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Scale-up of Scale-up of Programmatic MDR TB Programmatic MDR TB Management Management (PMTM) (PMTM)
in the Philippinesin the Philippines
ROSALIND G. VIANZON, MD, MPHROSALIND G. VIANZON, MD, MPHNTP ManagerNTP Manager
Department of HealthPhilippines
Magnitude of MDRTB in the Philippines:Magnitude of MDRTB in the Philippines:
Data Sources Type of Resistance
New Previously Treated
Phil. National Survey,1997(Tupasi, T., et.al) 1.4% 14.5%
National Drug Resistance SurveyNTP,WHO,JICA, 2004 (Preliminary)
4.4% 21%
Treatment Failure Rate (Smear +), NTP
Amongst NEW (%)
Amongst Re-Treatment
(%)
1999 2.0 -
2000 1.2 -
2001 1.3 -
2002 1.3 -
2003 1.0 6.0
Treatment Failure* Rate(Smear +) DOTS Center at
MMC
Amongst NEW(%)
Amongst Re-Treatment
(%)
1999 0 22.2
2000 4.3 6.7
2001 0 0
2002 0 15.4
2003 0 14.3
* All turned out to be MDR-TB
Pilot Stage:Pilot Stage: Initial Scope and context – GLC Pilot Project Privately Initiated DOTS Unit at MMC as the
starting point ““DOTS (+) Project at MMC ”DOTS (+) Project at MMC ” 75% referrals from: Private practitioners PPMD: need to harness PPs into DOTS Laboratory capacity for culture and DST 2nd line drugs need to be secured and
assured Sustainability - impending concern
Stages of PMTM in the PhilippinesGoes beyond DOTS “DOTS (+)”“DOTS (+)”
Stage of Mainstream:Stage of Mainstream: Integration of DOTS(+) into the public DOTS Stepwise implementation ““LCP DOTS (+) Project”LCP DOTS (+) Project”- public counterpart - in-house services Referrals from both public and private MDs Community-based approach: Decentralize to
public health centers with participation from community volunteers
Absorptive Capacity – prevailing concern
Stages of PMTM in the Philippines
Decentralized MDR-TB services in Metro Manila(DOTS facilities participating in MDR-TB management)
Caloocan City 3 (8%) + 2
2 (3%)Quezon
Paranaque3(20%) + 1
Taguig3(14%)
Pasig 2(5%)+1
1(6%)San Juan
2 ( 8%) + 1 Mandaluyong
Makati 6 (22%)
Pasay4(31%)+2
Manila16( 39%) +4
Malabon2(9%)+1
Las Pinas1 ( 3%)
Muntinlupa 1
Legend:
Treatment centers
Summary :
• 48/452 (11%) public health centers
4 (24%)Marikina
=407 patients (75%)
22 (5%)
61 (15%)17 (4%)
106 (26%)
14 (3%)6 (2%)
13 (3%)
22 (5%)
8 (2%)
86 (21%)
22 (5%)
5 (1%)
Region I– 7 (1%)
11 (3%)
6 (2%)
4 (1%)
4 (1%)
Region II -5 (1%)
Region III-30 (6%)
Region V -4 (0.7%)
Region IVA -78 (14%)Region IVB -3 (.6%)
Region VII -2 (0.4%)
Region VI – 3 (0.5%)
Region 10 -2 (0.4%)
Region VIII -3 (0.6%)
Outside Metro Manila = 137 (25%)
Places of residence99-Aug ‘06
MM -405 (75%)
MDR-TB, Philippines
C U R R E N T : G F A T M s u p p o r t ( R d 2 )M D R T B P a t ie n t a c c r u a l ‘9 9 - A u g ‘0 6 N = 5 4 4
D O H G F A T M )T D F , P C S O , e tc T D F ,P C S O
6 1 5
8 4 1 0 0
1 9 1
7 0
6 2 1
1 0 5
1 6 11 8 3
2 8 3
4 7 4
5 4 4
2 1 (1 4 G F )
5 5
0
1 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4 2 0 0 5 2 0 0 6
N e w p a ti e n ts C u m u la t iv eG F A T M = 3 7 5
Demographics: sex and age n=544 (Apr ’99- Aug ’06)
38% (207)
62% (337)
Male Female
1%
10%
30%
27%
20%
10%
2%
0% 10% 20% 30%
% (no) of patients enrolled
0-14
15-24
25-34
35-44
45-54
55-64
>65
Age
(ye
ars)
77%
MDR-TB, Philippines
Cohort Outcome 1999-2004 n=281
17
0
127
0 38
1713 13
25
13.5 15
7473
595860
50
17 20 15
93.5
0
10
20
30
40
50
60
70
80
1999 2000 2001 2002 2003 2004
Cure Failure Died Default
0
0
3 (13.5%)
3 (13.5%)
0
16 (73%)
22
200324 mo
001 ( 1 %) 0 0Transout
3 (3%)4 ( 7%)10 (12%)01 (17%)Failure
8 (8%)5 (9%)13 (15%)3 (20%)1 (17%)Died
15 (15%)14 (25%)11 (13 %)2 (13%)1 (17%)Default
00 0 1 (7%)0Completed
71 (74%)33 (59%)49 (58%)9 (60%)3 (50%)Cure
985684156Outcome
200424 mo
(partial)*2002
