DR. IRMA ASUNCION
National Center for Disease Prevention and Control
Department of Health
Programmatic Management of Drug-resistant TB(PMDT)in the Philippines
1
Outline
•Latest estimates on MDR-TB burden
•Background on PMDT
•Program Performance
•Case Finding/Case Holding Strategy on PMDT
•Plans/Challenges
2
Magnitude:
Latest Global TB estimates - 2012
Estimated no.of cases
Estimated no.of deaths
1.3 million
8.6 million
~170,000
~450,000
All forms of TBGreatest number of cases in Asia;greatest rates per capita in Africa
Multidrug-resistant
TB (MDR-TB)
Extensively drug-resistant TB (XDR-TB)
~ 50,000
~ 30,000
3
99
7,100
17
million
islands
geographicregions
4
DOH – NCDPC (NTP)
17 Centers for
Health Development
3,074 Rural Health Units
(DOTS Facilities)
16,038 Barangay
Health Stations
80 Provincial/129 City
Health Offices
• Formulate policies and guidelines
• Provide technical assistance
• Provide drugs/laboratory supplies
• Monitor and evaluate implementation
• Monitor and supervise implementation
• Distribute drugs/supplies to the city/mun
• QA Centers
• Manage TB patients
• Store anti TB drugs
• Microscopy services
• Identify TB symptomatics
• Do DOT
5
Vision
2050
2040
2030
2020
2010
TB FREEPhilippines
1 active case/1Mpopulation
2015
MDGoals
Prevalence rate: 500/100,000 (2012: 450)
Death rate: 29/100,000 (2012: 23)
CDR: 84 (2012) Treatment Success Rate 2011: 90
6
Mission
Ensure that TB DOTS services are available,accessible, and affordable to the communities incollaboration with the LGUs and other partners
Program Targets
•Treatment Success of at least 90%
•Case Detection Rate of All Forms of TB at least 90%
7
(SOURCE: WHO Global Tuberculosis Control. 2000-2012)
450
23
500
29
Prevalence and Mortality Rates from Tuberculosis,Philippines, 1990 - 2015 (per 100,000 population)
29
This iswhere
we are
8
Trends of CDR, Cure and Treatment Success
2000 - 2012
90%
83%
84%
9
Number of Cases Detected vs. EstimatedNumber of All Forms of TB
64,440 missing cases
10
CDR and Treatment Success Rate, Philippines
11
Current Status: Philippines
7th among the 22 high TB burdenedcountries (HBCs) worldwide (with highnumber of All Forms of TB) – Global TB Control Report 2013
One of the 27 high MDR-TB burdencountries – Global TB Control Report 2013
TB is 6th in mortality and 8th in morbidity –FHSIS Report 2010
12
Estimated % of New TBcases with MDR – TB
Estimated % ofRetreatment TB caseswith MDR – TB
Global
3.6
20.2
Western PacificRegion (WPR)
4.7
22
High
MDR – TBBurden Countries
4.2
21
Philippines
4.0
21
Estimated Proportion of TB Cases
that Have MDR - TB
Global tuberculosis control: WHO report 2013
13
Priority countries in the Western Pacific Region
High-burdencountries
•China
•Philippines
•Viet Nam
•Cambodia
•Lao PDR
•Mongolia
•PNG
Intermediate-burden countries
•Brunei
•Hong Kong (China)
•Japan
•Macau (China)
•Malaysia
•Republic of Korea
•Singapore
14
Estimated MDRTB burden 2012
15
The beginning…..1999
–Start of management of drug resistant TB in a privateDOTS clinic- Makati Medical Center through the TropicalDisease Foundation (TDF) and was the 1st GLC approvedpilot project worldwide
Year
Among NEW
(%)
Among Re-Treatment (%)
1999
0
22.2
2000
4.3
6.7
2001
0
0
2002
0
15.4
2003
0
14.3
Treatment Failure* Rate(Smear +) DOTS Center at MMC
* All turned out to be MDR-TB
Private PPMD
16
Phases of Implementation
Phase
# ofpatients
Geographicalcoverage
Support
1999
2000-2003
