Subject: Microbiology Topic: Symposium, TB Burden, NTP Lecturer: Dra.
Dalay Date of Lecture: September 13, 2011 Transcriptionist: JAK Stat Editor: the “j” Pages: 1
TB burden, DOTS Tuberculosis - A major public health problem for the past several decades. -A disease that many of us have come across with, maybe from a former patient in the hospital where we worked in, a neighbor, a relative, a friend or maybe even one of us has experienced having TB - Anyone of us can get TB. - preventableand curable Facts about TB: Caused by a “rod-shaped” bacteria = Mycobacterium tuberculosis
TB is NOT spread by: shaking someone’s hand sharing food or drink touching bed linens or toilet seats sharing toothbrushes kissing
Natural Course of TB:
Commonly affects the lungs (pulmonary TB) Can also cause extra-pulmonary disease (such as in lymph glands, bones, joints, abdomen, brain, kidney etc.). Contagious disease (like that of common colds) Spread through the air from one person to another
Transmission: Transmitted from person to person via: coughing sneezing talking spitting
When people become infected with TB bacilli, some will develop the disease or become sick and some will not. The immune system either kills the bacilli or “walls off” the bacilli where they can lie dormant or “sleeping” for years. But when the immune system becomes weak, the bacilli will multiply and will lead to active disease. Left untreated, a person with active TB disease will infect an average of 10-15 people per year. 1/3 of the world’s population or around 2 billion 1 people are infected 1 in every 10 of those people will become sick 2 with active TB
SOURCE: 1 WHO Global Tuberculosis Control Report 2009 2 WHO 10 Facts About Tuberculosis (http://www.who.int/features/factfiles/tuberculosis/en/)
Do NOT spit anywhere; WASH hands properly and; Protect your family and friends from TB — take the correct kind and quantity of drugs and complete the treatment! The Burden of TB
Signs and Symptoms: Pulmonary TB is suspected if a person has: o o cough for 2 weeks or more With or without: fever chest and back pain poor appetite weakness weight loss night sweats blood in sputum or phlegm
Global Situation National Situation Local Situation
Tuberculosis in the World, 2007: 1/3 of global pop ≈ 2 billion New TB cases 9.27 million (139/100,000 pop) New ss+ TB cases 4.1 million (61/100,000 pop) Cases of MDR-TB 0.5 million Deaths from TB (non-HIV) 1.3 million (20/100,000 pop) Deaths from TB (HIV positive) 456,000 SOURCE: WHO Global Tuberculosis Control Report 2009 This slide tells us about the Global situation of Tuberculosis gathered last 2007 from the WHO Global TB Control report. It shows that there are about 2 billion individuals infected with tuberculosis which is approximately 1/3 the global population. Most of the estimated number of cases in 2007 were in Asia (55%) and Africa (31%). There were also 9.27 million new cases of all types tuberculosis and 4.1 million of these cases are new sputum smear positive meaning that they have Pulmonary Tuberculosis. There were an estimated 0.5 million cases of multi-drug resistant TB (MDR -TB) in 2007. An estimated 1.3 million deaths occurred among HIV negative incident cases of TB (20 per 100 000 population) in 2007. There were an additional 456,000 deaths among incident TB cases who were HIV-positive; these deaths are classified as HIV deaths in the International Statistical Classification of Diseases (ICD-10). People infected
*The person should immediately seek medical consultation and must have his/her sputum examined to detect the presence of TB bacilli. TB is CURABLE! Tuberculosis is curable and can be treated with a six-month course of antibiotics which are available in DOTS facilities for FREE.
Drug Resistant TB: Resistant TB develops due to improper use of antiTB drugs improper treatment regimens e.g. wrong dosage, wrong time, patient does not complete whole courseof treatment
Two Classifications of Drug Resistant TB: a. Multi drug-resistant TB (MDR-TB) is a form of TB that does not respond to the standard treatment using first-line drugs. Specifically rifampicinand isoniazid. Extensively drug-resistant TB (XDR-TB) occurs when resistance to second-line drugs develops.
