Scale-up of Programmatic MDR TB Management (PMTM) in the Philippines ROSALIND G. VIANZON, MD, MPH...

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)


LCP DOTS(+) Treatment

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



LCP DOTS(+) Treatment

Center



KASAKADOTS(+)

Treatment Center

Microscopy

CultureTreatment Site (Health Center)


TreatmentCenter



Treatment Center

Treatment Center

DST

Microscopy

Culture Treatment Site (Health Center)


TreatmentCenter



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


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


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.


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


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


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

Scale-up of Programmatic MDR TB Management (PMTM) in the Philippines ROSALIND G. VIANZON, MD, MPH...

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