MDR TB out patient management

1
MDR TB out patient management

• Vaira Leimane
• WHO Collaborative Centre for Research and
  Training on MDR-TB, SATLD, Latvia

2
MDR TB case management

• At short-course it is hard for patient to take
  anti TB drugs regularly during 6 to 8 month.
• It is even much harder in case of MDR-TB.
• As the MDR-TB treatment course lasts 18-24 months
  it is more difficult for patient to complete full
  course

3
Different models for MDR TB case management

• Partners In Health (PIH) community-based (Peru)
• Public-private mix (Philippines)
• Standardized boxes- based (Nepal)
• Hospital-outpatient (Latvia)

4
Who are involved in MDR TB case management

• People with MDR-TB
• Multidisciplinary team of health care workers
• Peers and relatives of the person with MDR-TB
• Members of the community

5
Ambulatory treatment of MDR-TB

• Very good DOTS Program
• Laboratory network
• Very well trained TB Control staff
• Integrated TB services in the PHC
• Strong health information system at the district
  level
• Treatment with full support to patients
  throughout
• Management of drugs and supplies
• Data recording system

6
Program challenges in the MDR TB out patient
case management

• Alcohol/substance abuse
• Side effects
• Distance to treatment site
• Work conflicts
• Population migration
• Patient and staff motivation

7
What is needed to support patients during MDR-TB
treatment???
8
Supportive environment for the behaviour expected

• Material support
• Full treatment free of charge and at an
  affordable cost for all actors
• No charge for second-line and ancillary drugs
• Enablers to tackle material barriers to delivery
  and intake of drugs
• Nutrition etc.
• Emotional support
• Means to cope with the bereavement following
  diagnosis, fear of death, stigma and
  discrimination, identity crisis, length of
  treatment.
• Education and training support
• Means to understand, and critically reflect on
  the nature of the disease, the treatment, and the
  health care system

9
Situations related to MDR TB treatment that
required emotional support

• Treatment enrolment
• Guilt
• Stigma
• Adherence
• Side effects
• Socio-economic difficulties
• Special situations (domestic violence, HIV
  positive, elderly, pregnant women, children,
  patients from provinces, etc)
• Treatment failure and end of life
• Completion of treatment and cure
• Emotional support for other members of the
  medical team

Chalco K, et al Nurses as providers of emotional
support to patients with MDR-TB. International
Nursing Review 53, 253-260.
10
Patient adherence strategies

• Complete patient information
• Informed consent
• Health education
• Family involvement
• Telephone follow-ups
• Home visits for defaulters
• Incentives every day food coupons additional
  coupon every week
• Enablers transport compensation

11
INFORMED CONSENT1.I____________________am
informed that I have multirezistant
tuberculosis which is very infectious for
others very difficult to treat with very
long treatment time 18-24 months or more2.To
be cured -I have to start treatment at
hospital -it can be necessary to swallow
about 25 pills daily -have to take injections
for long time -treatment can cause difficult
bad feeling and I will have to learn to get on
with them3.If I will not undergo the full course
of treatment -I can infect with tuberculosis
others, especially my family and children,
because gtdisease spreads by air by coughing,
sneezing, expectorating, speaking, singing
-irregular anti TB drugs taking leads to
worsening -compulsory treatment can be
used4.Treatment is very expensive AFTER
TREATMENT INTERRUPTION DOCTORS COUNCILlLIUM CAN
DECIDE NOT RESTART THE TREATMENTMain reasons
when treatment cannot restart gtirregular drug
taking gtadvanced form of disease5.Treatment
output -I will be uninfectious -I will be
cured
12
In the case of MDR-TB treatment must be
supervised full treatment course

• Nurses observe the swallowing of each prescribed
  drug, do injections, make a specific register
• This register includes information about
• Each swallowed or not swallowed drug with ?
  (tick) or 0 (zero) in therapy sheet
• On the separate sheet patient and nurse signs
  that drugs have been taken

13
TO PROVIDE DOT

• Choice of facilities (day hospital, outpatient
  clinic)
• Work day reorganization to facilitate once or
  twice-daily DOT
• Home visits for sick patients, non-compliant
  patients, and those with comorbidities
• Sufficient transportation, fuel, staffing in
  urban and rural areas
• Search for defaulters

14
Monitoring

• Each MDR-TB case is monitored
• information is gathered and register special
  MDR-TB register
• Patient information
• Treatment results, conversion time
• Adherence
• Treatment results and patients adherence to
  treatment is analyzed monthly and reported in
  MDR-TB board meeting

15
HEALTH CARE WORKER TRAINING

• Training workers in community-based DOT
• Training workers in ambulatory management of
  side-effects
• Training of feldshers, nurses and physicians

16
Community-based MDR-TB treatment (Peru)

• In 1996, PIH, Socios En Salud and Peruvian NTP
  joined forces to initiate state-of-art therapy
  for MDR TB in the Northern Cone of Lima
• Each patient is prescribed an individualized
  regimen based on DST
• Patients are followed by
• local CHCWs,
• DOT workers and
• they continue to be seen by the local NTP TB
  specialists.

Initially, most patients receive their
medications at home once smear negative they
receive medications at local health centers
17
Community-based MDR-TB treatment (Peru)

• Helps to prevent nosocomial transmission
• Benefit of community- capacity building
• Well-trained community health workers a key
  element of the program are equipped with both
  clinical and organizational skills to manage a
  broad range of health issues

18
.
Community-based MDR-TB treatment (Peru) - The
Health Promoter for DOTS-Plus

• Knows his community well
• Lives near the patient
• Previous experience in community work
• Receives training in MDR-TB
• Recruited by SES and/or by MINSA
• Contributes to MDR-TB control within his
  community
• Becomes member of de DOTS-Plus team for his
  community.

