TB in Conflict Areas or Settings

TB in Conflict Areas

Charles Ssonko, TB/HIV Implementer, Manson Unit, MSF, UK Charles Ssonko

Presentation overview • Factors that drive the TB epidemic in an unstable setting • Is it possible to treat patients? MSF experience in treating TB in unstable areas in South Sudan • How treatment has been achieved (diagnostics, treatment strategies, notifications and outcomes) • Integration of TB/HIV services • Challenges

TB incidence rates/new cases increase as a result of: Overcrowding in camps encourage development and spread of TB

Malnutrition increases vulnerability of population to TB

Charles Ssonko

• Refugees may bring or find high levels of HIV in area–leading to high levels of TB - complicating diagnosis and management

Charles Ssonko

• Access to TB care and control is usually disrupted due to disruption in health care services and infrastructure damages.

• In conflicts/disasters, poor adherence to TB therapy is likely leading to increased risk of drug resistance and transmission.

• Though health care in these setting heavily relies on international agencies, very few embark on treating TB patients. And those that do intervene quite late.

Charles Ssonko

MSF experience in treating TB in unstable settings

Lessons from South Sudan

Charles Ssonko

The Conflict in South Sudan • Country declared independence on 9th July 12 from the North-Following decades of conflict estimated to have killed over 2M and displaced more than 4.5 M by 2005.

• Violent conflicts between tribal groups still exist-for example the Nuer and Mole tribes, land disputes btn the Dinkas and the cattle-keeping Misseriya Arabs • Ongoing Conflicts along the northern border of Abeyi (demanding referendum) and in the Nuba Mountains (Christians &pro SPLA andgovt of N.Sudan– threatens resurgence of another Charles Ssonko civil war in South Sudan.

OCA-TB projects in SS Nasir and Lankien in Upper Nile state

Leer in Unity state

•

Charles Ssonko

•MSF begun providing Tb treatment in South Sudan in 1994 in upper Nile for the Nuer people treated 2000 patients before shunting down due to insecurity Project

Year stated

Models of care

Leer

MSF stated in 2007

TB village plus Self administered treatment (SAT)

Nasir

MSF resumed activities in 2005

TB village

Lankien

Treatment resumed in 2001

Ambulatory with Self administered treatment (SAT)

Bentiu

Started with nutrition in 2010 and to full TB program in 2012

Ambulatory with self administered treatment.

(SAT)

Charles Ssonko

Treatment Goal • The main concern in South Sudan has been to treat as many patients as possible, while minimising the risk of drug resistance to a minimum by ensuring cure and treatment completion. • This will also interrupt transmissions

Charles Ssonko

This has been achieved through Simplification • Of Diagnosis • Treatment

• Follow up • And models of care Charles Ssonko

Achievement of proper Diagnosis • Aiming at microscopic diagnosis of TB and start treatment with 2 days.

• Using symptom checklists to identify possible TB suspects with minimal technical knowledge • Incorporating Xpert/MTB/Rif to rapidly diagnose MDRTB • Symptom based algorithms for to diagnosis smear negative TB • Clear guidelines including sample collection and referral to a central lab in Loki-Kenya for GeneXpert.

Charles Ssonko

Achievement of proper treatment• Rapid initiation of treatment – use of fixed dose combination packages by less skilled workers for smear positives.

• Implementation of the shorter ‘Bangladesh regimen’ for MDRTB • Clear written protocols/instructions Charles Ssonko

• Smear negatives diagnosed by skilled person (doctor or clinical officer) • Enabling patients to complete treatment- hence achieving cure.

- Transport refunds - Enhanced Health education - Food package - Individual /personal TB treatment records/cards • Ensuring enough drug supplies including buffer stocks Charles Ssonko

Achievement of proper Follow-up • With the adoption of Self administered treatment (SAT) as a policy in MSF • More flexibility towards patients – Weekly supplies during the intensive phase • TB community support from for example, CHW, DOTS supporters observing treatment from home.

• The calendar system for mastering appointments Charles Ssonko

Keep it simple -Models of care •

TB villages or shelters and provision of DOTS in the acute phase of the conflict in South Sudan

• Followed rapidly by adopting Self Administered Treatment (SAT) – after conflict • Ambulatory DOT for MDRTB

Charles Ssonko

Case Notifications and Outcomes 2012 Project

Notification (New cases) MDRTB cases

outcomes

LEER

629 cases

453 cases analysed

LANKIEN

4 2 died

(210 (32.7%) children)

Success rate 77% (349) cured plus completed; 58 (12.8%) defaulted

120 (19%) were HIV/TB co-infected.

2 (0.4%) Failed; 42 (9.3%) Died (possibly due to high TB/HIV group.

230 Cases treated

None

132(53%) children 7 (3%) were HIV/TB coinfected

Nassir

178 cases treated

Success rate 84% (204); 7% (17) defaulted; 6.6% (16) died; 0.4% (1) failed.

None

55 (30.9%) children

13 (7.3%) co infected

243 analysed

172 analysed Success rate 59.3% (101); 9.3% (16) defaulters; 8.7% died; 2.3% failed.

Charles Ssonko

19.8% Missing outcomes. Many patients come from Ethiopia.

Contingency planning • Contingence = anticipate difficulties, evacuations, and ensure continuity of drugs by- giving longer supplies, leaving enough stocks at the facility-pt may come back , Patients supplies could also be given to the treatment supporters.

• Runaway packs – one to 2 months pre-prepared drug packallows pts enough supply till insecurity calms or seek treatment elsewhere using TB treatment card.

• Enhanced patient education measures for self administered treatment stressing seeking treatment from other facilities Charles Ssonko if conflict continues for long periods.

• Community TB supporters could keep a buffer stock of TB drugs • Personal treatment records (the TB cards)could help support adherence in any setting where disaster threatens to disrupt TB programmes.

This applies as much to Rakhine as it does to South Sudan.

Charles Ssonko

Integrating TB/HIV/DRTB • Ensuring all TB patients are counselled and tested for HIV • Ensuring all TB patient with HIV receive Anti Retroviral Treatment • Ensuring that those with HIV are routinely tested for TB.

Charles Ssonko

Challenges • Changing security situation leading to unpredictable multiple evacuations of reliable international staff or sudden population displacement • Lack of qualified local staff • Testing for MDRTB TB – no point of care test, samples carried by plane (expensive to sustain) • Patients do present late with advanced disease as a result of displacements and lack of access to health facilities • Other treatment challenges are context specific Charles Ssonko

Summary • It is possible to treat TB in unstable settings with results quite similar to stable settings- South Sudan as an example; similar settings include; DRC Somalia, CAR and Chad.

• The main goal is to treat as many as possible, ensuring cure and completion while minimising resistance • It very challenging but with simplification, commitment, rapid diagnosis, patient support and use of shorter regimes, it is possible to treat TB in unstable settings.

• There is need for humanitarian agencies and national TB programmes to get more involved rather than turning Charles Ssonko away from TB during these daring situations

Thank you very much

Charles Ssonko