TB CONTROL PROGRAMME KZN KZN KZN Programme Overview
TB CONTROL PROGRAMMEKZNKZN
KZN Programme Overviewg
KZN TB Control Programme - Background• 1996
– TBC Programme started M d b CDC h i l d i f h CDC ( l ibl– Managed by CDC technical advisor as part of the CDC programme (also responsible for EPI Programme)
– KZN implemented its own guidelines ( 3 day a week continuation phase / no retreatment regimen)
• 1998 – Provincial CDC Programme Manager appointed, and EPI moved to MCWH
• 2000 – KZN adopt NTCP Guidelines– District CDC coordinators appointed
ETBR implemented– ETBR implemented• 2001
– District CDC Surveillance officers appointed• 2002
– District TB data capturers appointedDistrict TB data capturers appointed • 2006
– TB Crisis launched – Provincial Level - TB moved from CDC, and set up as its own directorate– Sub District TB coordinators appointed in 3 crisis plan districts
2009 2010• 2009 – 2010– District Level – TB moved from CDC and set up as a programme on its own (District
TB Coordinators appointed in all districts)
KZN TBCP Overview / Progress
W k h R t G b k t 2005 / 2006• Workshop Report Goes back to 2005 / 2006• Presentation covers period from 2006 to date
March 2006 – Launch of SA TB Crisis PlanMarch 2006 Launch of SA TB Crisis PlanSeptember / October 2006 - Tugela Ferry MDR/XDR TB Outbreak
O i lWHO 7 Point PlanConduct rapid surveys of MDR/XDR TBEnhance laboratory capacityImprove technical capacity of clinical and public health managers to effectivelyImprove technical capacity of clinical and public health managers to effectively respond to XDR-TB outbreaks Implement infection control precautions Increase research support for anti-TB drug development Increase research support for rapid diagnostic test developmentIncrease research support for rapid diagnostic test development Promote universal access to ARVs under joint TBHIV activities
What are we dealing with in KZN
TB Case Finding 2009 – Incidence Rate per 100,000 of population (Listed descending from highest to lowest)
Q1 – Q4 / 2010
ALL TB
120700
PTB 100667District Incidence Rate per 100,000 of population
Sisonke 1460 / 100,000 population
Uthungulu 1415 / 100,000 population
Ilembe 1378 / 100 000 population
83,4 % Of All TB
SM+VE 33340
33,1 % Of All PTB
SMEAR VE 31834 Ilembe 1378 / 100,000 population
Ugu 1311 / 100,000 population
Umgungundlovu 1220 / 100,000 population
Umkhanyakude 1197 / 100,000 population
SMEAR-VE 31834
31,6 % Of All PTB
NO SMEAR 35493
35,2 % Of All PTBEthekwini 1118 / 100,000 population
Zululand 1067 / 100,000 population
Umzinyathi 1040 / 100,000 population
Amajuba 1000 / 100,000 population
EXTRA PULMONARY 20033
16,6 % Of All TB
BAC COV 73 % j p p
Uthukela 728 / 100,000 population
KZN 1160 / 100,000 population
Reporting and Recording• Across the 11 districts, the data base is broken down ,
into 31 capturing units, with 12 merge units• A total of 752 facilities (TB Registration and Rx) are
on the reporting systemp g y• Fully inclusive = Provincial, Local Authority, Other
Govt Departments, State Aided, and some Private–– HospitalsHospitalsHospitalsHospitals– CHCs– Clinics– Mobiles– Prisons – SANDF
• System runs at about 95% efficiency, with about a 3 h l i dmonth lag in data entry
Diagnosis / Laboratory services
Activities – Diagnosis / Laboratoryg / y81 Microscopy Sites operational (85000 specimens PM)1 Culture DST site operational
