1. Strengths Contact management programs Established links between PHCs and district and provincial level hospitals. Example of electronic referral system Pediatric TB focal person (pediatrician) starting 2013

2. Pulmonary TB age < 5year ค age ≥ 5-18 year HIV Any age Treatment PE, CXR, TST ข TB disease Non-TB Give isoniazid 6-9 months TT ≥15 mm. give isoniazid 6-9 mo จ TT 10-14 mm. please consider TT <10 mm. observed Give isoniazid 9 months DOT Standard Take child household contact Contact Investigation and Management

3. Challenges Underreporting of child TB cases to ODPC7 –ODPC7-10 cases, PHO- 5 cases, Sisaket Hosp-25 cases (2012) Diagnosing TB disease in children particularly <5 year olds Crushed pill suspensions TB/HIV and DR-TB in children (including child contacts of DR-TB)

4. Recommendations District and Provincial level Hospitals: Report all child cases along with outcomes (0-4, 5-14 year age bands) –coordination between TB clinic and pediatricians Pediatricians: Consultation with Child TB experts in the Pediatric Infectious disease society of Thailand, for complex cases.

5. Recommendations PHO: Ensure awareness of District Hosp, PCU staff and VHVs: all child contacts <5 should get clinical assessment regardless of symptoms MoPH/GPO: Acquisition of WHO recommended pediatric dispersible FDC tablets MoPH/NHSO: use Xpert for TB diagnosis in children

6. 9. Pharmacy Pharmacists order TB drugs from GPO online (VMI) Well organized and clearly labeled Storage area with appropriate temperature and humidity control Patient kits prepared by pharmacist and double checked Appropriate documentation of ADR –ADR leaflets

7. Pharmacy- Sriratna hospital

8. Patient TB medicine kits

9. Challenges Occasional drug stockouts and delays in delivery from GPO FDC Rifafour e-275 (H-75/R-150/Z- 400/E-275) not always available and often not prescribed by physicians –Using only for >50kg (vs. >30kg) –Delayed culture conversion ? –Large pill size

10. Recommendations GPO: ensure timely drug delivery Physicians/pharmacists: FDCs should be preferred and stocked accordingly –Guideline >25kg MoPH/BTB: Pediatric dispersible FDCs

11. 10. TB/HIV Core indicators (HIV testing, CPT, ARV) significantly above national average Coordination between programs appears generally good

12. TB/HIV (II) ARV national guideline not clear (TB as AIDS-defining illness, ARV eligible at any CD4 level) Little use of IPT, little use of sensitive diagnostics for case finding

13. Recommendations National: –Clarify ARV guideline and improve communications to clinicians –Strengthen IPT guideline –Work with NHSO to increase support for sensitive diagnostics (liquid culture, molecular) for case finding in PLHA

14. 11. Infection Control Good examples of best practice including –one-stop TB clinics –triage (effective) with fast tracking –well ventilated OPDs –Surveillance of TB in HCW Inpatient cohorting and ventilation insufficient

16. Recommendations National –Strengthen guideline for outpatient management All facilities –Avoid admission unless clinically required SSK Provincial hospital –Assess air changes per hour (ACH) in OPD and consider whirlybird fan on roof –Review placement /cohorting procedures for TB (suspect) inpatients

17. 12. Engaging all providers: PPM 8 private hospitals in ODPC 7 –7 of 8 implementing DOTS –1 private hospital in Sisaket Province: 30 beds; AFB under EQA system; refers diagnosed TB cases to public sector for treatment One private clinic diagnoses TB; refers to public sector for treatment

18. Engaging all providers: PPM Private/non-MOPH sector coordinates well with MOPH system Currently no significant problem of private, non-standard TB care –may increase in future

19. 13. Program management, HR Strong political commitment and leadership: all levels Effective TB care and referral system Budget is committed for TB control activities –Ex. of accessing local gov’t funds –3 districts with GF support Excellent coordination between health facilities in SSK province

20. Program Management, HR (II) TB coordinators clearly designated at all levels including DTC Most TB coordinators received training within 2 years Highly competent PTC Strong, hard working TB teams

21. Challenges Staff turnover and civil service staffing trends: สร้างทายาท (build next generation) Limited availability of improved diagnostics (NHSO budget) Sustainability plan after ending GF Decentralization, different structures demand strong coordination skills

22. Recommendations Maintain strong political commitment Work with NHSO for expanded use of new diagnostics –Sensitive diagnosis of MTB –Follow up of MDR TB Share best practices with other health units Training: consider mentoring, buddy system exchanges

23. Thank You!!

24. ODPC 7 Dr.Sarayuth Uttamangkapong Mrs.Supasai Sangawong and team Srisaket Provincial Health Office Dr.Pravi Ampant Dr.Wanchai Lausatainragit Dr.Anupant Prajum Mrs.Vanida Somphunga Mr.Banjert Dechasilapachai Mrs.Ketsuma Wongkrai and team Srisaket Hospital Dr.Udom Petchphuvadee Dr.Noppol Buasri Dr.Taweevuth Temaeum Dr.Nitikul Temaeum Dr.Kanittha Saleewan Mrs.Phusanisa Khuntee Mrs.Onuma Thumasang Miss Chutima boonkwang And team Khukhan Hospital Dr. Pravit Saleekajonjaru Dr. Chayomon Dokpong Dr. Aree Butsorn And team

25. Srirattana Hospital Dr.Surachai Kampakdee And team Huai Nuea Primary Care Unit Dr. Peerawat Thamrongdulpark and team Pingpuay Primary Care Unit Mr. Samai Laprawat and team Samrongtagen Primary Care Unit Mr.Klai Ardsalee Mr.Ronarong Yokpol And team Sisaket Prison Mr. Traipob Wongplang And team