Introduction to the
National MDR-TB
Control Strategy
SESSION 1
[INSERT COUNTRY NAME HERE]
Insert
country/ministry
logo here
1
Outline of lecture
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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 2010
Estimated 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)
HIVassociated
TB
1.1 million (13%)
(range: 1.0–1.2 million)
350,000
(range: 320,000–390,000)
Multidrugresistant
TB
(Prevalent)
650,000
about 150,000
(range: 460,000–870,000)
USAID TB CARE II PROJECT
Source: WHO Global Tuberculosis Control Report 2011.
NB: currently under embargo until release later in Oct 2011
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
Estimated MDR-TB patient treatments
delivered per year through GDF
Estimated MDR Patient Treatments delivered per year
25,000
Patients
20,000
19,592
15,000
12,324
10,273
10,000
8,165
5,000
3,494
2007
USAID TB CARE II PROJECT
2008
2009
2010
ESTIMATED
2011
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
USAID TB CARE II PROJECT
[Insert the front cover
of each local TB
Guidelines that are
available]
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
among
notified
cases of
pulmonary
TB in 2010a
XXXX
Confidence
interval
XXXX-XXXX
a Calculated
Notified
cases of
MDR-TB in
2010b
XXXX
Notified
cases of
MDR-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
X.X%
XXXX
Expected number of cases
of MDR-TB to be treated
2012
2013
XXX
XXX
by applying the best combined estimate of MDR to the notified cases of pulmonary TB in 2010.
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.
b Percentage
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
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•
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 date
Cohort
Cured
Died
Failure
Default
Total
2006
XX
XX
XX
XX
XXX
2007
XX
XX
XX
XX
XXX
2008
XX
XX
XX
XX
XXX
2009
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
Dyspepsia
Anorexia
Vomiting
Skin Rash
Arthralgia
Hepatitis
Hearing loss
Hypothyroid
Psychosis
Sleep disturbance
Renal Failure
Electrolyte Disturbance
Number total = XXX
XX (X.X%)
XX (X.X%)
XX (X.X%)
XX (X.X%)
XX (X.X%)
XX (X.X%)
XX (X.X%)
XX (X.X%)
XX (X.X%)
XX (X.X%)
Depression
XX (X.X%)
USAID TB CARE II PROJECT
XX (X.X%)
XX (X.X%)
Operational flow — MDR-TB programme
Too many patients are lost in each step. Planning must find and retain in care all patients!
Suspects
Estimated burden ( Symptomatic cases in the
community)
Access
to
health
system
Diagnosed
Notified
Suspect
identification policy
(diagnostic
algorithm)
•
NTP management
capacity (linkage with
all-public-private
laboratories)
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Availability of
laboratory
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Accessibility to
laboratory
Reporting system
(data flow from lab to
treatment centres
and programme)
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Adequate human
resources
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Surveillance capacity
•
USAID TB CARE II PROJECT
Treatment
initiated
Availability of treatment centres
(hospital, clinic with infection
control measure) and
community network
Human resource (trained
clinician, nurse, health workers,
community volunteer)
Registration, availabilitystorage 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
Reintegration
in the
community
Treatment
completed
•
Provision of DOTS (adequate health
workers, community volunteers)
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Social support
mechanism
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Training, refresher and HRD plan for
HCW involved in MDR-TB
management
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Community
awareness and
involvement
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Default tracing mechanism
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Palliative care
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Capacity of laboratory to perform
follow up and monitoring tests
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Ethical framework
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Patient charter
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Capacity of adverse effect
monitoring mechanism
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Labour laws
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Recording and reporting mechanism
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Social support: transportation, food,
psychosocial
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
Capacity
USAID TB CARE II PROJECT
• Drugs – SLD, ancillary drugs
• Drug supply to match rapid detection
• Adverse effect management hospitalization capacity
• DOT provider - Community or health
workers?
• 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.
Turning off the source of DR-TB
1. Overcoming the causes of inadequate anti-TB treatment
Health-care providers:
inadequate regimens
Drugs: inadequate supply or
quality
Patients: inadequate drug
intake
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Inappropriate guidelines or
non-compliance with
guidelines;
Absence of guidelines;
Poor training;
No monitoring of
treatment;
Poorly organized or funded
TB control programmes.
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Poor quality;
Unavailability of certain
drugs (stock-outs or
delivery disruptions);
Poor storage conditions;
Wrong dose or combination
of drugs.
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USAID TB CARE II PROJECT
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.
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
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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
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
Hospital
Clinic
Daily DOT at home
(only for the very sick)
(Monthly Visits with
MDR-Outpatient team)
(with DOT Provider)
USAID TB CARE II PROJECT
Thank you and good luck
with the training
24