1. TB CONTROL PROGRAMMEOperational Situation and Programmatic Experience Erica Reynolds Hedmann Ministry of Health Jamaica

2. West Northeast South Southeast Jamaica Background • 550 miles south of Miami • 4,244 miles2 • population: 2.68M • main industry: tourism • per capita GDP US $3,390- $3,700 • 14 parishes - 4 health regions

3. Jamaica - Health Regions West North-East South-East South

4. Confirmed Tuberculosis Cases 1996-2003

5. TB IN JAMAICA Reported Annual Incidence of TB in Jamaica, 1991 - 2001

6. Age and Gender Distribution of Confirmed Tuberculosis Cases, 2003

7. Jamaica AIDS Cases & Deaths Reported Annually in Jamaica (1982 to 2003)

8. Jamaica Annual AIDS Case Rates by Sex (Per 100,000 population): 1982 - 2003

9. Percentage of TB Cases with HIV 1993-2003

10. S u m m a r y o f A I D S C a s e s b y P a r i s h i n J a m a i c a 1 9 8 2 - 2 0 0 1 ( R a t e p e r 1 0 0 , 0 0 0 P o p . ) N W E S H a n o v e r T r e l a w n y S t . A n n S t . M a r y W e s t m o r e l a n d P o r t l a n d S t . E l i z a b e t h S t . C a t h e r i n e M a n c h e s t e r C l a r e n d o n S t . T h o m a s AIDS/100,000 Pop. 8 5 . 1 - 9 5 . 5 9 5 . 5 - 1 4 9 . 7 1 4 9 . 7 - 2 0 3 . 5 2 0 3 . 5 - 2 1 7 . 1 2 1 7 . 1 - 5 5 2 . 6

11. TB/HIV Co-Infection by Parish 2003

12. Tuberculosis Control Programme in Jamaica Goal • ·   To reduce mortality, morbidity due to Tuberculosis Objectives • ·    Maintain case detection rate of at least 70% of expected cases • ·   Achieve a minimum cure rate of 85% of confirmed cases • ·Prevent multi-drug resistant TB

13. Tuberculosis Control Programme in Jamaica STRATEGIES • Treatment of all cases –DOTS • Surveillance, with emphasis on contact investigation • Identifying, treating and monitoring TB/HIV co-infected persons • Public Education • Staff Training • BCG vaccination • Research

14. TB ProgrammeHistorical Perspective • Vertical Programme • Prior to health reform • Responsible for all aspects of TB control • defined Budget • Staff at all levels assigned to TB • TB clinic • Admission at single hospital

15. TB ProgrammeHistorical Perspective After reform Central level Responsibility for providing guidelines, policy and monitoring Integration- • The NTP was merged with other areas under the Division of Health Promotion and Protection • Surveillance unit • Multi-purpose staff at central as well as other levels • TB Coordinator- coordinating other priority areas – competing programmes • ‘integrated’ budget

16. TB Programme Challenges • Impact of health reform • Drug procurement responsibilities shifted without the appropriate monitoring and input from central level

17. TB Programme • Decentralization • Shift of responsibility and accountability for planning, administration and implementation • Opportunity for increased response • Concerns regarding ownership and commitment to TB control at parish level • Issues - finances, human resources, training and supervision.

18. Elements of DOTS Strategy • Sustained political commitment to increase human and financial resources and make TB control a nation-wide activity integral to health systems

19. Political Commitment • TB control has been a national priority for the Ministry of Health • In keeping with and in recognition of the WHO tuberculosis target, Millennium Development Goals for TB

20. Political Commitment • In 1996, a five year TB strategic plan was prepared • A draft TB manual was started, however this was not completed. • In 2002, MOH strategic plan - TB listed as priority programme. • In 2005, the CMO has restated the commitment to the programme

21. Political Commitment Steps forward • Political Commitment needs to be reflected in adequate funding of TB programme • The national HIV/AIDS Program has demonstrated its commitment to the program and TB/HIV collaboration.

