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 2005

Confirmed 8 109 96 270 157

Suspected 1 5 20 19 17

5%

15%

25%

35%

45%

55%

65%

75%

85%

95%

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