Programmatic Management of Multi-drug Resistant Tuberculosis Report of the Regional Workshop Kathmandu, Nepal, 27 September- 1 October 2010
Regional Office for South-East Asia
SEA-TB-330 Distribution: General
Programmatic Management of Multi-drug Resistant Tuberculosis Report of the Regional Workshop Kathmandu, Nepal, 27 September- 1 October 2010
Regional Office for South-East Asia
© World Health Organization 2011
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Contents Page
Abbreviations .........................................................................................................v 1. Introduction ................................................................................................... 1 2. Inaugural session ............................................................................................ 2 3. Overview of MDR-TB in the South-East Asia Region and response to DR-TB ......................................................................................... 2 4. The framework for effective control of DR-TB................................................. 4 4.1 Country presentations ............................................................................ 4 4.2 Case-finding strategies ............................................................................ 4 4.3 Organization of laboratory network and minimal mycobacterial culture and DST requirement .......................................... 5 4.4 Treatment strategies for DR-TB............................................................... 6 4.5 Treatment delivery and community-based DR-TB support...................... 6 4.6 Infection control and protection of health care workers .......................... 7 4.7 Management of secondline drugs (SLDs) ................................................ 7 4.8 Planning for national DR-TB control ....................................................... 7 4.9 Recording and reporting for DR-TB ........................................................ 8 5. Conclusions and recommendations ................................................................ 9 Annexes 1. Country Presentations................................................................................... 12 2. Technical assistance requirements ................................................................ 17 3. Agenda......................................................................................................... 18 4. List of participants......................................................................................... 19
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Abbreviations ACSM DOTS DR-TB DRS DST FEFO HIV HR IC ISTC MDR-TB MRS NATA PMDT SLC SNRL WHA XDR-TB advocacy, communication and social mobilization internationally recommended strategy for tuberculosis control drug resistant tuberculosis drug resistance surveillance drug susceptibility testing first expiry first out human immune deficiency human resources Infection control international standards of TB care multi-drug resistant tuberculosis medical recording system Nepal anti-tuberculosis association programmatic management of drug-resistant tuberculosis secondline drugs supranational reference laboratory World Health Assembly extensively drug-resistant tuberculosis
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1.
Introduction The sustained progress made by national TB programmes in the Region has contributed to preventing, and in some countries, reversing the emergence of significant rates of anti-TB drug resistance in the community. Relatively low levels of multi drug-resistance (range: 1.2-4.2) are reported among newly detected cases but higher rates (range: 10.0-34.2%) are reported among previously treated cases in the Region. However, given the large numbers of TB cases, over a third (34%) or nearly 180 000 of the world’s MDR-TB cases are estimated to occur annually in the SEA Region. Extensively drug resistant TB (XDR-TB) has also been reported from six countries in the Region. In areas of high HIV prevalence, the potential for increased transmission of MDR-TB is high. While the first priority in addressing MDR-TB remains prevention of acquired drug resistance through ensuring higher case detection and cure rates through high quality of DOTS services, National TB programmes recognized the need to simultaneously address the existing pool of MDR-TB cases in line with internationally recommended protocols, including good infection control measures. With the introduction of diagnosis and case management of multidrug resistant tuberculosis (MDR-TB) at health facilities up to the district and sub-district level in countries from 2008 onwards, the need for updating guidelines for the programmatic management of drug-resistant TB, and designing better recording and reporting systems to monitor outcomes, has become a felt need for national TB control programmes in the Region. In this context, a regional workshop on Programmatic Management of Multi-Drug Resistant Tuberculosis was held during 27 September- 1 October 2010 in Kathmandu, Nepal with the following objectives: ¾ ¾ Review the status, challenges and experiences in managing MDR-TB in countries of the Region; Provide updates on the revised technical and programmatic guidelines for the management of MDR-TB under national programmes, and Review existing national plans in order to include any additional measures required to effectively scale-up MDR-TB management in countries.
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2.
