June 30, 2010 TB Program Thailand MOPH – U.S. CDC Collaboration TB Project Implementation: Impact on NTP?

Overview SurveillanceResearchTraining Technical Assistance

Active Population-Based Surveillance and Enhanced Control of TB: The Thailand TB Active Surveillance Network (TB-Net)

Partners and project sites Ministry of Public Health Bangkok Metropolitan Administration (BMA) Research Institute of Tuberculosis (Japan) Thailand MOPH – U.S. CDC Collaboration Non- and inter- governmental organizations Funded: USAID, GDD,GAP Chiang Rai Tak Ubon-ratchathani Bangkok Phuket

Difference between Active Surveillance Network and Routine TB Control in Thailand Active, not passive, surveillance of diagnosed cases Data from private, NGO, and non-MOPH government facilities Electronic recording of individual cases, not summary Expanded data collection Continuous data analysis More than microscopy: culture (province), DST (referred) Integration of HIV counseling, testing, treatment

Goal of TB Net Develop models for TB prevention and control by –Measuring incidence of diagnosed TB, HIV co-infection, and MDR-TB –monitoring epidemiologic and clinical features of TB –developing, studying, implementing, and monitoring TB prevention and control strategies in Thailand

Objectives of TB Net Develop model program for measuring incidence, mortality from TB, TB/HIV, and MDR-TB, and to monitor changes over time; Use surveillance data to assess impact of public health interventions, detect outbreaks, allocate resources, guide public health and clinical practice; Build human resources and technical capacity in epidemiology, laboratory, and information technology; Develop platform for operational research on TB and TB/HIV, and to assess the impact of public health interventions.

Activities of TB-Net All persons diagnosed with TB in public and private health care facilities Standard epidemiologic data at beginning and end of treatment Culture, susceptibility testing HIV counseling, testing Monitor HIV care services for TB patients Electronic recording and reporting Treatment Diagnosis HIV TB Private Sector Healthcare Surveillance Drug-resistance Research

Have we met the objectives? Model to assess incidence/mortality Model to assess incidence/mortality Assess interventions, guide practice Assess interventions, guide practice Build epi, lab, IT capacity Build epi, lab, IT capacity Platform for operational research Platform for operational research >10 manuscripts published addressing programmatic and surveillance questions >10 manuscripts published addressing programmatic and surveillance questions Many aspects of TB Net now routine Many aspects of TB Net now routine – TB/HIV initiatives (PITC, ART training) – Access to liquid culture – Electronic data collection

Have we met 2 nd Global Plan to Stop TB, ? DOTS expansion and enhancement Address TB/HIV and MDR-TB Establish Public-private partnerships Enable and promote research Strengthen health-system Empower patients and communities √√√√?√√√√?

Policy Change Impact TUC/TB Contribution National policy adopted to perform HIV counseling and testing on TB patients Built evidence base; tested strategy; financial support for planning workshop in Viet Nam; technical assistance on drafting initial plan National TB recording / reporting system revised to include HIV-related data Built evidence base;; revised national forms based largely on forms developed for Ubon project

Better Public Health Outcomes Impact TUC/TB Contribution Increased case finding in Bangkok, Phuket Provided infrastructure and technical guidance to enhanced public and private collaboration, TB program monitoring Decreased death rate and increased TB success rate among TB/HIV in Ubon, and Chiang Rai Provided infrastructure and technical guidance Increased sputum conversion rate and treatment success rate in Phuket and Bangkok Provided infrastructure and technical guidance Increased proportion of patients receiving HIV counseling and testing in Bangkok, Chiang Rai, Phuket, Tak, and Ubon Provided infrastructure and technical guidance

Enhanced Capacity (1) Impact TUC/TB Contribution More rapid, sensitive diagnostic methods for TB in Bangkok. Chiang Rai, Phuket, Tak, Ubon Provided infrastructure and technical guidance Access to routine drug susceptibility testing for Bangkok, Chiang Rai, Phuket, Tak, Ubon Provided infrastructure and technical guidance Electronic recording and reporting implemented in Bangkok, Chiang Rai, Phuket, Tak, Ubon, Bamrasnaradura Institute Provided infrastructure and technical guidance

