Workshop Report Regional Workshop on Recording and Reporting of Drug-Resistant Tuberculosis in the Western Pacific
24–26 November 2010 Manila, Philippines
WPR'20 1OIDCCISTB-E Report series nuniber: RS120 10lGEl69 (PHL) English only
REPORT REGIONAL WOPU(SNOP ON RECOIIDmG AND =PORTING OF DRUG-RESISTANT TUBERCULOSIS IN THE WlESTERN PACIFIC
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 24-26 November 20 10
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines May 201 1
NOTE The views expressed in this report are those of the participants of the Regional Workshop on Recording and Reporting of Drug-Resistant Tuberculosis in the Western Pacific and do not necessarily reflect the policies of the Organization.
This report has been printed by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Regional Workshop on Recording and Reporting of Drug-Resistant Tuberculosis in the Western Pacific, which was held in Manila, Philippines froin 24 to 26 November 2010.
CONTENTS
SUMMARY ..............................................................................................................................................
i
1. INTRODUCTION .................................................................................................................................. 1 1.1 1.2 1.3 Objectives
....................................................................................................................................... 1 1
Resource persoas .................................................................................................................................
Participants ....................................................................................................................................... 2
1.4 Agenda
.......................................................................................................................................
2
2 . PROCEEDINGS ...................................................................................................................................... 2 2.1 2.2 Surveillance of MDR-TB: Global and regional situation (Agenda item 3) ......................................... 2 Why monitor drug-resistant tuberculosis, aim of R&R, indicators. strategies for 2 detection of MDR-TB (Agenda item 4) .............................................................................................. 2.3 On anti-TB drug resistailce surveillailce and DR surveys. followed by group work (Agenda items 5 and 6) ....................................................................................................................... 3 2.4 2.5 2.6 2.7 2.8 Regional activities of the Eli Lilly Foundation (Agenda item 7) ........................................................3 Definitions for case registration and treatment (Agenda item 8).........................................................4 Presentation of Chapter 18 and forms. followed by group work (Agenda items 9 and 10) ................ 4 Forecasting system for improved procureinent (Agenda item 14) ...................................................... 5 Reporting of MDR-TB cases . Presentation of standard tools for deriving MDR-TB indicators. 5 followed by group work (Agenda items 15. 16 and 17) ...................................................................... 2.9 OpenMRS (Agenda item 18)...............................................................................................................6
2.10 OpenXdata (Agenda item 19)..............................................................................................................6 2.11 e-TB Manager. followed by group work (Agenda items 20 and 21) ................................................... 7 2.12 Principles of Laboratory Infonnation System (LIMS) (Agenda Item 22) ...........................................7 8 2.13 EpiAnywhere (Agenda Item 25) .........................................................................................................
2.14 Data cleaning. validation and cross-chechng (Agenda item 26) ........................................................ 8 2.15 Principles in developing a national plan for R&R for TBIMDR-TB in countries The Introduction to TB Surveillance System in China (Agenda item 27) ........................................... 8 9 2.16 On pharmacovigilance (Agenda item 28) ............................................................................................
2.17 Approaches toward data description. graphing and ailalysis - Using data for PMDT . Philippines, followed by GLC approval in the Region (Agenda item 29) ..........................................9 2.18 Practical exercises in data analysis -posters (Agenda item 30)........................................................ 10 2.19 Course Assessment (Agenda item 3 1)............................................................................................... 3. 11
CONCLUSIONS AND RECOMMENDATIONS ............................................................................ 12
3.2
13 Recommendations .............................................................................................................................
ANNEXES ANNEX 1 ANNEX 2 List of Participants .................................................................................... '15 Agenda and Timetable ................................................................................ 25
Key words:
Tuberculosis. Multidrug-resistant .prevention and control / Western Pacific
SUMMARY
The new STOP TB strategy identifies management of drug-resistant tuberculosis as an important element of effective tuberculosis control in the world. In May 2009, the Sixty-second World Health Assembly (WHA) adopted resolution WHA62.15, which urged Member States to strengthen "health information and surveillance systems to ensure detection and monitoring of nlultidrug-resistant and extensively drug-resistant tuberculosis and monitor achievement in its prevention and control". Improved information allows managers to monitor programme performance and trends in cases notified, plan drug supply and develop programnles and policy. It also helps clinical providers with the management of individual patients. It was therefore planned to hold a workshop to train key health workers involved in the monitoring and evaluation of drug-resistant tuberculosis (TB) in countries with a high burden of n~ultidrug-resistant(MDR) TB as well as other countries treating substantial numbers of MDR-TB patients. This three-day workshop was focused on the methodology of recording and reporting (R&R) of MDR-TB patients on treatment, and on the use of data for analysis to strengthen programme management. Of particular importance are: (1) (2) drug-resistant TB registration has additional data requirements to the basic directly observed treatment, short-course (DOTS) information system; accurate record-keeping is crucial both for patient care and for suweillance; and standardized monitoring of treatment outcomes both at national and regional levels will help with understanding the impact of drug-resistant TB control interventions and identify problems.
(3)
The objectives of the workshop were: (1) to improve information on TB control in Member States through strengthened national capacity in surveillance, registration, monitoring and evaluation of drug-resistant tuberculosis cases; to understand the need for standardized patient registratioil and case definitions as well as the importance of cohort analysis of registered MDR-TB patients on treatment and their outcomes; and to understand the importance of case evaluation for improved patient management.
(2)
(3)
About 20 participants from 12 countries in the Western Pacific Region attended the workshop. Most countries were represented by a senior National TB Programme (NTP) managerial staff and one person dealing with registration of multidrug- and extensively drug-resistant (MIXDR) TB patients. The agenda consisted of four sessions: (1) Introduction to the rationale of MDR surveillance and recording and reporting; (2) Parameters for standardized recording and reporting; (3) Electronic solutions for recording and reporting; and (4) Increasing capacity in analysis and planning. The sessions included formal lectures, directed reading and hands-on practical sessions with group discussions and demonstrations including software. Participants presented posters according to a te~nplate sent out before the workshop.
The main conclusions of the workshop were as follows:
(1)
The routine recording and reporting system for the basic TB programmes (e.g. DOTS) is well-established in the Region; however, many countries face challeizges in maintaining the good quality, in mollitorillg trends, and in identifying and monitoring groups defined as MDR suspects who should have drug-susceptibility testing (DST). The routine recording and reporting system for MDR-TB is clearly defined in WHO guidelines, but its implementation is still weak in many countries in the Region. It is difficult to assess trends in the MDR situation, e.g. incidence and burden of MDR-TB, since data on MDR cases by category are incoinplete. In the absence of well-functioning surveillance systems, periodic surveys have provided key information, but the overall picture remains incomplete. NTPs lack data on coverage of culture and DST in MDR suspects, partly because groups that are considered to be MDR suspects and have DST are not yet well-defined, and because the routine R&R system does not include all relevant groups such as so-called clxonics and early failures. The number of reported MDR cases is often incomplete because laboratories usually do not register category of patients. Often there is no direct link between laboratories and the TB programme, which manages the MDR registry. Also, different dates are used for the registration of cases. The Green Light Committee (GLC) has approved treatment for a considerable number of MDR cases in the Region, but so far, only a minority of cases have beell enrolled. The number of cases, however, has been rapidly increasiizg. There is a lack of solid data on MDR treatment coverage and delay, inside and outside the GLC mechanism. NTP data on MDR treatment outcoine are incomplete in most countries. This information is especially needed to monitor levels of defaults, deaths and failures in a timely way, so that the strategy can be modified when needed (e.g. social support, regimens); Supply of second-line drugs is affected by lack of reliable data on current MDR cases and reasonable projections, which are based on reported cases and not on estimates. The new drug procurement system promoted by the Global Drug Facility (GDF) is based on quarterly routine data from the TB programmes, and should coincide with strengthening of the R&R system. The R&R system for MDR-TB is paper-based in five countries and computerized with data linkage over the web in the Philippines and the four Pacific Islands. These paper-based systems may work well as long as the number of patients is limited. Computerized systems, however, may prove to be very useful especially for tabulation and analysis. The two main computer systems for MDR-TB presented, OpenMRS and e-TB Manager, are extensive electronic medical record systems, which, according to the WHO guidelines and list of indicators, contain more information than the minimum required.
