1. The implementation of the National Tuberculosis Control Program at a regional level: Voronezh TB Service JULY 13, 2015 Dr. Kornienko, Sergey

2. The biggest region in the central belt of the European part of Russia Distance from Moscow - 587 km The area 52,400 sq. km Area Population (2014) 2,328,959 Administrative center – the city of Voronezh with a population 1,014,600 Voronezh Region

3. Measures to optimize the TB service of the Voronezh Oblast 2005-2015 TB Site Number of beds 2005-20102012-2014From 2015 Total - Inpatient beds - Day Hospital - Hospital-at-Home 1590 - 1005 105 - 810 85 65 Oblast Dispensary - Inpatient beds - Day Hospital - Hospital-at-Home 1125 - 820 50 - 700 30 40 District Dispensary (DD) - Inpatient beds - Day Hospital - Hospital-at-Home 9 DD 465 - 4 DD 225 55 - 4 DD 110 55 25 Children Sanatorium -- 2490470 Adults’ Sanatorium -- 1160 Up to 2012 From 2012г.

4. 4 FSG.ORG © 2012 FSG Lilly 7 Team Meeting Regional Interdepartmental Commission General Medical Service Penitentiary System Russian Federal Service for Surveillance on Human Wellbeing Social Service The administration of municipal districts Service of Labor and Employment TB Service Migration Service

5. Main TB epidemiological indicators in the Region Indicators, per 100 000 200020052010201220132014 Territorial incidence of tuberculosis VRZRF 73.9 90.7 70.1 83.8 56.5 77.2 45.1 68.1 36.7 63.0 33.0 59.5 TB incidence of residential population VRZRF 49.0 65.5 53.7 67.9 45.1 69.6 35.3 57.6 28.1 53.4 25.4 50.7 TB incidence in children VRZRF 6.4 17.9 7.1 16.4 4.1 15.2 4.6 16.4 3.9 14.5 3.5 13.2 Territorial TB mortality VRZRF 11.9 20.4 14.8 21.1 11.0 15.4 7.9 12.4 6.0 11.3 5.2 10.0 TB mortality of residential population VRZRF 9.6 16.0 10.9 18.2 8.7 12.5 6.1 10.1 4.94.99.29.24.94.99.29.2 4.04.08.38.34.04.08.38.3

6. TB Incidence (per 100 000 population) In 2014, the first time in 50 years, it has been achieved a reduction in TB Incidence 33.0 per 100 000 population 200520102014 Dynamics RF83.377.259.5- 28.6% CFD60.655.439.0- 35.6% VRZ70.156.533.0- 52.9%

7. Reducing the reservoir of MDR TB in Voronezh region

8. 201420132012 TB/HIV situation

9. Reducing the burden of TB: Patient-Centered Service Active TB Case Finding Strategy Reducing the pool of hidden infection through active early detection POPULATION: Annual Mandatory Screening Timely Diagnostics, Adequate Treatment Reducing the pool of active infection by effectively curing TB patients TUBERCULOSIS EFFECTIVE TREATMENT Palliative Care Sanatorium TUBERCULOSIS-INDUCED DISABILITY

10. Active TB Case Finding Strategy (operational data) Indicators200020052010201220132014 Coverage with all types of screening methodsVRZRF % 63.4 57.1 66.1 57.9 89.0 63.6 89.1 65.7 86.6 65.8 85.6 66.5 Coverage with a chest radiography for population over 15 years oldVRZRF % 55.775.187.1 55.6 85.6 58.3 84.6 59.0 83.5 Detection per 1000 screenedVRZRF 0.60.60.60.6 0.76 0.6 0.42 0.58 0.34 0.61 0.28 0.56 0.25 Passive TB detection (doctors’ visits)VRZRF % 42.2 47.2 29.9 46.6 28.6 40.3 26.6 39.3 25.0 39.7 26.5 Detected “Post mortem”VRZRF % 0.40.40.82.80.82.8 0.81.80.81.8 0.91.60.91.6 0.71.60.71.6 0.71.70.71.7

11. International projects 2010 – 2012: Green Light Committee (World Health Organization) 2011 – Present: “Partners in Health” Eli Lilly MDR- TB Partnership – Major Initiative I: Improving tuberculosis infection/transmission control in the Russian Federation – Major Initiative II: Building a sustainable model for high-quality ambulatory MDR-TB care delivery

12. F-A-S-T: Improving tuberculosis transmission control Administrative control new approach Find cases Actively (identifying MDR-TB patients) GeneXpert MTB/RIF assay Separate patients safely to reduce exposure to drug-resistant strains (stopping nosocomial transmission), and Treat effectively with second-line drugs

13. Rapid Rif-susceptibility testing during the process of hospitalization, 2013 - 2015

14. Patient-Centered Approach (PCA) SupportVehicles 2011One PCA Team 2 nurses, designated TB doctor, PCA Coordinator (deputy chief TB physician), social worker Daily food packages, Mobile plans One vehicle 2012Two PCA Teams 2 nurses, 2 designated TB doctors, PCA Coordinator (deputy chief TB physician), social worker, addiction specialist Daily food packages, Mobile plans, symptomatic medications, в т.ч. АЗ Two vehicles 2013Three PCA Teams 2 nurses, 2 designated TB doctors, PCA Coordinator (deputy chief TB physician), social worker, addiction specialist Daily food packages, Mobile plans, symptomatic medications Three vehicles

15. Treatment outcomes for PCA patients, 2011 - 2015

16. Advancing strategies for quality outpatient TB services Context of Patient-centered Care (PCA) Enabling patients' environment Patients' circumstance Accessibility of DOT Patients education Social support Reduced vulnerabilities Improved outputs Content of Care Evidence-based Standards to Protocols and Guidelines Improved outcomes, Program efficiency Process of Care Compliance/Adherence Attitudes/Motivation Audiovisual educational practice using counseling approach School of Patiens

17. Main components to sustain effective TB program PCA team Social support: public transportation passes, daily food sets, monthly hygiene sets Substance abuse specialist, psychologist and social worker Rapid diagnostic methods, early start of treatment Sufficient supply of TB drugs, second line drugs and side effect medications Treatment TB according to the national standards of care DOT network: TB inpatient hospital, day-care TB hospital, TB policlinic, “Hospital at Home”, Patronage nurses, TB DOT points at the city general medical service

18. Challenges Plans Strengthening of the default retrieval system Sustain the success of the regional TB Control Program Expanding intensified patient-centered care with prioritization of vulnerable populations, such as children and adolescents -- to create the family- centered accompaniment (FCA) model of care (oversee families with TB patients with children)

19. For the sake of children's health we still have so much to do !!!

20. THANKS Contact details: vokpd@vmail.ru The Lilly MDR-TB Partnership is funded by the Lilly Foundation