HOW TO ENSURE POLITICAL COMMITMENT FOR MDR TB MANAGEMENT César Bonilla MD. REGION OF THE AMERICAS TUBERCULOSIS, YEAR 2004 Canada 9% USA Haiti Dom. Rep. Mexico 6.8% Honduras 75% Ecuador Total: 247,387 Peru Bolivia Brazil Peru 50% Nicaragua Brazil Source: WHO Report 2006. Global Tuberculosis Control. Surveillance, Planning, Financing BASIC PRINCPLES IN MDR-TB MANAGEMENT 1. To establish a National TB Program that is efficient, effective and integrated into general health care services 2. To assure free access to quality medication (through application to the Green Light Committee). 3. To coordinate with the community and local governments to establish strategies that help ensure treatment adherence of the TB patient. 4. To provide free access to drug sensitivity tests. 5. To design an appropriate TB treatment regimen for the patient. POSITIONING THE NATIONAL TB CONTROL PROGRAM AS A FUNDAMENTAL ELEMENT IN ENSURING POLITCAL COMMITMENT TECHNICAL EFFICIENCY IN MDR-TB MANAGEMENT 1. Clear objectives for the 6. Coordination and strategic short, medium, and long partnerships that facilitate term. a leadership role of MDR-TB 2. Clear components that management in the health improve processes care reform process, especially in regards to 3. Consistency in application Cross-sectional decentralization. of the DOTS strategy Approach: 4. Transparency in decision- 7. Organizational aspects: POLITCAL making and in the use of Laboratory conditions COMMITTMENT resources Treatment strategy 5. Work in a multidisciplinary Information system and team at different levels of data management health care. Supervision and monitoring of patient care PRODUCTS OF THE APPROPRIATE APPLICATION OF THE BASIC PRINCIPLES IN MDR-TB MANAGEMENT 1. Reliable distribution of medication. 2. Professional commitment, commitment at health care establishments, and experience in MDR-TB patient care that Cross-sectional helps ensure treatment adherence. Approach: 3. Implementation of reliable sensitivity tests POLITCAL for first- and second-line drugs. COMMITTMENT 4. Availability of human and physical resources. STEP-BY-STEP BUILDING OF POLITICAL COMMITMENT IN MDR-TB MANAGEMENT 1. Explanation of the causes of MDR-TB. 2. TB Control: • Towards our intended direction. • DOTS strategy, the right way. 3. Magnitude of the MDR-TB problem. 4. Intervention strategies. • Positioning. • Marketing and Merchandizing. • Strategic partnerships with the civil society and TB patient organizations. • Advocacy, social mobilization, and strategic communication. • Technical efficiency in resource utilization. • Investigation: operational, epidemiological, and clinical. 5. Consolidating political commitment. 1.EXPLAINING THE CAUSES OF MDR-TB MAGNITUDE OF THE MDR-TB PROBLEM IN PERU CHILDREN < 18 YEARS OLD WITH MDR-TB THAT HAVE ACCESS TO STANDARD AND INDIV. RETREATMENT, The presence of MDR-TB is the THREE-YEAR TREND LINE result of numerous failures by PERU 1996-2004 the health care system over 300 time: 1. Use of ineffective treatment regimes for MDR-TB during the 250 80’s and 90’s amplified y = 26,8x - 53,778 resistance. R2 = 0,9352 2. Persistent MDR-TB cases in the 213 community without timely 200 access to adequate treatments MDR-TB increased sources of infection 173 with MDR bacilli among the population. 