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TB CONTROL PROGRAMME Operational Situation and Programmatic Experience

TB CONTROL PROGRAMME Operational Situation and Programmatic Experience. Erica Reynolds Hedmann Ministry of Health Jamaica. West. Northeast. South. Southeast. Jamaica. Background. 550 miles south of Miami 4,244 miles 2 population: 2.68M main industry: tourism per capita GDP

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TB CONTROL PROGRAMME Operational Situation and Programmatic Experience

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  1. TB CONTROL PROGRAMMEOperational Situation and Programmatic Experience Erica Reynolds Hedmann Ministry of Health Jamaica

  2. West Northeast South Southeast Jamaica Background • 550 miles south of Miami • 4,244 miles2 • population: 2.68M • main industry: tourism • per capita GDP US $3,390- $3,700 • 14 parishes - 4 health regions

  3. Jamaica - Health Regions West North-East South-East South

  4. Confirmed Tuberculosis Cases 1996-2003

  5. TB IN JAMAICA Reported Annual Incidence of TB in Jamaica, 1991 - 2001

  6. Age and Gender Distribution of Confirmed Tuberculosis Cases, 2003

  7. Jamaica AIDS Cases & Deaths Reported Annually in Jamaica (1982 to 2003)

  8. Jamaica Annual AIDS Case Rates by Sex (Per 100,000 population): 1982 - 2003

  9. Percentage of TB Cases with HIV 1993-2003

  10. S u m m a r y o f A I D S C a s e s b y P a r i s h i n J a m a i c a 1 9 8 2 - 2 0 0 1 ( R a t e p e r 1 0 0 , 0 0 0 P o p . ) N W E S H a n o v e r T r e l a w n y S t . A n n S t . M a r y W e s t m o r e l a n d P o r t l a n d S t . E l i z a b e t h S t . C a t h e r i n e M a n c h e s t e r C l a r e n d o n S t . T h o m a s AIDS/100,000 Pop. 8 5 . 1 - 9 5 . 5 9 5 . 5 - 1 4 9 . 7 1 4 9 . 7 - 2 0 3 . 5 2 0 3 . 5 - 2 1 7 . 1 2 1 7 . 1 - 5 5 2 . 6

  11. TB/HIV Co-Infection by Parish 2003

  12. Tuberculosis Control Programme in Jamaica Goal • ·   To reduce mortality, morbidity due to Tuberculosis Objectives • ·    Maintain case detection rate of at least 70% of expected cases • ·   Achieve a minimum cure rate of 85% of confirmed cases • ·Prevent multi-drug resistant TB

  13. Tuberculosis Control Programme in Jamaica STRATEGIES • Treatment of all cases –DOTS • Surveillance, with emphasis on contact investigation • Identifying, treating and monitoring TB/HIV co-infected persons • Public Education • Staff Training • BCG vaccination • Research

  14. TB ProgrammeHistorical Perspective • Vertical Programme • Prior to health reform • Responsible for all aspects of TB control • defined Budget • Staff at all levels assigned to TB • TB clinic • Admission at single hospital

  15. TB ProgrammeHistorical Perspective After reform Central level Responsibility for providing guidelines, policy and monitoring Integration- • The NTP was merged with other areas under the Division of Health Promotion and Protection • Surveillance unit • Multi-purpose staff at central as well as other levels • TB Coordinator- coordinating other priority areas – competing programmes • ‘integrated’ budget

  16. TB Programme Challenges • Impact of health reform • Drug procurement responsibilities shifted without the appropriate monitoring and input from central level

  17. TB Programme • Decentralization • Shift of responsibility and accountability for planning, administration and implementation • Opportunity for increased response • Concerns regarding ownership and commitment to TB control at parish level • Issues - finances, human resources, training and supervision.

  18. Elements of DOTS Strategy • Sustained political commitment to increase human and financial resources and make TB control a nation-wide activity integral to health systems

  19. Political Commitment • TB control has been a national priority for the Ministry of Health • In keeping with and in recognition of the WHO tuberculosis target, Millennium Development Goals for TB

  20. Political Commitment • In 1996, a five year TB strategic plan was prepared • A draft TB manual was started, however this was not completed. • In 2002, MOH strategic plan - TB listed as priority programme. • In 2005, the CMO has restated the commitment to the programme

  21. Political Commitment Steps forward • Political Commitment needs to be reflected in adequate funding of TB programme • The national HIV/AIDS Program has demonstrated its commitment to the program and TB/HIV collaboration.

