DJIBOUTI PROPOSAL

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DJIBOUTI PROPOSAL

• ORGANISATION, MANAGEMENT AND COORDINATION

2
Number of patients planned for enrolment and
anticipated start and duration of the project

• 50 patients will be enrolled in the first year of
  the project. The start of the project is due on
  June 2009, which coincides with the start of the
  GF R6 grant second phase. The duration of the
  project is 3 years, that is the duration of phase
  2 of the GF R6 grant.

3
Facility of the TB control system that will be
involved in the treatment of patients with drug
resistant TB and the roles and responsibilities

• As Djibouti is a small country with low size
  population, the treatment of MDR TB patients will
  be carried out in the TB and chest diseases
  Reference Centre of Paul Faure to which Resistant
  suspected patients will be referred by all
  facilities involved in TB treatment.

4
Local personnel in the TB control system who will
be responsible for the treatment of patients
affected by drug resistant TB, and their
training/experience in the management of such
cases and use of second-line anti-TB drugs

• In Paul Faure Centre there are three physicians
  who are dealing with the management of MDR TB
  cases. Among these physicians one is trained and
  has experience in such management. The two others
  will need training at national level.

5
Local facilities outside the TB control system
that will be involved in the management of
patients with MDR TB

• No facility other the reference centre will be
  involved in this management

6
Infection control measures

• Like almost all EMRO countries this component is
  very weak. Furthermore the global fund project
  does not foresee such important aspect. And so,
  all required steps will be taken before launching
  the DOTS plus project taking advantage of the
  present MDR management course

7
Plan for the monitoring and supervision of the
project by the project itself and by any external
organisations

• The project will be monitored and supervised by
  the NTP and the MDR focal point with regular
  monitoring visits from the GLC.

8
Training programme for health care personnel,
laboratory technicians, and information
systems/data management personnel

• Before the launch of the project, all doctors who
  will be involved in the treatment of MDR TB
  patients will follow a two-day training course on
  treatment of MDR TB according to the national
  guidelines. This training should also include the
  information system. For this purpose national
  guidelines, the recording and reporting system
  will be developed beforehand.
• Besides, laboratory technicians will be trained
  on culture and DST as part of the global fund
  project R6 and French Cooperation project.

9
Plan for sustainability of MDR TB management
beyond the DOTS Plus pilot project

• The management of MDR TB cases will continue with
  the same organisation and procedures as during
  the pilot project and it is expected that the
  number of patients will decrease and the MOH can
  afford to buy drugs. However after the withdrawal
  of WHO at the end of the project, ways should be
  found to find pharmaceutical firms who will
  accept to sell drugs for a small number of
  patients.

10
Collaboration established with the prison system
for management of the drug resistant TB

• Collaboration has already been established with
  the prison health system on the occasion of a
  survey on case detection in non NTP facilities,
  which is underway. It is expected that all MDR
  cases will be transferred from the prison to the
  hospital for care.

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• LABORATORY ASPECTS

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Laboratory network and main laboratories that
will serve the project

• The only laboratory capable of performing smear
  microscopy, culture and DST is the NRL of Paul
  Faure Centre. The rest of existing laboratories
  perform only smear microscopy.
• The NRL is well staffed with 5 lab technicians
  and is performing the 2/3 of the total smear
  examinations in the country corresponding to
  14000 smear examinations.
• Within the laboratory network for TB control all
  aspects concerning specimen collection and
  transport are standardised. Smear microscopy uses
  Ziehl Nelson coloration techniques. Culture is
  performed with Lowenstein Jensen medium. DST uses
  the proportions method (1 threshold).

13
Schedule, frequency, and extent of
bacteriological evaluation of patients during
treatment and follow up

• For non MDR cases, two specimens are requested
  for follow up of treatment in the second month,
  the fifth month and the end of treatment.
• For MDR cases follow up smear and culture
  examinations will be performed monthly until
  culture conversion, confirmed by two successive
  negative cultures. Then cultures will be done on
  quarterly basis.

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Quality control and quality assurance systems

• Smear microscopy is quality assured through an
  EQA system which was put in place since October
  2007.
• The laboratory network is supervised by the
  National Laboratories Supervisor, who is a member
  of the NTP central unit, with the assistance of
  the NRL.

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Collaboration with an international laboratory
and the quality assurance system associated with
this laboratory

• External Quality assurance of the NRL will be
  carried out through the Supra National Reference
  Laboratory in EMRO, namely the Egypt NRL
  laboratory.

16
Process and infrastructure for specimens
collection, transport and referral

• The NRL is part of the Paul Faure Reference
  Centre and all specimens will be collected in the
  centre.

17
Information management (recording and reporting)
system

• The information system will be integrated in the
  MDR information system.
• The laboratory network performing only smear
  microscopy comprises 16 peripheral laboratories
  belonging the Ministry of Health, out of which 6
  are based in the rural districts, and 5
  laboratories outside the Ministry of Health.

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• FIELD VISIT

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Field visit

• Was beneficial
• Positive points
• Seperation of MDR patients based on
  bacteriological status
• Infection control measures
• To be improved
• Green space for patients or balcony for MDR
  patients