DOTS-Plus to DOTS Philippines Thelma E. Tupasi Tropical Disease Foundation Rosalind G. Vianzon NTP Manager, Philippines.

DOTS-Plus to DOTS Philippines

Thelma E. TupasiThelma E. Tupasi

Tropical Disease Tropical Disease FoundationFoundation

Rosalind G. VianzonRosalind G. Vianzon

NTP Manager, PhilippinesNTP Manager, Philippines

Reasons for embarking on Reasons for embarking on DOTS-Plus:DOTS-Plus: Outcome of Outcome of

DOTSDOTS DOTS Clinic at the MMCDOTS Clinic at the MMC, , February 1999-January

2002OutcomOutcom

eeNew cases New cases

(126)(126)Previously Previously

treatedtreated

(65)(65)

CureCure 83.3%83.3% 53.8%53.8%

FailureFailure 0.80.8 38.538.5

DiedDied 6.46.4 1.51.5

LostLost 7.17.1 1.51.5

MDR-TBMDR-TB 2.42.4 4141Quelapio MID et al: MDR-TB a threat to TB Control, Cohort Analysis, MMC DOTS-CLinic

Reasons for embarking on Reasons for embarking on DOTS-Plus:DOTS-Plus: Health and socioeconomic Health and socioeconomic

consequencesconsequences of no DOTS-Plusof no DOTS-Plus Patients are left untreated leading

to transmission Patients are managed

inadequately/inappropriately leading to amplified resistance

Patients deteriorate leading to absenteeism and lack of productivity

Patients die leading to lost income

Scarce resources and competing Scarce resources and competing priorities: DOTS vs DOTS-Pluspriorities: DOTS vs DOTS-Plus

Private practitioners lack of Private practitioners lack of adherence to the DOTS strategyadherence to the DOTS strategy

Absorptive capacityAbsorptive capacity Establishing a laboratory network Establishing a laboratory network

to support DOTS-Plusto support DOTS-Plus Shifting from pilot project to Shifting from pilot project to

policy developmentpolicy development

Constraints and major Constraints and major challenges to DOTS-challenges to DOTS-

PlusPlus

Scarce Resources: Access to Scarce Resources: Access to treatment: 304 patients treatment: 304 patients applying for treatmentapplying for treatment

not bacteriologicall

y confirmed12%

reclassified1%

no specimen16%

for enrollment7%

SAT0%

deceased7%

patient unwilling

1%

pending culture and dst

24%

enrolled32%

Scarce Resources

Scare Resources: Support for Scare Resources: Support for

DOTS-Plus in first 165 DOTS-Plus in first 165 patientspatients

United Laboratories

11%

BSL, 4% TDF, 14%

NTP, 46%PCSO, 25%

n=165 patientsn=165 patients

Scarce Resources: Global Fund Scarce Resources: Global Fund for DOTS+ for DOTS+ To utilize the GLC-approved To utilize the GLC-approved

DOTS-Plus pilot project for policy DOTS-Plus pilot project for policy development on MDR-TB in the NTPdevelopment on MDR-TB in the NTP

GFATM Philippine program GFATM Philippine program providing providing

USD 0.5 M/yearly for DOTS-PlusUSD 0.5 M/yearly for DOTS-Plus100-120 patients yearly for five 100-120 patients yearly for five yearsyears

22ndnd line anti-TB drugs line anti-TB drugsEnablers: Enablers:

Transport cost reimbursementTransport cost reimbursementDrugs for adverse reactionsDrugs for adverse reactions

1997 NTPS

Traditional healer

7%

Hospital17%

Private MD46%

Public health clinics30%

Role of the Private Medical Practitioners in TB Treatment

0

10

20

30

40

50

60

70

PrivatePhysicians

Public Healthcenters

Others

Referrals forReferrals forDOTS-PlusDOTS-Plus Care providers consulted

Private Practitioners and Private Practitioners and Fluoroquinolones in the Fluoroquinolones in the

