The implementation of the National Tuberculosis Control Program at a regional level: Voronezh TB Service JULY 13, 2015 Dr. Kornienko, Sergey

The biggest region in the central belt of the European part of Russia Distance from Moscow km The area 52,400 sq. km Area Population (2014) 2,328,959 Administrative center – the city of Voronezh with a population 1,014,600 Voronezh Region

Measures to optimize the TB service of the Voronezh Oblast TB Site Number of beds From 2015 Total - Inpatient beds - Day Hospital - Hospital-at-Home Oblast Dispensary - Inpatient beds - Day Hospital - Hospital-at-Home District Dispensary (DD) - Inpatient beds - Day Hospital - Hospital-at-Home 9 DD DD DD Children Sanatorium Adults’ Sanatorium Up to 2012 From 2012г.

4 FSG.ORG © 2012 FSG Lilly 7 Team Meeting Regional Interdepartmental Commission General Medical Service Penitentiary System Russian Federal Service for Surveillance on Human Wellbeing Social Service The administration of municipal districts Service of Labor and Employment TB Service Migration Service

Main TB epidemiological indicators in the Region Indicators, per Territorial incidence of tuberculosis VRZRF TB incidence of residential population VRZRF TB incidence in children VRZRF Territorial TB mortality VRZRF TB mortality of residential population VRZRF

TB Incidence (per population) In 2014, the first time in 50 years, it has been achieved a reduction in TB Incidence 33.0 per population Dynamics RF % CFD % VRZ %

Reducing the reservoir of MDR TB in Voronezh region

TB/HIV situation

Reducing the burden of TB: Patient-Centered Service Active TB Case Finding Strategy Reducing the pool of hidden infection through active early detection POPULATION: Annual Mandatory Screening Timely Diagnostics, Adequate Treatment Reducing the pool of active infection by effectively curing TB patients TUBERCULOSIS EFFECTIVE TREATMENT Palliative Care Sanatorium TUBERCULOSIS-INDUCED DISABILITY

Active TB Case Finding Strategy (operational data) Indicators Coverage with all types of screening methodsVRZRF % Coverage with a chest radiography for population over 15 years oldVRZRF % Detection per 1000 screenedVRZRF Passive TB detection (doctors’ visits)VRZRF % Detected “Post mortem”VRZRF %

International projects 2010 – 2012: Green Light Committee (World Health Organization) 2011 – Present: “Partners in Health” Eli Lilly MDR- TB Partnership – Major Initiative I: Improving tuberculosis infection/transmission control in the Russian Federation – Major Initiative II: Building a sustainable model for high-quality ambulatory MDR-TB care delivery

F-A-S-T: Improving tuberculosis transmission control Administrative control new approach Find cases Actively (identifying MDR-TB patients) GeneXpert MTB/RIF assay Separate patients safely to reduce exposure to drug-resistant strains (stopping nosocomial transmission), and Treat effectively with second-line drugs

Rapid Rif-susceptibility testing during the process of hospitalization,

Patient-Centered Approach (PCA) SupportVehicles 2011One PCA Team 2 nurses, designated TB doctor, PCA Coordinator (deputy chief TB physician), social worker Daily food packages, Mobile plans One vehicle 2012Two PCA Teams 2 nurses, 2 designated TB doctors, PCA Coordinator (deputy chief TB physician), social worker, addiction specialist Daily food packages, Mobile plans, symptomatic medications, в т.ч. АЗ Two vehicles 2013Three PCA Teams 2 nurses, 2 designated TB doctors, PCA Coordinator (deputy chief TB physician), social worker, addiction specialist Daily food packages, Mobile plans, symptomatic medications Three vehicles

Treatment outcomes for PCA patients,

Advancing strategies for quality outpatient TB services Context of Patient-centered Care (PCA) Enabling patients' environment Patients' circumstance Accessibility of DOT Patients education Social support Reduced vulnerabilities Improved outputs Content of Care Evidence-based Standards to Protocols and Guidelines Improved outcomes, Program efficiency Process of Care Compliance/Adherence Attitudes/Motivation Audiovisual educational practice using counseling approach School of Patiens

Main components to sustain effective TB program PCA team Social support: public transportation passes, daily food sets, monthly hygiene sets Substance abuse specialist, psychologist and social worker Rapid diagnostic methods, early start of treatment Sufficient supply of TB drugs, second line drugs and side effect medications Treatment TB according to the national standards of care DOT network: TB inpatient hospital, day-care TB hospital, TB policlinic, “Hospital at Home”, Patronage nurses, TB DOT points at the city general medical service

Challenges Plans Strengthening of the default retrieval system Sustain the success of the regional TB Control Program Expanding intensified patient-centered care with prioritization of vulnerable populations, such as children and adolescents -- to create the family- centered accompaniment (FCA) model of care (oversee families with TB patients with children)

For the sake of children's health we still have so much to do !!!

THANKS Contact details: The Lilly MDR-TB Partnership is funded by the Lilly Foundation