Short-course Treatment for Multidrug Resistant Tuberculosis Improves Treatment Success Rates by 88%: The need to scale up access to treatment

Abel Nkolo

Abel Nkolo, MSH’s Principal TB Technical Advisor for African Region, advocates for an improved global response to MDR-TB.

Every year, the Union World Conference on Lung Health brings together TB experts and organizations from around the world to share their achievements, challenges, innovations, and research related to tuberculosis (TB). This year, I was keen to learn what new information was available regarding multidrug resistant TB (MDR-TB), as this illness requires treatment with long and expensive drug regimes, making it difficult to control. Since nearly ten percent of the world’s TB-patients are already infected with MDR-TB, effective treatment is needed to keep this disease from spreading and potentially reversing decades of progress in TB control.

As Management Sciences for Health (MSH)’s Principal TB Technical Advisor in Africa, I interact daily with patients who are suffering from MDR-TB and unable to access treatment. I also see MDR-TB patients whose treatment has plagued them with severe side effects, including nausea and vomiting, joint pains, burning sensations, and hearing loss. Many of these patients default from the lengthy MDR-TB treatment course that requires them to take up to 20 pills each day for nearly two years.

In response to the devastating impact of MDR-TB, health professionals must advocate for improved MDR-TB care and prevention. These advocacy efforts could involve persuading donors and key stakeholders to fund and support shorter MDR-TB treatment regimens. As I learned at the Union Conference, one of these short-course treatment regimens currently being used in Bangladesh has reduced patient treatment time from over two years to just nine months. My colleagues’ presentation showed how this nine-month regime improved the MDR-TB treatment success rates by 88 percent among 206 patients. Today, others have followed suit and are implementing similar short course regimes in Cameroon, Benin, Central African Republic, DR Congo, Niger, and Swaziland.

The positive impact of these interventions cannot be ignored. The more countries we provide with these drugs and the more TB programs we help to roll out short course treatment, the more MDR-TB patients will be cured and prevalence rates will drop. Alternatively, the fewer resources we devote to treatment and the less attention we pay to these patients’ needs, the more MDR-TB will spread, mutate, and escalate as a public health crisis.

As a global health leader, MSH is advocating for an urgent response to the complex and threatening reality of MDR-TB. Through these efforts, we are targeting the nations in which we work and increasing awareness through national platforms, such as the upcoming World TB Day on March 24, 2014. We believe that, with timely action and realistic solutions, such as short-course treatment, MDR-TB can be controlled and eradicated.

Dr. Muluken Melese Discusses Leadership Strategies that Guide his Success as a TB Physician, Project Director, and Researcher

Twenty years ago, Muluken Melese was the only doctor serving thousands of residents at a rural health facility in southern Ethiopia. The community’s poverty and health system weaknesses made this position particularly challenging. Over time, the young doctor realized that the great majority of his patients’ illnesses could be prevented through community education or easily treated under a strengthened health system. This awareness piqued Muluken’s interest in public health and, after two years as a physician, he began pursuing other professional opportunities to supplement his clinical experience.

Recognizing his passion and skill, ActionAID invited Muluken to work as a project health manager and, later, the World Health Organization hired to him support the Ministry of Health in developing emergency health systems and addressing gender-based violence. He also served as the deputy country director for ORBIS International and as a program director at Columbia University’s International Center for AIDS Care and Treatment Programs. In these positions, Muluken coordinated health services, trained health workers, and led community-based water and sanitation projects. Muluken’s medical expertise and public health experience also gave him a unique perspective on the Ethiopian health care system and equipped him to publish over 30 journal articles on TB, HIV, and blindness.

