Treating tuberculosis in Chechnya: a “remote control” approach

1. Treating tuberculosis in Chechnya: a “remote control” approach Gabit Ismailov MedCo MSF-H, Russian Federation

2. Background • 1994-1996 – first Chechen war • 1999-… - second Chechen war

3. MSF in Chechnya • MSF programmes: • Donation of non-food items • Drug Distribution • Primary Health Care • Mental Health • TB • Surgery • Emergency response

4. TB programme background • TB programme in Chechnya started in May 2004 • 4 hospitals • 5 districts • 300,000 people in the catchment area • over 750 TB patients enrolled since the start of the programme

5. “Remote control” • MoH staff runs daily TB services • Experienced national staff in the project locations supervise and organise TB services • Regional coordination office in Nalchik, Kabardino-Balkaria • Infrequent visits by international staff to project sites since December 2004 • A small country management team in Moscow

6. Programme quality control mechanisms • Cross-checking of collected data (TB registers, lab registers, etc) • Regular meetings with national MSF staff; programme updates; discussions, etc. • Regular international and national trainings • Occasional supervisory visits by international staff including “on-site” validation, e.g. cross-checking slides, patient interviews, etc.

7. Project Goals • Cure all TB patients from the districts in Chechnya where MSF operates. • Establish and maintain a system of good quality diagnosis by the means of direct sputum smear microscopy. • Treat all diagnosed TB patients with the first-line anti-TB drugs and maintain good treatment adherence. • Ensure access to quality counselling services for all TB patients and relatives. • Ensure access to quality HIV/AIDS follow-up and ARV therapy for all TB-HIV co-infected patients in supported TB facilities.

8. Case Finding • Passive case finding • Direct Sputum Smear Microscopy • No reliable reference laboratory • Cross-checking between 4 participating laboratories with MSF involvement • QC % of agreement over 80% • Starting external MoH QC • PA Chest X-Ray • No culture, no DST • Active case finding among risk groups by MoH but only “on paper” • Systematic obligatory HIV testing by MoH

9. Treatment and follow-up • Standard treatment regimens: • 2HREZ(S)/4HR (new cases) • 2HREZS/1HREZ/5HRE (previously-treated cases) • Drugs: • local purchase • validation scheme by MSF pharmacists network • DOT by MoH healthcare workers: • Intensive phase in the TB hospital • Continuation phase DOT by primary healthcare workers in “DOTS corners” daily/intermittent • Follow-up: • Direct Sputum Smear Microscopy • Chest X-Ray

10. Assuring TB treatment adherence in a conflict zone • Individual case management • Defaulter tracing activities • Health education • Mental health counselling • Peer support groups • Continuing medical education • Incentives and enablers • food for patients • food for healthcare workers • “Runaway” bags • FDCs

11. Case Finding • From May 2004 up to March 2006, 670 patients were enrolled in the programme: • 543 smear+ pulmonary TB cases • 111 smear- pulmonary TB cases • 16 extrapulmonary TB cases • (only 12 children) • 433 new case • 237 previously treated cases • male:female ratio ~ 2:1 • 3 HIV+ cases

12. Outcomes Outcomes * Cohorts Q2-4 2004 and Q1 2005 ** Cohort Q1 2005, 47 previously treated patients

13. Problems • Some patients are not enrolled (“chronics”) • Some patients from outside the catchment area • Very few children with TB enrolled • Extrapulmonary TB • Few women enrolled • Drug resistance in previously-treated cases?

14. Success • Very good outcomes for new cases • Very good treatment adherence • Dedicated team • Motivated patients

15. Reasons for “success” in new cases in suspected high drug resistance settings • Null Hypothesis: The outcomes are true (we’ve done a great job!) • Or are there some caveats? • selection bias • unreliable data collection? • no primary drug resistance in the region • other …

16. Current Status • TB and HIV co-infection • Programme expansion? • MDR-TB?