Linking IMAI with palliative care
in M/XDR-TB
Aka "Using IMAI tools for palliative care of M/XDR TB"
Drs Akiiki Bitalabeho and Sandy Gove
for the IMAI team and palliative care expert group
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OI evidence check- IMAI District Clinician Manual October 26-27, 2010
Palliative care: symptom management (during acute and
chronic care) and end-of-life care
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OI evidence check- IMAI District Clinician Manual October 26-27, 2010
IMAI and Palliative Care
 The first IMAI PC tools were field-tested in 2003.
 Palliative care is integrated in all IMAI materials and trainings- for every
symptom, consider the specific treatment required and and symptom
management.
 All cadres of health workers should be trained in palliative care.
 Included in pre-service, in-service and second level training materials.
Aim is to ensure knowledge and skills for palliative care at all levels and
for all health workers.
 Clinical mentoring to assure quality of care.
 Palliative care in the community: Target is community-based caregivers,
community health workers, family and patient (self-management).
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OI evidence check- IMAI District Clinician Manual October 26-27, 2010
Emphasis on decentralization, to head
toward univeral access, equity.
Central/
Regional
Hospitals
District hospital
Health centre
Community-based care
Relevant IMAI PC tools for 3 levels
Central/
Regional
Hospitals
District hospital
Health centre
Community-based care
Chronic care approach prepares clinical
teams to partner with the patient
Patient centered
Patient self-management is supported
by:
• Education and booklets
• Preparation of treatment and prevention
supporters for ART and TB (adherence)
•Peer support groups
•Involvement by expert patients/lay
providers – as trainers, on clinical team
Flipcharts for patient education
Patient self-management and caregiver
booklets, cards for each ART regimen
Technically sound home-based care with
good supervision by facility teams
IMAI-IMCI tools empower patients and communities
IMAI/IMCI
Central,
Regional,
University,
Specialised
referral
DISTRICT HOSPITAL
Doctors/health officers/ inpatient RN
Emphasis on
strong
facilitycommunity
link
HEALTH CENTRE
Clinical care- nurses, pharm techs; ART aid.
Sometimes clinical/ health officer
COMMUNITY
Community-carers, family-based care, self-management,
community health workers, peer support groups, CBOs
Drugs, diagnostics, commodities, logistic support
National, Regional and District Management- includes tools to map services, NGOs
ART
Cotrimoxazole
Clinical staging
PITC policy
Positive prevention
PMTCT
OI management
TB, TB-HIV
Malaria treatment
IT bednets
Paediatrics
STI
Antenatal, Postpartum, L&D
Gender
Chronic care
Mental health
IDU, alcohol
Oral health
Cancer- palliative care
Safe water
Safe injections
Nutrition
IMAI/IMCI tool development
Simplify
for
lower cadres
Integrate
(multiple
interventions)
Operationalize
-Sequence of treatment,
care and prevention
Normative guidelines +
Country experience + Evidence check
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OI evidence check- IMAI District Clinician Manual October 26-27, 2010
Develop
tools
Harmonized
WHO IMAI- IMCI- IMPAC integrate:
Acute Care
HIV+, HIVPITC
TB casefinding
OI's
Cough, difficult breathing
STI's
Diarrhoea
Skin problems
Mental health, alcohol
Neurological problems
Fever/malaria
Palliative Care:
Symptom management
Not disease specific
All ages
Chronic Care
• General principles
• Chronic HIV Care
with ART and Prevention
• PreART care, ART
• PMTCT
• Positive dignity, health
and prevention
• TB care with TB-HIV Comanagement
• MDR TB
Prevention integrated with care and treatment (by age, serostatus- all)
Support for healthy pregnancy & childbirth (IMPAC)
Infant, child nutrition & development (IMCI-HIV)
IMAI general principles of good chronic care:
applicable for long-term
TB, TB-HIV, MDR-TB management
1. Develop a treatment partnership with
your patient.
2. Focus on your patient’s concerns and
priorities.
3. Use the 5 As—Assess, Advise, Agree,
Assist, Arrange.
4. Support the patient education and
self-management.