Enhanced Capacity (2) Impact TUC/TB Contribution Measuring outcomes of public health interventions by conducting operational research Provided infrastructure and technical guidance; Observational study launched to understand causes of high, early mortality rate in TB/HIV patients Training of public health staff in TB, Laboratory and TB/HIV management Provided infrastructure and technical guidance Enhanced capacity for TB outbreak response Outbreaks investigated at Phuket Vachira Hospital and Wat Tham Krabok with laboratory, IT, epidemiologic, statistical support from TUC

Exporting of Models Impact TUC/TB Contribution Expanded TB/HIV partnerships in Northeastern Thailand Lessons learned in Ubon project applied to other provinces by using resources from GFATM Expanded Public- Private- Partnerships (PPP) in Bangkok Lessons learned in 2 health centers (HC) of Bangkok project applied to 7 HCs then 19 HCs WHO TB/HIV training course for SEARO countries Curriculum development; organization; Hosting of site visits at project sites

Lab Capacity building to TB Active Surveillance Network (1) Improve lab capacity and ability including infrastructure, equipments and reagents Human resource: hiring full time staffs and support staff to present in international conference Provide Technical support for new diagnostic tools implementation (Liquid media culture, Capilia TB and Hain test)

Develop and implement Electronic data recording Support Lab quality control - Collaborate with NTRL for monitoring and supervision and supervision - Participation in External Quality Assurance of College of American Pathologists of College of American Pathologists - Organize training on Standard Operating Procedure of TB culture and Good Procedure of TB culture and Good Laboratory Practices Laboratory Practices Lab Capacity building to TB Active Surveillance Network (2)

Do we have Impact on TB Lab ? Liquid culture Implementation Liquid culture Implementation Implementation of Rapid identification by strip speciation (Capilia TB and SD Bioline) (Capilia TB and SD Bioline) Expansion of Electronic recording Expansion of Electronic recording for lab data for lab data

Lessons Learned Active surveillance increases case finding –Enables comparisons between public and private sector TB treatment outcomes Enhanced laboratory capacity, performance MDR-TB rates ~1-4% consistent with national estimates – no hidden epidemic Increased TB/HIV collaboration for testing, linkages to care Rich database for operational research

Challenges Have engaged private sector to share data for monitoring and evaluation, but need strategy to elevate private sector’s standard of care System developed and integrated into MOPH, but many competing reporting systems proposed in MOPH – need unified national standard for TB How to translate implementation models into routine practice and scale up?

Observational study of HIV-infected TB patients Improving diagnosis of TB in HIV-infected persons Improving diagnosis of TB in HIV-infected persons Public health impact of implementing the GenoType® MTBDRplus assay for diagnosis and management of drug-resistant TB in Thailand Research (1)

Evaluation of a program to enhance TB laboratory services in Thailand: Did providing TB drug-susceptibility results to physicians change clinical practice? Performance comparison of SD Bioline TB AG MTP 64 Rapid with Capilia TB NEO for mycobacterial species identification from broth- based culture at ODPC7, Ubon Ratchathani Research (2)

Training Operational research Counseling –HIV Diagnosis counseling and testing in TB patients Increasing ART use in HIV-infected TB patients TB infection control, collaboration with WHO TB/HIV inter-country, collaborate with WHO Laboratory: SOP, AFB, Culture, DST, EQA

Technical Assistance NTP program Outbreak response Lab capacity building Epidemiological & statistical consultation Manuscript development for TB-Net

Future Directions Continued focus on 3 key areas: research, training, technical assistance Focus on lab capacity building and improving diagnosis in routine care settings Operational research in improving IC, ICF/IPT in HIV Increased focus on MDR TB

Thank you for your attention