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Issues and lesson learned as a NRL in TB Management (GENETUP)

Issues and lesson learned as a NRL in TB Management (GENETUP). Dr. Bhabana Shrestha NATA/GENETUP 14 th July 2014. German Nepal TB project ( GENETUP). Providing the diagnostic & treatment services since 27 years Pioneer of Directly Observed Treatment Short Course (DOTS)

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Issues and lesson learned as a NRL in TB Management (GENETUP)

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  1. Issues and lesson learned as a NRL in TB Management (GENETUP) Dr. BhabanaShrestha NATA/GENETUP 14th July 2014

  2. German Nepal TB project (GENETUP) • Providing the diagnostic & treatment services since 27 years • Pioneer of Directly Observed Treatment Short Course (DOTS) • Pioneer of diagnosis of drug resistant tuberculosis (DR TB) • Alliance partner of NTP, for the DR-TB management program, ( DR-TB centre & National Reference laboratory for Culture & DST)

  3. GENETUP LABORATORY Facilities • Microscopy by LED microscope • Conventional culture and DST on first line and second line drugs • Gene Xpert/MTB/RIF • Molecular Line Probe assay for first line (H&R) and second line (Flq & AI) • Research puupose: • Bactec MGIT • Genotyping of MTB (only for research purpose)

  4. MDR-TB suspects - definition • Failures of cat. I and cat. II • Initially SS+ patients who are still positive after three months of DOTS and/or are doing poorly clinically (persistent cough, fever, loss of weight, tiredness, etc.) • People living with HIV (at the start of ANY anti-TB treatment to avoid MDR-related mortality) • Patients starting cat. II for any reason • Close contacts of proven X/MDR-TB cases

  5. Where to refer ?? • National Reference Lab, NTC, Thimi • National Reference lab, GENETUP,Kalimati • Nearest Gene Xpert Centres

  6. Result of MDR Survey in Nepal

  7. Result of XDR Survey in Nepal

  8. Diagnostic Gap Based on DRS-2011, 996 new MDR-TB develops every year • 550 MDR-TB cases among new smear-positive patients • 446 MDR-TB cases among estimated previously treated cases • 80 XDR-TB cases • Out of the estimated 996 MDR-TB cases, only 271 (27.3%) • Out of the estimated 80 XDR-TB cases, only 26 (33%) WERE ON TREATMENT.

  9. Case Finding (Pre-XDR/XDR-TB)

  10. Treatment Out Come of XDR-TB

  11. High initial quinolone resistant among the MDR-TB Initial SLDST of MDR patients N=169 (Dec 2013-July2014) Quinolone KamamycinCapreomycin n Susceptible Susceptible Susceptible 109(64.4%) ResistantSusceptible Susceptible 56 (33.1%) Resistant Resistant Resistant 1(0.6%) SensitiveResistant Resistant 3(1.7%) Total 169

  12. Result of Gene Xpert Gene Xpert test result at GENETUP Lab (Feb 2014-July 2014) TotalTB detected TB not detected MDR • Smear Positive 215202 13 55 (27.2%) • Smear Negative 471142 (30.1%) 329 20 (14.0%) • Error 14 (2%) • Total 700 Remarks: Gene Xpertdetects high case notification among the smear negatives

  13. MDR Diagnostic Method verses enrollment

  14. A High Case Load at GENETUP DR CENTER Enrollment ( 070/071) • MDR: • Total Nationwide Registered Cases 302 • GENETUP 87 (28.8%) • XDR: • Total Nationwide Registered Cases 31 • GENETUP 19 (61.2%)

  15. Challenges in DR TB management program 1- Pre-XDR, XDR & XXDR TB 2- 22 cases were tested for 11 drugs( KM, CM, AM, Ofx, Moxi, CS, PTH, PZA, Cfz, Lzd, PAS) Resistant to Lzd- 4.5 %(1case) High number of resistance to PZA & PTH (95.5 % & 90%) Cfz (63 %) PAS (45 %) CS (23 %) Remark: these are serious public health problem and need isolation and right treatment to prevent further transmission

  16. Think ,Think and Rethink • Alarming situation of DR TB cases • Management of the XXDR TB cases

  17. ISSUES • Workload at the NRL, GENETUP -Covering 8 DR treatment centers -Testing of 3 sputum specimens instead of 2 sputum specimens -Overload of Gene Xpert testing request • Weak Cross Referral / Tracking Mechanism • Diagnostic limitation of EP DR TB • Lack of motivating factors to the staff

  18. Problems • Inadequate budget for SLDST • Inadequate supply of ancillary drugs • Management of adverse effects of second line drugs • Management of MOTT

  19. Any Question ? ? ?

  20. Thank you Thank you

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