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Guide
for civil sector associates
in tuberculosis control
Guide prepared by:
Prim. Dr Dragana Mandic
Dr Radmila Curcic
Prim. Dr Lidija Sagic
Expert review: Project “TB Control in Serbia” of the Ministry of Health of the
Republic of Serbia
This publication would not exist if there was no huge contribution of the
following organizations:
Red Cross Belgrade, Red Cross Sabac, Red Cross Sremska Mitrovica, Red Cross
Sombor, Red Cross Smederevo, Red Cross Kragujevac, Red Cross Kraljevo,
Red Cross Bujanovac, Red Cross Pirot, NGO JAZAS, NGO VEZA, NGO Youth of
JAZAS Novi Sad, NGO Youth of JAZAS Kragujevac, NGO Prevent, NGO Putokaz,
NGO Timok Youth Center
Editor: Red Cross of Serbia
CIP – Publication cataloguing
National Library of Serbia, Belgrade
616-002.5(035)
MANDIC, Dragana, 1954Guide for Civil Sector Associates in Tuberculosis Control / [guide prepared by
Dragana Mandic, Radmila Curcic, Lidija Sagic]. – Belgrade: Red Cross of Serbia,
2013 (Bela Crkva: Birokup). – 40 pgs.; 17 cm
Information about the authors taken from colophon . –
Circulation 3,000.
ISBN 978-86-80205-41-0
1. Curcic, Radmila, 1963- [author] 2. Sagic, Lidija, 1959- [author]
a) Tuberculosis – handbooks
COBISS.SR-ID 201657612
CONTENTS
Preface ………………………………………………………………………………………… 5
Active case finding for the patients
in vulnerable populations …………………………………………………………….. 9
Activities of the Red Cross and associates
from the civil sector in active case finding ……………………………………… 10
Questions an RC or CS associate
should ask on the field in regard to problems
related to pulmonary tuberculosis …………………………………………………. 11
When will the Red Cross associates
and volunteers ask these questions? ……………………………………………… 12
If symptoms indicate on the possibility
of pulmonary tuberculosis ……………………………………………………………… 12
If a person does not have a health booklet ………………………………..…… 12
If a person does have symptoms
and a health booklet ………………………….…………………………………………… 14
Algorithm of active case finding for TB
patients ……………………………………… 16
Tracing for TB patient contacts
in especially vulnerable populations ……………………………………………… 17
Latent infection with TB bacilli and TB disease………………………………… 17
Objectives of interviewing contacts ……………………………………..………… 18
Priorities in interviewing persons
in contact with a TB patient …………….……………………………………………… 19
Priority in interviewing and time
of examination of persons in contact
with a TB patient ………………………………………………………………………….… 20
Procedures for the examination of children
older than 14 and adults ………………………………………………………………… 21
Procedures for the examination of children
age 5 to 14 ……………………………………………………………………………………… 23
Procedures for the examination of children
under the age of 5 …………………………….………………………………………….… 25
Preventive therapy and monitoring …………………………………………….…. 27
Contact tracings on the field …………………………………………………..… 27
How often can civil sector associates
expect examinations of certain age groups
in contact with TB patients …………………………………………………..………… 30
Support in treating TB patients
who belong to especially vulnerable
population groups ……………………………………………………………….………… 32
Objectives of TB control ……………………………………………………………….… 32
Challenges in TB treatment and control ……………………………………….… 32
Why do patients stop the treatment ……………………………………………… 33
Directly Observed Therapy – DOT …………………………………………….…… 34
Selected treatment strategy components
oriented towards a patient in the world ……………………………………….… 35
Activities of the civil sector in TB control ……………………………………….…35
Examples of CSO activities in TB control
in the world ………………………………………………………………………………….… 37
Assistance to the civil sector in TB control
TB and HIV ……………………………………………………………………………………… 38
Examples of activities of the civil sector
in TB/HIV control in the world ………………………………………………………… 38
Preface
The Project “Strengthening and improving the availability to
diagnostics and treatment of tuberculosis and multi resistant
tuberculosis, with special accent on the most vulnerable
populations”, which is realized in Serbia with use of funds of
the Global Fund to Fight AIDS, Tuberculosis and Malaria, is
implemented through the healthcare system with the
assistance of the civil sector. Working in partnership, a
synergy of interventions is achieved in state institutions
(Ministry of Health of the Republic of Serbia) and measures
directed towards vulnerable populations taken over by the
civil sector (The Red Cross in Serbia in partnership with the
non-government sector), giving an example of a good model
of TB control in the whole country.
