1

[INSERT COUNTRY NAME HERE]

Introduction to the National MDR-TB Control Strategy

SESSION 1

Insert country/ministry

logo here

USAID TB CARE II PROJECT

Outline of lecture

• Global situation of drug-resistant TB (DR-TB)• Country situation of <insert country name here>• History of DR-TB program to date• Challenges and planning• Objectives of this training

USAID TB CARE II PROJECT

Global situation of drug-resistant TB (DR-TB)

USAID TB CARE II PROJECT

Global burden of TB in 2010Estimated number of cases

Estimated number of deaths

All forms of TB

8.8 million(range: 8.5–9.2 million)

1.45 million(range: 1.2–1.6 million)

HIV-associated TB

1.1 million (13%)(range: 1.0–1.2 million)

350,000(range: 320,000–390,000)

Multidrug-resistant TB (Prevalent)

650,000(range: 460,000–870,000)

about 150,000

Source: WHO Global Tuberculosis Control Report 2011. NB: currently under embargo until release later in Oct 2011

USAID TB CARE II PROJECT

Global targets for TB and MDR-TB

USAID TB CARE II PROJECT

New diagnostics in TB: Xpert MTB/RIF roll-out

USAID TB CARE II PROJECT

Global drug facility is the main supplier of second line anti-TB drugs

Role of GDF:• Public Sector procurement of TB drugs, of the right quality, in the

right quantity, at the right price, and deliver them at the right time to the right people

• Provide technical assistance by monitoring procurement system management in countries utilising GDF’s services and highlight system strengthening requirements

USAID TB CARE II PROJECT

3,494

8,165 10,273

12,324

19,592

-

5,000

10,000

15,000

20,000

25,000

2007 2008 2009 2010 ESTIMATED2011

Patie

nts

Estimated MDR Patient Treatments delivered per year

Estimated MDR-TB patient treatments delivered per year through GDF

USAID TB CARE II PROJECT

Country situation of <insert country name>

Available TB Guidelines:• National TB Guidelines• TB/HIV Guidelines• Public-Private Mix Guidelines• DR-TB Guidelines• Infection Control Guidelines

[Insert the front cover of each local TB Guidelines that are available]

USAID TB CARE II PROJECT

TB program

<Insert the general TB outcomes of the country’s program here>• Number of patients enrolled for new cases• Outcomes of new cases• Number enrolled for retreatment cases• Outcomes of enrollment• % of HIV infected patients among TB Cases

USAID TB CARE II PROJECT

Country situation of <insert country name here> for DR-TB

MDR-TB, Estimates Among Notified Cases (survey year = 20XX)

% of new TB cases with MDR-TB X.X %

% of retreatment TB cases with MDR-TB X.X %

Estimated MDR-TB cases among new pulmonary TB cases notified in 20XX

XXXX

Estimated MDR-TB cases among retreated pulmonary TB cases notified in 20XX

XXXX

USAID TB CARE II PROJECT

Reported cases of MDR-TB in <insert country name here>2011 WHO Global TB Report for <insert country name here>

Estimated cases of MDR-TB amongnotified cases ofpulmonary TB in 2010a

Confidence interval

Notified cases of MDR-TB in 2010b

Notified cases ofMDR-TB as % of estimated cases of MDR-TB among all notified cases of pulmonary TB in 2010b

Cases enrolled on treatment for MDR-TB in 2010

Expected number of cases of MDR-TB to be treated

2012 2013

XXXX XXXX-XXXX XXXX X.X% XXXX XXX XXX

a Calculated by applying the best combined estimate of MDR to the notified cases of pulmonary TB in 2010.b Percentage may exceed 100% as a result of notifications of cases from previous years, inadequate linkages between notification systems for TB and MDR-TB, and estimates of the number of cases of MDR-TB that are too conservative.

USAID TB CARE II PROJECT

Resistance to second-line anti-TB drugs in MDR-TB isolates in <insert country name here and year of survey>

Year Resistant to

Total MDR-TB isolates

OFX KM CS CM PAS ETO

XXX X X X X X X

Resistant (%) X.X X.X X.X X.X X.X X.X

USAID TB CARE II PROJECT

Costs and budget of DR-TB program

<insert any information related to available budgets for the program and costs (including the average cost of a standard empiric regimen, and any regular social support budgeted for the patients)>

USAID TB CARE II PROJECT

History of DR-TB program

• National Reference Laboratory established <insert year and types of tests done>

• Enrollment of patients into the DR-TB treatment began <insert places and dates program began>

• Introduction of Xpert MTB/RIF instruments <insert date and number of machines, and places>

• Reference laboratories• Established MDR-TB Hospitals• Start dates of community-based program• GF or other funding <Insert any pertinent history of the

program>

USAID TB CARE II PROJECT

Outcomes of DR-TB program to dateCohort Cured Died Failure Default Total2006 XX XX XX XX XXX2007 XX XX XX XX XXX2008 XX XX XX XX XXX2009 XX XX XX XX XXX

