P ..Viiklepp,.A ..Kurbatova
National.Institute.for.Health.Development,.Tallinn
Consolidated Action Plan, area of intervention 7
73
Estonia |
TUBIDU materials are available in seven languages (Bul-garian, English, Estonian, Latvian, Lithuanian, Romanian and Russian) on the website of the project and can be down-loaded at http://www.tai.ee/en/tubidu/publications.
Outcomes
A final evaluation confirmed that the TUBIDU project had addressed many important issues in the field of TB preven-tion and harm reducpreven-tion, within and beyond the project area. The TUBIDU partners and other specialists involved expressed satisfaction with the project, confirming that the outcomes (i.e. training, network meetings, information and training materials) had met their professional needs and had already improved and facilitated work in their organization or facility. The feedback indicated that TUBIDU deliverables were well received and in some cases had already been used successfully in harm reduction or in the work of other rele-vant sites. The online feedback also revealed that TUBIDU events, internships and training were highly valued by the participants, both for the theory of TB in vulnerable groups and for practical knowledge and skills.
The project enhanced horizontal and vertical country-spe-cific and cross-border collaboration of various stakeholders to tackle TB. All the TUBIDU collaborators emphasized the importance of the project’s multilateral bridging nature, therewith also initiating new and strengthening existing collaboration between community-based and government organizations as well as social, harm reduction and medi-cal institutions. The project has therefore had an impor-tant impact on the partners in creating, strengthening and broadening international and national partnerships in the response to TB and injecting drug use at national and inter-national levels.
The project contributed to more active communication and collaboration among specialists in different fields, such as between medical (e.g. HIV and TB doctors and nurses) and harm reduction specialists. The contribution of the TUB-IDU project to improving collaboration with other national stakeholders and organizations was considered to be signifi-cant by 73% of the online feedback respondents.
Ensuring sustainability
The greatest challenge remains the sustainability of the activities. At the end of the project, some partners found difficulty in obtaining resources for continuing their work.
In Estonia, some of the activities will be integrated into the National Health Plan. Furthermore, the Estonian Ministry of Social Affairs has showed interest in sharing the TUB-IDU project outcomes, experience and recommendations at international level to keep the topic of TB in vulnerable groups high on the international agenda.
In Latvia, the Ministry of Health has supported the devel-opment of collaboration algorithms and mechanisms between community-based organizations and health care providers (e.g. TB/HIV services) in policy documents and has expressed willingness to use the project results in future policy planning.
TUBIDU partners emphasized the importance and bene-fit of maintaining the national and international network that was established during the project. Project partners will continue to advocate for sustainable implementation of TUBIDU policy recommendations through international networks and new projects in the same field. Thus, in Roma-nia, some of the TUBIDU project activities have been inte-grated into the new Global Fund project.
74 | Good practices in strengthening health systems for the prevention and care of tuberculosis and drug-resistant tuberculosis
Background
The incidence of TB in Hungary is decreasing stead-ily. In 2014, it had decreased to 8.4%, with nine cases of MDR-TB. Despite the decrease, some regions still have a higher-than-average incidence of TB, particularly counties bordering Romania and Ukraine, where poverty, unemploy-ment and cross-border trafficking are prevalent.
Hungary has a vertical TB surveillance system, with statu-tory case-based notification directly to the national level.
Surveillance involves obtaining data from treatment sites (i.e. pulmonary dispensaries responsible for TB treatment and screening, pulmonology departments) and from labo-ratories handling mycobacterial samples. As of 2010, these data have been registered online.
Health system challenge
The national surveillance unit required a team with special expertise in TB to increase efforts to decrease the rates of TB in Hungary.
Good practice in health system strengthening to improve prevention and care of M/XDR-TB
The national surveillance team has set up an online system to register TB cases and has formed a TB expert team within the surveillance unit to manage and monitor cases. The expert team includes pulmonologists, an M/XDR-TB treat-ment specialist, a microbiologist, a statistician, the head of the National Mycobacterium Reference Laboratory and the NTP manager; its work is supported by an information tech-nology expert. The aim of the team is to monitor TB status and to provide support to treatment facilities, health pro-fessionals, mycobacterial diagnosticians, laboratories and screening facilities to ensure adherence to the proper clin-ical pathways.
Although there remains room for improvement in the timely reporting of cases, the online system has led to faster iden-tification of possible discrepancies in data from different sources on the same TB patient or patients who may have been seen in only one or another setting (laboratory or
treatment facility). For example, when cases are detected in a laboratory, the national surveillance unit can help ensure that they are also found and referred to the geographically appropriate pulmonary dispensary or pulmonology depart-ment to initiate treatdepart-ment as quickly as possible.
When discrepancies and potential errors are found in diag-nosis and treatment, the expert team can contact the health professional in question to provide guidance and feedback for re-assessing the treatment plan or explain how to use the online system, should this be an issue. The expert team is also responsible for assessing and investigating all treat-ments still registered at 10 months to find the reason for the prolonged treatment and, if necessary, provide guidance to improve the treatment.
The expert team has also helped to address problems in regions of Hungary with a high TB incidence. For example, in 2010, the northeastern counties of Borsod-Abaúj-Zem-plén, Szabolcs-Szatmár-Bereg and Hajdú-Bihar, had higher rates of poverty, unemployment and local border traffic and therefore experienced incidence rates that were higher than the average rate in Hungary.
In 2011, discussions between the expert group and the main stakeholders in TB control in Borsod-Abaúj-Zemplén county resulted in a reduction in the incidence rate and led to intensified mandatory screening of the local population and increased awareness about proper diagnosis and treat-ment. In 2013, although screening programmes were in place, no significant decrease in the incidence rates of TB was observed in Szabolcs-Szatmár-Bereg county. The expert team therefore organized site visits to hold advisory forums for local practitioners, mycobacteriologists and public health officers on various aspects of TB care and control. Medical charts were revised.