Components of the project are as follows:
1) Improve diagnostics and treatment of TB resistant forms
and increase the availability of services
2) Maintain and consolidate 100% DOT1 coverage with a
strategy in the Republic of Serbia
3) Improve the TB control in vulnerable populations
4) Care for TB/HIV co-infection
In the frame of the project components referring to the
improvement of TB control in vulnerable populations and
care for TB/HIV co-infection, the objective is to provide
1
Directly Observed Therapy
timely detection of patients, apply DOT in out-of-hospital
conditions in a venerable Roma population and raise the
level of knowledge in regard to the possibilities of TB
prevention and control by active case finding for contacts
and TB patients in especially vulnerable populations.
Efficient measures for TB control within the national
program have resulted in significant improvement of the
epidemiological situation in Serbia. In the period 2005-2012,
the tuberculosis incidence rate dropped from 32 to 17 per
100,000 citizens2. Serbia strives to remain a country with low
tuberculosis incidence rate.
This project is also directed towards the patients of the
Roma national minority and their families, towards almost
20,000 adult soup kitchen users in 73 municipalities in Serbia,
500 sexual workers and 300 injecting drug users who benefit
from the needle exchange program in “drop in” centers in
Belgrade, Nis, Novi Sad and Kragujevac, aiming to improve
the diagnostics and treatment of TB resistant forms and
increase the availability of services, maintain and consolidate
100% DOTS3 coverage in the Republic of Serbia, improve the
TB control in vulnerable populations and provide care for
TB/HIV co-infection through the following activities:
• Strengthening capacities to implement activities in Roma
slams,
2
3
www.tbc.zdravlje.gov.rs
WHO Strategy
• Active TB tracing through the contact tracings in Roma
slams,
• Support to the DOT implementation in the extended
phase of treatment for Roma living in slams,
• Rising awareness on TB prevention and treatment among
the Roma living in slams,
• Active TB tracing in the population of especially
vulnerable categories of citizens who use the services of
the Soup Kitchen program,
• Rising awareness on TB prevention and treatment among
population categories that use the services of the Soup
Kitchen program,
• Activities for TB prevention and active case finding for
patients among sex workers (SW),
• Activities for TB prevention and active case finding for
patients among injecting drug users (IDU) who regularly
use the needs exchange programs.
With active approach to the tracing for patients, support is
provided to timely detection of patients in slams where TB
has already been registered, in the prevention of spreading
TB among family members and in the working and living
environment.
Through the network of organizations of the Red Cross of
Serbia, activities are implemented in cities and municipalities
regarding the prevention, diagnostics and treatment of TB in
Roma population living in slams and beneficiaries if soup
kitchens in Serbia. In cooperation with NGOs from Belgrade,
Novi Sad, Nis and Kragujevac, we are actively tracing for TB
patients in the population of injecting drug users benefiting
from the needle exchange services and in the population of
sex workers.
Legal framework for the action of the civil sector in TB
control is found in the Law on the Red Cross of Serbia (“The
Official Gazette of the Republic of Serbia” No. 107/05) in
Article 9, sections 6 and 7 reading: “The Red Cross of Serbia
shall implement programs and activities resulting from goals
and assignments of the International Movement, and
especially – it shall advocate ideas of voluntary work for the
benefit of vulnerable persons, register and implement
training of volunteers to work in the Red Cross of Serbia; in
cooperation with healthcare institutions, it shall organize
and participate in the implementation of activities to
improve health of certain population groups and prevent
diseases of larger social-medical significance.”
Using the legal framework and experience acquired during
the three years of project implementation, you are looking
at a guide for associates of non-medical professions who
implement the activities with especially vulnerable groups
within their CSOs. The Guide contains instructions in regard
to the possibilities to help the healthcare system to include
the especially vulnerable populations and ways how to
approach the healthcare system to individuals from
especially vulnerable groups. The Guide is complete with the
“Handbook for Civil Sector Associates in TB Control”, also
created out of a need to enable the civil sector to provide its
maximum contribution to the control of this disease.
The Guide should serve the associates in everyday work with
the especially vulnerable groups because it simply and
efficiently provides information, assistance and support in
the communication chain between the beneficiaries and the
healthcare system; it gives advices what to do in a situation
when there is suspicion on tuberculosis, what steps to take
and when to provide support to the treatment of patients
until healing.
