1. MSF TB Program for Migrants in Tak

3. Beginnings: MSF TB Programs in Thailand First MSF TB Program in Thailand started in 1985 in Karen camps (Shoklo, Maela) Residential TB programs with high cure rate and low default rate (AFB (+ ): cure rate = 79,5% completed rate = 5,6% ; default rate = 5,6%) Programs not aimed at highly mobile populations crossing the border frequently

4. Migrant Healthcare: Multiple Challenges Large unregistered population of migrants in border areas; Tak province alone with estimated 75,000 to 150,000 unregistered migrants Barriers to medical care: -cost -security concerns (deportation) -linguistic and cultural barriers

6. MSF Migrant TB Program: Planning MSF pilot study of migrant factory workers in Maesod in 1999: undertaken with Thai public health and with MSH (Dr. Witaya) Census: 71 factories assessed; estimated migrant factory population of 16,000 Random sample of 1000 workers from census: primarily young adults, 72% single, intermediate education level, only 11% speak Thai, most work >6m in same factory, basic housing conditions- overcrowding with enhanced chance of spreading communicable disease Not included in census: day workers, farmers

7. MSF TB Program for Migrants: Implementation MSF TB program reviewed by Thai National TB program advisors and WHO technical advisors to ensure collaboration with Thai national TB program and implementation of DOTS in Thailand; DOTS launched on a national scale in 1996

8. MSF TB Program for Migrants: Objectives Target Population: 1)Factory Workers (est. 16,000) 2)Day workers (est. 10,000) 3)Farmers (rural population, difficult to access) 4)Patients crossing from Myanmar for medical care in Thailand Target Area: Maesot, Tak province and 20 km radius; later extended to Phoe Phra

9. MSF TB program TB Village, Maela Camp Chest Clinic, Maesod DOTS Program TB education for migrant factory workers MDR Program

10. Chest clinic, Maesod Referral sources: Self (factory teachings, etc.), Maesod Hospital, Mae Tao Clinic Facilities: Complex with 14 patient rooms, lab, pharmacy, consultation room Maesot TB team: 1 physician, 2 medics, 6 DOTS supervisors, 1 lab supervisor, 2 lab technicians, 1 driver; 1 cleaner and 2 cooks

11. Diagnosis and Treatment Diagnosis: Sputum x 3, no culture; other diagnostic modalities: CXR, fine needle aspiration, lymph node biopsy, thoracentesis. Treatment: WHO short course Category 1: 2HERZ/4HR Category 2: 2HERZS/HERZ/5HER Category 3: Same protocol as category 1

12. DOTS Program All TB treatment by DOTS short course; RX 6 times per week in Mae Sod and 3 times per week in Phoe Phrae Patient population: migrant, undocumented, movements restricted DOTS team meets patient at home or workplace by motor bike or car Patient identification cards ชื่อ … Winnie the Pooh................... อายุ.. 50..... ปี เพศ... Male............ บัตรผู้ป่วยเลขที่.. 9000......................... วันที่ผู้ป่วยครบกำหนดการรักษา. 1.04.04 วันที่บัตรหมดอายุ.. 01.07.04............. ลายมือฃื่อ …Winnie the Pooh........ MEDECINS SANS FRONTIERES

21. Age and Sex of 311 M+ patients enrolled between Nov. 15, 1999 and Dec. 31, 2002 Age Group Male Female Total 0-14 8 8 16 15-24 50 35 85 25-34 68 34 102 35-44 42 21 63 45-54 18 12 30 55-64 10 2 12 65+ 3 0 3

22. Treatment Outcome in 311 new M+ Patients enrolled between Nov. 15, 1999 and Dec. 31, 2002 Outcome Number (%) of patients Cured 215 (69.1%) Completed 2 (.6%) Transfer out 11 (3.5%) Default 61 (19.6%) Died 8 (2.6%) success rate(cure +tx completed)=217/311 (69.7%)

23. Treatment Outcome in 508 patients enrolled between Nov. 15, 1999 and Dec. 31, 2002 Outcome Number (%) of patients Cured 256 (50.4%) Completed 100 (19.7%) Transfer out 14 (2.8%) Default 72 (14.2%) Failed 51 (10.0%) Died 15 (3.0%) success rate (cure + tx completed)=356/508(70.1%)

24. Treatment Outcome of 63 Cross Border patients enrolled between Nov. 15, 1999 and Dec. 31, 2002 Cured=6/63 (57%) Completed=5/63 (8%) Default=17/63 (27%) Fail= 3/63 (5%) Die= 2/63 (3%) In 2003, 54 cross border patients enrolled in DOTS, 17(31%) have already defaulted during tx. Another 10 pts did not start tx (default before tx).

25. Factory TB education and screening Factories in Mae Sot area with 20 to 2,000 migrant workers TB education program launched November 2002: TB transmission, symptoms, diagnosis, treatment discussed Offer of diagnostic sputum testing and treatment free of charge 37 factories visited in 2003 with approximately 6,500 workers attending sessions

26. MDR Program A residential treatment program at Maela started to address a growing public health problem First patients admitted in August 2001; 15 patients have been admitted to program since start Treatment regimen lasts at least 2 years Challenges: -continuing difficulties with drug importation -high default rate

27. Conclusions DOTS program for migrants has cure rates less than WHO target of 85% but given highly mobile population can be considered a success Keys to success: -security issues: medications brought to migrants; ID cards -coordination with other groups: Thai public health, MSH, WHO, Mae Tao Clinic, local authorities -culturally sensitive Burmese-speaking staff

28. Conclusions -2 DOTS Weak Points: -Program requires considerable investment of staff and resources -High default rates for ambulatory DOTS patients from Myanmar: cost, security concerns, inconvenience; other strategies: education based program, patient access on Myanmar side -No HIV testing or education done

29. Conclusions -3 Factory Education: Targeted education and case finding in factories worthwhile but program is hindered by continuing problems accessing factory owners (distrust of NGOs)