DOTS/ DOTSDOTS/ DOTS PLUS PLUS IMPLEMENTATION IMPLEMENTATION

AAND ND INTEGRATIONINTEGRATION

Vaira LeimaneVaira LeimaneState Centre of Tuberculosis and State Centre of Tuberculosis and

Lung Diseases of LatviaLung Diseases of LatviaParis, October, 28Paris, October, 28

LLATVIAATVIA

PRESENTATION OUTLINEPRESENTATION OUTLINE

EPIDEMIOLOGICAL SITUATIONEPIDEMIOLOGICAL SITUATION IMPLEMENTATION TB/MDR TB IMPLEMENTATION TB/MDR TB

CONTROL PROGRAMSCONTROL PROGRAMS PROGRESS IN TB CONTROL PROGRESS IN TB CONTROL

PROGRAMPROGRAM RESULTSRESULTS

INCIDENCE OF TB IN INCIDENCE OF TB IN LATVIA LATVIA 1971-2001971-20033

74,5

33,3

44,1

50,4

63,3

72,970,5

68,365,1

57,4

53,9

51,5

47,4

41,9

39,6

37,6

38,4

35,8

33,3

32,3

32

30,9

30,8

29,3

28,6

26,9 27,4

28,7

29

74

68,4

59

65,4

0

10

20

30

40

50

60

70

80

WHO IUTLD GWHO IUTLD GLOBAL SURVEY LOBAL SURVEY ON DRUG RESISTANCE INON DRUG RESISTANCE IN

LATVIA 1996LATVIA 1996

14,4

54

0

10

20

30

40

50

60

02468

101214

IINCIDENCE OFNCIDENCE OF MDR TB, MDR TB, GGLOBALLOBAL TB D TB DRUGRUG

RRESISTANCEESISTANCE S SURVEYURVEY, 1994-, 1994-19961996

% N

ew S

mea

r +

Cas

es

NTP PNTP PROGRAM RESPONSE – ROGRAM RESPONSE – DOTS AND DOTS PLUS DOTS AND DOTS PLUS

IMPLEMENTATIONIMPLEMENTATION Accepted first NTP, based on Accepted first NTP, based on

WHO-recommended DOTS WHO-recommended DOTS strategy ALL FIVE ELEMENTS strategy ALL FIVE ELEMENTS in in 19951995

DOTS countywide including DOTS countywide including prisons in prisons in 1996 1996

FIRSTS STEP OF National TB FIRSTS STEP OF National TB Control program for treating Control program for treating MDR TB patients in MDR TB patients in 19971997

Established drug resistance Established drug resistance surveillance surveillance 19971997

SUSTAINED POLITICAL SUSTAINED POLITICAL COMMITMENTCOMMITMENT

Government Committed to establish NTP Government Committed to establish NTP plan using existing staff and resourcesplan using existing staff and resources,, within the Health Care reformwithin the Health Care reform Well functioning DOTS program with Well functioning DOTS program with

additional treatment of MDRadditional treatment of MDR TB (within TB (within recourses available)recourses available)

Collaboration and coordination between Collaboration and coordination between community, local governments, social community, local governments, social services and international agenciesservices and international agencies

Established centralized procurement of Established centralized procurement of drugs through open tenderdrugs through open tender

DOTS PLUS DOTS PLUS IMPLEMENTATION STEP I - IMPLEMENTATION STEP I -

19971997 SITUATION ANALYSISSITUATION ANALYSIS

Results of drug resistance surveillance Results of drug resistance surveillance QA of laboratory for DSTQA of laboratory for DST MDRMDR TB case finding strategy – TB case finding strategy –

DST for all who starts treatmentDST for all who starts treatment Reporting and registration of MDRReporting and registration of MDR TB TB Evaluated access to TB drugs and Evaluated access to TB drugs and

created new drug management systemcreated new drug management system

TB CASE DETECTION AND TB CASE DETECTION AND IDENTIFICATION OF MDR-TBIDENTIFICATION OF MDR-TB

District-LevelSmear Microscopy

Regional-LevelCulture Laboratories

Central Laboratory -DST for all who starts treatment

CentralCentralDSTDST

Supranational ReferenceLaboratory (Sweden)

