Accelerating PMDT scale up
in Ethiopia
Ezra Shimeles (MD, MPH)
TBCARE/KNCV, Ethiopia
Outline
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Introduction and background
National TB and MDR TB situation
National Performance on TB
MDR TB Scale up
Challenges in PMDT Scale up
Way forward
Introduction and Background: Ethiopia
• 11 administrative units
• 90 million population
– 83.6 % in rural
• Economy(IMF)
– Agriculture 46.6%
– Industry 14.5%
– Services 38.9%
• GNI Per Capita:410
(World Bank 2012)
• Life expectancy at birth :59
(World Bank 2011)
The Health Tier System
Health Profile
• Health Service
– PHS coverage
= 92%
• No. of health facilities
– Hospital
= 132
– Health centers = 3000
– Health posts
= 15,700
• Human capital
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Physicians
= 2,115
Health officers = 1606
Nurses
= 20, 109
Health extension workers = 34, 382
National TB Situation and NTP overview
o Among the 22 HBC
o 16th among the 27 MDR-TB high priority countries
o Incidence:
o 258/100,000 population
o Prevalence :
o TB 237/100,000 population
o The TB related mortality rate : 18/100,000
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WHO 2012 TB Report
MDR-TB burden
– DRS survey 2003-2005
• 1.6%
New
• 11.8%
Previously treated
– WHO estimate
• 2500 MDR TB Cases are expected from notified cases
annually
– DST requirement per annum:
• 6000 new and 6000 retreatment cases (2013)
Tuberculosis Case finding
( All forms of TB (New and retreatment)
Treatment outcome for new PTB+
TB/HIV Integration services
TB/HIV Integration services(2)
National PMDT implementation plan
• Phase I: pilot phase (2009-11)
– Target: treat 45 patents
– Establish MDR treatment at one TB Hospital in 2009
• Scale Up phases: Five years expansion plan (2011-15):
– Target : treat 8,018 MDR-TB patients
– Phase II: Roll out phase using (2011-13)
• MDR TB referral centers
• Establishment of regional culture and DST centers
• Pilots Ambulatory model
– Phase III: Scale up phase(2013-15)
• Rapid diagnostic techniques
• Ambulatory centers up to Zonal hospitals level
Preparatory phase for initiation
• National technical working group on MDR-TB
established.
• Guidelines: PMDT; TB infection control
• Training material for health care workers
• Training of health care workers
• Renovation of MDR-TB wards
• Registration of second line anti-TB drugs conducted
• Procurement of SLDs
• Infection control items such N-95 respirators, were
made available
• Recording and reporting formats developed and
printed
• IEC materials including posters and stickers
developed and printed
Shifting the gear: Preparation for accelerated scale up
• Implementation protocol for ambulatory
care for DR-TB
• Customization of training material for
middle level
• Selection of TIC and TFC
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– 1 TIC linked to 8-10 TFC
Update case finding and diagnostic approaches
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Establishment of Sputum sample transport system
Efficient PSM for SLDs, ancillary drugs
Socio-economic support for patients
Renovations of TICs, TFCs
Improve Human capital and leadership
MDRTB specific ACSM
DR TB Treatment network
Case detection and enrollment,2007-13
Site expansion,2009-13
Scale up plan versus achievement, 2009-13
(Total enrolled n=1000)
Enrolment by DST status in Ethiopia, 2009-13
Proportion of patients by DST status at Enrolment
100%
90%
80%
70%
60%
50%
Suspected
Confirmed
40%
30%
20%
10%
0%
year2001
year2002
year2003
year2004
year 2005
Suspected
1
5
20
19
17
Confirmed
8
109
96
270
157
Interim Treatment outcome
Final Treatment outcome(2009-11 cohorts)
(Total n=173, Cure Rate 7% ;TSR 80%)
Major Challenges
• MDR TB Suspect identification and Sputum sample transportation
challenges
• GeneXpert rollout is very slow
• HR Capacity needs not met
• Poor Lab support for patient monitoring
• Ancillary drugs shortage - What, when, where
• Patient socioeconomic support system not standardized
• Infection control settings in most health facilities not satisfactory
• SLD Supply to TICs and TFCs not fully integrated to the national DSM
• Long turn around time for follow up Culture results
Targets for 2013 -2015 in PMDT
• To decentralize the MDRTB treatment service to PHC level by 2015:
• TIC at Zone level (40, 70, 96 zones in 2006, 7 and 8 respectively) and at
least one TFC at Woreda level (814 Woredas).
• DST screening for
– 10% of New PTB smear positives and
– 100% of previously treated TB
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To enroll 100% notified confirmed MDR TB cases for treatment
To achieve 95% interim result of culture conversion
To achieve TSR rate of 80% and reduce the death rate from 15% to 10%
To improve cases finding in pediatric age group
– to reach 7% of all cases
• To provide integrated MDR TB and HIV service in all MDRTB service
points
Major partners of MOH for PMDT Roll out
– Global Fund
– WHO, FIND, EXPAND TB Project
– USAID:TB CARE I(KNCV), HEAL TB (MSH), PHSP (Abt.)
– Global Health Committee
– CDC : JHU, I-TECH, ICAP, UCSD
– MSF Belgium
– International Organization for Migration
Thank you