1. DOTS/ DOTS PLUS IMPLEMENTATION AND INTEGRATION Vaira Leimane State Centre of Tuberculosis and Lung Diseases of Latvia Paris, October, 28

2. LATVIA

3. PRESENTATION OUTLINE EPIDEMIOLOGICAL SITUATION EPIDEMIOLOGICAL SITUATION IMPLEMENTATION TB/MDR TB CONTROL PROGRAMS IMPLEMENTATION TB/MDR TB CONTROL PROGRAMS PROGRESS IN TB CONTROL PROGRAM PROGRESS IN TB CONTROL PROGRAM RESULTS RESULTS

4. INCIDENCE OF TB IN LATVIA 1971-2003

5. WHO IUTLD GLOBAL SURVEY ON DRUG RESISTANCE IN LATVIA 1996

6. INCIDENCE OF MDR TB, GLOBAL TB DRUG RESISTANCE SURVEY, 1994-1996 % New Smear + Cases

7. NTP PROGRAM RESPONSE – DOTS AND DOTS PLUS IMPLEMENTATION Accepted first NTP, based on WHO- recommended DOTS strategy ALL FIVE ELEMENTS in 1995 Accepted first NTP, based on WHO- recommended DOTS strategy ALL FIVE ELEMENTS in 1995 DOTS countywide including prisons in 1996 DOTS countywide including prisons in 1996 FIRSTS STEP OF National TB Control program for treating MDR TB patients in 1997 FIRSTS STEP OF National TB Control program for treating MDR TB patients in 1997 Established drug resistance surveillance 1997 Established drug resistance surveillance 1997

8. SUSTAINED POLITICAL COMMITMENT Government Committed to establish NTP plan using existing staff and resources, within the Health Care reform Government Committed to establish NTP plan using existing staff and resources, within the Health Care reform Well functioning DOTS program with additional treatment of MDR TB (within recourses available) Well functioning DOTS program with additional treatment of MDR TB (within recourses available) Collaboration and coordination between community, local governments, social services and international agencies Collaboration and coordination between community, local governments, social services and international agencies Established centralized procurement of drugs through open tender Established centralized procurement of drugs through open tender

9. DOTS PLUS IMPLEMENTATION STEP I - 1997 SITUATION ANALYSIS SITUATION ANALYSIS Results of drug resistance surveillance Results of drug resistance surveillance QA of laboratory for DST QA of laboratory for DST MDR TB case finding strategy – MDR TB case finding strategy – DST for all who starts treatment DST for all who starts treatment Reporting and registration of MDR TB Reporting and registration of MDR TB Evaluated access to TB drugs and created new drug management system Evaluated access to TB drugs and created new drug management system

10. TB CASE DETECTION AND IDENTIFICATION OF MDR-TB District-Level Smear Microscopy Regional-Level Culture Laboratories Central Laboratory - DST for all who starts treatment CentralDST Supranational Reference Laboratory (Sweden) 95% lab accuracy (1998)

11. MDR TB REPRTING AND RECORDING MDR TB case MDR TB Register Mycobacteriology Lab All DST results District TB doctor Consilium Enrollment in MDR TB cohort Enrollment form Follow-up form

12. DOTS PLUS IMPLEMENTATION STEP II MDR TB TREATMENT AND MANAGEMENT STRATEGY MDR TB TREATMENT AND MANAGEMENT STRATEGY Established Expert consilium for case and program management 1997, June Established Expert consilium for case and program management 1997, June TB hospitals reorganized for MDR TB TB hospitals reorganized for MDR TB Start patient enrolment for treatment Start patient enrolment for treatment Empiric/Individualized treatment strategy Empiric/Individualized treatment strategy according to DST results according to DST results Directly observed therapy (DOT) Directly observed therapy (DOT) Monitoring and management of side effects Monitoring and management of side effects

