Multi-Drug Resistant Tuberculosis

Transcription

1 Multi-Drug Resistant Tuberculosis HOW FAR HAVE WE COME IN DECENTRALISING MDR-TB NATIONALLY Dr. Norbert Ndjeka Director, Drug-Resistant TB, TB and HIV

2 Outline 1. Introduction: historical background 2. Policy implementation 3. Structure, levels and functions of decentralized facilities 4. Conclusion 4/20/2013 Dr. Norbert Ndjeka 2

3 INTRODUCTION 4/20/2013 Dr. Norbert Ndjeka 3

4 South Africa Globally, every year, an estimated 650,000 MDR-TB patients are diagnosed Only 46,000 (7%) globally are initiated on treatment WHO Report 2011, Global TB Control WHO/htm/tb/ South Africa is among the high burden TB and MDR-TB countries worldwide In 2010 we diagnosed: MDR-TB patients (5313 started on treatment) and 741 XDR-TB diagnosed with 615 started on treatment Success rate of MDR-TB is low 42% (2007 cohort), 48 % (2008 cohort) Number of beds available: ~2500 beds 4/20/2013 Dr. Norbert Ndjeka 4

5 TB in South Africa South Africa has the 3rd highest incidence of TB cases in the world (WHO, 2011) 5 th highest number of drug-resistant TB cases in the world (WHO, 2011) TB leading cause of mortality in South Africa (Statistics South Africa, 2011) 60% 80% of all TB cases co-infected with HIV. (WHO, 2009; Gandhi et al., 2006) 4/20/2013 Dr. Norbert Ndjeka 5

6 4/20/2013 Dr. Norbert Ndjeka 6

7 An Overwhelming Burden South Africa is struggling with an escalating MDR-TB burden, recently aggravated by the emergence of XDR-TB 4/20/2013 7

8 Worsening Drug Resistance and this is contributing to the development of XDR-TB Source: Mlambo C, Warren R, Poswa X, Victor T, Duse A, Marais E. Genotypic diversity of extensively drug-resistant tuberculosis (XDR-TB) in South Africa. Int J Tuberc Lung Dis. 2008;12(1): /20/2013 8

9 Given this overwhelming burden, MDR-TB patients are not treated in accordance with the present South African Department of Health guidelines Source: WHO review of the South African TB Programme 6 th -17 th July 2009 and DR-TB directorate Clinical Audit June /20/2013 9

10 Previous flow for MDR-TB management DR-TB Patients are diagnosed at health facilities Referred to MDR-TB hospitals for initiation of treatment and initial hospitalization Patients admitted and started with standard regimen (6 K-Ofl-Eth-Trd or Cs-Z/ 18 Ofl-Eth-Trd or Cs) Patients kept for approx. 6 months or till 2 negative cultures Then referred back to the health facility to continue treatment Follow-up done at MDR-TB hospitals on monthly basis 4/20/

11 Challenges Nearly half of diagnosed cases are not started on treatment 1-2 months of waiting for admission, sometimes more Long distance of transportation for admission and follow up Negative impact on social and economic status of the individual and family due to a long stay in hospital Risk of transmission in hospital due to inadequate implementation of infection control measures Non-uniformity in current, sporadic efforts of decentralized management Issues of refusal to admission and aggressive demand for early discharge Poor outcome of DR-TB cases 4/20/2013 Dr. Norbert Ndjeka 11

12 Laboratory diagnosed MDR-TB 4/20/2013 Dr. Norbert Ndjeka 12

13 MDR-TB Cases Started on Treatment EC FS GP KZN LP MP NC NW WC Dr Norbert Ndjeka 13

14 Patient Load and Bed Availability (as of April 2011) 4/20/2013 Dr. Norbert Ndjeka 14

15 Solutions Advantages Challenges Increase no. of hospitals/ beds Decentralized management of DR- TB cases including community DOT Nurse Initiated PHC- Based MDR-TB Treatment Convenient to the health system Early initiation of treatment Reduce morbidity/ mortality Reduce transmission Convenient for the patients Cost effective Improve adherence More sustainable Increases access to care Care centered in PHC Clinics Care more convenient for patients Cost to the government/ patients Socio-economic problems Risk of transmission if inadequate IC Sustainability Establishment of new infrastructure Increase training need Other sector s/ Community involvement Increase demand for supervision Need for additional training programs Need for outcomes and patient safety data 4/20/