Active case finding for the patients in
vulnerable populations
Active detection of tuberculosis includes tracing for the
patients in population groups where there is increased risk
of TB incidence.
Objectives of active case finding for the patients
Objectives of active case finding are:
• early diagnosis of pulmonary tuberculosis,
• successful control of further spreading of the disease,
• successful treatment of patients.
Combination of social risk factors, (unemployment, poverty,
homelessness) and risky behavior (alcohol abuse, drug abuse,
sexual risky behavior) may lead certain population groups to
increased risk of infection and getting ill from tuberculosis.
Considering the way they live and conditions they are living
in, the recognized risk groups in our environment at this
moment are: homeless people, members of the Roma
population living in slams, soup kitchen beneficiaries,
injecting drug users and sex workers.
Besides having the increased risk to get ill from tuberculosis,
these are groups of people who do not take sufficient care of
their health due to health ignorance, lack of information on
the right to healthcare or due to other circumstances related
to their way of life.
Activities of the Red Cross and civil sector associates
in active case finding
The Red Cross (RC), through the network of its organizations
and the civil sector (CS), along with other activities related to
this population, has the opportunity to help the healthcare
service in active case finding for TB patients aiming to early
detection and treatment of the patients.
Thanks to the trust these organizations and their associates
have built through other programs, it is possible to improve
the accessibility of healthcare to these vulnerable groups
according to the principle “all at one place”.
Associates of the civil sector may:
• Ask five key questions regarding the TB symptoms,
• If answers are positive, advise the beneficiary to go for an
examination, explain the significance of examination for
him/her and their family,
• Check if they have a health booklet,
• If they do not have a health booklet, help them to get
one, in cooperation with other services if needed (Center
for Social Work, health mediators, etc.)
• Help them to choose a doctor,
• Schedule an appointment,
• Provide transportation to the doctor,
• Accompany the patient for examination, if necessary.
Table 1: Questions a CS associate should ask
on the field in regard to problems related to
pulmonary tuberculosis
_________________________________________________
1. Have you been coughing for more than three weeks?
2. Are you coughing blood?
3. Are you sweating at night?
4. Do you have high temperature?
5. Do you have loss of appetite of weight loss?
_________________________________________________
If the answer to one or more of these questions is
affirmative, one should suspect that there might be
pulmonary tuberculosis.
When will the RC associates and volunteers ask
these questions?
In unsanitary Roma settlements – each time they contact the
residents of the settlement due to other activities, especially
if there is information that one or more persons from the
settlement is being treated for pulmonary tuberculosis.
In soup kitchens – in situations when lists of soup kitchen
beneficiaries are being revised, twice a year.
Sex workers – each time a CS associate contacts a person
from this group on another occasion, preferably once a
month.
Injecting drug users – once a month or during each contact
with persons from this group on another occasion (needle
and syringe exchange, provision of other type of help,
voluntary testing for HIV, etc).
If symptoms indicate on the possibility of
pulmonary tuberculosis
It is required to check if such person has a health booklet or
another valid personal document – ID card or passport.
According to the applicable law on healthcare, the health
booklet is mandatory, except in emergency situations.
If a person does not have a health booklet because they are
unemployed or does not pay the health insurance, nor is a
member of a family of an insured person, there are other
possibilities anticipated by the Law on Health Insurance to
secure mandatory health insurance 4 and get a health
booklet, which inter alia are:
1) Persons in regard to treatment of HIV infection or other
contagious diseases defined by a separate law that
regulates the area of population protection against
contagious diseases,
2) Materially unsecured persons receiving financial social
help,
3) Beneficiaries of permanent financial help, as well as
assistance for the accommodation in the institutions of
social protection or other families,
4) Unemployed persons and other categories of socially
vulnerable persons whose monthly income is below the
income determined in compliance with this law,
5) Person of Roma nationality who have no permanent
address or residence in the Republic of Serbia due to
their traditional way of life.
If there are no other grounds, the TB patients are entitled to
free of charge healthcare from the diagnosis of the disease
to the end of treatment.
To receive a temporary health booklet, one needs to have a
doctor’s report that a patient suffers from tuberculosis and
that treatment is required and any other document serving
for the identification of a patient (ID card, passport, birth
certificate).
4
(Law on Health Insurance, The Official Gazette of the Republic of Serbia No.
119/2013, Article 22)
If a patient does not have any of the documents mentioned
above, it is possible to verify the identity with a statement of
two witnesses.
Due to the procedure, which sometimes might be
complicated, assistance of a social worker or health
mediator is required apart from the RC or CS associate.