Six years ago, learning of Muluken’s leadership experience and clinical expertise, Management Sciences for Health (MSH) asked him to serve as the technical director for the HIV/AIDS Care and Support (HCSP) project. USAID’s HCSP was one of the largest projects in Africa working to decentralize HIV & AIDS care and treatment services to the health center level.  Muluken’s success in this position inspired MSH to promote and, in 2011, he had accepted his current position as project director for the USAID funded-project, Help Ethiopia Address Low Tuberculosis (HEAL TB). Today, just half way through the project’s five-year lifespan, Muluken’s expert leadership has made HEAL TB a thriving and successful health project reaching thousands of residents in 21 zones of Ethiopia. Hardworking, yet humble, Muluken attributes this success to his dedicated project team and committed stakeholders at all levels of the health system.

“We have great support from USAID, not only financially but also technically. The government is also supportive – they feel as we are one of their team.  You know – they don’t consider us as an outsider – if something fails we’re also responsible. We are involved in the planning, implementing, decision making, and evaluation. The Ministry… considers us their own team. We’re not creating a parallel structure, we’re working in the existing system.”

For Muluken, these partnerships go beyond contractual agreements to include regular, transparent communication, and collaborative work planning.

“Before we develop our work plan, we discuss it with the ministry and the regions to determine what they need. It’s open—we share. I know what they have, they know what we have, so we don’t overlap.”

Muluken’s management strategies have allowed HEAL TB to effectively navigate the political context, while his clinical experience has guided the project’s technical strategy.

“Capacity building and community mobilization have allowed us to bring hundreds of TB patients to treatment. We also focus on helping these patients access proper treatment and adhere to their medications. If you do all of this, it reduces TB transmission and incidence. Furthermore, by building health extension workers’ capacity, we can reach neglected segments of the community, such as mothers, children, and the elderly.”

Muluken’s strong leadership experience is helping to improve TB control in Ethiopia and has equipped him to provide mentorship support to MSH’s other TB projects, such as USAID’s TRACK TB Activity project in Uganda. As an experienced physician and public health professional, Muluken’s work is also impacting the global health community at large. At this year’s Union World Lung Health Conference, for example, Muluken and the HEAL TB team presented five posters and one oral presentation showcasing the project’s results. This year, the team also published three journal articles detailing HEAL TB’s strategic approach to TB control and significant project results.

“Research and advocacy influence health systems… we should use our experiences to improve health-related policies and interventions at national and international levels. It’s the way you sell it – we don’t do it for conferences, we do it to address the gaps, to improve project implementation.”

For more information of HEAL TB’s work, please view their conference posters and the following journal articles:

MSH Shares its “Bread and Butter” TB Control Strategies at the Union Conference

The Union World Conference on Lung Health concluded on Sunday, November 3, with a symposium on tuberculosis (TB) case detection strategies in sub-Saharan Africa. Moderated by MSH’s Global Technical Lead for TB, Pedro Suarez, the symposium began with a riveting presentation from Rhehab Chimzizi, the TB CARE I Project Director and Management Sciences for Health (MSH)’s Country Representative in Ghana. Rhehab outlined the strategies his team used to implement standard operating procedures (SOPs) for TB case detection at six large Ghanaian hospitals and then discussed the significant improvements that occurred at these hospitals. He emphasized that this low cost, simple intervention involved training just 120 health workers and, in 12 months, increased TB case detection by 46 percent and reduced TB patient mortality by 38 percent.

“Ghana has 213 districts and we only did this in two,” Rhehab told the room. “The point is, if we do this in all hospitals, the national TB case detection rate will go up and TB deaths will also go down!”

After his speech, the room buzzed with energy as Rhehab fielded questions from six of his colleagues. Many of the audience members had been taking notes during his speech and these health professionals asked Rhehab to elaborate on the causes of patient mortality, the study design, the implications for expansion, the staff trainings, and the patient treatment strategies. Rhehab answered each of his colleagues and invited further questions and discussion by referring participants to his contact information.