Capacity increased from 5500 Specimens per month to 16500Capacity increased from 5500 Specimens per month to 16500 specimens per month
LIS operational in all TB microscopy centersDaily Lab transport to all facilitiesDaily Lab transport to all facilitiesSMS printers for lab results installed in 345 facilitiesParticipated in / supported Haines PCR / LPA Rapid MDR TB Di ti l tiDiagnostic evaluation
4 sites developed, 1 operational, other 3 pending finalization of diagnostic algorithm
Piloted Gene Expert3 sites operational, and expansion currently being planned
What is the situationWhat is the situationWhat is the situationWhat is the situationAndAnd
What are we doingWhat are we doing(Implementation of Crisis Plan)(Implementation of Crisis Plan)(Implementation of Crisis Plan)(Implementation of Crisis Plan)
TB Crisis Plan (2006) – Interventions / ProgressActivities - System Strengthening y g g(Management Capacity)
• Dedicated TB Directorate created Director ACSM• Dedicated TB Directorate created – Director, ACSM officer, 3 Surveillance Officers, Admin
• Dedicated District TB Coordinators appointed in all 11 districts11 districts
• Dedicated Sub-District TB Coordinators (10) appointed in Crisis Plan Districts (Ethekwini - 6, Umgungundlovu - 2 & Uthungulu - 2)Umgungundlovu - 2, & Uthungulu - 2)
• 15 District CDC/TBC Surveillance officers appointed in all districts, and 16 District CDC/TBC data capturers' – manage ETR Netcapturers manage ETR.Net
TB Crisis Plan (2006) – Interventions / Progress
Activities – Improve Case Finding / ManagementActivities – Improve Case Finding / Management• Targeted High Burden TB Facilities = 350 cases PA• Staffing Norms = 1 dedicated nurse per 250 cases PAStaffing Norms = 1 dedicated nurse per 250 cases PA
– 174 Nurses appointed since 2006 to date
• Intensified Case Find– Implementation of suspect register in all facilities– Intensified Contact Tracing
• Treatment calendar / diary system implemented• Treatment calendar / diary system implemented– System to track patient return dates, and identify defaulters
quickly
T i i / M&E S tM&E S t• Training / M&E Support M&E Support – Ongoing (NTCP Guideline In-Service Training / M&E visits M&E visits
TB Crisis Plan (2006) - Interventions / Progress
Activities – Improve Case RetentionActivities Improve Case Retention• Point of service patient TB education / Rx adherence counseling
implemented (Educational flipcharts)• TBHIV Community Outreach Teams (TB Community OfficersTBHIV Community Outreach Teams (TB Community Officers
(tracers)/ Staff nurses)– Strengthen community outreach ( Education, mobilisation, tracing of
contacts / defaulters64 TB it ffi i t d f 2006 t d t– 64 TB community officers appointed from 2006 to date
– 70 planned to be appointed 2011 / + 70 nurses for 70 planned to be appointed 2011 / + 70 nurses for injectablesinjectables– 129 vehicles purchased for TB outreach work from 2006 to date
70 planned to be purchased 2010 / 201170 planned to be purchased 2010 / 2011 –– just taken deliveryjust taken delivery–– 70 planned to be purchased 2010 / 2011 70 planned to be purchased 2010 / 2011 –– just taken deliveryjust taken delivery• ACSM (Prevention, Signs & Symtoms, Rx Adherence)
– KAP Survey– Community awareness / door to door campaigns / Radio Clips andCommunity awareness / door to door campaigns / Radio Clips and
