1 [INSERT COUNTRY NAME HERE] Introduction to the National MDR-TB Control Strategy SESSION 1 Insert country/ministry logo here

USAID TB CARE II PROJECT Outline of lecture Global situation of drug-resistant TB (DR-TB) Country situation of History of DR-TB program to date Challenges and planning Objectives of this training

USAID TB CARE II PROJECT Global situation of drug-resistant TB (DR-TB)

USAID TB CARE II PROJECT Global burden of TB in 2010 Estimated number of cases Estimated number of deaths All forms of TB 8.8 million (range: 8.5–9.2 million) 1.45 million (range: 1.2–1.6 million) HIV- associated TB 1.1 million (13%) (range: 1.0–1.2 million) 350,000 (range: 320,000–390,000) Multidrug- resistant TB (Prevalent) 650,000 (range: 460,000–870,000) about 150,000 Source: WHO Global Tuberculosis Control Report NB: currently under embargo until release later in Oct 2011

USAID TB CARE II PROJECT Global targets for TB and MDR-TB

USAID TB CARE II PROJECT New diagnostics in TB: Xpert MTB/RIF roll-out

USAID TB CARE II PROJECT Global drug facility is the main supplier of second line anti-TB drugs Role of GDF: Public Sector procurement of TB drugs, of the right quality, in the right quantity, at the right price, and deliver them at the right time to the right people Provide technical assistance by monitoring procurement system management in countries utilising GDF’s services and highlight system strengthening requirements

USAID TB CARE II PROJECT Estimated MDR-TB patient treatments delivered per year through GDF

USAID TB CARE II PROJECT Country situation of Available TB Guidelines: National TB Guidelines TB/HIV Guidelines Public-Private Mix Guidelines DR-TB Guidelines Infection Control Guidelines [Insert the front cover of each local TB Guidelines that are available]

USAID TB CARE II PROJECT TB program Number of patients enrolled for new cases Outcomes of new cases Number enrolled for retreatment cases Outcomes of enrollment % of HIV infected patients among TB Cases

USAID TB CARE II PROJECT Country situation of for DR-TB MDR-TB, Estimates Among Notified Cases (survey year = 20XX) % of new TB cases with MDR-TBX.X % % of retreatment TB cases with MDR-TBX.X % Estimated MDR-TB cases among new pulmonary TB cases notified in 20XX XXXX Estimated MDR-TB cases among retreated pulmonary TB cases notified in 20XX XXXX

USAID TB CARE II PROJECT Reported cases of MDR-TB in 2011 WHO Global TB Report for Estimated cases of MDR-TB among notified cases of pulmonary TB in 2010 a Confidence interval Notified cases of MDR-TB in 2010 b Notified cases of MDR-TB as % of estimated cases of MDR-TB among all notified cases of pulmonary TB in 2010 b Cases enrolled on treatment for MDR-TB in 2010 Expected number of cases of MDR-TB to be treated XXXX XXXX-XXXX XXXXX.X%XXXXXXX a Calculated by applying the best combined estimate of MDR to the notified cases of pulmonary TB in b Percentage may exceed 100% as a result of notifications of cases from previous years, inadequate linkages between notification systems for TB and MDR-TB, and estimates of the number of cases of MDR-TB that are too conservative.

USAID TB CARE II PROJECT Resistance to second-line anti-TB drugs in MDR-TB isolates in YearResistant to Total MDR-TB isolates OFXKMCSCMPASETO XXXXXXXXX Resistant (%)X.X

USAID TB CARE II PROJECT Costs and budget of DR-TB program

USAID TB CARE II PROJECT History of DR-TB program National Reference Laboratory established Enrollment of patients into the DR-TB treatment began Introduction of Xpert MTB/RIF instruments Reference laboratories Established MDR-TB Hospitals Start dates of community-based program GF or other funding

USAID TB CARE II PROJECT Outcomes of DR-TB program to date Cohort CuredDiedFailureDefaultTotal 2006XX XXX 2007XX XXX 2008XX XXX 2009XX XXX