95% lab accuracy (1998)

MDR TB MDR TB REPRTING AND REPRTING AND RECORDINGRECORDING

MDR TB caseMDR TB Register

Mycobacteriology LabMycobacteriology LabAll DST resultsAll DST results District TB doctor

ConsiliumEnrollment in MDR TB cohort

Enrollment formFollow-up form

DOTS PLUS DOTS PLUS IMPLEMENTATION STEP IIIMPLEMENTATION STEP II

MDRMDR TB TREATMENT AND MANAGEMENT TB TREATMENT AND MANAGEMENT STRATEGYSTRATEGY Established Expert consilium for case and Established Expert consilium for case and

program management program management 1997, June1997, June TB hospitals reorganized for MDRTB hospitals reorganized for MDR TB TB Start patient enrolment for treatment Start patient enrolment for treatment

Empiric/Individualized treatment strategy Empiric/Individualized treatment strategy according to DST resultsaccording to DST results Directly observed therapy (DOT)Directly observed therapy (DOT) Monitoring and management of side effectsMonitoring and management of side effects

CONSILIUM FOR MDRCONSILIUM FOR MDR TB TB TREATMENT AND TREATMENT AND

MANAGEMENTMANAGEMENT AdvantagesAdvantages Collective decisionCollective decision Possibility for Possibility for

patientpatients tos to receive receive most effective most effective treatment treatment

Possibility to Possibility to supervise supervise treatmenttreatment

Problem solvingProblem solving ImproveImprovement of ment of

program program managementmanagement

EEXPERT CONSILIUMXPERT CONSILIUM

TREATING TREATING

PHISICIANSPHISICIANS

HHOSPITALSOSPITALS

LLABORATORYABORATORY

AAMBULATORYMBULATORY

TREATMENTTREATMENT

MDRMDR TBTB

REGISTRYREGISTRY

SUPERVISIONSUPERVISION

BOARD OF EXPERTSBOARD OF EXPERTS

SOCIALSOCIAL

WORKERSWORKERS

NURSESNURSES

PPHARMACYHARMACY

SSTRUCTURE OF TRUCTURE OF DOTS-DOTS-PLUS PLUS PPROGRAMROGRAM

DOTS PLUS DOTS PLUS IMPLEMENTATION STEP IIIIMPLEMENTATION STEP III

ESTABLISHED CASE MANAGEMENT ESTABLISHED CASE MANAGEMENT SYSTEMSYSTEM Roles and responsibilities of HCWRoles and responsibilities of HCW Patient educationPatient education Default tracingDefault tracing

Improved infection control measuresImproved infection control measures Center of Excellence founded in Center of Excellence founded in 20002000

International training centre for treatment and International training centre for treatment and management for MDRmanagement for MDR TBTB

Built laboratory capacity –Built laboratory capacity – DST to all I and II line drugsDST to all I and II line drugs Rapid diagnostic methods for patient with risk of MDR-TBRapid diagnostic methods for patient with risk of MDR-TB

Established database, data management, Established database, data management, and information system 2002 -2003and information system 2002 -2003

IMPROVING ALL TB AND MDRIMPROVING ALL TB AND MDR TB PATIENT ADHERANCETB PATIENT ADHERANCE

Social Aid for TB PatientsSocial Aid for TB Patients Food couponsFood coupons

Transport ticketsTransport tickets Extra coupon weekly Extra coupon weekly

if adherence 100%if adherence 100%

Departments of WelfareDepartments of Welfare

Agreement with TB ambulatory Agreement with TB ambulatory departmentsdepartments

DOTS PLUS PROGRAM TREATMENT DOTS PLUS PROGRAM TREATMENT COHORTSCOHORTS

Begun in 1997 Begun in 1997

130

204 207 204 215188

153

13

18

293141

7

0

50

100

150

200

250

300

1 Cohort1997

2 Cohort1998

3 Cohort1999

4 Cohort2000

5 Cohort2001

6 Cohort2002

7 Cohort2003

Prison

Civil

DOTS PLUS DOTS PLUS IMPLEMENTATION STEP IVIMPLEMENTATION STEP IV

ACCESS TO II LINE DRUGSACCESS TO II LINE DRUGS Leaving funds after procurement of I line drugsLeaving funds after procurement of I line drugs Extra from reserved fundsExtra from reserved funds

