1. Program Management Of DR-TB (PMDT)
“Diagnose, Treat and Cure All Missing TB Cases”
Dr Mohan K Prasai
Consultant Chest Physician
NTC

2. Global Burden Of MDR-TB: 2012
Global Estimation 310,000
Diagnosed cases 86,000

3. Types of Drug Resistance
Mono-resistance : resistance to single first line drug
Poly-resistance: resistance to more than one drug other than HR together
Multi- Drug resistance (MDR): resistance to at-least Rifampicin & Isoniazide or RIF Resistance confirmed by GeneXpert.
Pre-XDR: MDR with resistance to one of injectable or floroquinolone.
Extensive Drug resistance (XDR): resistance to floroquinolone and injectable second line in addition with MDR TB.
XXDR: Resistance to almost all ATT.

4. Types of Resistance (By Treatment history)
Initial resistance ( New cases - never have prior ATT or less than one month)
Acquired resistance (Re-treatment or new case with more than one month of ATT)

5. Multi Drug resistant Tuberculosis
MDR TB is an increasing health problem.
A serious challenge to TB control programm.
It is regarded as a result of failure of effective implementation of Tuberculosis control program.
Minimize the transmission of DR-TB by Infection control measures.
GeneXpert is a gold standard diagnosis tool for early and confirmatory diagnosis of MDR-TB.

6. How is it caused ?
It is the result of inadequate or poorly administered treatment regimen.
Causes of inadequate treatment:
1. Health care providers- inadequate regimens
Drugs -inadequate supply or quality
3. Patients -inadequate drugs intake

7. When to Suspect of MDR TB ?
Failure of Re-treatment Regimen
Persistent positive sputum
Fall and Rise Phenomenon
Clinical and radiological Deterioration

8. DR-TB(M/XDR) Management sites
50% Treatment Centers and 25% Sub Treatment Centers in private sector
Rx Centres: 13 Rx Sub-centres: 71

9. Key Policies of PMDT GeneXpert test is gold standard test
Provision of free quality assured second line drugs
Fully supervised treatment
Prepare the patient for treatment
Clinical monitoring, treatment and documentation of side effects
Regular sputum microscopy and culture monitoring
Standardized recording and reporting system
Monitoring of treatment outcome and evaluation of program progress through cohort analysis

10. Candidates for Second line DST(SLDST)
Any patient who has had a past history of previous second line drugs
Any patient who remains culture positive on or after four months of the standard regimen used for MDR TB
Contacts of an individual documented with XDR TB.

11. Where To Refer ? Near by GeneXpert centre
Line Probe Assay (LPA)
Near by GeneXpert centre
National Reference Lab, GENETUP, Kalimati
National Tuberculosis Center, Thimi

12. Nepal Report In % (MDR-TB)

13. Nepal Report In % (XDR-TB)

14. DR TB Program Milestones
DOTS PLUS Pilot Program started with 350 pts for 2 yrs(Treatment Centers- 5, Sub Centers – 11)
GLC review and permission for expansion (300/year)
XDR-TB Treatment started
Treatment Centre - 12, Sub-Centre - 62 (8 DRTB Hostels established in 5 regions (EDR-1, CDR-3, WDR-1, MWDR-2, FWR-1)
hostels planned
Treatment centre 13,sub-centre-71, DR Home in Bandipur

15. List of DR-TB centers National TB centre,Thimi (G)
National Medical College,Birgunj (NG)
Lalgadh Hospital (G)
NATA Morang (NG)
BPKIHS Dharan(NG)
Regional TB centre, Kaski(G)
Bhim Hospital,Bhairawa(G)
Lumbini Zonal Hospital, Butwal(G)
NATA,Banke (NG)
Mahakali Zonal Hospital, Mahendra Nagar (G)
Seti Zonal Hospital,Dhangadhi(NG)
TEAM Hospital- Dadeldhura(NG)
NATA/GENETUP-Kathmandu(NG)

16. Differences between DR Centre and Sub centre
Treatment centre
Sub centre
Facility of Medicines
Facility of Sputum examination
Facility of Baseline investigations
Responsible for filling all the documents required for enrollment and follow-up
Responsible to transport the sputum samples to NRL for C/S
Facility of management of severe side effects
Responsible to Quarterly reporting to Regional monitoring & evaluation WS
Facility of medicines
Facility of management of minor side effects
Responsibility of referring the patient to DR Centre for each monitoring investigations
Responsible to Quarterly reporting to Treatment centre (DR-TB management WS)

