SPECIAL ARTICLE

Updating the International Standards for Tuberculosis Care

Entering the Era of Molecular Diagnostics
Philip C. Hopewell1, Elizabeth L. Fair1, and Mukund Uplekar2
1
Curry International Tuberculosis Center, University of California, San Francisco, San Francisco, California; and 2Global Tuberculosis
Program, World Health Organization, Geneva, Switzerland

Abstract performance characteristics for detecting Mycobacterium

The International Standards for Tuberculosis Care, rst published
in 2006 (Lancet Infect Dis 2006;6:710725.) with a second edition
in 2009 (www.currytbcenter.ucsf.edu/international/istc_report),
was produced by an international coalition of organizations
funded by the United States Agency for International
Development. Development of the document was led jointly by the
World Health Organization and the American Thoracic Society,
with the aim of promoting engagement of all care providers,
especially those in the private sector in low- and middle-income
countries, in delivering high-quality services for tuberculosis. In
keeping with World Health Organization recommendations
regarding rapid molecular testing, as well as other pertinent new
recommendations, the third edition of the Standards has been
developed. After decades of dormancy, the technology available
for tuberculosis care and control is now rapidly evolving. In
particular, rapid molecular testing, using devices with excellent
tuberculosis and rifampin resistance, and that are practical and
affordable for use in decentralized facilities in low-resource
settings, is being widely deployed globally. Used appropriately,
both within tuberculosis control programs and in private
laboratories, these devices have the potential to revolutionize
tuberculosis care and control, providing a conrmed diagnosis
and a determination of rifampin resistance within a few hours,
enabling appropriate treatment to be initiated promptly. Major
changes have been made in the standards for diagnosis. Additional
important changes include: emphasis on the recognition of groups
at increased risk of tuberculosis; updating the standard on
antiretroviral treatment in persons with tuberculosis and human
immunodeciency virus infection; and revising the standard on
treating multiple drugresistant tuberculosis.
Keywords: tuberculosis; drug resistance; human
immunodeciency virus infection; diagnosis; treatment

(Received in original form January 5, 2014; accepted in final form January 6, 2014 )
Supported by the United States Agency for International Development, which funded the development of the International Standards for Tuberculosis Care
through the TB CARE 1 coalition*.
*TB CARE I is a coalition of organizations funded by the United States Agency for International Development to implement a portion of its tuberculosis program.
The organizations are the American Thoracic Society, FHI 360, the Japan Antituberculosis Association, the KNCV Tuberculosis Foundation, Management
Sciences for Health, the International Union against Tuberculosis and Lung Disease, and the World Health Organization.
The views expressed in this article do not communicate an official position of the United States Agency for International Development. M.U. is a staff member of
the World Health Organization (WHO); the views expressed in this article are his own, and do not necessarily represent WHO policies.
Correspondence and requests for reprints should be addressed to Philip C. Hopewell, M.D., Division of Pulmonary and Critical Care Medicine, Room 5K1 San
Francisco General Hospital, San Francisco, CA 94110. E-mail: phopewell@medsfgh.ucsf.edu
Ann Am Thorac Soc Vol 11, No 3, pp 277285, Mar 2014
Published 2014 by the American Thoracic Society
DOI: 10.1513/AnnalsATS.201401-004AR
Internet address: www.atsjournals.org

The International Standards for Tuberculosis
Care (ISTC) was rst published in 2006,
with a second edition in 2009 (1, 15). Recent
advances in the diagnosis and treatment of
tuberculosis have prompted the publication
of a third edition of the ISTC, which was
released on World TB Day 2014 (March 24;
the complete version of the document can be
accessed at www.istcweb.org, and at www.
currytbcenter.ucsf.edu/international/istc, as
well as at the websites of the TB CARE 1
organizations) (3). As with the rst two
editions, the third edition was produced by
an international coalition of organizations,
TB CARE 1, funded by the United States
Agency for International Development
(USAID). Development of all three editions
of the ISTC was led jointly by the World
Health Organization (WHO) and the
American Thoracic Society. The ISTC aims
to promote engagement of all care providers,
especially those in the private sector in
low- and middle-income countries, in
delivering high-quality services for tuberculosis.

