Strengths

• Contact management programs

• Established links between PHCs and district and provincial level hospitals.

• Example of electronic referral system

• Pediatric TB focal person (pediatrician) starting 2013

Pulmonary TB

age <5year ค age ≥ 5-18 year HIV Any age

Treatment

PE, CXR, TSTข TB disease

Non-TB

Give isoniazid 6-9 months

TT ≥15 mm. give isoniazid 6-9 moจ

TT 10-14 mm. please consider

TT <10 mm. observed

Give isoniazid 9 months

 

DOT Standard

Take child household contact

 

Contact Investigation and Management

Challenges• Underreporting of child TB cases to

ODPC7

– ODPC7-10 cases, PHO- 5 cases, Sisaket Hosp-25 cases (2012)

• Diagnosing TB disease in children particularly <5 year olds

• Crushed pill suspensions

• TB/HIV and DR-TB in children (including child contacts of DR-TB)

Recommendations

• District and Provincial level Hospitals: Report all child cases along with outcomes (0-4, 5-14 year age bands)

– coordination between TB clinic and pediatricians

• Pediatricians: Consultation with Child TB experts in the Pediatric Infectious disease society of Thailand, for complex cases.

Recommendations• PHO: Ensure awareness of District

Hosp, PCU staff and VHVs: all child contacts <5 should get clinical assessment regardless of symptoms

• MoPH/GPO: Acquisition of WHO recommended pediatric dispersible FDC tablets

• MoPH/NHSO: use Xpert for TB diagnosis in children

9. Pharmacy• Pharmacists order TB drugs from GPO

online (VMI)

• Well organized and clearly labeled

• Storage area with appropriate temperature and humidity control

• Patient kits prepared by pharmacist and double checked

• Appropriate documentation of ADR

– ADR leaflets

Pharmacy- Sriratna hospital

Patient TB medicine kits

Challenges

• Occasional drug stockouts and delays in delivery from GPO

• FDC Rifafour e-275 (H-75/R-150/Z-400/E-275) not always available and often not prescribed by physicians

– Using only for >50kg (vs. >30kg)

– Delayed culture conversion ?

– Large pill size

Recommendations

• GPO: ensure timely drug delivery

• Physicians/pharmacists: FDCs should be preferred and stocked accordingly

– Guideline >25kg

• MoPH/BTB: Pediatric dispersible FDCs

10. TB/HIV

• Core indicators (HIV testing, CPT, ARV) significantly above national average

• Coordination between programs appears generally good

TB/HIV (II)

• ARV national guideline not clear (TB as AIDS-defining illness, ARV eligible at any CD4 level)

• Little use of IPT, little use of sensitive diagnostics for case finding

Recommendations• National:

– Clarify ARV guideline and improve communications to clinicians

– Strengthen IPT guideline

– Work with NHSO to increase support for sensitive diagnostics (liquid culture, molecular) for case finding in PLHA

11. Infection Control

• Good examples of best practice including

– one-stop TB clinics

– triage (effective) with fast tracking

– well ventilated OPDs

– Surveillance of TB in HCW

• Inpatient cohorting and ventilation insufficient

Recommendations• National

– Strengthen guideline for outpatient management

• All facilities

– Avoid admission unless clinically required

• SSK Provincial hospital

– Assess air changes per hour (ACH) in OPD and consider whirlybird fan on roof

– Review placement /cohorting procedures for TB (suspect) inpatients

12. Engaging all providers: PPM

• 8 private hospitals in ODPC 7

– 7 of 8 implementing DOTS

– 1 private hospital in Sisaket Province: 30 beds; AFB under EQA system; refers diagnosed TB cases to public sector for treatment

• One private clinic diagnoses TB; refers to public sector for treatment

Engaging all providers: PPM

• Private/non-MOPH sector coordinates well with MOPH system

• Currently no significant problem of private, non-standard TB care

– may increase in future

13. Program management, HR• Strong political commitment and leadership:

all levels

• Effective TB care and referral system

• Budget is committed for TB control activities

– Ex. of accessing local gov’t funds

– 3 districts with GF support

• Excellent coordination between health facilities in SSK province

Program Management, HR (II)

• TB coordinators clearly designated at all levels including DTC

• Most TB coordinators received training within 2 years

• Highly competent PTC

• Strong, hard working TB teams

Challenges• Staff turnover and civil service staffing

trends: สร้�างทายาท (build next generation)

• Limited availability of improved diagnostics (NHSO budget)

• Sustainability plan after ending GF

• Decentralization, different structures demand strong coordination skills

Recommendations• Maintain strong political commitment

• Work with NHSO for expanded use of new diagnostics

– Sensitive diagnosis of MTB

– Follow up of MDR TB

• Share best practices with other health units

• Training: consider mentoring, buddy system exchanges

Thank You!!

ODPC 7

Dr.Sarayuth UttamangkapongMrs.Supasai Sangawongand team

Srisaket Provincial Health OfficeDr.Pravi Ampant Dr.Wanchai LausatainragitDr.Anupant Prajum Mrs.Vanida SomphungaMr.Banjert Dechasilapachai Mrs.Ketsuma Wongkraiand team

Srisaket HospitalDr.Udom Petchphuvadee Dr.Noppol Buasri Dr.Taweevuth Temaeum Dr.Nitikul Temaeum Dr.Kanittha Saleewan Mrs.Phusanisa Khuntee Mrs.Onuma Thumasang Miss Chutima boonkwang And team

Khukhan HospitalDr. Pravit SaleekajonjaruDr. Chayomon Dokpong Dr. Aree ButsornAnd team

Srirattana HospitalDr.Surachai KampakdeeAnd team

Huai Nuea PrimaryCare UnitDr. Peerawat Thamrongdulparkand team

Pingpuay Primary Care Unit Mr. Samai Laprawat and team

Samrongtagen Primary Care UnitMr.Klai Ardsalee Mr.Ronarong YokpolAnd team

Sisaket PrisonMr. Traipob WongplangAnd team