The reconlmendations of the workshop were as follows:
In line with recoinmeildations from the Workshop on Surveillance and Impact (1) Monitoring in Ho Chi Midl City, Viet Nam, June 2010, NTPs should ensure a well-functioi~ing R&R systeln for basic TB programmes (e.g. DOTS) through training, regular supervision and use of data for analysis and management at all levels.
( 2 )
NTPs should ensure a well-functioning R&R systeln for MDR-TB as an extension of the basic R&R system in line with WHO recormnendations. Budgeting for programmatic management of drug-resistant TB (PMDRTB) should include proper R&R, through training and supervision. NTPs should use data for analysis at all levels as part of routine supervision visits, to stimulate better quality.
NTPs should monitor closely the coverage of culture and DST in MDR suspects (3) through a strengthened basic R&R system, and special collectioil of data on chronics and early failures using MDR suspects, laboratory and district TB registers. NTPs should strengthen the use of MDR registers and keep updated links with (4) laboratory registers to ensure completeness.
( 5 ) NTPs should take advantage of the new GDF system for improved drug procurenlent of first- and second-line drugs, as an integrated part of NTP routine quarterly R&R data.
( 6 ) NTPs should take lllaxinzum advantage of computerized systems for R&R. Challenges that need to be considered include high cost and high demand of technical con~petence and back-up. Countries with established computerized systems for nonnal TB inay add on an integrated MDR component in the same system. The countries without a coinputerized systein may develop their own based on local competence or use of one of the already developed electronic medical record systems such as OpenMRS or e-TB Manager. It is important to keep systems simple and compliant with the WHO requirements for reporting.
(7) Technical assistance needs to be provided for country staff to: (1) ensure good data quality in the R&R system; (2) tabulate, analyse and manage data; and (3) introduce feasible options for electronic systems.
1. INTRODUCTION
The new STOP TB strategy identifies inanagement of drug-resistant tuberculosis as an important elenlent of effective tuberculosis control in the world. In May 2009, the Sixty-second World Health Assenlbly (WHA) adopted resolution WHA62.15, which urged Member States to strengthen "health information and surveillance systems to ensure detection and nlonitoring of multidrug-resistant and extensively drug-resistant tuberculosis and monitor achievenlent in its prevention and control". Inlproved illfoimation allows managers to monitor programme perfonnance and trends in cases notified, plan drug supply and develop progranvlles and policy. It also helps clinical providers with the management of individual patients. It was therefore planned to hold a workshop to train key health workers iilvolved in the monitoring and evaluation of drug-resistant TB in countries with a high burden of multidrug-resistant (MDR) TB as well as other countries treating substantial numbers of MDR-TB patients. This three-day workshop was focused on the nlethodology of recording and reporting (R&R) of MDR-TB patients on treatment, and on the use of data for analysis to strengthen programme management. Of particular importance are:
(1) (2)
drug-resistant TB registration has more data requirements than the basic directly observed treatment, short-course (DOTS) information system; accurate record-keeping is crucial both for patient care and for surveillance; and standardized ~noilitorillgof treatment outcomes at both national and regional levels will help with understanding the inzpact of drug-resistant TB control interventions and identifying problems.
(3)
1.1
Objectives
(I)
To improve information on TB control in Member States through strengthened national capacity in surveillance, registration, monitoring and evaluation of drug-resistant tuberculosis cases. To understand the need for standardized patient registration and case definitions as well as the importance of cohort analysis of registered MDR-TB patients on treatment and their outcomes. To understand the importance of case evaluation for improved patient management.
(2)
(3) 1.2
Resource persons
The Stop TB Unit of the WHO Western Pacific Regional Office planned and conducted the workshop in close coordination with the Stop TB Department, WHO Headquarters. Eight facilitators made presentations and supervised the practical sessions. They included three temporary advisers who were invited to present computer systems used to manage MDR-TB, and a consultant to provide support to the workshop.
1.3
Participants
About 20 participants from 12 countries in the Western Pacific Region attended the workshop. Most countries were represented by a senior National TB Programme (NTP) manager and one person dealing wit11 the registratioil of inultidrug- and extensively drug-resistailt (MIXDR) TB patients. Seven national programme officers and medical officers based in five country offices also participated. The full list of participants is in Annex 1.
The agenda consisted of four sessions: (1) Introduction to the rationale of MDR sul-veillance and recording and reporting; (2) Parameters for standardized recordiilg and reporting; (3) Electronic solutions for recording and reporting; and (4) Increasing capacity in analysis and planning. The sessions included formal lectures, directed reading and hands-on practical sessions with group discussions and demonstrations (including software). Participants also presented posters according to a template sent out before the workshop. For more details see Annex 2 (agenda and timetable).
2.1
Surveillance of MDR-TB: Global and regional situation (Agenda item 3)
Dr Dennis Falzon, WHO Headquarters, presented surveillance data on the MJXDR-TB situation, in line with the 2010 global report on surveillailce and response. Although the amount of surveillance data has increased, 40% of countries globally have no data. More than half of the countries in the Region (14127) have data on first-line drug susceptibility testing (DST). Few MDR-TB cases have been notified in the Region through routine continuous TB surveillance. WHO has developed estimates for the number of MDR cases ainong new and previously treated TB cases in each country in 2009. While 122 212 MDR cases were estimated, only 1993 were reported (1.6%). Modern diagnostics are promoted through Expanding Access to New Diagnostics for TB (EXPAND-TB). Many countries report MDR treatment outcome, but with modest success rates and high iluinbers of deaths. The high cost of second-line drugs is a major limitation for the countries. The Global Plan to Stop TB 201 1-2015 has as its goal to reduce the incideilce of MDR-TB. By 2015 all re-treatment cases and 20% of new TB cases should have drug resistance testing as MDR suspects, and all those diagnosed should be started on treatment. WHO Headquarters collects annual drug-resistant TB data through the WHO Global TB data collection system. 2.2 Why monitor drug-resistant tuberculosis, aim of R&R, indicators, strategies for detection of MDR-TB (Agenda item 4)
Dr Einar Heldal announced that the aim of the R&R system was (1) to allow TB managers at different levels to monitor progranme performance, follow trends in number of cases notified, plan drug supply and provide the basis for programme and policy development, and (2) to aid clinical providers in the management of individual patients.