call in shows / school programmes - ongoing
TB Crisis Plan (2006) - Interventions / Progress
Activities – improve TBHIV combined management
• Intensified training• Incorporated into M&E reviews•• Supported 3Is projectsSupported 3Is projects•• Supported 3Is projectsSupported 3Is projects
–– Strongly recommendedStrongly recommended–– Intensify IPT / CPTIntensify IPT / CPT–– Intensify ARTIntensify ART
What’s the Impact ?What s the Impact ?Is It Making a Difference ?g
TB Progress / UpdateImpact
TATTATBaseline 51% of facilities achieving 48hr TATCurrent – 69% of facilities achieving 48hr TAT
Suspect register (active case finding)B li 2 5% f h d t dBaseline - 2,5% of headcount screenedCurrent - 3% of headcount screenedBaseline - 88% of suspects testedCurrent - 93% of suspects testedP iti it t t d 7%Positivity rate averages at around 7%Baseline - 86% of confirmed cases put on RxCurrent - 90% of confirmed cases put on Rx
TBHIVBaseline – 48% of TB patients counseled for HIVCurrent – 90% of TB patients counseled for HIVBaseline – 63% of TB patients tested for HIVCurrent – 85% of TB patients tested for HIVPositivity rate averages at around 68%Baseline – 42% of co-infected patients on CPTCurrent – 77% of co-infected patients on CPT
TB Progress / UpdateImpact
Not EvaluatedNot EvaluatedBaseline = 8,0 %Current = 2,8%
Smear Conversion RateSmear Conversion RateBaseline = 36,5 %Current = 69,0 %
Cure RateCure RateBaseline = 40,1 %Current = 70,6%
Interruption RatepBaseline = 11,7 %Current = 7,0%
Death RateBaseline = 7,4%Current = 6,4%
4
KZN SuspectsQrt 2 - 2011 Qrt 1 - 2011 Qrt 4 2010 Qrt 3 - 2010# % # % # % # %
Head Count 4718638 4971656 3938625 4205316No. Suspects 110773 2.3% 127225 3.0% 137279 3.0% 136128 3.0%No. Suspects tested 118376 93.0% 101985 92.0% 120477 88.0% 116184 85.0%No. Suspects positive 6877 6.7% 8183 6.9% 7785 6.5% 7646 7.0%o Suspects pos t e 68 6 % 8 83 6 9% 85 6 5% 6 6 0%
KZN Case FindingQrt 2 - 2011 Qrt 1 - 2011 Qrt 4 2010 Qrt 3 - 2010# % # % # % # %# % # % # % # %
All TB 17341 29726 28335 29378All PTB 14754 85.0% 25113 84.4% 23532 83.0% 24552 83.5%New Smr +ve PTB 4730 27 2% 7442 29 6% 6450 27 4% 7422 30 2%New Smr +ve PTB 4730 27.2% 7442 29.6% 6450 27.4% 7422 30.2%New Smr –ve PTB 3978 26.9% 6465 25.7% 6552 27.8 6508 26.5%Bacterial Coverage 80.4% 78.1% 76.3% 75.0%
All EPTB 2587 14.9% 4613 15.5% 4803 16.9% 4826 16.4%New EPTB 2357 91.1% 4212 91.3% 4430 92.2% 4431 91.8%Other Cases 230 1.3% 401 8.6% 373 1.3% 395 1.3%Other Cases 230 1.3% 401 8.6% 373 1.3% 395 1.3%
ReRx Relapse Cases (Smr +ve) 540 3.6% 795 17.2% 639 2.7% 602 2.4%ReRx after Default (Smr +ve) 156 1.0% 247 5.3% 160 0.6% 178 0.7%Rx After Failure (Smr +ve) 117 0.7% 165 3.5% 161 0.6% 195 0.7%ReRx Other 1014 5.8% 1581 5.3% 1277 4.5% 1362 4.6%
KZN Smear ConversionsQrt 1 - 2011 Qrt 4 - 2010 Qrt 3 2010 Qrt 2 - 2010# % # % # % # %
New Smr +ve Cases 7810 6293 7083 6789No Converted @ 2 mths 5375 69.0% 4231 67.2% 4057 57.2% 4895 72.1%No Converted @ 3 mths 5792 74.1% 4592 72.9% 4406 62.2% 5337 78.6%
R R C 1734 1451 1476 1253ReRx Cases 1734 1451 1476 1253No converted @ 3 mths 1055 60.8% 800 55.1% 738 50.0% 828 66.1%
KZN Treatment OutcomesQrt 2 / 2010 Qrt 1 / 2010 Qrt 4 / 2009 Qrt 3 / 2009
