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DOTS/ DOTS PLUS IMPLEMENTATION A ND INTEGRATION. Vaira Leimane State Centre of Tuberculosis and Lung Diseases of Latvia Paris, October, 28. L ATVIA. PRESENTATION OUTLINE. EPIDEMIOLOGICAL SITUATION IMPLEMENTATION TB/MDR TB CONTROL PROGRAMS PROGRESS IN TB CONTROL PROGRAM RESULTS.

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DOTS/ DOTS PLUS IMPLEMENTATION AND INTEGRATION

Vaira Leimane

State Centre of Tuberculosis and Lung Diseases of Latvia

Paris, October, 28


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LATVIA


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PRESENTATION OUTLINE

  • EPIDEMIOLOGICAL SITUATION

  • IMPLEMENTATION TB/MDR TB CONTROL PROGRAMS

  • PROGRESS IN TB CONTROL PROGRAM

  • RESULTS


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INCIDENCE OF TB IN LATVIA 1971-2003


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WHO IUTLD GLOBAL SURVEY ON DRUG RESISTANCE IN LATVIA 1996

%

primary

MDR-TB

acquired

MDR-TB


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INCIDENCE OF MDR TB, GLOBAL TB DRUG RESISTANCE SURVEY, 1994-1996

% New Smear + Cases


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NTP PROGRAM RESPONSE – DOTS AND DOTS PLUS IMPLEMENTATION

  • Accepted first NTP, based on WHO-recommended DOTS strategy ALL FIVE ELEMENTS in 1995

  • DOTS countywide including prisons in 1996

  • FIRSTS STEP OF National TB Control program for treating MDR TB patients in 1997

  • Established drug resistance surveillance 1997


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SUSTAINED POLITICAL COMMITMENT

  • Government Committed to establish NTP plan using existing staff and resources, within the Health Care reform

    • Well functioning DOTS program with additional treatment of MDRTB (within recourses available)

    • Collaboration and coordination between community, local governments, social services and international agencies

  • Established centralized procurement of drugs through open tender


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DOTS PLUS IMPLEMENTATION STEP I - 1997

  • SITUATION ANALYSIS

    • Results of drug resistance surveillance

    • QA of laboratory for DST

    • MDRTB case finding strategy –

      • DST for all who starts treatment

    • Reporting and registration of MDRTB

    • Evaluated access to TB drugs and created new drug management system


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TB CASE DETECTION AND IDENTIFICATION OF MDR-TB

District-Level

Smear Microscopy

Regional-Level

Culture Laboratories

Central Laboratory -

DST for all who

starts treatment

Central

DST

95% lab

accuracy (1998)

Supranational Reference

Laboratory (Sweden)


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MDR TB REPRTING AND RECORDING

Mycobacteriology Lab

All DST results

District TB doctor

Enrollment form

MDRTB case

MDRTB Register

Follow-up form

Consilium

Enrollment in

MDRTB cohort


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DOTS PLUS IMPLEMENTATION STEP II

  • MDRTB TREATMENT AND MANAGEMENT STRATEGY

    • Established Expert consilium for case and program management 1997, June

    • TB hospitals reorganized for MDRTB

    • Start patient enrolment for treatment

  • Empiric/Individualized treatment strategy

    • according to DST results

    • Directly observed therapy (DOT)

    • Monitoring and management of side effects


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CONSILIUM FOR MDRTB TREATMENT AND MANAGEMENT

  • Advantages

  • Collective decision

  • Possibility for patients to receive most effective treatment

  • Possibility to supervise treatment

  • Problem solving

  • Improvement of program management


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STRUCTURE OF DOTS-PLUS PROGRAM


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DOTS PLUS IMPLEMENTATION STEP III

  • ESTABLISHED CASE MANAGEMENT SYSTEM

    • Roles and responsibilities of HCW

    • Patient education

    • Default tracing

  • Improved infection control measures

  • Center of Excellence founded in 2000

    • International training centre for treatment and management for MDRTB

    • Built laboratory capacity –

      • DST to all I and II line drugs

      • Rapid diagnostic methods for patient with risk of MDR-TB

  • Established database, data management, and information system 2002 -2003


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IMPROVING ALL TB AND MDRTB PATIENT ADHERANCE

Departments of Welfare

Agreement with TB ambulatory departments

  • Social Aid for TB Patients

  • Food coupons

  • Transport tickets

  • Extra coupon weekly

  • if adherence 100%


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DOTS PLUS PROGRAM TREATMENT COHORTS

Begun in 1997


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DOTS PLUS IMPLEMENTATION STEP IV

  • ACCESS TO II LINE DRUGS

    • Leaving funds after procurement of I line drugs

    • Extra from reserved funds

  • DOTS-plus project accepted by WHO Green Light Committee in January 2001

    • Approval for 350 patients for drugs

  • Full coverage with treatment

  • LiPA test - study to determine usefulness for early MDRTB case detection

  • Established database, data management, and information system 2002 -2003


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TREATMENT OUTCOMES FOR COHORT 2000N=204 patients

Completed treatment (6)

Death (14)

3%

Cure (129)

7%

63%

13%

Default (26)

14%

Failure (29)


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TREATMENT OUTCOMES FOR NEW TB CASES AFTER DOTS AND DOTS PLUS COMPLEATION

Preliminary


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NUMBER OF PATIENTS WITH PRIMARY ANDACQUIRED MDRTB INCLUDING PRISON 1994 - 2003

Since 1998 total number of annually registered MDRTB cases decreased by 51% for previously treated by 65%


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CONCLUSIONS AND RECCOMENDATIONS

  • DOTS strategy has reduced MDRTB development by 51% in Latvia

  • DOTS-Plus in addition to DOTS in settings with high MDRTB level can reach WHO goal for cure 85%

  • 2/3 of patients who started treatment in DOTS plus were cured

  • Addressing treatment default could significantly improve program effectiveness

  • Strengthening of the DOTS strategy, rapid MDRTB diagnosis, contact investigation and genotyping to detect chain of transmission is the next steps to improve MDRTB control in Latvia


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