Control and Prevention of MDR-TB in the
Greater Mekong Sub-region
CAP-TB PROJECT
Strengthening the health system through basic
building blocks for TB control
TB/MDR-TB Control & Prevention
Prevention
Diagnosis
Treatment
Initiation
Treatment
Success
CAP-TB Strategic Model
Integration with the health system for
TB control and prevention
Implementing innovative strategies
with long-term sustainability
CAP-TB Strategy for FY14
• Evaluate implementation to date (FY12-FY13)
• Identify successful strategies to continue and
potentially scale up
– Increased case detection and treatment success as
“downstream” indicators of impact
• Review current literature for recent evidence on
potential innovations, etc., that can be piloted
through the project
WHO analysis of 30 countries to determine
progress toward universal access to MDRTB care by 2015
Lancet Infectious Disease Vol 13, No 7, July 2013
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Major Findings
• 6 of 30 countries will reach goal for universal
MDR-TB access by 2015.
• 19 of 30 countries (including Myanmar, China,
Thailand) need significant help to reach 2015
goal.
• Challenges: Lab capacity; “treatment gap”
between detection and enrollment; poor
treatment outcomes in some settings.
Lancet Infectious Disease Vol 13, No 7, July 2013
Recent literature emphasizes the
importance of MDR-TB decentralization
Lancet Infectious Disease Vol 13, No 7, July 2013
Thailand
• Support BTB to develop infrastructure for
national MDR-TB decentralization network
– Rayong as pilot model for provincial-level
decentralization
• Continue Rayong Hospital activities: call center,
MDR-TB case conferences, multi-disciplinary
teams for MDR-TB care
• Active case finding (DM, PLHIV clinics) and
community support: assess donor funding and
existing support
Building a provincial
model for TB/MDR-TB
decentralization in
Rayong:
Strengthening provincial,
district, sub-district, and
community levels of TB
network
Thailand
• Support BTB to develop infrastructure for
national MDR-TB decentralization network
– Rayong as pilot model for provincial-level
decentralization
• Continue Rayong Hospital activities: call center,
MDR-TB case conferences, multi-disciplinary
teams for MDR-TB care
• Active case finding (DM, PLHIV clinics) and
community support: assess GFATM funding and
existing capacity
Myanmar: Integration with the TB
network to strengthen TB control
Myanmar
• Continue with patient treatment support
• Identify risk groups for piloting innovative
methods to improve case detection/treatment
success
– Childhood TB
– Other risk groups: DM, PLHIV, etc.
• Organizational Capacity Development
Case notifications MDR-TB (2008-2013)
Year
Cases (Solid/Liquid
Culture/LPA)
Cases put on SLD
2010
312
192
2011
690
162
2012
778
442
2013 (Q1)
426
65
2013 (Q2)
376
218
Year
2010
2011
Notified
Treated
312
690
Waiting (Lab confirmed)
312
192
120
810
162
2012
778
442
2013 (1st Q)
426
65
2013 (2nd Q)
376
218
648
1426
984
1410
1345
1721
1503
Fund
UNITAID
112 (UNITAID)
50 (GF)
GF
GF
GF
• Engage community volunteers (in addition to
health care workers)
• Provide DOT throughout treatment
• Limit cohort size: decentralization
• Provide patient education
• Provide package of adherence interventions
• Provide standardized regimen (not
individualized)
Myanmar: Identifying TB/MDR-TB risk
groups to increase detection,
enrollment, and treatment success
Myanmar
• Continue with patient treatment support
• Identify risk groups to improve case detection
and treatment success
– PLHIV, geographic areas (border and remote) with
high treatment interruption/default rates, etc.
• Organizational Capacity Development
• Research: health financing, gender, 9 month
“short regimen”
China: Implementing innovative
strategies with long-term sustainability
Reported pulmonary TB incidence of Yunnan
compared with national average (1997-2012)
Reported incidence (1/100,000)
120
National average
100
80
60
Yunnan
40
20
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
The reported TB incidence has remained relatively stable since 2006 in Yunnan,
compared to a decline in the national incidence.
China
• Refine strategy for case-finding interventions to scale
up:
– Analyze data from FY13 to identify most effective
strategies
– DM/TB, private clinics/pharmacies, QQ groups, PLHIV,
community engagement (Women’s Federation)
• Engagement of private sector: #3 Hospital of Kunming
• Potentially for FY15, consider piloting CAP-TB model in
Zhao Tong prefecture: “chronic TB outbreak”
– Would enable Yunnan to have both an urban and rural
model for TB/MDR-TB control
Yunnan Province: 16 prefectures (2012)
Cases
Di Qing
Zhao Tong
3000- ﹤ 4000
Li Jing
Nu
Jiang
4663
2000- ﹤ 3000
Da Li
Chu Xiong
Kun
Ming
1000- ﹤ 2000
Qu
Jing
500- ﹤ 1000
196- ﹤ 500
Bao SHan
De Hong
Yu Xi
Lin Cang
Wen SHan
Pu Er
Xi Shuang Ban Na
Hong He
FY14 – FY16 Strategic Planning
• Continue integrated “Health System
Strengthening”
– model for service delivery
• Implement innovation:
– Focus on risk groups for TB/MDR-TB
• PLHIV, DM/TB, Migrant/mobile population
• Workplace interventions for those with risk for occupational
lung disease (miners and those with pulmonary silicosis)
• Childhood TB, smokers, closed/congregate settings
– QQ (China Facebook/Twitter): social media,
“mHealth”
FY14 – FY16 Strategic Planning
• Continue integrated “Health System
Strengthening”
– model for service delivery
• Implement innovation:
– Focus on risk groups for TB/MDR-TB
• PLHIV, DM/TB, Migrant/mobile population
• Workplace interventions for those with risk for occupational
lung disease (miners and those with pulmonary silicosis)
• Childhood TB, smokers, closed/congregate settings
– QQ (China Facebook/Twitter): social media,
“mHealth”
FY14 – FY16 Strategic Planning
• Research
– Health financing/cost-effectiveness
– TB gender disparity
– 9 month “short regimen” for MDR-TB
• Identify strategies for sustainability
– Counterpart funding from national and provincial
government (China, Thailand)
– Capacity building of Myanmar IAs to prepare for future
funding from international donors (USAID, GFATM, etc)
9 month “short regimen” for MDR-TB
Am J Respir Crit Care Med Vol 182. pp 684–692, 2010
9 month “short regimen” for MDR-TB
Am J Respir Crit Care Med Vol 182. pp 684–692, 2010
9 month gatifloxacin-based regimen:
87.9% treatment success
Am J Respir Crit Care Med Vol 182. pp 684–692, 2010
WHO Criteria for 9-Month Regimen
• Approval by a national ethics review committee
• Treatment delivered under operational research
conditions following international standards to
assess the safety and effectiveness of regimen
• Programmatic management of drug-resistant TB
and the research project are monitored by an
independent monitoring board set up by, and
reporting to, WHO
http://www.who.int/tb/challenges/mdr/short_regimen_use/en/index.html
9 month MDR-TB Regimen
• Funding
– China: national/provincial governments
– CAP-TB/IUATLD: primarily technical support
• Drug supply
– Domestic versus other
• Patient follow-up
– Resources (human and financial)
• Site-training
– clinical monitoring, DOT