36 mo2001
36 mo2000
36 mo1999
36 mYears
Treatment outcome of MDRTB patients: ‘99- ‘04
* 2 ongoingMDR-TB, Philippines
Stage of Scale-up:Stage of Scale-up: Expansion of Project into Program (PMTM)Geographic expansion (Region: Metro Manila)(Region: Metro Manila)Engaging more community-based facilities
- PPMD units (Public and Private-initiated) - Public DOTS Hospitals (District Hospitals) - Other Public Health Centers
More decentralized approach - realistic, viableAdded complexity and financial demand
Stages of PMTM in the Philippines
Culture CenterCulture Center
DST CenterDST Center
Metro Manila 2006
Culture CenterCulture Center
DST CenterDST Center
Metro Manila by 2008
Treatment CenterTreatment Center Treatment CenterTreatment Center
G FA TM su ppo rt in th e ex pan s io nM D R TB P atien t accru a l ‘9 9 - A u g ‘0 6 N = 5 4 4
G F AT MT D F , P C S O , D O H
6 15 84 100191
70 92 94184
396
640 640 640
6 21 105 161 183283
474
728
1216
1950
2590
3230
21 (14 GF)
55
0
500
1000
1500
2000
2500
3000
3500
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
pre GF/GF2 GF 5 Cumulative
G F A T M = 3 0 0 0
R5 Scale-upR2 Mainstream
4 5 4 5
9 0
4 5
1 3 5
4 9
1 8 4
9 1
2 7 5
1 0 0
3 7 5
1 0 2
4 7 7
1 0 3
5 8 0
0
1 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
No
. o
f p
atie
nts
Q 1 Q 2 Q 3 Q 4 Q 5 Q 6 Q 7 Q 8
G F A T M Q u a r te rs
N e w e n ro l le e s C u m u la tiv e
Gradual expansion from Metro Manila to Region VI I – Phase 1
3 add’l Tx Centers in MM
2 Tx Centers in Reg VI I
3 Tx Centers in MM3* culture centers, 2* DST sites in MM
1 DST site in Reg VI I
* I ncludes TDF lab, MMC Clinic, KASAKA and LCP
DOTSDOTS
Microscopy
PPMD Unit at MMC (Privately-Initiated)
PUBLIC Facility
(1st line drugs)
NTP
Evolution of a PPMD Unit into a DOTS-Plus unit
PUBLIC Facility
(1st line drugs)
Microscopy
CultureDST
DOTS DOTS
DOTS PlusDOTS Plus
PUBLIC Facility
(1st line drugs)
Microscopy
CultureDST
DOTS DOTS
DOTS PlusDOTS Plus
Treatment Site (Health Center)
Treatment Site (Health Center)
LCP DOTS(+) Treatment
Center
Treatment Site (Health Center)
Treatment Site (Health Center)
KASAKADOTS(+)
Treatment Center
Mainstream into theMainstream into thePublic DOTSPublic DOTS
Culture
Microscopy
Culture
Microscopy
PUBLIC Facility
(1st line drugs)
Microscopy
Culture
DST
DOTS DOTS
DOTS PlusDOTS Plus
Treatment Site (Health Center)
Treatment Site (Health Center)
LCP DOTS(+) Treatment
Center
Treatment Site (Health Center)
Treatment Site (Health Center)
KASAKADOTS(+)
Treatment Center
Microscopy
CultureTreatment Site (Health Center)
Treatment Site (Health Center)
TreatmentCenter
Treatment Site (Health Center)
Treatment Site (Health Center)
Treatment Center
Treatment Center
DST
Microscopy
Culture Treatment Site (Health Center)
Treatment Site (Health Center)
TreatmentCenter
Treatment Site (Health Center)
Treatment Site (Health Center)
Treatment Center
Treatment Center
DST
8 Treatment Centers8 Treatment Centers
4 Culture Centers4 Culture Centers
MORE MORE TreatmenTreatment t SitesSites
The Scale-The Scale-upup
3 DST Sites3 DST Sites
CEBUCEBU
Treatment Centers:Treatment Centers: - more than 10 patients being treated at a time- more comprehensive/specialized management
(e.g. LCP, KASAKA-QI)
Treatment Sites:Treatment Sites:- fewer patients (<10) being treated at a time- represented by public health centers, PPMDs other public facilities, faith-based DOTS units
Types of PMTM Types of PMTM Facilities Facilities
Microscopy
Microscopy
Culture
DST
Culture
Types of PMTM Types of PMTM FacilitiesFacilities
Culture Centers:Culture Centers:- perform culture services, NTRL supervises EQA- broader catchment areas- those identified under the DRS e.g. Cebu Ref. Lab.