Hopewell, Fair, and Uplekar: Updating International Standards for TB Care 277

Edition 1 of the ISTC stated, The
Standards should be viewed as a living
document that will be revised as
technology, resources, and circumstances
change (1, 2). After decades of dormancy,
the technology available for tuberculosis
care and control is now rapidly evolving. In
particular, rapid molecular testing, using
devices that have excellent performance
characteristics for detecting Mycobacterium
tuberculosis and rifampicin resistance, and
are practical and affordable for use in
decentralized facilities in low-resource
settings, is now widely available and are
being widely deployed globally (46). Used
appropriately, both within tuberculosis
control programs and in private
laboratories, these devices have the
potential to revolutionize tuberculosis care
and control by providing a conrmed
diagnosis and a determination of drug
resistance within a few hours, enabling
appropriate treatment to be initiated
promptly, thereby, reducing ongoing
transmission of the organism. The
availability and increasing use of rapid
molecular testing, together with substantial
guidance from the WHO, have highlighted
the need for revision of the ISTC to be
consistent with current guidelines (4, 6).
In addition to new technologic
approaches, circumstances have changed.
The treatment strategy recommended by the
WHO, known as DOTS, has now been
widely implemented and has been highly
successful (7, 8). The global tuberculosis
case rate is declining, although the decline
of approximately 2% per year is far too
slow. The success of DOTS in the diagnosis
and treatment of usual tuberculosis now
enables an intensied focus on the problem
areas that remain: improving the speed and
completeness of case detection, thereby
reducing transmission of M. tuberculosis;
addressing drug-resistant tuberculosis;
effectively managing tuberculosis in
persons with comorbidities, especially
human immunodeciency virus (HIV)
infection; and developing approaches to
tuberculosis detection and prevention in
groups at increased risk of the disease
(913). In addition, it is recognized that
DOTS implementation only by the public
sector of the health care system is insufcient
to bring about true tuberculosis control,
and that new, broader-based approaches
must be implemented in both public and
private sectors (14). Consequently, in
addition to the incorporation of new
278
information and recommendations
regarding diagnostic test technology,
additional important changes in Edition 3
include: emphasis on the recognition of
groups at increased risk of tuberculosis and
considerations for screening within such
groups; updating the standard on antiretroviral
treatment to indicate that treatment should
be initiated promptly for any person with
tuberculosis and HIV infection; and revising
the standard on treating multiple drug
resistant tuberculosis to be consistent with the
2011 WHO update (15).
It should be emphasized that the basic
principles that underlie the ISTC have not
changed. Case detection and curative
treatment remain the cornerstones of
tuberculosis care and control, and the
fundamental responsibility of providers to
ensure completion of treatment is
unchanged. Within these basic principles,
however, there have been changes that are
of sufcient importance to be incorporated
into the ISTC. Tables 14 present the
revised standards and summarize the
changes in Edition 3 compared with
Edition 2 (16).
Development Process
As with Editions 1 and 2, Edition 3 was
funded by USAID via TB CARE I. A steering
committee from the Global TB Program at
WHO identied areas in which revisions
were needed. It was felt that no new
systematic reviews were needed for this
edition, because the standards in the ISTC
are all supported by existing WHO
guidelines and policy statements, many of
which had recently been developed using
rigorous methodology, including systematic
reviews (17). The initial draft document
was then reviewed by an expert committee
of 27 members from 13 countries.
Subsequent drafts were reviewed and
approved by the expert committee. In
addition, the nal draft was reviewed and
approved by the TB CARE I member
organizations (see footnote).
Rationale
Although in the past decade there has been
substantial progress in the development and
implementation of the strategies necessary
for effective tuberculosis control, the disease
remains an enormous global health
AnnalsATS Volume 11 Number 3 | March 2014
SPECIAL ARTICLE
problem. It is estimated that one-third of
the worlds population is infected with
M. tuberculosis, mostly in developing
countries, where 95% of cases occur. In
2012, there were an estimated 8.6 million
new cases of tuberculosis (8). The number
of tuberculosis cases that occur in the world
each year has been declining slightly for
the past few years, and the global incidence
per 100,000 population is decreasing at just
over 2% per year (8).
Incidence, prevalence, and mortality
are now decreasing in all six of the WHO
regions. In Africa, the case rate has only
recently begun to decrease, but remains very
high both, because of the epidemic of HIV
infection in sub-Saharan countries and
the poor health systems and primary care
services throughout the region. In Eastern
Europe, after a decade of increases, case rates
reached a plateau in the early 2000s and
now have begun to decrease slightly.
However, in many countries, because of
incomplete application of proven care and
control measures, tuberculosis case rates are
either stagnant or decreasing more slowly
than should be expected. This is especially
true in high-risk groups, such as persons
with HIV infection, the homeless, and
recent immigrants. The failure to bring
about a more rapid reduction in
tuberculosis incidence, at least in part,
relates to a failure to fully engage providers
who are not part of tuberculosis control
programs in the provision of high-quality
care, in coordination with local and
national control programs. Fostering such
engagement is an important purpose of
the ISTC.
It is widely recognized that many
providers are involved in the diagnosis and
treatment of tuberculosis (14). Traditional
healers, general and specialist physicians
in private practice, nurses, clinical
ofcers, academic physicians, unlicensed
practitioners, and community
organizations, among others, all play roles
in tuberculosis care and, therefore, in
tuberculosis control. In addition, other
public sector providers, such as those
working in prisons, army hospitals, or
public hospitals and facilities, regularly
evaluate persons suspected of having
tuberculosis and treat patients who have
the disease.
Little is known about the adequacy
of care delivered outside of tuberculosis
control programs, but evidence from studies
conducted in many parts of the world show
 SPECIAL ARTICLE

