Mongolia Progress Report Dr. D. Otgontsetseg, Head of recording and reporting unit, TB surveillance and research department, NCCD The ninth Technical Advisory Group and National TB Programme Managers meeting for TB control in the Western Pacific Region Manila, Philippines December 2014

Notified all form TB cases, In Mongolia, GF project started DOTS implemented Nationwide screening

Number of smear positive TB cases, in Mongolia,

Age distribution of all forms of TB cases, in Mongolia,

Cure rate among smear positive pulmonary cases Mongolia, year

Failure and default rate among smear positive pulmonary patients Mongolia, year

Major successes  The global Millennium Development goal and regional targets for TB control are likely to be met  Increasing Government funding for TB control  Revised National TB care guidelines approved by Health Ministerial order  WHO revised definition and reporting framework for tuberculosis introduced in all levels of TB care – pilot in 2014, starting will be reported officially  Nationwide TB prevalence survey started in Apr 2014 and field data collection completed in urban areas  Introduction and roll out of GeneXpert

Major challenges  Dependence from external funding – sustainability of the National TB programme after the end of the GF grant  Diagnosis and management of EPTB and TB in children  Early detection and treatment of TB among high risk groups (homeless, alcoholics, migrants)  Increasing rates of default and failure among TB patients in the last two years, especially in Ulaanbaatar city  Lack of awareness of the public about TB

National TB Strategy/Policies Timeframe: Targets: by 2015, reduce TB prevalence to 154 per and by 2015, reduce TB mortality to 15 per Alignment with WHO End TB strategy: The new National Stop TB strategy will be developed in 2015 National Health Sector Plan will be end in National Strategic Plan to Stop TB is aligned. Budgeted 70% - GF supported project, 30% - government

Laboratory strengthening LED 2 LED: NRTL and 1 province A prison hospital and 3 provinces received in Nov 2014 Xpert 3 GeneXpert –NRTL and 2 provinces NRTL: Total tested 2659, MTB detected 50.2%, error 3.1%, rif resistance detected 18.6% Quality assurance EQA SSM 36 ZN, 1 LED labs, EQA DST, SSM from RIT, Japan Laboratory information management system Internet-based system TA partners SRL –RIT, Japan since 2005

Reach the unreached Active case finding: among high risk populations – prisoners, homeless, medical workers, pregnant women, people living with HIV Passive case finding: adults by smear examination and X-ray, children tuberculin skin test and X-ray Contact investigation: family members of smear positive patients, children, MDR-TB – target 100%, in practice – 86% TB-HIV: screening of people living with HIV for TB by Gene Xpert, all new and relapse TB cases (16 years old and above) tested for HIV. So far 181 HIV cases are reported, out of them 31 are co- infected Child TB: Operational research on contact investigation, strategy on child TB will be developed in 2015

Surveillance Quality of surveillance system –Use of national unique ID –Paper and internet based reporting: on time by paper; some difficulties using internet-based system due to internet connection New case definition roll out –WHO revised definition and reporting framework for tuberculosis introduced in all levels of TB care – pilot in 2014, starting will be reported officially

Surveillance e-R&R –Internet based reporting – ‘tubis’; –Update of the system based on WHO new definitions –90% of TB reporting units use ‘tubis’ platform Analysis and usage of data at national and sub-national levels –Analysis data at the national level on monthly, quarterly and annual basis –Limited capacity at the sub-national level

Notified (n=1375) and died (n=325) MDR-TB cases Mongolia,

Treatment success for MDRTB patients Mongolia,

Number of XDR-TB cases XDRTB Pre XDRTB total 4058 out of them: Died30 Address unclear4 Refused2 Waiting on treatment2 2 nd line treatment continued1 Cured1

PMDT Plan vs universal coverage –In 2014 planned 219 MDR-TB and 81 PDR patients to enroll in treatment Barriers –Lack of social support for MDR-TB patients –Lack of experienced health providers ( high turn over of staff) –Lack of management of side effects –Some MDR-TB patients refuse to receive treatment due to various reasons (religious, co-morbidities etc.)

PMDT: Priority actions –Strengthening management of MDR-TB patients (counseling, follow up of patients, capacity building of TB providers) –Establishment of patient support groups in collaboration with MATA –Treatment of XDR-TB patients with financial support of the GF –DRS planned in 2015 –TB prevalence survey results to be analyzed –Advocacy to include MDR-TB drugs in Government budget

Bold policies and supportive systems TB care financing and social protection –TB care financed by the Government –No health insurance coverage for TB services –No specific social protection services for TB patients –Within general social protection system TB patients (especially employed) may receive disability benefits for certain period Strengthening notification mechanism –An estimated 15-20% of diagnosed TB cases are not notified –Supportive supervision should be strengthened –Strengthen internet based reporting and recording Drug regulations – Progress since drug regulation meeting in March 2014 –New drugs for MDR-TB were included in national essential drug list –Drug information is in the process of revision in internet-based system

Patient centred care: involvement of patients and civil society Community mobilization activities –Patient support groups will be established by MATA with financial support of Stop TB Partnership CBO involvement and their role – MATA: lunch DOT and home DOT –World vision: TB services for prisoners, homeless –TB Coalition: advocacy for local governments

Patient centred care: involvement of patients and civil society Involvement of patient groups in TB control –In the process of establishment Forms of social support to TB patients (incentives? TB Pension? Reimbursement of costs related to care like transportation costs?) –Transportation cost only for MDR-TB patients (GF) –Within general social protection system TB patients (especially employed) may receive disability benefits for certain period

Thank you for your attention