1. Introduction to the National MDR-TB Control Strategy Session 1 [insert country name here] Insert country/ministry logo here

2. Outline of lecture • Global situation of drug-resistant TB (DR-TB) • Country situation of <insert country name here> • History of DR-TB program to date • Challenges and planning • Objectives of this training

3. Global situation of drug-resistant TB (DR-TB)

4. Global burden of TB in 2010 Source: WHO Global Tuberculosis Control Report 2011. NB: currently under embargo until release later in Oct 2011

5. Global targets for TB and MDR-TB

6. New diagnostics in TB:Xpert MTB/RIF roll-out

7. Global drug facility is the main supplier of second line anti-TB drugs Role of GDF: • Public Sector procurement of TB drugs, of the right quality, in the right quantity, at the right price, and deliver them at the right time to the right people • Provide technical assistance by monitoring procurement system management in countries utilising GDF’s services and highlight system strengthening requirements

8. Estimated MDR-TB patient treatments delivered per year through GDF

9. Country situation of <insert country name> [Insert the front cover of each local TB Guidelines that are available] Available TB Guidelines: • National TB Guidelines • TB/HIV Guidelines • Public-Private Mix Guidelines • DR-TB Guidelines • Infection Control Guidelines

10. TB program <Insert the general TB outcomes of the country’s program here> • Number of patients enrolled for new cases • Outcomes of new cases • Number enrolled for retreatment cases • Outcomes of enrollment • % of HIV infected patients among TB Cases

11. Country situation of <insert country name here>for DR-TB

12. Reported cases of MDR-TB in <insert country name here> a Calculated by applying the best combined estimate of MDR to the notified cases of pulmonary TB in 2010. bPercentage may exceed 100% as a result of notifications of cases from previous years, inadequate linkages between notification systems for TB and MDR-TB, and estimates of the number of cases of MDR-TB that are too conservative.

13. Resistance to second-line anti-TB drugs in MDR-TB isolates in <insert country name here and year of survey>

14. Costs and budget of DR-TB program <insert any information related to available budgets for the program and costs (including the average cost of a standard empiric regimen, and any regular social support budgeted for the patients)>

15. History of DR-TB program • National Reference Laboratory established <insert year and types of tests done> • Enrollment of patients into the DR-TB treatment began <insert places and dates program began> • Introduction of Xpert MTB/RIF instruments <insert date and number of machines, and places> • Reference laboratories • Established MDR-TB Hospitals • Start dates of community-based program • GF or other funding <Insert any pertinent history of the program>

16. Outcomes of DR-TB program to date

17. Side effects of patients enrolled in DR-TB <(if data is available add this slide)>

18. Operational flow — MDR-TB programme Too many patients are lost in each step. Planning must find and retain in care all patients! Access to health system Suspects Reintegration in the community Treatment initiated Treatment completed Diagnosed Notified Estimated burden ( Symptomatic cases in the community) • Suspect identification policy (diagnostic algorithm) • Availability of laboratory • Accessibility to laboratory • Adequate human resources • NTP management capacity (linkage with all-public-private laboratories) • Reporting system (data flow from lab to treatment centres and programme) • Surveillance capacity • Availability of treatment centres (hospital, clinic with infection control measure) and community network • Human resource (trained clinician, nurse, health workers, community volunteer) • Registration, availability- storage and distribution capacity of quality assured SLD and ancillary drugs • Availability of information to patients (ACSM) • Linkage with private sector (PPM) • Availability of funds for all intervention • Provision of DOTS (adequate health workers, community volunteers) • Training, refresher and HRD plan for HCW involved in MDR-TB management • Default tracing mechanism • Capacity of laboratory to perform follow up and monitoring tests • Capacity of adverse effect monitoring mechanism • Recording and reporting mechanism • Social support: transportation, food, psychosocial • Social support mechanism • Community awareness and involvement • Palliative care • Ethical framework • Patient charter • Labour laws

19. Challenges in planning of services • Conventional C and DST  Solid-liquid • Rapid diagnostics- LiPA/XpertMTB/Rif • Test needs to be done for how many suspects? • Consumables? • Staff time? • Sample transport Diagnosis • Drugs – SLD, ancillary drugs • Drug supply to match rapid detection • Adverse effect management - hospitalization capacity • DOT provider - Community or health workers? Treatment Capacity • Human resources: lab staff, heath care staff, supervisory staff, planning and financial staff • Are staff numbers sufficient to deliver all the required services? • Is there a need for task sharing or shifting? Hiring? Training capacity available? • Community care for DR-TB Public health sector; Public non-health sector; Private sector (for profit & not for profit); Universities & Research Institutes; NGOs, etc.

20. Turning off the source of DR-TB 1. Overcoming the causes of inadequate anti-TB treatment

21. Turning off the source of DR-TB 2. Early diagnosis of DR-TB and prompt DR-TB treatment

22. Hospitals: grounds for MDR-TB? • Many TB patients seek care at hospitals • Hospitals often do not follow recommended TB diagnostic and treatment practices • Hospitals cannot supervise treatment and follow up patients after discharge • Many hospitals lack TB infection control measures

23. Objectives of the community-based PMDT training Goals of this Training: • To train an “Outpatient MDR-TB Team” to clinically manage patients with DR-TB. • For the MDR-TB Team to supervise a DOT Provider and provide the support necessary to keep the patient at home. • To transition between hospital and the community when needed Hospital(only for the very sick) Clinic (Monthly Visits with MDR-Outpatient team) Daily DOT at home (with DOT Provider)

24. Thank you and good luck with the training