Sisaket Province Case Finding

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

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

HOS XP Himpro Smart TB TBCM

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

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

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

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

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?

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)

5. Migrants: Observations 400-500 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

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

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)

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

Sputum collection booth

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

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

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.

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

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)

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

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 (?).

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) ODPC7 2012 (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

PHO-Sisaket