Table 1. International Standards for Tuberculosis Care, Edition 3: Standards for Diagnosis

Standard Key Differences from Edition 2

Standard 1 To ensure early diagnosis, providers must be aware This is a new standard emphasizing the
of individual and group risk factors for responsibility of providers to be aware of
tuberculosis and perform prompt clinical individual and population risk factors for
evaluations and appropriate diagnostic testing for tuberculosis and to reduce diagnostic delay.
persons with symptoms and ndings consistent
with tuberculosis.
Standard 2 All patients (including children) with unexplained Formerly Standard 1. The wording has been
cough lasting >2 weeks or with unexplained changed to include radiographic abnormalities
ndings suggestive of tuberculosis on chest as an indication for evaluation for tuberculosis.
radiographs should be evaluated for tuberculosis. The standard emphasizes the importance of
including not only cough, but fever, night sweats,
and weight loss, as indications for evaluation for
tuberculosis.
Standard 3 All patients (including children) who are suspected Formerly Standard 2. The current WHO
of having pulmonary tuberculosis and are recommendations for use of rapid molecular
capable of producing sputum should have at testing as the initial microbiologic test in specied
least two sputum specimens submitted for smear patients are now included. The recommendation
microscopy or a single sputum specimen for against using serologic assays for diagnosing
Xpert MTB/RIF testing in a quality-assured tuberculosis is emphasized.
laboratory. Patients at risk for drug resistance
who have HIV risks, or who are seriously ill,
should have Xpert MTB/RIF performed as the
initial diagnostic test. Blood-based serologic
tests and interferon gamma release assays
should not be used for diagnosis of active
tuberculosis.*
Standard 4 For all patients (including children) suspected of Formerly Standard 4. Now combined with Standard
having extrapulmonary tuberculosis, appropriate 1. The importance of microbiological diagnosis of
specimens from the suspected sites of extrapulmonary tuberculosis is emphasized.
involvement should be obtained for WHO recommendations for the use of rapid
microbiological and histopathological molecular testing for samples from
examination. An Xpert MTB/RIF test is extrapulmonary sites are included.
recommended as the preferred initial
microbiological test for suspected tuberculous
meningitis, because of the need for a rapid
diagnosis.
Standard 5 In patients suspected of having pulmonary The WHO recommendations are presented for use
tuberculosis whose sputum smears are negative, of rapid molecular testing for diagnosis of
Xpert MTB/RIF and/or sputum cultures should be tuberculosis among persons who are suspected
performed. Among smear and Xpert- MTB/RIF of having the disease, but have negative sputum
negative persons with clinical evidence strongly smear microscopy.
suggestive of tuberculosis, antituberculosis
treatment should be initiated after collection of
specimens for culture examination.
Standard 6 In all children suspected of having intrathoracic The WHO recommendations are presented for the
(i.e., pulmonary, pleural, and mediastinal or hilar use of rapid molecular testing for the diagnosis of
lymph node) tuberculosis, bacteriological tuberculosis in children.
conrmation should be sought through
examination of respiratory secretions
(expectorated sputum, induced sputum, gastric
lavage) for smear microscopy, an Xpert MTB/RIF
test, and/or culture.