In recent years, a few couiltries have docuineilted a decline in MDR from high levels, such as Latvia and Estonia in the Baltic region. The main reason seemed to be a decline in the number of re-treatment cases, while the proportion of MDR in new cases did not clearly decline. One main approach to control MDR is to strengthell the basic DOTS programme to prevent the creation and transmission of MDR in the first place. Each TB programme needs to define clearly the groups of patients that should have DST done as MDR suspects. In no st countries, the groups include all re-treatment cases and a few new cases such as close contacts of confirmed MDR cases. The routine R&R system for DOTS provides the number of re-treatn~entcases, although the quality of data may be low. Two groups of MDR suspects are not reported in the DOTS R&R system, namely: (1) "chronics" or "backlog" cases who have failed re-treatment in the past; and (2) early failures, i.e. cases with positive smear after three to four months of treatment. So far, hardly any data are available on the proportion of re-treatment cases with DST result, and reported MDR cases are very few. NTPs at all levels should use the R&R system more actively for programme management to motivate better quality. However, in some settings, defining targets and use of incentives have affected the quality of data (political reporting). Real data are needed to detect low-performing areas so that improvements can be made. 2.3 On anti-TB drug-resistance surveillance and drug-resistance surveys, followed by group work (Agenda items 5 and 6)
Dr Falzon described the background and prerequisites for anti-tuberculosis drug-resistance surveillance and surveys. Minimum requireinellts are regular surveys among new cases and continuous surveillance among previously treated cases. DST should include rifainpicin and isoniazid, and, in case of rifanlpicin resistance, should also include fluoroquinolone, second-line injectable and ethambutol. The need to clearly separate new and previously treated cases was emphasized, including assurance of laboratory quality. Focus should be on smear-positive cases, but new tests will change this to focus on all cases. Ethical issues must be addressed to ensure that adequate treatment is made available to all drug-resistant cases detected. The planning and implemeiltation of drug-resistance surveys were described in detail. Routine surveillance data have been grouped into class A and B depending on culture and DST coverage. EXPAND-TB provides an opportunity to collect laboratory DST information and then report it to NTP more efficiently. The laboratory infonnation management system needs strengthening. Data and infonnation management is not given priority, services are specimen-focused and new diagnostics may change surveillance methods. There is a critical need to integrate laboratory, clinical, and population health programme information systems. In the first group work session, participants discussed plans to set up routine surveillance or nationwide surveys, and learnt how to write a drug-resistance survey protocol. 2.4 Revional activities of the Eli L i l l ~ Foundation (Agenda item 7)
Ms Sunita Prasad, Eli Lilly Foundation, India, presented The Eli Lilly MDR-TB Partnership, which addresses TB burden in some of the hardest-hit countries, including China, India, the Russian Federation and South Africa. The prograrmne reaches 80 countries on five continents. The Eli Lilly Foundation has organized health professionals, businesses, academic institutions and communities in a comprehensive US$ 135 million MDR-TB programme. Activities include health care professional training; community support with the International Federation of Red Cross (IFRC) and Red Crescent Societies; country support and technical assistance with WHO, the Centers for Disease Control and Prevention (CDC) and Stop TB
Partnership and Workplace programmes; communications and advocacy; transfer of technology; and research and development. 2.5 Definitions for case registration and treatment (Agenda item 8)
Dr Heldal presented definitions for case registration and treatment according to the WHO guidelines for tlze progranznzatic marzagenzent of drug-resistant tuberculosis (emergency update, 2008) in chapter 4 (i.e. defillitiolls of case registration, bactel-iology and treatlnent outcomes). He followed that with a presentation of chapter 18 (i.e. content of the recording and reporting system) and the fonns. A revision of the guidelines will be finalized in early 201 1. Definitions of drug resistance, category IV, enlpiric treatment and collversioll were also discussed. According to Dr Heldal, MDR registratioil groups are separated according to previous use of first- and second-line drugs to stratify analysis of treatment result. They are separated by result of previous treatnlent (very similar to the DOTS R&R system) in order to assess trends in case finding and to assess the coverage of DST in risk groups for MDR-TB. Definitions of cohort analysis of treatment outcome were discussed. Some key definitions are causing confusion. For example, identifying an MDR case can be difficult since the MDR treatment regimen niay be changed one or more times because of later information of DST. It is not quite clear when changes are so substantial that they should be considered when starting a new treatment period and the MDR patients should be registered again. This is related to the definition of failure of MDR treatment, which does not specify when to declare failure, i.e. after how many months on ineffective treatment. Some projects may consider several treatment periods in a row as one treatment, causing one treatment to last much inore than two years. "Cl~onics"or "backlog" patients (mainly patients who failed category I1 treatnlent in the past) are an important group of MDR suspects, but they are not included in the DOTS R&R system. Therefore incidence and prevalence of MDR-TB are often not clearly distinguished. XDR in case finding and treatment outcome are still not included in WHO guidelines. 2.6 Presentation of Chapter 18 and forms, followed bv group work (Agenda items 9 and 10)
Dr Heldal presented the following MDR forms, registers and reposts: sputum request fosm (including culture and DST), laboratory register for culture and DST, MDR treatment card and MDR register. For clarity of data, it is important to use dates corsectly. Date of TB register (when entered in the TB register) should be used for assessing the size of MDR risk groups, coverage of culture and DST, and proportion of cases with MDR. Date of MDR register (when entered in the MDR register) is used to assess MDR case finding. Date of MDR diagnosis is when the result of DST showing MDR is available. Date of MDR treatment start is used for cohort analysis of treatment result. The Guidelinesfor tlze surveillarzce of drug resistance in tuberculosis (2009) contains other key standard tables with resistance patterns in patients (pages 77-78). The MDR register allows quick assessment of MDR management in the unit. It facilitates comparison with the laboratory register to ensure completeness when updated with outcome and s d c u controls allow intermediate assessment. All MDR cases (including those who started treatment on suspicion) are entered by date of registration, but analysis of treatment is easier if a computerized system is used to sort MDR cases by date of treatment start. The R&R system should be kept simple by requesting and recording only data that are absolutely needed - R&R is not research! It is necessary to train staff, to provide supesvisory support, to conduct visits regularly (not only for R&R), and to maintain telephone contact.
As seen from the incomplete data in the 2010 MJXDR suiveillance report, most countries have had difficulties implementing the MDR-TB R&R systenl fully. There is underreporting of confirmed MDR cases and limited data on treatment outcome. Accurate counting of MDR cases requires both DST of acceptable quality and a DOTS R&R system providing correct numbers of MDR suspects in defined risk groups.
In the second group work sessions, participants discussed probleins/bottlenecks in implementing the R&R system in each country and suggested interventions for strengthening, and specified at which levels the different forn~s and registers would be used. 2.7 Forecasting system for improved procurement (Agenda item 14)
Mr Thieny Cordier-Lasalle from the Global Developillent Fund (GDF) described challenges in forecasting, planning and rapid response for supply of second-line drugs. Lack of real-time forecast data affects manufacturers' willingness to produce second-line drugs, thus, increasing piices and limiting the supply of quality assured products. The current stockpile is not sufficient for all emergencies. The Green Light Committee (GLC) I TB Monitoring and Evaluation (TME) annual sulvey does not enable rapid adjustment of plans and corrective-preventive actions. National TB Programmes' enrolments do not follow the Global Fund and UNITAID plan, which may lead to funding gap and bottlenecks. There was discrepancy between data and issues of data quality. GDF was therefore starting up a new forecasting systenl for first-line drugs and MDR-TB procurement. It requires countries to provide quarterly data on enrolnlents (number of patients by regimen, number of patients on treatment per regimen, and weight bands distribution) and diagnostics (number TB cultures, first- and second-line DSTs, line probe assays (LPAs), firstline drug and MDR patients diagnosed) and a quarterly report including drugldiagnostics forecasts, funding, stock levels and shelf-life. GDF is planning to start pilots soon in selected countries. 2.8 Reporting. of MDR-TB cases: Presentation of standard tools for deriving MDR-TB indicators, followed by group work (Agenda items 15, 16 and 17)
Dr Falzon presented data and information systems, individualized and aggregated, paper-based and conlputerized. A system that uses individualized data offers more detailed information, can streamline and improve accuracy, and allows more in-depth analyses. The disadvantages of such a system are that it is labour-intensive and raises concerns on confidentiality. The reasons for using computerized systems are such that it facilitates checks and controls, data storage and transmission, management of patients and drugs, surveillance and monitoring (reports), and statistical analysis. Challenges include cost, reliability, changing landscape and the process of communications. All countries had completed a questionnaire on the situation of R&R in their cou~tries. Five countries rely on paper systems, while only the four Pacific island countries and the Philippines use computerized systems with data linkage over the Web. Eight couiltries proposed to revise their data management systems; four of them have allocations from the Global Fund and other sources will be mobilized to reinforce R&R for drug-resistant TB. Dr Falzoll then presented the recent WHO publication, MDR-TB indicatoras: a minirnal set of iizdicato1*s for tlze programmatic rnanagenzent of MDR-TB in national TB controlprogranzmes (2010), which uses the same definitions, registers or treatment cards as the guidelines, but
focuses on indicators and templates rather than forms. The four areas are detection, enrolment, interim result and final outcome. The indicators include the number and proportion of MDR suspects with DST result of and isoniazid and rifanlpicin, and the proportion of MDR cases tested for fluoroquinoloi~es second-line injectible drugs. Changes introduced in the indicator publication include: separate stratifications for risk categories, children, fe~nales and HIV-positive individuals (+I- antiretrovirals (ART)), no stratification of outcome by prior treatment history, separate outcomes for XDR and HIV-positive individuals where indicated, intervals (delays) in diagnosis and in start of treatment, detection and enrolment reported every six months instead of every three months, ratio of enrolled patients to identified MDR cases, and outcomes including cases started on treatment for MIXDR-TB incorrectly. Exercise I11 focussed on the MDR-TB indicators, specifically, on detection and enrolment, interim results and final outcomes. 2.9 OpenMRS (Agenda item 18)
Dr Halnish Fraser from Partners in Health (PIH) presented OpenMRS (medical record system). Core functions include: clinical care and quality improvement, monitoring and reporting, and drug supply management. A general purpose medical record system architecture is required. Local users can create forms and reports. It is web-based but can also be run on a local computer. There are open standards for data exchange and integration with other systems. It is not limited to one disease. It is fully open source and is supported by a conlmunity of programmers. Countries that have OpenMRS sites include: Pakistan (see next agenda item), Haiti (PIH), Rwanda (PIH, Global Fund, Government of Rwanda, WHO), Botswana (NTP and University of Pennsylvania), and Nepal (WHOIIRD in progress). Standard OpenMRS software is fiee and a basic package with WHO forms and reports can be installed quickly. However, countries nearly always want to customize the system, and inodifications with new forms, reports and custom workflow are expected. Programmer time is the main cost as well as training. Challenges for OpenMRS include reliability and support for equipment, power supplies and software, data management and quality control, training, evaluation and sustainability. 2.10 Opeladata (Agenda item 19) Mr Aamir Khan from the h d u s Hospital Research Center, Karachi Pakistan (current chair of MDR working group of Stop TB Partnership), Interactive Research Development, presented innovations using mobile phones for DOT and community-based management of MDR-TB, including interoperability with OpenMRS MDR-TB module. Others collaborating on mobile OpenMRS include the University of Makarere (Uganda) and the University of Bergen (Norway). Mr Khan described the use of mobile OpenMRS by Indus Hospital MDR-TB Control Programme in Karachi, Pakistan, which began DOTS and programmatic management of drug-resistant TB (PMDRTB) in November 2007, approved by GLC in November 2008. The hospital was chosen as an NTP pilot site for Round 6, Global Fund (100 patients) from June 2010 and a subrecipient for Round 9, Global Fund from December 2010.
