SUSTAINING DOTS AND MOVING FORWARD WITH THE STOP TB STRATEGY César Bonilla MD.

SUSTAINING DOTS AND MOVING FORWARD WITH THE STOP TB

STRATEGY

César Bonilla MD.

MORBIDITY AND INCIDENCE RATE OF TUBERCULOSIS

PERU 1990-2003

Source: National Health Strategy for TB Prevention and Control (ESN-PCT)

DOTS DOTS Expansion and Sustainability Start of reform and loss of leadership

0

50

100

150

200

250

300

MORBIDITY 198.6 202.3 256.1 248.6 227.9 208.7 198.1 193.1 186.4 165.4 155.6 146.7 140.3 123.8TB INCIDENCE183.3 192.0 243.2 233.5 215.7 196.7 161.5 158.2 156.6 141.4 133.6 126.8 121.2 107.7BK+INCIDENC 116.1 109.2 148.7 161.1 150.5 139.3 111.9 112.8 111.7 97.1 87.9 83.1 77.4 68.8

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

PERIOD OF ADMINISTRATION (IN MONTHS) AT THE NATIONAL TB CONTROL PROGRAM

1991-2004

133

8 13 122

0

20

40

60

80

100

120

140

DR. PGSUAREZ

DR. R.ACCINELLI

DR. ETICONA

DR. RCANALES

DR. D.ZAVALA

Months

2 BK per SR are performed

530,000 SR were not tested

1,060,000 BK were not performed

SR Tested BK +2,4 %

per every 42 SR 1 case BK +

12,500 cases of SP-PTB went undiagnosed

DIAGNOSIS GAP OF SMEAR POSITIVE PULMONARY TB (SP PTB)

2,129,145

1,899,0821,938,781

1,000,000

1,500,000

2,000,000

2,500,000

1996 1997 1998 1999 2000 2001 2002 2003

BKsDX

Años

MAGNITUDE OF THE MDR-TB PROBLEM IN PERU

The presence of MDR-TB is the result of numerous failures by the healthcare system over time:

1. Use of ineffective treatment regimes for MDR-TB during the 80s and 90s which amplified the resistance.

2. Persistent MDR-TB cases in the community without timely access to adequate treatments which increased sources of infection with MDR bacilli among contacts.

3. Poorly defined therapeutic policies in relation to new MDR-TB cases among contacts of documented MDR-TB cases.

4. Underestimation of the magnitude of MDR-TB which prevented adequate diagnosis and treatment interventions.

CHILDREN < 18 YEARS OLD WITH MDR-TB WITH ACCESS TO STAND. AND INDIV. RETREATM, AND

THREE-YEAR TREND LINEPERU 1996-2004

1 5

2632

56

92

124

173

213

y = 26,8x - 53,778

R2 = 0,9352

0

50

100

150

200

250

300

96 97 98 99 00 01 02 03 04

Nº

of

chil

dre

n w

ith

MD

R-T

B< 18 years

Linear (< 18 y)

NEW PARADIGMS

1. Human dignity, bioethics, human rights within a health citizen context, for the control of TB and MDR-TB.

2. Comprehensive and integrated healthcare to enhance TB and MDR-TB control actions.

3. Intersectoriality, interinstitutionality and development of strategic partnerships for TB and MDR-TB control, for the advocacy and design of public policies.

4. Multidisciplinary teams made up by the healthcare team, civil society representatives and associations of people living with TB, for organizing and providing care to people with TB and MDR-TB.

5. Strategic communication.

• Coordination, Conducting, Communication, Cooperation.• Shared management, leadership and accountability.

National Health Strategy for TB Prevention and Control

Comité Técnico Permanente

Group of Experts

Strategies and Programs

Technical Criteria

EsSALUD

Dep. of Health

Scientific Associations

Universities

NGOs

Civil Society

Criteria, Strategies, Plans and Commitments

Technical Specialization

Criteria

Strategic Management

Public Healthand

Epidemiology

MINSA Representativ

es Departments

TECHNICAL STANDING

COMMITTEE

ADVISORY COMMITTEE

STOP TB Committee

Peru

TB/HIV Co-Infection

Committee

National Multisectorial

Health Coordinator

Sector Management

DecentralizationModernization

Health Prevention

and Promotion

HR

Comprehensive Care

Funding

Democratization

DOTS DOTS PLUS

MINSA

Multidisciplinary, Multifunctional, Intersectorial and Interinstitutional Team

AMSC Training

Research

Biosafety

HIV/TB

PAL

Others

Evaluation

Supervision

Monitoring

Strategic Partnership

s PPM

Advocacy Social

Mobilization

Con

tinu

os Q

uality

Imp

rovem

en

t

AND NATIONAL HEALTH STRATEGY FOR TB PREVENTION AND CONTROL

Tech

nic

al E

fficie

ncy

Comprehensive Insurance

Local Government

sHRTAs

Technologic. Developm.

