TUBERCULOSIS and COMPLEX EMERGENCY in LEBANON

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TUBERCULOSIS and COMPLEX EMERGENCY in LEBANON

• BY
• DOCTOR MTANIOS SAADE
• NTP MANAGER-LEBANON
• Eleventh NTP managers meeting
• CAIRO-SEPTEMBER 2006

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WHAT IS A COMPLEX EMERGENCY

• Humanitarian crisis in a country, region or
  society where there is total or considerable
  breakdown of authority resulting from internal or
  external conflict and which requires an
  international response that goes beyond the
  mandate or capacity of any single agency and/or
  the ongoing united nations country program.
• IASC, December
  1994

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CHARACTERIZATIONS OF A COMPLEX EMERGENCY

• Extensive violence and loss of life massive
  displacements of people widespread damage to
  societies and economies
• Need of humanitarian assistance
• Hindrance or prevention of humanitarian
  assistance by political and military constraints
• Significant security risks for humanitarian
  relief worker in some areas

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LEBANON BACKGROUND

• Located in the eastern coast of the
  Mediterranean sea
• -10452 Km square- 4 million inhabitants
• -World bank income country upper middle
  income
• -Population growth rate 1,64
• - Population under 15 years 28
• -Crude birth rate 20.7/1000
• -Crude death rate 4.3/1000
• -Infant mortality 26/1000

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BACKGROUND 2

• 
  HEALTH CARE SYSTEM
• - Mainly private sector with 157
  hospitals(13980 beds) , 6000 Clinics
  ,823dispensaries , 162 labs with microscope .
• - In parallel, there is a public sector with
  32hospitals (2734beds) and a semi governmental
  sector
• 20 semi governmental hospitals (MOH)
• 3 general hospitals (MOH) and 63dispensaries
• 1 military hospital
• -Social sector NGO(75of the PHC services)
• - 13156 Doctors ,majority private(90)

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TB SITUATION IN LEBANON

• 8 TB public control centers, 2 at the central
  level in Beirut 6 at the provincial level
• TB and DOTS Strategy
• The structure of TB services is based on 2
  levels
• - Central level Includes national committee ,
  central committee and scientific committee
• -Provincial level and peripheral level with 6 TB
  control centers, responsible for prevention ,
  diagnosis, treatment ,recording-reporting and
  supervision of DOTS strategy

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TB SITUATION IN LEBANON(2)

• Estimated incidence 11/ 100 000 inhabitants. The
  incidence decreased from 25/100 000 in 1993(993
  cases) to 10/100 000 in 2005(391 cases) -The
  impact of HIV is negligible I TB/HIV co
  infection 1.2/100000 , seroprevalence 0.2 per
  1000 pop
• Primary TB MDR is 0.66
• First launch of DOTS End of 1998
• DOTS ALL OVER June 2000
• 92 Success rate 74 Detection rate
• Launch of DOTS PLUS May2005
• PAL Strategy In progress

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Lebanon situation after the war
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GUIDELINES FOR TB CONTROL ACTIVITIES part of
DOTS strategy

• Detecting TB cases
• -identify TB suspects (TB symptoms cough
  more than 3 weeks ..)
• -diagnose TB among the suspects laboratory
  sputum smear, X-Rays,
• Treatment of TB patients
• - Classification of TB cases by categories
• -Recommended treatment regimens (categories,
  I,II,III IV)
• -Adherence to treatment DOT with free of
  charge services and drugs and uninterrupted drug
  supplies
• Recording reporting system with treatment outcome
• Special considerations HIV, MDR and Non
  Nationals

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GUIDELINES FOR TB CONTROL IN COMPLEX EMERGENCY
Case detection and diagnosis

• Continue to identify suspects
• In term of diagnosis, insist on the laboratory
  smear examination if available and secondary on
  the other examinations X-Ray
• Summer war in Lebanon
• - usually ,case detection and diagnosis made
  in 80 to 90 by the private sector,
• - during the complex, decrease of the
  detection rate displacement of population
  and their inaccessibility to the health
  facilities,
• displacement of private physicians inside or
  outside the country
• weakness of TB lab services in the private
  sector (priority to surgical acts) with presence
  of these activities in the NTP

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GUIDELINES FOR TB CONTROL IN COMPLEX EMERGENCY
Treatment

• Follow the regimen treatment by category
• Try to maintain in a safe place and in good
  conditions the whole TB drugs stock
• Be flexible in term of DOT and distribution of
  drugs
• Try to have the new address of TB patients
• If possible, hospitalize the displaced patients
• Try to find TB patients by local announcement
  using press, TV, radio..