If a person suspected to be suffering from
pulmonary tuberculosis does have a health booklet,
it is required to:
• establish a contact with a selected doctor in a Health
Center5,
• schedule an examination appointment,
• provide transportation, and company to the doctor if
needed,
• if they have not selected a doctor, help them to select
one,
• explain the patient the significance of going for an
examination for him/her and their family,
• insist that the patient gets examined,
• if they are going alone for the examination, check if they
have been examined and if there are further plant in
terms of diagnostics or treatment.
If a patient is going for the examination without a chaperone,
it is required that a CD associate provides them with a
5
If the case refers to a patient living on the territory of Belgrade and Nis, the
procedure is similar, except that an appointment for examination is scheduled with a
pneumophtisiologist in City Institutes for Pulmonary Disease and Tuberculosis
instead at the selected doctor.
completed form containing patient’s name and surname,
place and time of the appointment, name and surname of
the doctor the appointment is scheduled with, name and
surname and telephone of the contact person.
On the backside of the form, leave space for the doctor to
complete whether the person who came for examination is
healthy or is he/she referred to further outpatient testing or
hospital treatment.
Example of good practice
After being asked about health condition, a beneficiary of needle
exchange service in a “drop in” center in Belgrade complained about
problems to the center coordinator. He said that he feels exhaustion,
losses weight, has temperature, coughs and has chest pain when
breathing.
The coordinator contacted a pneumophtisiologist in the City Institute for
Pulmonary Disease and Tuberculosis and took him for an examination.
After the examination and lung radiography where changes in the lungs
and the existence of fluid in the pleura have been noticed, he was sent to
the Clinic for Pulmonary Diseases of the Clinical Center of Serbia for
further testing and treatment.
The patient did not have a health booklet. Accompanied by the
coordinator and a social worker, he was received as an emergency case.
With the assistance of the coordinator and the social worker, he received
a health booklet for the duration of the treatment.
The treatment was successful till the end. After being released from the
hospital, the patient reported regularly for examination at the City
Institute for Pulmonary Disease and Tuberculosis, and with the doctor’s
report he received stimulation packages (food and sanitary material)
from the Red Cross.
Diagram 1: Algorithm of active case finding for TB
patients
Questions about symptoms indicating the TB (5 questions)
Negative answers
One or more
positive answers
No suspicion on TB
Suspicion on TB
Further
examination not
required
Check if the
respondent has a
health booklet
Does have a
health
booklet
* Assistance with doctor
selection
* Schedule examination
appointment with the selected
doctor or pneumophtisiologist
* Provide transportation to the
doctor, if needed
* Get feedback on further flow
of examination and treatment
Does not have
a health
booklet
Assistance with
getting the
documents in
cooperation with
the social service
Contact tracings of TB patients in especially
vulnerable populations
Latent infection with TB bacilli and TB disease
Not all persons who have been in contact with the patients
will be infected with TB bacilli. Most people will instantly
“kill” the bacilli and there won’t even be a trace that they
have been in contact. Less people will get infected (about
10%). With persons infected with TB bacilli, the bacilli are
most often in the state of “sleepiness”, and such state is
called “latent infection”. Of those infected, only ten percent
will get ill immediately after the infection (before their
immune system starts fighting the TB bacilli) or later in life
when the defense ability of the organism drops (alcoholism,
major stress, starvation, diabetes or taking medicines that
lead to loss of immunity), and this is when we are talking
about the disease. In these conditions, the TB bacilli become
active in the body and start multiplying, so from latently
infected, a person becomes actively ill.
Characteristics of TB latent infection:
• The TB bacilli may live in our body although we are
healthy,
• Not everyone infected with TB bacilli will get ill of
tuberculosis,
• Latently infected persons do not feel ill and have no TB
symptoms,
• Latently infected persons are not contagious for the
environment; therefore, they cannot transmit the
tuberculosis to other persons.
Objectives of interviewing contacts
Objectives of interviewing contacts are:
• to reduce illness and dying from tuberculosis by early
detection and treatment of persons in contact,
• to reduce further transmission of the infection by early
detection of possible new sources of the infection,
• to contribute to the elimination of tuberculosis with the
prevention of future TB cases in the community, by
detection and preventive treatment of infected contacts
who are at risk of developing active disease, and
especially with vulnerable populations.
Priorities in interviewing persons in contact with a
TB patient
Priorities are determined on the basis of:
• Risk assessment for getting ill of tuberculosis,
• Length and intensity of exposure to the infection,
• Closeness of a person in contact and a TB patient.
