Accelerating PMDT scale up in Ethiopia Ezra Shimeles (MD, MPH) TBCARE/KNCV, Ethiopia

Outline Introduction and background National TB and MDR TB situation National Performance on TB MDR TB Scale up Challenges in PMDT Scale up Way forward

Introduction and Background: Ethiopia 11 administrative units 90 million population 83.6 % in rural Economy(IMF) Agriculture 46.6% Industry 14.5% Services 38.9% GNI Per Capita:410 (World Bank 2012) Life expectancy at birth :59 (World Bank 2011) Land mass not needed, located in the Horn of Africa not needed 11 admin units, subdivision in ? Subunits and 16000 municipalities ? GNI 410 – (LIC)

The Health Tier System

Health Profile Health Service No. of health facilities Human capital PHS coverage = 92% No. of health facilities Hospital = 132 Health centers = 3000 Health posts = 15,700 Human capital Physicians = 2,115 Health officers = 1606 Nurses = 20, 109 Health extension workers = 34, 382

National TB Situation and NTP overview Among the 22 HBC 16th among the 27 MDR-TB high priority countries Incidence: 258/100,000 population Prevalence : TB 237/100,000 population The TB related mortality rate : 18/100,000 WHO 2012 TB Report

MDR-TB burden DRS survey 2003-2005 1.6% New 11.8% Previously treated WHO estimate 2500 MDR TB Cases are expected from notified cases annually DST requirement per annum: 6000 new and 6000 retreatment cases (2013) Current survey is under way but result not ready.(unofficial among Retreatment 15%; among New 1.3%)

Tuberculosis Case finding ( All forms of TB (New and retreatment) New patients

Treatment outcome for new PTB+ New PTB + patients

TB/HIV Integration services

TB/HIV Integration services(2)

National PMDT implementation plan Phase I: pilot phase (2009-11) Target: treat 45 patents Establish MDR treatment at one TB Hospital in 2009 Scale Up phases: Five years expansion plan (2011-15): Target : treat 8,018 MDR-TB patients Phase II: Roll out phase using (2011-13) MDR TB referral centers Establishment of regional culture and DST centers Pilots Ambulatory model Phase III: Scale up phase(2013-15) Rapid diagnostic techniques Ambulatory centers up to Zonal hospitals level Difference phase 2 and 3 ? What does up to zones mean ? Scale-up plan in numbers of patients to be put on treatment ?

Preparatory phase for initiation National technical working group on MDR-TB established. Guidelines: PMDT; TB infection control Training material for health care workers Training of health care workers Renovation of MDR-TB wards Registration of second line anti-TB drugs conducted Procurement of SLDs Infection control items such N-95 respirators, were made available Recording and reporting formats developed and printed IEC materials including posters and stickers developed and printed Do you have pictures that illustrate these points ?

Achievement of pilot phase Treatment started at St Peter TB hospital Treatment follow up sites established Capacity built: infrastructure, staff, IC, M&E, Enrollment : 100% of target 45 patients put on treatment Treatment outcome Satisfactory = phase 1 ?

Shifting the gear: Preparation for accelerated scale up Implementation protocol for ambulatory care for DR-TB Customization of training material for middle level Selection of TIC and TFC 1 TIC linked to 8-10 TFC Update case finding and diagnostic approaches Establishment of Sputum sample transport system Efficient PSM for SLDs, ancillary drugs Socio-economic support for patients Renovations of TICs, TFCs Improve Human capital and leadership MDRTB specific ACSM

DR TB Treatment network

Case detection and enrollment,2007-13

Site expansion,2009-13 TIC –Treatment initiating center TFC –Treatment follow up center

Scale up plan versus achievement, 2009-13 (Total enrolled n=1000)

Enrolment by DST status in Ethiopia, 2009-13

Interim Treatment outcome

Final Treatment outcome(2009-11 cohorts) (Total n=173, Cure Rate 7% ;TSR 80%)

Major Challenges MDR TB Suspect identification and Sputum sample transportation challenges GeneXpert rollout is very slow HR Capacity needs not met Poor Lab support for patient monitoring Ancillary drugs shortage - What, when, where Patient socioeconomic support system not standardized Infection control settings in most health facilities not satisfactory SLD Supply to TICs and TFCs not fully integrated to the national DSM Long turn around time for follow up Culture results Suggest to remove the 1st Rewording – pictures ?

Targets for 2013 -2015 in PMDT To decentralize the MDRTB treatment service to PHC level by 2015: TIC at Zone level (40, 70, 96 zones in 2006, 7 and 8 respectively) and at least one TFC at Woreda level (814 Woredas). DST screening for 10% of New PTB smear positives and 100% of previously treated TB To enroll 100% notified confirmed MDR TB cases for treatment To achieve 95% interim result of culture conversion To achieve TSR rate of 80% and reduce the death rate from 15% to 10% To improve cases finding in pediatric age group to reach 7% of all cases To provide integrated MDR TB and HIV service in all MDRTB service points

Major partners of MOH for PMDT Roll out Global Fund WHO, FIND, EXPAND TB Project USAID:TB CARE I(KNCV), HEAL TB (MSH), PHSP (Abt.) Global Health Committee CDC : JHU, I-TECH, ICAP, UCSD MSF Belgium International Organization for Migration

Thank you