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Policy decision on multi drug

resistant(MDR) , extreme drug

resistant(XDR) tuberculosis screening: Ho

w it comes?Thanawat Wongphan1,2

Pairoj Saonuam3. Jongkol Lertiendumrong1,

Phusit Prakongsai1

1International Health Policy Program(IHPP), Nonthaburi, Thailand2 Banmoh Hospital, Saraburi, Thailand

3 Medical Physician, Senior Professional Level National AIDS Management Center (NAMc) Department of Disease Control,

Ministry of Public Health, Nonthaburi Thailand

The First Annual Conference of HTAsiaLinkGrand Pacific Sovereign Hotel, Petchaburi,Thailand

May 14‐16, 2012

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• Background information • Methodologies• Research findings • Conclusion and discussion.• Policy recommendations

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Outline of presentation

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ndBackground (1)

• Definition:• MDR-TB is the tuberculosis which

resists to Rifampicin or Isoniazid.• XDR is the tuberculosis which resists to

– Rifampicin or Isoniazid– Quinolone– At least one injectable

antibiotic(kanamycin, capreomycin or amikacin)

• [Ref]• 1. Centers for Disease Control and Prevention., Multidrug-Resistant Tuberculosis (MDR TB) Fact Sheet. 2011.• 2. World Health Organization., Press release: WHO Global Task Force outlines measures to combat XDR-TB

worldwide. 2006.

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ndBackground (2)

• The prevalence of all TB patients in Thailand is 130,000 cases per year, and the rate of MDR-TB ranges from 0 to 14.1 percent of all first diagnosed TB patients.

• The cost of treatment of MDR or XDR TB can be more than 100 times when compare to a normal pulmonary TB.

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• Incidence of MDR-TB in Thailand is 2,900 cases per year and 1,547 of them are in the first time of treatment.

• Five percent of all MDR-TB can develop to XDR-TB in the future.

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Background (3)

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Objectives

• To find the ways to increase potency of TB treatment system and to decrease incidence rate of MDR-TB we split the project into 3 parts to answer this– the most cost-benefit method of MDR-

TB screening – System gap analysis– Cost-utility analysis based on dynamic

models on MDR-TB screening.

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Methods (1)

The study is conducted with two methods: Cost-benefit analysis (CBA) and system gap analysis. •The CBA uses the decision tree algorithm among four choices of MDR-TB diagnosis: standard culture (L-J), Overbrooke 7H-10, Microscopic observation drug susceptibility (MODS), gene technique and the conservative technique (work up in all failure cases.). •The gap analysis uses an expert panel’s discussion and inductive conclusion to formulate the policy recommendations.

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Target population All TB diagnosis

Comparator

-Standard procedure

-Lowenstein-Jensen(L-J) in all cases.

-Microscopic observation drug susceptibility(MODS)

-Overbrooke 7H-10

-Gene technique(eg. geneXpert1)

Methods (2)

1 is a registered trademark from Cepheid, CA, USA

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COST

Use only direct medical cost:

•LAB: Department of Medical Science, Ministry of public health, Thailand

•Drug cost: Chest disease institute.

Lab’s duration

• Department of Medical Science, Ministry of public health, Thailand

• Expert panel’s adjustment

• Systematic review on MODS.

Methods (2)

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Comparison among MDR Screening and treatment

choices

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2 months of standard TB treatment

2 months of standard TB treatment

Culture waiting period(4-8 weeks)Culture waiting period(4-8 weeks)

Start MDR-TB

treatment

StandardStandard

6 Weeks(4-8 Weeks)

6 Weeks(4-8 Weeks)

L-J technique

L-J technique

6 Weeks(4-8 Weeks)

 

6 Weeks(4-8 Weeks)

 

7H107H10

6 Day

s

6 Day

s

MODsMODs

1 Day1

Day

Gene techni

que

Gene techni

que

  Sputum AFB still

be POSITIVE.

Start MDR-TB treatment

Start MDR-TB treatment

Start MDR-TB treatment

Start MDR-TB treatment

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Research findings

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Incidence of Thai TB patients and individual cost of treatment.

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Case

sCost(Baht)

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MDR diagnosed Lab duration and cost comparison

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Weeks Bah

t

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Cost-Benefit comparison on MDR TB diagnosis

Diagnosis procedure

LJ MODs 7H-10 Gene technique

Cost(Million Baht)

4.65 4.65 4.65 55.8

Benefit(Million Baht)

2 .3 8 –3 .30

4 .4 2 - 6 .1 3

2 .3 8 - 3 .30

4 . - 70

6 .5 3

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*Comparison based on standard TB treatment

program.

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•MDR screening is essential for all first diagnosed TB cases because –it can stop disease-spreading while patients are being treated with standard drug regimen,

–decrease drug side effects.–drug costs and patients’ expenses related to the inappropriate drugs use.

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Conclusions and discussion

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• Although MODS is the most cost-benefit method but the gap analysis shows that Thailand has many semi-liquid culturing facilities. So it is better to use them instead of investing more money to do MODS.

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Conclusions

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Policy recommendations

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Specific policies:

1. Enhance capacity of TB treatments in all modalities.

2. Establish the standardized logistic system of specimen transfering.

3. Increase support of lung surgery.

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General policies(1):

1. Increase co-operation between units to units including private sector and supertertiary hospital.

2. Establish the national MDR, XDR-TB caring guideline.

3. Concern in some high risk patients eg. HIV.

4. Medical staffs should be refreshed knowledge and be updated their system's knowledge.

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General policies(2):

5. Find sources of fund to support the system,6. Improve the follow up care system,7. National Health Security Office(NHSO)

should generate the ICT data system to be used in follow up care of treatment and easy to monitor,

8. NHSO should support the health staffs in many roles e.g. funding source for generating national guideline,

9. Link this treatment system to quality accreditation to increase sustainable development.

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• National Health Security Office (NHSO) of Thailand,• The Universal Coverage Benefit Package Subcommittee of

NHSO,• Dr. Charoen Chuchottaworn and Chest Disease Institute,

Ministry of Public Health, Thailand• Ms. Kumaree Patchanee, IHPP, Thainad• Banmoh hospital staff, Saraburi, Thailand

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Acknowledgement