June 30, 2010TB Program
Thailand MOPH – U.S. CDC Collaboration
TB Project Implementation: TB Project Implementation: Impact on NTP? Impact on NTP?
OverviewOverview
SurveillanceSurveillance
ResearchResearch
TrainingTraining
Technical AssistanceTechnical Assistance
Active Population-Based Active Population-Based Surveillance and Enhanced Control Surveillance and Enhanced Control
of TB: The Thailand TB Active of TB: The Thailand TB Active Surveillance Network (TB-Net)Surveillance Network (TB-Net)
Partners and project sitesPartners and project sites
Ministry of Public HealthMinistry of Public Health
Bangkok Metropolitan Bangkok Metropolitan Administration (BMA)Administration (BMA)
Research Institute of Research Institute of Tuberculosis (Japan)Tuberculosis (Japan)
Thailand MOPH – U.S. Thailand MOPH – U.S. CDC CollaborationCDC Collaboration
Non- and inter-Non- and inter-governmental organizationsgovernmental organizations
Funded: USAID, GDD,GAP Funded: USAID, GDD,GAP
Chiang RaiChiang Rai
TakTak
Ubon-ratchathaniUbon-ratchathani
BangkokBangkok
PhuketPhuket
Difference between Active Difference between Active Surveillance Network and Routine Surveillance Network and Routine
TB Control in ThailandTB Control in Thailand
Active, not passive, surveillance of diagnosed casesActive, not passive, surveillance of diagnosed casesData from private, NGO, and non-MOPH government Data from private, NGO, and non-MOPH government facilitiesfacilitiesElectronic recording of individual cases, not summaryElectronic recording of individual cases, not summaryExpanded data collectionExpanded data collectionContinuous data analysisContinuous data analysisMore than microscopy: culture (province), DST More than microscopy: culture (province), DST (referred)(referred)Integration of HIV counseling, testing, treatmentIntegration of HIV counseling, testing, treatment
Goal of TB NetGoal of TB Net
Develop models for TB prevention and Develop models for TB prevention and control bycontrol by– Measuring incidence of diagnosed TB, HIV Measuring incidence of diagnosed TB, HIV
co-infection, and MDR-TBco-infection, and MDR-TB– monitoring epidemiologic and clinical features monitoring epidemiologic and clinical features
of TB of TB – developing, studying, implementing, and developing, studying, implementing, and
monitoring TB prevention and control monitoring TB prevention and control strategies in Thailandstrategies in Thailand
Objectives of TB NetObjectives of TB Net
Develop model program for measuring incidence, Develop model program for measuring incidence, mortality from TB, TB/HIV, and MDR-TB, and to mortality from TB, TB/HIV, and MDR-TB, and to monitor changes over time;monitor changes over time;
Use surveillance data to assess impact of public Use surveillance data to assess impact of public health interventions, detect outbreaks, allocate health interventions, detect outbreaks, allocate resources, guide public health and clinical resources, guide public health and clinical practice;practice;
Build human resources and technical capacity in Build human resources and technical capacity in epidemiology, laboratory, and information epidemiology, laboratory, and information technology;technology;
Develop platform for operational research on TB Develop platform for operational research on TB and TB/HIV, and to assess the impact of public and TB/HIV, and to assess the impact of public health interventions.health interventions.
Activities of TB-NetActivities of TB-NetAll persons diagnosed with All persons diagnosed with TB in public and private TB in public and private health care facilitieshealth care facilitiesStandard epidemiologic data Standard epidemiologic data at beginning and end of at beginning and end of treatmenttreatmentCulture, susceptibility testingCulture, susceptibility testingHIV counseling, testingHIV counseling, testingMonitor HIV care services for Monitor HIV care services for TB patientsTB patientsElectronic recording and Electronic recording and reportingreporting
Tre
atm
en
tDia
gn
osi
s
HIV
TB
Private Sector
Healthcare
Surveillance
Drug-resistance
Research
Have we met the objectives?Have we met the objectives?
Model to assess incidence/mortalityModel to assess incidence/mortality
Assess interventions, guide practiceAssess interventions, guide practice
Build epi, lab, IT capacityBuild epi, lab, IT capacity
Platform for operational researchPlatform for operational research
>10 manuscripts published addressing >10 manuscripts published addressing programmatic and surveillance questionsprogrammatic and surveillance questions
Many aspects of TB Net now routineMany aspects of TB Net now routine– TB/HIV initiatives (PITC, ART training)TB/HIV initiatives (PITC, ART training)– Access to liquid cultureAccess to liquid culture– Electronic data collectionElectronic data collection
Have we metHave we met22ndnd Global Plan to Stop TB, 2006-2010? Global Plan to Stop TB, 2006-2010?
DOTS expansion and enhancementDOTS expansion and enhancement
Address TB/HIV and MDR-TB Address TB/HIV and MDR-TB
Establish Public-private partnerships Establish Public-private partnerships
Enable and promote research Enable and promote research
Strengthen health-system Strengthen health-system
Empower patients and communitiesEmpower patients and communities
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√
√
?