# % # % # % # %
New Cases 6933 6347 7263 8909Cured 4896 70.6% 4393 69.2% 4968 68.4% 5810 65.2%Completed 398 5.7% 380 5.9% 477 6.6% 581 6.5%Defaulted 487 7.0% 504 7.9% 466 6.4% 635 7.1%Died 446 6.4% 415 6.5% 435 6.0% 608 6.8%Transferred 280 4.0% 331 5.1% 338 4.7% 443 5.0%Failed 102 1.5% 127 2.0% 110 1.5% 135 1.5%
ReRx Cases 1238 1343 1355 1880Cured 635 51.3% 666 48.5% 649 47.9% 876 46.6%Cured 635 51.3% 666 48.5% 649 47.9% 876 46.6%Completed 153 12.3% 154 11.4% 170 12.5% 164 8.7%
Defaulted 163 13.2% 190 14.1% 146 10.8% 181 9.6%
Died 115 9.3% 145 10.7% 121 8.9% 196 10.4%Died 115 9.3% 145 10.7% 121 8.9% 196 10.4%Transferred 68 5.5% 71 5.2% 87 6.4% 124 6.6%
Failed 32 2.6% 37 2.7% 26 1.9% 45 2.4%
MDR TB Programme Overview• 2000 – Start of SA / KZN MDR TB programme
– MRC driven– COE = KGV– Implementation of standardized MDR TB Rx regimens
• 2006 – KZN start decentralization of MDR TB services• 2006 – First standardised WHO definitions / indicators• 2006 – MDR TB Programme officially incorporated into NTCP programme • 2007 – KZN start Community based Management of MDR Rx (mobile injection
teams)• 2008 – KZN decentralization / community based management programme
approved by NHC as pilot projectapproved by NHC as pilot project• 2008 – First Standardised paper based MDR TB reporting and recording system • 2009 – Decentralized / Community based management of MDR Tb approved in
principal by NHC– NTCP start to develop draft guidelines based on KZN protocolNTCP start to develop draft guidelines based on KZN protocol
• 2009 – Start of EDR software programme for MDR TB R&R • 2010 – NTCP Draft guidelines ready for submission to Minister for approval
– NHC decision – all provinces to submit draft plans for decentralization of MDR TB services
• 2010 – Upgrade of EDR software programme for MDR TB R&R (Basic model)• 2011 – Finalised draft MDR TB Guidelines – Submitted to NTC
MDR TB CASES AS 2000 - 2009
1600
1128
1372
1478
1200
1400
1600
690800
1000
OF
CASE
S
MDR
273
391
481 467
555
400
600NO. O
205
0
200
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
YEARS
XDR TB CASES 2000 - 2009
250
199200
168
109
150
OF
CA
SES
XDR
83
109
100NO
. O
1 4 7 6 6
35
0
50
2000 2001 2002 2003 2004 2005 2006 2007 2008 20092000 2001 2002 2003 2004 2005 2006 2007 2008 2009YEARS
Last Drug Resistance Survey in KZN 2001 to 2002 (MRC)( )
Weyer et al SAMJ 2007
MDR (2004 – 2007)Estimates / Lab Confirmed / On Rx
31993500
27152961
2472
3072
2572
3199 3060
2500
3000
3500
1461
6901128
1000
1500
2000 Estimates
Lab Diagnosis
Reg. on Rx Prog
467 550 690
0
500
1000
2004 2005 2006 20072004 2005 2006 2007
Survival of MDR & XDR at COSH (Jan 05-Jun 06)
Italian Co-operation, Issue 16 Epidemiology Bulletin, Sept 2007
MDR TB – Case Finding as per EDR Qrt1-Qrt 3 2010New Relapse Default TF1 TF2 Trans In Other Total
KGV 383 253 57 293 202 4 60 1252
Thulasizwe 84 39 1 6 10 0 1 141
M3 Greytown 27 8 3 33 14 1 0 86
Murchison 19 5 4 9 9 0 1 47
Total 513 305 65 341 235 5 62 1526
M(X)DR TB Progress / Update2006
Implemented Rapid Point Prevalence surveillanceOutpatient – 10 sites
Round 1 – 5 sitesRound 1 5 sitesRound 2 - 5 sites
Inpatient – 18 sites
Decentralized MDR TB Management1 center of excellence (KGV)5 decentralized sites operational3 satellite sites operationalRealised a MDR TB bed increase from 240 – 793
Mosvold• Out Patient Surveillance• Site selection:
Newcastle
Nkandla
