DOTS-PLUS IN TANZANIA: PREPARATION PHASE Global DOTS Expansion Working Group Meeting, Paris: 28 October 2004 Prepared by: Dr. S. M. Egwaga NTLP - Tanzania NTLP - MOH
Situation of MDR-TB in Tanzania • Drug Resistance data available (1999 – 2003) • MDR TB among new pulmonary cases 1% or about 60 new cases each year • MDR TB in previously treated cases – 6% or 30 cases per year • Some of the cases are clinicians dealing with TB patients • There is no provision in the DOTS strategy for the management of MDR-TB NTLP - MOH
Rationale to deliver MDR-TB in Tanzania • Government of Tanzanian has resolved do deliver standard TB care to all patients including the small pool of MDR-TB as part of equity to services and to minimise transmission and spread of MDR-TB • The Ministry of Health has decided to establish and integrate a DOTS-plus component within the regular DOTS-programme. • Priority remains DOTS-programme and DOTS-plus component will be complementary and not compete for funds. NTLP - MOH
External assessment to deliver MDR-TB in Tanzania • In May 2003 and March 2004, a DOTS-plus consultant visited the country to assess preparedness to implement DOTS-plus and eligibility to apply to the International Green Light Committee (GLC) for preferentially priced second line drugs. • The consultant concluded that DOTS-plus could be introduced in the Tanzanian situation, but a number of essential conditions should first be met. NTLP - MOH
Conditions to deliver MDR-TB in Tanzania • To update notification system for re-treatment cases to clearly distinguish failures, relapses, treatment after default, chronics and others • Strengthen systematic collection of specimen for culture and drug-susceptibility testing in the country for new and re-treatment cases • To build quality assured laboratory capacity in order to: – conduct Drug Resistance Surveillance(DRS) – Minimise contamination rate from present 15% to lower levels – diagnose MDR – microscopy, culture and DST – monitor, guide and evaluate category 4 treatment NTLP - MOH
Conditions to deliver MDR-TB in Tanzania • To establish a reference hospital (future centre of excellence) for the hospitalisation of MDR cases identified country wide • To adopt a centralized approach for the intensive phase of treatment of MDR-TB in Tanzanian situation (to concentrate expertise and build experience) • To decentralize the continuation phase, integrating treatment delivery within the regular DOTS programme • To appoint personnel (medical doctors and nurses) to work in the MDR-TB hospital NTLP - MOH
Conditions to deliver MDR-TB in Tanzania • Strengthen laboratory network with lower levels and improve feedback mechanism and with supranational laboratories (MRC) • To agree on a relatively cheap category 4 regimen since most of second-line drugs have never been used in the country • To consider applying for Category 4 drugs through the GLC • To apply to WHO to train personnel from the CRTL and MDR hospital through the GLC mechanism NTLP - MOH
Progress made to introduce MDR-TB in Tanzania • A new MDR-TB ward for 24 patients under construction within National TB hospital • Two medical doctors and 6 nurses deployed specifically to work in the MDR-TB ward • Formed a technical committee to oversee implementation of MDR-TB from NTLP, MUCHS and NIMR and TB hospital • Updated and computerised TB notification system countrywide with BOTUSA/CDC support to identify failures among re-treatment cases • WHO has agreed to train medical personnel together with other 2 countries in SS Africa NTLP - MOH
Progress made to introduce MDR-TB in Tanzania • Agreed on category 4 treatment regimen: 6 months Pyrazinamide, Ethionamide, Kanamycin, Ofloxacine, Cycloserin / 12 months Ethionamide, Ofloxacine, Pyrazinamide. • Estimated cost for cat. 4 regimen about $600 -700 per patient – relatively cheaper than in settings with a history of uncontrolled second line drug-use where PAS, Cycloserin and Capreomycin may need to be used, costing up to $3000 -3800. • Requests to be submitted to GLC for considerations NTLP - MOH
Progress made to introduce MDR-TB in Tanzania • Quality of laboratory services significantly improved: – Central laboratory under major rehabilitation – New equipment procured – Internal quality control adhered in all procedures – Contamination rate reduced from 15% to 10% in less than one year – Established centralised feedback mechanism to lower laboratories – Improved registration system of MDR-TB cases throughout the country and all data captured centrally NTLP - MOH
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