USAID TB CARE II PROJECT Side effects of patients enrolled in DR-TB Side effectNumber total = XXX DyspepsiaXX (X.X%) AnorexiaXX (X.X%) VomitingXX (X.X%) Skin RashXX (X.X%) ArthralgiaXX (X.X%) HepatitisXX (X.X%) Hearing lossXX (X.X%) HypothyroidXX (X.X%) PsychosisXX (X.X%) Sleep disturbance XX (X.X%) Renal FailureXX (X.X%) Electrolyte Disturbance XX (X.X%) Depression XX (X.X%)

USAID TB CARE II PROJECT Operational flow — MDR-TB programme Estimated burden ( Symptomatic cases in the community) Too many patients are lost in each step. Planning must find and retain in care all patients! Suspect identification policy (diagnostic algorithm) Availability of laboratory Accessibility to laboratory Adequate human resources NTP management capacity (linkage with all-public-private laboratories) Reporting system (data flow from lab to treatment centres and programme) Surveillance capacity Access to health system Availability of treatment centres (hospital, clinic with infection control measure) and community network Human resource (trained clinician, nurse, health workers, community volunteer) Registration, availability- storage and distribution capacity of quality assured SLD and ancillary drugs Availability of information to patients (ACSM) Linkage with private sector (PPM) Availability of funds for all intervention Provision of DOTS (adequate health workers, community volunteers) Training, refresher and HRD plan for HCW involved in MDR-TB management Default tracing mechanism Capacity of laboratory to perform follow up and monitoring tests Capacity of adverse effect monitoring mechanism Recording and reporting mechanism Social support: transportation, food, psychosocial Social support mechanism Community awareness and involvement Palliative care Ethical framework Patient charter Labour laws Suspects Diagnosed Notified Treatment initiated Treatment completed Reintegration in the community

USAID TB CARE II PROJECT Challenges in planning of services Diagnosis Conventional C and DST  Solid-liquid Rapid diagnostics- LiPA/Xpert MTB/Rif Test needs to be done for how many suspects? Consumables? Staff time? Sample transport Treatment Drugs – SLD, ancillary drugs Drug supply to match rapid detection Adverse effect management - hospitalization capacity DOT provider - Community or health workers? Capacity Human resources: lab staff, heath care staff, supervisory staff, planning and financial staff Are staff numbers sufficient to deliver all the required services? Is there a need for task sharing or shifting? Hiring? Training capacity available? Community care for DR-TB Public health sector; Public non-health sector; Private sector (for profit & not for profit); Universities & Research Institutes; NGOs, etc.

USAID TB CARE II PROJECT Turning off the source of DR-TB 1. Overcoming the causes of inadequate anti-TB treatment Health-care providers: inadequate regimens Drugs: inadequate supply or quality Patients: inadequate drug intake  Inappropriate guidelines or non-compliance with guidelines;  Absence of guidelines;  Poor training;  No monitoring of treatment;  Poorly organized or funded TB control programmes.  Poor quality;  Unavailability of certain drugs (stock-outs or delivery disruptions);  Poor storage conditions;  Wrong dose or combination of drugs.  Poor adherence (or poor DOT);  Lack of information on treatment,  Adverse effects of treatment;  Social barriers (stigma, restrictions);  Malabsorption due to other causes;  Substance dependency disorders;  Mental disorders;  Non-cooperative.

USAID TB CARE II PROJECT Turning off the source of DR-TB 2. Early diagnosis of DR-TB and prompt DR-TB treatment

USAID TB CARE II PROJECT Hospitals: grounds for MDR-TB? Many TB patients seek care at hospitals Hospitals often do not follow recommended TB diagnostic and treatment practices Hospitals cannot supervise treatment and follow up patients after discharge Many hospitals lack TB infection control measures

USAID TB CARE II PROJECT Objectives of the community-based PMDT training Hospital (only for the very sick) Clinic (Monthly Visits with MDR-Outpatient team) Daily DOT at home (with DOT Provider) Goals of this Training: To train an “Outpatient MDR-TB Team” to clinically manage patients with DR-TB. For the MDR-TB Team to supervise a DOT Provider and provide the support necessary to keep the patient at home. To transition between hospital and the community when needed

24 Thank you and good luck with the training