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DOTS-Plus to DOTS Philippines
Thelma E. TupasiThelma E. Tupasi
Tropical Disease Tropical Disease FoundationFoundation
Rosalind G. VianzonRosalind G. Vianzon
NTP Manager, PhilippinesNTP Manager, Philippines
Reasons for embarking on Reasons for embarking on DOTS-Plus:DOTS-Plus: Outcome of Outcome of
DOTSDOTS DOTS Clinic at the MMCDOTS Clinic at the MMC, , February 1999-January
2002OutcomOutcom
eeNew cases New cases
(126)(126)Previously Previously
treatedtreated
(65)(65)
CureCure 83.3%83.3% 53.8%53.8%
FailureFailure 0.80.8 38.538.5
DiedDied 6.46.4 1.51.5
LostLost 7.17.1 1.51.5
MDR-TBMDR-TB 2.42.4 4141Quelapio MID et al: MDR-TB a threat to TB Control, Cohort Analysis, MMC DOTS-CLinic
Reasons for embarking on Reasons for embarking on DOTS-Plus:DOTS-Plus: Health and socioeconomic Health and socioeconomic
consequencesconsequences of no DOTS-Plusof no DOTS-Plus Patients are left untreated leading
to transmission Patients are managed
inadequately/inappropriately leading to amplified resistance
Patients deteriorate leading to absenteeism and lack of productivity
Patients die leading to lost income
Scarce resources and competing Scarce resources and competing priorities: DOTS vs DOTS-Pluspriorities: DOTS vs DOTS-Plus
Private practitioners lack of Private practitioners lack of adherence to the DOTS strategyadherence to the DOTS strategy
Absorptive capacityAbsorptive capacity Establishing a laboratory network Establishing a laboratory network
to support DOTS-Plusto support DOTS-Plus Shifting from pilot project to Shifting from pilot project to
policy developmentpolicy development
Constraints and major Constraints and major challenges to DOTS-challenges to DOTS-
PlusPlus
Scarce Resources: Access to Scarce Resources: Access to treatment: 304 patients treatment: 304 patients applying for treatmentapplying for treatment
not bacteriologicall
y confirmed12%
reclassified1%
no specimen16%
for enrollment7%
SAT0%
deceased7%
patient unwilling
1%
pending culture and dst
24%
enrolled32%
Scarce Resources
Scare Resources: Support for Scare Resources: Support for
DOTS-Plus in first 165 DOTS-Plus in first 165 patientspatients
United Laboratories
11%
BSL, 4% TDF, 14%
NTP, 46%PCSO, 25%
n=165 patientsn=165 patients
Scarce Resources: Global Fund Scarce Resources: Global Fund for DOTS+ for DOTS+ To utilize the GLC-approved To utilize the GLC-approved
DOTS-Plus pilot project for policy DOTS-Plus pilot project for policy development on MDR-TB in the NTPdevelopment on MDR-TB in the NTP
GFATM Philippine program GFATM Philippine program providing providing
USD 0.5 M/yearly for DOTS-PlusUSD 0.5 M/yearly for DOTS-Plus100-120 patients yearly for five 100-120 patients yearly for five yearsyears
22ndnd line anti-TB drugs line anti-TB drugsEnablers: Enablers:
Transport cost reimbursementTransport cost reimbursementDrugs for adverse reactionsDrugs for adverse reactions
1997 NTPS
Traditional healer
7%
Hospital17%
Private MD46%
Public health clinics30%
Role of the Private Medical Practitioners in TB Treatment
0
10
20
30
40
50
60
70
PrivatePhysicians
Public Healthcenters
Others
Referrals forReferrals forDOTS-PlusDOTS-Plus Care providers consulted
Private Practitioners and Private Practitioners and Fluoroquinolones in the Fluoroquinolones in the
PhilippinesPhilippines
0 10 20 30 40 50
HRZES
HRZE
HRZS
HRES
HRE
HRS
HRZ
HR
Resis Pattern
No. of isolates
FQ Sen FQ Res
Resistance to Resistance to Fluoroquinolones and Fluoroquinolones and
KanamycinKanamycin
0102030405060708090
100
HRZES HRZE HRZS HRES HRE HRS HRZ HR Res Pattern
% of isolates % FQ Resistant %Kan Resistant
GLC technical assistance GLC technical assistance political commitment to the DOTS+ pilot
project among NTP and its technical advisers
uninterrupted supply of quality assured 2nd line anti-TB drugs
appropriate laboratory support for the diagnosis of MDR-TB including culture and DST under supranational laboratory supervision
treatment under DOT and management of adverse drug events,
reporting and recording.
