Transcript (PMTM) Scale-up of Programmatic MDR TB Management in the Philippines

Scale-up of Programmatic
MDR TB Management
(PMTM)
in the Philippines
ROSALIND G. VIANZON, MD, MPH
NTP Manager
Department of Health
Philippines
Magnitude of MDRTB in the Philippines:
Data Sources
Type of Resistance
Previously
New
Treated
Phil. National Survey,1997
(Tupasi, T., et.al)
1.4%
14.5%
National Drug Resistance Survey
NTP,WHO,JICA, 2004 (Preliminary)
4.4%
21%
Treatment Failure Rate
(Smear +), NTP
Amongst NEW
(%)
Amongst Re-Treatment
(%)
1999
2.0
-
2000
1.2
-
2001
1.3
-
2002
1.3
-
2003
1.0
6.0
Treatment Failure* Rate
(Smear +) DOTS Center at MMC
Amongst NEW Amongst Re-Treatment
(%)
(%)
1999
0
22.2
2000
4.3
6.7
2001
0
0
2002
0
15.4
2003
0
14.3
* All turned out to be MDR-TB
Stages of PMTM in the Philippines
Goes
beyond DOTS  “DOTS (+)”
Pilot Stage:
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




Initial Scope and context – GLC Pilot Project
Privately Initiated DOTS Unit at MMC as the
starting point
“DOTS (+) Project at MMC ”
75% referrals from: Private practitioners
PPMD: need to harness PPs into DOTS
Laboratory capacity for culture and DST
2nd line drugs need to be secured and assured
Sustainability - impending concern
Stages of PMTM in the Philippines







Stage of Mainstream:
Integration of DOTS(+) into the public DOTS
Stepwise implementation
“LCP DOTS (+) Project”- public counterpart
- in-house services
Referrals from both public and private MDs
Community-based approach: Decentralize to
public health centers with participation from
community volunteers
Absorptive Capacity – prevailing concern
Decentralized MDR-TB services in Metro Manila
(DOTS facilities participating in MDR-TB management)
Caloocan City
3 (8%) + 2
Malabon 2(9%)+1
Manila
16( 39%) +4
2 (3%)
Quezon
4 (24%)
Marikina
Summary :
1(6%)
San Juan
2 ( 8%) + 1 Mandaluyong
Pasay
4(31%)+2
Makati
6 (22%)
Taguig 3(14%)
Paranaque
3(20%) + 1
Las Pinas
1 ( 3%)
Muntinlupa
1
Pasig 2(5%)+1
• 48/452 (11%)
public health
centers
Legend:
Treatment centers
MDR-TB, Philippines
=407 patients
(75%)
Outside Metro Manila = 137 (25%)
22 (5%)
4 (1%)
6 (2%)
Region I– 7
(1%)
11 (3%)
86 (21%)
Region II -5 (1%)
14 (3%)
Region III-30 (6%)
4 (1%)
106 (26%)
17 (4%)
61 (15%)
22 (5%)
8 (2%)
MM -405 (75%)
Region IVB -3 (.6%)
22 (5%)
13 (3%)
Region VI – 3 (0.5%)
Region VII -2 (0.4%)
5 (1%)
Region 10 -2 (0.4%)
6 (2%)
Places of residence
99-Aug ‘06
Region VIII -3 (0.6%)
Region IVA -78 (14%)
Region V 4 (0.7%)
CURRENT: GFATM support (Rd 2)
MDRTB Patient accrual ‘99- Aug ‘06 N=544
600
GFATM = 375
New patients
Cumulative
544
474
500
400
283
300
200
105
84
100
6 6
15 21
1999
2000
161
55
191
183
21
(14 GF)
100
70
0
TDF, PCSO, etc
2001
2002
DOH TDF,
PCSO
2003
2004
2005
GFATM)
2006
Demographics: sex and age
n=544 (Apr ’99- Aug ’06)
>65
Female
38%
(207)
10%
55-64
Age (years)
Male
2%
20%
45-54
77%
27%
35-44
30%
25-34
10%
15-24
0-14 1%
62%
(337)
0%
10%
20%
% (no) of patients
enrolled
MDR-TB, Philippines
30%
Cohort Outcome 1999-2004
n=281
Cure
Failure
Died
80
73
70
60
50
Default
60
58
74
59
50
40
30
20
10
17
17
0
1999
20
13
0
2000
15
13
12
2001
25
9
7
2002
13.5
3.5
0
2003
15
8
3
2004
Treatment outcome of MDRTB
patients: ‘99- ‘04
Years
1999
36 m
2000
36 mo
2001
36 mo
2002
36 mo
2003
24 mo
2004
24 mo
(partial)*
Outcome
6
15
84
56
22
98
Cure
3 (50%)
9 (60%)
49 (58%)