Definition of abbreviations: HIV = human immunodeficiency virus; MTB = Mycobacterium tuberculosis; RIF = rifampin; WHO = World Health Organization.
*At this time, the only system on the market that has these qualifications is the Xpert MTB/RIF device marketed by Cepheid Inc. (Sunnyvale, CA) and
codeveloped by David Alland at the University of Medicine and Dentistry of New Jersey, Cepheid, Inc., and Foundation for Innovative New Diagnostics,
with additional financial support from the U.S. National Institutes of Health. Because Xpert MTB/RIF is currently the only system with the requisite
characteristics, it is specifically cited in the recommendations of the WHO.

great variability in the quality of tuberculosis
care, and poor quality care continues to
plague global tuberculosis control efforts
even in low-prevalence, high-income
settings (18, 19). A global situation
assessment reported by WHO suggested
that delays in diagnosis were common (20).
The delay was more often in receiving
a diagnosis rather than in seeking care,
although both elements have been shown to
be important (21, 22). Even after a patient
is found to have a positive sputum smear,
delays are common (23). The WHO survey
and other studies also show that clinicians,
in particular those who work in the private

Hopewell, Fair, and Uplekar: Updating International Standards for TB Care 279
 SPECIAL ARTICLE

Table 2. International Standards for Tuberculosis Care, Edition 3: Standards for Treatment

Standard Key Differences from Edition 2

Standard 7 To fulll her/his public health responsibility, as well No change

as responsibility to the individual patient, the
provider must prescribe an appropriate treatment
regimen, monitor adherence to the regimen, and,
when necessary, address factors leading to
interruption or discontinuation of treatment.
Fullling these responsibilities will likely require
coordination with local public health services
and/or other local services.
Standard 8 All patients who have not been treated previously No change
and do not have other risk factors for drug
resistance should receive a WHO-approved rst-
line treatment regimen using quality-assured
drugs. The initial phase should consist of 2
months of isoniazid, rifampicin, pyrazinamide,
and ethambutol (ethambutol may be omitted in
children who are HIV negative and who have
noncavitary disease). The continuation phase
should consist of isoniazid and rifampicin given
for 4 months. The doses of antituberculosis drugs
used should conform to WHO recommendations.
Standard 9 A patient-centered approach to treatment should No change
be developed for all patients in order to promote
adherence, improve quality of life, and relieve
suffering. This approach should be based on the
patients needs and mutual respect between the
patient and the provider.
Standard 10 Response to treatment in patients with pulmonary The role of microscopy in monitoring response in
tuberculosis (including those with tuberculosis patients who had the diagnosis established by
diagnosed by a rapid molecular test) should be a rapid molecular test is described.
monitored by follow-up sputum smear
microscopy at the time of completion of the initial
phase of treatment (2 mo). If the sputum smear is
positive at completion of the initial phase, sputum
microscopy should be performed again at 3
months and, if positive, rapid molecular drug
sensitivity testing (line probe assays or Xpert
MTB/RIF) or culture with drug susceptibility
testing should be performed. In patients with
extrapulmonary tuberculosis and in children, the
response to treatment is best assessed clinically.
Standard 11 An assessment of the likelihood of drug resistance, This standard describes the use of Xpert MTB/RIF
based on history of prior treatment, exposure to in assessing for rifampicin resistance and line
a possible source case having drug-resistant probe assay for detecting resistance to both
organisms, and the community prevalence of isoniazid and rifampicin.
drug resistance (if known), should be obtained for
all patients. Drug susceptibility testing should be
performed at the start of therapy for all previously
treated patients. Patients who remain sputum
smear positive at completion of 3 months of
treatment and patients in whom treatment has
failed, have been lost to follow-up, or relapsed
after one or more courses of treatment should
always be assessed for drug resistance. For
patients in whom drug resistance is considered to
be likely, an Xpert MTB/RIF test should be the
initial diagnostic test. Line probe assay or culture
and testing for susceptibility to at least isoniazid
and rifampicin should be performed promptly if
rifamycin resistance is detected. Patient counseling
and education, as well as an empiric second-line
treatment regimen, should begin immediately to
minimize the potential for transmission. Infection
control measures appropriate to the setting should
be applied.
(Continued )

