e-tb Manager: A Comprehensive Web-Based Tool for Programmatic Management

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1 e-tb Manager: A Comprehensive Web-Based Tool for Programmatic Management of TB and Drug-Resistant TB Management Sciences for Health

2 Facts about TB* TB is contagious and airborne; each untreated person with active TB can infect ~ 10 to 15 people a year One third of world population infected with TB (most vulnerable people with HIV) 1.8 million died in 2007 (TB is leading killer of people with HIV ~500,000 in 2007) 9.27 million new TB cases registered in 2007 TB is a worldwide pandemic: among the 15 countries with the highest estimated TB incidence rates, 13 are in Africa, while half of all new cases are in six Asian countries (Bangladesh, China, India, Indonesia, Pakistan and the Philippines) * from:

3 Facts about TB, cont. Multidrug-resistant TB (MDR-TB) is a form of TB that does not respond to the standard treatments using firstline drugs 511,000 new MDR-TB cases in 2007 Extensively drug-resistant TB (XDR-TB) occurs when resistance to second-line drugs develops WHO s Stop TB Strategy aims to reach all patients and achieve the target under the Millennium Development Goals (MDG): to reduce by 2015 the prevalence of and deaths due to TB by 50% relative to 1990 and reverse the trend in incidence Required investment to achieve the MDG target is estimated at US$ 67 billion (there s a 40 billion gap) * from:

4 International Response Guidance: WHO, StopTB, UNION TB control is well standardized (consensus on forms, guidelines, recommendations) Funding mechanisms: The Global Fund, UNITAID, Bill Gates, governments (USAID, DfID, etc) Sources of TB medicines: GDF, GLC Technical resources: UNION, KNCV, MSF, PIH, ICRC, MSH, etc.

5 Information management for TB: Information tools are required by Global Initiatives (GLC/GDF, Stop TB ) WHO ERR working group revised forms Catalogue (existing software) But to date there was no tool integrating consistently all programmatic dimensions for management purposes

6 NTP Challenges Most countries will not reach MDG by 2015 Lack of actual support from governments Low detection rate (poor diagnosis, advocacy, education) Poor compliance with treatment (by providers and patients) High default rate Co-infection with HIV Interruptions ti in drug supply (even the GDF countries) Spread of MDR/XDR TB (increased length of treatment and costs = X 1000) Lack of proper supervision, recording and reporting Many of the challenges can be addressed through strengthening MIS

7 e-tb Manager: Web based system Aligned with WHO recommendations for DOTS and DOTS Plus programs (standard data collection, recording and reporting) Easy online information sharing / consolidation between different levels and data extraction tool to other interfaces Rapid response to case and drug management issues Database protected by a validation process from upper level Internal security features and unique patient identification Developed with open sources technical solutions, no additional licenses needed Can be used with a mixed system of online reporting and paper system at periphery levels Easily customized, translated, adapted

8 Online notification and follow-up, recording clinical and laboratory results, tracking patient transfers in and out, providing data on patients regimen schemes, treatment adherence, patient contacts evaluation, consultation agenda Treatment and case management Data extraction tool / Operational and clinical research Information and surveillance management First Line medicines management Second Line medicines management Medicine needs forecasting, ordering, distributing, dispensing, and recording of stock movements + DM indicators at all levels For easy data analysis and export to statistical interfaces e-tb Manager Mapping of TB and MDR/XDR cases, epidemiological indicators, surveillance reports, previous treatment history, co-morbidities, up-dated information with ready access online at central and periphery levels

9 For the system to support the TB program appropriately, there must be clear guidelines and core staff must be experienced in MDR-TB management Diagnosis Treatment protocols, patient management Consistent flows for pharmaceutical management

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25 Slide 24 lh25 this doesn't show much--you could just use the next slide and talk about administration lhall, 05/22/2008

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27 Name displayed in the system Address (where to send orders to) Region and locality (also used in user view) Checked if the unit is a treatment health unit (case management) Checked if the unit stores medicine (medicine management module) Enables the unit to use the medicine receiving module Select who is going gto deliver medicine orders to this unit Used to calculate the quantity estimated when creating a new order If checked, the user may change the Check it if the unit quantity estimate when creating a new delivers medicine to order other units (order delivery) If the order has to be authorized before delivering, select the unit that authorizes it If the unit registers medicine dispensing, enter the dispensing registration frequency (daily, weekly or monthly)

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32 Online tools for medicines forecasting, ordering, distribution, and dispensing Tracks stocks positions at central and periphery p level; Calculates upcoming needs for medicines dispensing at treatment centers / sites Controls estimated and real consumption Provides reports and indicators

33 Distribution flow: Central Warehouse Sources: GLC/GDF MoH GF Regional Regional Regional Warehouse Warehouse Warehouse District District District District District Treatment Center Treatment Center Treatment Center Treatment Center Treatment Center Treatment Center TS TS TS TS TS TS TS TS TS TS TS TS TS

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46 Epidemiological Reports Incidence/incidence rate Prevalence/prevalence rate Demographic characteristics Resistance patterns Clinical/X-rays patterns HIV/AIDS(diagnosis/ co-infection rate) Co-morbidities Previous treatments/ treatment history Contamination C t i ti origin i Contacts identification and evaluation Adverse reactions Treatment outcomes/ cohort analysis (filters)