33 (59%)
16 (73%)
71 (74%)
0
1 (7%)
0
0
0
0
Default
1 (17%)
2 (13%)
11 (13 %)
14 (25%)
3 (13.5%)
15 (15%)
Died
1 (17%)
3 (20%)
13 (15%)
5 (9%)
3 (13.5%)
8 (8%)
Failure
1 (17%)
0
10 (12%)
4 ( 7%)
0
3 (3%)
0
0
1 ( 1 %)
0
0
0
Completed
Transout
MDR-TB, Philippines
* 2 ongoing
Stages of PMTM in the Philippines
Stage of Scale-up:
 Expansion
of Project into Program (PMTM)
 Geographic expansion (Region: Metro Manila)
 Engaging more community-based facilities
- PPMD units (Public and Private-initiated)
- Public DOTS Hospitals (District Hospitals)
- Other Public Health Centers
 More
decentralized approach - realistic, viable
 Added complexity and financial demand
Metro Manila
2006
Metro Manila
by 2008
Treatment Center
Treatment Center
Culture Center
Culture Center
DST Center
DST Center
GFATM support in the expansion
3500
MDRTB Patient accrual ‘99- Aug ‘06 N=544
3230
3000
GFATM = 30002590
2500
pre GF/GF2 GF 5 Cumulative
1950
2000
1500
1216
1000
728
640
474
500
6
105
6 15 21 84
55
21 183
100
(14 GF)
161
283
191
640
640
2009
2010
396
184
70
92
94
0
1999
2000
2001
2002
TDF, PCSO, DOH
2003
2004
2005
2006
2007
2008
GFATM
R2 Mainstream
R5 Scale-up
Gradual expansion from Metro
Manila to Region VII – Phase 1
2 Tx Centers in Reg VII
N o . o f p a t ie n t s
600
1 DST site in Reg VII
500
400
300
0
375
275
184
200
100
477
3 add’l Tx Centers in MM
3 Tx Centers in MM
3* culture centers,
2* DST sites in MM
580
90
45
Q1
45
Q2
135
91
100
102
103
49
45
Q3
Q4
Q5
Q6
Q7
Q8
G F A T M Q u a rte rs
N e w e n r o l le e s
C u m u la t i v e
*Includes TDF lab, MMC Clinic, KASAKA and LCP
PPMD Unit at MMC (Privately-Initiated)
Microscopy
NTP
DOTS
PUBLIC
Facility
(1st line drugs)
Evolution of a PPMD Unit into a
DOTS-Plus unit
Microscopy
Culture
DST
DOTS
DOTS Plus
PUBLIC
Facility
(1st line drugs)
Mainstream into the
Public DOTS
Treatment Site
(Health Center)
Microscopy
Treatment Site
(Health Center)
Culture
Treatment Site
DST
(Health Center)
Microscopy
Culture
KASAKA
DOTS(+)
Treatment
LCP DOTS(+)
Treatment
Center
DOTS
Center
Microscopy
DOTS Plus
PUBLIC
Facility
Culture
(1st line drugs)
Treatment Site
(Health Center)
Treatment Site
8 Treatment Centers
(Health Center)
4 Culture Centers
Microscopy
Culture
Treatment Site
DST
(Health Center)
3 DST Sites
KASAKA
DOTS(+)
Treatment
MORE
Treatment Site
(Health Center)
LCP DOTS(+)
Treatment
Center
DOTS
Center
DOTS Plus
Treatment
Sites
PUBLIC
Facility
CEBU
(1st line drugs)
Treatment Site
(Health Center)
Treatment Site
Treatment Site
(Health Center)
(Health Center)
Microscopy
Microscopy
Culture
Treatment Site
Treatment Site
DST
Treatment Site
(Health Center)
Culture
Treatment Site
(Health Center)
(Health Center)
DST
(Health Center)
Treatment
Treatment
Center
Center
Treatment
Treatment
Center
Center
Treatment
Treatment
Center
Center
Treatment Site
(Health Center)
Treatment Site
(Health Center)
The Scale-up
Types of PMTM Facilities
Treatment Centers:
- more than 10 patients being treated at a time
- more comprehensive/specialized management
(e.g. LCP, KASAKA-QI)
Treatment Sites:
- fewer patients (<10) being treated at a time
- represented by public health centers, PPMDs
other public facilities, faith-based DOTS units
Types of PMTM Facilities
Culture Centers:
- perform culture services, NTRL supervises EQA
- broader catchment areas
- those identified under the DRS e.g. Cebu Ref. Lab.