280 AnnalsATS Volume 11 Number 3 | March 2014

 SPECIAL ARTICLE

Table 2. (CONTINUED )
Standard Key Differences from Edition 2

Standard 12 Patients with or highly likely to have tuberculosis The standard has been changed to reect
caused by drug-resistant (especially MDR/XDR) the revised WHO recommendations for
organisms should be treated with specialized programmatic management of drug-resistant
regimens containing quality-assured second-line tuberculosis.
antituberculosis drugs. The doses of
antituberculosis drugs should conform to WHO
recommendations. The regimen chosen may be
standardized or based on suspected or
conrmed drug susceptibility patterns. At least
pyrazinamide and four drugs to which the
organisms are known or presumed to be
susceptible, including an injectable agent, should
be used in an 8-month intensive phase, and at
least three drugs to which the organisms are
known or presumed to be susceptible should be
used in the continuation phase. Treatment should
be given for at least 1824 months beyond
culture conversion. Patient-centered measures,
including observation of treatment, are required
to ensure adherence. Consultation with
a specialist experienced in treatment of patients
with MDR/XDR tuberculosis should be obtained.
Standard 13 An accessible, systematically maintained record of No change
all medications given, bacteriologic response,
outcomes, and adverse reactions should be
maintained for all patients.

Definition of abbreviations: HIV = human immunodeficiency virus; MDR = multiple drugresistant; MTB = Mycobacterium tuberculosis; RIF = rifampin;
WHO = World Health Organization; XDR = extensively drug-resistant.

healthcare sector, often deviate from
standard, internationally recommended
tuberculosis management practices. These
deviations include: underutilization of
microbiological tests for diagnosis,
generally associated with overreliance on
radiography; use of nonrecommended drug
regimens with incorrect combinations of
drugs and mistakes in both drug dosage
and duration of treatment; and failure to
supervise and assure adherence to
treatment (1820, 24). Evidence also
indicates overreliance on poorly validated
or inappropriate diagnostic tests, such as
serologic assays, often in preference to
conventional bacteriological evaluations
(25). Because of the unreliability of these
tests, WHO has taken the unusual step of
specically recommending against their use
(26).
Together, these ndings highlight aws
in health care practices 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 (27).
Thus, there is an ethical underpinning
that applies equally to program and
nonprogram providers, to the provision of
effective, appropriate tuberculosis care (28).
Tuberculosis care (including prevention)
is a public good. The disease not only
threatens the health of individualsthe
health of the community is also at risk. It is
generally agreed that universal access to
health care is a human right, and that
governments have the ethical responsibility
to ensure access, a responsibility that
includes access to quality-assured
tuberculosis services. In particular,
tuberculosis disproportionately affects poor
and marginalized people, groups that
governments and health care systems
have an ethical obligation to protect.
Tuberculosis not only thrives on poverty,
it breeds poverty by consuming limited
personal and family resources. Poor care
compounds the costs that already
impoverished individuals and families
cannot afford, and commonly results in
persons being unable to work for long
periods, while at the same time incurring
catastrophic costs (29, 30). Substandard
care, be it on the part of program or
nonprogram providers, is unethical. The
care and control measures in the ISTC
describe approaches to tuberculosis care,
control, and prevention that are consistent
with the ethical standards articulated by
the Guidance on Ethics of Tuberculosis
Prevention, Care, and Control developed by
the WHO (28).
Purpose and Scope
The fundamental purpose of the ISTC is
to improve the care of patients with or
suspected of having tuberculosis, as well as
for those at increased risk of the disease,
regardless of their source of care. The ISTC
is intended to promote the effective
engagement of all care providers in
delivering high-quality care using established
best practices. As such, the ISTC will provide
private sectorfocused support to the
high-quality integrated TB care and
prevention component of WHOs Post
2015 Strategy, currently under development.
Engagement of all providers is a critical
component of the updated strategy, and the
ISTC will serve as a means of promoting
implementation of the strategy, especially
among nonprogram providers.
The ISTC describes a widely accepted
level of care that all practitioners, public
and private, should seek to achieve in
managing patients who have, or are
suspected of having, tuberculosis. The ISTC
focuses on the contribution of good clinical

