Accelerating PMDT scale up in Ethiopia
Ezra Shimeles (MD, MPH)TBCARE/KNCV, Ethiopia
Outline
• Introduction and background• National TB and MDR TB situation• National Performance on TB • MDR TB Scale up• Challenges in PMDT Scale up• Way forward
Introduction and Background: Ethiopia
• 11 administrative units• 90 million population
– 83.6 % in rural
• Economy(IMF)– Agriculture 46.6%– Industry 14.5%– Services 38.9%
• GNI Per Capita:410 (World Bank 2012)
• Life expectancy at birth :59 (World Bank 2011)
The Health Tier System
Health Profile• Health Service
– PHS coverage = 92%
• No. of health facilities– Hospital = 132– Health centers = 3000– Health posts = 15,700
• Human capital– Physicians = 2,115– Health officers = 1606– Nurses = 20, 109– Health extension workers = 34, 382
o Among the 22 HBC
o 16th among the 27 MDR-TB high priority countries
o Incidence:
o 258/100,000 population
o Prevalence :
o TB 237/100,000 population
o The TB related mortality rate : 18/100,000– WHO 2012 TB Report
National TB Situation and NTP overview
MDR-TB burden
– DRS survey 2003-2005• 1.6% New • 11.8% Previously treated
– WHO estimate• 2500 MDR TB Cases are expected from notified cases
annually
– DST requirement per annum: • 6000 new and 6000 retreatment cases (2013)
Tuberculosis Case finding ( All forms of TB (New and retreatment)
Treatment outcome for new PTB+
TB/HIV Integration services
TB/HIV Integration services(2)
National PMDT implementation plan
• Phase I: pilot phase (2009-11)– Target: treat 45 patents – Establish MDR treatment at one TB Hospital in 2009
• Scale Up phases: Five years expansion plan (2011-15):– Target : treat 8,018 MDR-TB patients
– Phase II: Roll out phase using (2011-13)• MDR TB referral centers • Establishment of regional culture and DST centers• Pilots Ambulatory model
– Phase III: Scale up phase(2013-15)• Rapid diagnostic techniques• Ambulatory centers up to Zonal hospitals level
Preparatory phase for initiation• National technical working group on MDR-TB
established. • Guidelines: PMDT; TB infection control • Training material for health care workers• Training of health care workers• Renovation of MDR-TB wards • Registration of second line anti-TB drugs conducted• Procurement of SLDs• Infection control items such N-95 respirators, were
made available• Recording and reporting formats developed and
printed• IEC materials including posters and stickers
developed and printed
Shifting the gear: Preparation for accelerated scale up
• Implementation protocol for ambulatory care for DR-TB
• Customization of training material for middle level
• Selection of TIC and TFC– 1 TIC linked to 8-10 TFC
• Update case finding and diagnostic approaches• Establishment of Sputum sample transport system
• Efficient PSM for SLDs, ancillary drugs• Socio-economic support for patients• Renovations of TICs, TFCs• Improve Human capital and leadership• MDRTB specific ACSM
DR TB Treatment network
Case detection and enrollment,2007-13
Site expansion,2009-13
Scale up plan versus achievement, 2009-13(Total enrolled n=1000)
Enrolment by DST status in Ethiopia, 2009-13
year2001 year2002 year2003 year2004 year 20050%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Proportion of patients by DST status at Enrolment
SuspectedConfirmed
Interim Treatment outcome
Final Treatment outcome(2009-11 cohorts) (Total n=173, Cure Rate 7% ;TSR 80%)
Major Challenges• MDR TB Suspect identification and Sputum sample transportation
challenges
• GeneXpert rollout is very slow
• HR Capacity needs not met
• Poor Lab support for patient monitoring
• Ancillary drugs shortage - What, when, where
• Patient socioeconomic support system not standardized
• Infection control settings in most health facilities not satisfactory
• SLD Supply to TICs and TFCs not fully integrated to the national DSM
• Long turn around time for follow up Culture results
Targets for 2013 -2015 in PMDT• To decentralize the MDRTB treatment service to PHC level by 2015:• TIC at Zone level (40, 70, 96 zones in 2006, 7 and 8 respectively) and at
least one TFC at Woreda level (814 Woredas).• DST screening for
– 10% of New PTB smear positives and – 100% of previously treated TB
• To enroll 100% notified confirmed MDR TB cases for treatment• To achieve 95% interim result of culture conversion• To achieve TSR rate of 80% and reduce the death rate from 15% to 10%• To improve cases finding in pediatric age group
– to reach 7% of all cases
• To provide integrated MDR TB and HIV service in all MDRTB service points
Major partners of MOH for PMDT Roll out
– Global Fund
– WHO, FIND, EXPAND TB Project
– USAID:TB CARE I(KNCV), HEAL TB (MSH), PHSP (Abt.)
– Global Health Committee
– CDC : JHU, I-TECH, ICAP, UCSD
– MSF Belgium
– International Organization for Migration
Thank you