Pilot Phase
7
200 (165)
Metro Manila - MakatiMedical Center DOTSClinic
NGOs, GOP, PTSI
Global Fund
2003-2006
ExpansionPhase
500
Metro Manila – FBOs,NGOs, DOTS facilities,satellite TCs
Global Fund
2006-2008
Mainstreaming
2500
Metro Manila, 1 regionin the south
Global Fund
2009-2016
Scale up Phase
19,500
Nationwide
Global Fund, GOP
17
Source of DR-TB Suspect ReferralsScreened at selected PMDT TC, 2011 (n=1788)
Based from 2011 TB Symptomatics Masterlist of CHD 1, 4A, 7, 6, 9, 11, 12 & CAR
18
•Govt. DOTS facilities
•Pvt. facilities/ referringhealth providers
•Hospitals
TC or STC
Identificationand referral ofsuspects
Quality AssuredLaboratory
Screening,assessment,sputum collection
DSSM, TBCulture, DST
ConfirmedDR-TB
Category IV treatment
Case Finding Strategy
19
•Strict DOT for the entire course oftreatment (18 – 24 months)
•Default Tracing
•Decentralization to local healthfacilities
•Management of adverse drugreactions and other co-morbidities
•Monthly monitoring of treatment
•DSSM monthly
•TB Culture monthly duringintensive phase then every 2months
•CXR & Blood Chemistry every 6months
•Special diagnostics
•Other TC Interventions
•Psychosocial activities/GA
•Enabler Support
Case Holding Strategy
20
PMDT Facilities
•Treatment Centers
–Stand alone PMDT specific treatment facilities, attached andnetworked to DOTS facilities catering to patients within a region
•Satellite Treatment Centers
–DOTS facilities where PMDT services are available catering tothe catchment area of the facility
•Treatment Sites
–PMDT trained DOTS facilities, recognizes and refers presumptiveDRTB patients, continuation of patient’s treatment upondecentralization
21
Region
Treatment Center
Satellite Treatment Center
NCR
1.KASAKA – QI
2.LCP – NCPR DOTS clinic
3.DJNRMH –TALA PPMD
4.PTSI – Tayuman PPMD
5.San Lazaro Hospital DOTS Clinic
Lagrosa DOTS clinic, Pasay City
Gat Andres MMH , Tondo, Mla
Tondo foreshore , Tondo Mla
Moonwalk ,DOTS clinic Paranaque City
Super Batasan, QC
Grace Park DOTS clinic , Caloocan
Lacson DOTS Clinic, Mla.
QC BJMP DOTS clinic ,QC
7
Eversley Child’s DOTS clinic
Vicente Sotto Med.Center, Cebu City
1
Ilocos Training Regl Medical Center
Region 1 Medical Center,Pangasinan
4A
1.De La Salle Health Sciences Inc
2.Batangas Regional Hospital
Cainta PPMD, Gumaca District PPMDLos Banos DOTS Clinic, Laguna
4B
Ospital ng Palawan DOTS clinic
5
SMMGHHC
Bicol Medical Center
10
German Doctors , XU-Community
Iligan Specialty Internist , PPMD
11
Davao Southern Phil. Medical Center
Davao Regional Hospital ,Tagum City
Location of PMDT Facility
22
Region
Treatment Center
Satellite Treatment Center
6
Western Visayas Medical Center
Don Pablo O Torres Medical Hospital
(Riverside PPMD DOTS clinic)
Roxas CHO
8
Schistosomiasis General Hospital
9
Zambo. City and Medical Center
Dr. Jose Rizal Mem Hospital,
Dapitan City
12
Koronadal CHO PPMD
Cotabato Regional and Medical
Center DOTS clinic
CAR
Baguio General Hospital & Medical
Center
2
Cagayan Valley Regional Hospital
CARAGA
CARAGA PPMD DOTS
Total
20
20
Location of PMDT Facility
23
16 GeneXpert Center(3 TBC/DST; 10 TBC; 3 PMDT facility)
REgion
GX center
Facilitydescription
Date of Operation
NCR
National TB ReferenceLaboratory (2 units)
Culture/DST center
September 2011
NCR
Lung Center of the Phil (2units)
Culture/DST center
October 2011
1
ITRMC
Culture center
October 2011
9
Zamboanga City MedicalCenter
Culture center
October 2011
5