150 3. Poorly defined therapeutic 124 policies in regards to new MDR- of children with 100 TB cases among contacts of 92 documented MDR-TB cases. Nº < 18 years Trend line (< 18 y) 4. Underestimation of the 56 magnitude of MDR-TB resulted 50 in inadequate diagnosis and 32 treatment interventions. 26 5 0 1 96 97 98 99 00 01 02 03 04 2. TB CONTROL IN PERU: • TOWARDS OUR INTENDED DIRECTION • DOTS STRATEGY THE RIGHT WAY TB MORBIDITY AND INCIDENCE RATES IN PERU, 1990-2005 EpidemiPicoolog ical IniciStarto of de Ref Reformaorm GestManaiógementn y 300 EpidemiolPeak ógico DOTS ExpansiDOTS Expansión y Sostenibon and ilidadSustainab DOTSility anyd Perdida Loss of de Recuperaciand Recoveryón LeaderLidershipazgo deof Leadeliderazgorship 250 200 150 100 EpidemioloPico gical EpidemiolPeakógico 50 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 MORBILIDADMORBIDITY 198,6 202,3 256,1 248,6 227,9 208,7 198,1 193,1 186,4 165,4 155,6 146,7 140,3 123,8 124,4 129,0 INTBCID. INCID. TBC 183,3 192 243,2 233,5 215,7 196,7 161,5 158,2 156,6 141,4 133,6 126,8 121,2 107,7 107,7 109,7 INBKCID.+ IN CID.BK+ 116,1 109,2 148,7 161,1 150,5 139,3 111,9 112,8 111,7 97,1 87,9 83,1 77,4 68,8 66,4 67,1 Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA WHAT ARE WE LOOKING FOR IN MODERN PUBLIC HEALTH? Equity Efficiency Quality What is the target Human population? Guarantee good Resources use of the HR Clergy Collective To whom are we obligated? Health Management of Individual Services PLANNING EXECUTION Health What are the priorities when Avoid overlapping Sustainability considering the situation at each management level? of duties Social Participation PUBLIC HEALTH AND TB CONTROL PROGRAMS State Policies HOW TO CONFRONT THE CURRENT SCENARIO HUMAN RESOURCES EQUIPMENT INFRASTUCTURE GLOBAL CONTEXT • Aging of the population • Increase in public expectations • Globalization • Advances in science and knowledge • Epidemiological change • New demands in regards to learning POLICY GUIDELINES FOR THE HEALTH CARE SECTOR AND THE NATIONAL HEALTH STRATEGY FOR TB PREVENTION AND CONTROL Continuous QualityImprovement DOTS Supply and Rational Use of Drugs DOTS PLUS Technical Ef Sector Management Health HR Prevention Funding Technologic. Comprehensive MINSA and Developm. Care Promotion Democratization Decentralization ficiency Modernization Institutional Comprehensive Local Culture HIV/TB Insurance Governments Strategic Accreditation PAL Partnerships HRTAs PPM Service Others HRTA: High Risk AMSC Training Advocacy, of Transmission Evaluation Areas Social Research Supervision Mobilization Biosafety Monitoring Multidisciplinary, Multifunctional, Intersectorial and Interinstitutional Team Public Health Technical Strategic and Specialization Management Epidemiology Criteria STOP TB Committee Peru National Multisectorial • Coordination, Administration, National Health Strategy for Communication, Cooperation. Health TB Prevention and Control Coordinator • Shared management, leadership and accountability. TB/HIV Co- Infection Committee Group of Experts Scientific Associations Civil Society ComitéTECHNICALTécnic o ADVISORY NGOs PermanenteSTANDING COMMITTEE COMMITTEE Universities MINSA EsSALUD Representatives & Departments Dep. of Health Technical Strategies and Criteria, Strategies, Plans and Criteria Programs Commitments Public Stakeholders (Citizens) Citizen Watch National Health Strategy for Institutional and MINSA TB Prevention Intersectorial and Articulation Control Comprehensive Institutional Stakeholders Care AND Intersectorial Stakeholders TB CONTROL ATTITUDES AND COMMITMENTS 1. Promotion of a health culture in the context of TB control, considering the impact of TB on the person and the society. 