June 30, 2010 TB Program Thailand MOPH – U.S. CDC Collaboration TB Project Implementation: Impact on NTP?

June 30, 2010TB Program

Thailand MOPH – U.S. CDC Collaboration

TB Project Implementation: TB Project Implementation: Impact on NTP? Impact on NTP?

OverviewOverview

SurveillanceSurveillance

ResearchResearch

TrainingTraining

Technical AssistanceTechnical Assistance

Active Population-Based Active Population-Based Surveillance and Enhanced Control Surveillance and Enhanced Control

of TB: The Thailand TB Active of TB: The Thailand TB Active Surveillance Network (TB-Net)Surveillance Network (TB-Net)

Partners and project sitesPartners and project sites

Ministry of Public HealthMinistry of Public Health

Bangkok Metropolitan Bangkok Metropolitan Administration (BMA)Administration (BMA)

Research Institute of Research Institute of Tuberculosis (Japan)Tuberculosis (Japan)

Thailand MOPH – U.S. Thailand MOPH – U.S. CDC CollaborationCDC Collaboration

Non- and inter-Non- and inter-governmental organizationsgovernmental organizations

Funded: USAID, GDD,GAP Funded: USAID, GDD,GAP

Chiang RaiChiang Rai

TakTak

Ubon-ratchathaniUbon-ratchathani

BangkokBangkok

PhuketPhuket

Difference between Active Difference between Active Surveillance Network and Routine Surveillance Network and Routine

TB Control in ThailandTB Control in Thailand

Active, not passive, surveillance of diagnosed casesActive, not passive, surveillance of diagnosed casesData from private, NGO, and non-MOPH government Data from private, NGO, and non-MOPH government facilitiesfacilitiesElectronic recording of individual cases, not summaryElectronic recording of individual cases, not summaryExpanded data collectionExpanded data collectionContinuous data analysisContinuous data analysisMore than microscopy: culture (province), DST More than microscopy: culture (province), DST (referred)(referred)Integration of HIV counseling, testing, treatmentIntegration of HIV counseling, testing, treatment

Goal of TB NetGoal of TB Net

Develop models for TB prevention and Develop models for TB prevention and control bycontrol by– Measuring incidence of diagnosed TB, HIV Measuring incidence of diagnosed TB, HIV

co-infection, and MDR-TBco-infection, and MDR-TB– monitoring epidemiologic and clinical features monitoring epidemiologic and clinical features

of TB of TB – developing, studying, implementing, and developing, studying, implementing, and

monitoring TB prevention and control monitoring TB prevention and control strategies in Thailandstrategies in Thailand

Objectives of TB NetObjectives of TB Net

Develop model program for measuring incidence, Develop model program for measuring incidence, mortality from TB, TB/HIV, and MDR-TB, and to mortality from TB, TB/HIV, and MDR-TB, and to monitor changes over time;monitor changes over time;

Use surveillance data to assess impact of public Use surveillance data to assess impact of public health interventions, detect outbreaks, allocate health interventions, detect outbreaks, allocate resources, guide public health and clinical resources, guide public health and clinical practice;practice;

Build human resources and technical capacity in Build human resources and technical capacity in epidemiology, laboratory, and information epidemiology, laboratory, and information technology;technology;

Develop platform for operational research on TB Develop platform for operational research on TB and TB/HIV, and to assess the impact of public and TB/HIV, and to assess the impact of public health interventions.health interventions.

Activities of TB-NetActivities of TB-NetAll persons diagnosed with All persons diagnosed with TB in public and private TB in public and private health care facilitieshealth care facilitiesStandard epidemiologic data Standard epidemiologic data at beginning and end of at beginning and end of treatmenttreatmentCulture, susceptibility testingCulture, susceptibility testingHIV counseling, testingHIV counseling, testingMonitor HIV care services for Monitor HIV care services for TB patientsTB patientsElectronic recording and Electronic recording and reportingreporting

Tre

atm

en

tDia

gn

osi

s

HIV

TB

Private Sector

Healthcare

Surveillance

Drug-resistance

Research

Have we met the objectives?Have we met the objectives?

Model to assess incidence/mortalityModel to assess incidence/mortality

Assess interventions, guide practiceAssess interventions, guide practice

Build epi, lab, IT capacityBuild epi, lab, IT capacity

Platform for operational researchPlatform for operational research

>10 manuscripts published addressing >10 manuscripts published addressing programmatic and surveillance questionsprogrammatic and surveillance questions

Many aspects of TB Net now routineMany aspects of TB Net now routine– TB/HIV initiatives (PITC, ART training)TB/HIV initiatives (PITC, ART training)– Access to liquid cultureAccess to liquid culture– Electronic data collectionElectronic data collection

Have we metHave we met22ndnd Global Plan to Stop TB, 2006-2010? Global Plan to Stop TB, 2006-2010?

