Transcript 59 year old, female, Filipino CHIEF COMPLAINT: fever

DOTS-Plus to DOTS
Philippines
Thelma E. Tupasi
Tropical Disease Foundation
Rosalind G. Vianzon
NTP Manager, Philippines
Reasons for embarking on DOTS-Plus:
Outcome of DOTS
DOTS Clinic at the MMC, February 1999-January 2002
Outcome
Cure
New cases
(126)
83.3%
Previously treated
(65)
53.8%
Failure
0.8
38.5
Died
6.4
1.5
Lost
7.1
1.5
MDR-TB
2.4
41
Quelapio MID et al: MDR-TB a threat to TB Control,
Cohort Analysis, MMC DOTS-CLinic
Reasons for embarking on DOTS-Plus:
Health and socioeconomic consequences of no DOTSPlus
Patients are left untreated leading to
transmission
 Patients are managed inadequately/
inappropriately leading to amplified
resistance
 Patients deteriorate leading to
absenteeism and lack of productivity
 Patients die leading to lost income

Constraints and major
challenges to DOTS-Plus
Scarce resources and competing
priorities: DOTS vs DOTS-Plus
 Private practitioners lack of adherence
to the DOTS strategy
 Absorptive capacity
 Establishing a laboratory network to
support DOTS-Plus
 Shifting from pilot project to policy
development

Scarce Resources: Access to treatment:
304 patients applying for treatment
for enrollment SAT
0%
7%
no specimen
16%
pending culture
and dst
24%
reclassified
1%
Scarce Resources
enrolled
32%
deceased
7%
not
patient
bacteriologicall unwilling
y confirmed
1%
12%
Scare Resources: Support for
DOTS-Plus in first 165 patients
BSL, 4%
United
Laboratories
11%
TDF, 14%
n=165 patients
NTP, 46%
PCSO, 25%
Scarce Resources: Global Fund for DOTS+
To utilize the GLC-approved DOTS-Plus pilot project
for policy development on MDR-TB in the NTP
GFATM Philippine program providing
USD 0.5 M/yearly for DOTS-Plus
 100-120 patients yearly for five years
 2nd line anti-TB drugs
 Enablers:
 Transport
cost reimbursement
 Drugs for adverse reactions
Role of the Private Medical Practitioners
in TB Treatment
Private MD
46%
70
60
50
40
Public health
clinics
30%
30
20
10
0
Private
Physicians
Public Health
centers
Referrals for
DOTS-Plus
Others
Traditional
healer
7%
Hospital
17%
Care providers consulted
1997 NTPS
Private Practitioners and
Fluoroquinolones in the Philippines
FQ Sen
Resis Pattern
FQ Res
HR
HRZ
HRS
HRE
HRES
HRZS
HRZE
HRZES
0
No. of isolates
10
20
30
40
50
Resistance to Fluoroquinolones and
Kanamycin
% FQ Resistant
% of isolates
%Kan Resistant
100
90
80
70
60
50
40
30
20
10
0
HRZES
HRZE
HRZS
HRES
HRE
HRS
HRZ
HR Res
Pattern
GLC technical assistance





political commitment to the DOTS+ pilot project
among NTP and its technical advisers
uninterrupted supply of quality assured 2nd line
anti-TB drugs
appropriate laboratory support for the diagnosis of
MDR-TB including culture and DST under
supranational laboratory supervision
treatment under DOT and management of adverse
drug events,
reporting and recording.
Role of the GLC: Cost of 2nd-line drugs before and
after GLC in US$
1st order
2nd order
3rd order
4th order
1.8
1.62 1.42
1.44
1.6
1.21
1.4
5th order
1.573
1.4
0.92
1.13
1.2
USD
0.96
1
0.8
0.6
0.35 0.27
0.17
0.2 0.34
0.4
0.13
0.2
0.13
0.1
0.13
0.2
0.13
0.11
0
Capreomycin
Kanamycin
Cycloserine
Second-line drug
PASER
Eth/Pro
Cost of MDRTB Treatment
with and without GLC
Without GLC
250,000
With GLC
233,000
Cost (PhP)
200,000
150,000
100,000
50,000
121,000
80,000
30,000
0
HR-resistant
HRZES-resistant
Individualized Tx. Outcome of Therapy
Outcome
All
n
Cure
117
61%
Failure
Died
Default
Patients Patients who
who remain complete
in therapy
therapy
101
83
70%
85.5%
19
11.9
14.5
15
14
17.8
DOTS-Plus in the Philippines
is highly cost-effective
Cost per DALY averted: US $ 242 vs GNI of
$1,040 in the Philippines
1. Cost <per capita GNI is highly costeffective
2. 3x per capita GNI is cost-effective as
recommended by the Commission on
Macroeconomics and Health.
3. COST is within the range of "attractive"
investments defined by the World Bank
Katherine Floyd and Raj Gupta
From Pilot project to Policy: Issues