PhilippinesPhilippines

0 10 20 30 40 50

HRZES

HRZE

HRZS

HRES

HRE

HRS

HRZ

HR

Resis Pattern

No. of isolates

FQ Sen FQ Res

Resistance to Resistance to Fluoroquinolones and Fluoroquinolones and

KanamycinKanamycin

0102030405060708090

100

HRZES HRZE HRZS HRES HRE HRS HRZ HR Res Pattern

% of isolates % FQ Resistant %Kan Resistant

GLC technical assistance GLC technical assistance political commitment to the DOTS+ pilot

project among NTP and its technical advisers

uninterrupted supply of quality assured 2nd line anti-TB drugs

appropriate laboratory support for the diagnosis of MDR-TB including culture and DST under supranational laboratory supervision

treatment under DOT and management of adverse drug events,

reporting and recording.

1.21

0.92

0.96

1.13

0.35 0.270.2

0.2

0.34

1.4

0.17

0.130.13

1.62 1.421.44

1.573

0.130.13

0.10.11

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

US

D

Capreomycin Kanamycin Cycloserine PASER Eth/Pro

Second-line drug

Role of the GLC: Cost of 2nd-line drugs before and after GLC in US$

1st order 2nd order 3rd order 4th order 5th order

80,000

30,000

233,000

121,000

0

50,000

100,000

150,000

200,000

250,000

Cos

t (P

hP)

HR-resistant HRZES-resistant

Cost of MDRTB Treatment with and without GLC

Without GLC With GLC

Individualized Tx. Outcome of Individualized Tx. Outcome of TherapyTherapy

OutcoOutcomeme

nn

AllAll

117117

Patients Patients who who

remain remain in in

therapytherapy

101101

Patients Patients who who

complete complete therapytherapy

8383

Cure 61% 70% 85.5%Failure 19 11.9 14.5Died 15 17.8Default 14

DOTS-Plus in the DOTS-Plus in the Philippines is highly Philippines is highly

cost-effectivecost-effectiveCost per DALY averted: US $ 242 vs Cost per DALY averted: US $ 242 vs

GNI of $1,040 in the PhilippinesGNI of $1,040 in the Philippines1. Cost <per capita GNI is highly 1. Cost <per capita GNI is highly

cost-effective cost-effective 2. 3x per capita GNI is cost-effective 2. 3x per capita GNI is cost-effective

as recommended by the as recommended by the Commission on Macroeconomics Commission on Macroeconomics and Health.and Health.

3. COST 3. COST is within the range of is within the range of "attractive" investments defined "attractive" investments defined by the World Bankby the World BankKatherine Floyd and Raj GuptaKatherine Floyd and Raj Gupta

From Pilot project to Policy: From Pilot project to Policy: IssuesIssues

DOTS: Local ownership and sustainable DOTS: Local ownership and sustainable financial commitment to support basic financial commitment to support basic DOTS programmeDOTS programme

DOTS-Plus pilot project: Enunciation of DOTS-Plus pilot project: Enunciation of its current and potential relevance to its current and potential relevance to the National TB Control Programthe National TB Control Program

22ndnd line anti-TB drugs: Registration, line anti-TB drugs: Registration, availability and controlled distribution availability and controlled distribution to prevent abuse and emergence of drug to prevent abuse and emergence of drug resistanceresistance

Sputum culture

2-3 m AFS

Neg

DOTS

Previously Treated: CAT II

New: Cat I

NegPos

Continue Cat I Continue Cat II

CureCureDST: MDR-TB

DOTS Plus

Pos Neg

4-5m AFS

Neg

MDR-TB in the MDR-TB in the PhilippinesPhilippines Socioeconomic and health reasons for Socioeconomic and health reasons for

embarking on DOTS-Plusembarking on DOTS-Plus Constraints and barriersConstraints and barriers

Problem engendered by second-line anti-Problem engendered by second-line anti-TB drug use in the countryTB drug use in the country

