Tuberculosis Care and Control
Hopewell, Philip C., Migliori, G. B., Raviglione, Mario C., Bulletin of the World Health Organization
Tuberculosis care, a clinical function consisting of diagnosis and treatment of persons with the disease, is the core of tuberculosis control, which is a public health function comprising preventive interventions, monitoring and surveillance, as well as incorporating diagnosis and treatment. Thus, for tuberculosis control to be successful in protecting the health of the public, tuberculosis care must be effective in preserving the health of individuals.
There are three broad mechanisms through which tuberculosis care is delivered: public sector tuberculosis control programmes, private sector practitioners having formal links to public sector programmes (the public-private mix), and private providers having no connection with formal activities. In most countries, programmes in both the public sector and the public-private mix are guided by international and national recommendations based on the DOTS tuberculosis control strategy--a systematic approach to diagnosis, standardized treatment regimens, regular review of outcomes, assessment of effectiveness and modification of approaches when problems are identified. (1,2) As a consequence of this systematic approach, there is reasonable assurance that tuberculosis services are of acceptable quality in public sector and mixed public-private programmes. In contrast, though there are many published guidelines and recommendations for tuberculosis care, there are no formal mechanisms
directed towards ensuring that private sector services for tuberculosis meet acceptable standards.
There is limited information about the adequacy of tuberculosis care delivered by practitioners outside formal programmes, but evidence suggests that the poor quality of care delivered by non-programme providers hampers global tuberculosis control efforts. (3) For example, it is likely that under-diagnosis and underreporting by the private sector accounted, in part, for the fact that only 53% of the estimated global number of sputum smear-positive cases were reported in 2004. (4)
A global situation assessment reported by WHO suggested that delays in establishing a diagnosis are common. (1,5) This survey and other studies have also shown that clinicians who work in the private sector often deviate from standard, internationally recommended tuberculosis management practices. (6-8) These deviations include underutilization of sputum smear microscopy and over-reliance on radiography for diagnosis, as well as inappropriate use of poorly validated diagnostic tests such as serological assays. In addition, many practitioners use non-recommended drug regimens with incorrect combinations of drugs and mistakes in both drug dosage and duration of treatment. For example, in a survey of 100 private practitioners in Mumbai, India, 80 different tuberculosis treatment regimens were used, many of which were inappropriate. (6) Of equal importance, it is uncommon for private sector providers to be able to assess adherence to the treatment regimen and to correct poor adherence when it occurs. (9) These findings highlight shortcomings that lead to substandard tuberculosis care for populations that, sadly, are most vulnerable to the disease and are least able to bear the consequences of such systemic failures. …