ANALISIS SITUASI MDR TB DI INDONESIA

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ANALISIS SITUASI MDR TB DI INDONESIA

• NTP INDONESIA
• I Wayan Diantika

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INTRODUCTION (1)

• Mono resistance
• MDR
• Poly resistance
• X-DR

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INTRODUCTION (2)

• Magnitude of the MDR-TB Problem
• WHO/IUATLD Global Projection Drug Resistance
• Surveillance, which surveyed fifty-eight
  different countries between 1996 and 1999,
  revealed the presence of new hot spots for
  MDR-TB in addition to those reported in the first
  phase of the WHO/IUATLD Global Project on Drug
  Resistance Surveillance.
• MDR-TB was shown to range from 0 to 14.1 among
• new TB cases. Another review (1999) compiled
  by Harvard Medical School has shown that
  drug-resistant TB exists in 104 countries in
  recent years.

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Development of Drug Resistancefrom the
perspective of the patient

• The presence of drug resistant strains results
  from simple Darwinian pressures, brought out by
  the presence of antibiotics
• Multiple drug resistant strains result from the
  step-wise accumulation of individual resistance
  elements therefore MDR-TB is MAN-MADE

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Problem analysis MDR in Indonesia

• Only 30 of hospitals lt 5 of private
  providers are currently involved in DOTS
• No data on TB drug resistance, except for few
  small studies (West Java MDR 5 !!!).
• Some second line drugs are free available on the
  market and currently used in first line regimens!
• Under detection of re-treatment cases (Cat2)
  Neglect to take treatment history causes miss-
  classification and under-treatment..

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Risk factors for increase of MDR in Indonesia (1)

• Therapeutic chaos prescription of
  inadequate doses / combinations of drugs
• unsupervised treatment, no monitoring
• no registration, no reporting
• high costs to the patients (fees)
• inadequate drug supplies and distribution

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Risk factors for increased MDR in Indonesia (2)

• Many TB patients are treated by private providers
  (not following DOTS).
• Un-controlled use of second-line drugs in
  hospitals and private sector (quinolones,
  kanamycin etc)
• Poor treatment performance in most hospitals
• - low conversion rate - low cure rate
  because many patients drop-out from treatment.

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Risk factors for increased MDR in Indonesia (3)

• Currently the chronic TB cases cannot be treated
  (no DOTS plus available)These chronic cases
  continue to transmit drug resistant TB
• TB- HIV is looming

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Reason MDR-TB as an Alarm
Multi-Drug Resistant TB prevalence


The WHO/IUATLD Global Project on Anti-TB Drug
Resistance Surveillance (1994-1997). Countries
with good TB control gt33 DOTS coverage.
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The basis of anti-TB therapy and MDR-TB HDL -- a
comprehensive approach and unified system of care
Drugs
Smear/Culture
Case management
DST QC
Surgery
Government Health Services
Private Physicians and Hospitals
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THE NEW MDR-TB Guidelines

• a flexible framework approach combining both
  clinical and programmatic aspects of DOTS Plus
• based on essential programme conditions
• But encouraging programs to tailor their
  case-finding and treatment strategies to the
  local epidemiological and programme situation
• Reflect GLC expert consensus and evidence and
  experience from GLC projects thus far

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OBJECTIVES of DRS in Central Java

• To determine levels and pattern of resistance to
  first-line anti-TB drugs among new sputum smear
  positive cases and among previously treated TB
  cases in Central Java province
• To develop a survey model for routine
  surveillance of TB drug resistance in the country
  

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EXPECTED OUTCOMES of DRS

• Level and pattern of resistance to first-line
  anti-TB drugs among new sputum smear positive
  cases and among previously treated TB cases in
  Central Java.
• The outcome of treatment of patients with
  different resistance patterns.
• A model protocol for surveillance of drug
  resistance in Indonesia

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DOTS-Plus

• A comprehensive strategy of the WHO Stop TB
  Partnership, developed by the DOTS-Plus Working
  Group, for the diagnosis and management of MDR-TB
  and other forms of drug resistant TB

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THE DOTS-Plus Framework
1. Sustained Political commitment
2.Diagnosis of MDR-TB through quality-assured
culture and drug susceptibility testing (DST).
3. Appropriate treatment strategies that utilize
second line drugs under proper management
conditions.
4. Uninterrupted supply of quality assured
second-line anti-tuberculosis drugs.
5. Recording and reporting system designed for
DOTS-Plus programs.
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Mainstreaming DOTS-Plus into DOTS

• Referral from DOTS-programme failures, chronics
• Same (reference) laboratory
• Same treatment delivery system
• Drug-procurement and RR adapted but
  integrated!

