MSF TB Program for Migrants in Tak
Beginnings: MSF TB Programs in Thailand
• First MSF TB Program in Thailand started in 1985 in Karen camps (Shoklo, Maela)
• Residential TB programs with high cure rate and low default rate (AFB (+ ): cure rate = 79,5% completed rate = 5,6% ; default rate = 5,6%)
• Programs not aimed at highly mobile populations crossing the border frequently
Migrant Healthcare: Multiple Challenges
• Large unregistered population of migrants in border areas; Tak province alone with estimated 75,000 to 150,000 unregistered migrants
• Barriers to medical care:
-cost
-security concerns (deportation)
-linguistic and cultural barriers
MSF Migrant TB Program: Planning
• MSF pilot study of migrant factory workers in Maesod in 1999: undertaken with Thai public health and with MSH (Dr. Witaya)
• Census: 71 factories assessed; estimated migrant factory population of 16,000
• Random sample of 1000 workers from census: primarily young adults, 72% single, intermediate education level, only 11% speak Thai, most work >6m in same factory, basic housing conditions- overcrowding with enhanced chance of spreading communicable disease
• Not included in census: day workers, farmers
MSF TB Program for Migrants: Implementation
• MSF TB program reviewed by Thai National TB program advisors and WHO technical advisors to ensure collaboration with Thai national TB program and implementation of DOTS in Thailand; DOTS launched on a national scale in 1996
MSF TB Program for Migrants: Objectives
Target Population:
1) Factory Workers (est. 16,000)
2) Day workers (est. 10,000)
3) Farmers (rural population, difficult to access)
4) Patients crossing from Myanmar for medical care in Thailand
Target Area: Maesot, Tak province and 20 km radius; later extended to Phoe Phra
MSF TB program
TB Village, Maela Camp
Chest Clinic, Maesod
DOTS Program
TB education for migrant factory workers
MDR Program
Chest clinic, MaesodReferral sources: Self (factory teachings, etc.), Maesod
Hospital, Mae Tao Clinic
Facilities: Complex with 14 patient rooms, lab, pharmacy, consultation room
Maesot TB team: 1 physician, 2 medics, 6 DOTS supervisors, 1 lab supervisor, 2 lab technicians, 1 driver; 1 cleaner and 2 cooks
Diagnosis and Treatment
• Diagnosis: Sputum x 3, no culture; other diagnostic modalities: CXR, fine needle aspiration, lymph node biopsy, thoracentesis.
• Treatment: WHO short course
Category 1: 2HERZ/4HR
Category 2: 2HERZS/HERZ/5HER
Category 3: Same protocol as category 1
DOTS Program• All TB treatment by DOTS short course; RX 6 times per
week in Mae Sod and 3 times per week in Phoe Phrae
• Patient population: migrant, undocumented, movements restricted
• DOTS team meets patient at home or workplace by motor bike or car
• Patient identification cards
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MEDECINSSANS FRONTIERES
Age and Sex of 311 M+ patients enrolled between Nov. 15, 1999 and Dec. 31, 2002
• Age Group Male Female Total
0-14 8 8 16
15-24 50 35 85
25-34 68 34 102
35-44 42 21 63
45-54 18 12 30
55-64 10 2 12
65+ 3 0 3
Treatment Outcome in 311 new M+ Patients enrolled between Nov. 15, 1999 and Dec. 31, 2002
• Outcome Number (%) of patients• Cured 215 (69.1%)• Completed 2 (.6%)• Transfer out 11 (3.5%)• Default 61 (19.6%)• Died 8 (2.6%)
success rate(cure +tx completed)=217/311 (69.7%)
Treatment Outcome in 508 patients enrolled between Nov. 15, 1999 and Dec. 31, 2002
Outcome Number (%) of patients
Cured 256 (50.4%)
Completed 100 (19.7%)
Transfer out 14 (2.8%)
Default 72 (14.2%)
Failed 51 (10.0%)
Died 15 (3.0%)
success rate (cure + tx completed)=356/508(70.1%)
Treatment Outcome of 63 Cross Border patients enrolled between Nov. 15, 1999 and Dec. 31, 2002
Cured=6/63 (57%)
Completed=5/63 (8%)
Default=17/63 (27%)
Fail= 3/63 (5%)
Die= 2/63 (3%)
In 2003, 54 cross border patients enrolled in DOTS, 17(31%) have already defaulted during tx.
Another 10 pts did not start tx (default before tx).
Factory TB education and screening
• Factories in Mae Sot area with 20 to 2,000 migrant workers
• TB education program launched November 2002: TB transmission, symptoms, diagnosis, treatment discussed
• Offer of diagnostic sputum testing and treatment free of charge
• 37 factories visited in 2003 with approximately 6,500 workers attending sessions
Conclusions
• DOTS program for migrants has cure rates less than WHO target of 85% but given highly mobile population can be considered a success
• Keys to success:
-security issues: medications brought to migrants;
ID cards
-coordination with other groups: Thai public health, MSH,
WHO, Mae Tao Clinic, local authorities
-culturally sensitive Burmese-speaking staff
Conclusions -2
• DOTS Weak Points:
-Program requires considerable investment of staff
and resources
-High default rates for ambulatory DOTS patients
from Myanmar: cost, security concerns,
inconvenience; other strategies: education based
program, patient access on Myanmar side
-No HIV testing or education done
Conclusions -3
Factory Education: Targeted education and case finding in factories worthwhile but program is hindered by continuing problems accessing factory owners (distrust of NGOs)
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