1.21
0.92
0.96
1.13
0.35 0.270.2
0.2
0.34
1.4
0.17
0.130.13
1.62 1.421.44
1.573
0.130.13
0.10.11
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
US
D
Capreomycin Kanamycin Cycloserine PASER Eth/Pro
Second-line drug
Role of the GLC: Cost of 2nd-line drugs before and after GLC in US$
1st order 2nd order 3rd order 4th order 5th order
80,000
30,000
233,000
121,000
0
50,000
100,000
150,000
200,000
250,000
Cos
t (P
hP)
HR-resistant HRZES-resistant
Cost of MDRTB Treatment with and without GLC
Without GLC With GLC
Individualized Tx. Outcome of Individualized Tx. Outcome of TherapyTherapy
OutcoOutcomeme
nn
AllAll
117117
Patients Patients who who
remain remain in in
therapytherapy
101101
Patients Patients who who
complete complete therapytherapy
8383
Cure 61% 70% 85.5%Failure 19 11.9 14.5Died 15 17.8Default 14
DOTS-Plus in the DOTS-Plus in the Philippines is highly Philippines is highly
cost-effectivecost-effectiveCost per DALY averted: US $ 242 vs Cost per DALY averted: US $ 242 vs
GNI of $1,040 in the PhilippinesGNI of $1,040 in the Philippines1. Cost <per capita GNI is highly 1. Cost <per capita GNI is highly
cost-effective cost-effective 2. 3x per capita GNI is cost-effective 2. 3x per capita GNI is cost-effective
as recommended by the as recommended by the Commission on Macroeconomics Commission on Macroeconomics and Health.and Health.
3. COST 3. COST is within the range of is within the range of "attractive" investments defined "attractive" investments defined by the World Bankby the World BankKatherine Floyd and Raj GuptaKatherine Floyd and Raj Gupta
From Pilot project to Policy: From Pilot project to Policy: IssuesIssues
DOTS: Local ownership and sustainable DOTS: Local ownership and sustainable financial commitment to support basic financial commitment to support basic DOTS programmeDOTS programme
DOTS-Plus pilot project: Enunciation of DOTS-Plus pilot project: Enunciation of its current and potential relevance to its current and potential relevance to the National TB Control Programthe National TB Control Program
22ndnd line anti-TB drugs: Registration, line anti-TB drugs: Registration, availability and controlled distribution availability and controlled distribution to prevent abuse and emergence of drug to prevent abuse and emergence of drug resistanceresistance
Sputum culture
2-3 m AFS
Neg
DOTS
Previously Treated: CAT II
New: Cat I
NegPos
Continue Cat I Continue Cat II
CureCureDST: MDR-TB
DOTS Plus
Pos Neg
4-5m AFS
Neg
MDR-TB in the MDR-TB in the PhilippinesPhilippines Socioeconomic and health reasons for Socioeconomic and health reasons for
embarking on DOTS-Plusembarking on DOTS-Plus Constraints and barriersConstraints and barriers
Problem engendered by second-line anti-Problem engendered by second-line anti-TB drug use in the countryTB drug use in the country
Limited resources and absorptive capacityLimited resources and absorptive capacity Individualized treatment is effective, Individualized treatment is effective,
feasible, and cost-effectivefeasible, and cost-effective GLC mediated technical assistance: enabled GLC mediated technical assistance: enabled
pilot project to follow 5 elements of DOTS-pilot project to follow 5 elements of DOTS-Plus enforcedPlus enforced
Integration of DOTS-Plus within DOTS in Integration of DOTS-Plus within DOTS in the NTP: Clear Policy within the NTPthe NTP: Clear Policy within the NTP
DOTS-PLUS EXPANSION andMAINSTREAMING
PART II: PART II:
