Sisaket Province Case Finding

1. Sisaket Province Case Finding

2. 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

3. 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

4. Himpro HOS XP Smart TB TBCM

5. 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

6. 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

7. 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

8. 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

9. 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?

10. 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)

11. 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

12. 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

13. 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)

14. 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

15. Sputum collection booth

16. 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

17. 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 hosplab: complete info for culture/DST specimens referred Better integration of MLaband HIMpro, or single program

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

25. PHO-Sisaket