Prevention and Control: ALWAYS cover your mouth when you cough and sneeze;
14.8% of TB cases are co-infected with HIV
SOURCE: WHO Global Tuberculosis Control Report 2009
TB Burden in the Philippines, 2007: Aboveare the 22 High-burden Tuberculosis Countries indicated by the blue areas. According to the WHO, the 22 high-burden countries (HBCs) collectively account for 80% of incident (new) TB cases globally. Countries which have a high number of TB cases are mostly found in India, China, Indonesia, Nigeria, South th Africa, and others including the Philippines which ranks 9 among the 22 high burden countries. 9 among the 22 High burden countries
nd th 1
2 in the Western Pacific Region (New ss+ cases) 6 leading cause of Morbidity and Mortality 115,000 per year (New ss+ cases) 98 Filipinos die daily
WHO Global TB Control Report 2009
Tuberculosis Control in the Western Pacific Region 2009 Report
6 billion of annual income lost due to TB morbidity 27 billion pesos lost (foregone wages) annually 8 billion pesos in actual wages lost
Source: The Burden of Disease, Economic Costs and Clinical Consequences of Tuberculosis in the Philippines, 2005, Peabody, John et al.
Here is another map indicating the Estimated number of new TB cases (all forms of TB which maybe either extra-pulmonary or pulmonary) as of 2007 represented by the different colors depending on the number of cases. It shows that India and China have more than 1 million new cases indicated by the orange colored areas, while the Philippines has more than 100,000 new cases. The Extent of the Problem: 1/3 of the global population is infected with Mycobacterium tuberculosis 8 million suffer from TB annually 95 % of the cases in developing countries ≈ 2 million die of TB every year
Economically productive individuals who have the disease make them unfit to work and must also impose themselves to self-quarantine due to the highly infectiousness/contagiousness nature of TB. This has a very big impact economically because according to Peabody and colleagues at least 27 billion pesos is lost annually due to premature deaths and around 8 billion in actual wages are lost (due to TB morbidity and mortality).
Magnitude of TB: A Comparison of the (3) National TB Prevalence Surveys: 2007 NTPS Conclusions: The burden of TB disease in the country has declined over the past 10 years since the launching of the DOTS program. Significant decline in TB disease: o o 35.5% decline in ss+ Pulmonary TB 42.0% decline in sputum culture + PTB
1983 1 NTPS
1997 2 NTPS
2007 3 NTPS 2.0
Prevalence of Culture (+)/1000 MDR-TB cases among New
The rate of MDR-TB showed no significant difference from 1997 indicating no increase in generation, but ongoing transmission NTP interventions in the past decade has lead to better control, prevention, case management and better survival of TB patients Rate
MDR-TB among Re-treatment cases
Trend of TB* Mortality and Morbidity (Rate/100,000 Philippines 1993-2003)
New SS (+)’s by Gender and Age Groups, (2004-2008):
This slide shows the 10 year trend of TB Mortality and Morbidity rate in the Philippines from 1993 to 2003. The pink bars represent the morbidity rate while the blue line refers to the mortality rate. From 1997 to 1998, there was a significant decrease of the morbidity rate and continues to decrease until 2003. For the mortality rate, there also has been a decrease from 1999 to 2003. Our goal is to reach less than 10 deaths per 100,000 cases.
