DR-TB Model of Care in Myanmar
Dr. Tin Mi Mi Khaing 22nd August, 2013
Introduction Milestones of MDR-TB Management 2006
Preparation, establishment of DR-TB Committees
2009
DOTS Plus Pilot Project
2010
Opening of bio-safety laboratory level 3
2011
Programmatic Management of MDR-TB
MDR-TB (%) among new and previously treated cases: Myanmar (1st & 2nd Nationwide DRS)
ď ą 3rd Nationwide DRS in 2013
DST Results of Cat II Failure Cases (2007-2008) Resistant Total Isolates
Yangon Mandalay Aung San TB Hospital PSI Total
% on 86 pts
MD Ofx PAS Km R (HR)
S
Cm Eto
E
Not Cont All Neg teste amin sen. d ated
47 41
4
1
0
41
0
0
37
0
1
3
2
40 31
5
0
1
26
0
0
24
1
0
5
3
13 9
3
0
1
10
1
0
7
0
1
3
0
4 4
0
0
0
4
0
0
2
0
0
0
0
104 85
12
1
2
81
1
0
70
1
2
11
5
98.8 14 1.1 2.3 94.2 1
0 81.4
* Performed at (SRL) Antwerp, Belgium
Number of MDR-TB patients in DOTS Plus Project, July 2009-June 2010 NTP
MSF collaboration with NTP
Total
Year 1
75
25
100
Year 2
125
50
175
Total planned Total enrolled
200
75
275 309
2nd line anti-TB drugs supported from UNITAID through GDF
Standardized Treatment Regimen in DOTS Plus Project compared to PMDT DOTS Plus Project
PMDT
6 Am + Lfx + Eto + Cs + PAS + Z
6 (Amk Z Lfx Eto Cs)
18 Lfx + Eto + Cs + PAS +Z
18 (Lfx Eto Cs Z)
• Design was based on DST pattern Treatment regimen was of Cat II Failure (2007,2008) revised – PAS to be included for only Cat II failure MDR patients
Case-finding strategy in DOTS Plus Project compared to PMDT DOTS Plus Project • Failures of Category II
• • •
•
PMDT Failures of Category I and II All re-treatment cases Close contacts of MDR-TB patients with active TB All TB patients living with HIV
Number of implementing townships in DOTS Plus Project and PMDT DOTS Plus Project
PMDT
5 townships Yangon Region 5 townships Mandalay Region
2011 expansion to 22 townships Yangon and Mandalay
Collaborating partner: MSF -Holland
2012 - 38 townships 4 new States/Regions
Total 10 townships
• • • •
All patients hospitalized
2013 – 53 townships 6 new States/Regions • • • • • •
Sagaing Magway Mon Shan State
Kachin Kayin Ayeyarwaddy Bago Rakhine Tanintharyi
Model of Care in DOTS Plus Project and PMDT DOTS Plus Project Hospitalization then homebased care • Aung San TB Hospital in Yangon Region • Patheingyi TB Hospital in Mandalay Region
PMDT Home-based care • Hospitalization only if the patients condition is serious
Models of MDR-TB treatment •Hospitalization
•Community-based • Clinic-Based
• Home-based
Human Resource Development & Capacity Building
Social support • Lab investigation fees – FOC for patient • Ancillary drugs – FOC for patient • Nutritional support during hospitalization and ambulatory • Travel allowance for BHS and patients follow-up • Car rental for TB hospital and Regional TB Center • MDR-TB counseling service
Baseline laboratory investigations Blood samples from patients sent to National Health Laboratory Bring the results
Some investigations can be done at Aung San TB Hospital LFT, urea, uric acid, potassium and creatinine Yangon Regional TB Center Other Region and State Use private Laboratories Laboratory investigation fees from 3DF and Global Fund
Baseline and Follow-up Culture at NTRL and Upper Myanmar TB Laboratory
Trained and efficient lab personnel ISTC TB Training Modules 2009
History taking, clinical examination and registering MDR-TB patients to start treatment
Beginning of PMDT 2011 December
2013 August
Nutritional Support during hospitalization and ambulatory phase
From WHO/3DF (2009-2013)
2013 4 townships in Yangon Region from Pyigyikhin 4 townships in Mandalay Region from MHAA through FHI ( CAP project)
Car Rental
WHO/3DF
Patient counseling and education (2 of 3)
Patient-centered strategy
ISTC Standard 9: Fostering Adherence to Treatment
Supply Management • PAS Acid storage (cold boxes, vaccine carriers, Ice packs, Ice pack freezer) • PAS sodium • Infection control (N95 masks, Fit test kit, UVGI, exhaust fans, stand fans) • Laboratory consumables • Ancillary drugs to treat adverse events • Recording & Reporting format • Computer
Infection control • New MDR ward in Aung San TB Hospital (MSF) • Renovation of TB hospitals (MSF, USAID, MoH) • Patient’ visitors house • Patients waiting room, Lab renovation and infection control measure in DOTS-Plus piloted townships (USAID, MoH)
Supervision, Monitoring and Evaluation • Well established supervision plan from Central level, Regional level and Township level up to patient home • Monitor R&R and SLD procurement • Expert DR-TB committee meeting –accomplished • Regional/State DR-TB committee meeting • Monthly Township committee meeting • Annual evaluation meeting on DOTS-Plus (2010)
New Building (Single rooms for 20 MDR-TB Patients) was provided by MSF (Holland) and handed over to MOH on 18.6.09
Treatment Outcome of DOTS Plus Cohort ( n=281)
Still on treatment = 28 patients
Number of MDR enrolled on treatment 2009-2013 (second quarter) 1200 1079
1000 861 796 Cumulative number
800
523
600 426 354 400
287
376
304
247 158 125
200 43
64
92
192
End DOTS-Plus End of DOTS-Plus Pilot pilot project Project
0 2009 2009 2010 2010 2010 2010 2011 2011 2011 2011 2012 2012 2012 2012 2013 2013 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
Challenges Additional health workers in Regional MDR-TB Clinic, TB Hospitals and Laboratories
Over workload of BHS Timely arrival of second-line anti-TB drugs Accessibility of rapid diagnosis for DR/MDR-TB suspects Establishment of infection control system in Health Facilities Good counseling services Adequate patient support DOT Treatment of side effects Nutritional and social support Regular supervision and monitoring
Limitation of funding source
Resources for MDR-TB • Finanical and technical support from:
A midwife (DOT Provider) and the cured MDR-TB patient named Ma Thin Thin Wai and her family