Program Management Of DR-TB (PMDT)

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Program Management Of DR-TB (PMDT)Diagnose, Treat and Cure All Missing TB Cases

Dr Mohan K PrasaiConsultant Chest PhysicianNTC

Global Burden Of MDR-TB: 2012

Global Estimation 310,000Diagnosed cases 86,000Types of Drug Resistance Mono-resistance : resistance to single first line drug Poly-resistance: resistance to more than one drug other than HR togetherMulti- Drug resistance (MDR): resistance to at-least Rifampicin & Isoniazide or RIF Resistance confirmed by GeneXpert.Pre-XDR: MDR with resistance to one of injectable or floroquinolone.Extensive Drug resistance (XDR): resistance to floroquinolone and injectable second line in addition with MDR TB.XXDR: Resistance to almost all ATT.Types of Resistance (By Treatment history)Initial resistance ( New cases - never have prior ATT or less than one month)

Acquired resistance (Re-treatment or new case with more than one month of ATT)

Multi Drug resistant TuberculosisMDR TB is an increasing health problem.A serious challenge to TB control programm.It is regarded as a result of failure of effective implementation of Tuberculosis control program.Minimize the transmission of DR-TB by Infection control measures.GeneXpert is a gold standard diagnosis tool for early and confirmatory diagnosis of MDR-TB.How is it caused ?It is the result of inadequate or poorly administered treatment regimen.

Causes of inadequate treatment: 1.Health care providers- inadequate regimens2. Drugs -inadequate supply or quality3.Patients -inadequate drugs intakeWhen to Suspect of MDR TB ?Failure of Re-treatment Regimen

Persistent positive sputum

Fall and Rise Phenomenon

Clinical and radiological DeteriorationDR-TB(M/XDR) Management sitesRx Centres: 13Rx Sub-centres: 71

50% Treatment Centers and 25% Sub Treatment Centers in private sectorKey Policies of PMDTGeneXpert test is gold standard testProvision of free quality assured second line drugsFully supervised treatmentPrepare the patient for treatment Clinical monitoring, treatment and documentation of side effectsRegular sputum microscopy and culture monitoringStandardized recording and reporting systemMonitoring of treatment outcome and evaluation of program progress through cohort analysisCandidates for Second line DST(SLDST)Any patient who has had a past history of previous second line drugs

Any patient who remains culture positive on or after four months of the standard regimen used for MDR TB

Contacts of an individual documented with XDR TB.Where To Refer ?Near by GeneXpert centre

National Reference Lab, GENETUP, Kalimati

National Tuberculosis Center, Thimi

Line Probe Assay (LPA)GeneXpertNepal Report In % (MDR-TB)Nepal Report In % (XDR-TB)2005 - DOTS PLUS Pilot Program started with 350 pts for 2 yrs(Treatment Centers- 5, Sub Centers 11)2007 - GLC review and permission for expansion (300/year) 2010 - XDR-TB Treatment started 2011 - Treatment Centre - 12, Sub-Centre - 62 (8 DRTB Hostels established in 5 regions (EDR-1, CDR-3, WDR-1, MWDR-2, FWR-1) 2012 - 2 hostels planned2013 - Treatment centre 13,sub-centre-71, DR Home in BandipurDR TB Program Milestones14National TB centre,Thimi (G)National Medical College,Birgunj (NG)Lalgadh Hospital (G)NATA Morang (NG)BPKIHS Dharan(NG)Regional TB centre, Kaski(G)Bhim Hospital,Bhairawa(G)Lumbini Zonal Hospital, Butwal(G)NATA,Banke (NG)Mahakali Zonal Hospital, Mahendra Nagar (G)Seti Zonal Hospital,Dhangadhi(NG)TEAM Hospital- Dadeldhura(NG)NATA/GENETUP-Kathmandu(NG)

List of DR-TB centers15Differences between DR Centre and Sub centreTreatment centreFacility of MedicinesFacility of Sputum examinationFacility of Baseline investigationsResponsible for filling all the documents required for enrollment and follow-upResponsible to transport the sputum samples to NRL for C/SFacility of management of severe side effectsResponsible to Quarterly reporting to Regional monitoring & evaluation WS

Sub centreFacility of medicinesFacility of management of minor side effectsResponsibility of referring the patient to DR Centre for each monitoring investigationsResponsible to Quarterly reporting to Treatment centre (DR-TB management WS)