SMMGH
Culture center
(private facility)
October 2011
4A
Dela Salle Health SciencesInstitute
Culture center
(private facility)
October 2011
6
Western Visayas Medicalcenter
Culture center
November 2011
7
Cebu ReferenceLaboratory
Culture/DST center
December 2011
24
REgion
GX center
Facilitydescription
Date of Operation
10
XU-CHCC (German Doctors)
Culture Center
(private)
December 2011
11
Davao TB reference lab
Culture Center
December 2011
12
Koronadal CHO PPMD
PMDT TreatmentCenter
December 2011
CAR
Baguio General and MedicalCenter
Culture Center
December 2011
NCR
PTSI-QI Laboratory(2 units)
Culture Center
(private)
December 2011
NCR
Dr. Jose N. Rodriguez MemorialHospital
PMDT TreatmentCenter
December 2011
CARAGA
Caraga Regional Hospital
Culture Center
December 2011
NCR
San Lazaro Hospital
PMDT TreatmentCenter
October 2012
25
Examples of PMDT Treatment Centers
KASAKA-QI MDR-TB
Housing Facility, QC (2004)
Lung Center of the Phils.-PHDU, QC (2005)
Eversley-Childs Sanitarium PMDTTC the South
Mandaue, Cebu (Sept 2008)
PTSI-Tayuman,
Manila (Sept 2008)
Dr. Jose N. Rodriguez
DOTS Center, Caloocan
City (Mar 2008)
Private facility
Public PPMD in a DOH-retained hospital
Public PPMD in aregional hospital
Private PPMD
Gov’t PPMD: regionalhosp
Private Hospital
SMMGHHSC
Sorsogon (July 2009)
26
Examples of Satellite Treatment Centers
Roxas City CHO
Lob Baños RHU
Bicol Medical Center
Gumaca District Hospital
27
Examples of Treatment Sites
Public DOTS Facility
Private DOTS Facility (PPMD)
28
Expansion of PMDT Services
LUZON
Region
TC
STC
GX
1
1
1
1
2
1
CAR
1
1
3
1
NCR
5
11
11
4A
2
3
2
4B
1
1
5
1
1
1
VISAYAS
Region
TC
STC
GX
6
2
1
1
7
1
1
1
8
1
MINDANAO
Region
TC
STC
GX
9
1
1
1
10
1
1
1
11
1
1
1
12
2
1
CARAGA
1
1
ARMM
*
2007 = 3 facilities
2009 = 10 facilities
2011 = 25 facilities
2013 = 44 treatment facilities
29
DOTSFacilities as PMDT Treatment Sites(Partial ,as of January 2013)
NCR
CAR
1
3
4A
4B
5
6
7
8
10
11
12
CARAGA
TOTAL
RHU
LGU
479
6
23
71
138
3
36
12
52
4
20
30
10
3
887
Hospital
22
1
2
1
1
1
1
29
Jail
6
2
3
4
2
17
Otherprivate
6
1
7
513
6
24
71
142
3
37
16
57
4
20
34
10
3
940
30
GeneXpert equipment
31
Enrollment of DRTB patients
As of July 1, 2013
32
Enrollment of DRTB Patients
33
Treatment Success Rate per Year1999 to 2009
34
MDG: To reduceprevalence andmortality by half bythe year 2015
PMDT
35
Administrative
Order No, 2008-0018:Guidelines for theImplementation ofProgrammatic Managementof Drug-resistant TB signedby the Secretary of Health
Trainingsof differenthealthworkers onPMDT
36
2010 – 2016 Enhanced Philippine Plan ofAction to Control Tuberculosis(PhilPACT)
1.Reduce local variations inTB Control Programperformance (Governance)
2.Scale-up and sustaincoverage of DOTSimplementation (Servicedelivery, Health Info,Human Resource)
3.Ensure provision of qualityTB services (Regulation)
4.Reduce out-of-pocketexpenses related to TBcare (Financing)
37
8 Strategies of PhilPACT
1.Localize implementation of TB control
2.Monitor health system performance
3.Engage all health care providers
4.Promote and strengthen positive behavior ofcommunities
5.Address MDR-TB, TB-HIV and needs of vulnerablepopulations
6.Regulate and make available quality TB diagnostictests and drugs
7.Certify and accredit TB care providers and facilities
8.Secure adequate funding to improve allocation andfund utilization
38
Performance TargetsPerformance Targets