Inaugural session The workshop was inaugurated by Dr Lin Aung, WHO Representative to Nepal who delivered the keynote address on behalf of Dr Samlee Plianbangchang, WHO Regional Director for South-East Asia. The Regional Director emphasised the need to implement quality DOTS ensuring increased case detection and cure rates in the first place to prevent the emergence of DR-TB, adopt infection control measures to prevent the spread, and manage the existing pool of DR-TB cases in line with the international recommendations. He reiterated the resolution of the Sixtieth World Health Assembly (WHA) in 2007 and urged Member States to develop and implement long-term plans for tuberculosis including M/XDRTB prevention and control, in line with the global Plan to Stop TB 20062015, the Beijing Ministerial Call for Action on tuberculosis control and patient care in April 2009 and the resolution on “Prevention and control of Multidrug-resistant tuberculosis and extensively Drug-resistant Tuberculosis” endorsed at the Sixty-second World Health Assembly (WHA). Dr Praveen Mishra, Secretary, Ministry of Health and Population, Nepal in his address emphasized financial, human resources and political constraints and poverty as the main constraints for TB control. He stressed the need for countries to develop an action plan for DR-TB and TB-HIV integration. Dr Md Khurshid Alam Hyder, Medical Officer TB, WHO-SEARO briefed participants from Member States, regional experts and staff from WHO headquarters, the Regional Office and country offices on the objectives of the workshop. The inaugural session concluded with the introduction of all participants.
3.
Overview of MDR-TB in the South-East Asia Region and response to DR-TB Relatively low levels of multi drug-resistance (2.8%) are reported among newly detected cases but higher rates (18%) are reported among previously treated cases in the Region. However, given the large numbers of TB cases, over a third (34%) or nearly 180 000 of the world’s multidrug-resistant tuberculosis cases are estimated to occur annually in the South-East Asia
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Region. Though the extent of extensively drug resistant TB (XDR-TB) is not known in the Region, six countries have reported XDR-TB. All except DPR Korea, Maldives and Timor-Leste have established culture DST facilities, though they need to be scaled up with more quality assured laboratories especially in larger countries. Being a high-burden Region for DR-TB there are only two supranational reference laboratories in the Region which find it difficult to meet the mandated functions. The national reference laboratories in India and Thailand are currently undertaking DST for second-line anti-TB drugs to determine the extent of XDR-TB. Reference laboratories in India, Indonesia, Myanmar and Nepal are also engaged in rapid surveys for XDR-TB among mycobacterial isolates from patients who have failed re-treatment regimens, through linking with the SNRLs in the global network. All countries are linked to a supranational reference laboratory for either quality assurance or assistance in performing culture/DST. In order to achieve the TB-related Millennium Development Goals (MDGs), the regional action plan for managing M/XDR-TB seeks to: ¾ ¾ ¾ ¾ Strengthen basic DOTS; Scale-up programmatic management of MDR-TB and XDR-TB; Build laboratory services for timely diagnosis of MDR-TB and XDR-TB; Expand drug resistance surveillance to better understand the magnitude and trends of drug resistance to first and second-line anti-TB drugs; Foster sound infection control measures to avoid MDR-TB and XDR-TB transmission, especially in high HIV prevalence settings; Pursue resource mobilization at global, regional and country levels, and Promote research of new diagnostics and drugs, and field testing under programmatic conditions.
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4.
The framework for effective control of DR-TB While introducing of the framework for effective control of drug-resistant TB, the essential frame work remains the same as DOTS. Since the management of MDR-TB is more complex, there is a need for sustained political commitment, ensuring availability of quality assured microbiological diagnosis which would require setting up laboratories with facilities for culture, drug susceptibility testing with linkage to SNRL, monitoring of response to treatment, a patient-centered approach for direct observation of treatment on out-patient or hospitalized basis and quality assured second-line anti-TB drugs for the entire duration of treatment.
4.1
Country presentations During the workshop, Member states displayed posters on their activities for DR-TB management with challenges and plans of action for the future (Annex 1).The main issues discussed were the limited laboratory facilities for culture and DST in many countries and expanding the same to have 100% access across the country. Shortage of WHO pre-qualified secondline drugs was another major problem. Countries also presented their requirements for technical assistance during 2011-2012. (Annex 2).
4.2
Case-finding strategies The strategies for case-finding and diagnosis of patients with either suspected or confirmed DR-TB were presented and discussed during the workshop, taking into consideration that such programmes may have limited technical and financial capacity. The strategies range from testing all patients with TB to testing only a selected group of patients. The session reviewed case-finding of patients with DR-TB with respect to: ¾ ¾ ¾ ¾ The risk factors for drug resistance; Strategies for case-finding in programmes with minimal access to DST and limited resources; Information on sample collection and the use of rapid DST methods to identify drug resistance; Important issues in case-finding of drug resistance in the HIVinfected patient.