Responsibilities of DR TB centreCounseling to the patient Registration of the patientsBaseline and follow-up investigationsCollection & transportation of the samples to NRLProvide DOTManagement of the side effectsSupervision of DR Sub centersParticipation in the National monitoring and evaluation workshop

Responsibilities of DR TB Sub-centre1. Counseling to the patient2. Provide DOT3. Refer the patients to DR centre for regular investigations 4. Management of minor side effects

Standard MDR-TB Treatment RegimensFirst Phase 8 12 months (intensive phase)Kanamycin (KM)Pyrazinamide(Z)Levofloxacin (Lfx)Ethionamide (Eto)Cycloserine (Cs)

Second Phase 12 14 months (continuation phase)

All the drugs except the injectables.

Extensively Drug Resistance (XDR )TBXDR-TB is a form of TB which is resistant to at least four of the core anti-TB drugs.

XDR-TB involves resistance to the two most potential anti TB drugs, that is Isonized & Rifampicin, also known as MDR-TB in addition to resistance to any of the floroquinolone (ofloxacin,Moxifloxacin) and any injectable aminoglycosides (Capreomycin, Kanamycin).

Take substantially longer to treat than ordinary(drug susceptible).

Require the use of second line anti TB drugs ,which are more expensive and have more side effects.

Management of XDR TB casesStarted since Feb 2010Much more difficult to treat than MDR TB casesStandard regimen (but individualization is implemented in the substitution of drugs for severe side effects)Intensive phase for 12 months and continuation for another 12 months. (Injectable first 8 months six days a week ,and then 4 months thrice a week)

Standard XDR TB Treatment RegimensFirst Phase 12 16 months (intensive phase)Capreomycin(CM)Pyrazinamide(Z)Moxifloxacin(Mfx)Amoxycillin/clavunate(Amoxy/clav)Cycloserine (Cs)Paraaminosalicylic Acid (PAS)Clofazamine(cfz)

Second Phase 12 14 months (continuation phase)

All the drugs except Injectables one.

Drug Resistance Survey ReportYearInitial Any Resistance Initial MDRAcquired Any Resistance

Acquired MDR199913.32%3.74%28.20%11.96%200210.99%1.32%40.93%20.46%200714.71%2.86%25.3%11.72%20119.6%2.2%25.4%15.4%Estimation Of MDR/XDR TB In NepalDRS- 20112013-142014-152015-16Estimated MDR-TB cases among new cases2.2%553557561Estimated MDR-TB cases among retreatment cases15.4%455464467Total estimated MDR-TB among notified cases100810211027XDR-TB cases targeted for enrolment354045Pre-XDR 6395120MDR-TB patients enrolled in DR program of Nepal25Treatment : Comparisons

30Facility/SupportTo Health Care Providers:Health Hazard (Nrs.1000 per month)Supply of PPE (N-95 mask and gloves).To the patientsNutritional support (Nrs.1500 per month) throughout the treatment period.Supply of surgical mask Prevention of MDR TB ?????Rapid diagnosis and adequate treatment of TB with qualitative drugsSound implementation of DOTS programIdentify contacts who could have contracted TB, i.e family members, people in close contact etc.Patients with HIV/AIDS should be identified and diagnosed ASAP.Contact tracing for MDR -TB cases in placeEarly diagnosis of DR-TB cases referring suspected cases for GeneXpertInfection control measures taken where all DR- TB patients will be treatedIndoor Facilities ( Isolation) during Ss positiveWhat Improves Outcomes:Early identification (and treatment) of MDR-TBUse of an effective regimenAdequate patient supportDOTPrompt management of side-effectsSocial economic support

REQUESTDrug resistant tuberculosis is entirely the end results of a number of different Failures, which is possible to Avoid by providing qualitative service .

LET us work all together for the sake of future generation.

Be sincere towards to own responsibilities STOP TB IN MY LIFETIME

Challenges !!!Ignorance/PovertyLow MDR-TB case findingLimitation of sample currier systemLimitation of Diagnostic centersInsufficient socio-economic support to patientsHigh prevalence of Floroquinolone ResistanceInfection control measures are not in placeLimitation of qualified health personnel in DR centresSocial stigma

I am Stopping TBWe Must Stop TB36Thank you

Thank you for your kind Attention