13. CONSILIUM FOR MDR TB TREATMENT AND MANAGEMENT Advantages Advantages Collective decision Collective decision Possibility for patients to receive most effective treatment Possibility for patients to receive most effective treatment Possibility to supervise treatment Possibility to supervise treatment Problem solving Problem solving Improvement of program management Improvement of program management

14. EXPERT CONSILIUM TREATINGPHISICIANS SOCIALWORKERSNURSES HOSPITALS LABORATORY AMBULATORY TREATMENT MDR TB REGISTRY REGISTRYSUPERVISION BOARD OF EXPERTS PHARMACY STRUCTURE OF DOTS-PLUS PROGRAM

15. DOTS PLUS IMPLEMENTATION STEP III ESTABLISHED CASE MANAGEMENT SYSTEM ESTABLISHED CASE MANAGEMENT SYSTEM Roles and responsibilities of HCW Roles and responsibilities of HCW Patient education Patient education Default tracing Default tracing Improved infection control measures Improved infection control measures Center of Excellence founded in 2000 Center of Excellence founded in 2000 International training centre for treatment and management for MDR TB International training centre for treatment and management for MDR TB Built laboratory capacity – Built laboratory capacity – DST to all I and II line drugs DST to all I and II line drugs Rapid diagnostic methods for patient with risk of MDR-TB Rapid diagnostic methods for patient with risk of MDR-TB Established database, data management, and information system 2002 -2003 Established database, data management, and information system 2002 -2003

16. IMPROVING ALL TB AND MDR TB PATIENT ADHERANCE Social Aid for TB Patients Food coupons Food coupons Transport tickets Transport tickets Extra coupon weekly Extra coupon weekly if adherence 100% Departments of Welfare Agreement with TB ambulatory departments

17. DOTS PLUS PROGRAM TREATMENT COHORTS Begun in 1997

18. DOTS PLUS IMPLEMENTATION STEP IV ACCESS TO II LINE DRUGS ACCESS TO II LINE DRUGS Leaving funds after procurement of I line drugs Leaving funds after procurement of I line drugs Extra from reserved funds Extra from reserved funds DOTS-plus project accepted by WHO Green Light Committee in January 2001 DOTS-plus project accepted by WHO Green Light Committee in January 2001 Approval for 350 patients for drugs Approval for 350 patients for drugs Full coverage with treatment Full coverage with treatment LiPA test - study to determine usefulness for early MDR TB case detection LiPA test - study to determine usefulness for early MDR TB case detection Established database, data management, and information system 2002 -2003 Established database, data management, and information system 2002 -2003

19. TREATMENT OUTCOMES FOR COHORT 2000 N=204 patients Completed treatment (6) Death (14) Default (26) Failure (29) Cure (129)

20. TREATMENT OUTCOMES FOR NEW TB CASES AFTER DOTS AND DOTS PLUS COMPLEATION

21. NUMBER OF PATIENTS WITH PRIMARY ANDACQUIRED MDR TB INCLUDING PRISON 1994 - 2003 Since 1998 total number of annually registered MDR TB cases decreased by 51% for previously treated by 65%

22. CONCLUSIONS AND RECCOMENDATIONS DOTS strategy has reduced MDR TB development by 51% in Latvia DOTS strategy has reduced MDR TB development by 51% in Latvia DOTS-Plus in addition to DOTS in settings with high MDR TB level can reach WHO goal for cure 85% DOTS-Plus in addition to DOTS in settings with high MDR TB level can reach WHO goal for cure 85% 2/3 of patients who started treatment in DOTS plus were cured 2/3 of patients who started treatment in DOTS plus were cured Addressing treatment default could significantly improve program effectiveness Addressing treatment default could significantly improve program effectiveness Strengthening of the DOTS strategy, rapid MDR TB diagnosis, contact investigation and genotyping to detect chain of transmission is the next steps to improve MDR TB control in Latvia Strengthening of the DOTS strategy, rapid MDR TB diagnosis, contact investigation and genotyping to detect chain of transmission is the next steps to improve MDR TB control in Latvia

23. NATIONAL CHOIRS FESTIVAL Welcome to Latvia