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TB CONTROL PROGRAMME · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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Page 1: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

TB CONTROL PROGRAMMEKZNKZN

KZN Programme Overviewg

Page 2: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact
Page 3: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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)

Page 4: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 5: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 6: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 7: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 8: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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)

Page 9: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 10: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 11: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 12: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 13: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

What’s the Impact ?What s the Impact ?Is It Making a Difference ?g

Page 14: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 15: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 16: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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%

Page 17: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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%

Page 18: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact
Page 19: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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%

Page 20: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact
Page 21: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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%

Page 22: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact
Page 23: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact
Page 24: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact
Page 25: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact
Page 26: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 27: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 28: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 29: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

Last Drug Resistance Survey in KZN 2001 to 2002 (MRC)( )

Weyer et al SAMJ 2007

Page 30: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 31: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

Survival of MDR & XDR at COSH (Jan 05-Jun 06)

Italian Co-operation, Issue 16 Epidemiology Bulletin, Sept 2007

Page 32: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 33: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 34: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 35: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 36: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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%

Page 37: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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)

Page 38: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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%

Page 39: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

Decentralised and Community basedDecentralised and Community based Management of MDR TB

Page 40: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 41: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 42: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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)

Page 43: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 44: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

Considerations for Community Based Managementg

3 Considerations3 Considerations

• Patient Saftey

• Transmission

• Cost

Page 45: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 46: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 47: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 48: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 49: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

Greytown Decentralised MDR Unit 2006

Page 50: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

Thulasizwe Decentralised MDR TB Unit 2007

Page 51: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

Murchison Decentralised MDR TB Unit 2008

Page 52: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact
Page 53: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 54: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

CLINIC NURSESNurses More Nurses

Pharmacists

AudiologistData Capturer

Dietician

Page 55: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

HIV COUNSELOR

Physio

Social Worker

Doctor, If you can find one

Extremely Dedicated Community outreach teams

The PictureOfDedication

Page 56: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact
Page 57: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

Page 58: TB CONTROL PROGRAMME  · PDF fileKZN TB Control Programme - Background • 1996 – TBC Programme started ... TB Progress / Update Impact

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

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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

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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

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INJECTION TEAMINJECTION TEAM

Staff Nurse with a Willing Heart• Staff Nurse with a Willing Heart• Vehicle

C lb• Coolbag• Injectables• Sharp Container

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Reporting and RecordingReporting and Recording

Monitoring Side Effects

Recording Rx

Safe Disposal

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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%)

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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.

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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

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Design by Jacob Creswell

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Safe Waste DisposalSafe Waste Disposal

Packed, Readdy to take back to hospital

Safe Disposal

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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

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Msinga Sub District

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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

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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

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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

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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

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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

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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

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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

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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√√√√

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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

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Thank’sThank’sForFor

ListeningListening