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Depending on the facilities available, each country should establish priority for screening. In the order of priority, category II failures (chronic cases), close contacts to DR-TB cases and category I failures should be subjected to screening. In HIV-infected persons, DST should be performed at the start of anti-TB therapy to avoid mortality. The rapid DST methods should be used when possible for the initial screening of DR-TB. Patients at risk of XDR-TB should be screened for resistance with DST of isoniazid, rifampicin, second-line injectable agents and a fluoroquinolone. This was followed by a group work where participants discussed choosing a casefinding strategy given different situations.
4.3
Organization of laboratory network and minimal mycobacterial culture and DST requirement The country should first assess the burden of MDR-TB either by using available data on drug resistance or make an educated best guess of the burden. It should also make an assessment of the existing laboratory network including sputum transport mechanisms, hierarchy, number of culture and DST facilities. Based on the number of patients planned to be screened, diagnosed and treated, the laboratory expansion plan needs to be developed to include all aspects of diagnostic mycobacteriology from smear microscopy services to the use of newer tools for the rapid identification and effective follow-up of patients put on PMDT. The need for quality assured laboratory services for diagnosis of DRTB was highlighted along with the need for training staff at different levels. Availability and advantages of newer molecular methods was discussed while highlighting the need to maintain conventional culture techniques. New approaches for risk assessment for workers based on a risk assessment for each TB diagnostic procedure for generation of infectious aerosols and the concentration of bacilli and use of bio-safety measures according to the risk were also discussed. Among the laboratory procedures, the high risk of generating infectious aerosols during manipulation of liquid suspensions and the appropriate bio-safety measures to be adopted such as the need for a containment lab which has restricted access and a double-door entry, Impermeable surfaces for easy cleaning, air flows into lab without recirculation to non-lab areas (directional airflow), and availability of an autoclave on site was highlighted.
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Field Visits: The participants were divided into two groups for field visits. One team visited the laboratory (GENETUP) and the NATA hospital facilities for treating TB and the other team visited the National TB Centre. Teams presented their main observations. The main issue was the infection control practices adopted, the size and the opacity of the sputum cups supplied which makes it difficult to assess the quantity and quality of the sputum samples, availability of second-line, ambulatory treatment as well as supervision and monitoring.
4.4
Treatment strategies for DR-TB Any patient with chronic or DR-TB requiring treatment with second-line drugs falls under WHO diagnostic category IV and will require specialized regimens termed Category IV regimens according to PMDT guidelines. This session provided guidance on the strategy options, including standardized, empirical and individualized approaches, to treat MDR-TB as well as the more highly resistant strains such as XDR-TB. The principles of choosing an appropriate regimen for managing M/XDR-TB and poly-drug resistant TB were presented and discussed. The rationale for use of group 1 to group 5 drugs, selection of drugs, formulation of regimens, justification for the same in different scenarios of M/XDR and poly-drug resistant TB were outlined. Management of DR-TB under special situations such as pregnancy, diabetes, convulsive disorders, renal impairment, concomitant HIV etc. were also discussed stressing that DR-TB treatment can be started with minor modifications under all situations. The need for close monitoring of patients while on treatment with clinical, bacteriological and bio-chemical evaluations and the need to identify and manage adverse drug reactions promptly to ascertain compliance from patients for the prolonged duration of treatment was stressed. This was followed by participants’ group work to identify suitable DRTB regimens under different situations.
4.5
Treatment delivery and community-based DR-TB support Though ambulatory treatment for DR-TB is being recommended, hospital beds are still required for management of clinical and sociological problems. DR-TB patients need to be involved in the management and be
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provided with the necessary health education and counseling. Management under congregate settings could be considered if sufficient beds and resources are not available. The need to mobilize community support for successful treatment was stressed. The role play that followed brought out the community willingness to participate and the need for the Ministry of Health to involve them.
4.6
Infection control and protection of health care workers The need to integrate infection control procedures with the general health services was emphasized. There is also a need to develop human resource capacity, develop appropriate advocacy, communication and social mobilization strategy for spreading the message to ensure follow-up of infection control policies. The need for surveillance among health care workers, and proper use of personal protection equipments were detailed.
4.7
Management of secondline drugs (SLDs) The session highlighted the need for accurate drug forecasting, considering the long lead time and short shelf life of SLDs. The need to maintain a proper inventory system to avoid stock-outs was stressed. Whenever required, the cold-chain management system needs to be in place. Once the drug reaches the country level, the country is responsible for maintaining the quality ensuring prompt clearance, proper storage and adhering to the First Ended, First Out (FEFO) principle. The electronic drug ordering form was demonstrated and participants familiarized to use the same.
4.8
Planning for national DR-TB control Participants were given a country scenario and they prepared a plan for case detection and enrolment for DR-TB treatment and discussed the expected public health impact of the plan.