Rhehab Chimzizi prepares for his presentation on effective TB control strategies in Ghana. {Photo credit: Jessica Charles/MSH.}

Rhehab Chimzizi prepares for his presentation on effective TB control strategies in Ghana. {Photo credit: Jessica Charles/MSH.}

After Rhehab’s speech, the audience turned its attention to Habtamu Ayalneh, a TB and TB/TB Clinical Diagnosis Coordinator for USAID’s TB CARE I project in Ethiopia. Habtamu’s presentation showed how both the Help Ethiopia Address the Low TB Performance (HEAL TB) and TB CARE I projects have improved TB case detection in Ethiopia through health worker trainings, SOP development and distribution, TB patient contact screening, and staff supervision and mentoring. Habtamu also discussed how the projects are improving laboratory services in Ethiopia through by external quality assurance activities and enhanced recording and reporting systems. Slides detailing these interventions then led into results data showing a 1,034 percent increase in the number of TB suspects identified in the intervention areas and a 155 percent increase in the number of TB suspects examined.

Habtamu also shared data reflecting improved trends in the TB cure rate, diagnostic accuracy, and patients with multidrug resistant TB enrolled in treatment.

Habtamu Ayalneh. {Photo credit: Jessica Charles/MSH.}

Habtamu Ayalneh fields questions. {Photo credit: Jessica Charles/MSH.}

Audience members praised both Habtamu and Rhehab for sharing their project implementation strategies and one participant emphasized the importance of keeping these “bread and butter” interventions at the forefront of our discussions on TB prevention and control, especially at global conferences where innovation and technical research often take center stage. In line with this sentiment, Rhehab ended his talk by imploring the audience and donors to continue funding these critical interventions, even in, and especially in, countries where the TB epidemic is now more controlled.

“People are talking about zero TB deaths,” Rhehab said. “But let’s make sure that the zeros do not include zero funding – it should be zero TB deaths but more funding for TB control services!”

Rhehab and Habtamu’s presentations demonstrate their technical expertise, leadership capacity, and commitment to advocacy for improved TB control. Both presentations will be available below. The presenters are eager to engage in further discussions about their projects and findings.

Improving TB Case Detection in Big Hospitals in Ghana (PDF)
Authors: Rhehab Chimzizi, Bismarck Adusei, Angela Quaye, George Bonsu, Pedro Suarez, Frank Bonsu.

Improving TB Case Detection through Strengthening of the Health System in Ethiopia: From Pilot to Scale Up (PDF)
Authors: Habtamu Ayalneh; Muluken Melesse; Belaineh Girma.

For more information about the USAID-funded, TB CARE I project, led by KNCV Foundation with MSH and partners, visit: TB CARE I.

For more information about the PEPFAR- and USAID-funded, HEAL TB project, led by MSH and partners, visit: HEAL TB.

Promoting Safe and Effective Treatment for Multidrug-resistant Tuberculosis

Among patients identified with pulmonary tuberculosis (TB) in 2011, an estimated 310,000 had multidrug-resistant (MDR)-TB (1). However, less than 20% of these patients were diagnosed and treated for MDR-TB (1). By definition, MDR-TB is resistant to the two most effective TB medicines. Consequently, patients require complex treatment comprised of multiple drugs for up to two years. These medicines are not only more expensive and less effective than the standard treatment for TB, but they are also associated with severe side effects, such as permanent hearing loss.

In an effort to promote optimal treatment for MDR-TB, the USAID-funded Systems for Improved Access to Services and Pharmaceuticals (SIAPS) project sponsored a symposium on Saturday, November 20 titled “Rational Drug Use for MDR-TB: start safe, stay safe, breathe safe.”  TB medicine expert Dr. Jose Caminero and SIAPS Senior Technical Advisor Dr. Archil Salakaia facilitated discussion from a panel of TB specialists on how to design safe and effective MDR-TB treatment regimens. Presenters identified a number of challenges in administering MDR-TB treatment; for example, its long duration and high rates of side effects may prevent patients from completing their full treatment course. If patients stop medicine early, not only does their TB remain uncured but they also risk developing further resistance and spreading TB to others in the community.

To address this challenge and others, the symposium highlighted a number of useful approaches to prevent and manage MDR-TB, such as adherence to standard treatment guidelines, as well as the SIAPS tool “Guidelines for Conducting Drug Resistant Tuberculosis Drug Utilization Reviews”.  At a time when new medicines are under development and treatment recommendations are changing alongside evolving evidence, the symposium served as an important opportunity to discuss resources available to help both providers and patients.

