Transcript DR_Dr. Prasaix - National Tuberculosis Center

Program Management Of DR-TB (PMDT)
“Diagnose, Treat and Cure All
Missing TB Cases”
Dr Mohan K Prasai
Consultant Chest Physician
NTC
Global Burden Of MDR-TB: 2012
Global Estimation 310,000
Diagnosed cases 86,000
Types of Drug Resistance
• Mono-resistance : resistance to single first line
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drug
Poly-resistance: resistance to more than one drug
other than HR together
Multi- Drug resistance (MDR): resistance to atleast Rifampicin & Isoniazide or RIF Resistance
confirmed by GeneXpert.
Pre-XDR: MDR with resistance to one of injectable
or floroquinolone.
Extensive Drug resistance (XDR): resistance to
floroquinolone and injectable second line in
addition with MDR TB.
XXDR: Resistance to almost all ATT.
Types of Resistance (By Treatment history)
 Initial resistance ( New cases - never have prior ATT or
less than one month)
 Acquired resistance (Re-treatment or new case with
more than one month of ATT)
Multi Drug resistant Tuberculosis
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MDR TB is an increasing health problem.
A serious challenge to TB control programm.
It is regarded as a result of failure of effective
implementation of Tuberculosis control program.
Minimize the transmission of DR-TB by
Infection control measures.
GeneXpert is a gold standard diagnosis tool for
early and confirmatory diagnosis of MDR-TB.
How is it caused ?
 It is the result of inadequate or poorly administered
treatment regimen.
Causes of inadequate treatment:
1. Health care providers- inadequate regimens
2. Drugs -inadequate supply or quality
3. Patients -inadequate drugs intake
When to Suspect of MDR TB ?
 Failure of Re-treatment Regimen
 Persistent positive sputum
 Fall and Rise Phenomenon
 Clinical and radiological Deterioration
DR-TB(M/XDR) Management sites
50% Treatment Centers and 25% Sub Treatment Centers in private sector
Rx Centres: 13
Rx Sub-centres: 71
Key Policies of PMDT
• GeneXpert test is gold standard test
• Provision of free quality assured second line drugs
• Fully supervised treatment
• Prepare the patient for treatment
• Clinical monitoring, treatment and
documentation of side effects
• Regular sputum microscopy and culture
monitoring
• Standardized recording and reporting system
• Monitoring of treatment outcome and evaluation
of program progress through cohort analysis
Candidates for Second line DST(SLDST)
 Any patient who has had a past history of previous second
line drugs
 Any patient who remains culture positive on or after four
months of the standard regimen used for MDR TB
 Contacts of an individual documented with XDR TB.
Where To Refer ?
GeneXpert
Line Probe
Assay (LPA)
 Near by GeneXpert centre
 National Reference Lab, GENETUP, Kalimati
 National Tuberculosis Center, Thimi
Nepal Report In % (MDR-TB)
16
14
45
14.71
13.32
40.93
40
12
35
10.99
30
9.3
10
28.2
25.4
25.3
25
20.46
8
15.4
20
6
2.86
4
2.2
1.32
2
11.72
11.96
15
3.74
10
5
0
0
1999
2002
Initial Any Resistance
2007
2011
Initial MDR
1999
2002
Acquired Any Resistance
2007
2011
Acquired MDR
Nepal Report In % (XDR-TB)
28 %
30
24 %
25
20
15
8%
10
5%
5
0
2009
2010
XDR
Ofl Res
DR TB Program Milestones
 2005 - DOTS PLUS Pilot Program started with 350 pts
for 2 yrs(Treatment Centers- 5, Sub Centers – 11)
 2007 - GLC review and permission for expansion
(300/year)
 2010 - XDR-TB Treatment started
 2011 - Treatment Centre - 12, Sub-Centre - 62 (8
DRTB Hostels established in 5 regions (EDR-1, CDR-3,
WDR-1, MWDR-2, FWR-1)
 2012 - 2 hostels planned
 2013 - Treatment centre 13,sub-centre-71, DR Home
in Bandipur
List of DR-TB centers
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11.
12.
13.
National TB centre,Thimi (G)
National Medical College,Birgunj (NG)
Lalgadh Hospital (G)
NATA Morang (NG)
BPKIHS Dharan(NG)
Regional TB centre, Kaski(G)
Bhim Hospital,Bhairawa(G)
Lumbini Zonal Hospital, Butwal(G)
NATA,Banke (NG)
Mahakali Zonal Hospital, Mahendra Nagar (G)
Seti Zonal Hospital,Dhangadhi(NG)
TEAM Hospital- Dadeldhura(NG)
NATA/GENETUP-Kathmandu(NG)
Differences between DR Centre and Sub centre
Treatment centre
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


Facility of Medicines
Facility of Sputum examination
Facility of Baseline investigations
Responsible for filling all the
documents required for
enrollment and follow-up
 Responsible to transport the
sputum samples to NRL for C/S
 Facility of management of severe
side effects
 Responsible to Quarterly
reporting to Regional monitoring
& evaluation WS
Sub centre
 Facility of medicines
 Facility of management of
minor side effects
 Responsibility of referring the
patient to DR Centre for each
monitoring investigations
 Responsible to Quarterly
reporting to Treatment centre
(DR-TB management WS)
Responsibilities of DR TB centre
1.
2.
3.
4.
5.
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7.
8.
Counseling to the patient
Registration of the patients
Baseline and follow-up investigations
Collection & transportation of the samples to NRL
Provide DOT
Management of the side effects
Supervision of DR Sub centers
Participation in the National monitoring and
evaluation workshop
Responsibilities of DR TB Sub-centre
1. Counseling to the patient
2. Provide DOT
3. Refer the patients to DR centre for regular
investigations
4. Management of minor side effects
Standard MDR-TB Treatment Regimens
First Phase 8 – 12 months (intensive
phase)
1.