DST Sites: DST Sites: - perform DST, NTRL oversees quality of culture and
microscopy- fewer but strategically located (2 Manila, 1 Cebu)- under the supervision of supranational laboratory
DOTS DOTS is is STILLSTILL the OVERARCHING the OVERARCHING FRAMEWORKFRAMEWORK
1. Sustained political commitment.
2. Diagnosis of drug resistance through quality-assured culture and drug susceptibility testing (DST).
3. Uninterrupted supply of quality assured second-line anti-TB drugs.
4. Appropriate treatment strategies utilizing DOT with second-line drugs under proper management conditions.
5. Recording and reporting system designed for DOTS-Plus programs.
Political Political commitmentcommitment
Quality Quality microscopy microscopy serviceservice
Regular Regular availability of availability of 11stst line drugs line drugs
D.O.TD.O.T
Standardized Standardized records and records and reportsreports
Steps and Requirements for Steps and Requirements for the SCALE-UPthe SCALE-UP
Environmental scanningEnvironmental scanning* Existing resources and capacities - * Existing resources and capacities -
DRSDRS * For strategic selection of expansion sites* For strategic selection of expansion sites
Advocacy to ensure political commitmentAdvocacy to ensure political commitment* Memorandum of Understanding (MOU)* Memorandum of Understanding (MOU)
Create essential organizational structuresCreate essential organizational structures * PMTM Task Force, PMTM Consillium, * PMTM Task Force, PMTM Consillium,
Lab. SubCommitteeLab. SubCommittee
Policies, guidelines, standards developmentPolicies, guidelines, standards development
Human resource developmentHuman resource development* Task Analysis * Standardized training materials* Standardized training materials
Network of lab services and other Network of lab services and other diagnosticsdiagnostics
* Microscopy, EQA, Culture and DST* Microscopy, EQA, Culture and DST* Chest X-ray with TBDC participation* Chest X-ray with TBDC participation
Steps and Requirements for Steps and Requirements for the SCALE-UPthe SCALE-UP
HRH Capacity-BuildingHRH Capacity-Building
Training of Trainers
Training for Monitoring and
Supervision
Training for Implementers
Training (Region)(Region)
Monitoring &Supervision
(Province/City)(Province/City)
DOTS-Plus ImplementationTreatment CenterTreatment Center
DOTS-Plus ImplementationTreatment SiteTreatment Site
Scale-up Scale-up of of LaboratorLaboratory y CapacityCapacity
CultureCulture
EQAEQA
MicroscopyMicroscopy
NTRL & Other DST SitesDSTDST
Regional TB Reference
Laboratory
PHO/CHO Validation Center
DOTS-Plus ImplementationTreatment CenterTreatment Center
Supranational Laboratory
Logistics management: Logistics management: *22ndnd line drugs, 1 line drugs, 1stst line drugs and line drugs and
drugs for drugs for adverse reactions adverse reactions
Steps and Requirements for Steps and Requirements for the SCALE-UPthe SCALE-UP
SelectionSelectionNTP,TDFNTP,TDF
DistributionDistributionNTP, CHDs,NTP, CHDs,
LGUsLGUs
ProcurementProcurementTDF,GLC,WHOTDF,GLC,WHO
UtilizationUtilizationTx Centers,Tx Centers,
Tx SitesTx Sites
Drug Cycle forDrug Cycle for22ndnd Line Drugs Line Drugs
Community involvement to facilitate a Community involvement to facilitate a decentralized approachdecentralized approach
* Treatment Centers * Treatment Centers * Treatment Sites * Treatment Sites
Public-Private PartnershipPublic-Private Partnership - engaging PPMD - engaging PPMD units.units.
Private physicians need to be harnessed to the DOTS strategy to prevent them from proliferating MDRTB.
Steps and Requirements for Steps and Requirements for the SCALE-UPthe SCALE-UP
Standardized information/data Standardized information/data systemsystem
* Records and Reports* Records and Reports
Monitoring, Supervision and Monitoring, Supervision and EvaluationEvaluation
* Internal MSE* Internal MSE
* External MSE - GLC* External MSE - GLC
Steps and Requirements for Steps and Requirements for the SCALE-UPthe SCALE-UP
Access potential agencies for supportAccess potential agencies for support Government (National and Local)(National and Local)Non-Government Agencies, Private
sectorExternal Assistance (Technical and
Financial) GFATM, USAID, WHO, OthersGFATM, USAID, WHO, Others
Address the 5 dimensions of sustainability:Address the 5 dimensions of sustainability:PoliticalPolitical**TechnologicalTechnological**SocioculturalSociocultural**Economic/Economic/
Financial Financial
Steps and Requirements for Steps and Requirements for the SCALE-UPthe SCALE-UP
InstitutionaInstitutionall
Pilot
Mainstream
Scale-up
MDR Cases and Scaling-up
Approach – Impact RelationshipApproach – Impact Relationship
MDRs With MDRs With AppropriateAppropriate
Management Management
Undetected
XDR
Program Approach (PMTM)
LCP Project
MMC DOTS (+) Project
THANK YOUTHANK YOU
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