16 What is decentralized care? MDR-TB patients are diagnosed and treated closer to their homes The World Health Organization defines Community-based care for MDR-TB as any action or help provided by, with or from the community, including situations in which patients are receiving ambulatory or outpatient treatment 4/20/

17 Steps to decentralization of MDR-TB services July 09 Oct 09 May 10 Jun 10 Nov 10 May Aug 11 Oct 11 First workshop on community-based MDR-TB at Kopanong Hotel, Johannesburg, facilitators Drs. Jaramillo & Nkhoma. Funded by URC, Supported by WHO Workshop on best practices and community MDR-TB. Facilitators: Drs. Bayona & Alcantra from Peru Discussion and adoption of the decentralised MDR-TB approach by TB Managers during quarterly meeting at Grand Hotel, Boksburg Circulated draft policy framework on decentralized management of MDR-TB National MDR-TB workshop to plan implementation, facilitated by Drs. Ernesto Jaramillo & Wilfred Nkhoma from WHO Final draft of the policy framework presented to Technical Committee of the National Health Council at Civitas, Pretoria (NDOH) Approval of the policy framework to decentralize and deinstitutionalise the management of MDR-TB services granted Printing 4/20/2013 Dr. Norbert Ndjeka 17

18 Challenges encountered Community based MDR-TB service was not tolerated There was a great deal of resistance to accept such a concept My personal feeling was that of a salesman who is selling a product that is not liked by customers The debate around community based MDR-TB was often an emotional making it difficult to have a two-way communication 4/20/2013 Dr. Norbert Ndjeka 18

19 What was encouraging? Pilot community based MDR-TB in KZN The work of MSF in the Western Cape Global Plan of Stop TB partnership- by 2015 To integrate the management of MDR-TB as routine components of TB control To achieve universal access to high-quality diagnosis and treatment for people with TB including DR-TB 4/20/2013 Dr. Norbert Ndjeka 19

20 What was encouraging? (2) WHA and Beijing Ministerial meeting resolutions Moving urgently towards universal access to diagnosis and treatment of M/XDR-TB by 2015 Ensuring a comprehensive framework for management and care of M/XDR-TB including community-based care Ensuring the removal of financial barriers to allow all TB patients equitable access to TB care Literature supporting outpatients based MDR-TB services 4/20/2013 Dr. Norbert Ndjeka 20

21 Strategies to overcome challenges We switched from community based MDR-TB to decentralized management of MDR-TB because community based suggested to several people that we intend closing hospitals in order to treat everybody out of hospitals We packaged the product differently through several versions of the drafts policy framework considering inputs by reviewers We used TB quarterly meetings to discuss the matter and events such as the TB HIV Conference We asked questions to the International Experts such as Ed. Nardell and many others Every opportunity afforded to us was used to talk about decentralized management of MDR-TB 4/20/

22 Drafts and final versions 4/20/2013 Dr. Norbert Ndjeka 22

23 POLICY IMPLEMENTATION 4/20/2013 Dr. Norbert Ndjeka 23

24 DECENTRALIZATION OF MDR-TB SERVICES 4/20/2013 Dr. Norbert Ndjeka 24

25 Purpose of the Policy Framework Provides guidance for management of MDR-TB patients closer to their homes, both in health facilities and in community Enables provinces to start MDR-TB treatment as soon as diagnosis is made, hence decreasing risk of transmission 4/20/2013 Dr. Norbert Ndjeka 25

26 Provinces requested to Call meetings of all stakeholders to introduce the policy framework Identify health facilities for scale up of MDR-TB services (plan, decentralized units, satellite units, PHC and injection teams) Conduct facility readiness assessment of all proposed/identified facilities Train all potential Care providers Monitor & Evaluate decentralization of MDR-TB activities 4/20/2013 Dr. Norbert Ndjeka 26

27 NDOH targets : 1 Decentralized site per province : 1 Decentralized site per district & cascade through satellites and additional Decentralised Units where target already met : (proposition) NSP implementation: Focus on at least 2 high burden MDR districts to scale up and saturate with services and teams Rapid diagnosis Universal treatment Sufficient vehicles and equipment

28 Challenges to implementation Funds required to scale up MDR-TB treatment Non-uniformity in the speed and types of services for decentralization among provinces Various approaches in the field dedicated MDR- TB teams vs. Integrated PHC re-engineered teams HR: shortage of Medical Practitioners in DR-TB facilities yet nursing personnel are not yet trained to initiate and follow up MDR-TB patients 4/20/2013 Dr. Norbert Ndjeka 28

