Country Progress Report
LAO PDR
The ninth Technical Advisory Group and National TB
Programme Managers meeting for TB control in the
Western Pacific Region
Manila, Philippines
9 -12 December 2014
TB Epidemiology
WHO Global Tuberculosis Report 2014
2
Major successes
• DOTS started in 1995 with WHO and Damien Foundation Belgium
• In 5 central, 17 provincial, 142 districts hospitals and 903 health
centres (95%) and 175 private clinics and pharmacies (PSI)
• 4124 notified TB cases (2013) and treatment success rate 90%
(2012)
• First TB prevalence survey in 2010 and first external TB review in
2013
• Culture started in 2010 and DST in 2014
• GeneXpert in 2 central hospitals and 1 provincial hospital
(Savannakhet)
• 76% TB patients have HIV test result (Q3 2014)
• PMDT started in 2011: 25 MDR-TB patients on 9 month regimen
(July 2013-Nov 2014)
• The NSP 2015-2019 is based on prevalence survey and TB review
findings and recommendation to increase TB case detection
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1. Census
2. Interview
TB prevalence survey
3. Chest X-Ray
3. Specimen collection 4
Major challenges
• Stagnation in TB detection (31% CDR all forms, 2013)
• Low identification and referral of presumptive TB in
some provinces/districts
• Low referral by OPD, IPD, MCH etc.
• Child TB is under diagnosed
• TB HIV collaboration is still limited
• MDR is under diagnosed and often late
• Low sensitivity of direct microscopy
• Lack of information of the population on TB
• Insufficient involvement of community
• Managerial constraints (funding, infrastructure,
procurement, administrative procedures)
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Case detection
Notification rates of tuberculosis in Lao PDR, 1995-2013
stagnation
70.00
Rate per 100,000
60.00
50.00
All new and relapse TB
New S+ PTB
40.00
30.00
20.00
10.00
New S- PTB
Extra pulmonary
Relapse PTB
0.00
Source: NTC
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National TB Strategic Plan 2015-2019
• Aligned with National Health Sector Plan
• Budgeted
• Funded mostly by Global Fund (NFM request for 2015-2017) and other partners
(WHO, DFB, USAID):
• LAO PDR NTP will be member of the Mekong Basin Disease Surveillance
Vision: zero deaths, disease and suffering due to TB
Goal: To reduce TB burden and to reach the targets of WHO Post-2015 Global
Tuberculosis Strategy (adopted by 67th World Health Assembly 2014 on 19 May 2014)
Specific target: Increase TB case detection rate (CDR) from 31% in 2013 to 70% in 2019
Objectives:
1. Integrated patient centred TB care and prevention
2. Strengthening TB-HIV collaborative activities
3. Managing drug resistant tuberculosis (PMDT)
4. Improved management
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TB detection in Lao PDR, forecast 2015-2019
2013
2014
2015
2016
2017
2018
2019
Country Population
6,608 6,726 6,841 6,950 7,060 7,160 7,268
(X1000)
No. sputum smear
35,623 38,000 40,000 42,500 45,000 47,500 50,000
examination
(rate per 1000)
5.4
5.6
5.8
6.1
6.4
6.6
6.9
New and relapse
B+ (SSM and Xpert 3,197
3984
4246
4793
5358
5952
6545
MTB RIF*)
Clinically diagnosed
541
602
700
800
900
1000
1000
Pulmonary TB
Extra pulmonary
392
450
500
550
600
600
600
Total new and
4,130
5036
5446
6143
6858
7552
8145
relapse
Estimated incidence 13,080 12,836 12,584 12,325 12,071 11,816 11,559
Case Detection
Rate (CDR) all TB
32%
36%
43%
50%
57%
64%
70%
cases
Source NTC:
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*if 15% Xpert positive among new presumptive TB
Laboratory strengthening
•LED: not significant advantage compared to ZN in Lao
context of low work load
• Xpert MTB/RIF: 30% yield compared to microscopy
(as a first test, NRL April-Nov 2014)
• GeneXpert scaling-up: cumulative 10 in 2014 (being
procured), 15 in 2015, 20 in 2016
• EQA microscopy since 2004,
• QA Culture and DST with KIT as SRL
•Laboratory information management system
•TA partners: WHO, Stop TB partnership, KIT, Merieux
Foundation
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Scaling-up Xpert
MTB/RIF testing in
Lao PDR
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Reach the unreached: intensive case finding
• Engaging all health providers in public (OPDs, IPDs, MCH, ANC
etc. and private sector) at all levels of the PHC
• ICF among house hold TB contacts including children, PLWH,
prisoners, mine workers, mobile population, factories, patient
with diabetes and other co-morbidities,