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Introduction to WHO planning and budgeting tool Participants were introduced to the planning and budgeting tools evolved by WHO. Using the form to forecast the drug requirement for the country with budget readily made available by the software was demonstrated.
4.9
Recording and reporting for DR-TB Participants were introduced to the new recording and reporting requirements for DR-TB. The need for drug resistant survey and surveillance (DRS) was stressed. Lack of adequate information on DST from many countries makes it difficult for planning and implementing DR-TB control activities. Routine monitoring from the data collected, using a standardized methodology and periodicity, will be a very useful tool. Minimum requirements for drug resistance surveillance activities would include regularly spaced surveys among new cases and continuous surveillance among previously treated cases. Need for representativeness of the data, quality assured laboratory services, and well documented histories of previous anti-TB treatment by individual patients are necessary for useful interpretation of the findings. The methodology for planning a DRS survey was discussed and the participants worked out an example of including the budget considerations. The revised forms for recording and reporting including the definitions were discussed. Sample forms were shown and procedures for filling in were also discussed. Recording and reporting using open MRS Facilitators from Indus hospital, Pakistan, demonstrated a web-based system for recording and reporting of DR-TB used in their setting. Open MRS system which stands for Open Medical Record system is a free, open source and highly customizable electronic medical record system that has been deployed in at least 49 countries around the world. The web-based application supports the HL7 standard, allows the creation of custom forms and reports, and also allows easy extensions to support additional functionality. The research centre in Indus Hospital has modified an existing mobile phone-based application based on the openXdata platform to allow mobile phones to connect to Open MRS. While this system is currently
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being piloted as a tool for electronic mobile DOT for MDR-TB patients in Karachi; it can be extended to support additional functionality as well. Other tools like e- Manager (electronic Manager), which could be used was also demonstrated. Nepal and Myanmar plan to introduce open MRS for recording and reporting and Bangladesh has already introduced the eManager system. Pharmacovigilance The need to undertake pharmacovigilance of anti-TB drugs were presented and discussed. The aims of which are: ¾ ¾ improving patient care and safety in relation to the use of medicines and all medical and paramedical interventions, encouraging their safe, rational and more effective (including cost-effective) use and promoting understanding, education and clinical training in pharmacovigilance.
The need to stay alert when new drugs are being used for prolonged duration was stressed.
5.
Conclusions and recommendations Conclusion All Member states had initiated management of DR-TB with the exception of DPR Korea. Eight of the 11 Member States have developed national guidelines, established quality assured laboratories for culture and DST, while smaller countries such as DPR Korea, Maldives and Timor-Leste are availing services of the SNRL for culture/DST. Bangladesh, India, Indonesia and Myanmar are in the process of expanding laboratory services and plan to achieve coverage by 2012. Data on DRS profile is inadequate from the Region though based on estimates the Region carries 34% of the global DR-TB burden. Constraints faced for scaling up of DR-TB services to attain the global target of universal access to quality diagnosis and treatment by 2015, are due to inadequate laboratory capacity in terms of infrastructure and HR, availability of SLD, Page 9
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limited capacity for second-line drug management and inadequate hospital facilities. The other issues that were raised were: availability of quality assured drugs for rapid expansion, organization and monitoring of treatment, problems in decentralizing beyond the health facility level for management, making the ancillary drugs available for managing adverse drug reactions and concomitant illnesses. The need to have a guideline for patient counseling and implement infection control measures as part of general health services were highlighted.
Recommendations Recommendations for WHO and partners: ¾ Assist Member States in scaling up services and provide technical assistance for PMDT as requested by the country to strengthen laboratory capacity in terms of infrastructure and HR and drug management of SLD; Assist countries to procure sufficient SLD for scaling up of PMDT; Assist in mobilization of resources for social support for patients on DR-TB treatment considering the prolonged duration of treatment; Assist in developing guidelines/curriculum for systematic counseling for patient and family, and provide technical assistance to develop and implement the infection control plan; Support countries to train staff on electronic data management to analyze their own data and improve the programme and to have a more realistic evidence-based approach.
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Recommendations for national TB control programmes: ¾ ¾ Adhere to DOTS strategy to prevent emergence of DR-TB and ensure dissemination of ISTC among stakeholders; Prioritize DST for MDR-TB suspects in the order of risk as per the country capacity;
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Plan realistic scaling up of services to achieve the global target of universal access; Ensure availability of HR, laboratory services and second-line drugs; Identify funding gaps and take appropriate actions; Ensure maximum cooperation and coordination with the public and private sectors partners and organize training for all stakeholders; Mobilize necessary assistance from the technical partners; and Introduce electronic data management system.