Hopewell, Fair, and Uplekar: Updating International Standards for TB Care 281
 SPECIAL ARTICLE

Table 3. International Standards for Tuberculosis Care, Edition 3: Standards for Addressing Human Immunodeciency Virus
Infection and Other Comorbid Conditions

Standard Key Differences from Edition 2

Standard 14 HIV testing and counseling should be conducted No change

for all patients with, or suspected of having,
tuberculosis unless there is a conrmed negative
test within the previous 2 months. Because of the
close relationship of tuberculosis and HIV
infection, integrated approaches to prevention,
diagnosis, and treatment of both tuberculosis
and HIV infection are recommended in areas with
high HIV prevalence. HIV testing is of special
importance as part of routine management of all
patients in areas with a high prevalence of HIV
infection in the general population, in patients
with symptoms and/or signs of HIV-related
conditions, and in patients having a history
suggestive of high risk of HIV exposure.
Standard 15 In persons with HIV infection and tuberculosis who The standard has been modied to reect the
have profound immunosuppression (CD4 counts current WHO recommendations for treating HIV
,50 cells/mm3), ART should be initiated within 2 in people living with HIV who have tuberculosis.
weeks of beginning treatment for tuberculosis
unless tuberculous meningitis is present. For all
other patients with HIV and tuberculosis,
regardless of CD4 counts, antiretroviral therapy
should be initiated within 8 weeks of beginning
treatment for tuberculosis. Patients with
tuberculosis and HIV infection should also
receive cotrimoxazole as prophylaxis for other
infections.
Standard 16 Persons with HIV infection who, after careful No change
evaluation, do not have active tuberculosis
should be treated for presumed latent
tuberculosis infection with isoniazid for at least
6 months.
Standard 17 All providers should conduct a thorough No change
assessment for comorbid conditions and other
factors that could affect tuberculosis treatment
response or outcome, and identify additional
services that would support an optimal outcome
for each patient. These services should be
incorporated into an individualized plan of care
that includes assessment of and referrals for
treatment of other illnesses. Particular attention
should be paid to diseases or conditions known
to affect treatment outcomefor example,
diabetes mellitus, drug and alcohol abuse,
undernutrition, and tobacco smoking. Referrals to
other psychosocial support services, or to such
services as antenatal or well baby care, should
also be provided.

Definition of abbreviations: ART = antiretroviral treatment; HIV = human immunodeficiency virus; WHO = World Health Organization.

care of individual patients with or suspected
of having tuberculosis, and on appropriate
prevention measures in persons with
increased risks for the disease. A balanced
approach, emphasizing both individual
patient care and public health principles of
disease control, is essential to reducing the
suffering and individual and community
economic losses from tuberculosis.
Much of the content of the ISTC is
based on recommendations developed by
the WHO using a rigorous, evidence-based
approach (17). In this regard, the ISTC
presents a compendium of WHO-produced
recommendations that are of particular
relevance to private providers in a context
of care of individual patients.
The basic principles of care for persons
with, or suspected of having, tuberculosis
are the same worldwide: a diagnosis should
be established promptly and accurately;
standardized treatment regimens of proven
efcacy should be used, together with
appropriate treatment support and
supervision to assure successful completion
of the prescribed regimen; the response
to treatment should be monitored; and
essential public health responsibilities,
including case notication, must be
performed. The ways in which these
principles are applied vary depending on
available technology, epidemiological
circumstances, and resources. However,

