Countries are out of step with international recommendations for tuberculosis testing, treatment, and care: Findings from a 29-country survey of policy adoption and implementation
Authors: Saran Karishma , Masini Tiziana , Chikwanha Isaac , Paton Gregory , Scourse Rosalind , Kahn Patricia , Sahu Suvanand , Perrin Christophe , Ditiu Lucica , Lynch Sharonann 
Published: February 2019

ABSTRACTBackgroundTuberculosis (TB) poses a global health crisis requiring robust international and country-level action. Adopting and implementing TB policies from the World Health Organization (WHO) is essential to meeting global targets for reducing TB burden. However, many high TB burden countries lag in implementing WHO recommendations. Assessing the progress of implementation at national level can identify key gaps that must be addressed to expand and improve TB care.MethodsIn 2016/2017, Médecins Sans Frontières and the Stop TB Partnership conducted a survey on adoption and implementation of 47 WHO TB policies in the national TB programs of 29 countries. Here we analyze a subset of 23 key policies in diagnosis, models of care, treatment, prevention, and drug regulation to provide a snapshot of national TB policy adoption and implementation. We examine progress since an analogous 2015 survey of 23 of the same countries.ResultsAt the time of the survey, many countries had not yet aligned their national guidelines with all WHO recommendations, although some progress was seen since 2015. For diagnosis, about half of surveyed countries had adopted the WHO-recommended initial rapid test (Xpert MTB/RIF). A majority of countries had adopted decentralized models of care, although one-third of them still required hospitalization for drug-resistant (DR-)TB. Recommended use of the newer drugs bedaquiline (registered in only 6 high-burden TB countries) and delamanid (not registered in any high-burden country) was adopted by 23 and 18 countries, respectively, but short-course (9-month) and newer pediatric regimens by only 13 and 14 countries, respectively. Guidelines in all countries included preventive treatment of latent TB infection for child TB contacts and people living with HIV/AIDS, but only four extended this to adult contacts.ConclusionTo reach global TB targets, greater political will is needed to rapidly adopt and implement internationally recognized care guidelines.KEY MESSAGESWhat is already known?Countries may be slow to adopt and implement updated World Health Organization (WHO) Tuberculosis (TB) testing, treatment, and prevention recommendations.Implementing updated TB guidelines from WHO is a fundamental first step to honoring international commitments, made through the United Nations (UN) Sustainable Development Goals (SDGs) and UN High-Level Meeting on TB Political Declaration, to end TB by 2030.What are the new findings?Of 29 mostly high TB burden countries, none had fully aligned their national guidelines with WHO recommendations, although some progress has been made since 2015.A lack of alignment with WHO recommendations was found across all policy areas surveyed, including prevention, diagnosis, treatment, models of care and drug regulation, particularly regarding uptake of newer, faster, more effective approaches.What do the new findings imply?To reach global TB targets, greater political will is needed to adopt and implement internationally recognized care guidelines more rapidly, and specifically, to keep up with the latest recommendations.Periodic surveys of progress at the national level are a valuable way to identify specific areas where countries or regions have fallen behind and that require specific policy and/or programmatic attention.