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Annex 1
Country Presentations Country National guidelines for PMDT Developed in 2007 Central DRTB committee Established in 2007 QA lab established Lab functional, awaiting accreditation from SNRL, Antwerp, Belgium Initiated PMDT Bangladesh Implementing with GLC support from August 2008 Estimated no. of MDR cases 9,800 Pts on MDR-TB treatment 430 Plan by 2015 4,155 Plan for expansion Challenges Scale up MDR-TB management facilities country wide (diagnostic, hospital facilities, drug management and patient support mechanism). Funding from GFATM R8 (20112014) for management of additional 2500 patients. Establishment of MDR annex at NIDCH for capacity building and management of MDR-TB. Introduce rapid diagnostic method for MDR-TB diagnosis. Country-wide implementation of TB-IC. Bhutan Developed in 2009 Two laboratories for culture/DST for first line drugs. Initiated in 2007 33 38 50 Plan to expand culture facilities – in 3 Regions. Second-line DST – PHL sends samples to reference lab in Bangkok. PHL has planned to do a few second-line DST in the near future. DPR Korea PMDT not yet initiated 76,366 Development, print and distribution of national guideline for MDR-TB. Strengthening of laboratory capacity for diagnosis of MDR-TB. Nationwide survey for MDR-TB; Starting of treatment for MDR-TB patients wtih support from GF. Sustained highquality DOTS implementation. Diagnostic technology not yet accredited. To submit the proposal for procurement of secondline drugs to GLC. Human resource crisis to manage MDR-TB patients. Limited access to DST and culture in parts of the country. Limited MDR-TB management capacity and coverage. Recording and reporting for MDR-TB. Uninterrupted supply of GLC approved SLD. Limited linkage with private laboratories with capacity for culture and DST. Involvement of the private sector. Inadequate infection control measures. Secure continuation of funds.
Human resources. HIV/TB co-infections. DOT implementation. Hard-to-reach groups (students and monks).
India
National guidelines developed in
Established in 2005
Initiated in 2 states in 2007, expanded to
14 labs established
99,000
1,415
30,000
Most States need to develop an action plan.
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Country
National guidelines for PMDT 2006
Central DRTB committee
QA lab established 10 states in 2009
Initiated PMDT
Estimated no. of MDR cases
Pts on MDR-TB treatment
Plan by 2015
Plan for expansion
Challenges
Promote rational use of anti-TB drugs. Improve laboratory capacity in diagnosing MDRTB. Effective treatment of MDR-TB patients. Initiation and rapid scale-up of MDRTB services. Evaluate the extent of the threat of second-line anti-TB drug resistance and management of XDR-TB. Implement infection control measures. By 2010, RNTCP Category IV services will be introduced in all states with complete geographical coverage by 2012. By 2012, access to laboratory based quality assured MDR-TB diagnosis and treatment for all smear positive re-treatment TB cases. New cases who have failed an initial first-line drug treatment. By 2015, access to MDR-TB diagnosis and treatment for all smear positive TB (new and retreatment) cases registered under RNTCP. The first 5 years of PMDT implementation will be focussing on public health services. Dissemination of Information will be conducted to local NTP partners, including NGOs, professional NGOs, medical schools. The referral hospital for PMDT
Delay in establishment of accredited state-level laboratories due to administrative reasons. Sub-optimal functioning of the accredited labs. Non-availability of trained manpower. Dedicated regular staff in addition to the contractual posts. Uninterrupted power supply. Diagnostic delay with conventional method (3-4 months turnaround time). Special requirements for introduction of newer rapid diagnostics- lab infrastructure and training. Long duration, toxic, expensive treatment. Uninterrupted supply of drugs from GLC. Daily ambulatory DOT and ensuring treatment adherence. Availability of DOTS-Plus sites (1 per 10 million population). Training, supervision and monitoring at all levels. Ensuring timely follow-up.
