Upload
david-smith
View
214
Download
1
Tags:
Embed Size (px)
Citation preview
DOTS/ DOTSDOTS/ DOTS PLUS PLUS IMPLEMENTATION IMPLEMENTATION
AAND ND INTEGRATIONINTEGRATION
Vaira LeimaneVaira LeimaneState Centre of Tuberculosis and State Centre of Tuberculosis and
Lung Diseases of LatviaLung Diseases of LatviaParis, October, 28Paris, October, 28
LLATVIAATVIA
PRESENTATION OUTLINEPRESENTATION OUTLINE
EPIDEMIOLOGICAL SITUATIONEPIDEMIOLOGICAL SITUATION IMPLEMENTATION TB/MDR TB IMPLEMENTATION TB/MDR TB
CONTROL PROGRAMSCONTROL PROGRAMS PROGRESS IN TB CONTROL PROGRESS IN TB CONTROL
PROGRAMPROGRAM RESULTSRESULTS
INCIDENCE OF TB IN INCIDENCE OF TB IN LATVIA LATVIA 1971-2001971-20033
74,5
33,3
44,1
50,4
63,3
72,970,5
68,365,1
57,4
53,9
51,5
47,4
41,9
39,6
37,6
38,4
35,8
33,3
32,3
32
30,9
30,8
29,3
28,6
26,9 27,4
28,7
29
74
68,4
59
65,4
0
10
20
30
40
50
60
70
80
WHO IUTLD GWHO IUTLD GLOBAL SURVEY LOBAL SURVEY ON DRUG RESISTANCE INON DRUG RESISTANCE IN
LATVIA 1996LATVIA 1996
14,4
54
0
10
20
30
40
50
60
02468
101214
IINCIDENCE OFNCIDENCE OF MDR TB, MDR TB, GGLOBALLOBAL TB D TB DRUGRUG
RRESISTANCEESISTANCE S SURVEYURVEY, 1994-, 1994-19961996
% N
ew S
mea
r +
Cas
es
NTP PNTP PROGRAM RESPONSE – ROGRAM RESPONSE – DOTS AND DOTS PLUS DOTS AND DOTS PLUS
IMPLEMENTATIONIMPLEMENTATION Accepted first NTP, based on Accepted first NTP, based on
WHO-recommended DOTS WHO-recommended DOTS strategy ALL FIVE ELEMENTS strategy ALL FIVE ELEMENTS in in 19951995
DOTS countywide including DOTS countywide including prisons in prisons in 1996 1996
FIRSTS STEP OF National TB FIRSTS STEP OF National TB Control program for treating Control program for treating MDR TB patients in MDR TB patients in 19971997
Established drug resistance Established drug resistance surveillance surveillance 19971997
SUSTAINED POLITICAL SUSTAINED POLITICAL COMMITMENTCOMMITMENT
Government Committed to establish NTP Government Committed to establish NTP plan using existing staff and resourcesplan using existing staff and resources,, within the Health Care reformwithin the Health Care reform Well functioning DOTS program with Well functioning DOTS program with
additional treatment of MDRadditional treatment of MDR TB (within TB (within recourses available)recourses available)
Collaboration and coordination between Collaboration and coordination between community, local governments, social community, local governments, social services and international agenciesservices and international agencies
Established centralized procurement of Established centralized procurement of drugs through open tenderdrugs through open tender
DOTS PLUS DOTS PLUS IMPLEMENTATION STEP I - IMPLEMENTATION STEP I -
19971997 SITUATION ANALYSISSITUATION ANALYSIS
Results of drug resistance surveillance Results of drug resistance surveillance QA of laboratory for DSTQA of laboratory for DST MDRMDR TB case finding strategy – TB case finding strategy –
DST for all who starts treatmentDST for all who starts treatment Reporting and registration of MDRReporting and registration of MDR TB TB Evaluated access to TB drugs and Evaluated access to TB drugs and
created new drug management systemcreated new drug management system
TB CASE DETECTION AND TB CASE DETECTION AND IDENTIFICATION OF MDR-TBIDENTIFICATION OF MDR-TB
District-LevelSmear Microscopy
Regional-LevelCulture Laboratories