According to the data from 2004-2008, there are more males than females who have acquired TB. The majority of those who have TB belong to the economically productive group (25-54). THE NATIONAL TUBERCULOSIS CONTROL PROGRAM (NTP) Tuberculosis has been a major public health problem in the Philippines for the past several decades. Successful TB control depends largely on the capacity of various health care facilities to administer TB management based on technically sound, evidence-based, and consistent policies and procedures. Thus, the National Tuberculosis Control
Program (NTP) was established to address the problem of TB in the Philippines. VISION: A COUNTRY WHERE TB IS NO LONGER A PUBLIC HEALTH PROBLEM - which coincides with the UN’s Millennium Development Goals for Health. Health in the Millennium Development Goals Goal: To contribute to the attainment of the Millennium Development Goals (MDG 6, Target 8) MDG 6: To have halted and begun to reverse the incidence of TB. Target 8: Reduce the TB prevalence and death rates by 50% by 2015 The eight UN Millennium Development Goals (MDGs) – which range from halving extreme poverty to halting the spread of HIV/AIDS and providing universal primary education, all by the target date of 2015 – form a plan agreed to by all the world’s countries and all the world’s leading development institutions. The Millennium Project was commissioned by the United Nations SecretaryGeneral in 2002 to develop a concrete action plan for the world to achieve the MDGs and to reverse poverty, hunger and disease affecting billions of people. One of its goals is to Combat HIV/AIDS, malaria and other diseases and one of its specific targets is to halt by 2015 and begun to reverse the incidence of Tuberculosis, and also to reduce the TB prevalence and death rates by 50% by 2015.
As we can see from the picture, the DOTS strategy which stands for Directly Observed Treatment Short Course was officially adopted by the NTP in 1996. While in 2003, a 100% DOTS coverage in the public sector was attained and this is also when the PPMD was created. Tuberculosis is curable and DOTS is a strategy which aims to address this. WHY TB D.O.T.S.? •Cost effective •Proven to reduce morbidity and mortality (e.g. Peru) •Science and evidence based •Shortest and most effective chemotherapy we have •Interrupts TB infection in populations since it treats as a priority the sputum smear (+) cases •Can successfully and permanently treat > 90% of identified TB cases •Can add years of life to an HIV-positive individual •DOTS prevents new infections and development of MDRTB 5 Elements of DOTS Five key elements are essential for the DOTS strategy to be successful: 1.Sustained political commitment means to increase human and financial resources and make TB control a nationwide activity as part of a national health system. The government must ensure continuous monitoring and improvement of the quality of DOTS implementation. 2. Access to quality-assured TB sputum microscopy for case detection among people with, or found through screening to have, symptoms of TB (most importantly prolonged cough). Special attention is necessary for case detection among HIV-infected people and other high-risk groups, e.g. people in institutions. Since sputum microscopy remains to be the most cost effective way to detect pulmonary TB, there must be sufficient number of laboratories to carry out quality microscopy services. 3. Standardized short-course chemotherapy to all cases of TB under proper case-management conditions, including the direct observation of treatment.
4. Uninterrupted supply of high quality drugs with reliable drug procurement and distribution systems. TB drugs must always be made available, accessible and affordable. 5. Recording and reporting system enabling outcome assessment of each and every patient and assessment of the overall program performance. Records and reports are the source of statistics on TB that are used to guide programs. DOTS is still the overarching framework of the NTP Targets: •Case Detection Rate (CDR): 70% or more •Cure Rate:85% or more •Treatment Success Rate (TSR): 85% or more This graph shows the trends since the 100% DOTS coverage of the public sector of the operational targets namely the Case Detection Rate (CDR), Cure and Treatment Success rate of Tuberculosis from 2003 to 2008. For CDR (indicated by blue line), there was an increase from 61% in 2003 to 76 % in 2008. While for the Cure Rate (indicated by red line), there was an increase from 2003 to 2006 then slightly decreased from 2006 to 2008. The Treatment Success Rate (indicated by green line), shows an increasing and high TSR. From the given data, it shows that we have achieved the Global targets in CDR and Treatment Success Rate in 2004.
The DOTS strategy focuses on the following operational targets: to detect at least 70% of the new smear-positive TB cases, cure at least 85% of these cases, and with a treatment success rate of 85% or more. With direct observation of treatment, it is anticipated that 80% of deaths attributed to TB worldwide will be prevented.
