Transcript Strengths Contact management programs Established links

Strengths
• Contact management programs
• Established links between PHCs and
district and provincial level hospitals.
• Example of electronic referral system
• Pediatric TB focal person
(pediatrician) starting 2013
Contact Investigation and Management
Pulmonary TB
Treatment
DOT Standard
Take child
household contact
PE, CXR, TSTข
TB disease
Non-TB
age <5year ค
Give isoniazid
6-9 months
age ≥ 5-18 year
TT ≥15 mm. give isoniazid 6-9
moจ
TT 10-14 mm. please consider
TT <10 mm. observed
HIV Any age
Give
isoniazid
9 months
Challenges
• Underreporting of child TB cases to
ODPC7
– ODPC7-10 cases, PHO- 5 cases, Sisaket
Hosp-25 cases (2012)
• Diagnosing TB disease in children
particularly <5 year olds
• Crushed pill suspensions
• TB/HIV and DR-TB in children
(including child contacts of DR-TB)
Recommendations
• District and Provincial level Hospitals:
Report all child cases along with
outcomes (0-4, 5-14 year age bands)
– coordination between TB clinic and
pediatricians
• Pediatricians: Consultation with Child TB
experts in the Pediatric Infectious disease
society of Thailand, for complex cases.
Recommendations
• PHO: Ensure awareness of District
Hosp, PCU staff and VHVs: all child
contacts <5 should get clinical
assessment regardless of symptoms
• MoPH/GPO: Acquisition of WHO
recommended pediatric dispersible
FDC tablets
• MoPH/NHSO: use Xpert for TB
diagnosis in children
9. Pharmacy
• Pharmacists order TB drugs from
GPO online (VMI)
• Well organized and clearly labeled
• Storage area with appropriate
temperature and humidity control
• Patient kits prepared by pharmacist
and double checked
• Appropriate documentation of ADR
– ADR leaflets
Pharmacy- Sriratna hospital
Patient TB medicine kits
Challenges
• Occasional drug stockouts and
delays in delivery from GPO
• FDC Rifafour e-275 (H-75/R-150/Z400/E-275) not always available and
often not prescribed by physicians
– Using only for >50kg (vs. >30kg)
– Delayed culture conversion ?
– Large pill size
Recommendations
• GPO: ensure timely drug delivery
• Physicians/pharmacists: FDCs
should be preferred and stocked
accordingly
– Guideline >25kg
• MoPH/BTB: Pediatric dispersible
FDCs
10. TB/HIV
• Core indicators (HIV testing, CPT,
ARV) significantly above national
average
• Coordination between programs
appears generally good
TB/HIV (II)
• ARV national guideline not clear (TB
as AIDS-defining illness, ARV eligible
at any CD4 level)
• Little use of IPT, little use of sensitive
diagnostics for case finding
Recommendations
• National:
– Clarify ARV guideline and improve
communications to clinicians
– Strengthen IPT guideline
– Work with NHSO to increase support for
sensitive diagnostics (liquid culture,
molecular) for case finding in PLHA
11. Infection Control
• Good examples of best practice
including
– one-stop TB clinics
– triage (effective) with fast tracking
– well ventilated OPDs
– Surveillance of TB in HCW
• Inpatient cohorting and ventilation
insufficient
Recommendations
• National
– Strengthen guideline for outpatient
management
• All facilities
– Avoid admission unless clinically
required
• SSK Provincial hospital
– Assess air changes per hour (ACH) in
OPD and consider whirlybird fan on roof
– Review placement /cohorting
procedures for TB (suspect) inpatients
12. Engaging all providers:
PPM
• 8 private hospitals in ODPC 7
– 7 of 8 implementing DOTS
– 1 private hospital in Sisaket Province:
30 beds; AFB under EQA system; refers
diagnosed TB cases to public sector for
treatment
• One private clinic diagnoses TB;
refers to public sector for treatment
Engaging all providers: PPM
• Private/non-MOPH sector
coordinates well with MOPH system
• Currently no significant problem of
private, non-standard TB care
– may increase in future
13. Program management, HR
• Strong political commitment and
leadership: all levels
• Effective TB care and referral system
• Budget is committed for TB control
activities
– Ex. of accessing local gov’t funds
– 3 districts with GF support
• Excellent coordination between health
facilities in SSK province
Program Management, HR (II)
• TB coordinators clearly designated
at all levels including DTC
• Most TB coordinators received
training within 2 years
• Highly competent PTC
• Strong, hard working TB teams
Challenges
• Staff turnover and civil service
staffing trends: สร้ างทายาท (build next
generation)
• Limited availability of improved
diagnostics (NHSO budget)
• Sustainability plan after ending GF
• Decentralization, different structures
demand strong coordination skills
Recommendations
• Maintain strong political commitment
• Work with NHSO for expanded use of
new diagnostics
– Sensitive diagnosis of MTB
– Follow up of MDR TB
• Share best practices with other
health units
• Training: consider mentoring, buddy
system exchanges
Thank You!!
ODPC 7
Srisaket Hospital
Dr.Sarayuth Uttamangkapong
Mrs.Supasai Sangawong
and team
Dr.Udom Petchphuvadee
Dr.Noppol Buasri
Dr.Taweevuth Temaeum
Dr.Nitikul Temaeum
Dr.Kanittha Saleewan
Mrs.Phusanisa Khuntee
Mrs.Onuma Thumasang
Miss Chutima boonkwang
And team
Srisaket Provincial
Health Office
Dr.Pravi Ampant
Dr.Wanchai Lausatainragit
Dr.Anupant Prajum
Mrs.Vanida Somphunga
Mr.Banjert Dechasilapachai
Mrs.Ketsuma Wongkrai
and team
Khukhan Hospital
Dr. Pravit Saleekajonjaru
Dr. Chayomon Dokpong
Dr. Aree Butsorn
And team
Srirattana Hospital
Dr.Surachai Kampakdee
And team
Huai Nuea Primary
Care Unit
Samrongtagen Primary
Care Unit
Mr.Klai Ardsalee
Mr.Ronarong Yokpol
And team
Dr. Peerawat Thamrongdulpark
and team
Pingpuay Primary
Care Unit
Mr. Samai Laprawat
and team
Sisaket Prison
Mr. Traipob Wongplang
And team