- Five Hospitals in KZN- Prior identification of XDR isolates- Geographical
Durban
• Population- TB suspects presenting to Durban
Port Shepstone
p p goutpatient facilities
In Patient Surveillance
Site Selection• Hospitals > 200 beds (38 in KZN)
• Selected– Nine adjacent to COSH– Nine randomly from other
districts• Excluded
– TB hospitals– Specialist and referral hospitals
M(X)DR TB Progress / UpdateRapid point prevalence surveillanceRapid point prevalence surveillance
• Round 1 – OutpatientMDR – 6,4%XDR – 0,7%
• Round 2 – Outpatient• Round 2 – OutpatientMDR – 5,8%XDR - 0,6%
• Round 1 – InpatientMDR – 13,9%XDR – 2 0%XDR 2,0%
M(X)DR TB Progress / Update
20072007Implemented Community based management
Piloted in Umzinyathi DistrictCurrently 16 teams operating in 2 districtsExpanding to all districts this financial year – 70 additional teams in process of being put into placep g p p
2008Implemented SA standardised paper based reporting & recording system
2009Implemented electronic web based R&R data baseImplemented electronic web based R&R data base (EDR)
M(X)DR TB Progress / Update
iInterventionsActive case findingImproved ICpDecentralized MDR TB management Community based managementImproved HIV Services (ART)Improved HIV Services (ART)
2008 outcomesCure Rate – Central 47,0% / Decentralized 56,9%Interruption Rate - Central 10,3% / Decentralized 4,6%Death Rate – Central 11,4% / Decentralized 7,6%
Decentralised and Community basedDecentralised and Community based Management of MDR TB
Why Decentralisation • Problems with centralised MDR TB Center• Problems with centralised MDR TB Center
– Operated in a silo– Poor communication / referral withPoor communication / referral with
outlying districts– No space to increase beds for needs
b• As case numbers grew, – more resistance from patients – to far from
homehome – refusal of treatment / abscondment – patient unfriendly = poor case retention
•• Shoe no longer fitsShoe no longer fits
WHY COMMUNITY BASED MANAGEMENT OF MDR TB
2 Considerations / Issues
• Policy = Hospitalisation (6 mths) vs CapacityP li H it li ti (6 th ) P ti t• Policy = Hospitalisation (6 mths) vs Patient Issues, ie practicality of policy
Policy vs Capacity2005 2006 2007 2008
MDR 555 690 11281128 1134 (160)(160)
XDR 35 83 168168 109
Total 590 773 12961296 1243(1403)
B d N d 295 387 648648 622Bed Need 295 387 648648 622 (702)
Beds Avl 240 350 405405 581Beds Avl 240 350 405405 581
Short Fall 55 37 243243 41(121)
Patient Considerations / IssuesSocioeconomic conditions / circumstances of patientsSocioeconomic conditions / circumstances of patients
• COSH, Msinga – Patient profile
• 3219 contacts traced and interviewed
• 89% of households only source of income is a grant • 75% of households are woman headed households• 75% of households are woman headed households• 45 % are children < age 12yrs
Considerations for Community Based Managementg
3 Considerations3 Considerations
• Patient Saftey
• Transmission
• Cost
How does the proposed system work
• Center of excellence Durban patients / referral• Center of excellence – Durban patients / referral complicated / surgery / XDR
• Decentralised MDR TB Management unitsg• Target – one or more per district, depending on
patient load, and geography i di d f ili• Patient diagnosed at facility