Indonesia
Available
Established
5 QA labs established for first line drugs, three for second- line drugs
Yes
9,300
100
5,100
Convincing related sectors, units and medical specialists that: • Commitment of decision makers and related sectors for un-interrupted funding and to ensure the continuation of PMDT activities. • PMDT IS “DOTS” for MDR TB patients. • Expansion of laboratory for culture & DST has to be in line with
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Report of the Regional Workshop Country National guidelines for PMDT Central DRTB committee QA lab established Initiated PMDT Estimated no. of MDR cases Pts on MDR-TB treatment Plan by 2015 Plan for expansion Challenges
in the two pilot sites are teaching hospitals for two major medical schools in the country. Plan for stepwise expansion to cover 5,100 patients by 2015. Develop National guidelines on treatment of MDRTB. Conduct training workshop for rehabilitation and penitentiary workers on transmission and prevention of TB. Training workshop for community health workers on TB case management. Conduct awareness programme on TB/HIV co infection and active case finding on World TB Day 2011. Conduct awareness programme for expatriates recruiting agents on TB prevention and control. International training for TB laboratory workers on culture sensitivity. Develop, print and disseminate IEC information package on transmission and prevention of TB for school children. Strengthen the basic DOTS. Conduct operational research. Strengthen the MDR-TB surveillance. Gaining experience in MDR-TB management and care under the DOTS-plus pilot project in Yangon and Mandalay. Further broaden
•
•
the PMDT expansion. MDR TB Surveillance is important to guide the steps to be taken in the expansion plan. SLD abused.
Maldives
Under preparation
No
No
Yes
3
3
Lack of skilled manpower at all levels of the programme; Lack of trained staff for DOTS centre. Inadequate availability of capacity on DST, no official links have been established with and reliable external TB laboratory for DST for diagnosis as well as for follow up for X/MDR patients. Inadequate X/MDR TB management (including diagnosis and treatment).
Myanmar
Established in 2006
Established in 2006
Established in 2010
2009
9,300
121
400
Work burden in TB hospital and laboratories; Adverse event management; Linkages for rapid diagnosis of DR/MDR-TB – scale-up plan; Geographic scale-up; 3DF/WHO funding mechanism is a great barrier for project implementation.
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Country
National guidelines for PMDT
Central DRTB committee
QA lab established
Initiated PMDT
Estimated no. of MDR cases
Pts on MDR-TB treatment
Plan by 2015
Plan for expansion
Challenges
the partnership to fight MDR-TB in order to mobilize additional resources (including Global Fund). Develop the national guideline for MDR-TB management. Expand MDR TB programme sites (from 54 to 80). Provision of hostel accommodation (10 hostels). Upgrade Central NTP Laboratory to NRL; Establish culture facilities at Regional level (3) and DST (1 Region). Continue to expand collaboration with public and private sector partners. Upgrading of NRL. Introduction of new technology for culture and drug resistance identification. Expansion of culture facilities with four Regional culture laboratories. DRS in 2011/12 and 2014/15. Adoption of MDRTB Programmatic Management Guidelines (Draft available). Thailand 2,900 Target not set To increase the number. of treatment sites to 100 hospitals. Private sector to refer MDR suspects and confirmed MDR to the government hospitals. To develop a plan to involve medical schools. Human resource development in terms of > training, supervision, guideline revision and development. Encouraging MDR patients to accept daily DOT. Managing side effects. Delaying in reporting DST results. Delaying in submitting reports (also incorrect reports).
Nepal
2004
2004
Yes
2005
1,700
841
1,500
Culture facilities at regional level. Provision of hospital beds or hostel for MDR-TB patients. Inadequate supervision. Lack of infection control in health care setting. Upgradation of NTP Central Laboratory as National Reference laboratory. Lack of electronic data management.
Sri Lanka
Developed in 2009
Established in 2009
One national level lab and one regional level lab established
To be initiated
63
36 since 2006
40
Global Fund Round 6 – DRS survey planned in 2010 not done due to ‘no go’ status for PR2 (it was budgeted under PR2).
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Report of the Regional Workshop Country National guidelines for PMDT Central DRTB committee QA lab established Initiated PMDT Estimated no. of MDR cases Pts on MDR-TB treatment Plan by 2015 Plan for expansion Challenges
Strengthening of recording and reporting system. Expansion of number of hospitals approved by GLC. Timor Leste In place In place No, DST being done by SNRL 2008 130 5 Establishment of a link with supranational laboratory in AustraliaAdelaide for culture and DST. Collection and transportation of MDR-TB samples to supranational laboratory. Training for MDRTB staff by International expert. Hiring MDR-TB clinical doctor. Extension of MDRTB rooms in NGO Klibur Domin and National Hospital. Limited capacity for MDRTB management. Low community awareness for MDR-TB and treatment. Medical doctors not following TB guideline in public facilities. Promoting rational use of second-line drugs (particularly quinolones) by private practitioners.
