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[INSERT COUNTRY NAME HERE]
Introduction to the National MDR-TB Control Strategy
SESSION 1
Insert country/ministry
logo here
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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
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USAID TB CARE II PROJECT
Global situation of drug-resistant TB (DR-TB)
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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
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USAID TB CARE II PROJECT
Global targets for TB and MDR-TB
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USAID TB CARE II PROJECT
New diagnostics in TB: Xpert MTB/RIF roll-out
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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
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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
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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]
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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
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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
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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.
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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
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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)>
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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>
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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
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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%)
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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
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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.
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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.
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USAID TB CARE II PROJECT
Turning off the source of DR-TB
2. Early diagnosis of DR-TB and prompt DR-TB treatment
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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
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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
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Thank you and good luck with the training