Kanamycin (KM)
2.
Pyrazinamide(Z)
3.
Levofloxacin (Lfx)
4.
Ethionamide (Eto)
5.
Cycloserine (Cs)
Second Phase 12 – 14 months
(continuation phase)
All the drugs except the injectables.
Extensively Drug Resistance (XDR )TB
 XDR-TB is a form of TB which is resistant to at least four of the
core anti-TB drugs.
 XDR-TB involves resistance to the two most potential anti TB
drugs, that is Isonized & Rifampicin, also known as MDR-TB in
addition to resistance to any of the floroquinolone
(ofloxacin,Moxifloxacin) and any injectable aminoglycosides
(Capreomycin, Kanamycin).
 Take substantially longer to treat than ordinary(drug
susceptible).
 Require the use of second line anti TB drugs ,which are more
expensive and have more side effects.
Management of XDR TB cases
 Started since Feb 2010
 Much more difficult to treat than MDR TB cases
 Standard regimen (but individualization is implemented in
the substitution of drugs for severe side effects)
 Intensive phase for 12 months and continuation for another
12 months. (Injectable first 8 months six days a week ,and
then 4 months thrice a week)
Standard XDR –TB Treatment Regimens
First Phase 12 – 16 months (intensive
phase)
1.
Capreomycin(CM)
2.
Pyrazinamide(Z)
3.
Moxifloxacin(Mfx)
4.
Amoxycillin/clavunate(Am
oxy/clav)
5.
Cycloserine (Cs)
6.
Paraaminosalicylic Acid
(PAS)
7.
Clofazamine(cfz)
Second Phase 12 – 14 months
(continuation phase)
All the drugs except Injectables one.
Drug Resistance Survey Report
Year
Initial Any
Resistance
Initial
MDR
Acquired Any
Resistance
Acquired
MDR
1999
13.32%
3.74%
28.20%
11.96%
2002
10.99%
1.32%
40.93%
20.46%
2007
14.71%
2.86%
25.3%
11.72%
2011
9.6%
2.2%
25.4%
15.4%
Estimation Of MDR/XDR TB In Nepal
DRS2013-14
2011
2014-15
2015-16
2.2%
553
557
561
Estimated MDR-TB cases among retreatment
15.4% 455
cases
464
467
Total estimated MDR-TB among notified cases
1008
1021
1027
XDR-TB cases targeted for enrolment
35
40
45
Pre-XDR
63
95
120
Estimated MDR-TB cases among new cases
MDR-TB patients enrolled in DR program of
Nepal
300
251
250
200
150
271
213
194
192
131
138
158
100
50
0
2062/63 2063/64 2064/65 2065/66 2066/67 2067/68 2068/69 2069/70
Trend of Cured Rate
75.00
73.20
72.15
72.52
74.18
70.00
65.63
65.00
65.22
60.00
2062
2063
2064
2065
In %
2066
2067
Trend of Death Rate
15.00
10.00
13.0
8.70
11.6
5.70
5.00
5.15
6.57
0.00
2062
2063
2064
2065
In %
2066
2067
Trend of Failure Rate
10.00
7.97
9.79
8.23
8.00
6.00
4.69
4.00
7.98
4.58
2.00
0.00
2062
2063
2064
2065
In %
2066
2067
Trend of Defaulter Rate
20.00
18.1
17.4
15.00
11.86
10.00
5.00
11.27
13.3
10.0
0.00
2062
2063
2064
2065
In %
2066
2067
Treatment : Comparisons
80%
74%
75%
71.50%
70%
60%
60%
50%
50%
40%
30%
20%
10%
0%
Rep Of
Maldova(2008)
Kazakhstan(2008)
Nepal (2065)
Global status
(2009)
Global Plan (2015)
Facility/Support
 To Health Care Providers:
 Health Hazard (Nrs.1000 per month)
 Supply of PPE (N-95 mask and gloves).
 To the patients
 Nutritional support (Nrs.1500 per month) throughout
the treatment period.
 Supply of surgical mask
Prevention of MDR TB ?????
 Rapid diagnosis and adequate treatment of TB with
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qualitative drugs
Sound implementation of DOTS program
Identify contacts who could have contracted TB, i.e family
members, people in close contact etc.
Patients with HIV/AIDS should be identified and
diagnosed ASAP.
Contact tracing for MDR -TB cases in place
Early diagnosis of DR-TB cases referring suspected cases for
GeneXpert
Infection control measures taken where all DR- TB patients
will be treated
Indoor Facilities ( Isolation) during Ss positive
What Improves Outcomes:
• Early identification (and treatment) of
MDR-TB
• Use of an “effective” regimen
• Adequate patient support
•
DOT
• Prompt management of side-effects
• Social economic support
REQUEST
 Drug resistant tuberculosis is entirely the end results
of a number of different Failures, which is possible to
Avoid by providing qualitative service .
 LET us work all together for the sake of future
generation.
 Be sincere towards to own responsibilities
“ STOP TB IN MY LIFETIME”
Challenges !!!
• Ignorance/Poverty
• Low MDR-TB case finding
• Limitation of sample currier system
• Limitation of Diagnostic centers
• Insufficient socio-economic support to patients
• High prevalence of Floroquinolone Resistance
• Infection control measures are not in place
• Limitation of qualified health personnel in DR
centres
• Social stigma
I am Stopping TB
We Must Stop TB
Thank you for your
kind Attention
Thank you