5 tb symposium eastern europe and central asia ministry of ... · 1.4% 1.6% 1.8% minsk city brest...
TRANSCRIPT
Patients and TB: Improving treatment outcomes through a patient centred approach and
access to new treatments
5th TB Symposium – Eastern Europe and Central Asia Ministry of Labour, Health and Social Affairs of Georgia
and Médecins Sans Frontières
22- 23 March , 2016 , TBILISI , GEORGIA
Addressing adherence issue in high-burden MDR-TB countries: example from Belarus
Alena Skrahina The Republican Research and Practical Centre for pulmonology and TB, Minsk,
Belarus
TB
MDR-TB TB mortality
Belarus TB epidemiology
2015, 4.1
0
2
4
6
8
10
12
14
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
2015, 33
0
10
20
30
40
50
60
200420052006200720082009201020112012201320142015
2015, 66
2015, 33
0
20
40
60
80
100
2004 20052006 2007 20082009 20102011 20122013 20142015
previously treated
%
new
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
LTFU in regions, 2015, non-MDR
0.7%
0.2%
1.7%
1.0% 1.1% 1.1%
1.6%
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
1.8%
Minsk city Brest reg Vitebsk reg Gomel reg Grodno reg Minsk reg Mohilev reg
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
LTFU in 2010-2015, non-MDR
2.2% 1.9% 1.9% 2.0%
1.7%
1.0%
4.8% 4.2%
2.7%
1.3% 1.9% 1.1%
8.4%
5.3%
1.6%
4.4% 4.6%
1.5%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
2010 2011 2012 2013 2014 2015
New Relapses Other PT
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
Outcomes of MDR-TB treatment, 2011-2013
43%
45%
41%
15.5%
10%
10%
8%
3.8%
24%
22%
21%
21.7%
11%
11%
10%
8.6%
11%
11%
12%
9.0%
1%
8%
41.4%
2011
2012
2013
2014
Cured Completed Failure Death LTFU Not evaluated
2347
2528
1618
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
Pre-
Treatmentat
LTFU
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
MDR-TB patients demographic characteristics
Social group Proportion
Unemployed 25.2%
Homeless 1.1%
With previous imprisonment history
2.1%
Alcohol addicts 15.3%
HIV-infected 5.8%
Patients living in rural area 37.1%
Skrahina A. et. all, Bull World Health Organ, 2013
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments
Tuberculosis Symposium – Eastern Europe and Central Asia Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
ID department
TB treatment + cART
Discharged
Outpatient follow-up cART + TB tretament
OST
Methadone cART TB treatment
+ social support
Management of TB/HIV patient in Western Europe
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
ID Hospital
TB Hospital
Discharged
MTB+
Consultation of HIV specialist
TB outpatient unit AIDS Centre
OST???
Social support???
Management of TB/HIV patient in Eastern Europe
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
Improving adherence of TB patients
• Identify potential risk factors and targeted intervention
• Extensive adherence counselling
• Provision of Enablers: Food package and transport ticket
• Aggressive and immediate management of drug AE
• Screening for co-morbidities (HIV) and other related conditions (IDU, alcohol abuse) and ensure adequately treated
• Screening for mental health problems and ensure adequately treated
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
MDR-TB Consilium (Expert Board) 1 National, 6 Regional and 1 Prison MDR-TB Consiliums
• M/XDR-TB, HIV/TB, Child TB, Difficult-to-treat TB
All registered MDR-TB cases
Adherence issues
Management of co-morbidities
Management of AE
Alcohol abuse, IDU
Mental health problems
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments
Tuberculosis Symposium – Eastern Europe and Central Asia Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
Health care financial problems
• Financing - the number of beds
• Lack of mechanisms for
paying supplementary benefits to primary HCP
social support to outpatients
• Unnecessary long term hospitalization:
61 days S-TB
153 days MDR-TB
Weak out-patient care
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
In-patient vs. out-patient
In-patient care: Out-patient care:
• Isolation of sm+/cult+ • Daily observation and more
intensive management • No patient’s costs (transport,
food, etc.)
• Need for IC • Expensive for HC system • Isolation from family • Inability to work • Cross contamination
• Not expensive for HC system • No cross contamination • Ability to work • Living with families
• Need for sm- sputum • Costly for patient (food, transport) • Poor adherence and LTFU
– alcoholics, IDU, former prisoners – Drug side effects
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
Mogilev project
Actions
• TB beds
• MoH approved new contracts for PHC staff, i.e. payment for every visit
Results
• early discharge
• treatment outcomes – Incl. ↓LTFU
• developing new financial mechanisms for ambulatory strengthening
• saving money and resources
Funds reallocation from TB hospitals to PHC settings
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
NTP measures to increase adherence
• aDSM
– CEM: HIV-M/XDR TB (2012), LZD (2014), BDQ (2015)
• HIV testing in all TB patients
• cART+Co-trimaxasol in all HIV/TB
• MST for IDU HIV/TB patients
• Psychiatrist (narcologist), psychologist – in each TB hospital
• Mandatory transportation freed prisoners with TB
• Provision of Enablers (food packages) at out-patient phase for each TB patients from state budget (2015)
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
VOT procedure
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
IV central port for patients on new drugs
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières
Future steps
• Change financial mechanism • Stronger motivation of staff and patients
• Close collaboration with Ministry of Labor and Social Protection • Social support from government (transport) • Work permission for TB patients
• MST in TB DOT facilities • Management of alcohol abuse to incorporate in TB treatment • Psychological support at out-patient settings • Scaling up eDOT (VOT)
Patients and TB: Improving treatment outcomes through a patient centred approach and access to new treatments Tuberculosis Symposium – Eastern Europe and Central Asia
Ministry of Labour, Health and Social Affairs of Georgia and Médecins Sans Frontières