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Treating tuberculosis in Chechnya: a remote control approach
Treating tuberculosis in Chechnya: a remote control approach
Background
Background
MSF in Chechnya
MSF in Chechnya
TB programme background
TB programme background
Remote control
Remote control
Programme quality control mechanisms
Programme quality control mechanisms
Project Goals
Project Goals
Case Finding
Case Finding
Treatment and follow-up
Treatment and follow-up
Assuring TB treatment adherence in a conflict zone
Assuring TB treatment adherence in a conflict zone
Case Finding
Case Finding
Outcomes
Outcomes
Problems
Problems
Success
Success
Reasons for success in new cases in suspected high drug resistance
Reasons for success in new cases in suspected high drug resistance
Current Status
Current Status

: Treating tuberculosis in Chechnya: a remote control approach. : . : Treating tuberculosis in Chechnya: a remote control approach.ppt. zip-: 240 .

Treating tuberculosis in Chechnya: a remote control approach

Treating tuberculosis in Chechnya: a remote control approach.ppt
1 Treating tuberculosis in Chechnya: a remote control approach

Treating tuberculosis in Chechnya: a remote control approach

Gabit Ismailov MedCo MSF-H, Russian Federation

2 Background

Background

1994-1996 first Chechen war 1999- - second Chechen war

3 MSF in Chechnya

MSF in Chechnya

MSF programmes: Donation of non-food items Drug Distribution Primary Health Care Mental Health TB Surgery Emergency response

4 TB programme background

TB programme background

TB programme in Chechnya started in May 2004 4 hospitals 5 districts 300,000 people in the catchment area over 750 TB patients enrolled since the start of the programme

5 Remote control

Remote control

MoH staff runs daily TB services Experienced national staff in the project locations supervise and organise TB services Regional coordination office in Nalchik, Kabardino-Balkaria Infrequent visits by international staff to project sites since December 2004 A small country management team in Moscow

6 Programme quality control mechanisms

Programme quality control mechanisms

Cross-checking of collected data (TB registers, lab registers, etc) Regular meetings with national MSF staff; programme updates; discussions, etc. Regular international and national trainings Occasional supervisory visits by international staff including on-site validation, e.g. cross-checking slides, patient interviews, etc.

7 Project Goals

Project Goals

Cure all TB patients from the districts in Chechnya where MSF operates. Establish and maintain a system of good quality diagnosis by the means of direct sputum smear microscopy. Treat all diagnosed TB patients with the first-line anti-TB drugs and maintain good treatment adherence. Ensure access to quality counselling services for all TB patients and relatives. Ensure access to quality HIV/AIDS follow-up and ARV therapy for all TB-HIV co-infected patients in supported TB facilities.

8 Case Finding

Case Finding

Passive case finding Direct Sputum Smear Microscopy No reliable reference laboratory Cross-checking between 4 participating laboratories with MSF involvement QC % of agreement over 80% Starting external MoH QC PA Chest X-Ray No culture, no DST Active case finding among risk groups by MoH but only on paper Systematic obligatory HIV testing by MoH

9 Treatment and follow-up

Treatment and follow-up

Standard treatment regimens: 2HREZ(S)/4HR (new cases) 2HREZS/1HREZ/5HRE (previously-treated cases) Drugs: local purchase validation scheme by MSF pharmacists network DOT by MoH healthcare workers: Intensive phase in the TB hospital Continuation phase DOT by primary healthcare workers in DOTS corners daily/intermittent Follow-up: Direct Sputum Smear Microscopy Chest X-Ray

10 Assuring TB treatment adherence in a conflict zone

Assuring TB treatment adherence in a conflict zone

Individual case management Defaulter tracing activities Health education Mental health counselling Peer support groups Continuing medical education Incentives and enablers food for patients food for healthcare workers Runaway bags FDCs

11 Case Finding

Case Finding

From May 2004 up to March 2006, 670 patients were enrolled in the programme: 543 smear+ pulmonary TB cases 111 smear- pulmonary TB cases 16 extrapulmonary TB cases (only 12 children) 433 new case 237 previously treated cases male:female ratio ~ 2:1 3 HIV+ cases

12 Outcomes

Outcomes

Outcomes

Cured

Rx comp-leted

Died

Failure

Rx inter-rupted

Trans-ferred out

TOTAL

New sputum smear-positive cases*

94% (138)

2% (3)

1% (1)

1% (2)

1% (2)

1% (1)

100% (147)

New sputum smear-negative and extrapulmonary*

0% (0)

94% (15)

0% (0)

0% (0)

6% (1)

0% (0)

100% (16)

Previously treated cases**

66% (33)

0% (0)

16% (8)

16% (8)

0% (0)

2% (1)

100% (50)

ALL CASES

80% (171)

8% (18)

4% (9)

5% (10)

1% (3)

1% (2)

100% (213)

* Cohorts Q2-4 2004 and Q1 2005 ** Cohort Q1 2005, 47 previously treated patients

13 Problems

Problems

Some patients are not enrolled (chronics) Some patients from outside the catchment area Very few children with TB enrolled Extrapulmonary TB Few women enrolled Drug resistance in previously-treated cases?

14 Success

Success

Very good outcomes for new cases Very good treatment adherence Dedicated team Motivated patients

15 Reasons for success in new cases in suspected high drug resistance

Reasons for success in new cases in suspected high drug resistance

settings

Null Hypothesis: The outcomes are true (weve done a great job!) Or are there some caveats? selection bias unreliable data collection? no primary drug resistance in the region other

16 Current Status

Current Status

TB and HIV co-infection Programme expansion? MDR-TB?

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