1. International Health Policy Program -Thailand Policy decision on multi drug resistant(MDR), extreme drug resistant(XDR) tuberculosis screening: How it comes? Thanawat Wongphan 1,2 Pairoj Saonuam 3. Jongkol Lertiendumrong 1, Phusit Prakongsai 1 1 International Health Policy Program(IHPP), Nonthaburi, Thailand 2 Banmoh Hospital, Saraburi, Thailand 3 Medical Physician, Senior Professional Level National AIDS Management Center (NAMc) Department of Disease Control, Ministry of Public Health, Nonthaburi Thailand The First Annual Conference of HTAsiaLink Grand Pacific Sovereign Hotel, Petchaburi,Thailand May 14 ‐ 16, 2012

2. International Health Policy Program -Thailand Background information Methodologies Research findings Conclusion and discussion. Policy recommendations 2 Outline of presentation

3. International Health Policy Program -Thailand Background (1) Definition: MDR-TB is the tuberculosis which resists to Rifampicin or Isoniazid. XDR is the tuberculosis which resists to –Rifampicin or Isoniazid –Quinolone –At least one injectable antibiotic(kanamycin, capreomycin or amikacin) [Ref] 1. Centers for Disease Control and Prevention., Multidrug-Resistant Tuberculosis (MDR TB) Fact Sheet. 2011. 2. World Health Organization., Press release: WHO Global Task Force outlines measures to combat XDR-TB worldwide. 2006. 3

4. International Health Policy Program -Thailand Background (2) The prevalence of all TB patients in Thailand is 130,000 cases per year, and the rate of MDR-TB ranges from 0 to 14.1 percent of all first diagnosed TB patients. The cost of treatment of MDR or XDR TB can be more than 100 times when compare to a normal pulmonary TB. 4

5. International Health Policy Program -Thailand Incidence of MDR-TB in Thailand is 2,900 cases per year and 1,547 of them are in the first time of treatment. Five percent of all MDR-TB can develop to XDR-TB in the future. 5 Background (3)

6. International Health Policy Program -Thailand Objectives To find the ways to increase potency of TB treatment system and to decrease incidence rate of MDR-TB we split the project into 3 parts to answer this –the most cost-benefit method of MDR-TB screening –System gap analysis –Cost-utility analysis based on dynamic models on MDR-TB screening. 6

7. International Health Policy Program -Thailand 7 Methods (1) The study is conducted with two methods: Cost-benefit analysis (CBA) and system gap analysis. The CBA uses the decision tree algorithm among four choices of MDR-TB diagnosis: standard culture (L-J), Overbrooke 7H- 10, Microscopic observation drug susceptibility (MODS), gene technique and the conservative technique (work up in all failure cases.). The gap analysis uses an expert panel’s discussion and inductive conclusion to formulate the policy recommendations.

8. International Health Policy Program -Thailand 8 Target population All TB diagnosis Comparator -Standard procedure -Lowenstein-Jensen(L-J) in all cases. -Microscopic observation drug susceptibility(MODS) -Overbrooke 7H-10 -Gene technique(eg. geneXpert 1 ) Methods (2) 1 is a registered trademark from Cepheid, CA, USA

9. International Health Policy Program -Thailand 9 COST Use only direct medical cost: LAB: Department of Medical Science, Ministry of public health, Thailand Drug cost: Chest disease institute. Lab’s duration Department of Medical Science, Ministry of public health, Thailand Expert panel’s adjustment Systematic review on MODS. Methods (2)

10. International Health Policy Program -Thailand Comparison among MDR Screening and treatment choices 10 2 months of standard TB treatment Culture waiting period(4-8 weeks) Start MDR- TB treatment Standar d 6 Weeks(4-8 Weeks) L-J techniq ue 6 Weeks(4-8 Weeks) 6 Weeks(4-8 Weeks) 7H10 6 Days MOD s 1 Day Gene techniq ue Sputum AFB still be POSITIVE. Start MDR-TB treatment

11. International Health Policy Program -Thailand Research findings

12. International Health Policy Program -Thailand Incidence of Thai TB patients and individual cost of treatment. 12 Cases Cost(Baht)

13. International Health Policy Program -Thailand MDR diagnosed Lab duration and cost comparison 13 Weeks Baht

14. International Health Policy Program -Thailand Cost-Benefit comparison on MDR TB diagnosis Diagnosis procedure LJMODs7H-10 Gene technique Cost (Million Baht) 4.65 55.8 Benefit (Million Baht) 2.38 – 3.30 4.42 - 6.13 2.38 - 3.304.70 - 6.53 14 *Comparison based on standard TB treatment program.

15. International Health Policy Program -Thailand MDR screening is essential for all first diagnosed TB cases because –it can stop disease-spreading while patients are being treated with standard drug regimen, –decrease drug side effects. –drug costs and patients’ expenses related to the inappropriate drugs use. 15 Conclusions and discussion

16. International Health Policy Program -Thailand Although MODS is the most cost- benefit method but the gap analysis shows that Thailand has many semi-liquid culturing facilities. So it is better to use them instead of investing more money to do MODS. 16 Conclusions

17. International Health Policy Program -Thailand Policy recommendations

18. International Health Policy Program -Thailand Specific policies: 1.Enhance capacity of TB treatments in all modalities. 2.Establish the standardized logistic system of specimen transfering. 3.Increase support of lung surgery. 18

19. International Health Policy Program -Thailand General policies(1): 1.Increase co-operation between units to units including private sector and supertertiary hospital. 2.Establish the national MDR, XDR-TB caring guideline. 3.Concern in some high risk patients eg. HIV. 4.Medical staffs should be refreshed knowledge and be updated their system's knowledge. 19

20. International Health Policy Program -Thailand General policies(2): 5. Find sources of fund to support the system, 6. Improve the follow up care system, 7. National Health Security Office(NHSO) should generate the ICT data system to be used in follow up care of treatment and easy to monitor, 8.NHSO should support the health staffs in many roles e.g. funding source for generating national guideline, 9.Link this treatment system to quality accreditation to increase sustainable development. 20

21. International Health Policy Program -Thailand 21

22. International Health Policy Program -Thailand National Health Security Office (NHSO) of Thailand, The Universal Coverage Benefit Package Subcommittee of NHSO, Dr. Charoen Chuchottaworn and Chest Disease Institute, Ministry of Public Health, Thailand Ms. Kumaree Patchanee, IHPP, Thainad Banmoh hospital staff, Saraburi, Thailand 22 Acknowledgement