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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 a nd integration

DOTS/ DOTS PLUS IMPLEMENTATION AND INTEGRATION

Vaira Leimane

State Centre of Tuberculosis and Lung Diseases of Latvia

Paris, October, 28

presentation outline
PRESENTATION OUTLINE
  • EPIDEMIOLOGICAL SITUATION
  • IMPLEMENTATION TB/MDR TB CONTROL PROGRAMS
  • PROGRESS IN TB CONTROL PROGRAM
  • RESULTS
ntp p rogram response dots and dots plus implementation
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
sustained political commitment
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
dots plus implementation step i 1997
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
tb case detection and identification of mdr tb
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)

mdr tb reprting and recording
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

dots plus implementation step ii
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
consilium for mdr tb treatment and management
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
dots plus implementation step iii
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
improving all tb and mdr tb patient adherance
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%
dots plus implementation step iv
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
treatment outcomes for cohort 2000 n 204 patients
TREATMENT OUTCOMES FOR COHORT 2000N=204 patients

Completed treatment (6)

Death (14)

3%

Cure (129)

7%

63%

13%

Default (26)

14%

Failure (29)

number of patients with primary andacquired mdr tb including prison 1994 2003
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%

conclusions and reccomendations
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
slide23
Welcome to Latvia

NATIONAL CHOIRS FESTIVAL

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