• ACF mobile camps in high prevalence areas (with CXR and
GeneXpert)
• Diagnosis and treatment of child-TB
• Identify and refer all presumptive TB patients to the TB unit
or to the TB laboratory
• Support health centres (training, supervision, budget for
transportation of specimens)
• Advocate to local authority, chiefs of villages, village health
committees to involve in TB control activities
• Use NGOs/CBOs (LYU, LOPHA, MAAP, PEDA, PSI)
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Patient centred care: involvement of
patients and civil society
• All stakeholders, public sector, donors, partners,
NGOs/CBOs, key affected population and patients
representatives provided their input in situation analysis,
NSP elaboration and country dialogue (workshops)
• TB technical working group (TWG) includes NGOs/CBOs
and partners
• NGOs/CBOs conduct joint need assessment surveys with
local authorities to identify at risk population and explore
gaps and barriers in accessing TB services
• NGOs/CBOs mobilize village health committees, chiefs of
villages and villagers for TB case detection and sending
patients/specimens in relation with the health centres and
to participate in ACF campaigns
• NTP supports specimen transportation from health centres
to TB laboratory
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TB/VIH
Collaboration with CHAS (planning, training and supervision)
Rapid HIV testing for all TB patients (77% in 2014, target 100%)
Coordination with CHAS for CPT and early ART among all TB-HIV patients
«3 Is » among the PLWH: Intensive case finding, infection control and IPT
TB patients with an HIV test result, Lao PDR 2001-2014
5000
No. of TB patients
•
•
•
•
4000
Total new TB cases (all
3392
forms)
2367
Total HIV tested
2088 1869
3000
2000
1220 1233
1000
0
78
59
497 533
177 280 265 400
*2014: projection of 3Q, NTC data
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PMDT
Achieved
Target
Presumptive MDR-TB patients examined by
Xpert MTB/RIF or culture/DST (retreatment)
60%
100%
RR/MDR-TB patients enrolled
90%
100%
25
35 in 2014, 40 in 2015,
45 in 2016, 50 in 2017
In preparation with
KIT
2015
100%
100%
9 months MDR treatment: 25 MDR-TB patients
under treatment in Dec 2014
Surveillance (DRS in 2015)
MDR-TB patients support for transportation,
food, examinations
Follow-up and care of adverse drugs events
(report to FDD)
Report severe ADE
to FDD
Cohort event
monitoring (2015)
Training of all physicians on PMDT (including
diagnosis, treatment and infection control)
Central level
Train all provinces by
2015
Infection Control (administrative, environment,
personal protection)
Training of limited
number of staff
Train health staff at all
levels on IC
Data management
E-RR under
development
Electronic R/R in 2015
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Surveillance
• Quality of surveillance system: EQA microscopy established
since 2004
• QA culture and DST with KIT
• DRS to be conducted in 2015
• New case definition rolled out in new national TB guidelines
3 rd edition (2014)
• e-R&R: under development for MDR-TB
• Analysis and usage of data at national and sub-national
levels: briefing and debriefing meeting of NTP supervisors
• LAO PDR NTP will become member of the Mekong Basin
Disease Surveillance (cross-border information and
collaboration on TB control)
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Policies and supportive systems
• TB care financing and social protection:
– social protection is limited to only 10-15% of the
population
• Strengthening notification mechanism:
– Training all physicians and nurses in TB wards, OPD, IPD
in public and private hospitals, in health centres, village
health volunteers (VHV) and village health workers
(VHW), private clinics and pharmacists
– paper based RR system to be upgraded to electronic RR
• Drug regulations:
– No change since drug regulation meeting in March 2014
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Management
•
•
•
•
Supervising all levels (central, province, district hospitals and
health centre) and visit TB patients
Improving communication, reporting and feed back (web based
R/R)
Train staff of all levels on administration, finances and
reporting
Ensure procurement, maintenance, logistic and storage
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Partners
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Thank
you
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