  22. Political Commitment • TB/HIV task force was established • In 2004, work was done on a draft national TB manual that is to be completed in this quarter of 2005. • Is preparing a strategic plan for TB and TB/HIV collaboration. • Evaluation of TB program in 2005 • Plans for capacity building,, policies, drug procurement, lab supplies etc

  23. Elements of the DOTS Strategy • access to quality-assured TB sputum microscopy for persons presenting with symptoms • Screening of symptomatic persons and high risk groups

  24. Access to quality lab evaluation • One central lab(National Public Health Lab) that does sputum culture and other sensitivity testing • All samples for TB testing are sent to this laboratory • smear Microscopy • Culture • Sensitivity testing is also done • All regional labs have the capacity to do smear microscopy

  25. Access to quality lab evaluation • Challenges • Ensuring adequate supplies of reagents • Ensuring adequate laboratory conditions • Human resources and their development • Quality assurance activities

  26. Method of Diagnosis of Tuberculosis Cases, 1999 - 2003.

  27. Method of Diagnosis of Tuberculosis Cases, 2003. N=120

  28. Screening of Symptomatic and High risk groups • Early Screening of symptomatic cases by private practitioners needs strengthening • Case Detection among PLWHA and other high risk groups • PLWHA are ‘screened’ for prolonged cough • HOWEVER follow-up investigation, notification NOT always done • Routine screening of PLWHA is a Priority for TB/HIV task force • Guidelines • Training • Monitoring

  29. Elements of the DOTS Strategy Standardized Chemotherapy to all confirmed cases of TB under proper case-management conditions including direct observation of treatment

  30. Standardized Chemotherapy to all confirmed cases of TB Policy- ALL TB confirmed cases are to have direct observation of treatment based on the WHO guidelines

  31. Standardized Chemotherapy to all confirmed cases of TB • initial intensive phase of treatment as in-patients (until smear negative or app 2 months ) • Continuation phase- as outpatient, community DOTS

  32. Standardized Chemotherapy to all confirmed cases of TB • Approximately 100% of confirmed cases are hospitalized for initial phase • > 75% admitted at National Chest Hospital • Challenges • Hospitalized far from home • Treatment by regional hospitals needs to be monitored • National guidelines needed • Strengthen training in TB management at teaching institutions

  33. Standardized Chemotherapy to all confirmed cases of TB • Continuation Phase of Treatment • Completed as out-patient • DOT by health team, review visit with institution • Weakness in Community DOTS in continuation phase of treatment • Linkage between secondary care and public health needs strengthening to ensure coordinated management • Violence in some areas limits community DOTS • Training, organization needed • Monitoring by supervisor needs to strengthened

  34. Standardized Chemotherapy to all confirmed cases of TB Treatment Outcome for 2003 Cohort • Completion- 47% (51) • Died – 24% (26) • Defaulters – 18.5% (20)

  35. Elements of DOTS Strategy • Uninterrupted supply of quality-assured drugs with reliable drug procurement and distribution

  36. Regular Drug Supply • Procurement and distribution of Anti-Tb drugs is done by a central body • National TB programme –limited role in advising on quantification of national drug needs- reactive rather than proactive • Policy- drugs provided free of charge

  37. Regular Drug Supply • Shortage of drugs on and off • Issues with accessibility, charges • Steps being taken by NTP, TB/HIV task force to improve its role to ensure a steady supply of anti-TB drugs

  38. Elements of the DOTS Strategy Recording and reporting system enabling outcome assessment of each patient and assessment of overall programme performance

  39. Monitoring and Evaluation • Well established Case –based surveillance system • Monitoring tools and system to monitor treatment

  40. Monitoring and Evaluation • TB surveillance • TB Class 1 notifiable disease- report on suspicion within 24 hours • TB investigation at parish level • Investigation of the case • Investigation of contact • Report submitted to national level • Known indicators for surveillance

  41. Total number of Confirm Cases Contacts Investigated Cases Diagnosed From Contact Tracing % of Total Cases 2003 120 368 8 7 2002 108 531 5 4.6 2001 121 304 5 4.1 TB Cases Diagnosed From Contact Tracing

  42. Monitoring and Evaluation • Challenges of Tuberculosis Case and Contact Investigation • Timeliness of investigation • Completeness of investigation • Monitoring of investigation by supervisors

  43. Monitoring and Evaluation TB Monitoring • TB register is established at all levels • Parish, lab, national, hospital • Utilization of TB registers is a challenge at parish level • Monitoring of Cases by parish is a challenge • Training, guidelines • Supervision • Plans to enhance monitoring and evaluation

  44. Public Education • Training • Research • TB/HIV collaboration

  45. Happy Valentine’s Day

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