Mobile OpeilMRS is also using OpenMRS to manage MDR patients. Mobile OpenMRS was developed in-house as a inobile phone-based application that uploads DOT data directly illto an electronic medical record. Health staff are using mobile phones to enter patient data during field visits, including DOT data. The system is improviilg patient care and enhancing operations. A mobile DOT form is currently being piloted. Proposed work includes: ellhaace mobile DOT form and given ability to collect real-time programnlatic data; and build reporting and management tools (e.g. cliniciaiz alerts, operational flags). There is also a Geographic Informatioil Systein (GIs) ~ a t Visualization a showiilg the localization of health facilities and individual patients. 2.1 1 e-TB Manager, followed by group work (Agenda items 20 and 21) Dr Nerizza Muiies, representative of Management Sciences for Health in the Philippines, presented e-TB Manager: a comprehensive web-based tool for streilgtheniilg TB programmes by integrating case izotification and manageinent, medicine supply and stock control and epidemiological surveillance/reports informatioil into a single platform. and infonnation-sharing. Key The case module allows real-time case n~anageinent functionalities include: (1) case management tool, (2) search tool that allows patient monitoring and avoids entry duplication, and (3) validation tool that checks data consistency before recording on database. The medicine module allows first- and second-line inedicines manageinent. Key fuilctionalities include: (1) inediciile mailageineilt tool, and (2) forecastiilg tool that estimates future stock levels, consunlptioil levels and procurement needs. Key functioilalities of the inailageinent module, which provides the information required for timely interventions, include: (1) comprehensive reporting tool, (2) data extraction tool that exports the system's database to MS Excel, and (3) other statistical tools. The e-TB Manager has been adopted as national TB surveillance management information systein (MIS) for drug-resistant TB in Brazil. The drug management module has been integrated with the national drug-resistant TB MIS in Romania and in the Republic of Moldova. Final field-testing has been done for the advanced version in English for the Phlippines (drug-resistant TB) and in Ukraine. Implementation has been initiated in the Dominican Republic, in Indonesia (in cooperation with KNCV) and the Caucasus region. In Asia, there are plans to start using e-TB Manager in Viet Nan1 and Bangladesh in cooperation with WHO. System inlpleinentatioil in a new country usually requires one to two years depending on countesparts' preparedness and inputs. New upcoming developments include a desktop version for countries with low Internet coverage, automatic e-mail alerts (in case of low stock of medicines to launch a new order, make a new appointmeilt for case follow-up or realize a new exam), link with GIs, use of Short Message Service (SMS) or text messages for rapid data exchange, and enhanced laboratory module. Practical work in using key system functionalities of OpenMRS MDR Module and e-TB Manager was carried out in agenda items 21 and 25. 2.12 Principles of laboratory information system (Agenda Item 22) Dr Hamish Fraser presented general information on the electronic laboratory information system (LIMS). An LIMS is the goal of larger laboratories, especially those with automated analysers. Open source systems include: (1) OpenElis (Viet Nam, Haiti, Cote d'Ivoire), (2) E-Chasqui (Peru), and (3) OpenMRS-TB (Haiti, Rwanda, Pakistan, others). The systein is
free but costs are incurred from: customizations, hardware and system software, and human resources needed to support the customized system. TB laboratory reporting systems include personal digital assistant (PDA) data management: collecting laboratory data in sites without Internet, palm project, E-Clzasqui laboratory reporting system, and potential components of integrated national eHealth architecture in Rwanda. 2.13 EpiAnvwhere (Agenda Item 25) Dr Maylee11Ekiek, Federated States of Micronesia, presented EpiAnywhere, an electronic solution supported by CDC and used in solne Pacific island countries. Before EpiAnywhere was developed, United States-affiliated Pacific islands used a paper-based reporting form that required six pages for each TB case to be faxed to CDC. Data were then entered electronically by staff at CDC. Negotiating changes or discrepancies with data was challenging and timeconsuming. With Epihywhere, users only require access to the Internet to enter and approve case data, conduct analysis, and generate reports. Electronic forms with built-in validation and error-checking iinprove the accuracy and standardization of TB case data. Once data are entered and approved, they are available inmediately for local analysis and reporting. This reduces the (SPC) and/or WHO resources needed to meet CDC, Secretariat of the Pacific Coin~nunity reporting requireinents and removes the need to return to logs and charts for reporting. Future developlnent includes expanded surveillance reports, additional andlor co-morbid disorders, multilingual versions, operability on handheld devices, and geographic mapping. Users of EpiAnywhere need to have Internet access, need to know how to use a computer and need to be trained to input data. Computers need to be registered and data need to be inputted on a timely basis. 2.14 Data cleaning, validation and cross-checking (Agenda item 26) Dr Falzon presented routines for managing surveillance data. Routines for data validation were discussed, including definitions, data entry errors, missing data and invalid data. Data cleaning and challenges in data processing and data reporting were covered, as well as two types of software for data analysis: Epi Info for Windows and " R . 2.15 Principles in developing-a national plan for R&R for TBIMDR-TB in countries: Introduction of the TB surveillance system in China (Agenda item 27) Dr Fei Huang, National Center for TB Control and Prevention, China CDC, presented China's TB surveillance system. In 2004, the Ministiy of Health launched a web-based infectious disease reporting system (IDRS). About 37 notifiable infectious diseases, including TB, can be reported in real-time by all health facilities. This system was updated in 2008 and the second version was used in 2009. All infonnation and data on TB suspects and TB cases are entered at TB facility level (township and county, including hospitals) and the key infonnation and data are stored in a relational database management system at central level. It also allows producing standard or customized analyses. While TB in general is diagnosed and treated at county TB dispensaries, MDR suspects are referred to prefecture TB dispensaries for diagnosis and treatment. So far, MDR R&R is basically paper-based. The weaknesses of the current MDR system include: only MDR-TB cases