29 Indicative costing for mobile injection teams... Case of KZN Initial set up TYPE OF STAFF URBAN RURAL Staff Nurse 132, ,264 TB Officer 111, ,808 Vehicle 110, ,000 Running Costs 24,000 36,000 TOTAL 378, ,072 Maintenance phase Source: Bruce Margot, , ,072

30 Benefits of Decentralization Ease the burden on the health system Reduce transmission of DR-TB by initiating treatment sooner Make more beds available Improve patient adherence to medication Improve cost effectiveness (i.e., reduce lengthy hospital stays in specialized hospitals Accommodate patient roles and responsibilities by treating them closer to home 4/20/2013 Dr. Norbert Ndjeka 30

31 MDR-TB case finding and number put on treatment Lab Diagnosed Started Treatment /20/2013 Dr. Norbert Ndjeka 31

32 STRUCTURES, LEVELS AND FUNCTIONS 4/20/2013 Dr. Norbert Ndjeka 32

33 Levels for the Decentralised Management of DR-TB 4/20/2013 Dr. Norbert Ndjeka 33

34 Responsibilities at every level Functions Provincial/Centralised MDR-TB unit Decentralised MDR-TB unit Satellite MDR-TB unit Mobile team Community Supporters Initiation of treatment of all DR-TB cases Admission of all MDR-TB cases till two successive smear negative Admission of all XDR-TB cases till two successive culture negative Monthly follow up of all DR- TB cases attending at clinic DOT to all DR-TB patients attending daily Recording and reporting (R & R) to the provincial department of health Monitoring and supervising DR-TB clinical management in the province NO NO NO No, unless no bed at Prov. or dec. unit NO NO NO NO NO NO NO NO NO NO NO NO NO NO 4/20/2013 Dr. Norbert Ndjeka 34

35 Minimum hospital staffing requirements Staff Provincial/ Centralised MDR-TB unit Decentralised MDR- TB unit Satellite MDR-TB unit Mobile team Doctor 1/40 beds 1/40 beds if occupancy is > 75% P/T optional 0 Professional nurse/ Staff nurse or Nursing Assistant 4/11 per 40 beds 4/ 11 per 40 beds 1 for 20 beds 1 for 20 patients Pharmacist 1 per beds P/T 1 for patients 0 0 Social worker 1 for > 40 beds P/T for patients P/T optional 0 Dietician 1 for > 40 beds P/T for patients 0 0 Clinical Psychologist 1 for > 40 beds P/T for patients 0 0 Occupational Therapist 1 for > 40 beds P/T for patients 0 0 4/20/2013 Dr. Norbert Ndjeka 35

36 Minimum hospital staffing level Staff Provincial/ Centralised MDR- TB unit Decentralised MDR-TB unit Satellite MDR-TB unit Mobile team Audiologist 1 for > 100 beds P/T 1 for patients 0 0 Physiotherapist 1 for > 40 beds P/T 1 for patients 0 0 Data Capturer/ Admin Clerk 1 for beds P/T 1 for patients P/T optional 0 Driver 1 for > 40 beds for 20 patients Community Health Care Worker for 10 patients 1 for 10 patients 4/20/2013 Dr. Norbert Ndjeka 36

37 Infection control at home & in the community Ventilation/open windows Isolation of patient (ideally own bed room) Cough hygiene Refrain from close contact with children Maximise time in open-air environment (e.g., receive visitors outside) Minimise contact with known HIV positive patients 4/20/2013 Dr. Norbert Ndjeka 37

38 CONCLUSION & RECOMMENDATIONS 4/20/2013 Dr. Norbert Ndjeka 38

39 Flow of DR-TB Patients 4/20/2013 Dr. Norbert Ndjeka 39

40 MDR-TB Units in South Africa 40 MDR-TB Units before 2009 Decentralised MDR-TB Units after 2009 North West Limpopo Gauteng Mpumalanga Free State Kwa-Zulu Natal Northern Cape Western Cape Eastern Cape 24 M(X)DR Units ~2,500 Beds 4/20/2013 Dr. Norbert Ndjeka

41 The policy framework is in place Implementation has begun officially, although varying from very slow to fast among provinces The number of MDR-TB patients initiated in ambulatory is increasing Provinces have bought into the idea hence they have all developed implementation plans 4/20/2013 Dr. Norbert Ndjeka 41

42 Thank you 4/20/2013 Dr. Norbert Ndjeka 42