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DOTS/ DOTS PLUS IMPLEMENTATION AND INTEGRATION

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INCIDENCE OF TB IN LATVIA 1971-2003. WHO IUTLD GLOBAL SURVEY ON DRUG RESISTANCE IN ... LiPA test - study to determine usefulness for early MDR TB case detection ... – PowerPoint PPT presentation

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Title: DOTS/ DOTS PLUS IMPLEMENTATION AND INTEGRATION


1
DOTS/ DOTS PLUS IMPLEMENTATION AND INTEGRATION
  • Vaira Leimane
  • State Centre of Tuberculosis and Lung Diseases of
    Latvia
  • Paris, October, 28

2
LATVIA
3
PRESENTATION OUTLINE
  • EPIDEMIOLOGICAL SITUATION
  • IMPLEMENTATION TB/MDR TB CONTROL PROGRAMS
  • PROGRESS IN TB CONTROL PROGRAM
  • RESULTS

4
INCIDENCE OF TB IN LATVIA 1971-2003
5
WHO IUTLD GLOBAL SURVEY ON DRUG RESISTANCE IN
LATVIA 1996

primary MDR-TB
acquired MDR-TB
6
INCIDENCE OF MDR TB, GLOBAL TB DRUG RESISTANCE
SURVEY, 1994-1996
New Smear Cases
7
NTP PROGRAM RESPONSE DOTS AND DOTS PLUS
IMPLEMENTATION
  • Accepted first NTP, based on WHO-recommended 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

8
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

9
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

10
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)
11
MDR TB REPRTING AND RECORDING
  • Mycobacteriology Lab
  • All DST results

District TB doctor
Enrollment form
MDR TB case MDR TB Register
Follow-up form
Consilium Enrollment in MDR TB cohort
12
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

13
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

14
STRUCTURE OF DOTS-PLUS PROGRAM
15
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

16
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

17
DOTS PLUS PROGRAM TREATMENT COHORTS
  • Begun in 1997

18
DOTS PLUS IMPLEMENTATION STEP IV
  • ACCESS TO II LINE DRUGS
  • Leaving funds after procurement of I line drugs
  • Extra from reserved funds
  • DOTS-plus project accepted by WHO Green Light
    Committee in January 2001
  • 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

19
TREATMENT OUTCOMES FOR COHORT 2000N204 patients
Completed treatment (6)
Death (14)
3
Cure (129)
7
63
13
Default (26)
14
Failure (29)
20
TREATMENT OUTCOMES FOR NEW TB CASES AFTER DOTS
AND DOTS PLUS COMPLEATION
Preliminary
21
NUMBER OF PATIENTS WITH PRIMARY ANDACQUIRED MDR
TB INCLUDING PRISON 1994 - 2003
Since 1998 total number of annually registered
MDR TB cases decreased by 51 for previously
treated by 65
22
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

23
Welcome to Latvia
NATIONAL CHOIRS FESTIVAL
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