DOTS-plus project accepted by WHO DOTS-plus project accepted by WHO Green Light Committee in January Green Light Committee in January 20012001 Approval for 350 patients for drugsApproval for 350 patients for drugs

Full coverage with treatmentFull coverage with treatment LiPA test - study to determine usefulness for LiPA test - study to determine usefulness for

early MDRearly MDR TB case detection TB case detection Established database, data management, Established database, data management,

and information system and information system 2002 -20032002 -2003

TREATMENT OUTCOMES FOR TREATMENT OUTCOMES FOR COHORT 2000COHORT 2000

N=204 patientsN=204 patientsCompleted treatment (6)Completed treatment (6)

Death (14)Death (14)

Default (26)Default (26)

Failure (29)Failure (29)

Cure (129)Cure (129)

TREATMENT OUTCOMES FOR TREATMENT OUTCOMES FOR NEW TB CASES AFTER DOTS NEW TB CASES AFTER DOTS

AND DOTS PLUS COMPLEATIONAND DOTS PLUS COMPLEATION

1998 1999 2000 2001 2002

998 919 957 1004 934

9 10,8 9 10,9 9,8

Cured % 74,4 77,3 75,6 76,6 78

Failure % 1,5 1 2,3 1 1

Default % 7,6 4,5 6,4 6,7 5,5

Died % 8,5 7,6 8,9 6,9 7,1Continue Tretment

on Dots Plus % 7 8 6,4 8,8 8

80 84 80,4 84 84,5Total Cured DOTS and

DOTS - Plus %

YearRegistered Culture +

cases

MDR-TB %

DO

TS

Ou

tco

me

s

NUMBER OF PATIENTS WITH PRIMARY NUMBER OF PATIENTS WITH PRIMARY ANDACQUIRED MDRANDACQUIRED MDR TB INCLUDING TB INCLUDING

PRISON 1994 - 2003PRISON 1994 - 2003

1928

47 53

91

144

82

175

257

117

218

332

90

200

290

90

156

255

86

148

234

97

132

229

83

126

209

8380

163

0

50

100

150

200

250

300

350

400

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Primary Acquired Total

Since 1998 total number of annually registered MDRSince 1998 total number of annually registered MDR TB cases decreased TB cases decreased by 51% for previously treated by 65%by 51% for previously treated by 65%

CONCLUSIONS AND CONCLUSIONS AND RECCOMENDATIONSRECCOMENDATIONS

DOTS strategy has reduced MDRDOTS strategy has reduced MDR TB TB development by 51% in Latvia development by 51% in Latvia

DOTS-Plus in addition to DOTS in settings with DOTS-Plus in addition to DOTS in settings with high MDRhigh MDR TB level can reach WHO goal for cure TB level can reach WHO goal for cure 85% 85%

2/3 of patients who started treatment in DOTS 2/3 of patients who started treatment in DOTS plus were curedplus were cured

Addressing treatment default could significantly Addressing treatment default could significantly improve program effectivenessimprove program effectiveness

Strengthening of the DOTS strategy, rapid MDRStrengthening of the DOTS strategy, rapid MDR TB diagnosis, contact investigation and TB diagnosis, contact investigation and genotyping to detect chain of transmission is the genotyping to detect chain of transmission is the next steps to improve MDRnext steps to improve MDR TB control in LatviaTB control in Latvia

NATIONAL CHOIRS FESTIVALNATIONAL CHOIRS FESTIVAL

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