DOTS expansion and enhancementDOTS expansion and enhancement

Address TB/HIV and MDR-TB Address TB/HIV and MDR-TB

Establish Public-private partnerships Establish Public-private partnerships

Enable and promote research Enable and promote research

Strengthen health-system Strengthen health-system

Empower patients and communitiesEmpower patients and communities

√

√

√

√

?

Policy ChangePolicy Change

ImpactImpact TUC/TB ContributionTUC/TB ContributionNational policy adopted to National policy adopted to perform HIV counseling and perform HIV counseling and testing on TB patientstesting on TB patients

Built evidence base; tested Built evidence base; tested strategy; financial support for strategy; financial support for planning workshop in Viet Nam; planning workshop in Viet Nam; technical assistance on drafting technical assistance on drafting initial planinitial plan

National TB recording / National TB recording / reporting system revised to reporting system revised to include HIV-related datainclude HIV-related data

Built evidence base;; revised Built evidence base;; revised national forms based largely on national forms based largely on forms developed for Ubon forms developed for Ubon projectproject

Better Public Health OutcomesBetter Public Health OutcomesImpactImpact TUC/TB ContributionTUC/TB Contribution

Increased case finding in Increased case finding in Bangkok, PhuketBangkok, Phuket

Provided infrastructure and technical Provided infrastructure and technical guidance to enhanced public and guidance to enhanced public and private collaboration, TB program private collaboration, TB program monitoringmonitoring

Decreased death rate and Decreased death rate and increased TB success rate among increased TB success rate among TB/HIV in Ubon, and Chiang RaiTB/HIV in Ubon, and Chiang Rai

Provided infrastructure and technical Provided infrastructure and technical guidanceguidance

Increased sputum conversion rate Increased sputum conversion rate and treatment success rate in and treatment success rate in Phuket and BangkokPhuket and Bangkok


Increased proportion of patients Increased proportion of patients receiving HIV counseling and receiving HIV counseling and testing in Bangkok, Chiang Rai, testing in Bangkok, Chiang Rai, Phuket, Tak, and UbonPhuket, Tak, and Ubon


Enhanced Capacity (1)Enhanced Capacity (1)

ImpactImpact TUC/TB ContributionTUC/TB ContributionMore rapid, sensitive diagnostic More rapid, sensitive diagnostic methods for TB in Bangkok. methods for TB in Bangkok. Chiang Rai, Phuket, Tak, UbonChiang Rai, Phuket, Tak, Ubon


Access to routine drug Access to routine drug susceptibility testing for Bangkok,susceptibility testing for Bangkok, Chiang Rai, Phuket, Tak, UbonChiang Rai, Phuket, Tak, Ubon


Electronic recording and reporting Electronic recording and reporting implemented in Bangkok,implemented in Bangkok, Chiang Chiang Rai, Phuket, Tak, Ubon, Rai, Phuket, Tak, Ubon, Bamrasnaradura InstituteBamrasnaradura Institute


Enhanced Capacity (2)Enhanced Capacity (2)

ImpactImpact TUC/TB ContributionTUC/TB ContributionMeasuring outcomes of public Measuring outcomes of public health interventions by health interventions by conducting operational researchconducting operational research

Provided infrastructure and technical Provided infrastructure and technical guidance; Observational study launched guidance; Observational study launched to understand causes of high, early to understand causes of high, early mortality rate in TB/HIV patientsmortality rate in TB/HIV patients

Training of public health staff in Training of public health staff in TB, Laboratory and TB/HIV TB, Laboratory and TB/HIV managementmanagement


Enhanced capacity for TB Enhanced capacity for TB outbreak responseoutbreak response

Outbreaks investigated at Phuket Outbreaks investigated at Phuket Vachira Hospital and Wat Tham Krabok Vachira Hospital and Wat Tham Krabok with laboratory, IT, epidemiologic, with laboratory, IT, epidemiologic, statistical support from TUCstatistical support from TUC

Exporting of ModelsExporting of Models

ImpactImpact TUC/TB ContributionTUC/TB ContributionExpanded TB/HIV partnerships in Expanded TB/HIV partnerships in Northeastern ThailandNortheastern Thailand

Lessons learned in Ubon project Lessons learned in Ubon project applied to other provinces by using applied to other provinces by using resources from GFATMresources from GFATM

Expanded Public- Private-Expanded Public- Private-Partnerships (PPP) in BangkokPartnerships (PPP) in Bangkok

Lessons learned in 2 health centers Lessons learned in 2 health centers (HC) of Bangkok project applied to (HC) of Bangkok project applied to 7 HCs then 19 HCs7 HCs then 19 HCs

WHO TB/HIV training course for WHO TB/HIV training course for SEARO countriesSEARO countries

Curriculum development; Curriculum development; organization; Hosting of site visits at organization; Hosting of site visits at project sitesproject sites

Lab Capacity building to TB Active Lab Capacity building to TB Active Surveillance Network (1)Surveillance Network (1)

