Multi-Drug Resistant Tuberculosis HOW FAR HAVE WE COME IN DECENTRALISING MDR-TB NATIONALLY Dr. Norbert Ndjeka Director, Drug-Resistant TB, TB and HIV

Outline 1. Introduction: historical background 2. Policy implementation

3. Structure, levels and functions of

decentralized facilities 4. Conclusion

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INTRODUCTION

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South Africa 

Globally, every year, an estimated 650,000 MDR-TB patients are diagnosed 

Only 46,000 (7%) globally are initiated on treatment •

WHO Report 2011, Global TB Control WHO/htm/tb/2011.16



South Africa is among the high burden TB and MDR-TB countries worldwide  In 2010 we diagnosed: 7 386 MDR-TB patients (5313 started on treatment) and 741 XDR-TB diagnosed with 615 started on treatment  Success rate of MDR-TB is low 42% (2007 cohort), 48 % (2008 cohort)



Number of beds available: ~2500 beds

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TB in South Africa  South Africa has the 3rd highest incidence of

TB cases in the world (WHO, 2011)  5th highest number of drug-resistant TB cases

in the world (WHO, 2011)  TB leading cause of mortality in South Africa (Statistics South Africa, 2011)

 60% – 80% of all TB cases co-infected with

HIV. (WHO, 2009; Gandhi et al., 2006) 4/20/2013

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An Overwhelming Burden



South Africa is struggling with an escalating MDR-TB burden, recently aggravated by the emergence of XDR-TB

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Worsening Drug Resistance



… and this is contributing to the development of XDR-TB

Source: Mlambo C, Warren R, Poswa X, Victor T, Duse A, Marais E. Genotypic diversity of extensively drug-resistant tuberculosis (XDR-TB) in South Africa. Int J Tuberc Lung Dis. 2008;12(1):99-104.

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

Given this overwhelming burden, MDR-TB patients are not treated in accordance with the present South African Department of Health guidelines

Source: WHO review of the South African TB Programme 6th -17th July 2009 and DR-TB directorate Clinical Audit June 2009

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Previous flow for MDR-TB management DR-TB Patients are diagnosed at health facilities Referred to MDR-TB hospitals for initiation of treatment and initial hospitalization Patients admitted and started with standard regimen (6 K-Ofl-Eth-Trd or Cs-Z/ 18 Ofl-Eth-Trd or Cs)

Patients kept for approx. 6 months or till 2 negative cultures Then referred back to the health facility to continue treatment

Follow-up done at MDR-TB hospitals on monthly basis 4/20/2013

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Challenges        

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Nearly half of diagnosed cases are not started on treatment 1-2 months of waiting for admission, sometimes more Long distance of transportation for admission and follow up Negative impact on social and economic status of the individual and family due to a long stay in hospital Risk of transmission in hospital due to inadequate implementation of infection control measures Non-uniformity in current, sporadic efforts of decentralized management Issues of refusal to admission and aggressive demand for early discharge Poor outcome of DR-TB cases

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Laboratory diagnosed MDR-TB

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MDR-TB Cases Started on Treatment 2000 1800 1600 1400 1200

2007 2008

1000

2009

800

2010

600 400 200 0 EC

FS

GP

KZN

LP NdjekaMP Dr Norbert

NC

NW

WC

13

Patient Load and Bed Availability (as of April 2011)

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Solutions

Advantages

Increase no. of hospitals/ beds

• Convenient to the health system • Cost to the government/ patients • Socio-economic problems • Risk of transmission if inadequate IC • Sustainability

Decentralized management of DRTB cases including community DOT

• Early initiation of treatment  Reduce morbidity/ mortality  Reduce transmission • Convenient for the patients •Cost effective • Improve adherence • More sustainable

• Establishment of new infrastructure • Increase training need • Other sector s/ Community involvement • Increase demand for supervision

Nurse Initiated PHCBased MDR-TB Treatment

• Increases access to care • Care centered in PHC Clinics • Care more convenient for patients

• Need for additional training programs • Need for outcomes and patient safety data

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Challenges

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What is decentralized care?  MDR-TB patients are diagnosed and treated

closer to their homes

 The World Health Organization defines

Community-based care for MDR-TB as any action or help provided by, with or from the community, including situations in which patients are receiving ambulatory or outpatient treatment