2. Personal dignity & bioethical behavior. 3. Promotion & social participation as an expression of active citizenship. 4. Evidence-based information to guide social, technical & political interventions. NEW PARADIGMS 1. Promoting TB and MDR-TB control while preserving human dignity, bioethics, and human rights within a healthy citizen context. 2. Comprehensive and integrated health care to enhance TB and MDR- TB control actions. 3. Promoting advocacy and guiding public policy through intersectoriality, interinstitutionality and development of strategic partnerships for TB and MDR-TB control. 4. Organizing and providing care to people with TB and MDR-TB through multidisciplinary teams comprised of a healthcare team, civil society representatives, and associations of people living with TB. 5. Strategic communication. 4. MAGNITUDE OF THE MDR-TB PROBLEM INITIAL RESISTENCE OF MDR-TB (Americas, 1994-2002) CAN 1.2% USA 1.2% MEX DOM REP 6.6% CUBA 0.3% 3 estadostates s2.4% 2.4% PR 2.5% GUA 3.7% HON 1.8% ELS 0.3% VE 0.3% >= 4 HOT SPOTS NIC 1.2% CO 1.47% WITH MDR ECU 5.0% 0.9% PER 3.0% Bo 1.2% Ch 0.6% (MDR-TB >= 3%) Ar Ur 0.01% (MDR-TB < 3%) 1.8% (MDR-TB =< 1%) No data Sources: PAHO DRUG-RESISTANT TB IN DRUG-RESISTANT TB IN NEW PREVIOUSLY TREATED PATIENTS, PATIENTS, WHO/UICTER 1999 WHO/UICTER 1999 25 23.3 23.5 %20 17.8 WORLD 20 WORLD PERU 15 PERU 15 % 10.7 % 12.3 10 9.3 10 5 3 5 1 0 0 DR TB MDR TB DR TB MDR TB Fuente: WHO/IUATLD. Anti-tuberculosis drug-resistance in the world. Report Nº2. Prevalence and trends. DRUG-RESISTANT TB IN PREVIOUSLY TREATED PATIENTS, WHO/UICTER 1999 25 23.3 23.5 % WORLD 20 PERU 15 12.3 9.3 10 5 0 DR TB MDR TB Fuente: WHO/IUATLD. Anti-tuberculosis drug-resistance in the world. Report Nº2. Prevalence and trends. CHILDREN WITH MDR-TB <18 YEARS THAT CONSENTED TO STANDARD AND INDIVUDUALIZED RETREATMENT, TREND LINE AT THREE YEARS. PERU 1996-2004 300 250 y = 26,8x - 53,778 R 2 = 0,9352 213 200 MDR-TB th 173 wi 150 dren l 124 chi of 100 92 Nº < 18 years Trend line (< 18 años) 56 50 32 26 5 0 1 1996 1997 1998 1999 2000 2001 2002 2003 2004 5. MDR-TB INTERVENTION STRATEGIES METHODOLOGICAL FOUNDATIONS AND IMPACT OF MDR-TB CONTROL Bacteriological “Fitness” of the etiological agent Microorganism Phenomenon of genetic mutation of M-TB Identification of probable cases and Clinical clinical presentation. Individual Diagnostic and therapeutic methods. Epidemiology of MDR-TB Epidemiological Community Identification of high risk areas Operational Intervention strategies Control Control principles POINT OF EQUILIBRIUM OR RUPTURE OF BALANCE Control Strategies M.TB Resistant M. TB Sensitive DOTS PLUS Treatment DOTS Prevention MULTI-DRUG RESISTANT TUBERCULOSIS ORIGIN OF MDR-TB DOTS Human error Bad treatments Responsibility of the health care system & the Medical responsibility ESNC-TB Administration of inadequate Logistics of inadequate Inadequate treatment treatment chemotherapy Uninformed patient Unsupervised treatment DOTS PLUS ACQUIRED RESISTANCE PRIMARY RESISTANCE AmericanThoracic Society/CDC. Treatment of tuberculosis infection in adults and children. Am Resp Crit Care Med 1994;149:1359-1374 FOCUS ON MDR-TB CONTROL WITHIN THE CONTROL PROGRAM PLANS 9 Adequate therapeutic arsenal.