1. MDR-TB and TB Update: Rayong Province CAP-TB Strategic Planning Meeting August 1, 2013 Bangkok, Thailand Chittima Thibbadee, M.D.

2. Presentation Outline Latest MDR-TB and TB prevalence At-risk populations Current effort – Prevention – Care and treatment

3. Presentation Outline Available resources/fundings – Available resources e.g. equipment, human resources, number of health facilities with the diagnosis and treatment capacity, etc. – Funding sources, period and focuses Challenges and Gaps

4. Rayong Pattaya

5. Latest MDR-TB and TB Prevalence

6. TB Prevalence Rate in Rayong Province Between 2008 - 30 June 2013* Year *2013 data is between 1 October 2012 – 30 June 2013

7. TB incidence (per 100,000) by WHO region, and in Thailand, 2011 source: WHO, Global Tuberculosis Report 2012 TB incidence in Thailand is 2.5 – 4 times higher than Europe & America regions

8. Number of case between 2008-June 2013 645 case 683 case 651 case 690 case 640 case 606 case ที่มา : TB 07

9. MDR-TB Prevalence Rate in Rayong Province Between 2008 - 30 June 2013 *2013 data is between 1 October 2012 – 30 June 2013 พ.ศ.พ.ศ.

10. Number of MDR-TB Patients by District Districts Number of MDR-TB Patients 2007 (n=10) 2008 (n=19) 2009 (n=25) 2010 (n=8 ) 2011 (n=11) 2012 (n=29) 2013 (October12-June13) (n=19) Muang 56144517178 Klaeng 3652322 Ban Khai 2121312 Ban Chang -11--32 Pluak Daeng -31---2 Wang Chan --1--11 Nikom Pattana -11---- Khao Cha-mao ------- Rayong Central Prison -----21 Other provinces -1 ( Chonburi ) -1 (Songkla) -3 (Chonburi) 1 (Chonburi)

11. Number of MDR-TB case between 2007-2013

12. Estimates of MDR-TB burden (2011),Thailand Estimates among notified cases % of new TB cases with MDR-TB1.7 (1.0–2.6) % of retreatment TB cases with MDR-TB35 (28–42) Estimated MDR-TB cases among new pulmonary TB cases notified in 2010 890 (540–1 400) Estimated MDR-TB cases among retreated pulmonary TB cases notified in 2010 1 300 (1 000–1 600) Source: WHO Global TB Report 2012

13. Number of MDR-TB case between 2007-2013

15. At-risk Populations Population groupNumber of Population 1. Elderly67,987 2. Diabetics17,779 3. Migrants14,770 4. HIV infected persons12,560 5. Inmates6,211

16. Current Effort

17. Prevention 1.Early (MDR-TB) case detection, contact investigation 2.Quality DOT in drug-sensitive TB (DS TB) 3.Proper management of MDR-TB 4.Increase public awareness 5.World TB Day campaign

18. Care and Treatment 1.TB clinics staffed with trained health personnel 2.Active /intensified case finding in different at-risk population groups 3.Sputum smear tests/culture to diagnose pulmonary TB by the National TB Program 4.Quality DOT

20. Care and Treatment (cont) 5.Uninterrupted supply of quality TB drugs 6.Infection control in hospital/household levelsInfection control in hospital/household levels 7.Integrated HIV/AIDS and TB program 8.Patient’s registration and reporting completeness 9.MDR-TB patient register implemented

27. Available Resources

28. Health Facilities and Diagnosis Capacity 1.65 culture and identification laboratories (Solid media culture is performed at Rayong Hospital) 2.35 DST laboratories (DST for FLDs/SLDs is also available at Siriraj Medical School/BTB) 3.24 Molecular Assay laboratories (14 GeneXpert machines in Thailand, one at Rayong hospital with support from USAID|Asia through CAP-TB Project)

29. Public and Private Health Facilities in Rayong Province District Public Health FacilitiesPrivate Health Facilities regional (n) community (n) sub-district (n) Health center (n) Private hospital (n) Mueang1119103 Klaeng012310 Ban Khai011500 Pluak Daeng011000 Ban Chang01900 Wang Chan01700 Khao Chamao01600 Nikhom Phatthana01500 Total1894113

30. Human Resources Health personnel who care for MDR-TB patients at Rayong Hospital 2 Medical physicians (pulmonologist) 1 Paediatrician 1 Pharmacist 1 Register Nurse (& counselor)

31. Human Resources (cont) Health personnel who care for MDR-TB patients at Rayong Hospital 4 Medical Technologist (lab staff) 1 Counselor Health worker (home visit) - Full time 2 - Part time 3

32. Current Funding Sources National Health Security Office (NHSO) – ongoing Objectives: 1. Active case findings/screening amongst at-risk populations and close contacts of TB/MDR-TB patients 2. Directly-observed therapy (DOT) by trained personnel for TB/MDR-TB patients

33. Criteria for Diagnostic Technique Laboratory diagnostic technique Molecular assay Solid/Liquid Culture & DST Benefit Only one test per course of treatment Group of patients Re-treatment with AFB+ (Relapse,TAD) Re-treatment with AFB+/- (Relapse,TAD) On-treatment with AFB+ (Failure of sputum conversion after 3 months) On-treatment with AFB+ (Failure of sputum conversion after 3 months) Pre-treatment (new case) especially for household MDR- TB contact with AFB + Pre-treatment (new case) in Household MDR-TB contact, HIV and prisoner (AFB +/-) Sputum criteria Sputum with smear positive only Sputum with smear positive or negative (except for on-treatment group) 33

34. Current Funding Sources Global Fund – to be ended in September 2014 Objectives: 1. Support the implementation of DOTS in all communities in three districts in Rayong Province 2.Facilitate TB/HIV activities 3.Empower community in TB prevention and control 4.Provide living support to patients

35. Current Funding Sources USAID | Asia through CAP-TB Project – to be ended in September 2016 Objectives: 1.Strengthen MDR-TB prevention and management among at-risk population groups 2.Support active case findings/screening among HIV infected persons, diabetics, elderly persons and migrant population in four communities in three districts in Rayong Province. 3.Provide package of service to patients to support treatment adherence.

36. Current Funding Sources  Local administration organization – ongoing Objectives: – To support project implementation according to the need and priority of the areas

37. Current Funding Sources  Local administration organization – ongoing Objectives: – To support project implementation according to the need and priority of the areas

38. Thai – Health insurance  National Health Security Office (NHSO) – Other  global fund Non-Thai – Global fund Current Funding Sources

40. Challenges and Gaps

41. Prevention ChallengesWay forward 1. Prevention of acquired MDR-TB -Strengthen quality DOT for TB patients -Improve infection control practice in household 2. Prevention the continuing spread of MDR-TB strain -Strengthen early MDR-TB case detection in community 3. Stop chain of transmission-Strengthen MDR-TB management

42. Diagnosis ChallengesWay forward 1. Culture and DST test reimbursement - Number of tests (throughout the treatment course) to be reimbursed is in discussion 2. Use of GeneXpert to diagnose MDR-TB beyond at- risk populations

43. Care and Treatment ChallengesWay forward 1. Promote treatment adherence and success -Side effect management -Provide socio-economic support to patients 2. Stigmatization-Public/community education 3. Information sharing-Improve communication and record tracking and keeping system 4. Quality DOT provision for MDR-TB patients -Community engagement

44. Thank you For your attention