1. From TB control to integrated respiratory disease control
Royaume du Maroc
Ministère de la Santé
From TB control to integrated respiratory disease control
Dr Jaouad Mahjour
Director of Epidemiology and Disease control
Ministry of Health, Morocco

2. INTRODUCTION Population : about 29 million
Morocco :
Population : about 29 million
Demographic transition : life expectancy = 69 years
Epidemiological transition : More chronic conditions : asthma, diabetes, heart dis. And still transmissible diseases : IST, hepatitis, TB
Ongoing health sector reform

3. public health in Morocco
TB is a major problem of
public health in Morocco
28,000 to 29,000 new TB cases / year
In 2001:
Incidence = 97 N. cases / 100,000 pop.
Incidence = 44 Smear positive cases / 100,000 pop.

4. DOTS strategy adopted as of 1991
Political commitment  NTP budget  3.5
Development of microscopy network
Short course chemotherapy + DOT
Regular supply (no anti-TB drug shortage)
Recording/reporting system in line with DOTS

5. DOTS outcomes in Morocco
Treatment success rate = 90% since DOTS implementation
Detection rate about 90%

7. DOTS impact on TB morbidity
Slow decrease of pulmonary TB incidence
Decrease of smear-positive case incidence on yearly basis since 1995 : 2 to 3% decrease per year

9. Involvement of private health sector in TB control in Morocco
30 to 40% of notified TB cases are sent by private doctors to public sector
Survey data from 4 provinces showed that general practitioners do not treat TB cases
2 surveys in Casablanca showed that chest physicians may treat few TB cases : their drug prescriptions in line with NTP and their treatment success rate > 75%

10. Involvement of prison health services in TB control
Fully integrated to NTP
12 main prisons equipped by microscopy lab
Drug, reagent and stationary supplied by NTP
Supervision by provincial TB co-ordinators

11. Involvement of army health
services in TB control
Represented in the National TB Control Board
Training ensured by NTP
Anti-TB drugs supplied by NTP

12. Morocco is a low HIV prevalence country
AIDS/HIV and TB in Morocco
Morocco is a low HIV prevalence country
Cumulative number of AIDS cases since 1986 : 1016
1 to 2 per 10,000 blood donors are HIV+
Among 857 TB patients, 1 was HIV+ (0,12%)
Sentinel surveillance system data show that less than 1% of TB patients are HIV+

13. MDR and chronic TB cases in Morocco
DRS survey in Casablanca in 1998 : among 510 new TB cases, 8.6% primary drug resistance and 2.2% primary MDR
Pool of about 200 chronic TB cases nationwide, 40 to 45 % are in Casablanca
Specific management strategy implemented nationwide for chronic TB cases (DOTS-PLUS)

14. Why combining TB and respiratory disease
case management in Morocco ? (1)
To cope with health sector reform and decentralization : need of standardized health interventions and standardized formulations (IMCI, IST, PAL)
Need of sound cost-effective health procedures
Need of a better rationalization of health services

15. Why combining TB and respiratory disease
case management in Morocco ? (2)
Logical step to sustain TB control process
NTP activities are fully managed by chest physicians : TB control co-ordinator at province/prefecture level
TB clinic (CDST) is a referral level not only for TB but also the other respiratory conditions
Demand for health care services regarding respiratory diseases other than TB (asthma)

16. Survey data from PHC facilities :
Why combining TB and respiratory disease
case management in Morocco ? (3)
Survey data from PHC facilities :
30 % of patients > 5 years are patients with respiratory symptoms
1 to 2% of are pulmonary TB patients
About 70% of patients receive antibiotic prescription
Reduction of antibiotic prescription by 30% with PAL
Cost reduction on drug prescription by 18% with PAL

17. Why combining TB and respiratory disease
case management in Morocco ? (4)
Preliminary survey data from referral level (TB clinic) :
About 40% of work activities related to TB patients
About 60% of patients are not TB/TB suspect cases
25% of patients are CRD cases
17% of patients are asthma cases

18. Conclusion
Standardization of respiratory condition management by health level will result into:
Improving TB detection and TB diagnosis quality
Making TB problem remain visible among health priorities in Morocco
Contributing to strengthen PHC services in the ongoing context of the health sector reform
Better management of health resources
Promotion of respiratory health in public health service settings

19. Thank you