Policy ChangePolicy Change
ImpactImpact TUC/TB ContributionTUC/TB ContributionNational policy adopted to National policy adopted to perform HIV counseling and perform HIV counseling and testing on TB patientstesting on TB patients
Built evidence base; tested Built evidence base; tested strategy; financial support for strategy; financial support for planning workshop in Viet Nam; planning workshop in Viet Nam; technical assistance on drafting technical assistance on drafting initial planinitial plan
National TB recording / National TB recording / reporting system revised to reporting system revised to include HIV-related datainclude HIV-related data
Built evidence base;; revised Built evidence base;; revised national forms based largely on national forms based largely on forms developed for Ubon forms developed for Ubon projectproject
Better Public Health OutcomesBetter Public Health OutcomesImpactImpact TUC/TB ContributionTUC/TB Contribution
Increased case finding in Increased case finding in Bangkok, PhuketBangkok, Phuket
Provided infrastructure and technical Provided infrastructure and technical guidance to enhanced public and guidance to enhanced public and private collaboration, TB program private collaboration, TB program monitoringmonitoring
Decreased death rate and Decreased death rate and increased TB success rate among increased TB success rate among TB/HIV in Ubon, and Chiang RaiTB/HIV in Ubon, and Chiang Rai
Provided infrastructure and technical Provided infrastructure and technical guidanceguidance
Increased sputum conversion rate Increased sputum conversion rate and treatment success rate in and treatment success rate in Phuket and BangkokPhuket and Bangkok
Provided infrastructure and technical Provided infrastructure and technical guidanceguidance
Increased proportion of patients Increased proportion of patients receiving HIV counseling and receiving HIV counseling and testing in Bangkok, Chiang Rai, testing in Bangkok, Chiang Rai, Phuket, Tak, and UbonPhuket, Tak, and Ubon
Provided infrastructure and technical Provided infrastructure and technical guidanceguidance
Enhanced Capacity (1)Enhanced Capacity (1)
ImpactImpact TUC/TB ContributionTUC/TB ContributionMore rapid, sensitive diagnostic More rapid, sensitive diagnostic methods for TB in Bangkok. methods for TB in Bangkok. Chiang Rai, Phuket, Tak, UbonChiang Rai, Phuket, Tak, Ubon
Provided infrastructure and technical Provided infrastructure and technical guidanceguidance
Access to routine drug Access to routine drug susceptibility testing for Bangkok,susceptibility testing for Bangkok, Chiang Rai, Phuket, Tak, UbonChiang Rai, Phuket, Tak, Ubon
Provided infrastructure and technical Provided infrastructure and technical guidanceguidance
Electronic recording and reporting Electronic recording and reporting implemented in Bangkok,implemented in Bangkok, Chiang Chiang Rai, Phuket, Tak, Ubon, Rai, Phuket, Tak, Ubon, Bamrasnaradura InstituteBamrasnaradura Institute
Provided infrastructure and technical Provided infrastructure and technical guidanceguidance
Enhanced Capacity (2)Enhanced Capacity (2)
ImpactImpact TUC/TB ContributionTUC/TB ContributionMeasuring outcomes of public Measuring outcomes of public health interventions by health interventions by conducting operational researchconducting operational research
Provided infrastructure and technical Provided infrastructure and technical guidance; Observational study launched guidance; Observational study launched to understand causes of high, early to understand causes of high, early mortality rate in TB/HIV patientsmortality rate in TB/HIV patients
Training of public health staff in Training of public health staff in TB, Laboratory and TB/HIV TB, Laboratory and TB/HIV managementmanagement
Provided infrastructure and technical Provided infrastructure and technical guidanceguidance
Enhanced capacity for TB Enhanced capacity for TB outbreak responseoutbreak response
Outbreaks investigated at Phuket Outbreaks investigated at Phuket Vachira Hospital and Wat Tham Krabok Vachira Hospital and Wat Tham Krabok with laboratory, IT, epidemiologic, with laboratory, IT, epidemiologic, statistical support from TUCstatistical support from TUC
Exporting of ModelsExporting of Models
ImpactImpact TUC/TB ContributionTUC/TB ContributionExpanded TB/HIV partnerships in Expanded TB/HIV partnerships in Northeastern ThailandNortheastern Thailand
Lessons learned in Ubon project Lessons learned in Ubon project applied to other provinces by using applied to other provinces by using resources from GFATMresources from GFATM
Expanded Public- Private-Expanded Public- Private-Partnerships (PPP) in BangkokPartnerships (PPP) in Bangkok
Lessons learned in 2 health centers Lessons learned in 2 health centers (HC) of Bangkok project applied to (HC) of Bangkok project applied to 7 HCs then 19 HCs7 HCs then 19 HCs
WHO TB/HIV training course for WHO TB/HIV training course for SEARO countriesSEARO countries
Curriculum development; Curriculum development; organization; Hosting of site visits at organization; Hosting of site visits at project sitesproject sites
Lab Capacity building to TB Active Lab Capacity building to TB Active Surveillance Network (1)Surveillance Network (1)
Improve lab capacity and ability including Improve lab capacity and ability including
infrastructure, equipments and reagentsinfrastructure, equipments and reagents
Human resource: hiring full time staffs and Human resource: hiring full time staffs and
support staff to present in international support staff to present in international
conferenceconference
Provide Technical support for new diagnostic Provide Technical support for new diagnostic
tools implementation (Liquid media culture, tools implementation (Liquid media culture,
Capilia TB and Hain test)Capilia TB and Hain test)
Develop and implement Electronic data recording Develop and implement Electronic data recording Support Lab quality control Support Lab quality control
- Collaborate with NTRL for monitoring- Collaborate with NTRL for monitoring and supervisionand supervision
- Participation in External Quality Assurance- Participation in External Quality Assurance of College of American Pathologistsof College of American Pathologists
- Organize training on Standard Operating- Organize training on Standard Operating Procedure of TB culture and Good Procedure of TB culture and Good
Laboratory PracticesLaboratory Practices
Lab Capacity building to TB Active Lab Capacity building to TB Active Surveillance Network (2)Surveillance Network (2)
Do we have Impact on TB Lab ?Do we have Impact on TB Lab ?