Improve lab capacity and ability including Improve lab capacity and ability including

infrastructure, equipments and reagentsinfrastructure, equipments and reagents

Human resource: hiring full time staffs and Human resource: hiring full time staffs and

support staff to present in international support staff to present in international

conferenceconference

Provide Technical support for new diagnostic Provide Technical support for new diagnostic

tools implementation (Liquid media culture, tools implementation (Liquid media culture,

Capilia TB and Hain test)Capilia TB and Hain test)

Develop and implement Electronic data recording Develop and implement Electronic data recording Support Lab quality control Support Lab quality control

- Collaborate with NTRL for monitoring- Collaborate with NTRL for monitoring and supervisionand supervision

- Participation in External Quality Assurance- Participation in External Quality Assurance of College of American Pathologistsof College of American Pathologists

- Organize training on Standard Operating- Organize training on Standard Operating Procedure of TB culture and Good Procedure of TB culture and Good

Laboratory PracticesLaboratory Practices

Lab Capacity building to TB Active Lab Capacity building to TB Active Surveillance Network (2)Surveillance Network (2)

Do we have Impact on TB Lab ?Do we have Impact on TB Lab ?

Liquid culture Implementation Liquid culture Implementation

Implementation of Rapid Implementation of Rapid

identification by strip speciation identification by strip speciation

(Capilia TB and SD Bioline)(Capilia TB and SD Bioline)

Expansion of Electronic recording Expansion of Electronic recording

for lab datafor lab data

Lessons LearnedLessons Learned

Active surveillance increases case findingActive surveillance increases case finding– Enables comparisons between public and Enables comparisons between public and

private sector TB treatment outcomesprivate sector TB treatment outcomes

Enhanced laboratory capacity, performanceEnhanced laboratory capacity, performance

MDR-TB rates ~1-4% consistent with national MDR-TB rates ~1-4% consistent with national estimates – no hidden epidemicestimates – no hidden epidemic

Increased TB/HIV collaboration for testing, Increased TB/HIV collaboration for testing, linkages to care linkages to care

Rich database for operational researchRich database for operational research

ChallengesChallenges

Have engaged private sector to share data for

monitoring and evaluation, but need strategy to

elevate private sector’s standard of care

System developed and integrated into MOPH, but

many competing reporting systems proposed in

MOPH – need unified national standard for TB

How to translate implementation models into

routine practice and scale up?

2004-20082004-2008

Observational study of HIV-infected TB patientsObservational study of HIV-infected TB patients

2005-20082005-2008

Improving diagnosis of TB in HIV-infected Improving diagnosis of TB in HIV-infected personspersons

2008-20112008-2011

Public health impact of implementing the Public health impact of implementing the GenoType®GenoType® MTBDRMTBDRplusplus assay for diagnosis assay for diagnosis and management of drug-resistant TB in and management of drug-resistant TB in ThailandThailand

Research (1)Research (1)

2009-20102009-2010

Evaluation of a program to enhance TB Evaluation of a program to enhance TB laboratory services in Thailand: Did laboratory services in Thailand: Did providing TB drug-susceptibility results to providing TB drug-susceptibility results to physicians change clinical practice?physicians change clinical practice?

2009-20102009-2010

Performance comparison of SD Bioline TB AG Performance comparison of SD Bioline TB AG MTP 64 Rapid with Capilia TB NEO for MTP 64 Rapid with Capilia TB NEO for mycobacterial species identification from broth-mycobacterial species identification from broth-based culture at ODPC7, Ubon Ratchathanibased culture at ODPC7, Ubon Ratchathani

Research (2)Research (2)

TrainingTrainingOperational research Operational research

Counseling –HIV Diagnosis counseling and Counseling –HIV Diagnosis counseling and testing in TB patientstesting in TB patients

Increasing ART use in HIV-infected TB Increasing ART use in HIV-infected TB patientspatients

TB infection control, collaboration with WHOTB infection control, collaboration with WHO

TB/HIV inter-country, collaborate with WHO TB/HIV inter-country, collaborate with WHO

Laboratory: SOP, AFB, Culture, DST, EQA Laboratory: SOP, AFB, Culture, DST, EQA

Technical AssistanceTechnical Assistance

NTP program NTP program

Outbreak responseOutbreak response

Lab capacity building Lab capacity building

Epidemiological & statistical consultationEpidemiological & statistical consultation

Manuscript development for TB-NetManuscript development for TB-Net

Future DirectionsFuture Directions

Continued focus on 3 key areas: research, Continued focus on 3 key areas: research, training, technical assistancetraining, technical assistance

Focus on lab capacity building and Focus on lab capacity building and improving diagnosis in routine care improving diagnosis in routine care settingssettings

Operational research in improving IC, Operational research in improving IC, ICF/IPT in HIVICF/IPT in HIV

Increased focus on MDR TBIncreased focus on MDR TB

Thank you for your attentionThank you for your attention

June 30, 2010 TB Program Thailand MOPH – U.S. CDC Collaboration TB Project Implementation: Impact on NTP?

Documents

tb patientselectronic

activities of tb

routine tb control

enhanced control of

tb programthailand moph

clinical features of

monitoring tb prevention

aspects of tb net