• Decentralised MDR unit = registered, counselled, treatment started (Hospitalised 2 weeks – 2 months)treatment started (Hospitalised 2 weeks 2 months)
• Moved to community based management• Monthly follow-up at Decentralised MDR TB unit y p
COEKGV
C li t d MDR TB / XDR TB / D b P ti tComplicated MDR TB / XDR TB / Durban Patients
Decentralized MDR TB SitesDecentralized MDR TB SitesRx Initiation Uncomplicated MDR TB
Satellite MDR TB SitesSatellite MDR TB SitesDown referral from decentralized sites
Daily Management
Community Based ManagementClinic or Mobile Injection Team
ProtocolCONFIRMED MDR CLIENTS
TRACING OF CLIENT
DECENTRALISED MDR TB UNIT
ADMISSION TO HOSPITAL
(PROPOSED 2 wks - 2 MTHS)
Would reduce the bed needs by 2/3 rds
REGISTRATION / EDUCATION / TREATMENT START / SIDE
EFFECT MONITORING
DISCHARGE ACCORDING TO CRITERIA TO COMMUNITY BASED MANAGEMENT
PROGRAMME
MONTHLY FOLLOW-UP AT DECENTRALISED MDR TB UNIT
OUPATIENT CLINIC
KZN MDR TB Services Progress Facility 2000
to20052006 2007 2008 2009 2010
KGV -COE 240 160 160 192 192 224
Fosa - Sat 160 160 190 190 185
M3 Greytown – Sat /Dec 24 24 32 37 37+ 10 Comm inject Teams
Thulasizwe – Sat / Dec 40 110 106 90
Manguzi – Sat / Dec 16 16 40 40
CBH Sat / Dec 13 13 13 13 /40CBH – Sat / Dec 13 13 13 13 /40
Murchison - Dec 40 40 40
Madadeni – Sat / Dec 23 23 23 / 36
Hlabisa – Sat / Dec 34 34 34 / 34
Doris Goodwin - Sat / Dec
32 64 64 / 64
T t l 240 160 160 390 415 605Total (2006-2010=236% increase in beds)
240 160184344
160253413
390292682
415324739
605185790
Greytown Decentralised MDR Unit 2006
Thulasizwe Decentralised MDR TB Unit 2007
Murchison Decentralised MDR TB Unit 2008
Services Required to Support Decentralised / Satellite Units / Community Based Management
• Clinical – Doctor / Nurse• Laboratory – Bloods, AFB, Culture, DST etc.• PharmacyPharmacy• X-Ray• Audiology• Social Worker• Social Worker• Physio, Occupational Therapy (Rehab)• Psychiatric• IC• Stats – Surveillance Officer and Data capturer • VCT / HIV / ART/ /• Outreach Community Teams (Tracing / Injection teams) = 1
TB Community officer, and 1 Staff Nurse
CLINIC NURSESNurses More Nurses
Pharmacists
AudiologistData Capturer
Dietician
HIV COUNSELOR
Physio
Social Worker
Doctor, If you can find one
Extremely Dedicated Community outreach teams
The PictureOfDedication
Selection Criteria for Decentralized MDR TB Care
Decision taken by multi-disciplinary team(M di l D N /MDR TB C di S i l k / Di i i )(Medical Doctor, Nurse/MDR TB Coordinator, Social worker / Dietician)
DECENTRALISED CARE: REFER TO KGV
All non-complicated MDR TB XDRpcases:
- patient education- initiate MDR TB treatment
Pregnancy<13 yearsLiver diseaseUncontrolled diabetestreatment Renal failurePsychiatric disorder
Selection CriteriaSpecial Circumstances
Decision taken by multi-disciplinary team(Medical Doctor Nurse/MDR TB Coordinator Social worker / Dietician)(Medical Doctor, Nurse/MDR TB Coordinator, Social worker / Dietician)
DECENTRALISED ADMISSION
ADMISSION TO KGV
For non-complicated casesIf beds are not available at decentralised site:
For complicated cases:If beds are not available at KGV (or long waiting list):decentralised site:
Consider initiating MDR treatment in patient’s home in the community.
KGV (or long waiting list):Consider starting treating
XDR patients at decentralized sitesy
Consider discharging healthier hospitalized MDR patient to continue Rx at home.