5.1) A total of 19,500 MDR TB cases have beendetected and provided with quality assuredsecond-line anti-TB drugs
5.2) At least 75% of enrolled MDR TB patients aresuccessfully treated
STRATEGY 5. Address MDRTB, TB-HIV andneeds of vulnerable populations
39
PMDT Subplan of the PhilPACT
1.Integration of PMDT services in Basic DOTS Services of Health Facilities
2.Building the capacity and capability of Basic DOTS facilities to providequality PMDT services
3.Empowerment of the Patient and support groups
4.Enhancing PMDT management
5.Support systems strengthening
6.Operations researches and studies
7.Resource mobilization
40
Today
3 DST Centers
18 Culture Centers
44 TCs and STCs
887 HCs
41
2016
7 DST Centers
29 Culture Centers
100 STCs centers
All HCs are ready
42
PMDT Challenges
Challenge
•Cost and Sustainability
–High cost of quality secondline anti-TB drugs
–High cost of laboratory needsand infrastucture
–Estimated cost of Php 200k –280k per patient put onMDRTB treatment for 18-24months treatment
–Almost all MDRTB funds areGFATM sourced
Addressing the challenge
•Global Fund Presence until2016 because of the “NewFunding Model” $75M for2014 to 2016
•DOH to ensure sustainabilityof PMDT beyond 2016
•Philhealth currentlydeveloping DRTB package
•Expansion and inclusion ofPMDT in DOTS facilities
•Advocating for LGU supportfor indigent patients
43
PMDT Challenges
Challenge
•Accessibility
–44 facilities across 16 ofthe 17 regions
–99 M population,estimated 13000MDRTB patients
–Provinces still withoutaccess to PMDT
Addressing the challenge
•Implementation of the PMDTscale-up and expansion plan
•Continuous advocacy andexpansion to all CHD’s andpotential treatment facilities
•PMDT expansion to everyprovince, 2 or more facilities inbig provinces
•PMDT services to be available inall cities of the national capitalregion
•Continuous training for all CHD’sfor capacity building
•Roll-out of GeneXpert facilities
44
PMDT Challenges
Challenge
•Decreased MDRTBenrollment and increasingburden
–Non adherence to DOHapproved treatmentguidelines and regimens
–Poor referrals from privatepractitioners
–Not all health workers areoriented on MDRTB
–Poor health seeking behavior
Addressing the challenge
•Revised NTP-MOP
•Enhanced 2010-2016 PhilPACT
•Rollout of TB/HIV strategic planand AO
–All HIV+ to be screened for DRTB
–All DRTB for Provider InitiatedCounseling and Testing
•Intensifying Contact Tracing notjust to include household
•Establishment of PMDTservices in Jails and Prisons
•Private physician advocacy andinvolvement
45
PMDT Challenges
Challenge
•Difficulty to treatpatients
–18 to 24 monthstreatment
–ADR’s from second linedrugs
–High defaulter rate
–Competing priorities totreatment (work,finances, etc.)
Addressing the challenge
•Decentralization of PMDTservices and expansion
•Introduction of the 9 monthregimen
•Introduction of new availabledrugs - Bedaquiline
•Enabler and psychosocialsupport
•Default tracing mechanisms
•LGU financial support forindigent patients
46
PMDT Challenges
Challenge
•Awareness of MDRTB
–Self medication
–Improper treatment ofMDRTB
–Private practitionerstreating DRTB suspects
–Stigma of MDRTBpatients
Addressing the challenge
•Revision of MOP, PMDTTraining Manuals
•PhilPACT Revision andDissemination
•Continued training to allNTP service providers
•Advertisements andeducational references(ACSM)
47
Thank youfor your attention....
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