Myanmar DR TB Symposium Yangon, August 22, 2013
MSF TB Project in Cambodia
Dr. Jean Phillippe DOUSSET Medical Coordinator Cambodia
Cambodia
MSF
MSF
Kompong Cham Province, Operational Districts
MSF
MSF
TB / DR-TB epidemiology in Cambodia Second TB Prevalence Survey 2011: decrease of 38% of Smear + cases in 10 years BUT Cambodia
Thailand
Vietnam
Myanmar
Rwanda
14
70
89
48
11
Notification rate (/100k)
270
95
111
283
61
Estimated prevalence /100k)
817
161
323
506
117
Estimated incidence (/100k)
424
124
199
381
94
Population (millions)
2007 Drug Resistance Survey: Prevalence of MDR-TB Previously treated patients is 11%, 8 times higher than in new patients (1.4%). Combined prevalence is 2%.
Historical Description of NTP and MSF DR-TB care 2006: First MDR cases diagnosed among PLHAs Taken in charge by Cambodian Health Committee and MSF in Phnom Penh and Kompong Cham (KC)
2009: NTP received funds from Global Fund Round 7 MSF HIV/AIDS Project at KC DR-TB project
2010: NTP initiated the DR-TB TWG MSF: DR-TB project Comprehensive TB project with a DR-TB component, in the KC Provincial Hospital and in 2 Operational Districts.
Historical Description of NTP and MSF DR-TB care Collaboration with NTP through Technical Working Groups (DR-TB and Laboratory): Programmatic Management of Drug resistant TB Plan (2010) National DR-TB guideline (2010-2012) Guideline for the screening of DR-TB suspects: Standard of Procedures for referral / criteria for Genexpert testing (2012) In 2013, MSF supports the NTP by providing 2nd line drugs (+ monitoring) to DR TB patients from Phnom Penh and Kandal province in collaboration CHC.
KC PH TB Department: Chest Clinic
KC PH TB Department: Chest Clinic reception
KC PH TB Department: Screening Area
KC PH TB Department: TB Paediatric rooms
KC PH TB Laboratory: Microscopy
KC PH TB Laboratory: Culture and Genexpert
Case Finding (common criteria for NTP and MSF): Criteria for presumptive DR-TB cases (request for Genexpert, culture plus DST): All
retreatment cases (relapse, failure, return after default)
All
non converters at month 2 (+/-) and 3
All
HIV+ /(or suspect HIV) regardless of previous TB treatment history
Contact
of DR-TB cases, TB Health Care Workers and prisoners.
MSF Treatment Approach
Most of Patients are detected by Genexpert
Start ETR: E / PZA / Km / Lfx / Eto / Cs (PAS if HIV+) MSF: add PAS
IT according to DST results
DST 2nd line: Km, Cm, Lfx, requested at Day 1 by MSF If no culture conversion at M4 by NTP
MSF Treatment Approach
Before starting ETR: Medical
and laboratory assessment 1 nurse/drug educator and 1 counsellor deliver 5 sessions to patient and family (around 1 week): HIV VCCT Assessment of the emotional and social status Education on disease, drug, side effects, infection control
DR-TB committee (Medical/nurse/counseling team): Collegial decision to start DR-TB treatment. Mutual Contract.
MSF Treatment Approach
ETR Initiation in Hospital: Week 1: Individual treatment adherence counseling, education on drugs DOT and Home Based Care process Week 2: DR TB Support Group for experience sharing, depression evaluation (PHQ9) Follow up of the adherence, side effects
Before Discharge (smear conversion, clinical and psycho social status) to set up the Home Based Care process: Identification and training of HBC nurse (health centre) for DOT and injection Home assessment, infection control, shelter Hotline
MSF Treatment Approach
After Discharge: Monthly medical consultation and peer support group at Chest Clinic
Monthly (or required home) visit to assess PS status, adherence, HBC nurse performance, nutritional status, infection control, family support
Transportation fee support, Gift within the treatment course, Food basket
DOTs training for DRTB patients
Nurse Home visit DRTB patients
Lessons Learned: Case finding
Case notification: at HC level, no retreatment cases: patients refused to be hospitalised during the injection period, thus they are registered as New Cases No Cat2 and no Streptomycine: all previously treated patients referred for Genexpert, culture
Retreatment cases limited to smear-positives, if smear negative or EPTB reported as new cases or others May expand to include smear-negatives (as resources and capacity become available)
Lessons Learned: Case Finding
Non Converter at M2-M3: poor quality of the samples sent (saliva, contamination) To refer patients to the PH (Infection Control, acceptability, workload and capacity at PH)
Difficulty in advancing money from central to periphery to refer patient or sample: During more than 1 year, we did not get any referrals from OD or the 5 provinces of the catchment area
Lessons Learned: Case Finding In the 2 ODs where MSF runs TB activities: Clinical
assessment and smear control of TB patients at M2 and M6
Facilitation
of the Referral of patients or samples to
PH Searching
for retreatment cases at HC level.
Lessons learned: case management DR TB cohort Outcomes :
2010
2011
2012
2013
Number
%
Number
%
Number
%
Number
%
Cured
0
0%
6
50%
3
17%
0
0%
Treatment completed
1
25%
1
8%
0
0%
0
0%
Failure
0
0%
0
0%
0
0%
0
0%
Defaulters
1
25%
3
25%
0
0%
2
20%
Deaths
2
50%
1
8%
2
11%
1
10%
Transfer out
0
0%
0
0%
0
0%
0
0%
Still on treatment
0
0%
1
8%
13
72%
7
70%
Total
4
12
18
10
Culture conversion at M6
na
4/4
3/3
10/11
HIV Co infection
0
17%
28%
20%
Lessons learned: case management
High rates of defaulters, mostly due to drug adverse effect (PAS) and psychological troubles (depression) 2011: upgrade initial assessment decrease of defaulters since 2012
Non supportive environment: discouraging patient to continue the treatment Strengthen education, information and support to relatives
Nutritional status: death or rehospitalisation due to weight loss and poor feeding Nutritional support, anticipate important weight loss and degrading clinical status by hospitalising on time.
Lessons learned: case management
Psychological status: depression Assessment of the psychological status at pre-treatment phase. Importance
of the follow up at home and good communication within DR TB team. Patient care meeting Importance of the pre initiation phase for patients and relatives