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India COUNTRIES
Nepal
Bhutan
Thailand
Maldives
Sri Lanka
Myanmar
Indonesia
DPR Korea
Bangladesh
Timor-Leste National guidelines for MDRTB PMDT training Clinical MDR-TB training Expansion plan/ scale up of MDR-TB DRS protocol development DRS implementation plan
Annex 2
TA Requirements for 2011-2012 R&R/electronic systems
Laboratory for culture and DST / expansion plan
Technical assistance requirements
Infection control
GLC monitoring mission
Programmatic Management of Multi-drug Resistant Tuberculosis
Visit MDR-TB Existing Programme/on job training Second-line anti-TB drug management & forecasting
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Annex 3
Agenda (1) (2) (3) (4) (5) (6) (7) (8) (9) Overview of MDR-TB in the South-East Asia Region and response to DR-TB The framework for effective control of DR-TB Case finding strategies and prioritization of risk groups Organization of laboratory network and minimal mycobacterial culture and DST requirement Treatment strategies for DR-TB Treatment delivery and community-based DR-TB support Infection control and protection of health care workers Management of second-line drugs Planning for national DR-TB control
(10) Introduction to WHO planning and budgeting tool (11) Recording and reporting for DR-TB (12) Conclusions and recommendations
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Annex 4
List of participants Country Participants Bangladesh Dr Sk. Abdul Kadir Junior Consultant Chest Disease Clinic Khulna Email: kadirkhulna56@gmail.com Dr Md Wahiduzzaman Akhanda Asst. Professor (Respiratory Medicine) Department of Respiratory Medicine NIDCH Dhaka Email: drakhanda1957@gmail.com Mr Mohammed Mafizul Hoque Statistical Assistant NTP Dhaka Email: mmhoque23@gmail.com Bhutan Mr Chewang Rinzin Sr Progamme Officer TB Programme Department of Public Health Ministry of Health Thimphu Email: crinzin@health.gov.bt Mr Ugyen Wangdi Dy Chief Medical Record Officer Eastern Regional Referral Hospital Mongar Email: ugyenwangdi60@hotmail.com DPR Korea Dr Ri Hyon Chol Director Department of TB Prevention and Control Ministry of Public Health Pyongyang Dr Choe Kum Song National TB Preventive Institute Ministry of Public Health Pyongyang Mr Ri Su Nam Interpreter Ministry of Public Health Pyongyang India Dr M.S. Srinivas Rao Joint Director (TB) and State TB Officer Hyderabad Andhra Pradesh Email: staop@rntcp.org Dr Kuldeep Singh Sachdeva CMO (TB) 528-C, Dte. GHS, Nirman Bhawan New Delhi Email: sachdevak@rntcp.org; sachdevak@rntcp.org Indonesia Dr Dyah Erti Mustikawati NTP Manager Jl Pereetakan Negara No 29 Jakarta Pusat 10560 Email: dmustika_2007@yahoo.co.id Dr Purwantyastuti Chair TWG MDR-TB Jl Pereetakan Negara No 29 Jakarta Pusat 10560 Email: purwanty2703@yahoo.com Dr Widyastuti Head of CDC Jakarta Health Office Jl Pereetakan Negara No 29 Jakarta Pusat 10560 Email: widyendro@gmail.com Page 19
Report of the Regional Workshop Maldives Ms Fathmath Reeza Assistant Programme Officer Centre for Community Health and Disease Control Male Email: reeza.ntp@live.com Ms Aminath Niusha Assistant Community Health Officer L. Gan Regional Hospital Male Email: a.niusha@live.com Myanmar Dr Moe Zaw Assistant Director (TB) Department of Health Naypyitaw Email: moezaw07@gmail.com Dr Thandar Thwin Divisional TB Officer Mandalay Division Mandalay Email: ntp01@baganmail.net.mm Nepal Mr Sitaram Ghimire Statistical Officer National Tuberculosis Centre Thimi, Bhaktapur Email: sitaram5@hotmail.com Dr Menu Acharya MDR Coordinator National Tuberculosis Centre Thimi Bhaktapur Email:safal_menu@yahoo.com; mdr_pmu@mail.com.n Sri Lanka Dr Wijitha Senaratne Chest Physician Chest Hospital Welisara Email: wichitra5861@yahoo.com Dr Bandu Gunasena Chest Physician Chest Hospital Welisara Email: bandugunasena@yahoo.com Thailand Ms Sonjit Pongpanit Registered Nurse, Sr Professional Level Bureau of Tuberculosis Department of Disease Control Ministry of Public Health Nonthaburi Email: sonjit33@hotmail.com Ms Auyporn Petborisuit Public Health Technical Officer Sr Professional Level Office of Disease Prevention and Control 12 Songkhla Province Department of Disease Control Ministry of Public Health Nonthaburi Email: auyporn_p@yahoo.com; auyporn10@gmail.com Dr Sirinapha Jittimanee Public Health Technical Officer Sr Professional Level Bureau of Tuberculosis Department of Disease Control Ministry of Public Health Nonthaburi Email: sxj47@yahoo.com Timor-Leste Mr Domingos Pereira Regional Supervisor National TB Control Programme Dili Email: gosodomy@yahoo.com Mr Laurindo da Silva District TB Coordinator District Liquica Email: alausilva@yahoo.com.au