Outcomes
This scaled-up, concerted approach resulted in a marked improvement in data quality, and 30–40 cases of infection with non-tuberculous mycobacteria are de-notified. In
addi-Hungary
Forming an expert team for active TB surveillance
Á ..Bakos,.I ..Gaudi,.I ..Horváth,.G ..Kovács
National.Korányi.Institute.for.TB.and.Pulmonology,.Budapest
Consolidated Action Plan, area of intervention 5
75
Hungary |
tion, there is more rapid de-notification in cases of misdiag-nosis (Fig. 1) and adoption of the recommended interval for treating DS pulmonary TB treatment (Fig. 2).
The expert group and online registration system also contrib-uted to better control and management of TB in the target counties of Borsod-Abaúj-Zemplén, Szabolcs-Szatmár-Bereg and Hajdú-Bihar. Fig. 3 shows the observed decreases in inci-dence between 2010 and 2014.
As a result Hungary has been able to maintain a low pro-portion of MDR-TB cases: in 2014, only 1.5% of new cul-ture-positive pulmonary TB cases and 11.8% of re-treated cases were MDR-TB. In 2010, 14 new and no re-treatment cases were detected in the northeastern counties (out of all 22 Hungarian MDR-TB cases), whereas by 2014, not a sin-gle case of MDR-TB was registered, and only five cases of MDR-TB in re-treatment patients appeared in that region.
These results underline the importance of ensuring compli-ance and treatment completion among patients with new TB to prevent acquired MDR-TB.
Fig 1 Time.to.de-notification.in.cases.of.
misdiagnosis,.2010–2014.(relative.frequency)
Fig 2 Interval.before.treatment.of.pulmonary..
DS-TB,.2010–2014.(relative.frequency)
Fig 3 ..Incidence.of.TB.per.100.000.in.high-risk.
counties,.2010–2014
BAZ,.Borsod-Abaúj-Zemplén;.SSB,.Szabolcs-Szatmár-Bereg;.HB,.Hajdú-Bihar.
76 | Good practices in strengthening health systems for the prevention and care of tuberculosis and drug-resistant tuberculosis
Background
Serbia has a well-organized TB programme, which in the past 5–6 years has stabilized the MDR-TB situation in the country. The incidence of all TB fell from 37/100 000 in 2003 to 17/100 000 in 2013. The success rates of treatment for DS TB were good until 2011, when the rate was 85%. In 2012, the rate was 82% for new cases, with increasing death rates due to population ageing.
MDR-TB treatment in the country started with a Global Fund grant in 2009, and during the first 2 years treatment was given mainly for chronic and difficult-to-treat MDR-TB cases. Although many patients died during treatment, most (60%) were successfully treated in 2009; subsequently, they treatment success rate has been increasing (71% in 2010 and 76% in 2011). The number of new MDR-TB cases appears to have stabilized at 10 patients a year, and mortality among these patients has fallen.
Since December 2004, Serbia has had external funding from the Global Fund of a total of US$ 10 million. The Serbian Government has shown political will to support the NTP and the Global Fund Project Implementation Unit to make best use of the external resources. The money was invested in training health staff in hospitals and in the primary sector in introducing the DOTS strategy, for MDR-TB treatment, use of a new information and registration system, upgrading the national reference laboratory and supplying laboratory equipment and consumables for TB drugs. In 2008–2009, guidelines for MDR-TB management were published, staff were trained in use of the guidelines, second-line TB drugs were procured through the Green Light Committee mech-anism, and treatment of MDR-TB was started. Until then, there had been no organized treatment of MDR-TB in Ser-bia, and there was a considerable backlog of patients with (chronic) MDR-TB when treatment was first offered in 2009.
The health institution with longest tradition in treating TB patients in Serbia is the Ozren-Sokobanja Specialized Hos-pital for Pulmonary Diseases, which opened in 1942 in a beautiful mountainous area. The MDR-TB department has
been newly refurbished, and 10 beds are available for these patients. The rooms are large and pleasant, and all face a wide balcony to which patients have access under proper infection control measures. The central store of second-line TB drugs for the country is located in this hospital. Medical staff in the hospital were trained in the WHO Collaborating Centre for M/XDR TB in Riga, Latvia.
Health system challenge
Despite good hospital capacity for MDR-TB patients in Serbia, measures were needed to improve ambulatory care services once patients with MDR-TB were discharged from hospital, with a focus on improving adherence to treatment.
Good practice in health system strengthening to improve prevention and care of M/XDR-TB
In order to increase adherence to treatment by M/XDR TB patients and improve the treatment success rate, the NTP, with financial support from the Global Fund, intro-duced practical training for ambulatory teams (doctors and nurses) to conduct outpatient treatment of MDR-TB. The first course, in 2010, was organized by Ozren Hospital with technical assistance from the Global Fund unit of the Min-istry of Health; from 2012, training was fully organized by the hospital itself.
The courses covered the organization of treatment and fol-low-up, disease management, storage of second-line TB drugs, case reports of treated patients, management of patients to be discharged with continuation of treatment, principles of continuous health education of patients and their families and the patient-centred approach to medi-cal care. Trainees also visited an M/XDR-TB ward and held health education sessions with the patients, using a bro-chure and a PowerPoint presentation on the most interest-ing topics for patients, prepared by national TB experts.
Each patient received a brochure, and trainees and patients got to know one another. Patients were encouraged to ask questions and to participate actively in their treatment, thus initiating a trusting relationship, which is important for the continuation of long-term treatment. The ambulatory teams