ISSUES and CHALLENGESISSUES and CHALLENGES
in INTEGRATING DOTS-PLUS in INTEGRATING DOTS-PLUS
into the PUBLIC HEALTH DOTSinto the PUBLIC HEALTH DOTS
- - Setting-up theSetting-up the policy environmentpolicy environment
operational feasibility - reality settingoperational feasibility - reality setting 100% DOTS coverage in the public 100% DOTS coverage in the public
sectorsector
evidence is available from the pilot project evidence is available from the pilot project that DOTS is feasible & cost effective in the that DOTS is feasible & cost effective in the country; support evidence from the DRScountry; support evidence from the DRS
potential impact & equity in accesspotential impact & equity in access
economic and social productivity, (MDG) economic and social productivity, (MDG) safe and healthy environment safe and healthy environment
ISSUESISSUES
- Readiness in integrating the system- Readiness in integrating the system
strategic implementation strategic implementation development of human resourcesdevelopment of human resources enhancing QA laboratory support under enhancing QA laboratory support under
supranational laboratory supervisionsupranational laboratory supervision ensuring logistical support for second-line ensuring logistical support for second-line
drugsdrugs institutionalized technologyinstitutionalized technology
ISSUESISSUES
CHALLENGESCHALLENGES
Policy Environment:Policy Environment:
High political agendum within the NTPHigh political agendum within the NTP NTP point person for DOTS (+)NTP point person for DOTS (+) DOTS (+) Task Force vis-à-vis NTP-TWGDOTS (+) Task Force vis-à-vis NTP-TWG Increase advocacy for strong political Increase advocacy for strong political
commitment of all stakeholderscommitment of all stakeholders Support from NTP partners - Advisory BodySupport from NTP partners - Advisory Body (L(Local & International advisers) ocal & International advisers)
Systems Integration:Systems Integration:Strategic Implementation:Strategic Implementation:
- area analysis for an impact implementation - DRS resultsHuman resource development:Human resource development:- additional Staff and/or re-tasking of existing roles and functions- intensive training with immersion in the DOTS(+) Project-multidisciplinary approach at all levels of health care
CHALLENGESCHALLENGES
Systems Integration:Systems Integration:Laboratory Capacity and Proficiency:Laboratory Capacity and Proficiency:- maximize developed laboratory under the DRS Strengths:Strengths: QA center for microscopy Established lab network in place
Proficient laboratory Staff Not integrated with other
laboratory works
CHALLENGESCHALLENGES
Systems Integration:Systems Integration:Logistical Support:Logistical Support:- NTP budget for 2nd line drugs plus GFATM support-unified system for drug management (1st &2nd line drugs)- regulation and control in the distribution of 2nd line drugs- technical / financial assistance from other partners
CHALLENGESCHALLENGES
Institutionalized Technology:Institutionalized Technology:
- multi-sectoral coordination of stakeholders
NTP, LGUs, Private Providers, Experts /
Academe, Professional
societies/International Agencies/
community
- community-based approach
CHALLENGESCHALLENGES
Strategic Area
Human ResourceDevelopment
Laboratory Capacity& Proficiency
LogisticalSupport
InstitutionalizedTechnology
DOTS(+)
within NTPNTP
Stepwise Approach
to Mainstream DOTS (+)
into
the NTPNTP