are generated from on-treatment, pulmonary tuberculosis (PTB) can be entered into the system, very limited information from MDR-TB cases is collected, MDR-TB and PTB data are stored in one database, and poor output cannot meet the requirements of NTP and WHO. This system is being revised again, mainly focusing on diug-resistant TB. The plan is to include: (1) drug-resistant TB suspects - PTB case on treatment retrieved from nomlal TB record, chronic TB cases entered by county and/or prefecture TB dispensary, and cases generated autoillatically by system from on-treatment MDR-TB case; and (2) all drug-resistant TB cases - mono-resistant, poly-resistant, MDR, and XDR. Advantages of the new surveillance system include: (1) IDRS, TBlMS and DR-TB system are linked with each other and are exchanging data in real-time; (2) dsug-resistant TB suspects, drug-resistant TB cases and PTB cases are integrated into one web-based system, but data for each are stored in different databases; (3) all kinds of drug-resistant TB suspects and cases can be captured by this system; (4) combined search can identify any specific suspects/cases in the database; and (5) enhanced output, including WHO form 51617, etc. Improvements to this TB R&R systenl were funded by the Central Government with financial suppoi-t froin the Ministry of Health~WHO Regional Office collaborative project (regular budget) and the Bill & Melinda Gates Foundation project. Technical support was provided by the WHO country office and Management Sciences for Health. 2.16 On pharmacovigilance (Agenda item 28) Dr Falzon presented phannacovigilance for tuberculosis. The World Health Assembly (WHA) invited Members States to do systeinatic collection of serious drug reactions in 1963, and WHO'S Intesnational Dsug Monitoring Programme had 96 full members and 30 associate members in 2009. Minimum requirements for a functional national pharmacovigilance system have been defined. WHO is currently raising awareness on this issue, including developing a practical handbook on the phasmacovigilance of antituberculosis medicaton. 2.17 Approaches toward data description, graphing and analysis - Using data for programme management of drug-resistant TB (PMDT) - Philippines, followed bv GLC approval in the Region (Agenda item 29) Dr Anna Marie Celina G. Garfin, NTP - Philippines, described how MDR management had evolved fi-om pilot phase 1999-2003 in Metro Manila, to expansioil phase 2003-2006 in Metro Manila with Global Fund Round 2 support, to mainstreaming phase 2006-2008 in Metro Manila (regionwide) and Region 7 (Cebu) with Global Fund Round 5, to the current scale-up phase 2009-2014 in more than five regions with the Global Fund Rolling Continuation Channel. In the pilot and expansion phases, an electronic medical record was used, and in the scale-up phase, the Philippines e-TB Manager (merging DOTS and MDRTB) was used. Treatment outcome data are therefore available from the start, with 608 cases evaluated during the period 1999-2006, with cure rate increasing in 2006 to 78%, with 25% deaths, 22% default and 2% failure. The categories of MDR cases during the period 2000-2009 were: "others" (60%), failure of category I1 (17%) and relapses (12%). Data were also available by category on the number of MDR suspects (9744), confirmed (2125) and enrolled (1 116). In 2007-2009,22% of suspects were confirmed overall, ranging from 67% of those treated after failure, 28% of relapses, 25% of others, 24% of those after default, and to 3% of new cases. The proportion enrolled was 53% overall, ranging froin 74% of those treated after failure, 7% of others, 65% of relapses, and to 48% of new cases.
Based on the DST pattern, the treatment regimen in MDR cases among new, relapses and after default cases included: Lfx, IOn, Cs, Pto and Z, while MDR cases treated after failure of category I or I1 and others replaced Z with PAS. Among 45 patients who started standard MDR treatinent in the second and third quarter 2010,34 (76%) were confirmed with MDR, while four had mono or poly-resistance and seven were pan-sensitive. Dr Angelito Bravo, WHO Headquarters, Stop TB Department, provided updated information about GLC approvals in seven countries in the Region (see Table I). So far, only a minority of approved patients have been enrolled on treatment. Treatment success among patients starting in 2007 was 63.1% (but numbers not shown) (GLC annual report, 2009). Table 1: GLC-approved countries in the Western Pacific Region by December 2010
Year approved
Total approved cohort
Preliminary cumulative number of patients enrolled "
1
Cambodia I
China Lao People's Democratic Republic Federated States of Micronesia Mongolia Philippines (includes TDF, Department of Health and Tibotec project)
2006 2010 2007 2005 2000
17 231 45 6 1 563 7 183
600
372 1 843
1 a
~amoa
1
2007
1
1
I
-
I
As reported to GLC Secretariat
2.18 Practical exercises in data analvsis - posters (Agenda item 30) Participants discussed the posters very actively as they were briefly presented. Almost all of the countries presented data on case finding during the period 2005-2009 (including different groups of re-treatments) and treatment outcome. For some countries, the number of cases notified and the number of cases with treatment outcome did not quite correspond, suggesting challenges in the quality of the R&R system. Data on MDR cases and treatment outcome were more limited. Here are MDR data from some selected countries: e
Philippines (refer also to agenda item 29): MDR treatment status at the sixth month was available for a subgroup of patients (TBC+ at baseline) who started treatment in 2007-2008. MDR treatment final outcomes were available for the period 2000-2008, although inany patients were still on treatment in 2007-2008. The success rate ranged
from 57% to 74%, default rate ranged from 7% to 23% (already 17% in 2007), failure rate ranged froin 5 % to 19% (already 11% in 2007 and 10% 2008), with very few deaths. e
China: Data on MDR cases were available for the first six months of 2010: total 1950 confii-nled cases: maiilly relapses (758), after failure of category I1 (463), "clu-onics" classified as others (371), after failure of category I (209), new (134) and after default (15). During the same period, 1049 confirmed MDR cases had started treatment. The difference between total cases started on treatment and those with interim outcome reported was discussed. Viet Nam: A total of 101 confirmed MDR cases were reported in 2009 - 52 chronics, 36 after failure category I1 and 13 after failure category I. All 101 registered in 2009 had started treatment and their six-month status was available. III 2010, so far, 300 have been registered; among them, 16 after failure categoiy I1 have started MDR treatment.
e
Mongolia: MDR data were available for the period 2006-2010. In 2007-2010, 702 confinned MDR cases were reported and 357 started on MDR treatment, including 224 after failure category 11, 78 after failure category I, and 17 relapses. At the sixth month of treatment, 10% were smear-positive. Malaysia provided data from the Sabah region only, while Cambodia, the Lao People's Democratic Republic and Papua New Guinea did not provide data on MDR-TB.
e
The Pacific island countries and areas had few TB cases but in general provided data on MDR-TB, including treatment outcome.
2.19 Course assessment (Agenda item 3 1) About 20 participants completed the questionnaire and expressed overall satisfaction. Some individual suggestions were as follows: (1) Field visits to health centres should be included in the workshop to see the R&R system in use. For calculating the indicators, a coilcrete example sliould be given in order to liniit or preveilt confusion. More sessions on data analysis, e.g. hands-on practical session on the Philippiiles should be provided. It should be kept in mind that some of the participants are not computer literate. There should have been inore practice than lectures.
(2)
(3)
(4)
(5)
3.