Microscopy
Culture
Microscopy
Culture
DST Sites:
- perform DST, NTRL oversees quality of culture and
microscopy
- fewer but strategically located (2 Manila, 1 Cebu)
- under the supervision of supranational laboratory
DST
DOTS is STILL the OVERARCHING FRAMEWORK
Political
commitment
1. Sustained political commitment.
Quality
microscopy
service
2. Diagnosis of drug resistance
through quality-assured culture and drug
susceptibility testing (DST).
Regular
availability of
1st line drugs
3. Uninterrupted supply of
quality assured second-line anti-TB drugs.
D.O.T
Standardized
records and
reports
4. Appropriate treatment strategies
utilizing DOT with second-line drugs under
proper management conditions.
5. Recording and reporting system
designed for DOTS-Plus programs.
Steps and Requirements for
the SCALE-UP
Environmental scanning
* Existing resources and capacities - DRS
* For strategic selection of expansion sites
Advocacy to ensure political commitment
* Memorandum of Understanding (MOU)
Create essential organizational structures
* PMTM Task Force, PMTM Consillium,
Lab. SubCommittee
Steps and Requirements for
the SCALE-UP
Policies, guidelines, standards development
Human resource development
* Task Analysis
* Standardized training materials
Network of lab services and other diagnostics
* Microscopy, EQA, Culture and DST
* Chest X-ray with TBDC participation
HRH Capacity-Building
Training of Trainers
Training for
Monitoring and
Supervision
Training for
Implementers
Training
(Region)
Monitoring &
Supervision
(Province/City)
DOTS-Plus
Implementation
Treatment Center
DOTS-Plus
Implementation
Treatment Site
Scale-up of
Laboratory
Capacity
Culture
Supranational Laboratory
NTRL & Other DST Sites
DST
Regional
TB Reference
Laboratory
EQA
PHO/CHO
Validation Center
Microscopy
DOTS-Plus
Implementation
Treatment Center
Steps and Requirements for
the SCALE-UP
Logistics management:
*2nd line drugs, 1st line drugs and
drugs for adverse reactions
Utilization
Selection
Tx Centers,
Tx Sites
NTP,TDF
Drug Cycle for
2nd Line Drugs
Procurement
TDF,GLC,WHO
Distribution
NTP, CHDs,
LGUs
Steps and Requirements for
the SCALE-UP
Community involvement to facilitate a
decentralized approach
* Treatment Centers
* Treatment Sites
Public-Private Partnership - engaging PPMD
units.
Private physicians need to be harnessed to the DOTS
strategy to prevent them from proliferating MDRTB.
Steps and Requirements for
the SCALE-UP
Standardized information/data system
* Records and Reports
Monitoring, Supervision and Evaluation
* Internal MSE
* External MSE - GLC
Steps and Requirements for
the SCALE-UP
Access potential agencies for support
Government (National and Local)
Non-Government Agencies, Private sector
External Assistance (Technical and Financial)
GFATM, USAID, WHO, Others
Address the 5 dimensions of sustainability:
Political*Technological*Sociocultural*Economic/Financial
Institutional
MDR Cases and Scaling-up
Approach – Impact Relationship
XDR
Undetected
MDRs With
Appropriate
Management
Scale-up
Mainstream
Pilot
Program Approach (PMTM)
LCP Project
MMC DOTS (+) Project
THANK YOU