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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


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    1. DOTS/ DOTS PLUS IMPLEMENTATION AND INTEGRATION Vaira Leimane State Centre of Tuberculosis and Lung Diseases of Latvia Paris, October, 28

    2. LATVIA

    3. PRESENTATION OUTLINE • EPIDEMIOLOGICAL SITUATION • IMPLEMENTATION TB/MDR TB CONTROL PROGRAMS • PROGRESS IN TB CONTROL PROGRAM • RESULTS

    4. INCIDENCE OF TB IN LATVIA 1971-2003

    5. WHO IUTLD GLOBAL SURVEY ON DRUG RESISTANCE IN LATVIA 1996 % primary MDR-TB acquired MDR-TB

    6. INCIDENCE OF MDR TB, GLOBAL TB DRUG RESISTANCE SURVEY, 1994-1996 % New Smear + Cases

    7. 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

    8. 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

    9. 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

    10. 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)

    11. 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

    12. 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

    13. 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

    14. STRUCTURE OF DOTS-PLUS PROGRAM

    15. 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

    16. 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%

    17. DOTS PLUS PROGRAM TREATMENT COHORTS Begun in 1997

    18. 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

    19. TREATMENT OUTCOMES FOR COHORT 2000N=204 patients Completed treatment (6) Death (14) 3% Cure (129) 7% 63% 13% Default (26) 14% Failure (29)

    20. TREATMENT OUTCOMES FOR NEW TB CASES AFTER DOTS AND DOTS PLUS COMPLEATION Preliminary

    21. 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%

    22. 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

    23. Welcome to Latvia NATIONAL CHOIRS FESTIVAL