Targets for Fighting Tuberculosis NTP: •Detect at least 70% of the estimated smear positive TB cases. •Cure at least 85% of the detected cases Global: •Reduce Morbidity and Mortality by 50% by 2015 In order to combat TB, specific targets were set by the NTP and the MDG. For the NTP: •Detect at least 70% of the estimated smear positive TB cases. •Cure at least 85% of the detected cases And the Global target for fighting tuberculosis is: •To reduce Morbidity and Mortality by 50% by 2015
Data gathered last 2007 for the Treatment Outcome shows in this pie chart that 81% were cured using the DOTS strategy while 9% completed the chemotherapy which gives a total of 90% for the Treatment Success Rate.
PPMD (private public mix DOTS) Accomplishments Future direction of PPMD (private public mix DOTS) NTP External Evaluation • July 2002 by WHO, JICA, USAID, CIDA-World Vision and Medicos del Mundo • Findings: – Acknowledged the remarkable expansion and coverage of public sector DOTS – Need to focus on quality-control as far as DOTS implementation is concerned – Correct some problems in drug supplies – Focus on promoting private-public mix (PPM) in DOTS implementation – WHY ENGAGE THE PRIVATE SECTOR This slide demonstrates that among the 22 high-burden countries with Tuberculosis in 2007, the Philippines is within the “target zone” together with China and Vietnam. This indicates that not only have we achieved the set targets for CDR and TSR, but also surpassed the given targets. To summarize what has been discussed for this topic: • The National Tuberculosis Control Program (NTP) was established to address the problem of TB in the Philippines. • The NTP adopted the DOTS strategy in 1996 which is proven to be the most successful and costeffective treatment strategy. • The DOTS strategy focuses on the following operational targets: - to detect at least 70% of the new smear-positive TB cases and; - to cure at least 85% of these cases. • The Five key elements that are essential for the DOTS strategy to be successful include: political commitment; sputum microscopy; directly observed treatment; uninterrupted supply of drugs; and recording and reporting. • Since the 100% DOTS coverage of the public sector, the Philippines has achieved the global targets for Case Detection Rate (CDR) and Treatment Success Rate (TSR) in 2004 and has surpassed these targets last 2007.
WHY ENGAGE THE PRIVATE SECTOR
Action Taking Behavior of TB Symptomatics
Private MD Health Center Family Member Hospital Traditional Healer
(This pie chart represents the Action Taking Behavior of TB Symptomatics in 1997 wherein large proportion approximately 36% of TB patients seek the care of private MDs followed by those seeking care in health centers) TB Case Load in the Private Sector (2000)
Retail Sales (USD Million)
Cost/ Course (USD)
The Need for Public-Private Collaboration • • • PPMD (private public mix DOTS) strategy Structure of PPM (private public mix) DOTS Implementation PPMD (private public mix DOTS) Installation India 85.3 100 853000
Survey of KAPs of Private Practitioners Indonesia 12.3 100 123000 (This table shows two surveys that were independently conducted about the Knowledge, Attitudes, and Practices (KAPs) of Private Physicians regarding Tuberculosis. These surveys were conducted by Medicos, which did a telephone survey of over 1300 private physicians, and PhilCAT (philippine coalition against TB) which did a more limited study in the NCR and Cavite areas covering 188 MDs. Both studies showed similar findings in that private MDs see an average of 5-10 new TB patients per month, 88 to 95% use X-rays and only 17 to 59% use sputum microscopy as a method to diagnose TB. Adherence to NTP guidelines ranges from 10.7-16% and practice treatment variations can be as much as 64 to 80 variations.)
Medicos del Mundo* 2001 n=1300
PhilCAT/CDC 2002 n= 188
Need for Private Sector Involvement Total surveyed Area X-rays Sputum AFB Treatment adherence to NTP Ave # new TB pxs seen/month Practice tx variations 1355 nationwide 87.9% 17.4 10.7 188 NCR-Cavite 95% 59 16 • • As government reaches almost 100% coverage in the public sector, it is apparent that global and national targets of 70% detection rate cannot be reached without active involvement of the private sector; The Philippines has a large private sector (for profit and non-profit ); Private sector is a valuable resource available and widely utilized even by the lower income groups.
