e-TB Manager: gA Comprehensive Web-Based Tool

for Programmatic Management of TB and Drug Resistant TBof TB and Drug-Resistant TB

Management Sciences for HealthManagement Sciences for Health

Facts about TB*TB is contagious and airborne; each untreated person with active TB can infect ~ 10 to 15 people a yearOne third of world population infected with TB (most vulnerable – people with HIV)1 8 million died in 2007 (TB is leading killer of people1.8 million died in 2007 (TB is leading killer of people with HIV ~500,000 in 2007) 9.27 million new TB cases registered in 2007gTB is a worldwide pandemic: among the 15 countries with the highest estimated TB incidence rates, 13 are in Af i hil h lf f ll i i A iAfrica, while half of all new cases are in six Asian countries (Bangladesh, China, India, Indonesia, Pakistan and the Philippines)

* from: http://www.who.int/features/factfiles/tuberculosis/en/index.html

Facts about TB contFacts about TB, cont. Multidrug-resistant TB (MDR-TB) is a form of TB that does not respond to the standard treatments using firstdoes not respond to the standard treatments using first-line drugs – 511,000 new MDR-TB cases in 2007 Extensively drug-resistant TB (XDR-TB) occurs when y g ( )resistance to second-line drugs developsWHO’s Stop TB Strategy aims to reach all patients and achieve the target under the Millennium Developmentachieve the target under the Millennium Development Goals (MDG): to reduce by 2015 the prevalence of and deaths due to TB by 50% relative to 1990 and reverse the trend in incidenceRequired investment to achieve the MDG target is estimated at US$ 67 billion (there’s a 40 billion gap)estimated at US$ 67 billion (there s a 40 billion gap)

* from: http://www.who.int/features/factfiles/tuberculosis/en/index.html

International ResponseInternational Response

Guidance: WHO, StopTB, UNIONGuidance: WHO, StopTB, UNIONTB control is well standardized (consensus on forms, guidelines, recommendations)

Funding mechanisms: The Global Fund, UNITAID, Bill Gates, governments (USAID, DfID, etc)Sources of TB medicines: GDF, GLCTechnical resources: UNION, KNCV, MSF, PIH, ICRC, MSH tMSH, etc.

Information management for TB:Information management for TB:

•Information tools are required by Global Initiatives (GLC/GDF, Stop TB…)WHO ERR working group revised formsWHO ERR working group revised formsCatalogue (existing software)

http://www.who.int/tb/err/catalogue/

But to date there was no tool integrating consistently all programmatic dimensions for management purposesprogrammatic dimensions for management purposes

NTP ChallengesgMost countries will not reach MDG by 2015

Lack of actual support from governmentspp gLow detection rate (poor diagnosis, advocacy, education)Poor compliance with treatment (by providers and patients)High default rateCo-infection with HIV I t ti i d l ( th GDF t i )Interruptions in drug supply (even the GDF countries)Spread of MDR/XDR TB (increased length of treatment and costs = X 1000)costs X 1000)Lack of proper supervision, recording and reporting

Many of the challenges can be addressed through strengthening MIS

e-TB Manager: Web based systemg yAligned with WHO recommendations for DOTS and DOTS Plus programs (standard data collection recording andPlus programs (standard data collection, recording and reporting)Easy online information sharing / consolidation between different levels and data extraction tool to other interfacesRapid response to case and drug management issues Database protected by a validation process from upper levelInternal security features and unique patient identificationDeveloped with open sources technical solutions, no additional licenses neededCan be used with a mixed system of online reporting and paper system at periphery levelsEasily customized, translated, adaptedy , , p

Online notification and follow-up, recording clinical and laboratory results, tracking patient transfers in and out,

providing data on patients regimen schemes, treatment adherence, patient contacts’ evaluation,

consultation agenda

Treatment and case management

First Line medicines management

Medicine needs’ forecasting,

ordering, distributing,

Data extraction

Information and surveillance management

dispensing, and recording of stock movements + DM

indicatorsat all levels

Second Line medicines

management

tool / Operational and clinical

research

at all levels

For easy data analysis and export to statistical interfaces

Mapping of TB and MDR/XDR cases, epidemiological indicators, surveillance reports,

previous treatment history, co-morbidities, up-dated information with ready access online

at central and periphery levelsat central and periphery levels

e-TB Manager

For the system to support the TB program appropriately, there must be clear guidelines and coreclear guidelines and core staff must be experienced in MDR-TB managementMDR TB management

DiagnosisTreatment protocols, patient managementmanagementConsistent flows for pharmaceutical management

www.etbmanager.org

Note: Simulation Data for Demo

Note: Simulation Data for DemoNote: Simulation Data for Demo

Note: Simulation Data for Demo

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lh25

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lh25 this doesn't show much--you could just use the next slide and talk about administrationlhall, 05/22/2008