 

Citation:(1) Stop TB Partnership. Stop TB Working Group on MDR-TB. http://www.stoptb.org/wg/mdrtb/keyfacts.asp

Pharmacists, Drug Sellers, and Pharmacy Associations: Key Players in the Fight against TB

While the National Tuberculosis Programs (NTP) of most countries offer free diagnosis and treatment for tuberculosis (TB), many people worldwide first seek care from other providers, such as physicians in the private sector, pharmacists, or informal drug sellers. Partnerships between NTPs and providers in the private sector have long been touted by the World Health Organization (WHO) as a way to increase patient access to timely diagnosis and quality treatment regimens; however, pharmacists and pharmacy associations have only recently been recognized as key players in these partnerships.

On Saturday, November 2 the USAID-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS) program organized a symposium on the involvement of private pharmacists in TB, titled “Engaging pharmacists for TB control: rhetoric or reality?”

The symposium featured country experiences from Tanzania, Pakistan, and India, all of whom have done innovative work building collaborations between private sector pharmacies and the NTP.

The symposium highlighted that while pilot projects have shown the value of engaging pharmacists, additional data is needed about the specific costs and returns that countries can expect when engaging pharmacists, as well as the incentives that are needed to motivate all stakeholders. Public-private mix (PPM) expert Mukund Uplekar facilitated an interactive session and lively discussion that highlighted both the importance of pharmacists in TB as well as the need to understand the local health system when designing interventions.

Emily Delmotte (@edelmott) is a technical associate in the Center for Pharmaceutical Management at MSH.

Informed Choices for Improved Health: Training Health Professionals in Data-Driven Decision-Making

The decisions we make in public health have a direct impact on people’s quality of life and well-being. Whether working at the national or community level, with millions of beneficiaries, or a single village, we have a responsibility to make well-informed choices and timely decisions regarding interventions, resources, and finances. Each life is invaluable. Each decision critical.

On October 31, 23 Union Conference participants from 21 nations completed a post-graduate course designed to improve their use of data for decision making. Some of these professionals struggle with a lack of data to inform health programming, whereas others shared that the abundance of data is often overwhelming when it comes to strategic planning and effective project implementation. As members of the USAID-funded TB CARE I Program Management Unit, the course facilitators from KNCV Tuberculosis Foundation and Management Sciences for Health (MSH) empathize with these concerns. Using their program implementation experience and expertise in data management, these six professionals developed a course called, “Data for Decision for Making and Use of Data for Continuous Improvement.” During this full-day course, the facilitators led presentations and discussions that challenged participants to apply intuition, personal experience, and prioritization strategies to decision making. They also highlighted the importance of assessing outcomes to inform and refine decision, rather focusing only on the data.

 [They] emphasized that we need to look at the impact – there’s so much data that you get but it’s also helpful to focus on the effect. Rather than look at the process indicators – we should look at the outcomes, said participant Bernard Sichinga, a monitoring and evaluation officer from Zambia.

Dr. Ersin Topcuoglu, TB CARE I’s Deputy Director of Operations and M&E, encouraged participants to make timely decisions and take action with the understanding that all choices require regular reassessment and revision.

It’s important to be predictive not reactive – you have data so, based on this data, you make a decision and predict what’s going to happen next. Then you just need to test and improve – not only the data but also the decision.

Claire Moodie, TB CARE I’s Monitoring and Evaluation Officer, and Rosanne van Halm, TB CARE I’s Finance Team Leader, helped participants apply these strategies by facilitating a case study activity. In the first case study round, Claire and Rosanne divided the class into groups and gave each team a country map and 12 magnets representing GeneXpert machines (TB diagnostic instruments). They asked the teams to make a plan for distributing the GeneXpert machines throughout the country in a manner that would maximize health impact. As they’d been taught, participants assessed the information provided in the map and applied their intuition and field experience to fill in the gaps and develop a dissemination plan in the allotted time.