We can get all these information talking to (interviewing)
the patient’s family members, the patients and persons who
have been in contact.
Based on the interview priorities, persons in contact with s
TB patient are divided to persons of high, medium and low
priority. Depending on the interview priority, examinations
of persons in contact, and especially children, are done in
optimal time intervals, what is shown in diagram 2.
Diagram 2. Priority in interviewing and time of
examination of persons in contact with a TB
patient
Priority in interviewing persons
in contact
High
Examinations are done in the interval of 7 days
Medium
Examinations are done 8 weeks from the last contact
with a TB patient
Low
Examinations are done 8 weeks from the last contact with
a TB patient
Manners of examining the persons in contact with
TB patients
Depending of the age, different procedures are applied in
the examination of persons in contact with TB patients. For
all age groups, the first step is the interview on the basis of
which further activities are planned. The interview is done
with persons who are close to TB patients if we are talking
about adults, but if we are talking about minors the
information is received from parents or custodians.
Examination of adults and children older than 14
(Diagram 3)
• Medical examination
• Chest X-ray
If there are no suspicious changes in the X-ray, the X-ray is
repeated in 3 months from the first examination if it refers
to a contact close to the patient who coughs the TB bacilli in
the environment. If needed, it may be repeated earlier if the
person in contact has symptoms that rise suspicion on
tuberculosis.
• Bacteriology diagnostics
If suspicious changes are noticed in the chest X-ray, sputum
samples are taken for testing.
Sputum positive:
tuberculosis
Further testing not required
Bacteriological diagnostics
(sputum)
Sputum negative:
monitoring
No suspicion of TB
Suspicious changes
on X-rays
Interview and medical examination
Chest X/rays
Diagram 3.
Procedures for the examination of children older than 14 and adults
Examination of children age 5 to 14
(Diagram 4)
• Medical examination
• Tuberculin skin test (PPD). The test shall be read after 3
days (72 hours)
If the tuberculin test is negative and it has been less than 8
weeks since the last contact with an infected patient, the
test shall be repeated after the expiration of this period.
If the tuberculin test is positive, additional diagnostics is
required:
• Chest X-ray
If there are no suspicious changes in the X-ray, the X-ray is
repeated in 3 months from the first examination if it refers
to a contact close to the patient who coughs the TB bacilli in
the environment. If needed, it may be repeated earlier if the
child in contact has symptoms that rise suspicion on
tuberculosis.
• Bacteriology diagnostics (sputum or gastrolavage –
lavage of the stomach)
Repeated PPD
negative. No further
testing required
Repeated PPD
positive. Continue
with testing
PPD repeated if less than 8 weeks passed since
the last contact with the contagious patient
PPD test negative
Bacteriological negative:
monitoring
No changes on Xrays, control X/ays in 3 months
Interview and medical examination
Tuberculin skin test (PPD)
Bacteriological positive: active
TB - treatment
Bacteriological diagnostics
(sputum, gastric lavage)
Changes on X-rays,
suspicion on TB
Chest X-rays
PPD test positive
Diagram 4.
Procedures for the examination of children age 5 to 14
Examination of children under the age of 5
(Diagram 5)
• Medical examination
• Tuberculin skin test (PPD). The test shall be read after 3
days (72 hours)
If the tuberculin test is negative and it has been less than 8
weeks since the last contact with an infected patient, the
test shall be repeated after the expiration of this period.
EXCEPTION: if the patient is treated at home, the PPD test
shall be repeated 8 weeks after the termination of
contagiousness of the patient, this being usually after 3
weeks from the beginning of treatment.
• Chest X-ray (done with all children until the age of 5
regardless of the positivity of the PPD test)
If there are no suspicious changes in the X-ray, the X-ray is
repeated in 3 months from the first examination if it refers
to a contact close to the patient who coughs the TB bacilli in
the environment. If needed, it may be repeated earlier if the
child in contact has symptoms that rise suspicion on
tuberculosis.
If it refers to a close contact with a contagious patient,
children with negative PPD test and normal X-ray are given
preventive therapy (chemoprophylaxis) until the test and
X-ray are repeated.
If suspicious changes are noticed on the X-ray, samples are
taken for bacteriological testing.
• Bacteriology diagnostics (lavage of the stomach or
sputum)
Repeated PPD negative.
No further testing
required
PPD repeated if less than 8
weeks passed since the last
contact with the contagious
patient
PPD
No changes, control
in 1 yesr
PPD test positive.
