Universal Access to MD TB Program in Cambodia ITM, Antwerp 08 December 2012 Sam Sophan Cambodian Health Committee (CHC) 1
Cambodia 2
Basic Info About Cambodia Location: South East Asia Border countries: Laos 541km; Thailand 803km; Vietnam 2,338km Coastline: 443km Area: 181,035 sq km Population: 14.7 million in 2012 24 provinces; 159 districts Health System: 24 PHD and 77 OD (75 RH; 873 HCs; 35 HP)
TB in Cambodia (*WHO 2011) Cambodia is still one of 22 high burden countries with TB in the World Prevalence Rate of all form of TB for 2010: 660 / 100,000 pop* TB Prevalence declined from 1258 in 1990 to 660 in 2010(47% reduction);cambodia will most probably achieve MDG target by 2015 ( MDG target :626/100,000)(50%) Incidence Rate of all form of TB for 2010: 437 / 100,000pop * Incidence Rate of Sm+ for 2011: 171/ 100,000pop (~ 23,900 cases per year) (Preliminary result of Prevalence survey 2011) (it was 269/100,00 in 2002:first survey) Death rate: 61/100,000 pop* Death rate declined from 153 in 1990 to 61/100,000 pop in 2010;Cambodia is achieving MDG target for this indicator( MD target 2015: 87/100,000) Prevalence of HIV in TB patients: 6.3%; HIV prevalence in adults: 0.5% MDR TB Prevalence (in 2006): among new smear positive= 1.4% and among re treatment cases= 10.5% 3
Cambodian Health Committee (CHC) Cambodian not for profit, non partisan, non religious, nongovernmental organization Established: in Cambodia on March 9 th, 1994 Founded by: Dr. SOK THIM present Executive Director Dr. Anne Goldfeld, Harvard University & Global Health Committee Director Human Resources: CHC staff: 130 Government staff supported: 398 Village Level Workers supported: 3304 Funded by: Multiple Private and Public Donors 5
Mission Focused on Tuberculosis/MDR TB and HIV/AIDS controls Aim to: 1) improve access to and quality of services (Prevention, diagnostic, care and treatment) 2) build capacity of local government and NGO managers and staff, 3) mobilize and empower target groups and communities for problem solving, self care and advocacy, 4) improve infrastructure, 5) support basic needs of clients, 6) provide financial opportunities for clients to improve economic viability, 7) conduct clinical research to find better methods of care and treatment, develop a clinical research capacity and a network for HIV and TB. Carried out through multiple connected projects. 6
MDR TB Program Launched in Oct. 2006 and started expending nationwide in early 2011 In 2007, CHC applied to the GLC trough fast tract application and it got approval to treat first 30 MDR TB patients and later on another 200 patients ( sponsored by UNITAID) MDR TB treatment and relevant documentation developed and in practice ( NTP has draft guidelines ) Training by CHC (2006 2009) : CHC staff 19 Government health staff: 85 7
MDR TB Program: Objective 1 Build basic infrastructure and initiate effective supporting systems for MDR TB program 2 Promote universal access with the national program, Local health/tb staffs and other related staffs to provide effective diagnosis, treatment/care, prevention and solution to the MDR and XDR TB 3 Assist/support MoH, NTP in developing policies in the regards of MDR TB 4 Improve the norms and mechanisms for regulating quality of MDR TB services.. 8
MDR TB Program: Current activities Assist screening and treatment of DR TB cases for the whole country in close cooperation with NTP ( on job training ) Support/Coordinate for treatment follow up to patients in the community ( CHC mobile team works very closely with all MDR TB treatment sites ) 9
MDR TB isolation facilities in Cambodia 11 treatment sites; 65 isolation rooms BMC 10 rooms Siem Reap 2 rooms Kg Chhnang 3 rooms BTB 6 rooms Kg Cham (MSF-F) 6 rooms Koh Kong 2 rooms Svay Rieng 2 rooms KSFH 10 rooms CENAT 14 rooms Takeo; 4 rooms Kandal 6 rooms 10
Guidelines for Programmatic Management of Drug-resistant TB 2008 Emergency Update WHO/HTM.TB/2008.402 Draft 2011 Update WHO/HTM.TB/2011.6
Number of MDR TB suspected screened by years 1400 1305 1200 1000 800 600 515 650 400 200 0 84 102 326 2007 2008 2009 2010 2011 Oct. 2012
Case Finding Strategies All re treatment Pulmonary TB cases: Failure Relapse Return after default Other: S( )PTB Symptomatic contacts of known drug resistant TB case Non converter at month 2 (Cat 1) or at month 3 (Cat 2) S(+)PTB/HIV. 13
Number patients registered for SL treatment by year for all treatment sites Total MDR-TB: 274/364 cases 100 80 60 40 20 0 1 48 45 31 16 6 5 0 0 0 0 2 1 3 2 87 52 14 10 10 10 0 0 2 2 0 0 0 2006 2007 2008 2009 2010 2011 Oct. 2012 17 MDR PDR Mono XDR Xpert
Treatment outcome for cohort analysis by year of enrolment Cohort: 2006 2007 2008 2009 2010 Cured: n (%) 1 10 (62.5) 34 (64.2) 43 (76.8) 25 (65.8) Completed: n(%) 0 1(6.3) 3 (5.7) 0 1 (2.6) Died: n (%) 0 2 (12.5) 9 (17.3) 11 (19.6) 11 (28.9) Default: n(%) 0 3 (18.7) 7 (17.0) 2 (3.6) 0 Still on treatment 0 0 0 0 1 TOTAL 1 16 53 56 38