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Steps to decentralization of MDR-TB services July ‘09

• First workshop on community-based MDR-TB at Kopanong Hotel, Johannesburg, facilitators Drs. Jaramillo & Nkhoma. Funded by URC, Supported by WHO

Oct ‘09

• Workshop on best practices and community MDR-TB. Facilitators: Drs. Bayona & Alcantra from Peru

May ‘10 Jun ‘10

• Discussion and adoption of the decentralised MDR-TB approach by TB Managers during quarterly meeting at Grand Hotel, Boksburg • Circulated draft policy framework on decentralized management of MDR-TB

Nov ‘10

• National MDR-TB workshop to plan implementation, facilitated by Drs. Ernesto Jaramillo & Wilfred Nkhoma from WHO

May ’11

• Final draft of the policy framework presented to Technical Committee of the National Health Council at Civitas, Pretoria (NDOH)

26 Aug ’11 Oct ‘11

• Approval of the policy framework to decentralize and deinstitutionalise the management of MDR-TB services granted • Printing

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Challenges encountered  “Community based MDR-TB” service was not

tolerated  There was a great deal of “resistance” to accept such a concept  My personal feeling was that of a “salesman” who is selling a product that is not liked by “customers”  The debate around “community based MDR-TB” was often an “emotional” … making it difficult to have a “two-way” communication 4/20/2013

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What was encouraging? Pilot community based MDR-TB in KZN  The work of MSF in the Western Cape  Global Plan of Stop TB partnership- by 2015  To integrate the management of MDR-TB as routine components of TB control  To achieve universal access to high-quality diagnosis and treatment for people with TB including DR-TB 

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What was encouraging? (2) 



WHA and Beijing Ministerial meeting resolutions  Moving urgently towards universal access to diagnosis and treatment of M/XDR-TB by 2015  Ensuring a comprehensive framework for management and care of M/XDR-TB including community-based care  Ensuring the removal of financial barriers to allow all TB patients equitable access to TB care Literature supporting outpatients’ based MDR-TB services

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Strategies to overcome challenges  We switched from “community based MDR-TB” to “decentralized management of MDR-TB” because community based suggested to several people that we intend closing hospitals in order to treat everybody out of hospitals  We packaged the “product” differently through several versions of the drafts policy framework considering inputs by reviewers  We used TB quarterly meetings to discuss the matter and events such as the TB HIV Conference  We asked questions to the “International Experts” such as Ed. Nardell and many others  Every opportunity afforded to us was used to talk about “decentralized management of MDR-TB”

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Drafts and final versions

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POLICY IMPLEMENTATION

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DECENTRALIZATION OF MDR-TB SERVICES

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Purpose of the Policy Framework

Provides guidance for management of MDR-TB patients closer to their homes, both in health facilities and in community  Enables provinces to start MDR-TB treatment as soon as diagnosis is made, hence decreasing risk of transmission 

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Provinces requested to  Call meetings of all stakeholders to introduce the

policy framework  Identify health facilities for scale up of MDR-TB services (plan, decentralized units, satellite units, PHC and injection teams)  Conduct facility readiness assessment of all proposed/identified facilities  Train all potential Care providers  Monitor & Evaluate decentralization of MDR-TB activities 4/20/2013

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NDOH targets  2010-2011: 1 Decentralized site per province  2011-2012: 1 Decentralized site per district &

cascade through satellites and additional Decentralised Units where target already met  2012-2013: (proposition)  NSP implementation: • Focus on at least 2 high burden MDR districts to scale up and saturate with services and teams – Rapid diagnosis – Universal treatment – Sufficient vehicles and equipment

Challenges to implementation  Funds required to scale up MDR-TB treatment  Non-uniformity in the speed and types of

services for decentralization among provinces  Various approaches in the field “dedicated MDRTB teams” vs. “Integrated PHC re-engineered teams”  HR: shortage of Medical Practitioners in DR-TB facilities yet nursing personnel are not yet trained to initiate and follow up MDR-TB patients 4/20/2013

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Indicative costing for mobile injection teams ... Case of KZN Initial set up TYPE OF STAFF