Changes on X-rays
Changes on Xrays
Bacteriological
diagnostics (gastric
lavate, sputum)
Preventive therapy,
Isoniazid 6 months
PPD test positive. No
changes on X-rays
X-rays in 3 months and at
the end of preventive
Bacteriological positive:
active TB, treatment
Bacteriological negative:
active TB, treatment
PPD test negative.
Changes on X-rays
Repeated PPD
positive. Continue
with testing
Preventive therapy,
Isoniazid until control
PPD test negative. No
hanges on X-rays
Interview and medical examination
Tuberculin skin test (PPD) and chest X-rays
Diagram 5. Procedures for the examination of children under the age of 5
Preventive therapy and monitoring
Preventive therapy of tuberculosis is implemented with
children under the age of 5 with the medication Isoniazid
(exceptionally with older children if a doctor assesses its
required). The medicine is taken once a day. The therapy
may last until the PPD test is repeated with children whose
first test was negative, and the test repeated after two
months was also negative or 6 months with PPD positive
children without changes on the chest X-ray.
Children taking preventive therapy are controlled once a
month while taking isoniazid (blood and biochemical
analysis).
Contact tracings on the field, in slams first of all
These activities include:
• determining various types of contact tracing,
• bringing contacts to pulmonary department and
• contact tracings in slams according to the national
regulation
It has been agreed that, for the duration of the project, the
CSOs in Serbia get information about new TB patients
whose contacts need to be included in the examinations,
from:
1) the authorized pulmonary department,
2) Red Cross organizations / civil sector organizations,
health mediators, etc.
The authorized pulmonary departments shall notify the
regional Red Cross coordinators about each new case of
new TB patient in slams. If a pulmonary department does
not report a new case in two weeks, the regional Red Cross
coordinator shall call the responsible person in the
pulmonary department and check the information.
In the projects, the authorized Red Cross coordinator
receives information about the new patients from the
activists of the civil sector, the mediators or volunteers. It is
required to check the information with the authorized
pulmonary department, which performs the examinations
according to the recommendations of the national
guidelines for examination of persons in contact with TB
patients.
Activities of the Red Cross coordinator
Regional coordinator organized a visit to a patient’s
household (in Belgrade this is done together with a
visiting nurse of the City Institutes for Pulmonary Disease
and Tuberculosis) which also includes the local
organization of the Red Cross or another CSO on whose
territory the unsanitary settlement in need of
intervention is locates. They jointly identify the persons
who were in contact with the patient.
Civil sector associates may help to provide and enable:
• Taking patient from contact to the pulmonary
department for examination according to the national
regulations,
• Getting a health booklet, transportation and company to
the pulmonary department, coordination in the
department and safe return to the settlement,
• If this is a child, they shall provide presence or consent
for examination from the parents or custodians, and if
this is not possible, contact shall be established with the
Center for Social Work.
Pulmonary department:
• Notifies the civil sector associates about the need to
examine contacts in vulnerable populations or receives a
notification from the associates about a patient in slams,
• After jointly visiting the field and determining the scope
of contact examinations, it refers the civil sector
associates to the procedure of contact tracings with TB
patients and schedules the time and place of examination,
• Examines children and adults in contact with TB patients
in vulnerable populations,
• After the examinations, the pulmonary department
provides feedback to the CSOs about the examination
results, whether a person is diseased or not, and for each
person confirms in written if that person came for
examination (in the existing project reporting forms).
• If needed, the pulmonary department proposes measures
for further controls of the vulnerable population.
How often can the civil sector associates expect
examinations of certain age groups in contact with
TB patients?
Adults and children older than 14
They shall come to the pulmonary department 1 or 2 times.
First examination,
chest X-ray
Second visit for bacteriology
diagnostics with positive X-ray
Children age 5 to 14
The first examination and completion of findings require 2 to
3 visits to the pulmonary department.
First
examination,
PPD test
Second visit after 72
hours (3 days), PPD
test reading and Xrays
Third visit for
bacteriology
diagnostics with
positive X-ray
Children under the age of 5
The first examination and completion of findings require 2 to
3 visits to the pulmonary department.
First
examination,
PPD test and Xrays
Second visit after 72
hours (3 days), PPD
test reading and
eventual beginning
of the preventive
therapy
Third visit for
bacteriology
diagnostics
with positive
X-ray
If a child receives preventive therapy, it should come for
control once a month.
