Transcript DOTS/ DOTS PLUS IMPLEMENTATION AND INTEGRATION Vaira Leimane

DOTS/ DOTS PLUS
IMPLEMENTATION
AND INTEGRATION
Vaira Leimane
State Centre of Tuberculosis and Lung
Diseases of Latvia
Paris, October, 28
LATVIA
PRESENTATION OUTLINE




EPIDEMIOLOGICAL SITUATION
IMPLEMENTATION TB/MDR TB
CONTROL PROGRAMS
PROGRESS IN TB CONTROL PROGRAM
RESULTS
INCIDENCE OF TB IN LATVIA
1971-2003
80
74
74,5
72,9
70,5
70
68,4
65,1
68,3
65,4
63,3
60
57,4
59
53,9
51,5
50
50,4
47,4
44,1
41,9
38,4
39,6
40
35,8
37,6
33,3
32
33,3
30,8
28,7
28,6
30
32,3
30,9
29
29,3
27,4
26,9
20
10
03
02
20
01
20
00
20
99
20
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
19
89
19
88
19
87
19
86
19
85
19
84
19
83
19
82
19
81
19
80
19
79
19
78
19
77
19
76
19
75
19
74
19
73
19
72
19
19
19
71
0
WHO IUTLD GLOBAL SURVEY ON
DRUG RESISTANCE IN LATVIA 1996
60
54
50
40
30
20
10
0
14,4
Un
i
te
d
es
St
at
Pe
ru
La
tv
Do
ia
m
Es
in
ic
to
an
ni
a
Re
pu
bl
Iv
ic
or
y
Co
as
Ar
t
Iv
ge
an
nt
ov
in
a
o,
Ru
ss
ia
Th
ai
la
nd
Ro
m
an
ia
INCIDENCE OF MDR TB, GLOBAL
TB DRUG RESISTANCE SURVEY,
1994-1996
14
12
10
8
6
4
2
0
NTP PROGRAM RESPONSE – DOTS
AND DOTS PLUS IMPLEMENTATION




Accepted first NTP, based on WHOrecommended DOTS strategy ALL FIVE
ELEMENTS in 1995
DOTS countywide including prisons in
1996
FIRSTS STEP OF National TB Control
program for treating MDR TB patients in
1997
Established drug resistance surveillance
1997
SUSTAINED POLITICAL
COMMITMENT

Government Committed to establish NTP plan
using existing staff and resources, within the
Health Care reform
Well functioning DOTS program with additional
treatment of MDR TB (within recourses available)
 Collaboration and coordination between community,
local governments, social services and international
agencies


Established centralized procurement of drugs
through open tender
DOTS PLUS IMPLEMENTATION
STEP I - 1997

SITUATION ANALYSIS
Results of drug resistance surveillance
 QA of laboratory for DST
 MDR TB case finding strategy –


DST for all who starts treatment
Reporting and registration of MDR TB
 Evaluated access to TB drugs and created new drug
management system

TB CASE DETECTION AND
IDENTIFICATION OF MDR-TB
District-Level
Smear Microscopy
Regional-Level
Culture Laboratories
Central Laboratory DST for all who
starts treatment
Central
DST
95% lab
accuracy (1998)
Supranational Reference
Laboratory (Sweden)
MDR TB REPRTING AND
RECORDING
Mycobacteriology Lab
All DST results
District TB doctor
Enrollment form
MDR TB case
MDR TB Register
Consilium
Enrollment in
MDR TB cohort
Follow-up form
DOTS PLUS IMPLEMENTATION
STEP II


MDR TB TREATMENT AND MANAGEMENT
STRATEGY
 Established Expert consilium for case and program
management 1997, June
 TB hospitals reorganized for MDR TB
 Start patient enrolment for treatment
Empiric/Individualized treatment strategy



according to DST results
Directly observed therapy (DOT)
Monitoring and management of side effects
CONSILIUM FOR MDR TB
TREATMENT AND MANAGEMENT