The PPMD Strategy • It is a strategy adopted by the Department of Health (DOH), in partnership with the Philippine Coalition Against TB (PhilCAT) and other various organizations, in addressing the problem of TB in the country. PPMD is broadly defined as “any initiative or collaboration involving the public and private sector working towards TB Control”. This strategy integrates private practitioners in the NTP (national TB control program) through referral of TB patients to PPMD units.
(Further evidence of the significant role played by the private sector is shown in this table which estimates TB drug sales. Studies have shown private MD tend to over diagnose and over treat TB patients but that perhaps half of TB patients default after going through treatment and so for the Philippines, we can probably double the figure of 83,000 as far as private sector is concerned)
PMMD BACGROUND • (1994) = Philippine Coalition Against Tuberculosis was established • (1995) = First PPM DOTS : UST • (1996 ) = Public sector introduced DOTS • (1997) = Private Sector management of the National TB Prevalence Survey • (2001-2004) = CDC implemented and evaluated 5 PPMD Models • (2003) = PPM DOTS was officially adopted as a strategy • (March 2003) = Declaration of CUP on TB = Comprehensive and Unified Policy (CUP) management was declared and signed by the public, private, academic, other government agencies than DOH, NGOs, academia and corporate sector.
The PPMD Strategy Accomplishments • The total Coordinating structures and PPMD units that have been established in the country as of 2009 are: 1 NCC (national coordinating committee), 16 RCCs (regional coordinating committee), and 221 PPMD units with a coverage of 36 million or around 40% of the total population. The list of units that are green in color represent Round 2 units, while those that are color blue belong to Round 5 units. The units that are red in color are Non-Global Fund PPMD units.PPMD Contribution to CDR in Areas Covered (2004 – 2008)
PPMD Contribution to National CDR (2004 – 2008)
What are the Objectives of the PPMD? • Increase case detection and synchronize management of TB among all health care providers Ensure compliance to the National Tuberculosis Program policies for case finding, case holding, recording and reporting by all health care providers
15% 11% 10% 7% 5%
2.5M 7 units 6M 28 units 14 M 70 units
30 M 168 units
36 M 220 units
0% 2004 2005 2006 2007 2008
What are the Approaches for a PPMD? Public-initiated PPMD (LGU – provincial and city coordinators) Private-initiated PPMD ((UST, MaDocs, MMC, DLSUMC)
(Since the implementation of the PPMD strategy from 2004 to 2008, there has been a significant contribution to the Case Detection Rate (CDR) of TB. This graph basically shows that there is an increase in CDR from 7% in 2004 to 14% in 2008.)
PPMD Contribution to National CDR (2004 – 2008)
10% R2 8% R5 NGF Total
A PPM DOTS unit shall implement the NTP in consonance with its existing operational policies, standards and guidelines.
88.7M R2 - 70 units
90.4M R2 - 70 units
3% 3% 2% 1%1% 1%
0% 2004 2005 2006 2007 2008
(The graph shows the PPMD contribution to the National CDR from 2004 to 2008. There is an increase in CDR as the number of installed PPMD units also increases) Trend of CDR: Public and with PPMD (2004 – 2008)
The picture Illustrates the proposed PPMD expansion sites shown by the yellow dots while the purple areas represent the proposed 44 Provincial Coordinating Committee Sites or PCCs for PPMD. The Provincial Coordinating Structure for PPMD
60 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008
A new program has been started early the year of 2009 for which there had been a recent Situational Analysis Workshop during the month of July. Ladies and gentlemen, may we introduce the Provincial Coordinating Structure for PPMD, which launched last December 2009. Objectives of the PCC
General – Help reduce the prevalence, incidence and mortality of TB by 50% in 2015 and beyond 50% from a baseline established in 2000 in support of the Millennium Development Goals (MDG) for poverty alleviation.
(The trend of CDR when combining the public and with PPMD shows that the PPMD (represented by the red line) by itself has contributed an additional 6% to the total CDR of the country last 2008. This illustrates the important role of the PPMD in the control against TB) What is the Direction of PPMD in the Country • Country wide engagement of health care providers using the ISTC; Expand TB services to cover TB in children & MDRTB.