CONCLUSIONS AND RECOMMENDATIONS
The main collclusiolls of the workshop were as follows: 3.1.1 The routine recording and reporting system for the basic TB programmes (e.g. DOTS) is well-established in the Region; however, many countries face challenges in maintaining the good quality, in monitoring trends, and in identifying and monitoring groups defined as MDR suspects who should have drug-susceptibility testing (DST). 3.1.2. The routine recording and reporting systeln for MDR-TB is clearly defined in WHO guidelines, but its ilnplementation is still weak in many countries in the Region. It is difficult to assess trends in the MDR situation, e.g. incidence and burden of MDR-TB, since data on reported MDR cases by category are incomplete. Iu the absence of well-functioning surveillance systems, periodic surveys have provided key infonnatioll, but the overall picture remains incomplete. 3.1.3 NTPs lack data on coverage of culture and DST in MDR suspects, partly because groups that are considered to be MDR suspects and have DST are not yet well-defined, and because the routine R&R system does not include all relevant groups such as so-called chronics and early failures. 3.1.4 The number of reported MDR cases is often incomplete because laboratories usually do not register the category of patients. Often there is no direct link between laboratories and the TB programme, which Inailages the MDR registry. Also, different dates are used for the registration of cases. 3.1.5 GLC has approved treatment for a coilsiderable number of MDR cases in the Region, but so far, only a minority of cases have been enrolled. The number of cases, however, has been rapidly increasing. There is lack of solid data on MDR treatment coverage and delay, inside and outside the GLC mechanism. 3.1.6 NTP data on MDR treatment outcome are illcomplete in most countries. This information is especially needed to monitor levels of defaults, deaths and failures in a timely way, so that the strategy call be modified when needed (e.g. social support, regimens). 3.1.7 Supply of second-line drugs is affected by lack of reliable data on current MDR cases and reasonable projections, which are based on reported cases and not on estimates. The new drug procurement system promoted by GDF is based on quarterly routine data from the TB programmes, and should coincide with the strengthening of the R&R system. 3.1.8 The R&R system for MDR-TB is paper-based in five countries and computerized with data linkage over the web in the Philippines and the four Pacific Islands. These paper-based systems may work well as long as the number of patients is limited. Computerized systems, however, may prove to be very useful especially for tabulation and analysis. 3.1.9 The two main computer systems for MDR-TB presented, OpenMRS and e-TB Manager, are extensive electrol~ic medical record systems, which, according to the WHO guidelines and list of indicators, contain more information than the minimum required.
The recommendations of the workshop were as follows: 3.2.1 In line with recolllinendations from the Worksbop on Surveillance and Impact Monitoring in Ho Chi Minh City, Viet Nam, June 2010, NTPs should ensure a well-hnctioll~g R&R system for basic TB programmes (e.g. DOTS) tluough training, regular supervision and use of data for analysis and management at all levels. 3.2.2 NTPs should ensure a well-hnctioning R&R system for MDR-TB as an extension of the basic R&R system in line with WHO recommendations. Budgeting for PMDRTB should include proper R&R, thsough training and supeiiision. NTPs sl~ould use data for analysis at all levels as past of routine supervision visits, to stimulate better quality. 3.2.3 NTPs should monitor closely the coverage of culture and DST in MDR suspects through a strengthened basic R&R system, and special collection of data on chsonics and early failures using MDR suspects, laboratory and district TB registers. 3.2.4 NTPs should strengthen the use of MDR registers and keep updated links with laboratory registers to ensure completeness. The projected expansion in the use of rapid drug-susceptibility testing (e.g. line probe assay and Xpert MTBIRIF) should make this need even more relevant. 3.2.5 NTPs should take advantage of the new GDF system for improved drug procurement of first- and second-line drugs, as an integrated past of NTP routine quarterly R&R data. 3.2.6 NTPs should take maximum advantage of computerized systems for R&R. Challenges that needs to be considered include high cost and high demand of technical conlpetence and back-up. Countries with established computerized systems for nosrnal TB may add on an integrated MDR component in the same system. The countries without a computerized system may develop their own based on local competence or use of one of the already developed electronic medical record systeill such as OpenMRS or e-TB Manager. It is important to keep systems simple and compliant with the WHO requirements for reporting. 3.2.7 Technical assistance needs to be provided for country staff to: (1) ensure good data quality in the R&R system; (2) tabulate, analyse and manage data; and (3) introduce feasible options for electronic systems.
ANNEX 1
WORLD
HEALTH
ORGANISATION WIONDIALE DE LA S A N T ~
ORGANIZATION
REGIONAL OFFiCE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
WORKSHOP ON RECORDING AND REPORTING OF DRUG-PIESISTANT TUBERCULOSIS IN THE \.VESTEIW PACIFIC REGION Manila, Philippines 24-26 November 2010
'CVPWDCC/STB(5)/201O/IB/2
ENGLISH ONLY
I N F O U A T I O N BUELETIN NO. 2 FINAL LIST OF PARTICIPANTS
1. PARTICIPANTS Dr Keo Sokonth Chief of T e c h c a l Bureau National Center for TB and Leprosy Control (CENAT) Ministry of Health No. 151-153 Kampuchea Krom Str Phnom Penh Tel: (855) 12 870 042 Fax: (855) 23 21 8090 E-mail: ksokonth@yahoo.com Dr Narith Ratha Technical Bureau Officer Training, Supervision and Research Section Chief of National TB Reference Laboratory National Center for TB and Leprosy Control (CENAT) Ministry of Health No. 1, Str. 278-95, Boeung Keng Kang 2 Khan Chamkar Mom Phnom Penh Tel.: (855) 23 219 274 / 275 / 219 Fax: (855) 23 218090 Email: narith.ratha@yahoo.com
Annex 1 CHINA, PEOPLE'S REPUBLIC OF Dr Huang Fei Assistant Researcher Surveillance Department National Center for TB Control and Prevention China CDC No. 155 Chan~Bai. Road Changping ~ i g t r i c t Beiiing- 102206 Tel.: (8610) 58900536 Fax: (8610) 58900533 Dr Zhao Jin Practitioner-Reseacher National Center for TB Prevention and Control China CDC No. 155 ChangBai, Road Cliangpiiig District Beiiing 102206 Tel.: (8610) 68792661 Fax: (8610) 68792662 E-mail: zhaojin@chinatb.org Ms Estelle-Marie Alig Coordinator Communicable Disease Control TB Control Prograinme Department of Public Health and Social Services 123 Chalan Kareta Mangilao 969 13-6304 Tel.: (671) 735-7157 Fax: (671) 735-731 8 Einail: Estelle.alig@dphss.guarn.gov
E-aligahotmail.corn LAO PEOPLE'S DER%OCRATIC REPUBLIC Dr Bounkong Fongosa Chief of Technical Division National Tuberculosis Centre Ministry of Health Vientiane Tel.: (856) 21 414259 Fax: (856) 21 452855 E-mail: bounkongfongosa@yahoo.com Dr Khamloune Choumlivong Deputy Chief Infectious Disease and Tuberculosis Department Settliathirat Hospital Ministry of Health Dongpalane thong Village, Sisattanak District Vientiane Tel.: (856) 305 262053 Fax: (856) 021 351 160 Email: khamlouch@ya1~oo.fr
