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Thanawat Wongphan 1,2 Pairoj Saonuam 3 . Jongkol Lertiendumrong 1 , Phusit Prakongsai 1

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

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Thanawat Wongphan 1,2 Pairoj Saonuam 3 . Jongkol Lertiendumrong 1 , Phusit Prakongsai 1

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  1. Policy decision on multi drug resistant(MDR), extreme drug resistant(XDR) tuberculosis screening: How it comes? Thanawat Wongphan1,2 Pairoj Saonuam3. Jongkol Lertiendumrong1, Phusit Prakongsai1 1International 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. Outline of presentation • Background information • Methodologies • Research findings • Conclusion and discussion. • Policy recommendations

  3. Background (1) • Definition: • MDR-TB is the tuberculosis which resists to Rifampicin orIsoniazid. • XDR is the tuberculosis which resists to • Rifampicin orIsoniazid • 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.

  4. 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.

  5. Background (3) • 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-TBcan develop to XDR-TB in the future.

  6. 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.

  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. Methods (2) 1 is a registered trademark from Cepheid, CA, USA

  9. Methods (2)

  10. Comparison among MDR Screening and treatment choices Sputum AFB still be POSITIVE. Standard StartMDR-TB treatment 2months of standard TB treatment Culture waiting period(4-8 weeks) L-J technique 6 Weeks(4-8 Weeks) 7H10 6 Weeks(4-8 Weeks) MODs 6 Days Gene technique 1 Day StartMDR-TB treatment StartMDR-TB treatment StartMDR-TB treatment StartMDR-TB treatment

  11. Research findings

  12. Incidence of Thai TB patients and individual cost of treatment. Cases Cost(Baht)

  13. MDR diagnosed Lab duration and cost comparison Baht Weeks

  14. Cost-Benefit comparison on MDR TB diagnosis *Comparison based on standard TB treatment program.

  15. Conclusions and discussion • 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.

  16. Conclusions • 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.

  17. Policy recommendations

  18. Specific policies: • Enhance capacity of TB treatments in all modalities. • Establish the standardized logistic system of specimen transfering. • Increase support of lung surgery.

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

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

  21. END Please follow our cua on mdr-tb screening in the future

  22. Acknowledgement • 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

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