47 Operational Reports Suspects or cases search/identification Laboratory L b t exams at a glance (patient t or cohort) with conversion rates Treatment history/regimens at a glance (patient or cohort) Case management agenda (dates for exams, appointments, defaulters list, etc.) Mapping case transfers Treatment adherence/medicines dispensing reports Treatment costs (Social Security systems)

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54 Resistance Profile Jan Mar (n= 3,798) Brazil or States City of Residence Treatment Health Facility Probably DR-TB Generate Report Month/Year Begins Month/Year Ends Nº of treatments for DR-TB Confirmed DR-TB Resistance Profile Sensitive to R Sensitive to H Sensitive to RH Sensitive to all drugs tested Other combinations of resistance Source: DR-TB Data Base Hélio Fraga Reference Center / Fiocruz / MoH

55 Evaluation of Contacts (Pará State) Jan Mar (n= 1,218 identified) City of Residence Identified Examined with TB Source: DR-TB Data Base Hélio Fraga Reference Center / Fiocruz / MoH

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57 e-tb Manager: Where Are We Today? Currently adopted as national TB surveillance MIS for DR-TB in Brazil (including all re-treatment cases for better prevention of MDR-XDR emergence) Integrated with the national DR-TB MIS in Romania and Moldova Active field pilot testing in the Philippines, Dominican Republic and Ukraine (on MOH server) Being adapted for: Armenia, Georgia, Azerbaijan, Uzbekistan Requests from countries: Namibia Collaboration with WHO a possibility for e-tbm to become a WHOrecommended MIS tool WHO request to implement in: Kenya, Ethiopia, Bangladesh, Vietnam

58 Challenges and Lessons Learned E-TBM cannot just be installed and used: Need for extensive TA to streamline the existing MIS for TB (procedures, SOPs, data forms) Need for adaptation to country requirements Training of users, TOT Lack of clear national treatment guidelines for TB and MDR TB, and SOPs for lab and drug management WHO is constantly changing data forms Lack of infrastructure: must develop PC-based provincial i databases

59 Challenges and Lessons Learned, cont. Need to sign a MOU: NTP may lack authority, bureaucratic procedures Engaging stakeholders national working groups Competition (most NTPs already have some electronic tools in place) Very limited it funding for e-tbm implementation ti Partnering with other projects in the field is crucial (but not clear how to formalize relations) Endorsement from major players is important (WHO, KNCV, UNION, GDF/GLC, UNITAID, etc.)

60 Implementation steps in a new country: May take from 2-3 months to one year Reconnaissance visit Present e-tbm main features Understand country s health system structure, operation, standards for TB and/or DR-TB, and needs Define necessary system customization Define working group, responsibility matrix and MoU On-site pilot On-site pilot on selected TB units to evaluate system effectiveness, fit with current flows and procedures and acceptance by end users System customization Customize e-tbm functionalities and interfaces to address country needs Final system adjustments Adjust system based on pilot outcome Remote testing Remotely test initial e-tbm version to identify potential bugs and need for further adjustments Implementation/ training Implement system on country s proprietary server and train IT personnel Train potential trainers or end users (depends on number of sites) System adjustments Adjust system based on remote testing outcome Maintenance Guarantee remote on-going support to country`s IT team and end users 59

61 System cost to USAID/MSH, from customization to implementation and maintenance, ranges from US$50-70k Estimates based on a comprehensive cost model designed for e-tbm System cost to USAID/MSH ESTIMATIVE PROJECT SCHEDULE AND CHARACTERISTICS COST (USD) System cost $ Duration Time required (weeks FTE per phase) Number of intl. trips PHASES weeks Programmer MSH Other 1. Reconnaissance visit $ System customization $ Remote testing 1 0 $0 4. System adjustments $ On-site pilot $ Final system adjustments $ Implementation/training $ Total to implement $ Maintenance/support $ Monthly $6.194 Infrastructure MONTHLY cost IT infrastructure Number required Server 1 $283 Computers 40 $1.111 Internet access 40 $1.600 Helpdesk FTE required 1 $3.200 Weeks FTE* Prog. MSH Intl.* trips Weeks FTE* Prog. MSH Intl.* trips 1. Reconnaissance visit 2. System customization 3. Remote testing 4. System adjustments 5. On-site pilot 6. Final system adjustments 7. Implementation/training ti i i 8. Maintenance/support ** ½ 1 ½ 1 1** ** ** * FTE: Full Time Equivalent; Intl.: International ** Within the total phase duration (52 weeks) 60

62 Ongoing operational and maintenance costs for host country depend on number of sites and infrastruture required ESTIMATIVE Estimates based on a comprehensive cost model designed for e-tbm Monthly maintenance/operational cost to host country PROJECT SCHEDULE AND CHARACTERISTICS COST (USD) System cost $ Duration Time required (weeks FTE per phase) Number of intl. trips PHASES weeks Programmer MSH Other 1. Reconnaissance visit $ System customization $ Remote testing 1 0 $0 4. System adjustments $ On-site pilot $ Final system adjustments $ Implementation/training $ Total to implement $ Maintenance/support $ Monthly $6.194 Infrastructure MONTHLY cost IT infrastructure Number required Server 1 $283 Computers 40 $1.111 Internet access 40 $1.600 Helpdesk FTE required 1 $3.200 Number of total sites* Number of servers required Number of IT** infrastructure required (computer + internet) * Influences number of support staff required. Model assumes 1 helpdesk FTE can support up to 50 sites ** Information technology 61

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