Treatment Outcome of the Cohort 2006 2010 Total: 164: 54 (33%) female Median age: 42 ys (IQR: 30 52); Median BMI: 16.5 (IQR: 14.6 18.9) HIV positive: 40 (24.4%) Cured: 113 (70%) Completed: 5 (3%) Defaulted: 12 (7%) Died: treatment: 227 days (2 856) 33 (20%) Median time after starting DR TB 16
Treatment Outcome of the Cohort 2006 2010 (n=164) Death: 33 (20%) Median time after starting DR TB treatment: 227 days (2 856) XDR TB: 2 ( 2 out of 4)=50% MDR TB: 28 (28 out of 141) = 20% PDR TB: 3 (3 out of 13)=23% HIV+: 14 /40 (35%) vs HIV : 19/ 124 (15%) [OR:2.86; 95%CI: 1.22 7.24; p=0.006] Median BMI of death cases: 14.8 ( 14.9 : 55%) vs median BMI of cured cases: 17.5 ( 14.9 : 20%) [ OR:6.33; 95%CI: 2.5 16.2; p=0.0001} 17
Characteristics of 1 st line DST patterns DR TB in 2010 (n=38) DR TB in 2011 (n=76) MDR TB (n=31) [81.6%] RHES: 4 (12.9) RHE: 1 (3.2) RHS: 15 (48.4) RH: 11 ( 35.5) MDR TB (n=52) [68.4%] RHES: 15 (28.8) RHE: 6 (11.5) RHS: 12 (30.1) RH: 19 ( 36.6) PDR TB (n=5) [13.1%] RS: 5 (100.0) PDR TB (n=10) [13.2%] RS: 1 (10.0) RE: 1 (10.0) HE: 3 (30.0) HS: 5 ( 50.0) Mono (n=2) [ 5.3%] R: 2 (100.0) Mono (n=14) [18.4%] R: 8 ( 57.2) H: 3 (21.4) S: 3 (21.4) 18
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DST confirmation to XpertMTB/Rif+ MDR TB (n=36) [73.5%] PDR TB (n=1) [2.0%] Mono (n=10) [ 20.4%] Xpert MTB/Rif DETECTED N=49 RHES: 10 (27.8) RHE: 2 (5.6) RHS: 8 (22.2) RH: 16 ( 44.4) RS: 1(100.0) R: 10 (100.0) Culture not growth (n=3) [6.1%] 2 contaminated 20
Number of NTM cases treated n=64 35 30 25 20 15 10 5 0 NTM 29 21 6 3 5 2008 2009 2010 2011 2012 NTM Outcome: Cured: 53; Died: 3; Default: 2; Pending: 6 21
Current DR TB patients on FU at Home by CHC mobile team (N=132) Province/City Number Province Number Phnom Penh 32 Kratie 1 Kandal 17 Stung Treng 1 Takeo 11 Kg. Cham 8 Siem Reap 7 Kg. Speu 3 Svay Rieng 5 Pursat 2 Koh Kong 1 Sihanouk Ville 5 Battambang 8 Bantey Meanchey 4 Kg Chhnang 9 Prey Veng 8 Kg Thom 3 Ratanakiri 2 Kampot 4 Ouddar Meanchey 1 22
. Follow Up: We have accompanied patients from hospital to Home. 32.2% for community based treatment (2006 2010)
Out patient Management Those who have been treated the whole period at home from the beginning Those who first hospitalized ( 1 month) and then discharged home to continue the treatment at home
Out patients management Receive down referral of stable patient from TS Maintain MDR TB registers and copies of treatment cards of all patients DOT supporters (DS): select treatment supporters & provide them training, supervision DS1: local nurse ( nearby HC) DS2 or DS3: VHSG, neighbor or family member Establish a basic infection control in place Request drugs for the patients Nutrition, social support and adherence support Provide incentives and transportation support to patients & DS Manage common side effects, sputum control, lab tests monitoring.. Link with treatment sites: M&S, complicated side effect management, other relevant supports
HOME BASE Infection Control: Establish isolation at home Infection control plan: 1. Build a simple open room at the back of the house to allow air and sun light pass through 2. Instruct the family to limit small children to make contact with the patient 3. Mask supplies to the patient and train patient how to use it 4. Mask supplies to the DSs, family members and train them how to use it properly Educate family about temporary restriction Discuss family roles in supporting the patient s care
Purposes: Demonstrate that MDRTB is a serious disease; treatment lasts at least 2 years Agree: A symbol of commitment of all parties ( DS1, DS2 & patient) to support treatment to the end Cambodian value this thumbprint very much 27
Follow up Patients in the communities The CHC monitoring team goes monthly to the patient to take sputum for followup and blood tests as needed and also supervises the work of DOTS-watchers.
Follow up Patients in the communities The CHC monitoring team goes monthly to the patient to take sputum for followup and blood tests as needed and also supervises the work of DOTS-watchers.
Side effect management Doctor from TS visit patient at home Doctor from TS visit Patient at home
Side effect management Doctor from TS visit patient at home Doctor from TS visit Patient at home
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., Sputum collection C-DOTS
Challenges Limited capacity of staff in treatment sites and PMDT Limited need of social support to patients ( enablers ) Quality assurance of Laboratories, sputum & blood samples transportation DST of SL drugs is not available in the national program Co morbidity management and side effects, complications & sequelae Mortality is high Palliative care & End of life care? 34
Acknowledgement CHC Team Anne Goldfeld Private donors, The Annenberg Foundation UNITAID GLC of stop TB partnership, WHO regional and country representative Cambodia NTP, CENAT Staffs who involve in this projects All patients and their family members and community members
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