URBAN

RURAL

Staff Nurse TB Officer Vehicle Running Costs TOTAL

132,264 111,808 110,000 24,000 378,072

132,264 111,808 170,000 36,000 450,072

268,072

280,072

Maintenance phase Source: Bruce Margot, 2011

Benefits of Decentralization  Ease the burden on the health system  Reduce transmission of DR-TB by initiating

treatment sooner  Make more beds available  Improve patient adherence to medication  Improve cost effectiveness (i.e., reduce lengthy hospital stays in specialized hospitals  Accommodate patient roles and responsibilities by treating them closer to home 4/20/2013

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MDR-TB case finding and number put on treatment 10 000 9 000 8 000

7 000 6 000

Lab Diagnosed

5 000

Started Treatment 4 000 3 000 2 000 1 000 0 2004

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2005

2006

2007

2008

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2009

2010

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STRUCTURES, LEVELS AND FUNCTIONS 4/20/2013

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Levels for the Decentralised Management of DR-TB

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Responsibilities at every level

Functions

Initiation of treatment of all DR-TB cases Admission of all MDR-TB cases till two successive smear negative Admission of all XDR-TB cases till two successive culture negative Monthly follow up of all DRTB cases attending at clinic DOT to all DR-TB patients attending daily Recording and reporting (R & R) to the provincial department of health Monitoring and supervising DR-TB clinical management in the province 4/20/2013

Provincial/Central- Decentralised Satellite Community Mobile team ised MDR-TB unit MDR-TB unit MDR-TB unit Supporters

√

√

NO

NO

NO

√

√

No, unless no bed at Prov. or dec. unit

NO

NO

√

NO

NO

NO

NO

√

√

√

√

NO

√

√

√

√

√

√

√

NO

NO

NO

√

NO

NO

NO

NO

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Minimum hospital staffing requirements

Staff

Doctor

Provincial/ Decentralised MDR- Satellite MDR-TB Centralised MDR-TB TB unit unit unit 1/40 beds

Professional nurse/ Staff nurse or 4/11 per 40 beds Nursing Assistant

Mobile team

1/40 beds if P/T optional occupancy is > 75%

0

4/ 11 per 40 beds

1 for 20 beds

1 for 20 patients

Pharmacist

1 per 100 - 200 beds

P/T 1 for 10- 20 patients

0

0

Social worker

1 for > 40 beds

P/T for 10- 20 patients

P/T optional

0

Dietician

1 for > 40 beds

P/T for 10- 20 patients

0

0

Clinical Psychologist 1 for > 40 beds

P/T for 10- 20 patients

0

0

Occupational Therapist

P/T for 10- 20 patients

0

0

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1 for > 40 beds

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Minimum hospital staffing level

Staff

Provincial/ Centralised MDRTB unit

Decentralised MDR-TB unit

Satellite MDR-TB unit

Mobile team

Audiologist

1 for > 100 beds

P/T 1 for 20- 40 patients

0

0

Physiotherapist

1 for > 40 beds

P/T 1 for 10- 20 patients

0

0

1 for 100- 200 beds

P/T 1 for 10- 20 patients

P/T optional

0

1 for > 40 beds

0

0

1 for 20 patients

0

0

1 for 10 patients

1 for 10 patients

Data Capturer/ Admin Clerk Driver Community Health Care Worker 4/20/2013

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Infection control at home & in the community  Ventilation/open windows  Isolation of patient (ideally own bed room)  Cough hygiene  Refrain from close contact with children  Maximise time in open-air environment

(e.g., receive visitors outside)  Minimise contact with known HIV positive patients 

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CONCLUSION & RECOMMENDATIONS 4/20/2013

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Flow of DR-TB Patients 4/20/2013

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MDR-TB Units in South Africa

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MDR-TB Units before 2009

Limpopo

Decentralised MDR-TB Units after 2009

North West

Gauteng Mpumalanga

Free State

Kwa-Zulu Natal

Northern Cape

Eastern Cape Western Cape

• 24 M(X)DR Units • ~2,500 Beds

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 The policy framework is in place  Implementation has begun officially,

although varying from very slow to fast among provinces  The number of MDR-TB patients initiated in ambulatory is increasing  Provinces have bought into the idea hence they have all developed implementation plans 4/20/2013

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Thank you

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