282 AnnalsATS Volume 11 Number 3 | March 2014

 SPECIAL ARTICLE

Table 4. International Standards for Tuberculosis Care, Edition 3: Standards for among the factors that interfere with
Diagnosis: Standards for Public Health and Prevention persons seeking or receiving care. Also not
addressed by the ISTC is the necessity of
Standard Key Differences from having a sound, effective tuberculosis
Edition 2 control program based on established
public health principles. The level of care
Standard 18 All providers should ensure that persons who No change described in the ISTC cannot be achieved
are in close contact with patients who have without there being an enabling
infectious tuberculosis are evaluated and environment, generally provided by an
managed in line with international effective public health program supported
recommendations. The highest priority
contacts for evaluation are: by appropriate legal and regulatory
d Persons with symptoms suggestive of framework and nancial resources. The
tuberculosis. requirements of such programs are
d Children aged ,5 years.
described in publications from WHO and
d Contacts with known or suspected
immunocompromised states, particularly the Union (31, 32). Having an effective
HIV infection. control program at the national or local
d Contacts of patients with MDR/XDR level with linkages to nonprogram providers
tuberculosis. enables bidirectional communication of
Standard 19 Children ,5 years of age and persons of any No change information, including case notication,
age with HIV infection who are close
contacts of a person with infectious consultation, patient referral, provision of
tuberculosis and who, after careful drugs or services, such as treatment
evaluation, do not have active tuberculosis, supervision/support for private patients,
should be treated for presumed latent and contact evaluation. In addition, the
tuberculosis infection with isoniazid for at
least 6 months. program may be the only source of
laboratory services for the private sector.
Definition of abbreviations: HIV = human immunodeficiency virus; MDR = multiple drugresistant;
XDR = extensively drug-resistant.
Audience
prompt, accurate diagnosis and effective a context of what is generally considered to
timely treatment are not only essential for be feasible now or in the near future. Clinicians (both private and public) who are
good patient care, they are the key elements There is continued recognition that not all not part of a government-funded
in the public health response to tuberculosis, of the standards in this edition can be met tuberculosis control program are the main
and are the cornerstone of tuberculosis in all places at this time. However, given target audience. These providers generally
control. Thus, all providers who undertake the rapidity of technical advances and lack the guidance and systematic evaluation
evaluation and treatment of patients with deployment of new technologies and of outcomes provided by programs and,
tuberculosis must recognize that, not only approaches, it is anticipated that commonly, are not in compliance with the
are they delivering care to an individual, compliance with the standards will be ISTC. It should be emphasized, however,
they are assuming an important public possible in most places in the near future. that public tuberculosis control programs
health function that entails a high level It is hoped that having standards that are may need to develop policies and
of responsibility to the community, as well higher than the minimum necessary will procedures that enable nonprogram
as to the individual patient. serve to stimulate more rapid improvements providers to adhere to the ISTC. Such
The ISTC is also intended to facilitate in tuberculosis care worldwide. There are accommodations may be necessary, for
coordination of activities and collaboration many situations in which local conditions, example, to facilitate treatment supervision
between tuberculosis control programs and practices, and resources will support a level and contact investigations. In addition to
nonprogram providers. Given that public of care beyond what is described in the healthcare providers and government
health authorities are responsible for ISTC. To meet the requirements of the tuberculosis programs, both patients and
normative functions, surveillance, monitoring, ISTC, approaches and strategies determined communities are part of the intended
evaluation, and reporting, it is crucial that by local circumstances and practices, audience. Patients are increasingly aware of
there be coordination between control and developed in collaboration with local (and have the right to care that) measures
programs and nonprogram providers, and national public health authorities, up to a high standard. Having generally
especially in dealing with complicated issues, will be necessary. agreed upon standards will empower
such as diagnosis and management of There are several critical areas that are patients to evaluate the quality of care
patients with drug-resistant tuberculosis. beyond the scope of the document. The they are being provided. Good care for
The ISTC provides a common ground ISTC does not address access to care. individuals with tuberculosis is also in the
of understanding on which to build Obviously, if there is no care available, the best interest of the community. Community
collaborations at national, regional, or local quality of care is not relevant. In addition, contributions to tuberculosis care and
levels, or even within individual institutions. there are many factors that impede access, control are increasingly important in
It was stated in Edition 1 that, As even when care is available: poverty, sex, raising public awareness of the disease,
written, the Standards are presented within stigma, and geography are prominent providing treatment support, encouraging