Examination and control
laboratory analysis every
month
Chest X-ray after 3 months and at the
end of the preventive therapy (after 6
months)
Support in treating TB patients who belong to
especially vulnerable population groups
Objectives of TB control
Basic objective in the control of tuberculosis is to provide
completion of treatment through strict compliance with the
therapy regime in order to prevent further spreading of
tuberculosis through healing of patients.
Challenges in TB treatment and control
There are many challenges in TB control: late diagnostics and
delayed beginning of treatment both due to untimely visit to
a doctor and slow implementation of diagnostic tests and
procedures by healthcare institutions; impossibility of
treatment due to shortage of medicines or lack of health
insurance; difficulties in completing the therapy due to the
appearance of undesired effects of medicines or lack of
understanding of the importance of treatment completion
and after the significant improvement of general condition
after only a month or two from the beginning of treatment;
lack of knowledge and information leading to stigmatization
and discrimination so the patients are scared that they will
be ostracized from the community, family or workplace if it
is known that they are ill and treated of tuberculosis; lack of
understanding and presence of prejudice regarding the
tuberculosis, especially a belief that it is an incurable disease
and lack of political will and funds.
Why do patients stop the treatment?
• Communication problems,
• Cultural and language barriers,
• Lifestyle differences,
• Homelessness,
• Drug addiction, alcohol addiction,
• Prejudices of patients that TB is incurable disease,
• Mental illness,
• Transportation problems,
• Inadequate working hours of healthcare institutions etc.
THE STATE AND THE
HEALTHCARE SYSTEM ARE
OBLIGED to provide the
most efficient access and
interventions for all patients
suffering from heavy
diseases. For this approach
to be successful, health
workers within the
healthcare system must
provide services in
compliance with patients’
needs and wishes. If a large
number of patients fails to
complete the treatment, the
healthcare system has not
worked well.
In the name of public
health, PATIENTS MUST
be treated. This
imperative is regulated
by the law. It is
considered that these
patients do not know, do
not understand or do not
care why it is essential to
complete the treatment.
This is why it is insisted
on education,
motivation, monitoring
and penalty if they fail to
comply with the
recommendations.
Programs that are not patient-oriented
Patient-oriented program
There are two approaches in resolving problems with
patients who stop the treatment:
In order for the majority of patients (if not all) to complete
the treatment, these two approaches must conciliate.
Programs oriented to patients apply large number of
approaches adjusted to each patient individually, requiring
assistance from the civil sector for their implementation.
Most often applied are the DOT (Directly Observed Therapy)
and DOT with facilitations and incentives.
Directly Observed Therapy – DOT
Directly Observed Therapy (DOT) means that the patients
take the therapy supervised, during the initial phase of
treatment (first two months of the therapy) everyday, and in
the continuation of treatment, they come for therapy in a
healthcare institution once or twice a month. Most patients
are treated in hospitals during the first two months of
treatment, which means that DOT is implemented in the
healthcare institutions in that period.
Improved DOT means that facilitiations and incentives are
applied with the directly observed treatment.
Table 2: Selected treatment strategy components
oriented towards a patient in the world
_______________________________________________________________
Facilitations: Intervention facilitating a patient to complete
the treatment:
• Transportation tickets,
• Including the Center for Social Work, health mediators,
CSOs,
•
•
•
•
System reminds about the visit,
Joined services (TB/HIV),
Adequate working hours of healthcare institutions,
Babysitting etc.
Incentives: Interventions motivating the patients, made on
the basis of patients’ needs:
• Food coupons, food,
• Clothes,
• Assistance with accommodation,
• Books etc.
_______________________________________________________________
Activities of the civil sector in TB control
Certain number of CSOs has the capacity to provide support
in treatment, education and consultation of the patients and,
with their action, significantly contribute to the activities
regarding the treatment and healing of the patients, thereby
contributing to the protection of public health.
Table 3: Examples of CSO activities in TB control in
the world
_________________________________________________
• Education of patients and their families on diagnostics of
tuberculosis, beginning of treatment and requirement of
perseverance in treatment
• Verification of patient’s exact address of residence,
• Assisting patients having problems with alcohol and drug
addiction,
• Assisting patients to get social help and other facilitations,
• Assistance in DOT implementation,
• Assistance in finding patients who have stopped the
treatment and informing the authorized healthcare
institutions if they have failed to find them,
• Informing the healthcare institutions about the intention
of patients to change the place of residence in order to
organize the continuation of treatment in a timely
manner,
• Public advocacy.