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Treatment(2bis)

• Summer war in Lebanon
• -all TB drugs are available till the end of
  2006
• -supplement stock of drugs sent, during the
  first days of war, from the national level to the
  provincial level operational TB centers
• - ambulatory treatment of TB patients by
  distribution of drugs on a monthly basis
• -weekly media announcement in an attempt to
  catch TB patients (indicating location of
  operational TB centers)
• - hospitalized TB patients (mainly MDR)
  followed by a specialized team (sanatorium)
• -hospitalization of new diagnosed TB patient
  from the pool of displaced people (sanatorium)

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GUIDELINES FOR TB CONTROL IN COMPLEX
EMERGENCY Recording-Reporting, outcome

• Try to maintain a good recording reporting system
  (not easy)
• Nominal electronically system facilitates the
  recording-reporting, the follow-up and tardily
  the treatment outcome
• Summer war in Lebanon
• - mobile phones used between the NTP and the
  chiefs of operational TB centers to assist the
  recording reporting system
• - mobile phones used between NTP and TB
  patients , inviting them to continue their
  treatment
• - the quarterly report should give a better
  clarification of the problem (number of patients
  with their distribution) and the treatment
  outcome will elucidate the efficacy of our action
  during the war period

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GUIDELINES FOR TB CONTROL IN COMPLEX EMERGENCY
MDR -TB/HIV and NON NATIONALS

• Give priority to MDR patients and to TB/HIV co
  infection
• Keep Non Nationals tying with national TB
  patients
• Summer war in Lebanon
• - drugs for MDR patients available till the
  end of 2006
• - majority of MDR patients are hospitalized in
  a safe area in the Lebanese mountain and followed
  by a competent team, in the continuation phase,
  treatment is given exceptionally on a monthly
  basis. Culture and DST still available (lab.
  American university of Beirut)
• - non nationals TB patients most of them left
  the country, some stayed and continued their
  treatment on a monthly basis . Non Nationals
  represent 17 of the total annual number of TB
  patients

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ADMINISTRATIVE ASPECT OF THE PROBLEM

• Designate a central Team for the management of
  the crisis with a focal point. (provincial team)
• Collaborate with WHO, to provide a technical
  support to the MOH(NTP)
• Collaborate with NGO
• Use generators to overcome the electricity cut
  off.
• Transportation car, driver, fuel, road ,
  security level..
• Stay in contact with patients
• Use local possibilities to make of the different
  steps a success and that with the elaboration of
  complex emergency guidelines

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ADMINISTRATIVE ASPECT LEBANON

• Central team composed by the members of the NTP
  central committee. Dr Saade designated as a focal
  point .
• Collaboration and information between the program
  and WHO-Cairo (EMR), during and after the war
• Collaboration with NGO, volunteers , Lebanese
  army, red cross
• Use of generators to overcome the electricity cut
  off in order to stay in contact with partners and
  patients (phones, mobiles, fax and internet) to
  keep drugs in good conditions, to smear
  examination, culture, X-Ray..
• Hot line for any TB difficulties (mobile phone
  NTP manager)
• Gentle agreement between the NTP and the central
  drug store to collect any TB drug given by the
  international community in the NTP central
  pharmacy , and to avoid a bad use of these drugs
  in the Lebanese drug market.
• Use the existing health facilities ,under the
  monitoring and the supervision of competent TB
  people, to serve the displaced TB patients ,
  especially when it comes to continue treatment
  (BAALBEK)

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CONSEQUENCES OF THE COMPLEX EMERGENCY

• Depend on the gravity and the time period of the
  complex
• Perturbation of the DOTS strategy with its five
  elements
• - political commitment TB is still a
  priority?
• - diagnosis by smear is still available?
• -DOT is still followed?
• - drugs are still available?
• - recording reporting system is still
  efficient ?
• Suspension of supervision
• Suspension of meeting, scientific events,
  operational researches.

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CONCLUSION

• EMR is an unstable area (AFGHANISTAN,IRAQ,SUDAN
  , SOMALIA,PALESTINE,LEBANON and..)
• In such circumstances , possible fall of strong
  TB programs
• - Morbidity, mortality and prevalence of
  TB can increase ( poverty and crowded areas ,
  refugees and displaced people..)
• - Detection rate and success rate can
  decrease,
• - MDR can emerge .
• Complex emergency measures should be taken
• - Generally following the TB control
  guidelines
• - Particularly following the local situation
  of each country.
• In LEBANON
• - Perturbation of the DOTS strategy,
  suspension of the PAL strategy, suspension of
  monitoring and supervision, stopping of
  trainings, meetings and operational researches.
• The hope
• - That the period of war, despite its
  atrocity, will have no influence on our NTP
• - That a sustainable peace prevails in our
  region
• - That international agencies ,donors and
  external partners come to our help
• Lebanon is a
  stricken country

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THANK YOU