Hopewell, Fair, and Uplekar: Updating International Standards for TB Care 283
 SPECIAL ARTICLE

adherence, reducing the stigma associated
with having tuberculosis, and demanding
that healthcare providers in the community
adhere to a high standard of tuberculosis
care (33). The community should expect
that care for tuberculosis will be up to the
accepted standard and, thus, create
a demand for high-quality services.
Utilization
The ISTC is potentially a very powerful tool
for improving the quality of tuberculosis
care. Because of the way in which the ISTC
was developed and the international
endorsements that it has received through
the two previous editions, the document is
broadly credible across categories of
practitioners. This credibility is a major
strength of the ISTC, and should be
capitalized upon in its utilization. Since
publication of the rst edition in 2006, the
ISTC has been endorsed by more than 50
international and national organizations,
including many medical professional
societies, has been translated into at least
15 languages, and has been used by many
national tuberculosis control programs to
guide the development of national program
guidelines and policies. Endorsement by
professional societies is particularly
important in that they can serve to exert
peer pressure, both on their members and,
when necessary, on government programs
to adhere to the ISTC. Moreover,
professional societies often provide the only
systematic conduit through which to deliver
practice recommendations.
To inform future utilization of the
ISTC, we conducted an online survey to
ascertain the current awareness and usage
of the Standards (Editions 1 and 2). A link
to the survey was sent to the regional
advisors of the six WHO regions, and was
disseminated from the regional ofces to
119 national tuberculosis control programs.
There was a 59% response rate (70/119),
with the majority of responders coming
from the Americas (36%), European region
(23%), and Eastern Mediterranean region.
Of the responders, 90% (87% of whom
were program managers and staff) had
heard of the ISTC; of those who had heard
of the Standards, 85% said that they use the
ISTC, and 95% indicated that the ISTC
was applicable and relevant to their work.
When asked how they have used the ISTC,
79% said for developing national guidelines
or policies, 66% for education or training,
38% for engaging the private sector, 34%
for monitoring and evaluation activities,
and 28% for developing local guidelines
or policies. Given that a primary purpose
of the ISTC has always been to engage
the private sector, it was somewhat
disappointing to learn that there was not
greater utilization for this purpose.
However, it was encouraging to hear that
many respondents use the ISTC in
developing national guidelines and policies.
Adaptation
The ISTC has been developed for a global
audience, and it is expected and desirable
that regions and countries adapt the
document to suit their own circumstances.
These circumstances include consideration
of the epidemiology of tuberculosis and
the facilities and resources available in both
the public and private sectors. The ultimate
goal of these adaptations should be to
improve the quality of services for
tuberculosis within a more limited setting.
For example, the ISTC has served as
a model framework for more locally
developed standards for the European
Union and India (34, 35). Local adaptations
have also been developed in Kenya and
Indonesia.
Ideally, a consultative process involving
all relevant stakeholders should be
undertaken to ensure that the adaptation
of the ISTC is appropriate for the
environment and provides appropriate
guidance for implementation of the
practices described in the document.
Moreover, broad input is necessary to
ensure that the document reects the
perspectives of all sectors of the health care
system and creates a sense of ownership of
and commitment to the principles and
practices described in the ISTC.
The Future
It is anticipated that the pace of change in
the tools available for tuberculosis care will
continue to be rapid. For too long, the
science of tuberculosis has seemed to move
at a pace consistent with the slow replication
time of M. tuberculosis. Now, however,
using rapid molecular methods and user-
friendly platforms, the speed with
which the organism can be identied has
been greatly accelerated. Hopefully, the
science of new tools development and
implementation will advance at this more
rapid rate. Although the principles of care
that underlie the ISTC will not change, the
ways in which they are applied will evolve.
A challenging aspect of the hoped for
evolution will be (already is) providing
rapid updates of guidance documents, such
as the ISTC. To approach this challenge,
we intend to make the ISTC primarily an
electronic document, with applications
through which updates can rapidly and
automatically be delivered. Through this
and other yet-to-be-dened mechanisms,
we hope to achieve the full engagement
of all sectors of the healthcare system in
delivering high-quality tuberculosis
diagnostic, treatment, and preventive
services. n
Author disclosures are available with the text
of this article at www.atsjournals.org.
Acknowledgment: This article is copyrighted
by the World Health Organization, which has
granted the ATS permission for this publication.
The authors acknowledge important
contributions from staff members of the World
Health Organization, Global Tuberculosis
Programme: Haileyesus Getahun, Chris Gilpin,
Malgosia Grzemska, Ernesto Jaramillo, Knut
Lonnroth, Mario Raviglione, Diana Weil, and Karin
Weyer.

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