Advantages

Collective decision
Possibility for patients
to receive most
effective treatment
Possibility to
supervise treatment
Problem solving
Improvement of
program management




STRUCTURE OF DOTS-PLUS
PROGRAM
EXPERT CONSILIUM
TREATING
PHISICIANS
NURSES
SOCIAL
WORKERS
PHARMACY
HOSPITALS
LABORATORY
MDR TB
REGISTRY
AMBULATORY
TREATMENT
SUPERVISION
BOARD OF EXPERTS
DOTS PLUS IMPLEMENTATION
STEP III

ESTABLISHED CASE MANAGEMENT SYSTEM





Roles and responsibilities of HCW
Patient education
Default tracing
Improved infection control measures
Center of Excellence founded in 2000


International training centre for treatment and management
for MDR TB
Built laboratory capacity –



DST to all I and II line drugs
Rapid diagnostic methods for patient with risk of MDR-TB
Established database, data management, and
information system 2002 -2003
IMPROVING ALL TB AND MDR TB
PATIENT ADHERANCE
Departments of Welfare
Agreement with TB ambulatory departments
Social Aid for TB Patients
 Food coupons
 Transport tickets
 Extra coupon weekly
if adherence 100%
DOTS PLUS PROGRAM TREATMENT
COHORTS
300
Prison
Civil
250
Begun in 1997
41
31
29
7
18
200
13
150
204
100
50
130
207
204
215
188
153
0
1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 Cohort 7 Cohort
1997
1998
1999
2000
2001
2002
2003
DOTS PLUS IMPLEMENTATION
STEP IV

ACCESS TO II LINE DRUGS



DOTS-plus project accepted by WHO Green Light
Committee in January 2001




Leaving funds after procurement of I line drugs
Extra from reserved funds
Approval for 350 patients for drugs
Full coverage with treatment
LiPA test - study to determine usefulness for early
MDR TB case detection
Established database, data management, and
information system 2002 -2003
TREATMENT OUTCOMES FOR
COHORT 2000
N=204 patients
Completed treatment (6)
Cure (129)
Death (14)
Default (26)
Failure (29)
TREATMENT OUTCOMES FOR NEW
TB CASES AFTER DOTS AND DOTS
PLUS COMPLEATION
1998
1999
2000
2001
2002
Registered Culture +
cases
998
919
957
1004
934
MDR-TB %
9
10,8
9
10,9
9,8
Cured %
74,4
77,3
75,6
76,6
78
Failure %
1,5
1
2,3
1
1
Default %
7,6
4,5
6,4
6,7
5,5
Died %
8,5
7,6
8,9
6,9
7,1
7
8
6,4
8,8
8
80
84
80,4
84
84,5
DOTS Outcomes
Year
Continue Tretment
on Dots Plus %
Total Cured DOTS and
DOTS - Plus %
NUMBER OF PATIENTS WITH PRIMARY
ANDACQUIRED MDR TB INCLUDING PRISON
1994
2003
400
350
Primary
332
Acquired
290
300
257
250
255
234
218
229
209
200
200
175
156
144
150
148
163
132
117
91
100
50
Total
28
82
90
90
86
97
126
83
8380
47 53
19
0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Since 1998 total number of annually registered MDR TB cases decreased
by 51% for previously treated by 65%
CONCLUSIONS AND
RECCOMENDATIONS

DOTS strategy has reduced MDR TB development by
51% in Latvia

DOTS-Plus in addition to DOTS in settings with high
MDR TB level can reach WHO goal for cure 85%

2/3 of patients who started treatment in DOTS plus
were cured

Addressing treatment default could significantly
improve program effectiveness

Strengthening of the DOTS strategy, rapid MDR TB
diagnosis, contact investigation and genotyping to
detect chain of transmission is the next steps to
improve MDR TB control in Latvia
Welcome to Latvia
NATIONAL CHOIRS FESTIVAL