Consider treating patients with manageable complications at decentralized site
Telephonic Consultation with KGV
Selection Criteria for Community CareDecision taken by multi-disciplinary team
(Medical Doctor, Nurse/MDR TB Coordinator, Social worker / Dietician)
• Ambulant• Low grade transmission - preferably smear negative• Low grade transmission - preferably smear negative• Stable accommodation - i.e. not roaming• Nutritional support - adequate food supply at home or food
supplements from dietician• Treatment support - household member or DOTS•• Patient / family education Patient / family education –– Rx Adherence, side effects & infection Rx Adherence, side effects & infection
controlcontrolFeasible plan for administering injections (if intensi e phase• Feasible plan for administering injections (if intensive phase treatment);– Refer to Mother Hospital (Coordination) – Injection team making household visits 5 days / week, orjec o ea a g ouse o d s s 5 days / ee , o– Patient returning to clinic 5 days / week
TB CLINIC AT MOTHER HOSPITAL• Mother Hospital TB Focal Point
– TB Doctor (Champion), PN, EN/NA
• Responsible for referral coordination • Attach patient to Injection Team and Treatment• Attach patient to Injection Team and Treatment
Supporter• Make sure patient has enough treatment • Monitor Adherence•• Monitor Side EffectsMonitor Side Effects• Transport to Monthly Clinic
INJECTION TEAMINJECTION TEAM
Staff Nurse with a Willing Heart• Staff Nurse with a Willing Heart• Vehicle
C lb• Coolbag• Injectables• Sharp Container
Reporting and RecordingReporting and Recording
Monitoring Side Effects
Recording Rx
Safe Disposal
MONTHLY MDR CLINIC VISIT• Blood TestsBlood Tests• Sputum for micro and culture• Pregnancy test and contraception
Audiology monthly during intensive phase• Audiology – monthly during intensive phase• Dietary consultation• CXR – if indicated• Check / reinforce treatment adherence• Pill counts• Assess side-effects and treat if necessaryssess s de e ects a d t eat ecessa y• Major Side Effect Unique to MDR TB treatment:
– Hearing Loss (estimated 20%)
DEFAULT TRACING
• Paramount to successful treatment!!!!• Defaulters identified on appointment• Defaulters identified on appointment
diary • Patients not arriving for clinicPatients not arriving for clinic
appointment- will be traced a.s.a.p.be t aced a s a p- treatment taken to them
• Outcome of tracing must be reported on.Outcome of tracing must be reported on.
MEASURES TO ENSURE COMPLIANCEMEASURES TO ENSURE COMPLIANCE
• Patient Literacy• Photographs of tabletsPhotographs of tablets• Phone patients the day before clinic
appointmentappointment• Daily treatment tick sheets
Design by Jacob Creswell
Safe Waste DisposalSafe Waste Disposal
Packed, Readdy to take back to hospital
Safe Disposal
Decentralised and Community Based Management of MDR TBManagement of MDR TB
• Is it safe ?• Will it make the epidemic worse ?• Especially in a high HIV setting• Will you accelerate transmission by managing
culture +ve and sometimes AFB +ve patients in theculture +ve, and sometimes AFB +ve patients in the community ?
• How do you do effective infection control ?y
•• Can you actually control, and turn an outbreak back Can you actually control, and turn an outbreak back managing patients in this manner managing patients in this manner
Msinga Sub District
COSH, Msinga, Umzinyathi DistrictBack Ground Back Ground • Outbreak discovered mid 2005• Large numbers & shortage of beds to initiate Rx =
P ti t b k d iti f t t tPatients backed up waiting for treatmentResponseResponse• Started satellite management of MDR TB 2006 (M3• Started satellite management of MDR TB 2006 (M3
Greytown)• Started community based management of MDR TB
2007 (Mobile Injection Teams)• Started Decentralized Management (Rx Initiation)
Feb 2008Feb 2008• Intensified Facility IC, and Community/Patient Educ
Infection ControlWhat is infection control in relation to an outbreak ?• What is infection control in relation to an outbreak ?
