Current Issues in Infectious Disease Programming

• So What’s New About TB?– Irene Koek & Cora Manaloto

• TB Monitoring & Evaluation– Cheri Vincent

• Controlling Drug Resistance in Developing Countries

– Andrew Clements

• Questions & Discussion

So What’s New About TB?

State of the Art Course

October, 2002

Tuberculosis Still:

• Infects 1/3 of the world’s population, usually the poorest of the poor

• Results in 23,000 new active cases each day• Kills 5000 people each day• Increasing in regions of the world with high HIV

burdens and high rates of drug resistance

22 Countries Accounts for 80% of the TB Cases in the World

Key Issues in TB

• Political commitment increasing, but still need more• Lack of in-country and internat’l capacity• Public/private sector interactions weak• HIV/TB - rapidly expanding• Need more attention to drug management• No simple diagnostics• Drug regimen - still 6-8 months long• Information of poor quality

International Political Commitment

• The Global Partnership to Stop TB

• The Global Plan to Stop TB

• Stop TB Working Groups on targeted topicsDOTS Expansion Drugs

MDR-TB Diagnostics

TB-HIV Vaccines

Drugs

International Political Commitment

• Global Drug Facility (GDF)– Donates quality drugs

– Bulk drug procurement by the GDF has resulted in a 30% cost decrease for TB drugs

– Procurement mechanism for governments/NGOs

• Green Light Committee (GLC)– Access to quality, discounted 2nd line drugs

• Global Fund to Fight AIDS, TB, and Malaria

DOTS Strategy Refresher

• Government commitment to sustained TB control activities

• Case detection by smear microscopy in symptomatic individuals

• Standardized 6-8 month regimes with DOT for at least first 2 months

• Regular, uninterrupted supply of TB drugs• Standardized recording/reporting system

DOTS Strategy

• Developed to address irrational care

• Not a one size fits all approach

• DOT does not require health workers

• OR to determine appropriate settings for alternate care delivery systems

• Community-based care (CBC) projects

• Private sector involvement

DOTS Strategy

Community Based Care

• CBC successful approaches include:– Good collaboration between general health services, the

TB control program and the community – Good education of the TB patient and his or her family – Good training for community DOTS supporters as well as

health workers – Good systems of supervision of community DOTS

supporters by TB program staff

• Guidelines for CBC implementation in future

TB Control Program PhilippinesTB Control Program PhilippinesDOTS Strategy Private Sector

ACTION TAKEN BY TB SYMPTOMATICS

None 43%

Self-medication 31%

Hospitals,mostly private 4%Traditional healers 2%

Public Health Centers 8%

Private MDs 12%

Source: 1997 National Prevalence Survey, Philippines

TB Control Program PhilippinesTB Control Program Philippines Private-Public Partnerships in

TB Control

TB Control Program PhilippinesTB Control Program Philippines Private-Public Partnerships in

TB Control • Challenges/Constraints:

– Stigma– Overburdened public health sector– Limited private sector participation

• Opportunities: – Philippine Coalition Against

Tuberculosis (PhilCAT) - ground for collaboration

– Private sector models currently providing DOTS services

TB Control Program PhilippinesTB Control Program Philippines

Expected Outputs: (2002-2005)Expected Outputs: (2002-2005)

Baseline TB cure rate data and scale of measurement indicators

Comprehensive pocket of policies, guidelines and regulations

OR strategies to improve and expand TB DOTS in private sector

Private sector TB DOTS service models implemented in specific areas, to demonstrate potential for replication.

TB DOTS approaches/service models are implemented in at least 25 strategic urban cities/ large municipalities nationwide.

Training of TB DOTS in medical schools and behavior change campaigns to improve the health seeking behavior of the public.

Appropriate guidelines and regulations are developed to promote necessary reimbursement program among private health groups.

Regular, Uninterrupted Supply of TB Drugs

• Global Drug Facility

• Global Fund for AIDS, TB, and Malaria

• DOTS-Plus Working Group

• RPM-Plus/MSH

HIV/TB

• Stop TB WG to coordinate global efforts• New TB/HIV framework

– Not simply dual strategy for dual epidemics– Intensified case finding where high HIV– Strengthen health service providers to control

TB as part of overall response to HIV/AIDS– Innovative approaches to support treatment

completion

• USAID support for OR - e.g. ProTEST

Laboratory/Diagnostics Progress

• Microscopy is the primary for of diagnosis• Limitations

• Non-infectious TB cases

• Laboratory maintenance

• Issue-- not reaching goals on case detection• USAID supporting development of TB diagnostic

tools: – “dipstick” - affordable, field appropriate, easy to use,

sensitive in HIV+ and HIV- populations

Surveillance Update

• Annual WHO Surveillance report– Annually reported data– Based on national reporting systems– Trend analysis

• Biannual MDR report– Current data and trend analysis

• Electronic surveillance system– Expanded, translated regionally tailored

TB Monitoring and Evaluation Systems

• Coordinated Effort on Expanded M&E Guidelines – National program monitoring and evaluation– Multinational/donor program assessment– USAID reporting requirements

• Evaluation of Operational Research– Identify best practices– Share lessons learned

• Capacity Building– Enhance the quality of data collected– Improve the interpretation and use

USAID TB Strategy-draft revision

• Expanding and strengthening TB control in priority countries– DOTS, MDR/TB, TB/HIV

• Strengthening of global and regional partnerships • Expanding the cadre of TB experts • Research to improve DOTS and TB control  • Advocacy and communication

• Strengthening the monitoring and evaluation system

USAID Primary Partners

• TB Coalition for Technical Assistance (TBCTA)– Royal Netherlands TB Association (KNCV)– International Union Against TB and Lung Disease

(IUATLD)– American Lung Association– American Thoratic Society– CDC– WHO

• RPM-PLUS• Gorgas Institute

Child Survival & Health Grants Program

• PVOs submitting a “100% TB Application” are exempt from the rule of no more than six on-going grants

• PVOs will need to demonstrate a clearly defined role within the context of a NTP

• Demonstration of past performance / collaboration

• PVOs have the capacity to offer a community-centered approach:– DOT supporters

– Raise awareness / provide education & training

Resources

• www.usaid.gov/pop_health/id/index.html

• Join-stop-tb@healthdev.net

• www.stoptb.org

• www.iuatld.org

• www.artsen.net/kncv

• www.who.int/health_topics/tuberculosis/en/