5. Organize proactive follow-up.
6. Involve "expert patients", peer
Simplification and decentralization of treatment
delivered through primary health care
TB led the way with decentralized delivery at health centre and community level
based on decades of experience
Home-based palliative care/hospice approaches when IMAI started often did
not involve the health centre
In a short 6 years, HIV care and ART have caught up
• Now substantial experience and success with delivery by nurse-led teams in
health centres and district outpatient clinics, with strong community-based
treatment support
• This has gone to scale in a number of countries
> 300 health centres in Ethiopia, hundreds of health centres in Tanzania use countryadapted IMAI tools to decentralize ART
More than 50 countries with high HIV burden have adapted IMAI-IMCI tools
Almost all countries have adapted Palliative Care guideline module but not as
extensively implemented
TB-HIV co-management including TB-ART co-treatment now simplified for
primary health care delivery – also used expert patient trainers
Simplified MDR TB management, based on same chronic care approach, now
can be supported at district hospitals and select accredited health centres
Management of MDRTB: A field guide
• In the context of a national
response to MDR- and XDRTB
• Target: health workers in TB
clinics in district hospitals and
some accredited health
centres
• Draws on the experience of
Partners In Health (PIH) in
Lesotho- active training and service
delivery
Based on the Emergency Update
2008 of Guidelines for
programmatic management of
drug-resistant tuberculosis
WHO/HTM/TB/2008.402- companion
document to these guidelines
• Diagnose MDR-TB
• Initiate second-line anti-TB
drugs
• Monitor MDR-TB treatment
• Chronic care approach using
IMAI general principles of good
chronic care (long-term care);
defined sequence of care.
Other relevant IMAI tools
Guidance and tools:
Psychosocial support– see Chronic HIV Care
Peer support groups
Therapeutic peer supporting groups
Clinical mentors- prepared to support symptom management, as
well as specific disease management
Expert patient trainers– to train and later on clinical team
(importance for stigma reduction)
3 interlinked patient monitoring systems
Learning programmes:
Preservice
Inservice (first level palliative care training course)
Continuing education; support for self-learning
Relevant evidence collection
Role of district clinician in district network
The implementation of many clinical interventions for
public health at primary care level requires district
hospital clinicians able to manage:
 uncomplicated as well as complicated patients
 those who fail initial empirical treatment interventions
 those with severe illness requiring urgent treatment and
inpatient care, including inpatient management of pain
and other symptoms
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OI evidence check- IMAI District Clinician Manual October 26-27, 2010
Palliative care
within the IMAI DCM
Part of the second level
learning programme
Fieldtested in 5 countries
(Zambia, Tanzania, Uganda,
Ethiopia, India-currently
occurring in Rwanda)
Volume 1 submitted to GRC
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OI evidence check- IMAI District Clinician Manual October 26-27, 2010
Target audience and assumptions
(stable from start of development;
matches child pocket book) :
 Limited resource settings ONLY
 HR assumptions:
– Targets medical officer, clinical officer, senior nurses, and other senior
health workers working at a district hospital in limited resource setting.
– Multipurpose practitioners such as a medical or clinical officer but do not
have specialist clinicians such as an internist, paediatrician or psychiatrist
(although it may be possible to consult with one).
 Limited essential drugs (see drug section at end of the Manual; this is
subject to adaptation based on the national essential drug list).
 Limited equipment No mechanical ventilation for medical patients
 Limited laboratory and other investigations
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OI evidence check- IMAI District Clinician Manual October 26-27, 2010
Volume 1
Quick Check and Emergency treatments
Manage Severely Ill Patient- including TB patients
in severe respiratory distress, septic shock
(approximately the first 24 hours of care)
Manage Acutely Injured Patient
Infection Control, Procedures
Drugs- all including for palliative care
Volume 2
Acute, subacute illness
Multisystem diseases: OIs, NTD, Kaposi sarcoma
Chronic management:
HIV/ART : including TB-HIV co-management
TB: TB treatment, DR TB
PMTCT-FP
Alcohol, other substance use
Prevention
Palliative care- applicable to DR TB, special considerations
Patient monitoring, pharmacovigilance, notifiable diseases
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OI evidence check- IMAI District Clinician Manual October 26-27, 2010
Symptom management
In other sections of
District Clinician Manual
Symptom management
• What is the same, what is different for PLHIV, DR TB, cancer?
