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World TB day and TB in Mongolia

• O.Batbayar MD,MPH (University of London)
• National Tuberculosis Program

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World TB day-Stop TB in my Life Time
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2012 ??? ????????? ?????? ????
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TB in Mongolia

• Mongolia is one of the 7th high burden TB
  country in West Pacific region of WHO.
• 3985 cases last year per 2.7 population ( 12000
  cases per 270 mln USA population)
• 185 MDR cases
• Total 19 XDR cases
• 400 paediatric cases
• TB incidence 219 per 100000
• TB prevalence 280 per 100000
• TB Mortality 21 per 100000
• 2011 statistics is promising

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Last ten years incidence, treatment success and
mortality
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Last ten years incidence and treatment success
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Timeline

• 1968 The TB laboratory was established
• 1992 The TB laboratory network was developed
• 1994 NTP was established and DOTS launched
• 1994 Organization of the National Reference
  Laboratory
• 1997 Quality assurance system was introduced,
  Supranational Reference Laboratory (SRL) Japan
• 1997 First Drug Resistance Survey (DRS)
  conducted
• 1999 100 DOTS coverage
• 2001Reogranization of the TB Department under
  the National Center for Communicable Disease
  (NCCD)
• 2001 GFATM Round1 launched, later on RCC1
• 2002 National Programme of Communicable Diseases
  (NPCD) approved, TB program is a sub-programme of
  the NPCD
• 2005 GFATM Round 4 launched, Later on RCC 4
• 2006 launching of GLC approved project for
  management of 375 patients with drug-resistant TB
  (DR-TB)
• 2007 Second DRS conducted
• 2008 The review of the NTP
• 2009 Testing of drug resistance to second-line
  anti-TB drugs (SLD) started
• 2010 second National Programme of Communicable
  Diseases (NPCD) approved for the years 2010-2015,
  TB program is a sub-programme of the NPCD
• 2010 National strategic plan to stop TB in
  Mongolia, 2010-2015 (Objective 3-expand
  programmatic management of MDR-TB)
• 2010 Updated the guidelines on tuberculosis care
  and service (appendix 3- guidelines on drug
  resistant TB services and care) approved by MOH,
  2010
• 2010 National TB Infection control (IC)
  guidelines developed and approved

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Current TB situation

• Political and financial commitment
• National strategic plan to stop TB in Mongolia
  (Objective 3-expand programmatic management of
  MDR-TB), MoH, 2009
• National guidelines on tuberculosis care and
  service updated and approved by MoH, 2009
  (appendix 3- guidelines on drug resistant TB
  services and care)
• Successful resource mobilization from the GFATM
  (since 2006 present, single stream funding)

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MDR-TB patients enrolled (2003- 2011)

• MDR-TB estimates burden by WHO 106 new MDR-TB
  cases every year
• BUT BY END OF 2011 WE DIAGNOSED 180
• First three month of 2012 22 new cases
• DRS survey 2007
• among new cases 1.4
• Among retreatment cases 27.5
• 893 MDR-TB cases were diagnosed, out of them
• 58.1 (519) have been enrolled to treatment,
  26.5 (237) died, and 1.3 (12) refused
  treatment, 1.1 (10) were treated abroad or
  private hospital, 0.8 (7) were not able to be
  enrolled in treatment due co-morbidities, 12.1
  (108) were on the waiting list.

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National TB reference laboratory with 37 branches
and sputum transportaion scheme
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Current MDR-TB situation

• Available infrastructure
• NTRL (DST, culture, liquid culture, LPA on FLDs)
• Treatment is available through GFATM support
• Infection control
• Administrative measures
• General infection control order, approved by MoH,
  2010
• TB infection control guidelines, 2010

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Treatment outcomes
Final outcomes for 2008 cohort
Year Total Cured Treatment completed Failed Defaulted Died Cure rate Treatment success rate
2006 50 21(42.0) 11(22.0) 8 (16.0) 2(4.0) 8(16.0) 42.0 64.0
2007 64 40(62.5) 9(14.1) 4(6.3) 6(9.4) 5(7.8) 62.5 76.6
2008 65 48(73.8) 2(3.1) 3(4.6) 6(9.2) 6(9.2) 73.8 76.9
Total 179 109(60.9) 22(12.3) 15(8.4) 14(7.8) 19(10.6) 60.9 73.6
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Partners

• World Vision International Mongolia (WVIM)
  started the implementation of the GF TB grants
  since 2005. It has been collaborating with
  the Enerel charity and Prison Hospital on
  provision of TB care services for
  vulnerable population as homeless and
  prisoners, conducting active case finding and
  ACSM activities
• Mongolian Anti-Tuberculosis Association (MATA)
  worked as sub-recipient (SR) for GF supported
  project since 2003 on the implementation of
  home-based and lunch-DOT for TB patients through
  trained health volunteers nationwide. Also they
  led ACSM activities for general population as
  well as for patients and their family to reduce
  stigma and discrimination against TB.
• Mongolian Association of Family Clinics (MAFC)
  implemented the PPMD since April 2009 within the
  Round 1 RCC. The MAFC has been carrying out the
  following interventions training TOT among
  family physicians on early detection and
  treatment, referral of TB suspects to a secondary
  and tertiary level of TB services, transportation
  of sputum samples from primary health care
  services to TB dispensaries, and developing
  clinical guidelines for family doctors

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Partners

• Mongolian Antituberculosis Union newly formed in
  2011
• Health Science University of Mongolia (HSUM)
  collaborates closely with the NTP on the
  revision of the curriculum of relevant
  health sciences courses including medical
  course, nursing and pharmacy. The HSUM is
  instrumental in on formalizing of policy
  documents in collaboration with the Ministry of
  Education.
• The GFATM provides financial support
• World Health Organization (WHO) provides
  technical assistance through its Country and
  Regional Offices.

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Strength and Weakness

• Strengths of T B Control Program
• Good and detailed National Strategic Plan to Stop
  TB in Mongolia (2010-2015)
• KAP survey for health providers completed and
  published
• KAP survey with general population in final
  stages
• Partnerships in place and community mobilization
• Commitment of staff and available technical
  support

• Challenges in TB Control Program
• Human resources (all)
• Limited knowledge of TB (all)
• Stigma and discrimination (all)
• Coordination
• Significant amount of data but not used
  appropriately, TB prevalence survey not contacted
  
• Engaging all providers/community groups
• Political commitment

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Challenges and some factors

• Various vulnerable groups (homeless, alcoholics,
  poor) difficult to reach
• Seeking diagnosis late
• Treatment default
• Infection Control practices/guidelines not
  implemented
• No diversified funding for TB control activities

• Limited knowledge on TB (all) and availability of
  services among population
• Limited knowledge on Interpersonal Communication
  and Counseling skills (providers)
• Lack of target specific messaging on TB
• No coordination or/and consistency of TB messages
  among partners
• Coordination, planning, partnerships, networks
• No standardized training curriculum and tools for
  providers and community volunteers
• Health providers have no interest to work in TB
  sector
• Currently limited efforts to gain political
  support for TB

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Best TB Dispensary
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TB HR seminar and Paediatric department
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TB day

• HRD strategy
• ACSM strategy
• TB patient social care and isolation
• KAP survey
• TB incidence among HCW
• MoU with high burden districts
• TB registration web

• Media and web
• Activity among TB patients
• AXA among school children
• Debjee- amongTB Voluntary Workers
• TV education program

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Thank you