تعليقWHO aims to use the best available evidence on interventions to ensure adequate patient care and support and in order to inform policy decisions made by national TB control programme managers, national policy-makers and medical practitioners in a variety of geographical, economic and social settings.
This module of the WHO consolidated guidelines on tuberculosis aims to provide a summary of existing valid WHO recommendations on care and support during tuberculosis treatment.
The recommendations included in this module were developed by three Guidelines Development Groups (GDGs) convened by the WHO Global Tuberculosis Programme in 2011, 2016 and 2021 (1–3) in order to review the evidence available on key aspects of TB care and support. The GDGs were composed of a multidisciplinary group of TB experts external to WHO.
The recommendations were formulated by the GDGs using the GRADE approach. The recommendations were then reviewed by external review groups which were composed of experts and end-users from all WHO regions.
The recommendations on TB care and support are as follows:
1. Care and support interventions for all people with TB
Recommendations:
1.1. Health education and counselling on the disease and treatment adherence should be provided to patients on TB treatment (strong recommendation, moderate certainty of evidence).
1.2. A package of treatment adherence intervention¹ may be offered for patients on TB treatment in conjunction with the selection of a suitable treatment administration option² (conditional recommendation, low certainty of evidence).
1.3. One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers:
- tracers³ or digital medication monitor⁴ (conditional recommendation, very low certainty of evidence);
- material support to patient⁵ (conditional recommendation, moderate certainty of evidence);
- psychological support⁶ to patient (conditional recommendation, low certainty of evidence);
- staff education⁷ (conditional recommendation, low certainty of evidence).
1.4. The following treatment administration options may be offered to patients on TB treatment:
- Community- or home-based treatment support is recommended over health facility-based treatment support or unsupervised treatment (Conditional recommendation, moderate certainty of evidence).
- Treatment support administered by trained lay providers or health-care workers is recommended over treatment support administered by family members or unsupported treatment (conditional recommendation, very low certainty of evidence).
- Video-supported treatment (VST) can replace in-person treatment support when the video communication technology is available and can be appropriately organized and operated by health-care providers and patients (conditional recommendation, very low certainty of evidence).
2. Models of care for people with drug-resistant TB
Recommendations:
2.1. Patients with multidrug-resistant TB (MDR-TB) should be treated using mainly ambulatory care rather than models of care based principally on hospitalization (conditional recommendation, very low certainty of evidence).
2.2. A decentralized model of care is recommended over a centralized model for patients on MDR-TB treatment (conditional recommendation, very low certainty of evidence).
3. Models of care for children and adolescents exposed to TB or with TB disease
Recommendations:
3.1. In TB high-burden settings, decentralized models of care may be used to deliver TB services to children and adolescents with signs and symptoms of TB and/or those exposed to TB (conditional recommendation, very low certainty of evidence).
3.2. Family-centred, integrated models of care to deliver TB services may be used in children and adolescents with signs and symptoms of TB and/or those exposed to TB, in addition to standard models of care (conditional recommendation; very low certainty of evidence)
It is critical that national TB programmes and public health leaders consider these recommendations in the context of countries’ TB epidemics, the strengths and weaknesses of health systems, and the availability of financial, human and other essential resources. In adapting these guidelines, care must be exercised to protect access for the populations most in need in order to achieve the greatest impact for the greatest number of people and to ensure sustainability. It is similarly important to ensure that the adaptation of these guidelines does not stifle ongoing or planned research; the new recommendations reflect the current state of knowledge and new information will be needed for sustainability and future modifications of the existing guidelines.
¹ Treatment adherence interventions include social support such as: patient education and counselling; material support (e.g. food, financial incentive and transport fees); psychological support; tracers such as home visits or digital health communications (e.g. SMS, telephone calls); medication monitor; and staff education. The interventions should be selected on the basis of the assessment of the
individual patient’s needs, provider’s resources and conditions for implementation.
² Suitable treatment administration options include various forms of treatment support, such as video-supported treatment and regular community or home-based treatment support.
³ Tracers refer to communication with the patient including via SMS, telephone (voice) calls, or home visit.
⁴ A digital medication monitor is a device that can measure the time between openings of the pill box. The medication monitor may have audio reminders or send an SMS to remind patient to take medications, along with recording when the pill box is opened.
⁵ Material support can be food or financial support such as: meals, food baskets, food supplements, food vouchers, transport subsidies,
living allowance, housing incentives, or financial bonus. This support addresses indirect costs incurred by patients or their attendants
in order to access health services and, possibly, tries to mitigate consequences of income loss related to the disease.
⁶ Psychological support can be counselling sessions or peer-group support.
⁷ Staff education can be adherence education, chart or visual reminder, educational tools and desktop aids for decision-making
and reminder.