End-of-life care
• What is the same, what is different for PLHIV, DR TB, cancer?
Psychosocial support
• What is the same, what is different for PLHIV, DR TB, cancer?
Programmatic approach
• What is the same, what is different for PLHIV, DR TB, cancer?
Symptom management
appears throughout
IMAI District Clinician Manual
Some improvements to IMAI DCM
suggested yesterday by expert review
 Difficult breathing in chronic lung conditions- include continuous oxygen
 Decisions on end of life care
– Decision on discontinuing DR TB treatment
• Team, not individual clinician
• Choice of the patient, with full information especially of toxicity, resources, quality of life
• No blanket decision on failure of treatment
 Will examine issue of polypharmacy in palliative care and drug
interactions with DR TB treatments
 Expect further input to happen on management toxicity from M/XDR TB
treatment
 Statements on human rights (with current references) at start of palliative
care chapter
 Expecting other inputs from this meeting
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OI evidence check- IMAI District Clinician Manual October 26-27, 2010
For cough or difficult breathing



Control bronchospasm:
– Give salbutamol by metered-dose inhaler with spacer or mask or, if available, by nebuliser.
Stop bronchodilators if the patient is not able to use them anymore, or if breathing is very
shallow or laboured.
– Consult to consider giving prednisone 40 mg by mouth daily for 5–7 days.
Relieve excessive sputum:
– If cough with thick sputum, give steam inhalations.
– If more than 30 ml/day, try forced expiratory technique (“huffing”) with postural drainage.
For bothersome dry cough, if an opioid not already being used, give codeine phosphate 30 mg
four times daily, if no response, oral morphine (2.5– 5 mg)
If patient is terminal and is dying from COPD, lung cancer, AIDS, or any terminal pulmonary
problem (but NOT acute pneumonia or TB that can be treated with antibiotics), there are
additional measures to relieve dyspnoea:



In end-of-life care, a small dose of morphine can reduce dyspnoea. Monitor respiratory rate
closely, but do not let fears of respiratory depression prevent trying this drug.
– For a patient not on morphine for pain – give morphine sulphate 2.5 mg every
four hours.
– For a patient already on morphine – increase the dose by 25%. If this does not work,
increase by another 25%.
To relieve symptoms of heart failure and to treat pitting oedema, give furosemide 40 mg daily.
To relieve anxiety or terminal agitation, consult to consider giving diazepam.
Health centre support for home-based care:
Medication/medical
Additional hospital palliative care
relevant for M/XDR TB
•
•
•
•
Oxygen (if adequate supply)
Additional analgesic options- IV morphine
IV/subcutaneous infusion
Differential diagnosis and skilled
management of symptoms
IMAI tools to support
implementation of palliative care
 Will be progressively updated as the GRADE-based
WHO guidelines on pain and other symptom
management are produced (if funding and interest from
donors and partners)
– These GRADE reviews will happen over years
 Integrated tools serve as efficient 'vehicle' for
implementation of palliative care for HIV, TB, cancer,
COPD patients
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OI evidence check- IMAI District Clinician Manual October 26-27, 2010
Updating the IMAI District Clinician Manual
New WHO
guideline
Section revised
New WHO
guideline
Section revised
2010
2012
2011
Annual print of updated manual
(every July Vol 1, December Vol 2)
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Update of applicable section of manualon EZ collab- within 3 months
OI evidence check- IMAI District Clinician Manual October 26-27, 2010
Advantages of 'sharing' IMAI-IMCI palliative care tools
Co-sponsorship and co-supervision can bring real advantages.
Using the same simplified guidelines, training, and management support for
palliative care for HIV, cancer, TB, COPD, other conditions 
Stronger implementation through shared programmes of work, between
several international and national programmes
More coverage
More opportunity to maintain quality
Responds to reality of greater integration at district level:
District management team members often 'cover' several programmes
Health workers multipurpose
Patients need integrated, holistic care; most have more than one problem.
Integrated clinical management provides better care.
IMAI is very open to collaboration and improvement of the tools and to better
serving TB patients and their families