19
Clinical Care
Nurse
DOTS-Plus Promoter
MDR-TB Patient
DOTS-Plus Promoter
DOTS-Plus Promoter
Nurse
Nurse
C O M M U N I T Y
Emotional Support
Socioeconomic Support
Community-based MDR-TB treatment (Peru)
20
DOT plus ambulatory started in 1998, Latvia

• Separate TB ambulatory patient admission room for
  MDR TB patients in Riga- city since April 1999
  with
• 1 MDR TB ambulatory physician
• 1 MDR TB office nurse
• 256 MDR TB cases (both on treatment and
  follow-up)

21
Expansion of MDR TB out-patients care, Latvia

• Situation with MDR TB patients in May 1999
• 95 in hospitals
• 16 DOT ambulatory
• 8 on symptomatic treatment
• 22 - interrupted treatment with 2 line drugs
  during last 2 month
• 18 interrupted treatment more than 2 month ago

• Situation with MDR TB patients in February 2001
• 99 in hospitals
• 42 DOT ambulatory
• 20 on symptomatic treatment
• 5 - interrupted treatment with 2 line drugs
  during last 2 months
• 3 interrupted treatment more than 2 month
  ago.

22
MDR TB patient in Riga region
MDR TB patient in Riga
Receive II line drugs in TB system
Receive II line drugs in PHC
II line drugs for 30 days /- container for
ss
Using patient named boxes
23
Improving patient adherence, Latvia

• Alcohol abuse?
• Drug abuse?
• Methadone /buprenorfine therapy possibility
• IF patient has no living place?
• Agreement with city shelter these patients
  can stay in shelter during all treatment time.

24
Improving patient adherence, Latvia

• Ambulatory DOT compatibility with possible work.
• In case of MDR TB there is a big chance to loose
  regular job due to disease
• DOT at home for patient with limited movement
• Old people
• Mothers with small children
• Disable persons

25

• Social assistance for Riga- city TB patients
• Every day food coupons 2 USD
• Every day transport compensation to DOT office
  and back 0,75 USD
• Additional food coupon at the end of week if all
  prescribed doses are taken 2 USD
• Social assistance for Riga region TB patients
• Depends on decision of particular municipality
• Monthly allowance
• Rent or other debt coverage
• Firewood supply

26
Monthly visit to doctor, Latvia

• patient examination,
• sputum analyses for smear and culture,
• drug prescription for next month,
• side effects evaluation
• Full blood count
• Urine analysis
• Liver function test
• Kreatinine- monthly while on injection

• Special attention for
• liver toxicity
• psychiatric disorders
• hematological disorders
• allergic reactions
• hearing and vestibular toxicity

x-ray examination is made once in 3 months
before case demonstration in doctors councillium
27
Team work for MDR TB out patients case
management, Latvia
1 training nurse
physicians for MDR TB patients
PHC team
1 office nurse
4 DOT nurses in 2 DOT offices
Physicians councillium
Ambulatory head nurse
1 social worker
1 DOT provider at home
1 nurse assistant for patients tracing back
113
active MDR TB patient 01_01_2006 (Riga) 69 on
ambulatory treatment (2005)
28
Supervision on Case Management
Physicians from all MDR TB facilities reports on
progress and Tx interruptions
Coordinator from prison system reports on
released patients
MDR TB consilium design and oversee treatment
TB registry supervise patients adherence
Daily reporting about patients who did not
received DOT
ambulatory department trace back defaulters
29

• All necessary drugs for free
• Possibility to chose hospital or ambulatory
  treatment
• Physician's consultation available
• Accessible DOT offices with quite long working
  hours out patient department (7 times per week
  from 700 -1900)
• Treatment at home or in PHC
• Enablers
• Incentives, bonuses
• Psychosocial support
• Social rehabilitation
• Possibility to joint treatment with job
• Training for patients
• Patient to patient support group
• Compulsory isolation and treatment

30
Weekly team meeting, Latvia

• Every office nurse reports about the number of
  non adherent patients during last week
• Every case is discussed separately
• What was done
• Which team members were involved in problem
  solving
• Result is positive or no
• What else is possible to do in each case

31
Basic assumption or common purpose

• If the patient takes the drugs and the health
  care provider deliver the drugs as per the
  approved protocol it is very likely the patient
  gets cured

32
Our satisfaction and will to keep supporting our
community are motivated by the joy we experience
when we see our patient recovered, together with
his family , sharing a smile and hope, and
re-inserting into society DOTS-PLUS HEALTH
PROMOTER, Peru
33
Infection Control in Public Health clinics
34
Risk Classification ExamplePublic Health Clinic

• Ambulatory-care setting where TB clinic is held 2
  days/week
• In past year, 6 TB patients treated
• No evidence of transmission
• Risk classification Medium

35
TB Patient Characteristics That Increase Risk for
Infectiousness

• Coughing
• Undergoing cough-inducing or aerosol-generating
  procedure
• Failing to cover cough
• Having cavitation on chest radiograph

36
Prompt Triage - Think TB!

• Primary TB risk to HCWs is patient with
  undiagnosed or unrecognized infectious TB
• Promptly initiate AII precautions and manage or
  transfer patients with suspected or confirmed TB
• Ask about and evaluate for TB
• Check for signs and symptoms
• Mask symptomatic patients
• Separate immunocompromised patients

37
AII Precautions for Outpatient SettingsTB
Treatment Facilities (TB Clinics)
38
Evaluating TB IC Procedures andIdentifying
Problems (1)

• Annually evaluate TB IC plan
• Review medical records of a sample of patients
  with suspected or confirmed TB disease to find
  possible problems in TB IC

39
(No Transcript)