-Thailand
Policy decision on multi drug resistant(MDR),
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-Thailand
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Policy
Health
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screening: How it comes?
extreme drug resistant(XDR) tuberculosis
Thanawat Wongphan1,2
Pairoj Saonuam3.
Jongkol Lertiendumrong1,
Phusit Prakongsai1
1International
Health Policy Program(IHPP), Nonthaburi, Thailand
Hospital, Saraburi, Thailand
3 Medical Physician, Senior Professional Level National AIDS Management Center (NAMc)
Department of Disease Control,
Ministry of Public Health, Nonthaburi Thailand
2 Banmoh
The First Annual Conference of HTAsiaLink
Grand Pacific Sovereign Hotel, Petchaburi,Thailand
May 14‐16, 2012
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Outline of presentation
•
•
•
•
•
Background information
Methodologies
Research findings
Conclusion and discussion.
Policy recommendations
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Background (1)
• Definition:
• MDR-TB is the tuberculosis which resists to Rifampicin or
Isoniazid.
• XDR is the tuberculosis which resists to
– Rifampicin or Isoniazid
– Quinolone
– At least one injectable antibiotic(kanamycin,
capreomycin or amikacin)
•
•
•
[Ref]
1. Centers for Disease Control and Prevention., Multidrug-Resistant Tuberculosis (MDR TB) Fact Sheet.
2011.
2. World Health Organization., Press release: WHO Global Task Force outlines measures to combat XDR-TB
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worldwide. 2006.
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Background (2)
• The prevalence of all TB patients in Thailand is
130,000 cases per year, and the rate of MDR-TB
ranges from 0 to 14.1 percent of all first diagnosed TB
patients.
• The cost of treatment of MDR or XDR TB can be more
than 100 times when compare to a normal pulmonary
TB.
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Background (3)
• Incidence of MDR-TB in Thailand is 2,900 cases per
year and 1,547 of them are in the first time of
treatment.
• Five percent of all MDR-TB can develop to XDR-TB in
the future.
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Objectives
• To find the ways to increase potency of TB treatment
system and to decrease incidence rate of MDR-TB we
split the project into 3 parts to answer this
– the most cost-benefit method of MDR-TB screening
– System gap analysis
– Cost-utility analysis based on dynamic models on MDRTB screening.
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Methods (1)
The study is conducted with two methods: Cost-benefit analysis
(CBA) and system gap analysis.
• The CBA uses the decision tree algorithm among four choices
of MDR-TB diagnosis: standard culture (L-J), Overbrooke 7H10, Microscopic observation drug susceptibility (MODS), gene
technique and the conservative technique (work up in all
failure cases.).
• The gap analysis uses an expert panel’s discussion and
inductive conclusion to formulate the policy recommendations.
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Methods (2)
Target population All TB diagnosis
-Standard procedure
-Lowenstein-Jensen(L-J) in all cases.
Comparator
-Microscopic observation drug
susceptibility(MODS)
-Overbrooke 7H-10
-Gene technique(eg. geneXpert1)
1
is a registered trademark from Cepheid, CA, USA
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Methods (2)
Use only direct medical cost:
COST
• LAB: Department of Medical Science,
Ministry of public health, Thailand
• Drug cost: Chest disease institute.
• Department of Medical Science,
Ministry of public health, Thailand
Lab’s duration
• Expert panel’s adjustment
• Systematic review on MODS.
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Comparison among MDR Screening
and treatment choices
Sputum AFB still be POSITIVE.
Standard
2 months of standard TB treatment
L-J
technique
6 Weeks(4-8 Weeks)
Culture waiting period(4-8 weeks)
Start MDR-TB
treatment
Start MDR-TB treatment
7H10
6 Weeks(4-8 Weeks)
Start MDR-TB treatment
MODs
6 Days
Gene
technique
1 Day
Start MDR-TB treatment
Start MDR-TB
treatment
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Research findings
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Incidence of Thai TB patients and
individual cost of treatment.
Cases
100,000
90,000
Cost(Baht)
฿1,200,000.00
93,000
฿1,039,770
฿1,000,000.00
80,000
70,000
฿800,000.00
60,000
฿600,000.00
50,000
40,000
฿400,000.00
30,000
20,000
฿165,455
2,900
10,000
0
฿2,391
normal-TB
MDR-TB
Number of patients
฿200,000.00
145
฿0.00
XDR-TB
Minimum cost of treatment
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MDR diagnosed Lab duration and
cost comparison
7
6
Baht
Weeks
6
6
฿600.00
5
฿700.00
฿600.00
฿500.00
4
฿400.00
3
฿300.00
2
฿200.00
0.86
1
0
฿50.00
฿50.00
฿50.00
L-J
MODs
7H-10
Lab period(Weeks)
0.14
฿100.00
฿0.00
Gene
technique
Lab cost(Baht)
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Cost-Benefit comparison on MDR TB
diagnosis
Diagnosis
procedure
Cost
(Million
Baht)
Benefit
(Million
Baht)
LJ
MODs
7H-10
Gene
technique
4.65
4.65
4.65
55.8
2.38 –
3.30
4.42 6.13
2.38 - 3.30 4.70 - 6.53
*Comparison based on standard TB treatment program.
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Conclusions and discussion
• MDR screening is essential for all first
diagnosed TB cases because
–it can stop disease-spreading while patients are
being treated with standard drug regimen,
–decrease drug side effects.
–drug costs and patients’ expenses related to the
inappropriate drugs use.
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Conclusions
• Although MODS is the most cost-benefit method
but the gap analysis shows that Thailand has many
semi-liquid culturing facilities. So it is better to use
them instead of investing more money to do MODS.
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Policy recommendations
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Specific policies:
1. Enhance capacity of TB treatments in all
modalities.
2. Establish the standardized logistic system of
specimen transfering.
3. Increase support of lung surgery.
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General policies(1):
1. Increase co-operation between units to units
including private sector and supertertiary
hospital.
2. Establish the national MDR, XDR-TB caring
guideline.
3. Concern in some high risk patients eg. HIV.
4. Medical staffs should be refreshed
knowledge and be updated their system's
knowledge.
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General policies(2):
5. Find sources of fund to support the system,
6. Improve the follow up care system,
7. National Health Security Office(NHSO)
should generate the ICT data system to be
used in follow up care of treatment and easy
to monitor,
8. NHSO should support the health staffs in
many roles e.g. funding source for
generating national guideline,
9. Link this treatment system to quality
accreditation to increase sustainable
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development.
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Acknowledgement
• National Health Security Office (NHSO) of
Thailand,
• The Universal Coverage Benefit Package
Subcommittee of NHSO,
• Dr. Charoen Chuchottaworn and Chest
Disease Institute, Ministry of Public Health,
Thailand
• Ms. Kumaree Patchanee, IHPP, Thainad
• Banmoh hospital staff, Saraburi, Thailand
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