Specific – Detect an additional 6% of smear (+) TB cases existing nationwide and maintain a treatment success rate of 85%.
Strategy • Establish a Provincial Coordinating Committee who will initiate and sustain the engagement of all non-NTP care providers both in the public and the private sectors using the International Standards of TB care (ISTC); Link existing DOTS facilities and all care providers to ensure universal access to quality DOTS services by all TB patients and Generate political commitment towards the attainment of Millennium Development Goals for TB control.
Proposed PPMD Expansion Sites
Engagement Process of Non-NTP Providers • Through the PCC Core Team and the committees, the engagement of non-NTP care providers becomes a step-by-step process. On this diagram, the engagement process is symbolized by the horizontal arrow pushed forward by steps 1
through 8, with each step mostly prepared and performed by the core teams. • Step 1: the preparatory visit by central/regional teams, is done to explore possibility of partnership with LGU to establish Provincial Coordinating Committee for PPM DOTS. Step 2 follows, which trains the committees on situational assessment for their respective provinces—this is in preparation for PCC members to learn competencies in conducting the situational assessment phase, which is step 3 of this process. Once data has been gathered and analyzed, step 4 — the strategic planning workshop—follows. This aims to incorporate what data has been gathered from the situational assessment with strategies for the engagement of non-NTP providers. Next is step 5, which is the DOTS advocacy symposium to promote awareness on the global, local, and provincial situations on TB control and care. This targets DOTS providers and private care providers. Step 5 precedes step 6, which is a DOTS training for referring physicians and also includes an LOA signing. Step 7 is the launching of Provincial PPM Initiatives and the signing of their respective Memorandums of Understanding. Lastly would be step 8: the monitoring and evaluation of provinces.
On one hand, the chair leads in identifying, targeting, and engaging all public health practitioners in the province, while on the other hand, the co-chair does the same with the target focused on soliciting commitment from the private health services, NGOs (Non Govt Org) targeting vulnerable sectors as beneficiaries, medical schools, pharmacies, practitioners of traditional/alternative medicines, and other organizations that can help in attaining the over-all goal and purpose of the NTP. Both share equal status and are supported by a vice-chair, who is elected by, and from among, the representatives of the national governments, a secretariat is made up of the NTP provincial team from one’s PHO, and a secretary—who is the provincial NTP medical coordinator. Principal Functions of PCC The PCC has three principal functions to be able to achieve the project’s goals. Primarily, the PCC engages all non-NTP care providers in the province, both public and private using the International Standards of TB Care by developing a plan for the engagement of all non-NTP care providers and monitor this. The PCC also reports on the non-NTP care providers engaged and address issues related to sustaining the said engagement. The PCC will also provide all TB patients access to quality TB care by linking existing DOTS facilities and all care providers by developing strategies to provide vulnerable and special population groups, like indigenous people and prisoners, to access quality TB care and its monitoring. The Committee also ensures the availability of laboratory supplies and antiTB drugs—and ensures the overall quality of DOTS services provided. Also, the PCC generates political commitment to sustain PPM initiative beyond the project life by developing a PPM sustainability plan and the mobilization of resources from private and public sectors as well as the community and the monitoring of sustainability direction. TB Control Initiative is like a puzzle. If one piece of the puzzle would be lost, the beauty of the picture would not be appreciated. Each piece can represent each of us here in this room, if are not with us in TB Control Initiative, then the puzzle of controlling tB in our midst could not be possibly done.
Organizational Structure of PCC The Regional Coordinating Committee, in accordance with NCC directions, policies, and standards, oversees the establishment of the (Provincial) PCC, providing technical advice to the PCC as necessary in conduct of their functions and plans, along with enforcing the policies, guidelines, and standards set in their respective regions while ensuring that these are consistent with the direction, strategy, and policies of the NTP DOTS. The PCC is comprised of a chair- an LGU representative who is also the province’s PHO (provincial health office), cochaired by the province’s private health sector representative.