Liquid culture Implementation Liquid culture Implementation
Implementation of Rapid Implementation of Rapid
identification by strip speciation identification by strip speciation
(Capilia TB and SD Bioline)(Capilia TB and SD Bioline)
Expansion of Electronic recording Expansion of Electronic recording
for lab datafor lab data
Lessons LearnedLessons Learned
Active surveillance increases case findingActive surveillance increases case finding– Enables comparisons between public and Enables comparisons between public and
private sector TB treatment outcomesprivate sector TB treatment outcomes
Enhanced laboratory capacity, performanceEnhanced laboratory capacity, performance
MDR-TB rates ~1-4% consistent with national MDR-TB rates ~1-4% consistent with national estimates – no hidden epidemicestimates – no hidden epidemic
Increased TB/HIV collaboration for testing, Increased TB/HIV collaboration for testing, linkages to care linkages to care
Rich database for operational researchRich database for operational research
ChallengesChallenges
Have engaged private sector to share data for
monitoring and evaluation, but need strategy to
elevate private sector’s standard of care
System developed and integrated into MOPH, but
many competing reporting systems proposed in
MOPH – need unified national standard for TB
How to translate implementation models into
routine practice and scale up?
2004-20082004-2008
Observational study of HIV-infected TB patientsObservational study of HIV-infected TB patients
2005-20082005-2008
Improving diagnosis of TB in HIV-infected Improving diagnosis of TB in HIV-infected personspersons
2008-20112008-2011
Public health impact of implementing the Public health impact of implementing the GenoType®GenoType® MTBDRMTBDRplusplus assay for diagnosis assay for diagnosis and management of drug-resistant TB in and management of drug-resistant TB in ThailandThailand
Research (1)Research (1)
2009-20102009-2010
Evaluation of a program to enhance TB Evaluation of a program to enhance TB laboratory services in Thailand: Did laboratory services in Thailand: Did providing TB drug-susceptibility results to providing TB drug-susceptibility results to physicians change clinical practice?physicians change clinical practice?
2009-20102009-2010
Performance comparison of SD Bioline TB AG Performance comparison of SD Bioline TB AG MTP 64 Rapid with Capilia TB NEO for MTP 64 Rapid with Capilia TB NEO for mycobacterial species identification from broth-mycobacterial species identification from broth-based culture at ODPC7, Ubon Ratchathanibased culture at ODPC7, Ubon Ratchathani
Research (2)Research (2)
TrainingTrainingOperational research Operational research
Counseling –HIV Diagnosis counseling and Counseling –HIV Diagnosis counseling and testing in TB patientstesting in TB patients
Increasing ART use in HIV-infected TB Increasing ART use in HIV-infected TB patientspatients
TB infection control, collaboration with WHOTB infection control, collaboration with WHO
TB/HIV inter-country, collaborate with WHO TB/HIV inter-country, collaborate with WHO
Laboratory: SOP, AFB, Culture, DST, EQA Laboratory: SOP, AFB, Culture, DST, EQA
Technical AssistanceTechnical Assistance
NTP program NTP program
Outbreak responseOutbreak response
Lab capacity building Lab capacity building
Epidemiological & statistical consultationEpidemiological & statistical consultation
Manuscript development for TB-NetManuscript development for TB-Net
Future DirectionsFuture Directions
Continued focus on 3 key areas: research, Continued focus on 3 key areas: research, training, technical assistancetraining, technical assistance
Focus on lab capacity building and Focus on lab capacity building and improving diagnosis in routine care improving diagnosis in routine care settingssettings
Operational research in improving IC, Operational research in improving IC, ICF/IPT in HIVICF/IPT in HIV
Increased focus on MDR TBIncreased focus on MDR TB
Thank you for your attentionThank you for your attention