Institutional Culture

AccreditationService

Supply and Rational Use of Drugs

POLICY GUIDELINES OF THE HEALTH SECTOR

HRTA: High Risk of Transmission Areas

MINSA

Citizen Watch

Institutional and Intersectorial Articulation

Comprehensive Care

National Health

Strategy for TB Prevention

and Control

Public Stakeholders(Citizenship)

Institutional StakeholdersAND

Intersectorial Stakeholders

STRATEGIC PLAN 2004-2010

Ministry Decision 721-2005

VisionTo consolidate and maintain by 2010 higher levels of efficiency and effectiveness by ensuring the progressive and sustained decrease of tuberculosis incidence in Peru.

MissionTo ensure early detection and diagnosis, as well as timely, supervised and free-of-cost treatment of people affected by TB, MDR-TB and the TB/HIV co-infection in all healthcare services in Peru, in order to reduce the TB morbidity and mortality rate as well as its social and economic implications.

STRATEGIC PLAN 2004-2010

RM 721-2005

General Objective

To progressively and sustainably decrease TB incidence through timely, supervised and free-of-cost detection, diagnosis and treatment of people with TB in all healthcare services in the country by providing comprehensive quality care in order to reduce the morbidity and mortality rate and its social and economic implications.

Impact Goal

To decrease the incidence rate of smear positive pulmonary TB from 66.39/100,000 inhabitants (Annual Report ESN-PCT 2004) to 53/100,000 inhabitants by the end of 2010.

TS MDR-TB

Building Strategic Partnerships

Biosafety Training Module

TS – TUBERCULOSIS

Evaluation Report ESN-PCT 2004

TECHNICAL HEALTH STANDARDS (TS) AND PUBLICATIONS

Tuberculosis Training Module

PERU STOP TB PARTNERSHIP

CEREMONY FOR SETTING-UP THE COMMITTEE

IDENTIFICATION OF SYMPTOMATIC RESPIRATORY PATIENTS

PERU 1990-2005

16 %

Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA

0

0.2

0.4

0.6

0.8

1

1.2

1.4

90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05

Mill

ions

0

0.5

1

1.5

2

2.5

Millions

S.R. Ex.

Bk Diag Total

% CASE DETECTION, ESTIMATED RATE AND REPORTED RATEOF SP-PTB PERU 2000-2005

Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA and

Global Tuberculosis Control WHO Report 2006

WHO GOAL

CASE DETECTION:

70 %

96 %

% C

ase

Dete

ctio

n

Rate

of

SP P

TB

x 1

00

,00

0 in

hab

itan

ts

0

20

40

60

80

100

120

2000 2001 2002 2003 2004 2005

0

10

20

30

40

50

60

70

80

90

100

% Detection Reported SP PTB Estimated SP PTB

MORBIDITY AND INCIDENCE RATE OF TB IN PERU 1990-2005


0

50

100

150

200

250

300

MORBILIDAD198,6 202,3 256,1 248,6 227,9 208,7 198,1 193,1 186,4 165,4 155,6 146,7 140,3 123,8 124,4 129,0

INCID. TBC 183,3 192 243,2 233,5 215,7 196,7 161,5 158,2 156,6 141,4 133,6 126,8 121,2 107,7 107,7 109,7

INCID. BK+ 116,1 109,2 148,7 161,1 150,5 139,3 111,9 112,8 111,7 97,1 87,9 83,1 77,4 68,8 66,4 67,1

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

DOTS Expansión y Sostenibilidad DOTS

Pico Epidemiológico

Inicio de Reforma y Perdida de

Liderazgo

Gestión y Recuperación de liderazgo

Pico Epidemiológico

0

50

100

150

200

250

300

MORBIDITY 198,6 202,3 256,1 248,6 227,9 208,7 198,1 193,1 186,4 165,4 155,6 146,7 140,3 123,8 124,4 129,0

TB INCID. 183,3 192 243,2 233,5 215,7 196,7 161,5 158,2 156,6 141,4 133,6 126,8 121,2 107,7 107,7 109,7

BK+ INCID. 116,1 109,2 148,7 161,1 150,5 139,3 111,9 112,8 111,7 97,1 87,9 83,1 77,4 68,8 66,4 67,1

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

DOTS DOTS Expansion and Sustainability

Epidemiological

Peak

Start of Reformand Loss of Leadership

Managementand Recoveryof Leadership

Epidemiological Peak

COHORT STUDIES OF NEW SP-PTB CASES

2001-2005*

* First Semester** Compendium of indicators for monitoring and evaluating national tuberculosis programs WHO/HTM/TB/2004.344