Central Laboratory -DST for all who starts treatment
CentralCentralDSTDST
Supranational ReferenceLaboratory (Sweden)
95% lab accuracy (1998)
MDR TB MDR TB REPRTING AND REPRTING AND RECORDINGRECORDING
MDR TB caseMDR TB Register
Mycobacteriology LabMycobacteriology LabAll DST resultsAll DST results District TB doctor
ConsiliumEnrollment in MDR TB cohort
Enrollment formFollow-up form
DOTS PLUS DOTS PLUS IMPLEMENTATION STEP IIIMPLEMENTATION STEP II
MDRMDR TB TREATMENT AND MANAGEMENT TB TREATMENT AND MANAGEMENT STRATEGYSTRATEGY Established Expert consilium for case and Established Expert consilium for case and
program management program management 1997, June1997, June TB hospitals reorganized for MDRTB hospitals reorganized for MDR TB TB Start patient enrolment for treatment Start patient enrolment for treatment
Empiric/Individualized treatment strategy Empiric/Individualized treatment strategy according to DST resultsaccording to DST results Directly observed therapy (DOT)Directly observed therapy (DOT) Monitoring and management of side effectsMonitoring and management of side effects
CONSILIUM FOR MDRCONSILIUM FOR MDR TB TB TREATMENT AND TREATMENT AND
MANAGEMENTMANAGEMENT AdvantagesAdvantages Collective decisionCollective decision Possibility for Possibility for
patientpatients tos to receive receive most effective most effective treatment treatment
Possibility to Possibility to supervise supervise treatmenttreatment
Problem solvingProblem solving ImproveImprovement of ment of
program program managementmanagement
EEXPERT CONSILIUMXPERT CONSILIUM
TREATING TREATING
PHISICIANSPHISICIANS
HHOSPITALSOSPITALS
LLABORATORYABORATORY
AAMBULATORYMBULATORY
TREATMENTTREATMENT
MDRMDR TBTB
REGISTRYREGISTRY
SUPERVISIONSUPERVISION
BOARD OF EXPERTSBOARD OF EXPERTS
SOCIALSOCIAL
WORKERSWORKERS
NURSESNURSES
PPHARMACYHARMACY
SSTRUCTURE OF TRUCTURE OF DOTS-DOTS-PLUS PLUS PPROGRAMROGRAM
DOTS PLUS DOTS PLUS IMPLEMENTATION STEP IIIIMPLEMENTATION STEP III
ESTABLISHED CASE MANAGEMENT ESTABLISHED CASE MANAGEMENT SYSTEMSYSTEM Roles and responsibilities of HCWRoles and responsibilities of HCW Patient educationPatient education Default tracingDefault tracing
Improved infection control measuresImproved infection control measures Center of Excellence founded in Center of Excellence founded in 20002000
International training centre for treatment and International training centre for treatment and management for MDRmanagement for MDR TBTB
Built laboratory capacity –Built laboratory capacity – DST to all I and II line drugsDST to all I and II line drugs Rapid diagnostic methods for patient with risk of MDR-TBRapid diagnostic methods for patient with risk of MDR-TB
Established database, data management, Established database, data management, and information system 2002 -2003and information system 2002 -2003
IMPROVING ALL TB AND MDRIMPROVING ALL TB AND MDR TB PATIENT ADHERANCETB PATIENT ADHERANCE
Social Aid for TB PatientsSocial Aid for TB Patients Food couponsFood coupons
Transport ticketsTransport tickets Extra coupon weekly Extra coupon weekly
if adherence 100%if adherence 100%
Departments of WelfareDepartments of Welfare
Agreement with TB ambulatory Agreement with TB ambulatory departmentsdepartments
DOTS PLUS PROGRAM TREATMENT DOTS PLUS PROGRAM TREATMENT COHORTSCOHORTS
Begun in 1997 Begun in 1997
130
204 207 204 215188
153
13
18