22. Political Commitment • TB/HIV task force was established • In 2004, work was done on a draft national TB manual that is to be completed in this quarter of 2005. • Is preparing a strategic plan for TB and TB/HIV collaboration. • Evaluation of TB program in 2005 • Plans for capacity building,, policies, drug procurement, lab supplies etc

23. Elements of the DOTS Strategy • access to quality-assured TB sputum microscopy for persons presenting with symptoms • Screening of symptomatic persons and high risk groups

24. Access to quality lab evaluation • One central lab(National Public Health Lab) that does sputum culture and other sensitivity testing • All samples for TB testing are sent to this laboratory • smear Microscopy • Culture • Sensitivity testing is also done • All regional labs have the capacity to do smear microscopy

25. Access to quality lab evaluation • Challenges • Ensuring adequate supplies of reagents • Ensuring adequate laboratory conditions • Human resources and their development • Quality assurance activities

26. Method of Diagnosis of Tuberculosis Cases, 1999 - 2003.

27. Method of Diagnosis of Tuberculosis Cases, 2003. N=120

28. Screening of Symptomatic and High risk groups • Early Screening of symptomatic cases by private practitioners needs strengthening • Case Detection among PLWHA and other high risk groups • PLWHA are ‘screened’ for prolonged cough • HOWEVER follow-up investigation, notification NOT always done • Routine screening of PLWHA is a Priority for TB/HIV task force • Guidelines • Training • Monitoring

29. Elements of the DOTS Strategy Standardized Chemotherapy to all confirmed cases of TB under proper case-management conditions including direct observation of treatment

30. Standardized Chemotherapy to all confirmed cases of TB Policy- ALL TB confirmed cases are to have direct observation of treatment based on the WHO guidelines

31. Standardized Chemotherapy to all confirmed cases of TB • initial intensive phase of treatment as in-patients (until smear negative or app 2 months ) • Continuation phase- as outpatient, community DOTS

32. Standardized Chemotherapy to all confirmed cases of TB • Approximately 100% of confirmed cases are hospitalized for initial phase • > 75% admitted at National Chest Hospital • Challenges • Hospitalized far from home • Treatment by regional hospitals needs to be monitored • National guidelines needed • Strengthen training in TB management at teaching institutions

33. Standardized Chemotherapy to all confirmed cases of TB • Continuation Phase of Treatment • Completed as out-patient • DOT by health team, review visit with institution • Weakness in Community DOTS in continuation phase of treatment • Linkage between secondary care and public health needs strengthening to ensure coordinated management • Violence in some areas limits community DOTS • Training, organization needed • Monitoring by supervisor needs to strengthened

34. Standardized Chemotherapy to all confirmed cases of TB Treatment Outcome for 2003 Cohort • Completion- 47% (51) • Died – 24% (26) • Defaulters – 18.5% (20)

35. Elements of DOTS Strategy • Uninterrupted supply of quality-assured drugs with reliable drug procurement and distribution

36. Regular Drug Supply • Procurement and distribution of Anti-Tb drugs is done by a central body • National TB programme –limited role in advising on quantification of national drug needs- reactive rather than proactive • Policy- drugs provided free of charge

37. Regular Drug Supply • Shortage of drugs on and off • Issues with accessibility, charges • Steps being taken by NTP, TB/HIV task force to improve its role to ensure a steady supply of anti-TB drugs

38. Elements of the DOTS Strategy Recording and reporting system enabling outcome assessment of each patient and assessment of overall programme performance

39. Monitoring and Evaluation • Well established Case –based surveillance system • Monitoring tools and system to monitor treatment

40. Monitoring and Evaluation • TB surveillance • TB Class 1 notifiable disease- report on suspicion within 24 hours • TB investigation at parish level • Investigation of the case • Investigation of contact • Report submitted to national level • Known indicators for surveillance

41. Total number of Confirm Cases Contacts Investigated Cases Diagnosed From Contact Tracing % of Total Cases 2003 120 368 8 7 2002 108 531 5 4.6 2001 121 304 5 4.1 TB Cases Diagnosed From Contact Tracing

42. Monitoring and Evaluation • Challenges of Tuberculosis Case and Contact Investigation • Timeliness of investigation • Completeness of investigation • Monitoring of investigation by supervisors

43. Monitoring and Evaluation TB Monitoring • TB register is established at all levels • Parish, lab, national, hospital • Utilization of TB registers is a challenge at parish level • Monitoring of Cases by parish is a challenge • Training, guidelines • Supervision • Plans to enhance monitoring and evaluation

44. Public Education • Training • Research • TB/HIV collaboration

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