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DOTS: Local ownership and sustainable
financial commitment to support basic DOTS
programme
DOTS-Plus pilot project: Enunciation of its
current and potential relevance to the National
TB Control Program
2nd line anti-TB drugs: Registration, availability
and controlled distribution to prevent abuse
and emergence of drug resistance
DOTS
New: Cat I
2-3 m AFS
Neg
Continue Cat I
Pos
Sputum culture
Previously Treated:
CAT II
Neg
Continue Cat II
4-5m AFS
Neg
Pos
Neg
DST: MDR-TB
Cure
Cure
DOTS Plus
MDR-TB in the Philippines





Socioeconomic and health reasons for embarking
on DOTS-Plus
Constraints and barriers
 Problem engendered by second-line anti-TB
drug use in the country
 Limited resources and absorptive capacity
Individualized treatment is effective, feasible,
and cost-effective
GLC mediated technical assistance: enabled pilot
project to follow 5 elements of DOTS-Plus
enforced
Integration of DOTS-Plus within DOTS in the
NTP: Clear Policy within the NTP
DOTS-PLUS EXPANSION and
MAINSTREAMING
PART II:
ISSUES and CHALLENGES
in INTEGRATING DOTS-PLUS
into the PUBLIC HEALTH DOTS
ISSUES
- Setting-up the policy environment
 operational feasibility - reality setting
100% DOTS coverage in the public sector
 evidence is available from the pilot project
that DOTS is feasible & cost effective in the
country; support evidence from the DRS
 potential impact & equity in access
economic and social productivity, (MDG)
safe and healthy environment
ISSUES
- Readiness in integrating the system
strategic implementation
development of human resources
enhancing QA laboratory support under
supranational laboratory supervision
ensuring logistical support for second-line
drugs
institutionalized technology
CHALLENGES
Policy Environment:
High political agendum within the NTP
 NTP point person for DOTS (+)
 DOTS (+) Task Force vis-à-vis NTP-TWG
 Increase advocacy for strong political
commitment of all stakeholders
 Support from NTP partners - Advisory Body
(Local & International advisers)

CHALLENGES
Systems Integration:
Strategic Implementation:
- area analysis for an impact implementation
- DRS results
Human resource development:
- additional Staff and/or re-tasking of existing
roles and functions
- intensive training with immersion in the
DOTS(+) Project
-multidisciplinary approach at all levels of
health care
CHALLENGES
Systems Integration:
Laboratory Capacity and Proficiency:
- maximize developed laboratory under the
DRS
Strengths: QA center for microscopy
Established lab network in
place
Proficient laboratory Staff
Not integrated with other
laboratory works
CHALLENGES
Systems Integration:
Logistical Support:
- NTP budget for 2nd line drugs plus
GFATM support
-unified system for drug management
(1st &2nd line drugs)
- regulation and control in the distribution of
2nd line drugs
- technical / financial assistance from
other partners
CHALLENGES
Institutionalized Technology:
- multi-sectoral coordination of
stakeholders
NTP, LGUs, Private Providers, Experts /
Academe, Professional
societies/International Agencies/ community
- community-based approach
DOTS(+)
within NTP
Institutionalized
Technology
Logistical
Support
Laboratory Capacity
& Proficiency
Human Resource
Development
Strategic
Area
Stepwise
Approach
to
Mainstream
DOTS (+)
into
the NTP