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A decentralised, community-based DR-TB model of care in northern Uganda M Shoaib,1 K Velivela,1 S Sharmin,1 P Seshadri,1 S Kasozi,2 E C Casas,3 M Verputten3 1

Médecins Sans Frontières, Uganda, 2 National MDR-TB Programme, Ministry of Health, Uganda, 3 Public Health Department, Médecins Sans Frontières, The Netherlands

Introduction • Drug-resistant tuberculosis (DR-TB) is an emerging issue globally, with an estimated 650,000 cases worldwide.1 • The Ugandan Ministry of Health estimates that there are 330 new cases for every 100,000 people. Prevalence of multidrug-resistant tuberculosis (MDRTB) is between 1.1 and 1.4% amongst new TB cases and 12% among retreatment cases.1,2 There are approximately 226 confirmed cases of DR-TB in Uganda,3 but the true figure is likely to be much higher. • In Uganda, treatment for DR-TB is not yet available from the Ministry of Health (MoH).

Photo: © Andrea Stultiens

• In December 2009, Médecins Sans Frontières (MSF) set up a comprehensive, decentralised and community-based programme to treat DR-TB patients in Kitgum, a rural district of northern Uganda.

Objective We describe the model of care and present interim treat-

ment outcomes of DR-TB patients from December 2009 to December 2011. Our objective is to share our experience so that this model of care can be used for DR-TB patients in Uganda and similar settings.

A DR-TB patient receives one-to-one counselling outside his home - a thatched hut built for him by MSF in his family’s compound - near the town of Kitgum.

• Drug-resistant tuberculosis (DR-TB) describes all those strains of TB that show resistance to one or more of the common first-line drugs. • Monodrug-resistant tuberculosis (mono DR-TB) describes TB that is resistant to any one first-line drug. • Multidrug-resistant tuberculosis (MDR-TB) describes TB that is resistant to both isoniazid and rifampicin, the two most powerful first-line TB drugs. • Polydrug-resistant tuberculosis (PDR-TB) describes strains that are resistant to more than one first-line TB drug, but not to both isoniazid and rifampicin.

Results

Descriptive analysis of components of model of care Observational analysis of DR-TB cohort of patients Data collected under routine programmatic conditions DR-TB patients are evaluated for infection control using a checklist

MSF programme

Treatment outcomes for patients in each DR-TB group

The programme follows WHO 2010 recommendations for DR-TB diagnosis, treatment and care, as well as all programmatic and outcomes definitions TB suspects are identified in the community by village health teams, and by MSF and MoH staff in health facilities Screening for DR-TB – by referring sputum samples for culture and drug susceptibility testing (DST) – is carried out for: • patients failing first-line treatment • retreatment cases • close contacts of DR-TB patients • HIV-positive TB suspects Diagnosis: provided by an onsite lab technician, using microscopy and Ziehl-Neelsen staining. Sputum samples are sent through Posta Uganda to the National Tuberculosis Reference Laboratory in Kampala for culture and DST 8

Treatment for DR-TB has two phases: intensive and continuation • MDR-TB intensive phase: lasts 6-8 months; involves daily injections and 10+ pills per day • MDR-TB continuation phase: lasts 14-18 months; involves daily doses of multiple drugs

Infection control measures include: • renovating patients’ homes to improve ventilation • constructing traditional huts when needed so patients are isolated from family members Medical follow-up: the DR-TB team (composed of a clinical officer, a nurse and a counsellor, supervised by a medical doctor) visits patients on a daily basis Counselling, education and psychosocial support: provided by staff, treatment supporters or expert clients, to patients and their caretakers Contact tracing: carried out for each patient by the DR-TB team Hospital care is provided only when: • a patient’s clinical condition is severe and requires close monitoring • household infection control measures have not yet been implemented • a dedicated medical team to ensure community-based care has not yet been identified The aim is to shift the patient to community-based care as soon as possible.

1 2 3

World Health Organization. Global Tuberculosis control: WHO Report 2011. Geneva. Available at: http://www.who.int/tb/publications/golbal_report/2011/gtbr11_full.pdf. Lukoye D, Adatu F, Musisi K, Kasule GW, Babirye, J, Moses L, Joloba. Anti-tuberculosis drug resistance and HIV infection among sputum smear-positive pulmonary tuberculosis patients in Uganda: results of the first national anti-tuberculosis drug resistance survey. Ugandan Ministry of Health. 2011. Number of cases detected between Jan 2008 and Oct 2011.

Total N (%)

Poly N (%)

5 (28%)

1 (6%)

18 (100%)

Microbiological confirmation 12 (100%) N (% of DR-TB group)

5 (100%)

1 (100%)

18 (100%)

HIV co-infected N (% of cohort)

3 (17%)

2 (11%)

0

5 (28%)

Completed treatment and been declared cured N (% of cohort)

1 (6%)

3 (17%)

0

4 (22%)

Currently on treatment with >3 negative sputum culture N (% of cohort)

9 (50%)

2 (11%)

0

11 (61%)

Median (range) days to sputum conversion for MDR-TB patients

79 (59-130)

NA

NA

NA

12 (67%) Patients N (% of cohort)

Main adverse effects in MDR-TB patients

77 66

42%

55

No of patients

Directly observed treatment (DOT): DOT providers/village health team members visit patients twice a day to ensure they take medication and to provide psychosocial support

Mono MDR N (%) N (%)

58%

Regimen (used for most cases): kanamycin/amikacin + levofloxacin + prothionamide + cycloserine +/- PAS + pyrazinamide Care is provided within patients’ homes in both intensive and continuation phases (with certain exceptions – see below)

All patients and family members were observed to comply with infection control measures as per checklist during the DR-TB team’s visits Number of defaulters: 0 (0%) Number of deaths: 0 (0%)

Method

Number of patients in cohort: 18 Median age: 35 years IQR (28, 51) Gender: female 4/18 (22%) HIV-positive: 5/18 (28%)

44

25%

33

25%

25%

22 11 00

Nausea/vomiting Nausea/ vomiting

Upper abdominal pain Upper

abdominal pain

Hearing loss Hearing loss

Arthralgia Arthralgia

Side effects

Clinically evident hypothyroidism  Clinically evident requiring thyroxin  hypothyroidism supplementation

requiring thyroxin supplementation

Conclusion The interim treatment results are favourable. Advantages of a community-based model of care for the treatment of drug-resistant TB: • Allows close follow-up • Allows close monitoring of side effects • Promotes adherence to treatment • Promotes adherence to infection control As the Ugandan government prepares to start treating DR-TB patients, we conclude that this model of care is feasible for rural Uganda.

A decentralised, community-based DR-TB model of care in northern Uganda  

Research by M Shoaib, K Velivela, S Sharmin, P Seshadri, S Kasozi, E C Casas and M Verputten

A decentralised, community-based DR-TB model of care in northern Uganda  

Research by M Shoaib, K Velivela, S Sharmin, P Seshadri, S Kasozi, E C Casas and M Verputten

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