Annex 1 MALAYSIA Dr Rafidah Baharudin Principal Assistant Director Disease Control Division Ministry of Health Level 3, Block E10, Complex E Federal Government Administrative Centre 62590 Putraiava Tel: (603) 8883 4527 Mobile: (6013) 8602897 Fax: (603) 8889 1013 Email: rafidahb@moh.gov.my Ms Zirwatul Adilah Aziz Science Officer National Public Health Laboratory Ministyr of Health Lot 1853, Kg. Melayu Sg. Buloh 47000 Sungai Buloh Sela~igor Tel: (603) 61261200 Fax: (603) 61402249 Ernail: adilahaziz@moh.gov.iny Dr Kennar Briand Director of Public Health TB/Leprosy National Manager Ministry of Health PO Box 16 Maiuro 96960 Tel.: (692) 625 3355 Fax: (692) 625-4372 / 3422 Email: knsbriand@yahoo.com Dr Mayleen Jack Ekiek National TB/HD/STD Progralnme Manager (Communicable Disease Physician) Department of Health and Social Affairs Palikir, Pohnpei 96941 Tel.: (691) 320 2619 Fax: ((691) 320 8632 Email: mekiek@fsmhealth.fm Ms Khongorzul Byambajav Deputy Director Department of Information, Monitoring and Evaluation Ministry of Health Government Building 8 Olympic Street-2, Sukhbaatar District Ulaanbaatar Tel: (976-5 1) 26368 1 Fax: (976-1 1) 320916 E-mail: khongorzul@moh.mn
REPUBLIC OF
MICRONESIA, FEDERATED STATES OF
MONGOLIA
Annex 1 Ms Tserenkhand Tserenjav Quality Manager Shastin Hospital Bavanool Ditrict ~ l i a n g a a t 21 r 0648 Tel.: (976) 687900 Fax: (976-1 1) 450492 E-mail: munkhuuleiz@yal~oo.com NORTHEW MmAPdA I S L ~ D S Dr Shirisb Balachandra Acting TB Controller Commonwealth Health Centre Department of Public Health 1 Lower Navy Hill Rd. Saipan, MP 96950 Tel.: (670) 287 2222 Fax: (670) 236-8608 Email: saipanbala@gnlail.com PAPUA NEW GUINEA Dr Margaret Kal Medical Officer TB for Highlands Region Department of Health P.O.Box 807 Waigani, NCD Tel: (675) 301 3808 Fax: (675) 325 0368 Email: margaretkal@gmail.com Dr Paul Harino Clinical Researcher Papua New Guinea Institute of Medical Research P.O. Box 378 Madang 5 11 MP Tel.: (675) 422 2909 Fax: (675) 422 3289 Email: nuen09@gmail .corn
PHILIPPINES
Dr Anna Marie Celina Garfin Medical Specialist I V National Center for Disease Prevention and Control Department of Health Sta. Cruz Manila Telefax: (632) 71 1 7846 E-mail: garfinamc@yahoo.com Mr Roberto Belches Programme Management Office Staff Lung Center of the Philippines Quezon Citv Telefax: (632) 924 6101 extn. 305 Email: robbelchez@yahoo.com
Annex 1 VIET N M , SOCP&IST REPUBLIC OF Dr Tran Van Thieu Medical Doctor National TB Prograinme National Lung Hospital Ministry of Health 463 Hoang Hoa Thain, Badinh Ha Noi Tel.: 84-4-37618396 Fax: 84-4-37614901 E-mail: tienthieu60@yahoo.com.vn Dr Pham The Anh Vice Chief Networking Department Hospital 74 Central Trung Wong Ha Noi Tel.: 84-02116-268 623 Fax: 84-02116-268 674 Email: chidaotuyen74@gmail.coin
Dr Hamish Fraser Director of Informatics and Teleinediciile Partners in Health 888 Commonwealth Avenue, 3rdFloor Boston, Massachusetts 02215 Ui~ited States of America Tel.: (1-617) 432-3930 (1-617) 998-8973 Email: eldal-fraser@hms.harvard.edu R/Ir Aamir Khan Director MDR-TB Control Programme The Indus Hospital Research Center Korangi Crossing 75 190 -Karachi Pakistan Tel: 9221 511 2709 Fax: 9221 511 2718 Email: ajkhan@jhsp .edu
3. CONSULTANT Dr Einar Heldal TB consultant Arvollveien 60D 0590 Norway Tel.: +47-975 17465 Mobile: +47 975 17465 Email: elda.heldal@,c2i.net
Annex 1
4. REPRESENTATIVES OF PARTNER AGENCIES AND OBSERVERS ELI LILLY AND COMPANY Ms Sunita Prasad MDR-TB Partnership Director Eli Lilly and Company (India) Pvt. Ltd. Plot No. 92, Sector 32 Gurgaon - 122001 Havana, India Tel.: +91-124-4753213 +91-9910491578 Fax: +91-124-47753012 Email: prasadsu@lilly.com Dr Nerizza Muiiez Drug Management Consultant 270 Benito St., Kauswagan, Cagayan de Oro City, Philippines 9000 Tel.: +63-08822-711811 Eniail: zaza.munez@gmail.con~
MANAGEMENT SCIENCES FOR HEALTH
DEPUTMENT OF HEALTH, PHILIPPINES
Ms Virna C. Turbolencia, RN Bldg 9, San Lazaro Colnpound National Epidei~iology Center Department of Health Rizal Avenue, Sta. Cmz, Manila Tel.: +632 - 7436076 Email: v-c-tl3@yahoo.com; vcturbolencia@gmail.com Ms Evangeline De Keyser Bldg 9, San Lazaro Compound National Epidemiology Center Department of Health Rizal Avenue, Sta. Cmz, Manila Tel.: +632 - 7436076 Email: vangie0415@yahoo.com
Dr Mary Rose Santiago Clinic Physician Lung Center of the Philippines Public Health and Domiciliary Unit Bldg. Quezon Avenue Extension, Quezon City Philippines 1100 Tel.: +632 - 9271 126 Fax: +632 - 9271 126 Email: maryrosarytagui~lod@yahoo .com
Annex 1
WIIO WESTERN PACIFIC REGIONAL OFFICE (WOnvBRO)
Dr John Ehrenberg Director Combating Comlnunicable Diseases WHOIWPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9701 Fax: (632) 521 1036 Email: ehrenbergj@wpro.who .int Dr Catharina van Weezenbeek (Responsible Officer) Team Leader Stop TB and Leprosy Elimination WHOIWPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9706 Fax: (632) 521 1036 E-mail: vanwezenbeekc@wpro.who.illt Dr Daniel Sagebiei (Co-Responsible Officer) Medical Officer Stop TB and Leprosy Elimination WHOIWPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9720 Fax: (632) 521 1036 E-mail: sagebield@wpro.who.int Dr Katsunori Osuga Medical Officer Stop TB & Leprosy Elimination WHOIWPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9709 Fax: (632) 521 1036 E-mail: osugak@wpro.who.int Dr Nobuyuki Nishikiori Medical Officer Stop TB & Leprosy Elimination WHOIWPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9726 Fax: (632) 521 1036 E-mail: nishikiorin@wpro.who.int
Ms Catherine Lijinsky Teclmical Officer Stop TB & Leprosy Eliillination WHOIWPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9726 Fax: (632) 521 1036 E-mail: lijinskyc@wpro.who.int RO COUNTRY OFFICES Dr Fabio Scano Medical Officer, Stop TB & Leprosy Elimination Office of the WHO Representative in China 40 1, Dongwai Diplomatic Office Building 23, Dongzl~imenwai Dajie Chaoyang District Beiiing 100600 China Tel.: (8610) 6532 1288 Fax: (8610) 6532 2359 Email: scanof@clm.wpro.who.int Dr Wang Xuejing National Professional Officer, Stop TB & Leprosy Elimination Office of the WHO Representative in China 40 1, Dongwai Diplolllatic Office Building Dajie 23, Dongzhin~enwai Chaoyang District Beiiing 100600 China Tel..: (8610) 6532 7189 Fax.: (8610) 6532 2359 E-mail: wangxu@chn.wpro.who.int Dr Jadambaa Narantuya National Professiollal Officer Office of the WHO Representative in Mongolia Ministry of Health Government Building - 8 Ulaanbaatar, Mongolia Tel.: (976) 11-327870 Fax: (976) 11-324683 E-mail: narantuyaj @mog.wpro.who.int Dr Woo-jin Lew Medical Officer, Stop TB and Leprosy Elimination Office of the WHO Representative in the Philippines P.O. Box 2932 Manila Philippines Tel. No.: (632) 5289767 Fax No.: (632) 7313914 E-mail: leww@phl.wpro.who.int
Annex 1
Dr Mariquita Mantala National Professional Officer, Tuberculosis Office of the WHO Representative in the Philippines P.O. Box 2932 Manila Philippines Tel. No.: (632) 5289767 Fax No.: (632) 7313914 E-mail: mantalarn@phl.wpro.who.int Dr Nguyen What Linh Medical Officer, Stop TB & Leprosy Elimination Office of the WHO Representative in the South Pacific Level 4 Provident Plaza One Downtown Boulevard 33 Ellen Street F$ Tel.: (679) 3-304600; 30463 1 Fax: (679) 330 0462; 331-1 530
a,
