1. Sisaket Province Case Finding

2. 2. Recording and Reporting
Quality and completeness of data is impressive
Timely submission of reports
Initiatives to create own systems to meet program monitoring needs
Examples of good integrated systems at local level for both monitoring and case coordination

3. Recording and Reporting
Multiple paper and electronic data systems: high documentation burden
Specific issues with childhood, MDR TB, TB/HIV data
Examples of good analysis/use of program data at different levels
Some prov/regional data discrepancies
SSK PHO, Samrong PCU

4. HOS XP
Himpro
Smart TB
TBCM

5. Recommendations National level:
Careful review of systems still required to minimize duplication among systems
Assess state of data standards for hospital systems (HIMPro, HosXP, HosOS) to ensure cross-communication
Provincial level: Consider electronic case records to reduce multiple line-list systems

6. 4. TB in Prisons
Longstanding TB screening policy; more systematic approach since 2003
Strong collaboration in place and clear roles among
Srisaket prison
Srisaket provincial hospital
Srisaket PHO
Challenges of crowding, low staffing

7. Case Finding
On entry (<1 month): Symptom screening, AFB smear for symptom+
After entry (>1 month): Periodic awareness raising, diagnostic testing and referral SSK hospital for care-seekers
Very few cases identified from new prisoner screening; most from symptomatic care-seekers

8. Case Finding (II) Screening protocol is not sensitive
Symptom questions appropriate
AFB smear (insensitive)
CXR only after SS+ or continued illness on observation in SS-
Good initiative to define populations (new vs. old) for better monitoring

9. Treatment and Outcomes
SS+ patients are isolated
Coordination with SSK hospital clinical services is strong
Evidence of effectiveness (not fully quantified): sharply decreased death rates
No MDR TB cases to date
Good treatment adherence?
Insufficient testing?

10. Recommendations
SSK prison: continue monitoring and use of own data; maintain staffing
Dept of Corrections/DDC: review guidance
sensitive screening algorithms, increased use of CXR, including staff
Routine molecular testing for prisoners as MDR risk group
Consider HIV VCT for all given risk groups (review national data)

11. 5. Migrants: Observations
registered migrants in SSK; unregistered unknown but likely low
Registered migrants have insurance and access to care
ODPC 7 provides SLDs to 10 people--“marginalized” population who are unable to access NHSO/GPO services

12. Migrants: Recommendations
Reconsider the definition of vulnerable populations for this province
Prisoners and migrants: where to invest?
Identify strategy for sustainability beyond GFATM for vulnerable populations

13. 6. Laboratory Microscopy: well resourced, good IQC and EQA system.
Staff skilled and well trained
LED-FM in 2 hospitals, planned for all next year
Both paper and electronic records kept (duplication of work)
Good recording of sputum quality and indication (incl month of f/u)

14. Laboratory (II) Sputum containers: aerosol risk
Low slide positivity rate
Sputum quality?
Case finding in low risk population?
Sputum collection booths well designed and located
Good specimen transport systems
BSC class II installed with good maintenance records

15. Sputum collection booth

16. Challenges
At one hospital: high proportion of sputum specimens are saliva
SSK hospital lab not logging specimens sent for culture, DST; incomplete information on ODPC7 request form
Monitoring of number of sputum specimens: only done for confirmed cases
Two electronic systems not fully integrated: M-lab and HIMPRO

17. Recommendations
Clarify procurement specs for sputum cups (wide mouth, clear, screw cap lid)
IQC slide preparation: 1+ slides, not 3+
Review sputum collection patient education: improved sputum quality
SSK hosp lab: complete info for culture/DST specimens referred
Better integration of MLab and HIMpro, or single program

18. 7. MDR TB 62 cases of MDR-TB in ODPC 7 in 2012
6 cases in Sisaket Province
2 cases in Khuk Khan District
1 case in Kantaralak District
Culture, DST performed by ODPC 7
Molecular diagnostics: available in ODPC7 since Jan 2013
Approximately 300 molecular tests have been done on samples (300 patients?).
Some of these are GeneXpert, some are See Gene (C-Gene?)
Nok will get more information about the molecular tests by Wednesday
From which provinces, positive/negative tests, etc.

19. MDR TB (II)
Management system works well for 6 patients in Sisaket Province
Provincial hospital manages overall care (treatment regimen, adverse events)
District Hospital oversees DOT, which is done by PCU and VHV

20. MDR TB (III)
Monthly reporting (Excel) to Sisaket PHO and quarterly case reporting to ODPC7 since this year; NSHO case report
System adequate for current low case load
MDR clinical case reporting to ODPC7 not done until GFATM project (2012)
Lab request/report forms often first notification; not enough patient information for case management
Lab requests/report forms: PHO requesting additional information on lab forms (address, contact information) as the lab report forms are often the first notification of MDR-TB cases. PHO unable to contact patients without contact information on the lab forms.
Is it necessary for PHO to be the ones primarily responsible for contacting the patient? Presumably that should be the responsibility of the district hospital level on down (PCU, community)

21. MDR TB: Recommendations
Support clinical management decisions
Monthly (quarterly?) clinical case conferences coordinated by ODPC
Link with BTB MDR-TB network being developed: connecting provincial physicians with national-level experts
Second-line drugs: levofloxacin should replace ofloxacin as soon as possible

22. Recommendations (II)
Duration of injectables: at least 4 months post conversion
Updated national PMDT guideline in process of finalization
Complex cases should be discussed on case-by-case basis with experts
Diagnostics: NHSO support for follow up cultures, expanded risk categories
You can revise this if you wish (wording).
Not sure how to word the second one---they should follow the most recent guideline, but I haven’t seen it myself yet. And there are some cases where physician’s judgment is required---although that should be done in consultation with central-level experts---or at least regional experts, whoever that may be. Dr. Vibha (?).

23. 8. Childhood TB
TB disease and infection in children is being diagnosed and treated but not necessarily reported to ODPC7
Low child TB disease prevalence
Child TB 0.2% of the total caseload (10/5224) ODPC (national 1.3%)
No TB disease in <5 year olds reported from Sisaket in the last 3-4 years
Child contact management
No focal point in pediatric TB before 2013

25. PHO-Sisaket