• Traditionally we normally tend to relate it to a facility• Traditionally we normally tend to relate it to a facility
• It’s actually many thingsy y g
• And we interpretated it in many ways in the Tugella F MDR/XDR TB b kFerry MDR/XDR TB outbreak
• It’s not just one thing but a combination of activities• It s not just one thing, but a combination of activities
COSH, Msinga, Umzinyathi DistrictInterventionsInterventionsInterventionsInterventions• Active Case Finding – Find the cases quickly and get
them out of circulation o Culture and DST on all TB suspects
• Get them onto Rx QuicklyO d S lli C I i i d R KGV do Opened Satellite Center – Initiated on Rx at KGV at day clinic, and brought back to M3, to avoid delays in starting Rx
o Discharged patients quickly to community based ( bil i j i ) f b d f imanagement (mobile injection teams), to free beds for in-
coming patients, don’t forget safe sharp/waste disposalo Decentralised Rx initiation to manage patients closer to
h ff ti t l d f llhome = more effective control and follow-upoo Rx includes ART for all HIV +Rx includes ART for all HIV +veve patients = intensify ARTpatients = intensify ART
Cosh, Msinga, Umzinyathi DistrictInterventions cont…Interventions cont…• Intensive Patient / Family Education (Hospitalized for at least 2 weeks)
o Disease, treatment adherence, side effects (inclusive of ART)oo Cough hygiene provide windows open windows/doorsCough hygiene provide windows open windows/doorsoo Cough hygiene, provide windows, open windows/doors, Cough hygiene, provide windows, open windows/doors,
separate rooms, sit outside , separate rooms, sit outside , o Intensified Community education, and mobilization (Tribal
authorities Councillors Taxi ranks door/door campaignsauthorities, Councillors ,Taxi ranks, door/door campaigns, road shows)
• Improved Infection Control at Facility Levelo Administrative
• Fully functional IC committee, Protocols, Facility related, Triaging of patients
• Patient education in waiting areas• Patient education, in waiting areas• Cough hygiene, monitored and enforced• Open window policy, monitored and enforced
Cosh, Tugela Ferry, Umzinyathi DistrictInterventions contInterventions contInterventions cont…Interventions cont…• Environmental
o Mechanical air extraction systems (Open Window has more air changes per hour than mechanical)
• Protective Equipmento N95 respirators for staffo N95 respirators for staffo Surgical masks for patients
So What are the results ?So What are the results ?So, What are the results ? So, What are the results ? Does it all work ?Does it all work ?Are we Controlling/Turning back the Epidemic/OutbreakAre we Controlling/Turning back the Epidemic/OutbreakAre we Controlling/Turning back the Epidemic/Outbreak Are we Controlling/Turning back the Epidemic/Outbreak
What’s the Impact on Community Transmission ?What’s the Impact on Community Transmission ?Total Index Cases Jan 2008 – Sept 2010
189 MDR TB Cases106 XDR TB Cases1262 household Contacts
Diagnostic Visit (1262 Contacts)Diagnostic Visit (1262 Contacts)7 TB cases = 0,5%4 MDR TB cases = 0,3%1 XDR TB Case = 0,07%s 0,0 %
Follow-up visit at 6 mths (573 Contacts)Nil TB Cases = 0%Nil MDR TB Cases = 0%1 XDR TB Cases = 0,1%
Follow-up visit at 12/18 mths (179 contacts)Nil TB / MDR TB / XDR TB
What’s the Overall Impact on the What’s the Overall Impact on the Epidemic = Bottom LineEpidemic = Bottom Linepp
Combined MDR and XDR cases diagnosed
708090
100
MDR
2030405060 MDR
XDRTotal
01020
Bottom LineBottom LineCan you Implement Decentralized and Can you Implement Decentralized and
Community Based Management Of MDR TB, Community Based Management Of MDR TB, ith d t I f ti C t l t C t l/ith d t I f ti C t l t C t l/with adequate Infection Control, to Control/ with adequate Infection Control, to Control/
Turn Back an MDR TB Epidemic/Outbreak in Turn Back an MDR TB Epidemic/Outbreak in a High HIV Setting ?a High HIV Setting ?a High HIV Setting ?a High HIV Setting ?
I W ld S YI W ld S YI Would Say YesI Would Say Yes√√√√
What Next ?What Next ?
• MRC / John Hopkins p– Nurse Case Management of MDR TB -Training in
progress– Nurse Initiated MDR TB – in consultation with nursingNurse Initiated MDR TB in consultation with nursing
council
• Unpack Monthly follow-up to Outlying hospitals / ClinicsClinics– Continuation phase patients - Stable patients, with no
side effects, converted, and responding to treatment– Required – Staff trained, and R&R in place = move files,
instead of patients
Thank’sThank’sForFor
ListeningListening