293141
7
0
50
100
150
200
250
300
1 Cohort1997
2 Cohort1998
3 Cohort1999
4 Cohort2000
5 Cohort2001
6 Cohort2002
7 Cohort2003
Prison
Civil
DOTS PLUS DOTS PLUS IMPLEMENTATION STEP IVIMPLEMENTATION STEP IV
ACCESS TO II LINE DRUGSACCESS TO II LINE DRUGS Leaving funds after procurement of I line drugsLeaving funds after procurement of I line drugs Extra from reserved fundsExtra from reserved funds
DOTS-plus project accepted by WHO DOTS-plus project accepted by WHO Green Light Committee in January Green Light Committee in January 20012001 Approval for 350 patients for drugsApproval for 350 patients for drugs
Full coverage with treatmentFull coverage with treatment LiPA test - study to determine usefulness for LiPA test - study to determine usefulness for
early MDRearly MDR TB case detection TB case detection Established database, data management, Established database, data management,
and information system and information system 2002 -20032002 -2003
TREATMENT OUTCOMES FOR TREATMENT OUTCOMES FOR COHORT 2000COHORT 2000
N=204 patientsN=204 patientsCompleted treatment (6)Completed treatment (6)
Death (14)Death (14)
Default (26)Default (26)
Failure (29)Failure (29)
Cure (129)Cure (129)
TREATMENT OUTCOMES FOR TREATMENT OUTCOMES FOR NEW TB CASES AFTER DOTS NEW TB CASES AFTER DOTS
AND DOTS PLUS COMPLEATIONAND DOTS PLUS COMPLEATION
1998 1999 2000 2001 2002
998 919 957 1004 934
9 10,8 9 10,9 9,8
Cured % 74,4 77,3 75,6 76,6 78
Failure % 1,5 1 2,3 1 1
Default % 7,6 4,5 6,4 6,7 5,5
Died % 8,5 7,6 8,9 6,9 7,1Continue Tretment
on Dots Plus % 7 8 6,4 8,8 8
80 84 80,4 84 84,5Total Cured DOTS and
DOTS - Plus %
YearRegistered Culture +
cases
MDR-TB %
DO
TS
Ou
tco
me
s
NUMBER OF PATIENTS WITH PRIMARY NUMBER OF PATIENTS WITH PRIMARY ANDACQUIRED MDRANDACQUIRED MDR TB INCLUDING TB INCLUDING
PRISON 1994 - 2003PRISON 1994 - 2003
1928
47 53
91
144
82
175
257
117
218
332
90
200
290
90
156
255
86
148
234
97
132
229
83
126
209
8380
163
0
50
100
150
200
250
300
350
400
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Primary Acquired Total
Since 1998 total number of annually registered MDRSince 1998 total number of annually registered MDR TB cases decreased TB cases decreased by 51% for previously treated by 65%by 51% for previously treated by 65%
CONCLUSIONS AND CONCLUSIONS AND RECCOMENDATIONSRECCOMENDATIONS
DOTS strategy has reduced MDRDOTS strategy has reduced MDR TB TB development by 51% in Latvia development by 51% in Latvia
DOTS-Plus in addition to DOTS in settings with DOTS-Plus in addition to DOTS in settings with high MDRhigh MDR TB level can reach WHO goal for cure TB level can reach WHO goal for cure 85% 85%
2/3 of patients who started treatment in DOTS 2/3 of patients who started treatment in DOTS plus were curedplus were cured
Addressing treatment default could significantly Addressing treatment default could significantly improve program effectivenessimprove program effectiveness
Strengthening of the DOTS strategy, rapid MDRStrengthening of the DOTS strategy, rapid MDR TB diagnosis, contact investigation and TB diagnosis, contact investigation and genotyping to detect chain of transmission is the genotyping to detect chain of transmission is the next steps to improve MDRnext steps to improve MDR TB control in LatviaTB control in Latvia
NATIONAL CHOIRS FESTIVALNATIONAL CHOIRS FESTIVAL
Welcome to Latvia