17. Responsibilities of DR TB centre
Counseling to the patient
Registration of the patients
Baseline and follow-up investigations
Collection & transportation of the samples to NRL
Provide DOT
Management of the side effects
Supervision of DR Sub centers
Participation in the National monitoring and evaluation workshop

18. Responsibilities of DR TB Sub-centre
1. Counseling to the patient
2. Provide DOT
3. Refer the patients to DR centre for regular investigations
4. Management of minor side effects

19. Standard MDR-TB Treatment Regimens
First Phase 8 – 12 months (intensive phase)
Kanamycin (KM)
Pyrazinamide(Z)
Levofloxacin (Lfx)
Ethionamide (Eto)
Cycloserine (Cs)
Second Phase 12 – 14 months (continuation phase)
All the drugs except the injectables.

20. Extensively Drug Resistance (XDR )TB
XDR-TB is a form of TB which is resistant to at least four of the core anti-TB drugs.
XDR-TB involves resistance to the two most potential anti TB drugs, that is Isonized & Rifampicin, also known as MDR-TB in addition to resistance to any of the floroquinolone (ofloxacin,Moxifloxacin) and any injectable aminoglycosides (Capreomycin, Kanamycin).
Take substantially longer to treat than ordinary(drug susceptible).
Require the use of second line anti TB drugs ,which are more expensive and have more side effects.

21. Management of XDR TB cases
Started since Feb 2010
Much more difficult to treat than MDR TB cases
Standard regimen (but individualization is implemented in the substitution of drugs for severe side effects)
Intensive phase for 12 months and continuation for another 12 months. (Injectable first 8 months six days a week ,and then 4 months thrice a week)

22. Standard XDR –TB Treatment Regimens
First Phase 12 – 16 months (intensive phase)
Capreomycin(CM)
Pyrazinamide(Z)
Moxifloxacin(Mfx)
Amoxycillin/clavunate(Amoxy/clav)
Cycloserine (Cs)
Paraaminosalicylic Acid (PAS)
Clofazamine(cfz)
Second Phase 12 – 14 months (continuation phase)
All the drugs except Injectables one.

23. Drug Resistance Survey Report
Year
Initial Any Resistance
Initial MDR
Acquired Any Resistance
Acquired MDR
1999
13.32%
3.74%
28.20%
11.96%
2002
10.99%
1.32%
40.93%
20.46%
2007
14.71%
2.86%
25.3%
11.72%
2011
9.6%
2.2%
25.4%
15.4%

24. Estimation Of MDR/XDR TB In Nepal
 DRS- 2011
Estimated MDR-TB cases among new cases
2.2%
553
557
561
Estimated MDR-TB cases among retreatment cases
15.4%
455
464
467
Total estimated MDR-TB among notified cases
1008
1021
1027
XDR-TB cases targeted for enrolment 35 40 45
Pre-XDR 63 95
120

25. MDR-TB patients enrolled in DR program of Nepal

30. Treatment : Comparisons

31. Facility/Support To Health Care Providers: To the patients
Health Hazard (Nrs.1000 per month)
Supply of PPE (N-95 mask and gloves).
To the patients
Nutritional support (Nrs.1500 per month) throughout the treatment period.
Supply of surgical mask

32. Prevention of MDR TB ?????
Rapid diagnosis and adequate treatment of TB with qualitative drugs
Sound implementation of DOTS program
Identify contacts who could have contracted TB, i.e family members, people in close contact etc.
Patients with HIV/AIDS should be identified and diagnosed ASAP.
Contact tracing for MDR -TB cases in place
Early diagnosis of DR-TB cases referring suspected cases for GeneXpert
Infection control measures taken where all DR- TB patients will be treated
Indoor Facilities ( Isolation) during Ss positive

33. What Improves Outcomes:
Early identification (and treatment) of MDR-TB
Use of an “effective” regimen
Adequate patient support
DOT
Prompt management of side-effects
Social economic support

34. “ STOP TB IN MY LIFETIME”
REQUEST
Drug resistant tuberculosis is entirely the end results of a number of different Failures, which is possible to Avoid by providing qualitative service .
LET us work all together for the sake of future generation.
Be sincere towards to own responsibilities
“ STOP TB IN MY LIFETIME”

35. Challenges !!! Ignorance/Poverty Low MDR-TB case finding
Limitation of sample currier system
Limitation of Diagnostic centers
Insufficient socio-economic support to patients
High prevalence of Floroquinolone Resistance
Infection control measures are not in place
Limitation of qualified health personnel in DR centres
Social stigma

36. I am Stopping TB
We Must Stop TB

37. Thank you for your kind Attention