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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


DR-TB Model of Care in Myanmar