_______________________________________________________________
Example of good practice:
During the project “Control of Tuberculosis in Serbia”, it
is provided that all patients belonging to the category of
socially vulnerable persons, especially diseased patients
of the Roma national minority living in slams, during the
outpatient phase of treatment, twice a month, with a
certificate of an attending doctor that they regularly
come for examination, get sanitary and food packages.
Diagram 6. Assistance to the civil sector in TB
control
Person having
symptoms of
tuberculosis
Medical procedures for
confirmation of diagnosis
Confirmed diagnosis
of tuberculosis
Hospital treatment
Outpatient treatment
Control every 2 weeks
Control every 2 weeks
Healing
The civil sector may help by:
- Giving significance to timely TB detection and
treatment for a beneficiary and his/her family,
- Encouraging a beneficiary to go for a medical
exam,
- Removing practical obstacles regarding the visit
for medical exam (e.g. gathering the
documentation, scheduling an appointment,
providing transportation).____________________
- Removing practical obstacles regarding the visit
for a diagnostic exam (e.g. scheduling an
appointment, providing transportation…)
- Providing additional information._____________
- Providing psycho-social support,
- Educating beneficiaries about TB in terms of
prevention of further spreading of the infection,
- Educating family members about TB in terms of
prevention of further spreading of the infection,
- Educating beneficiaries about the occurrence of
resistant TB,
- Removing practical obstacles regarding the visit to
the hospital (providing transportation…)_________
- Motivating beneficiaries to persevere in the
treatment and taking therapy,
-Removing practical obstacles regarding the
outpatient treatment (e.g. scheduling an
appointment, providing transportation…)_______
- Motivating beneficiaries to persevere in the
treatment and taking therapy,
-Removing practical obstacles regarding the
outpatient treatment (e.g. scheduling an
appointment, providing transportation…)
TB and HIV
HIV infection is the biggest risk factor for the development of
tuberculosis. On the other hand, tuberculosis is the leading
cause of death of persons living with HIV. Joined TB/HIV
activities aim to prevent the increase of getting ill of
tuberculosis of persons living with HIV and, on the other
hand, to reduce the burdening with HIV of TB patients.
Table 3. Examples of activities of the civil sector in
TB/HIV control in the world
_______________________________________________________________
1) Active detection of tuberculosis:
• survey about the TB symptoms by civil sector associates
during every contact with the target population, referring
persons with symptoms to a healthcare institutions for
further diagnostics and treatment,
• survey about the TB symptoms of clients using CSO
counseling and clinics.
2) Assisting patients with the referral to and
implementation of diagnostic tests and coordination with
healthcare institutions,
3) Verification of patient’s exact address of residence,
4) Giving therapy:
• When allowed by the law6, therapy giving may be
organized through CSOs, whether the medicines are
given by the employees or volunteers from the civil
sector or an adequate person from the patient’s
environment, and with his/her consent, is found through
them.
5) Compliance with the therapy:
• Civil sector associates provide regular medical controls,
• Informing the healthcare institutions about the intention
of patients to change the place of residence in order to
organize the continuation of treatment in a timely
manner.
6) Activities with associates from the civil sector
participating in the support against HIV/AIDS need to
include:
• education of various populations about the healthcare
system,
• building capacities of these organizations to work in TB
control,
• cooperation with the network of organizations of persons
living with HIV in TB control.
6
At this moment, the law in Serbia sets forth that medicines shall be given by
medical workers exclusively
In its work, the civil sector is not making a parallel system.
National protocols for diagnostics, treatment and control of
TB are complied with and all activities are coordinated with
the healthcare system.
On the other hand, it is necessary that the healthcare system
“opens the door” more and show trust to the civil sector in
this area. First steps in establishing the trust have been
made with the participation of the civil sector in the
implementation of the project “Control of Tuberculosis in
Serbia”. A small but important step of trust is also seen in
the preparation of this one and similar publications. They
need to contribute not only with their specific instructions
they contain, but also to the building of trust of beneficiaries
in the healthcare system, as well as better understanding of
the civil sector by the healthcare system. Finally, the civil
sector needs to have trust in their capacities and the
awareness about own limitations.
In this respect, joined work in the field of TB control has well
established foundations in previous work, which will be
additionally built and added with new experiences in the
years to come.
The publication is part of the activities within the project “Control of
Tuberculosis in Serbia”, for the implementation of which funds were
provide by Global Fund to Fight AIDS, Tuberculosis and Malaria.