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S9.2 Private public mix DOTS: The Philippine experience
Speakers' Abstracts I lnternational Journal of Antimicrobial Agents 26S (2005) S1 $63 them, 211 MBL-producing isolates were detected. Numbers of MBL producers were 42 P putida (19%), 34 /~ aeruginosa (16%), and 135 Aeinetobaeter species (164%1). Among them, 157 (74%) had VIM 2 type MBL and 47 (122%1) had IMP 1 type. Seven Aeinetobaeter isolates were positive for MBL pfienotype tests, but b/aIMP or b/aVIM alleles were not detected from the strains by PCR. Sequencing of the MBL genes showed that the deduced amino acid had 64% identity with the closest relative IMP 12. There fore, the gene was named b/aSIM 1 (after Seoul IMipenemase). It is a great concern that various types of MBL have been increasingly reported worldwide.
$9. Decreasing TB Mortality and Morbidity $9.1 DOTS Works Donald A. ENARSON. International Union Against rib attd Lung
Disease, Paris, France
Background: The global strategy for the control and elimination of tubeiculosis (DOTS) was adopted by the World Health Organization in the early 1990s. It consists of five key elements: political conmfftment; diagnosis and follow-up based on bacteriology; ensured supplies; standardized treatment with measures to protect iifampicin; a system of recording and reporting. This strategy has now been adopted by almost all countries heavily affected by tuberculosis. Main messages: The DOTS strategy, as a method of primary proven tion, is based upon long-tema commitment to high-quality services for tubeiculosis patients. Tiffs poses major challenges to its implementation and sustainability. It is important to recognize the objectives of the strategy, as it was originally formulated: the reduction in the "contagious vectoF' represented by the burden of sputum smear positive cases in a community, reducing the numbers of young people infected with Myeobaeteriztm tuberculosis and, in favorable circumstances, arrival at a generation of the population flee of tuberculous infection, without having rendered the strategy impossible through the promotion of drug iesistance. Implementation of this strategy, although demanding, has been shown to be feasible in most countries where it has been conscientiously applied. Demonstrating impact, in terms of reduction in the burden of tuberculosis, has been much more difficult. It has been probably most convincingly demonstrated in China where first demonstrations in a Beijing municipality showed a substantial decline in tubelx:ulosis morbidity in the general population with a dramatic decline in infection of children. Elsewhere in Chin~ prevalence surveys have shown greater reduction in burden of disease in those areas with, as compared to without, the DOTS strategy. The situation in locations heavily affected by H1V or with multidrug resistant tuberculosis is much mm'e challenging. Conclusion and reconmrendation; The DOTS strategy, wtfile extiemely challenging and not optimal, has been shown to be feasible and may have an impact on burden of disease.
$9.2
Private Public Mix DOTS: The Philippine Experience Amelia G. SARMIENTO. Philippine Coalition Against Tuberculosis
(PhilCAT), Philippines
$27
Ptfilippines has a large private health sector widely utilized even by the lower income group. The 1997 National TB Survey showed that when patients consult for symptoms, the private physician was the most frequently consulted (36.2%). Tuberculosis patients perceive private care to be of a better quality and one that helps them conceal their stigmatizing disease. Discussion: In 2003, Private Public Mix DOTS (PPMD) was adopted by the NTP as a national strategy to increase case detection and hat monize the TB management among all health care providers. Under the Philippines' NTP, there are two ways for establishing PPMD Units: (1) public-initiated PPMD unit, and (2) private-initiated PPMD unit. In a public-initiated PPMD, operations are centered on a public DOTS facility, while in a private-initiated PPMD, these are focused on a private DOTS facility. Both implement DOTS in consonance with the NTP approved operational policies, standards and technical guidelines. A National Co ordinating Committee on PPMD (NCC PPMD) orchestrates and monitors the implementation of all PPMD units across the country. Regional Coordinating Cortmffttees (RCC-PPMD) enfolx:e policies, guidelines and standards in the regions. Initiated as early as 1995, about 70 PPMD units are now operating across the country. These units serve as referral centers for TB patients of private physicians and secure high quality TB diagnosis and treatment. An external evaluation of PPMD units by the World Health Organization, supported by the Global Fund for AIDS, TB and Malaria (GFATM) project in the Pliilippines, showed a substantial increase in case detection, ranging from 21% to 104 in five GFATM areas visited, wine modest in one (8%). Again, all except one site have reached the 70% target.