Outcomes 2001%

2002%

2003 %

2004 %

2005* %

2001-2005*% %

Cured 92 91,5 89,3 89,6 89,5 90,3 85

2 2,2 3 3 3,3 2,7 3

2,2 2,2 2,4 2,2 2,1 2,2 5

Defaults 3 3,2 4,3 4,2 4,3 3,8 4

0,8 0,9 1,9 1,1 0,8 1,1 3

2001%

2002%

2003 %

2004 %

2005* %

2001-2005*%

WHO GOALS **%

92 91,5 89,3 89,6 89,5 90,3 85

Failures 2 2,2 3 3 3,3 2,7 3

Deaths 2,2 2,2 2,4 2,2 2,1 2,2 5

3 3,2 4,3 4,2 4,3 3,8 4

Referrals0,8 0,9 1,9 1,1 0,8 1,1 3


0

500

1000

1500

2000

2500

3000

1997 1998 1999 2000 2001 2002 2003 2004 2005

0

2

4

6

8

10

12

14

16

Nº

of

MD

R-T

B c

ase

s enro

lled in R

etr

eatm

ent

% M

DR

-TB

Death

s

2,641

68

14.7 %

3 %


CASES ENROLLED IN MDR-TB TREATMENTAND % OF DEATHS PERU 1997 – 2005

0

10

20

30

40

50

60

70

80

90

100

2005-2006 0 73.3 86.3 90.6 93.9 92.5 93.9

2002-2004 0 32.3 42.3 47.2 43.8 42.6 42.8

1997-2001 0 15.4 32.5 36.9 41.7 40.7 40.1

0 1 2 3 4 5 6

% N

eg

ati

ve C

ult

ure

in

MD

R-T

B R

etr

eatm

en

t C

ase

s

Months of Re-Treatment


BACTERIOLOGICAL CONVERSION AT SIXTH MONTH OF MDR-TB RETREATMENT PERU 1997 – 2006

Implementation of MDR-TB Technical Standard, New Standardized Regime and Strengthening of MDRTB-Technical Unit

Implementation of Former Standardized Regime (To access this treatment patients had to go through various first-line drug treatments)

Changes in Inclusion Criteria for Former Standardized Regime (Recommended for failures to primary and secondary regime)


BUDGET OF NATIONAL HEALTH STRATEGY FOR TB PREVENTION AND CONTROL PERU 1991-

2006

0

2

4

6

8

10

12

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Average Annual Budget

1991- 2005: $ 3 000,000 USD

DOTS STRATEGY:

POLITICAL COMMITMENT

Millions $ USD

9 780,000 $ USD

THE FUTURE OF THE COUNTRY IS SHAPED

HAVING THEIR NEEDS IN MIND

Tuberculosis can be cured

Discrimination too

Let us show our support and understanding towards this

cause

Health Sector Reform:

• Decentralization, and the new concepts of quality care, equity, participation of civil society and information

transparency, represent the most relevant aspects of the reform and an opportunity for National TB Control Programs.

• Without technical and regulatory support and commitment to national goals, decentralization is the main enemy of any National TB Control Program, since it dismantled all processes aimed at achieving success.

• Reform should be applied gradually.

LESSONS LEARNED

Management in the National Health Strategy for TB Prevention and

Control :

• DOTS is not only measured by its ability to provide diagnosis and treatment but also for promoting

values, managerial capacity and commitment.

• Healthcare services must articulate supply and demand so they can be adapted to the actual health needs.

• An opportunity must be identified in the multifunctionality and turnover of staff.

LESSONS LEARNED

Strategic Partnerships:

• TB control must incorporate new stakeholders since we have shifted from a biomedical approach to a community and participatory approach.

• TB is a public health issue that concerns us all.

• The concept of citizen rights and responsibilities must be included in the new management of the ESN-PCT.

• The integration of the State with the civil society allows an

increase in collective health awareness.

LESSONS LEARNED

Strategic Partnerships:

• The updating of the Technical Standard legitimized by the participation of civil society and organizations of people living with TB strengthens the governing role of MINSA.

• The participation of community health promoters enhances the DOTS strategy.

• The participation of organizations of people living with TB gives a human face to the social mobilization efforts aimed at controlling the disease.

LESSONS LEARNED

Within the framework of the Millennium Development Goals and the prioritized public health objectives of the Americas, policies must be established to subsidize those affected by TB, starting with the mother and child component.

Strategic multidisciplinary partnerships must be set up to monitor the extent and impact of the intervention in the poverty, exclusion and tuberculosis component.

Respect for human dignity, bioethics and human rights must be promoted at all management levels in order to eradicate stigmatization and discrimination against people living with TB.

NEXT STEPS

As part of the TB Control Strengthening in Peru, the following actions must be taken :

• Maintain current indicators and propose others to be used at a management level such as:

Social participation in citizen watch actions,

Incorporation of tuberculosis as a socioeconomic development indicator.

Subsidy coverage in health and nutrition (access to diagnosis, treatment and rehabilitation of complications and aftereffects).

NEXT STEPS

As part of the TB Control Strengthening in Peru, the following actions must be taken:

• Improve the managerial capacity of the intermediate multidisciplinary working teams.

• Consider High Vulnerability Areas with High Risk of Transmission (urban-marginal areas, borderline

communities, indigenous populations, people deprived of their liberty and others).

• Promote decentralization of care to people co-infected with TB/HIV.

• Continue to improve comprehensive household care (personalized care) of people co-infected with MDR-TB/HIV in accordance with the particular needs of each patient.

• Address the problem of incurable MDR-TB.

NEXT STEPS

THANK YOU

SUSTAINING DOTS AND MOVING FORWARD WITH THE STOP TB STRATEGY César Bonilla MD.

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Transcript of SUSTAINING DOTS AND MOVING FORWARD WITH THE STOP TB STRATEGY César Bonilla MD.