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Programmatic Management of Multi-drug Resistant Tuberculosis
Temporary Advisers/Resource Persons Dr Kashi Kant Jha Director National Tuberculosis Centre Thimi Bhaktapur Nepal Email: drkkjha@hotmail.com; director_ntp@mail.com.np Dr T. Santha Devi 11-A, Kilpauk Garden Colony Western Extension Kilpauk Chennai – 600 010 Tamil Nadu India Email: santhasethu@gmail.com ; santha_sethu@yahoo.com Dr Bhabana Shrestha Chief Medical Officer GENETUP Nepal Anti TB Association Kalimati, Kathmandu Nepal Email: genegup@wlink.com.np; bhabp@hotmail.com Observers Dr Zakia Sultana Siddique Technical Officer BRAC Health Programme 75 Mohakhali Dhaka Bangladesh Email: zs_siddiqui@yahoo.com WHO Country Offices Dr Chawalit Natpratan TIP-TB WCO Indonesia Email: natpratanc@searo.who.int Dr Muhammad Akhtar Medical Officer-TB WCO Nepal Email: akhtarm@searo.who.int
Dr Supriya Warusavithana NPO-CDS WCO Sri Lanka Email: warusavithanas@searo.who.int Dr Vikarunnessa Begum TNP (TBCAP) WCO Bangladesh Email: begumv@searo.who.int WHO-HQ Dr Dennis Falzon Medical Officer STOP TB Dept Email: falzond@who.int Dr Mohamed Guled Farah Consultant WHO EMRO Email: m.g.farah@medisin.uio.no; mohamed_guled_fa@hotmail.com Dr A.B.M. Tauhidul Islam Technical Officer TB Operations and Coordination (TBC) Email: islamt@who.int Ms Saira Khowaja Director, TB Control Program Indus Hospital 4th Floor, Main Korangi Crossing Karachi Pakistan Email: saira.khowaja@irdresearch.org Dr Hamidah Hussain Adviser, MDR-TB Programme Indus Hospital Main Korangi Crossing Karachi Pakistan Email: hamidah.hussain@irdresearch.org Mr Ali Habib Manager, IT Development Interactive Research and Development (IRD) Email: ali.habib@irdresearch.org
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Report of the Regional Workshop WHO-SEARO Dr Md Khurshid Alam Hyder Medical Officer-TB Email: hyderk@searo.who.int Ms Nigorsulton Muzafarova Technical Officer-GDF Email: muzafarovan@searo.who.int Mr Ankur Tanwar Secretary Email: tanwara@searo.who.int
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The World Health Organization’s South-East Asia (SEA) Region has the highest burden of tuberculosis in the world. Appreciable progress has been made with TB control using the DOTS strategy, and several countries in the Region have reached the global targets. Renewed emphasis has been placed on reaching universal case detection and treatment of all forms of TB through improving diagnosis and management of all forms and, in particular, better managing multi- and extensively drug-resistant tuberculosis, as well as HIV-associated TB. The specific objectives of this meeting were to review progress and constraints in implementing the Stop TB strategy in Member States of the SEA Region; and provide guidance on adopting and applying the revised WHO policies and guidelines to more comprehensively address TB control in the specific context of Member States of the Region. The overall recommendations for WHO and technical partners were to collaborate with countries to improve the estimates for the TB burden in the countries; gather evidence that can guide countries in more accurately defining case suspects based on symptoms other than cough (>2 weeks) in order to improve case detection; evaluate the performance of diagnostic algorithms in the context of smear-negative EPTB and childhood TB, and consider appropriate revisions; assist countries in deploying new tools, developing operational research on new diagnostic tools, and elaborating guidelines on the basis of the outcomes.
Regional Office for South-East Asia World Health House Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110002, India
SEA-TB-330