$9.3 Amplified Resistance in TB Donald A. ENARSON. Internatiorml Union Against TB ami Lung
Disease, Paris, France
Background: Drug resistmlce is a clear flueat to effective treatment and control of tubeiculosis. Clinically significant drug iesistance in tuberculosis is always a man-made problem. In most instances, the faultlies with the health service. Main messages: The worst effect of amplification of drug resistance is the development of multidrug resistance as this has the greatest negative consequences in terms of successfully treating a patient. Initial resistance is well establisfied in many countaies and frequently affects around one in six patients. Standard regimens for treatment of new cases must be carefully constructed to ensure that a "retrieval" plan is possible for those who fail on the first line of treatment. The original treatment sequence developed by Dr Styblo in the development phases of the DOTS strategy ensured that virtually all patients who began treatment who were not already multidrug-resistant would be successfully treated if they followed tiffs sequence. The principle in constructing such a hierarchy was to assume the existence of isoniazid resistance mid to construct a sequence that ensured that the patient would always receive at least one medication never previously used alone with isoniazid and rifampicin. Such a system has been systematically applied in the countries that were partners with the Union in the development of the DOTS strategy. In those countries where sufficient flffomaation is available (Tanzmffa and Benin), evidence suggests that medications can be widely used for treatment of tubeiculosis without the emergence of substantial prevalence of multidrug resistance, even where the HIV epidemic has dramatically increased the numbers of eases.
Session objective: To present an overview of Public Private Mix DOTS (PPMD) in the Plfflippines and its contribution towards achieving global and national targets of 70% detection rate and 85% cure rate Background: As the Philippines' National Tuberculosis Control Pro gram (NTP) approaches 100% DOTS coverage in the public sector, it is apparent that global and national targets of 70% detection rate cannot be attained without involving the private sector. Tiffs is because the
Conclusion and recmninendatioits; Great care is required in the construction of recommendations on the hieiarcfiy of standard regimens to ensure that amplification of drug iesistance (especially the promotion of multidrug resistance) is avoided.
$9. Decreasing TB Mortality and Morbidity $9.1 DOTS Works Donald A. ENARSON. International Union Against rib attd Lung
Disease, Paris, France
Background: The global strategy for the control and elimination of tubeiculosis (DOTS) was adopted by the World Health Organization in the early 1990s. It consists of five key elements: political conmfftment; diagnosis and follow-up based on bacteriology; ensured supplies; standardized treatment with measures to protect iifampicin; a system of recording and reporting. This strategy has now been adopted by almost all countries heavily affected by tuberculosis. Main messages: The DOTS strategy, as a method of primary proven tion, is based upon long-tema commitment to high-quality services for tubeiculosis patients. Tiffs poses major challenges to its implementation and sustainability. It is important to recognize the objectives of the strategy, as it was originally formulated: the reduction in the "contagious vectoF' represented by the burden of sputum smear positive cases in a community, reducing the numbers of young people infected with Myeobaeteriztm tuberculosis and, in favorable circumstances, arrival at a generation of the population flee of tuberculous infection, without having rendered the strategy impossible through the promotion of drug iesistance. Implementation of this strategy, although demanding, has been shown to be feasible in most countries where it has been conscientiously applied. Demonstrating impact, in terms of reduction in the burden of tuberculosis, has been much more difficult. It has been probably most convincingly demonstrated in China where first demonstrations in a Beijing municipality showed a substantial decline in tubelx:ulosis morbidity in the general population with a dramatic decline in infection of children. Elsewhere in Chin~ prevalence surveys have shown greater reduction in burden of disease in those areas with, as compared to without, the DOTS strategy. The situation in locations heavily affected by H1V or with multidrug resistant tuberculosis is much mm'e challenging. Conclusion and reconmrendation; The DOTS strategy, wtfile extiemely challenging and not optimal, has been shown to be feasible and may have an impact on burden of disease.