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Preliminary results of DOTS-Plus projects

• In Estonia and Latvia a large proportion of cases
  enrolled on MDR-TB treatment are new while in
  Peru, Philippines and Tomsk the majority are
  chronic
• Treatment success rates range from 61-82
• Only 2 of patients have stopped treatment due to
  adverse events
• Future plans Case-based data is being collected
  from these pilot sites to serve as evidence for
  MDR-TB policy development

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Supranational Laboratory Network 2005
Coordinating Centre
SRL
Under evaluation
3 New SRLs, 2 new candidates and 120
countries/settings linked to SRLN
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Global Project coverage 2005
Baseline achieved
Ongoing/Finalizing
Planned
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Parameters to consider when designing a DOTS-Plus
strategy

• Government and NTP commitment
• Well performing basic DOTS
• Program is able to implement the 5 components of
  DOTS-Plus
• Rational case-finding strategy using quality
  assured smear, culture and DST ( concordance with
  a SRL)
• Representative DRS data for rational
  country/area-specific treatment design and
  planning of procurement
• Reliable DOT throughout treatment
• Free effective side-effect management
• Regular supply of ALL drugs involved!

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Assessment national level (1)Strengths

• Impressive progress of NTP in recent years
  (expansion, quality and innovations)
• Strong internationally recognized NTP leadership
  focal point for DOTS Plus/lab
• Establishment hospital/NTP linkages
• Increasing collaboration with Medical
  Associations
• Approval by the GFATM and extensive international
  support
• 4 types of SLDs not yet available (no DR)

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Assessment national level (2)Priority issues to
address

• EQA laboratory capacity for DRS and selected
  pilot sites
• Expansion of DRS (for Cat 2 and 4)
• Technical DOTS-Plus development
• Protection of crucial second-line drugs
  (Kanamycine and Quinolones)
• SLD procurement
• HRD plan in the field of DOTS Plus

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Assessment of sites Issues that need to be
addressed in all sites

• Lack of EQA assured lab capacity
• Inadequate use of available second line drugs
  (inadequate regimens, financial barriers, no
  SL-DST)
• No experience with 4 types of SLD
• Alternative for family member DOT
• Funding of hospitalization, lab tests, human
  resources, incentives.

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Next steps

• To do an assessment on MDR situation in
  Indonesia,
• assist in identifying potential pilot sites for
  implementation of DOTS plus
• provide the necessary technical assistance to the
  NTP to starting the project
• To draft a plan for the management of MDR-TB
  cases including the possible application to Green
  Light Committee

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Why should Indonesia consider to use the GLC
mechanism ?

• Access to a complex market of quality assured
  second line drugs
• Preferential prices (pooled procurement)
• Technical assistance benefiting from GLC
  experiences worldwide
• Requirement of the GFATM grant / International
  quality label (donors)

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Expected output from the assessment

• Assessment report with recommendations to the NTP
  (next steps) concerning implementation of DOTS
  plus and requirements for GLC application.
• Draft work plan for implementation of DOTS plus

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DOTS-Plus scale up of through the GLC
September 2005 35 projects
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GLC approved DOTS-Plus projects
AbkhaziaAzerbaijan Bolivia Costa Rica Dominican
Republic Egypt El Salvador Estonia
Georgia Haiti Honduras India Jordan Kenya
Kyrgyzstan Latvia Lebanon Malawi Mexico Moldova
Nepal Nicaragua Peru Philippines Romania Russia
Syria Tunisia Uzbekistan
GLC-approved DOTS-Plus projects