Name displayed in the system

Address (where to send orders to)

Region and locality (also used in user view)

Checked if the unit is a treatment health unit (case management)

Checked if the unit stores medicine (medicine management module)

Enables the unit to use the medicine receiving module

Select who is going to deliver medicine orders to this unitg g

Used to calculate the quantity estimated when creating a new order

If checked, the user may change the quantity estimate when creating a new Check it if the unit y gorder

If the order has to be authorized before delivering, select the unit that authorizes it

If the unit registers medicine dispensing enter the

delivers medicine to other units (order delivery)

If the unit registers medicine dispensing, enter the dispensing registration frequency (daily, weekly or monthly)

Note: Simulation Data for Demo

Note: Simulation Data for Demo

Note: Simulation Data for Demo

Online tools for medicines forecasting, ordering, distribution, and dispensing

Tracks stocks positions at central and periphery level;p p y ;Calculates upcoming needs for medicines dispensing at p gtreatment centers / sitesControls estimated and real consumptionProvides reports and indicators

Distribution flow:S

Central Warehouse

Sources:GLC/GDF

MoHGF

Regional Regional RegionalRegionalWarehouse

RegionalWarehouse

RegionalWarehouse

DistrictDistrict DistrictDistrict District

TreatmentCenter

TreatmentCenter

TreatmentCenter

TreatmentCenter

TreatmentCenter

TreatmentCenter

TS TSTS TSTS TS TS TS TSTSTSTSTS

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Note: Simulation Data for Demo

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Epidemiological Reportsp g p

Incidence/incidence Co-morbiditiesrate

Prevalence/prevalence t

Previous treatments/treatment history

C t i ti i irateDemographic characteristics

Contamination originContacts identificationand evaluationcharacteristics

Resistance patternsClinical/X-rays patterns

and evaluationAdverse reactionsTreatment outcomes/Clinical/X rays patterns

HIV/AIDS(diagnosis/co-infection rate)

Treatment outcomes/cohort analysis(filters)

Operational Reportsp p

Suspects or cases search/identification L b t t l ( ti t h t) ithLaboratory exams at a glance (patient or cohort) withconversion rates

Treatment history/regimens at a glance (patient orTreatment history/regimens at a glance (patient or cohort)

Case management agenda (dates for examsCase management agenda (dates for exams, appointments, defaulters list, etc.)

Mapping case transfersMapping case transfersTreatment adherence/medicines dispensing reportsTreatment costs (Social Security systems)Treatment costs (Social Security systems)

Note: Simulation Data for Demo

Note: Simulation Data for Demo

Note: Simulation Data for Demo

Note: Simulation Data for Demo

Resistance ProfileJan. 1994 – Mar. 2009 (n= 3,798)

Brazil or States

City of Residence

Month/Year Begins

Month/Year Ends

Residence

Treatment Health Facility

Nº of treatments for DR-TBGenerate Report

Probably DR-TB Confirmed DR-TB

Resistance Profile

Probably DR TB Confirmed DR TB

Sensitive to R

Sensitive to H

Sensitive to RH

Sensitive to all drugs tested

Other combinations of resistance

Source: DR-TB Data Base – Hélio Fraga Reference Center / Fiocruz / MoH

Evaluation of Contacts (Pará State) Jan. 1994 – Mar. 2009 (n= 1,218 identified)( , )

City of Residence Identified Examined with TB

Source: DR-TB Data Base – Hélio Fraga Reference Center / Fiocruz / MoH

e-TB Manager: Where Are We Today ?

Currently adopted as national TB surveillance MIS for DR-TB in Brazil (including all re-treatment cases for better prevention of MDR-XDR(including all re treatment cases for better prevention of MDR XDR emergence)Integrated with the national DR-TB MIS in Romania and MoldovaActive field pilot testing in the Philippines, Dominican Republic and Uk i ( MOH )Ukraine (on MOH server)Being adapted for: Armenia, Georgia, Azerbaijan, UzbekistanRequests from countries: Namibia

Collaboration with WHO – a possibility for e-TBM to become a WHO-recommended MIS toolWHO request to implement in: Kenya, Ethiopia, Bangladesh, Vietnamq p y , p , g ,

Challenges and Lessons LearnedE-TBM cannot just be installed and used:

Need for extensive TA to streamline the existing MIS forNeed for extensive TA to streamline the existing MIS for TB (procedures, SOPs, data forms)Need for adaptation to country requirementsTraining of users, TOT