In each subsequent round, Claire and Rosanne offered slightly more data, allowing the groups to revise and improve their plans as they developed their knowledge of the nation’s population density, disease burden, resources, and other details.

Participants were eager to apply these strategies and others to improve decision making and data quality in their respective countries. Alexinah Muadinohamba, deputy director of the Health Sector Response for Namibia’s Ministry of Health, explained how she would apply the course’s lessons on shared ownership of decision making:

Health workers should be able to use the [data] tools themselves to make decisions. They should be able to analyze it [and] use it themselves for operational research. If you don’t do that, staff feel demotivated and they don’t provide quality data.

As he concluded the session, Dr. Ersin Topcuoglu reminded the class that decision-making is a process.

Don’t be paralyzed waiting for the perfect set of data. Put your experience on the table and then constantly evaluate the data to determine how well the decision-making is working.

Eugenne Elliott nodded at Dr. Topcuoglu’s remarks from the back row. “It’s true,” she said. “I love data but we have to remember we’re not treating numbers – we’re treating real people.”

team_pic-web

Learn more about TB CARE I.

Jessica Charles is a communications specialist at MSH.

Covering All the Bases: Ensuring Availability of TB Medicines

When purchasing a medicine from the shelf of a local pharmacy, it’s easy to forget the many miles traveled and challenges overcome to make it available to consumers. This is especially true for tuberculosis medicines, which come from a limited number of manufactures and often have short shelf-lives. Unless countries have accurate information on the number of patients who need treatment at any given time, medicines can expire, with great financial cost, or become stocked out, with great cost to the health of patients.

At the 44th Union World Conference on Lung Health, the Global Drug Facility collaborated with the USAID-funded, MSH-led Systems for Improved Access to Pharmaceuticals and Services (SIAPS) program to address the ways in which countries can ensure patients have access to quality medicines when they are needed.

The full day workshop, titled “Global Drug Facility (GDF): Universal Access to Internationally Quality Assured (IQA) TB Commodities” centered on the tools and techniques National Tuberculosis Programs can use to ensure they maintain adequate stocks of TB medicines. Representatives from the GDF described early experiences from a pilot project titled Early Stock-out Warning System, an approach designed to help countries extract and analyze data to avoid stock outs or expiry of medicines.

The presentation paved the way for the launch of a new SIAPS tool called QuanTB. QuanTB, a free, downloadable tool, is designed to simplify the way in which TB staff forecast and quantify the number of medicines needed. SIAPS staff provided a demonstration of the tool, which allows users to modify items such as treatment regimens, buffer stock, and lead time in order to reflect the local environment.

Through tools such as QuanTB, and approaches like the GDF’s early warning system, the workshop provided participants with concrete ideas about how to guarantee shelves are stocked with quality medicines when patients seek treatment.

Dr. Salakaia speaking at the SIAPS-GDF workshop

Dr. Archil Salakaia, Senior Technical Advisor for SIAPS, moderates the GDF workshop.

Andre Zagorski, Principal Technical Advisor for TB in the SIAPS Program, discusses the GDF workshop with Dr. Mahshid Nasehi, National Manager of the Iran TB & Leprosy Control Programmes

Andre Zagorski, Principal Technical Advisor for TB in the SIAPS Program, discusses the GDF workshop with Dr. Mahshid Nasehi, National Manager of the Iran TB & Leprosy Control Programmes

(from left) SIAPS Senior Technical Advisors Philo Kakanda, Chinwe Owunna, and Salama Mwatawala after the GDF session. Ms. Owunna coordinated the workshop while Ms. Mwatawala presented two sessions.

(from left) SIAPS Senior Technical Advisors Philo Kakanda, Chinwe Owunna, and Salama Mwatawala after the GDF session. Ms. Owunna coordinated the workshop while Ms. Mwatawala presented two sessions.

Emily Delmotte (@edelmott) is a technical associate in the Center for Pharmaceutical Management at MSH.