Limited resources and absorptive capacityLimited resources and absorptive capacity Individualized treatment is effective, Individualized treatment is effective,

feasible, and cost-effectivefeasible, and cost-effective GLC mediated technical assistance: enabled GLC mediated technical assistance: enabled

pilot project to follow 5 elements of DOTS-pilot project to follow 5 elements of DOTS-Plus enforcedPlus enforced

Integration of DOTS-Plus within DOTS in Integration of DOTS-Plus within DOTS in the NTP: Clear Policy within the NTPthe NTP: Clear Policy within the NTP

DOTS-PLUS EXPANSION andMAINSTREAMING

PART II: PART II:

ISSUES and CHALLENGESISSUES and CHALLENGES

in INTEGRATING DOTS-PLUS in INTEGRATING DOTS-PLUS

into the PUBLIC HEALTH DOTSinto the PUBLIC HEALTH DOTS

- - Setting-up theSetting-up the policy environmentpolicy environment

operational feasibility - reality settingoperational feasibility - reality setting 100% DOTS coverage in the public 100% DOTS coverage in the public

sectorsector

evidence is available from the pilot project evidence is available from the pilot project that DOTS is feasible & cost effective in the that DOTS is feasible & cost effective in the country; support evidence from the DRScountry; support evidence from the DRS

potential impact & equity in accesspotential impact & equity in access

economic and social productivity, (MDG) economic and social productivity, (MDG) safe and healthy environment safe and healthy environment

ISSUESISSUES

- Readiness in integrating the system- Readiness in integrating the system

strategic implementation strategic implementation development of human resourcesdevelopment of human resources enhancing QA laboratory support under enhancing QA laboratory support under

supranational laboratory supervisionsupranational laboratory supervision ensuring logistical support for second-line ensuring logistical support for second-line

drugsdrugs institutionalized technologyinstitutionalized technology

ISSUESISSUES

CHALLENGESCHALLENGES

Policy Environment:Policy Environment:

High political agendum within the NTPHigh political agendum within the NTP NTP point person for DOTS (+)NTP point person for DOTS (+) DOTS (+) Task Force vis-à-vis NTP-TWGDOTS (+) Task Force vis-à-vis NTP-TWG Increase advocacy for strong political Increase advocacy for strong political

commitment of all stakeholderscommitment of all stakeholders Support from NTP partners - Advisory BodySupport from NTP partners - Advisory Body (L(Local & International advisers) ocal & International advisers)

Systems Integration:Systems Integration:Strategic Implementation:Strategic Implementation:

- area analysis for an impact implementation - DRS resultsHuman resource development:Human resource development:- additional Staff and/or re-tasking of existing roles and functions- intensive training with immersion in the DOTS(+) Project-multidisciplinary approach at all levels of health care

CHALLENGESCHALLENGES

Systems Integration:Systems Integration:Laboratory Capacity and Proficiency:Laboratory Capacity and Proficiency:- maximize developed laboratory under the DRS Strengths:Strengths: QA center for microscopy Established lab network in place

Proficient laboratory Staff Not integrated with other

laboratory works

CHALLENGESCHALLENGES

Systems Integration:Systems Integration:Logistical Support:Logistical Support:- NTP budget for 2nd line drugs plus GFATM support-unified system for drug management (1st &2nd line drugs)- regulation and control in the distribution of 2nd line drugs- technical / financial assistance from other partners

CHALLENGESCHALLENGES

Institutionalized Technology:Institutionalized Technology:

- multi-sectoral coordination of stakeholders

NTP, LGUs, Private Providers, Experts /

Academe, Professional

societies/International Agencies/

community

- community-based approach

CHALLENGESCHALLENGES

Strategic Area

Human ResourceDevelopment

Laboratory Capacity& Proficiency

LogisticalSupport

InstitutionalizedTechnology

DOTS(+)

within NTPNTP

Stepwise Approach

to Mainstream DOTS (+)

into

the NTPNTP