Dr Pham Huyen Khanh National Professional Officer Stop TB & Leprosy Elimination Office of the WHO Representative in Viet Nam 63 Ti-an Hung Dao Street Hoan &em District Ha Noi Socialist Republic of Viet Nam Tel.: (844) 943 3734 Fax: (844) 943 3740 Email: phamh@vtn.wpro.who.int Dr Dennis Falzon Stop TB Department World Health Organization Avenue Appia 20 CH - 1211 Geneva 27 Switzerland Tel.: 4122 791 1469 Fax: 4122 791 1589 E-mail: falzond@who.int Mr Thierry Cordier-Lassalle GDF Principal Officer Stop TB Partnership Global Drug Facility World Health Organization Avenue Appia 20 CH - 1211 Geneva 27 Switzerland Tel.: 4122 791 4541 Fax: 4122 791 4886 E-mail: cordierlassallet@who.int
Annex 1
Dr Angelito Bravo Technical Officer TB Operations and Coordination (TBC) Stop TB Department World Health Organization Avenue Appia 20 CH- 1211 Geneva 27 Switzerland Tel.: 4122 791 3627 Fax: 4122 791 4199 E-mail: bravoa@who.int
ANNEX 2
WORLD
HEALTH
ORGANISATION MONDIALE DE LA S A W €
ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL BU PAClFlQUE OCCIDENTAL
IVORKSHOP ON RECORDING AND REPORTING OF DRUG-RIESISTANT TUBERCULOSIS IN THE WESTEI-ZN PACIFIC REGION
Manila, Philippines 24-26 November 2010
ENGLISH ONLY
AGENDA Opening cerelnony Objectives and expected outcomes of the workshop Session 1: Irztroductiorz to tlze rationale of iMDR suweillarzce and recordirzg and reporting
Surveillance of MDR-TB: Global and regional situation Why monitor drug-resistant TB, ail11 of R&R, indicators, strategies for detection of MDR-TB On anti-TB drug resistance surveillance (DR) and DR surveys Exercise 1: Strengthening the surveillance for DR-TB Regional activities of the Eli Lilly Foundation Session 2: Paranzeters for standardized recosding and reporting
Definitions for case registration and treatment Presentation of Chapter 18 and forms (part 1: Case finding): Case finding forms and registers (Form I), Treatment register (Form 02), Request for sputum examination form (Form 03), Lab register for culture and DST (Fonn 04), MDR-TB suspect register Exercise 2: Familiarization and use of standard tools in recording of MDR-TB cases Plenary discussion Assessment of each day's proceedings Summary of presentations from each day
Annex 2 14. 15. Forecasting system for inlproved procurement Reporting of MDR-TB cases: Presentation of standard tools for deriving MDR-TB iildicators
16-17. Exercise 3: Familiarization and use of standard tools for deriving MDR-TB indicators 18. OpenMRS - Demoilstration (to present the software, its costs, prerequisites to be in place, quality assurance, and some models of how countries have used these packages, obtained support and dealt with problems) Session 3: Electronic solutiorzsfor recording and reporting
19.
openXdata - Innovatioils in use of mobile phones for DOT and community-based management of MDR-TB, interoperability with OpenMRS MDR-TB module e-TB Manager - Deinonstratioil (An integrated web-based platfonn for case management, drug management and epidenziological surveillance for TBIMDR-TB country experiences, data QA, overview of implementation process) Practical work in using key system functionalities - 1 Principles of laboratory infomation systems Assessment of each day's proceedings Summary of presentations froin each day Practical work in using key system hnctionalities - 2 EpiAnywhere Data cleaning, validation and cross-checking Session 4: Incr*easirzgcapacity in analysis and planning
20.
21. 22. 23. 24. 25. 26.
27.
Principles in developing a national plan for recording R&R for TBMDR-TB in countries The lntroduction to TB Surveillance System in China On pharmacovigilance Approaches towards data description, graphing and analysis - Using data for PMDT-Philippines GLC Approval in the Region Practical exercise on data analysis Course assessment Distributioil of certificates Closing
28.
29. 30. 3 1.
WPR/DCC/STB(5)2010.1.a PROVISIONAL TIMETABLE WORKSIIOP ON IiECORDING AND REPORTING OF DRUG-RESISTANT TUBERCULOSIS IN THE WESTERN PACIFIC REGION 24-26 November 2010, Pliilippiries Time 24 November, Wednesday Registration (1) Opening ceremony - Wclcorne remarks: Dr John Ehrenberg, Director, Combating Cornniunicablc Discascs (in bchalf of Dr Shin Young-soo, Regional Dircctor, WI-IOJWPRO) - Sclf-introduction of participants and facilitators - Ad~ninistrative announccmcnts (2) Objcctives and cxpcctcd outcomes of thc workshop
Time
25 November, Thursday (13) S i ~ ~ n ~ nof a rpresentations y kom Day 1 (14) Forecasting systcnl for improved procurement (15) Reporting of MDR-TB cases: Presentation of standard tools for deriving MDR-TB intlicators (16) Excrcisc 3: Fa~niliarizationand use of standard tools for deriving MDR-TB indicators
Time
26 November Friday (24) Summary of presentations from Day 2 (25) Practical work in using key system functionalitics - 2 EpiAnywhcrc (26) Data cleaning, validation and cross-chcclting
PHOTO SESSION - COFFEE / TEA BREAK Session I : Irrtro(li~ctiort to tire ratiorrale ofMDR surveillajzce rirlrl recording arrd reportirtg (3) Survcillance of MDR-TB: Global ancl regional situation (4) Why monitor drug-resistant TB, aim of R&R, indicators, strategies for dctcction of MDR-TB (5) On anti-TB drug resistance survcillance and DR surveys (6) Excrcisc 1: Strcngthcning thc survcillance for DR-TB
COFFEE / TEA BREAK (17) Excrcisc 3: Fa~niliarizationand use of standard tools for dcriving MDR-TB indicators and discussions (cont.) (1 8) OpenMRS - Demonstration (to present thc software, its costs, prerequisites to bc in placc, quality assurance, and solnc models of how countrics have uscd thesc packages, obtainccl support and dealt with problems)
COFFEE / TEA BREAK Sessiort 4: Ijrcr~easit~g capacity in arralysis ( l j z ( 1 plannijrg (27) Principles in dcvcloping a national plan for reinforcing R&R for TBIMDR-TB in countrics Thc Introduction to TB Surveillance Systc~n in China (28) On phar~nacovigilancc (29) Approaches towards data dcscription, graphing and analysis - Using data for PMDT-Philippines GLC Approval in the Region
LUNCH BREAK (7) Regional activities of thc Eli Lilly Foundation Session 2: P(irrrrtretersji)rstanrklrrlizerl recording artrl reportirrg (8) Definitions for casc registration and trcat~nent (9) Presentation of Chapter 18 and forins (part 1: Casc finding): Casc finding forms and registers (Form I), Trcatmcnt rcgistcr (Form 02), Rcqucst for sputu~n examination form (Form 03), Lab rcgister for culture and DST (Form 04), MDR-TB suspect rcgister (10) Exercise 2: Fanliliarization and use of standard tools in recording of MDR-TB cases
LUNCH BREAK Sessiorr 3: Electronic solcrtiorrs for recorrlirtg and repoj'ting (19) OperiXdata - Innovations in usc of rnobilc phoncs for DOT and con~munity-basccl managcmcnt of MDR-TB, interoperability with OpenM RS MDR-TB ~nodulc (20) e-TB Manager - Dc~nonstration (An intcgratcd wcb-bascd platform for casc management, drug lnanagclncnt and cpidcmiological survcillancc for TBJMDR-TB country expcricnccs, data QA, ovcrvicw of itnplcn~cntation process)
LUNCH BREAK (30) Practical cxcrciscs on data analysis (3 1) Course assesslncnt Distribution of certificates Closing
COFFEE / TEA BREAK (1 1) Plcnaly discussion (12) Day's asscssmcnt and closurc -+dzrected evozztlg readrngj?oriz tile Gz~~delztzes atzd Revzsed MDR-TB rtzclrcnlot~s Receptiojr
COFFEE / TEA BREAK (21) Practical work in using key system Sunctionalities - 1 information systc~ns (22) Principles of laborato~y (23) Day's asscssmcnt and closul-c evenitig readitig j?oiiz "Tlie Itizportance oJPl~at~~zncovigilance. Sc!/kty Mot7itoving oJ t11etticinalprodi~cts.World Healtli 01-gatziza/ior~, 2002 (appx .who. inthizedicinedocs/p~f/s48Y3e/s4893e.p~fl" + directed
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