$9.2
Private Public Mix DOTS: The Philippine Experience Amelia G. SARMIENTO. Philippine Coalition Against Tuberculosis
(PhilCAT), Philippines
$27
Ptfilippines has a large private health sector widely utilized even by the lower income group. The 1997 National TB Survey showed that when patients consult for symptoms, the private physician was the most frequently consulted (36.2%). Tuberculosis patients perceive private care to be of a better quality and one that helps them conceal their stigmatizing disease. Discussion: In 2003, Private Public Mix DOTS (PPMD) was adopted by the NTP as a national strategy to increase case detection and hat monize the TB management among all health care providers. Under the Philippines' NTP, there are two ways for establishing PPMD Units: (1) public-initiated PPMD unit, and (2) private-initiated PPMD unit. In a public-initiated PPMD, operations are centered on a public DOTS facility, while in a private-initiated PPMD, these are focused on a private DOTS facility. Both implement DOTS in consonance with the NTP approved operational policies, standards and technical guidelines. A National Co ordinating Committee on PPMD (NCC PPMD) orchestrates and monitors the implementation of all PPMD units across the country. Regional Coordinating Cortmffttees (RCC-PPMD) enfolx:e policies, guidelines and standards in the regions. Initiated as early as 1995, about 70 PPMD units are now operating across the country. These units serve as referral centers for TB patients of private physicians and secure high quality TB diagnosis and treatment. An external evaluation of PPMD units by the World Health Organization, supported by the Global Fund for AIDS, TB and Malaria (GFATM) project in the Pliilippines, showed a substantial increase in case detection, ranging from 21% to 104 in five GFATM areas visited, wine modest in one (8%). Again, all except one site have reached the 70% target.
$9.3 Amplified Resistance in TB Donald A. ENARSON. Internatiorml Union Against TB ami Lung
Disease, Paris, France
Background: Drug resistmlce is a clear flueat to effective treatment and control of tubeiculosis. Clinically significant drug iesistance in tuberculosis is always a man-made problem. In most instances, the faultlies with the health service. Main messages: The worst effect of amplification of drug resistance is the development of multidrug resistance as this has the greatest negative consequences in terms of successfully treating a patient. Initial resistance is well establisfied in many countaies and frequently affects around one in six patients. Standard regimens for treatment of new cases must be carefully constructed to ensure that a "retrieval" plan is possible for those who fail on the first line of treatment. The original treatment sequence developed by Dr Styblo in the development phases of the DOTS strategy ensured that virtually all patients who began treatment who were not already multidrug-resistant would be successfully treated if they followed tiffs sequence. The principle in constructing such a hierarchy was to assume the existence of isoniazid resistance mid to construct a sequence that ensured that the patient would always receive at least one medication never previously used alone with isoniazid and rifampicin. Such a system has been systematically applied in the countries that were partners with the Union in the development of the DOTS strategy. In those countries where sufficient flffomaation is available (Tanzmffa and Benin), evidence suggests that medications can be widely used for treatment of tubeiculosis without the emergence of substantial prevalence of multidrug resistance, even where the HIV epidemic has dramatically increased the numbers of eases.
Session objective: To present an overview of Public Private Mix DOTS (PPMD) in the Plfflippines and its contribution towards achieving global and national targets of 70% detection rate and 85% cure rate Background: As the Philippines' National Tuberculosis Control Pro gram (NTP) approaches 100% DOTS coverage in the public sector, it is apparent that global and national targets of 70% detection rate cannot be attained without involving the private sector. Tiffs is because the
Conclusion and recmninendatioits; Great care is required in the construction of recommendations on the hieiarcfiy of standard regimens to ensure that amplification of drug iesistance (especially the promotion of multidrug resistance) is avoided.