MDR PROPOSAL FOR G'L'C

1
MDR PROPOSAL FOR G.L.C

• PAKISTAN

2
Demography

• POPULATION 160
  MILLION
• ADMINSTRATIVE UNITS 4 PROVINCES
• INCIDENCE ALL
  CASES 181/100000
• 
  SMEAR POSITIVE 81/100000
• 
  MDR (untreated) 2.5
• 
  ACQUIRED MDR ?18
• DOTS STATUS
  100
• CDR SMEAR POSITVE
  70
• TREATMENT SUCCES RATE
  85
• DEFAULT RATE
  3
• TRANSFERRED OUT
  4

3
PROPOSED SITE FOR PILOT PROJECT

• PROVINCE NORTH WESTERN
  FRONTIER
• NWFP is divided into 24 administrative units
  called districts
• POLITICAL COMMITMENT
• Funding Sufficient G.O.P resources with donor
  support of KFW
• Human Resource All districts having full time
  District TB Control Officers with support staff.
• The province has 200 diagnostic centers with 800
  treatment centers and a provincial reference lab
  doing EQA for Peripheral Labs and performing
  culture for AFB only. NO DST available presently.
• Three tertiary care hospitals available

4
Project steering committee

• Project Director Senior Pulmonologist of
  tertiary care hospital
• Members
• a. Programme manager TB Control NWFP
• b. In charge Aga Khan Reference lab
• c. In charge PRL
• d. President Pakistan Chest Society NWFP
• e. Provincial pharmacist

5
Organisation, management and coordination

• The project based in district of Peshawar,
• Duration three years with 100 MDR cases in the
  first year (8-10/month).
• Peshawar
• 19 diagnostic centers, one provincial reference
  laboratory
• 90 treatment centers and three tertiary care
  hospitals involved in DOTS program

6
Organisation, management and coordination

• Patients hospitalized for 10 days for
  investigations, counseling and education.
• Post discharge referred to treatment centers for
  DOT provided by lady health workers. Referred
  back to the tertiary care hospitals monthly for
  routine evaluation and if complications arise.
• Doctors and lady health workers will be trained
  in second line drug therapy.
• Patient information to be sent to the district TB
  control officer responsible for follow up. Who
  will be responsible for drug distribution.
• Infection control policies in accordance with WHO
  guidelines will be adapted for local context and
  implemented.

7
Laboratory aspects

• Specimen for culture and DST will be sent from
  the tertiary care hospital to the reference lab.
• NTP has links with Aga Khan University (AKU)
  laboratory to serve as a national reference
  laboratory.
• AKU has culture, identification, DST and
  molecular capacity. Including strain typing
  capacity.
• It offers training for undergraduate, PhD,
  residency and technologist training programs.
• It has a well established infection control
  program
• Clinical microbiology section has 5 consultants
  and 35 staff.
• The lab. processes over 10,000 TB specimens
  annually DST on approx 2000 cultures/ year.

8
Lab. techniques

• Culture on MIGIT and LJ. Identified MTB/MOTT.
• DST (7H10) for isoniazid, rifampicin, ethambutol,
  streptomycin and Pyrazinamide. Pyrazinamide
  sensitivity with BACTEC.
• Second line for ofloxacin, capreomycin,
  cycloserine and ethionamide.
• Participates in EQA and has internal QC.
• Culture and DST in BSL3 lab.
• The AKU lab will be linked with the supranational
  reference

9
Patient follow up

• Schedule for and extent of bacteriological
  evaluation of patients during treatment /
  follow-up in line with WHO recommendation.
• The Aga Khan University laboratory has a system
  of 170 collection points spread through out the
  country. These receive specimen and forward to
  the central laboratory in Karachi for processing.
  
• The specimen are stored and transported at the
  appropriate temperature and received in the
  central lab within 24 hours.
• The NTP will use this system of collection points
  to send specimen for culture and DST to the NRL.
• Results will be transmitted electronically

10
VISIT TO ABBASIA CHEST HOSPITAL

• Ward
• Wards extremely clean and well maintained
• Infection control policies good
• Patient record well kept
• Laboratory
• Very informative
• Extremely clean
• Functioning beyond capacity designed for.