Title: DOTS/ DOTS PLUS IMPLEMENTATION AND INTEGRATION
1DOTS/ DOTS PLUS IMPLEMENTATION AND INTEGRATION
- Vaira Leimane
- State Centre of Tuberculosis and Lung Diseases of
Latvia - Paris, October, 28
2 LATVIA
3PRESENTATION OUTLINE
- EPIDEMIOLOGICAL SITUATION
- IMPLEMENTATION TB/MDR TB CONTROL PROGRAMS
- PROGRESS IN TB CONTROL PROGRAM
- RESULTS
4INCIDENCE OF TB IN LATVIA 1971-2003
5WHO IUTLD GLOBAL SURVEY ON DRUG RESISTANCE IN
LATVIA 1996
primary MDR-TB
acquired MDR-TB
6INCIDENCE OF MDR TB, GLOBAL TB DRUG RESISTANCE
SURVEY, 1994-1996
New Smear Cases
7NTP 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
8SUSTAINED 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
9DOTS 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
10TB 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)
11MDR 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
12DOTS 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
13CONSILIUM 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
14STRUCTURE OF DOTS-PLUS PROGRAM
15DOTS 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
16IMPROVING 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
17DOTS PLUS PROGRAM TREATMENT COHORTS
18DOTS 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
19TREATMENT OUTCOMES FOR COHORT 2000N204 patients
Completed treatment (6)
Death (14)
3
Cure (129)
7
63
13
Default (26)
14
Failure (29)
20TREATMENT OUTCOMES FOR NEW TB CASES AFTER DOTS
AND DOTS PLUS COMPLEATION
Preliminary
21NUMBER 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
22CONCLUSIONS 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
23Welcome to Latvia
NATIONAL CHOIRS FESTIVAL