Tuberculosis in LAO PDR

GRABIEL meeting , Annecy 10th-12th Dec 2012

Dr Phimpha Paboriboune, Scientific Director of CICML

Dr Silaphet Somphavong,, Research assistant, CICML

Centre d’Infectiologie Christophe Merieux du Laos (CICML)

Affiliated to Ministry of Health (Communicable Disease Control Dept)

Support by Fondation Merieux , France

Main activities: Hepatitis virus (HBV/HCV), HIV and TB

Plan

• TB situation in Lao PDR

• National TB prevalence survey

– Method

– Result

• CICML research on TB

• Update TB MDR patients in Laos

• Project collaboration in 2013

Diagnostic tools :

- Microscopy by ZN stain in all level of health facility.

- Plan to implement Fluorescence microscopic (LED) for all provincial hospitals in 2013

- Solid culture: NRL, 2 provincial laboratories and CICML.

- Identification of M.tb and Multi Drug Resistance(MDR) Testing by Molecular test (LIPA) is available only at CICML.

1st line drugs : RIF, INH, E , Z and S

Centre of MDR patients

Located at Setthathirath Hospital and 2nd line drugs were available since May 2011, under control of Green Light Committee.

Diagnosis and treatment of TB in Laos

Laboratories:

Culture

• NRL(Center)

• Luangnamtha(Province)

• Savannakhet(Province)

Identification by LIPA:

• CICML

First National TB prevalence survey

NTC and partners conducted a first

National population based TB

prevalence survey in 2010-2011 on a

sample of 40,000 people in 50 clusters

Source: NTP

1. Census collection 2. Interview

3. Chest X-Ray 4. Specimen collection

Role of CICML in the prevalence national survey

Screening patients (age >15 yr) in the field by interview

TB Suspect

Chest X-Ray Microscopy: ZN

Sample collection

Sent sputum to NRL, LNT, SVN to make culture (Ogawa)

All POS cultures sent to CICML for resistance test MTBDR plus

Sent results to NRL/hospitals

scre

en

ing

Dia

gno

sis

MD

R t

est

an

d

Tre

atm

en

t

NTP

CICML

Result at CICML by LIPA (Hain Test) among

Cultures+ from national prevalence survey

48.2% (n=225) TB strains

N=467 culture+

Sensible 93.3% (n=210)

resistance 6.7% (n=15)

51.8% (n=242) Non TB

86.7% (n= 13) Mono Resistance to INH

13.3% (n= 2) Resistance to Rif+INH (MDR)

17 isolates selected among 242 of Non TB

- 2 M.fortuitum

- 1 M.Peregr

- 11 M.spec (unidentified)

- 3 other Bacteria

Result of National TB prevalence survey *

1) Smear Positive cases**:

* Age 15 year and more, adjusted for cluster and participation rate, no imputation of missing results. **Definite and Probable Smear positive cases. ***Definite and Probable Smear positive and Smear negative cases.

263 per 100,000 (95%CI 189-339)

606 per 100,000 (95%CI 458-753)

2) Bacteriological Positive cases***:

Source: NTP

TB Research at CICML : 2010-11

Resistance of MTB to

antituberculous: two

multicentric studies conducted

in 3 hospital in Lao PDR.

First MDR case (XDR)

discovered !

Thakek

n=181 Culture +

76.2% (n=138) TB strain

Sensible 90.6% (n=125)

Resistances 9.4% (n=13)

23.8% (n=43) Non TB

60.5% (n=26) MOTT

39.5% (n=17) Others

Result of multicentric studies

- Mono Resistance to INH : 11

- Resistance to Rif and INH : 2 (MDR-TB)

Among 13 resistance strains:

• New cases (77%) : 10 (INH)

• Retreated (23%) : 3 (1 INH, 2 MDR )

M. Abscessus =1

M.fortutium= 10

M.Scrofulaceum =5

M.gordonae= 1

MOTT (unidentified) =9

Until Nov 2012:

• 1 XDR patient : refuse treatment (Disappeared before

receiving treatment)

• 16 MDR patients :

4 (25%) dead

12 (75%) following their treatment on 2nd line

• 6 patients had resistance to Mono Resistance to Rif

1 (17%) dead

5 (83%) following their treatment

Current situation in Lao PDR regarding MDR (Multicentric study + Prevalence survey + Routine suspected MDR)

Participants : 72 people

• MoH : Curative, Food & Drug Dept.

• Vientiane cap: 5 hospitals, NRL, NTP, CICML.

• 16 provinces : 1 physician, 1 Provincial TB Coordinator, except for 2 hospitals (TB culture): add 1 biologist.

• Support by

Myanmar

China

Thaïlland

Cambodia

Vietnam

Vientiane

Organized

First National Workshop on Drug Resistant Tuberculosis Vientiane, 13th -15th November, 2012

Conclusion/Discussions

Lao PDR has now:

- Capacities for solid culture at National level

- Capacities to detect resistance with LIPA at CICML

- MDR patients receive 2nd line treatment

CICML works closely with NTP: technical support and MDR TB

patient’s management

Questions that arise are:

- Long delay for MDR diagnosis and treatment after diagnosis :

remote areas, severely sick, social economic barrier etc….

- High rate of Non TB/MOTT : Need research for identification

- What are the circulating lineages and trends of M.tb?

• At National level:

Molecular epidemiology on national prevalence survey strains:

Mycobacterial Interspersed Repetitive Unit -Variable Number of Tandem

Repeat (MIRU-VNTR).

- Collaboration with: NTP-CICML-Fondation Merieux

• At regional level :

Molecular Epidemiology of Tuberculosis in Southeast Asia :

Jeunes Equipes AIRD (JEAI) Team (Dr Anne Laure Banuls).

Vietnam: NIHE (Dr Van Anh), VNTP

Cambodia: CENAT, IPC

Laos: NTP, CICML

Perspectives

Khop chay ! Thank you

MoH, CDC Dep.

CICML Team

Fondation Mérieux, CRABIEL net work

National Tuberculosis Center of Lao PDR

National Reference Laboratory

Institut de la Francophonie pour la Médecine Tropicale (IFMT)

Hospitals in VTE Capital and in Provinces