USAID TB CARE II PROJECT

Side effects of patients enrolled in DR-TB <(if data is available add this slide)>Side effect Number total = XXXDyspepsia XX (X.X%)Anorexia XX (X.X%)Vomiting XX (X.X%)Skin Rash XX (X.X%)Arthralgia XX (X.X%)Hepatitis XX (X.X%)Hearing loss XX (X.X%)Hypothyroid XX (X.X%)Psychosis XX (X.X%)Sleep disturbance XX (X.X%)

Renal Failure XX (X.X%)Electrolyte Disturbance XX (X.X%)

Depression XX (X.X%)

USAID TB CARE II PROJECT

Operational flow — MDR-TB programme

Estim

ated

bur

den

( Sym

ptom

atic

cas

es in

the

com

mun

ity)

Too many patients are lost in each step. Planning must find and retain in care all patients!

• Suspect identification policy (diagnostic algorithm)

• Availability of laboratory

• Accessibility to laboratory

• Adequate human resources

• NTP management capacity (linkage with all-public-private laboratories)

• Reporting system (data flow from lab to treatment centres and programme)

• Surveillance capacity

Access to health system

• Availability of treatment centres (hospital, clinic with infection control measure) and community network

• Human resource (trained clinician, nurse, health workers, community volunteer)

• Registration, availability- storage and distribution capacity of quality assured SLD and ancillary drugs

• Availability of information to patients (ACSM)

• Linkage with private sector (PPM)

• Availability of funds for all intervention

• Provision of DOTS (adequate health workers, community volunteers)

• Training, refresher and HRD plan for HCW involved in MDR-TB management

• Default tracing mechanism

• Capacity of laboratory to perform follow up and monitoring tests

• Capacity of adverse effect monitoring mechanism

• Recording and reporting mechanism

• Social support: transportation, food, psychosocial

• Social support mechanism

• Community awareness and involvement

• Palliative care

• Ethical framework

• Patient charter

• Labour laws

Sus

pect

s

Diagnosed Notified Treatment initiated

Treatment completed

Reintegration in the community

USAID TB CARE II PROJECT

Challenges in planning of services

Diagnosis

• Conventional C and DST Solid-liquid• Rapid diagnostics- LiPA/Xpert MTB/Rif• Test needs to be done for how many suspects?• Consumables?• Staff time?• Sample transport

Treatment

• Drugs – SLD, ancillary drugs• Drug supply to match rapid detection• Adverse effect management - hospitalization capacity

• DOT provider - Community or health workers?

Capacity

• Human resources: lab staff, heath care staff, supervisory staff, planning and financial staff

• Are staff numbers sufficient to deliver all the required services?

• Is there a need for task sharing or shifting? Hiring? Training capacity available?

•Community care for DR-TB

Public health sector; Public non-health sector; Private sector (for profit & not for profit); Universities & Research Institutes; NGOs, etc.

USAID TB CARE II PROJECT

Turning off the source of DR-TB

1. Overcoming the causes of inadequate anti-TB treatmentHealth-care providers: inadequate regimens

Drugs: inadequate supply or quality

Patients: inadequate drug intake

Inappropriate guidelines or non-compliance with guidelines;

Absence of guidelines; Poor training; No monitoring of

treatment; Poorly organized or funded

TB control programmes.

Poor quality; Unavailability of certain

drugs (stock-outs or delivery disruptions);

Poor storage conditions; Wrong dose or combination

of drugs.

Poor adherence (or poor DOT);

Lack of information on treatment,

Adverse effects of treatment;

Social barriers (stigma, restrictions);

Malabsorption due to other causes;

Substance dependency disorders;

Mental disorders; Non-cooperative.

USAID TB CARE II PROJECT

Turning off the source of DR-TB

2. Early diagnosis of DR-TB and prompt DR-TB treatment

USAID TB CARE II PROJECT

Hospitals: grounds for MDR-TB?

• Many TB patients seek care at hospitals

• Hospitals often do not follow recommended TB diagnostic and treatment practices

• Hospitals cannot supervise treatment and follow up patients after discharge

• Many hospitals lack TB infection control measures

USAID TB CARE II PROJECT

Objectives of the community-based PMDT training

Hospital (only for the very sick)

Clinic(Monthly Visits with

MDR-Outpatient team)

Daily DOT at home(with DOT Provider)

Goals of this Training:• To train an “Outpatient MDR-TB Team” to clinically manage

patients with DR-TB.• For the MDR-TB Team to supervise a DOT Provider and provide

the support necessary to keep the patient at home. • To transition between hospital and the community when needed

24

Thank you and good luck with the training