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Accelerating PMDT scale up in Ethiopia

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.

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Accelerating PMDT scale up in Ethiopia

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  1. Accelerating PMDT scale up in Ethiopia Ezra Shimeles (MD, MPH) TBCARE/KNCV, Ethiopia

  2. 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

  3. 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)

  4. The Health Tier System

  5. HealthProfile • 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

  6. National TB Situation and NTP overview • Among the 22 HBC • 16th among the 27 MDR-TB high priority countries • Incidence: • 258/100,000 population • Prevalence : • TB 237/100,000 population • The TB related mortality rate : 18/100,000 • WHO 2012 TB Report

  7. 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)

  8. Tuberculosis Case finding ( All forms of TB (New and retreatment)

  9. Treatment outcome for new PTB+

  10. TB/HIV Integration services

  11. TB/HIV Integration services(2)

  12. 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

  13. 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

  14. 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

  15. DR TB Treatment network

  16. Case detection and enrollment,2007-13

  17. Site expansion,2009-13

  18. Scale up plan versus achievement, 2009-13(Total enrolled n=1000)

  19. Enrolment by DST status in Ethiopia, 2009-13

  20. Interim Treatment outcome

  21. Final Treatment outcome(2009-11 cohorts) (Total n=173, Cure Rate 7% ;TSR 80%)

  22. 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

  23. 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

  24. 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

  25. Thank you

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