MDR TB Management in Community LRS Experience

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MDR TB Management in CommunityLRS Experience

• LRS INSTITUTE OF TB RESPIRATORY DISEASES
• SRI AUROBINDO MARG NEW DELHI

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DOTS-Plus LRS Process

• Strengthening Lab
• Preparing operational guidelines
• Revising records Reports
• Training
• Ensuring logistics
• Implementation

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DOTS-Plus LRS Case Enrollment

• Suspect MDR - Cat II failure
• Patient work up
• Sputum C/S
• 2 consecutive days
• If one ve, correlate with X-ray Clinical
• MDR Case - in vitro RH resistance

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DOTS-Plus LRS Flow of Patient
Suspect (Cat-II failure)
Referred to RNTCP Department
Sputum C/S
Lab. Informs RNTCP Department of the sensitivity
result
Non-MDR
MDR
Cat II
DOTS-Plus
Repeat C/S at end of I.P. and review
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DOTS-Plus LRS Management Protocol

• Informed consent
• MDR case registration
• Hospitalization
• Pretreatment investigations
• Treatment initiation under Specialist

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DOTS-Plus LRS Treatment Regimen

• IP - Kana, Cyclo, Ethio, PZ, Oflox
• - 6-9 mths
• - 3 consecutive monthly spt culture negative
• CP - Cyclo, Ethio, Oflox
• - Minimum 18 mth after spt. Conv.
• Daily DOTS Evening dose family DOT provider,
• empty blister Pac next
  morning

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DOTS-Plus LRS Treatment Regimen

• Resistance / Toxicity to any drug - replace it
  with PAS
• Capreo replaces Kana
• Premature termination - Committee

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DOTS-Plus LRS Hospitalization

• Minimum one month
• Linkage with TBHV in field
• Health education social support
• Ascertain tolerability to drugs

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DOTS-Plus LRS Follow up

• Spt. Smear culture
• IP - monthly
• CP - every 2 month
• 2 samples each time
• If 6 months ve
• Continue IP
• Repeat Sensitivity
• Ensure DOTS
• X-ray every 6 months

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DOTS-Plus LRS Clinical Follow up

• Specialist to see
• During hospitalization
• Switch from IP to CP
• To define treatment outcome
• Serious adverse reactions
• Socio Psychological support at every visit
• Clinical Psychologist
• MSW
• Health Education team

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DOTS-Plus LRS Defaulter Action Protocol

• TBHV
• Same afternoon
• Revisit next day
• STS visit 3rd day
• MOTC visit 4th day
• More than one such default - Intensive Health
  Education at LRS

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DOTS-Plus LRSLRS AREA

• RNTCP DOTS Plus guidelines
• 3 year data analysis (2002-04)
• 16 lakh population in South Delhi
• 14 peripheral centres
• Total patients 58

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DOTS-PLUS LRSAge Distribution
Age Group
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DOTS-Plus LRS Resistance Pattern
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DOTS-Plus LRS Resistance Pattern of S,Z,Em MDR
Patients
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DOTS-Plus LRS Sputum Conversion
Cohort 2002-03 (2 year) n 38
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DOTS-Plus LRS Time to Conversion
Cohort 2002-03 (2 year) n 26

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DOTS-Plus LRS Treatment Outcome
2002 Cohortn 13
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DOTS-Plus LRS Issue Before Treatment

• Pre-treatment home address verification
• Hospitalization - not patients friendly
• Socio economic problem
• Need for training
• Need for effective linkage between RNTCP and
  hospital

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DOTS-Plus LRS Issue during Treatment

• Management of adverse reaction
• Medicine storage difficulties
• Effective blisters pack counting
• Lack of patients complaince

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DOTS-Plus LRS Other Issues

• Mechanism of supervision and monitoring
• Flow of medicine
• Monthly quarterly and annual reporting

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THANK YOU