Control and Prevention of MDR-TB in the Greater Mekong Sub-region

CAP-TB PROJECT

Strengthening the health system through basic building blocks for TB control

TB/MDR-TB Control & Prevention

Prevention Diagnosis Treatment Initiation

Treatment Success

CAP-TB Strategic Model

Integration with the health system for TB control and prevention

Implementing innovative strategies with long-term sustainability

CAP-TB Strategy for FY14

• Evaluate implementation to date (FY12-FY13)

• Identify successful strategies to continue and potentially scale up– Increased case detection and treatment success as

“downstream” indicators of impact

• Review current literature for recent evidence on potential innovations, etc., that can be piloted through the project

Lancet Infectious Disease Vol 13, No 7, July 2013

WHO analysis of 30 countries to determine progress toward universal access to MDR-

TB care by 2015

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Lancet Infectious Disease Vol 13, No 7, July 2013

Major Findings

• 6 of 30 countries will reach goal for universal MDR-TB access by 2015.

• 19 of 30 countries (including Myanmar, China, Thailand) need significant help to reach 2015 goal.

• Challenges: Lab capacity; “treatment gap” between detection and enrollment; poor treatment outcomes in some settings.

Lancet Infectious Disease Vol 13, No 7, July 2013

Recent literature emphasizes the importance of MDR-TB decentralization

Thailand

• Support BTB to develop infrastructure for national MDR-TB decentralization network– Rayong as pilot model for provincial-level decentralization

• Continue Rayong Hospital activities: call center, MDR-TB case conferences, multi-disciplinary teams for MDR-TB care

• Active case finding (DM, PLHIV clinics) and community support: assess donor funding and existing support

Building a provincial model for TB/MDR-TB decentralization in Rayong:

Strengthening provincial, district, sub-district, and community levels of TB network

Thailand

• Support BTB to develop infrastructure for national MDR-TB decentralization network– Rayong as pilot model for provincial-level decentralization

• Continue Rayong Hospital activities: call center, MDR-TB case conferences, multi-disciplinary teams for MDR-TB care

• Active case finding (DM, PLHIV clinics) and community support: assess GFATM funding and existing capacity

Myanmar: Integration with the TB network to strengthen TB control

Myanmar

• Continue with patient treatment support• Identify risk groups for piloting innovative

methods to improve case detection/treatment success– Childhood TB– Other risk groups: DM, PLHIV, etc.

• Organizational Capacity Development

Case notifications MDR-TB (2008-2013)Year Cases (Solid/Liquid

Culture/LPA)Cases put on SLD

2010 312 192

2011 690 162

2012 778 442

2013 (Q1) 426 65

2013 (Q2) 376 218

Year Notified Treated Waiting (Lab confirmed) Fund2010 312 312

192 120 UNITAID2011 690 810

162 648112 (UNITAID)

50 (GF)2012 778 1426

442 984 GF2013 (1st Q) 426 1410

65 1345 GF2013 (2nd Q) 376 1721

218 1503 GF

• Engage community volunteers (in addition to health care workers)

• Provide DOT throughout treatment • Limit cohort size: decentralization• Provide patient education• Provide package of adherence interventions• Provide standardized regimen (not

individualized)

Myanmar: Identifying TB/MDR-TB risk groups to increase detection,

enrollment, and treatment success

Myanmar

• Continue with patient treatment support• Identify risk groups to improve case detection

and treatment success– PLHIV, geographic areas (border and remote) with

high treatment interruption/default rates, etc.

• Organizational Capacity Development• Research: health financing, gender, 9 month

“short regimen”

China: Implementing innovative strategies with long-term sustainability

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

20

40

60

80

100

120

Repo

rted

inc

iden

ce (1

/100

,000

)

National average

Yunnan

Reported pulmonary TB incidence of Yunnan compared with national average (1997-2012)

The reported TB incidence has remained relatively stable since 2006 in Yunnan, compared to a decline in the national incidence.

China• Refine strategy for case-finding interventions to scale

up: – Analyze data from FY13 to identify most effective strategies– DM/TB, private clinics/pharmacies, QQ groups, PLHIV,

community engagement (Women’s Federation)

• Engagement of private sector: #3 Hospital of Kunming

• Potentially for FY15, consider piloting CAP-TB model in Zhao Tong prefecture: “chronic TB outbreak”– Would enable Yunnan to have both an urban and rural

model for TB/MDR-TB control

Yunnan Province: 16 prefectures (2012)

Cases

4663

3000- 4000﹤

2000- 3000﹤

1000- 2000﹤

500- 1000﹤

196- 500﹤

Zhao Tong

Qu Jing

Wen SHanHong He

Da Li Kun Ming

Di Qing

Chu Xiong

Pu Er

Xi Shuang Ban Na

Lin Cang

Li Jing

De Hong

Bao SHan

NuJiang

Yu Xi

FY14 – FY16 Strategic Planning

• Continue integrated “Health System Strengthening” – model for service delivery

• Implement innovation: – Focus on risk groups for TB/MDR-TB

• PLHIV, DM/TB, Migrant/mobile population• Workplace interventions for those with risk for occupational

lung disease (miners and those with pulmonary silicosis)• Childhood TB, smokers, closed/congregate settings

– QQ (China Facebook/Twitter): social media, “mHealth”

FY14 – FY16 Strategic Planning

• Continue integrated “Health System Strengthening” – model for service delivery

• Implement innovation: – Focus on risk groups for TB/MDR-TB

• PLHIV, DM/TB, Migrant/mobile population• Workplace interventions for those with risk for occupational

lung disease (miners and those with pulmonary silicosis)• Childhood TB, smokers, closed/congregate settings

– QQ (China Facebook/Twitter): social media, “mHealth”

FY14 – FY16 Strategic Planning

• Research– Health financing/cost-effectiveness– TB gender disparity– 9 month “short regimen” for MDR-TB

• Identify strategies for sustainability– Counterpart funding from national and provincial

government (China, Thailand)– Capacity building of Myanmar IAs to prepare for future

funding from international donors (USAID, GFATM, etc)

9 month “short regimen” for MDR-TB

Am J Respir Crit Care Med Vol 182. pp 684–692, 2010

9 month “short regimen” for MDR-TB

Am J Respir Crit Care Med Vol 182. pp 684–692, 2010

9 month gatifloxacin-based regimen: 87.9% treatment success

Am J Respir Crit Care Med Vol 182. pp 684–692, 2010

WHO Criteria for 9-Month Regimen

• Approval by a national ethics review committee

• Treatment delivered under operational research conditions following international standards to assess the safety and effectiveness of regimen

• Programmatic management of drug-resistant TB and the research project are monitored by an independent monitoring board set up by, and reporting to, WHO

http://www.who.int/tb/challenges/mdr/short_regimen_use/en/index.html

9 month MDR-TB Regimen

• Funding– China: national/provincial governments– CAP-TB/IUATLD: primarily technical support

• Drug supply– Domestic versus other

• Patient follow-up– Resources (human and financial)

• Site-training – clinical monitoring, DOT