Retooling and DOTS Expansion Perspective of DOTS Expansion

Retooling and DOTS Expansion Perspective of DOTS Expansion WG Retooling Task Force 16 January 2008 Léopold BLANC Ikushi ONOZAKI TB Strategy and operations WHO Geneva

Tools to benefit more patients 1. Sm- Cult + represent ~30% of cases (more in high HIV settings) 2. Childhood TB: 10 -20% of cases 3. People with poor access to TB diag: point of care technology. Can benefit to 30% to 50% of TB cases 4. Early diagnosis of TB: better recovery, less expensive (avoid multiple investigations) 5. Diagnose MDR/XDR: better outcomes, less expensive (avoid multiple investigations, referals) 6. Limit over diagnosis: (very high in some countries, private sector)

Tools to benefit health workers 1. Simpler: less time, less training (fast expansion) 2. Safer: no special precautions for biosafety or contamination (fast expansion) 3. More sensitive: point of care technology. Only positives to be sent to district for confirmation if needed 4. Can diagnose MDR/XDR: easier to manage patients, less expensive (avoid multiple investigations), contribute to infection control (prevention) 5. Limit over diagnosis: increase reputation, improve diagnosis capacity of private sector

Operational issues for NTP 1. Initial defaulters: increase sensitivity of the system 2. Flow of diagnosis: less steps for diagnosis (fast expansion) 3. Transportation of specimens: very often more complicated than transferring patient (slow the expansion) 4. Used by public and private sector: easier to manage patients, less expensive (avoid repetition of investigations) 5. Balance between improvement of efficacy and field implementation (effectiveness) 6. Balance between increased cost and benefit

Retooling and Health Systems 1. Coordination between NTP and specialized lab: quality control to be defined, training of peripheral lab 2. Change in NTP structure: for example 1. Point of care: no lab (or very basic) at periphery, responsibility of NTP (fast expansion) 2. Liquid culture: skilled staff, equipment, structure, responsibility of laboratory department (expansion more complicated) 3. One/2 weeks treatment: no or light FU, hospitalization? 3. Change of recording and reporting

Implications for the country 1. Anticipate increase in 1. Drug supply because of increase in number of cases 2. Treatment supporters 3. Stronger involvement of community 2. Measure the changes 1. Effect of one change 2. Combine effect of several changes (technologies and operational 3. Knowledge management: NTP to be kept informed of tool development, timelines 4. Close collaboration between "developers" and "implementers"