Lack of clear national treatment guidelines for TB and MDR TB, and SOPs for lab and drug managementWHO is constantly changing data formsLack of infrastructure: must develop PC-based

i i l d t bprovincial databases

Challenges and Lessons Learned contChallenges and Lessons Learned, cont.Need to sign a MOU:

NTP may lack authority, bureaucratic procedures Engaging stakeholders – national working groupsCompetition (most NTPs already have some electronic tools in place)V li it d f di f TBM i l t tiVery limited funding for e-TBM implementationPartnering with other projects in the field is crucial (b t t l h t f li l ti )(but not clear how to formalize relations)Endorsement from major players is important (WHO KNCV UNION GDF/GLC UNITAID etc )(WHO, KNCV, UNION, GDF/GLC, UNITAID, etc.)

Implementation steps in a new country: May take from 2-3 months to one yearfrom 2 3 months to one year

Recon-

• Present e-TBM main features• Understand country’s health system

structure, operation, standards for TB d/ DR TB d d

• On-site pilot on selected TB units to evaluate system ff ti fit ithnaissance

visitand/or DR-TB, and needs

• Define necessary system customization• Define working group, responsibility

matrix and MoU

On-site piloteffectiveness, fit with current flows and procedures and acceptance by end users

System customization

• Customize e-TBM functionalities and interfaces to address country needs

Final system adjustments

• Adjust system based on pilot outcome

Remote testing

• Remotely test initial e-TBM version to identify potential bugs and need for further adjustments

Implementation/ training

• Implement system on country’s proprietary server and train IT personnel

• Train potential trainers or end users (depends on number of

System adjustments

• Adjust system based on remote testing outcome

Maintenance

sites)

• Guarantee remote on-going support to country`s IT team and end usersadjustments

59

System cost to USAID/MSH, from customization to implementation and maintenance, ranges from US$50-70k ESTIMATIVE

Estimates based on a comprehensive cost model designed for e-TBM

System cost to USAID/MSH

PROJECT SCHEDULE AND CHARACTERISTICS COST (USD)

System cost $70.112

DurationPHASES weeks Programmer MSH Other1. Reconnaissance visit 1 2 2 1 $10.9282. System customization 4 6 2 0 $14.4003. Remote testing 1 0 $04. System adjustments 1 2 1 0 $5.2005. On-site pilot 1 1 1 1 $7.7286. Final system adjustments 1 2 1 0 $5.2007. Implementation/training 1 1 1 2 $12.256

Total to implement 10 14 8 0 $55.712

Time required (weeks FTE per phase) Number of intl. trips

Intl.* Weeks FTE* Intl.* Weeks FTE*

p

8. Maintenance/support 52 6 2 0 $14.400

MonthlyInfrastructure MONTHLY cost $6.194

IT infrastructure Number requiredServer 1 $283Computers 40 $1.111Internet access 40 $1.600

HelpdeskFTE required 1 $3.200

1. Reconnaissance visit2. System customization

1-

14

11

tripsProg. MSH

1-

26

22

tripsProg. MSH

3. Remote testing4. System adjustments5. On-site pilot6. Final system adjustments7 I l t ti /t i i

--1-1

-1111

-½ 1½1

--1-2

2121

11117. Implementation/training

8. Maintenance/support1-

14**

11**

2-

16**

12**

60* FTE: Full Time Equivalent; Intl.: International

** Within the total phase duration (52 weeks)

Ongoing operational and maintenance costs for host country depend on number of sites and infrastruture required ESTIMATIVE

Monthly maintenance/operational cost to host countryEstimates based on a comprehensive cost model designed for e-TBM

PROJECT SCHEDULE AND CHARACTERISTICS COST (USD)

System cost $70.112

DurationPHASES weeks Programmer MSH Other1. Reconnaissance visit 1 2 2 1 $10.9282. System customization 4 6 2 0 $14.4003. Remote testing 1 0 $04. System adjustments 1 2 1 0 $5.2005. On-site pilot 1 1 1 1 $7.7286. Final system adjustments 1 2 1 0 $5.200

$

Time required (weeks FTE per phase) Number of intl. trips

7. Implementation/training 1 1 1 2 $12.256Total to implement 10 14 8 0 $55.712

8. Maintenance/support 52 6 2 0 $14.400

MonthlyInfrastructure MONTHLY cost $6.194

IT infrastructure Number requiredServer 1 $283Computers 40 $1.111Internet access 40 $1.600

HelpdeskFTE required 1 $3.200

• Number of total sites*• Number of servers required• Number of IT** infrastructure

required (computer + internet)

201

20

601

20

1001

50required (computer internet) 50

61* Influences number of support staff required. Model assumes 1 helpdesk FTE can support up to 50 sites

** Information technology