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