“World TB day and TB in Mongolia” O.Batbayar MD,MPH (University of London) National Tuberculosis Program

World TB day-Stop TB in my Life Time

2012 оны Сүрьеэтэй Тэмцэх Өдөр

TB in Mongolia Mongolia is one of the 7th high burden TB country in West Pacific region of WHO. 3985 cases last year per 2.7 population ( 12000 cases per 270 mln USA population) 185 MDR cases Total 19 XDR cases 400 paediatric cases TB incidence 219 per 100000 TB prevalence 280 per 100000 TB Mortality 21 per 100000 2011 statistics is promising

Last ten years incidence, treatment success and mortality

Last ten years incidence and treatment success

Timeline 1968: The TB laboratory was established 1992: The TB laboratory network was developed 1994: NTP was established and DOTS launched 1994: Organization of the National Reference Laboratory 1997: Quality assurance system was introduced, Supranational Reference Laboratory (SRL) Japan 1997: First Drug Resistance Survey (DRS) conducted 1999: 100% DOTS coverage 2001:Reogranization of the TB Department under the National Center for Communicable Disease (NCCD) 2001: GFATM Round1 launched, later on RCC1 2002: National Programme of Communicable Diseases (NPCD) approved, TB program is a sub-programme of the NPCD 2005: GFATM Round 4 launched, Later on RCC 4 2006: launching of GLC approved project for management of 375 patients with drug-resistant TB (DR-TB) 2007: Second DRS conducted 2008: The review of the NTP 2009: Testing of drug resistance to second-line anti-TB drugs (SLD) started 2010: second National Programme of Communicable Diseases (NPCD) approved for the years 2010-2015, TB program is a sub-programme of the NPCD 2010: National strategic plan to stop TB in Mongolia, 2010-2015 (Objective 3-expand programmatic management of MDR-TB) 2010: Updated the guidelines on tuberculosis care and service (appendix 3- guidelines on drug resistant TB services and care) approved by MOH, 2010 2010: National TB Infection control (IC) guidelines developed and approved 2010: GLC approved second cohort for 790 patients 2011: GFATM Round 10 approved and the consolidated grant will be launched in July 2011 2012 ; ACSM strategy is in development process

Current TB situation Political and financial commitment National strategic plan to stop TB in Mongolia (Objective 3-expand programmatic management of MDR-TB), MoH, 2009 National guidelines on tuberculosis care and service updated and approved by MoH, 2009 (appendix 3- guidelines on drug resistant TB services and care) Successful resource mobilization from the GFATM (since 2006 –present, single stream funding)

MDR-TB patients enrolled (2003- 2011) MDR-TB estimates burden by WHO: 106 new MDR-TB cases every year BUT BY END OF 2011 – WE DIAGNOSED 180 First three month of 2012 – 22 new cases DRS survey 2007: among new cases: 1.4% Among retreatment cases 27.5% 893 MDR-TB cases were diagnosed, out of them: 58.1% (519) have been enrolled to treatment, 26.5% (237) died, and 1.3% (12) refused treatment, 1.1% (10) were treated abroad or private hospital, 0.8% (7) were not able to be enrolled in treatment due co-morbidities, 12.1% (108) were on the waiting list.

National TB reference laboratory with 37 branches and sputum transportaion scheme

Current MDR-TB situation Available infrastructure: NTRL (DST, culture, liquid culture, LPA on FLDs) Treatment is available through GFATM support Infection control: Administrative measures General infection control order, approved by MoH, 2010 TB infection control guidelines, 2010

Treatment success rate Treatment outcomes Final outcomes for 2008 cohort Year Total Cured Treatment completed Failed Defaulted Died Cure rate Treatment success rate 2006 50 21(42.0) 11(22.0) 8 (16.0) 2(4.0) 8(16.0) 42.0 64.0% 2007 64 40(62.5) 9(14.1) 4(6.3) 6(9.4) 5(7.8) 62.5 76.6% 2008 65 48(73.8) 2(3.1) 3(4.6) 6(9.2) 73.8 76.9% 179 109(60.9) 22(12.3) 15(8.4) 14(7.8) 19(10.6) 60.9 73.6%

Partners World Vision International Mongolia (WVIM) started the implementation of the GF TB grants since 2005. It has been collaborating with the “Enerel” charity and Prison Hospital on provision of TB care services for vulnerable population as homeless and prisoners, conducting active case finding and ACSM activities Mongolian Anti-Tuberculosis Association (MATA) worked as sub-recipient (SR) for GF supported project since 2003 on the implementation of home-based and lunch-DOT for TB patients through trained health volunteers nationwide. Also they led ACSM activities for general population as well as for patients and their family to reduce stigma and discrimination against TB. Mongolian Association of Family Clinics (MAFC) implemented the PPMD since April 2009 within the Round 1 RCC. The MAFC has been carrying out the following interventions: training TOT among family physicians on early detection and treatment, referral of TB suspects to a secondary and tertiary level of TB services, transportation of sputum samples from primary health care services to TB dispensaries, and developing clinical guidelines for family doctors

Partners Mongolian Antituberculosis Union newly formed in 2011 Health Science University of Mongolia (HSUM) collaborates closely with the NTP on the revision of the curriculum of relevant health sciences courses including medical course, nursing and pharmacy. The HSUM is instrumental in on formalizing of policy documents in collaboration with the Ministry of Education. The GFATM provides financial support World Health Organization (WHO) provides technical assistance through its Country and Regional Offices.

Strength and Weakness Strengths of T B Control Program Good and detailed National Strategic Plan to Stop TB in Mongolia (2010-2015) KAP survey for health providers completed and published KAP survey with general population in final stages Partnerships in place and community mobilization Commitment of staff and available technical support Challenges in TB Control Program Human resources (all) Limited knowledge of TB (all) Stigma and discrimination (all) Coordination Significant amount of data but not used appropriately, TB prevalence survey not contacted Engaging all providers/community groups Political commitment

Challenges and some factors Various vulnerable groups (homeless, alcoholics, poor) difficult to reach Seeking diagnosis late Treatment default Infection Control practices/guidelines not implemented No diversified funding for TB control activities Limited knowledge on TB (all) and availability of services among population Limited knowledge on Interpersonal Communication and Counseling skills (providers) Lack of target specific messaging on TB No coordination or/and consistency of TB messages among partners Coordination, planning, partnerships, networks No standardized training curriculum and tools for providers and community volunteers Health providers have no interest to work in TB sector Currently limited efforts to gain political support for TB

Best TB Dispensary

TB HR seminar and Paediatric department

TB day HRD strategy ACSM strategy TB patient social care and isolation KAP survey TB incidence among HCW MoU with high burden districts TB registration web Media and web Activity among TB patients AXA among school children Debjee- amongTB Voluntary Workers TV education program

Thank you