1. Accelerating PMDT scale up in Ethiopia
Ezra Shimeles (MD, MPH)
TBCARE/KNCV, Ethiopia

2. Outline Introduction and background National TB and MDR TB situation
National Performance on TB
MDR TB Scale up
Challenges in PMDT Scale up
Way forward

3. Introduction and Background: Ethiopia
11 administrative units
90 million population
83.6 % in rural
Economy(IMF)
Agriculture 46.6%
Industry 14.5%
Services 38.9%
GNI Per Capita:410
(World Bank 2012)
Life expectancy at birth :59
(World Bank 2011)
Land mass not needed, located in the Horn of Africa not needed
11 admin units, subdivision in ? Subunits and municipalities ?
GNI 410 – (LIC)

4. The Health Tier System

5. Health Profile Health Service No. of health facilities Human capital
PHS coverage = 92%
No. of health facilities
Hospital = 132
Health centers = 3000
Health posts = 15,700
Human capital
Physicians = 2,115
Health officers = 1606
Nurses = 20, 109
Health extension workers = 34, 382

6. National TB Situation and NTP overview
Among the 22 HBC
16th among the 27 MDR-TB high priority countries
Incidence:
258/100,000 population
Prevalence :
TB 237/100,000 population
The TB related mortality rate : 18/100,000
WHO 2012 TB Report

7. MDR-TB burden DRS survey 2003-2005 1.6% New 11.8% Previously treated
WHO estimate
2500 MDR TB Cases are expected from notified cases annually
DST requirement per annum:
6000 new and 6000 retreatment cases (2013)
Current survey is under way but result not ready.(unofficial among Retreatment 15%; among New 1.3%)

8. Tuberculosis Case finding ( All forms of TB (New and retreatment)
New patients

9. Treatment outcome for new PTB+
New PTB + patients

10. TB/HIV Integration services

11. TB/HIV Integration services(2)

12. National PMDT implementation plan
Phase I: pilot phase ( )
Target: treat 45 patents
Establish MDR treatment at one TB Hospital in 2009
Scale Up phases: Five years expansion plan ( ):
Target : treat 8,018 MDR-TB patients
Phase II: Roll out phase using ( )
MDR TB referral centers
Establishment of regional culture and DST centers
Pilots Ambulatory model
Phase III: Scale up phase( )
Rapid diagnostic techniques
Ambulatory centers up to Zonal hospitals level
Difference phase 2 and 3 ? What does up to zones mean ?
Scale-up plan in numbers of patients to be put on treatment ?

13. Preparatory phase for initiation
National technical working group on MDR-TB established.
Guidelines: PMDT; TB infection control
Training material for health care workers
Training of health care workers
Renovation of MDR-TB wards
Registration of second line anti-TB drugs conducted
Procurement of SLDs
Infection control items such N-95 respirators, were made available
Recording and reporting formats developed and printed
IEC materials including posters and stickers developed and printed
Do you have pictures that illustrate these points ?

15. Achievement of pilot phase
Treatment started at St Peter TB hospital
Treatment follow up sites established
Capacity built:
infrastructure, staff, IC, M&E,
Enrollment : 100% of target
45 patients put on treatment
Treatment outcome
Satisfactory
= phase 1 ?

16. Shifting the gear: Preparation for accelerated scale up
Implementation protocol for ambulatory care for DR-TB
Customization of training material for middle level
Selection of TIC and TFC
1 TIC linked to 8-10 TFC
Update case finding and diagnostic approaches
Establishment of Sputum sample transport system
Efficient PSM for SLDs, ancillary drugs
Socio-economic support for patients
Renovations of TICs, TFCs
Improve Human capital and leadership
MDRTB specific ACSM

17. DR TB Treatment network

18. Case detection and enrollment,2007-13

19. Site expansion,2009-13 TIC –Treatment initiating center
TFC –Treatment follow up center

20. Scale up plan versus achievement, 2009-13 (Total enrolled n=1000)

21. Enrolment by DST status in Ethiopia, 2009-13

22. Interim Treatment outcome

23. Final Treatment outcome(2009-11 cohorts) (Total n=173, Cure Rate 7% ;TSR 80%)

24. Major Challenges
MDR TB Suspect identification and Sputum sample transportation challenges
GeneXpert rollout is very slow
HR Capacity needs not met
Poor Lab support for patient monitoring
Ancillary drugs shortage - What, when, where
Patient socioeconomic support system not standardized
Infection control settings in most health facilities not satisfactory
SLD Supply to TICs and TFCs not fully integrated to the national DSM
Long turn around time for follow up Culture results
Suggest to remove the 1st
Rewording – pictures ?

25. Targets for in PMDT
To decentralize the MDRTB treatment service to PHC level by 2015:
TIC at Zone level (40, 70, 96 zones in 2006, 7 and 8 respectively) and at least one TFC at Woreda level (814 Woredas).
DST screening for
10% of New PTB smear positives and
100% of previously treated TB
To enroll 100% notified confirmed MDR TB cases for treatment
To achieve 95% interim result of culture conversion
To achieve TSR rate of 80% and reduce the death rate from 15% to 10%
To improve cases finding in pediatric age group
to reach 7% of all cases
To provide integrated MDR TB and HIV service in all MDRTB service points

26. Major partners of MOH for PMDT Roll out
Global Fund
WHO, FIND, EXPAND TB Project
USAID:TB CARE I(KNCV), HEAL TB (MSH), PHSP (Abt.)
Global Health Committee
CDC : JHU, I-TECH, ICAP, UCSD
MSF Belgium
International Organization for Migration

27. Thank you