs for the manage ment of adverse effects should
be available to the patient.
Chapter 12
Use disease education, DOT,
A section on communityTreatment socioeconomic support, based care and support is
delivery and emotional support, manage- added to this chapter. NTPs
adherence ment of adverse effects and are encouraged to add
monitoring systems to improve community-based care and
adherence to treatment. support into their national
National TB control programmes strategies and plans.
(NTPs) are encouraged to
incorporate community-based
care and support into their
national plans.*
Chapter 14
MDR-TB contact investigation
NTPs should consider
Management of should be given high priority, contact investigation of
contacts of and NTPs should consider XDR-TB as an emergency
MDR-TB patients contact investigation of XDR-TB situation.
as an emergency situation.*
Infection control, including
Infection control measures
Chapter 15
Drug resistance administrative and engineering are proposed, with special
and infection controls as well as personal attention to XDR-TB and the
control protection, should be made a high mortality of patients
high priority in all MDR-TB coinfected with HIV and
control programmes. DR-TB.
XDR-TB patients should be
XDR-TB patients should be
placed isolated following a placed in ward isolation until
patient-centred approach and no longer infectious.
WHO ethical and legal guidance MDR-TB patients should
until no longer infectious.* receive routine care outside
of normal HIV care settings.
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Chapter
Key recommendations
Key changes
(* indicates updated recommendation)
Chapter 18
A standardized method of
Chapter 18 has been
Category IV recording and reporting should rewritten to be simpler and
recording and be implemented in DR-TB more consistent with the
reporting system control programmes. DOTS recording and
DR-TB treatment cards should reporting system.
have an expanded section for The treatment card described
information on patients with in Chapter 18 has an
HIV.* expanded section for
The International Health information on patients with
Regulations (IHR2005) should HIV.
be followed.*
Box 18.1 provides additional
recording and reporting
components, which are
optional for programmes.
The International Health
Regulations 2005 should be
followed.
Chapter 19
Not applicable
Chapter 19 is the only
Managing DR-TB completely new chapter in
through patient- this revision.
centered care
Any patient in whom MDR-TB or
XDR-TB is suspected or
diagnosed should be provided
with high-quality patient
centered care, as outlined in
both the International
Standards for Tuberculosis
Care, the Patients Charter for
Tuberculosis Care and in the
WHO Good Practice in
Legislation and Regulations for
TB Control.
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