National Tuberculosis Center

Multi Drug Resistant Management

MULTI DRUG RESISTANT MANAGEMENT (MDR) TUBERCULOSIS MANAGEMENT

MDR TB management programme started in September 2005 with WHO Green Light Committee approval. Guideline, training modules and specific recording reporting forms and registers were developed by NTC with technical support from WHO.

MDR TB PATIENT REGISTRATION CATEGORIES:

N1. Smear positive CAT 2 failure

N2. CAT 1 failure with culture & Drug Sensitivity Testing confirmed MDR TB

N3. Any MDR TB Patient household contact, who is smear positive, with culture &

DST confirmed MDR TB

N4. MDR TB patient who is smear positive, with culture & DST confirmed MDR-TB

NTP offers fully supervised standard regimen for treatment of MDR TB.

Multi Drug Resistant TB Treatment regimens:

Intensive Phase (8-12 months)	Continuation phase (16-20 months)
Kanamycin (KM)	Pyrazinamide (Z)
Pyrazinamide (Z)	Ofloxacin(Ofx)
Ofloxacin(Ofx)	Ethionamide (Eto)
Ethionamide (Eto)	Cycloserine (Cs)
Cycloserine (Cs)

Technical Working Group at the national level periodically reviews programme policies, strategy, performace as well as it provides guidance on management of clinically complex MDR TB cases.

MDR TB management services are available from all five Regions of the country. By mid July 2008, 10 treatment centres and 34 sub-centres were offering MDR TB treatment and follow up services.

Treatment progress is monitored with sputum culture examination every months during intensive phase first (8-12 months) and bimonthly during continuous phase (9 to 24/32 months).

By 2008 NTP registered 494 MDR TB cases for treatment. Following table provides details of the MDR TB patients registered under different registration categories:

Registration Categories

	Year 2005*	2006	2007	2008	Total
N1	79	136	116	109	440
N2	4	10	12	3	29
N3	1	2	2	0	5
N4	4	12	2	2	20
Total	88	160	132	114	494

* 2005 data is for September-December only

The largest number of MDR TB cases registered belongs to failures of CAT 2 (89%) followed by CAT failures with culture and DST confirmed MDR (5.8%).

During first twelve months male MDR TB cases accounted for almost 64% of the total registered cases, while during the subsequent twelve month periods it proportion was 63 and 69% respectively. This trend corresponds with ratio of male to female registered under DOTS programme.

The largest number and proportion of MDR TB Patient belongs to 15-54 age groups with almost half of the registered patients in age group 15-34. Again, this trend is in line with gender wise number and proportion of new TB patients registered under DOTS.

Cure rate among 88 MDR patients registered during first year of the programme (Sep-Dec 2005) was 70% while 9% of the patients failed the treatment, 7% died and 14% defaulted. Cure rate among patients registered during 2006 is 58% with 8% of the patients still on treatment. Key reason of decline in cure rate during this year is due to very high default rate (22%) which is because of limited number of sites offering MDR TB treatment and lack of hospice facilities. Default rate during 2007 declined and NTP also managed to provide little financial support for transportation (NRs 300/month) through Government resources.

MDR-TB MANAGEMENT PLAN AND TARGETS

According to the initial approval from Green Light Committee of WHO NTP was allowed to register 350 MDR TB patients for treatment. After two consecutive international annual reviews by WHO Green Light Committee NTP has received approval for continuation of the programme till 2011. Under this approval NTP will treat 300 MDR TB patients per annum till 2011.

MDR TB MANAGEMENT AND PRIVATE PUBLIC PARTNERSHIP

Nepal MDR TB Management Programme is a unique example of Private Public Partnership. Under the leadership and guidance of NTP several private sector partners are providing MDR TB management services.

German Nepal Tuberculosis Project (GENTUP) provides culture and Drug Sensitivity Testing (DST) for this programme. GENTUP laboratory is working under quality control of Gauting Supra National Reference Laboratory in Germany.

Almost half of the MDR TB Treatment Centres and close of 30% of the Sub Treatment Centres are operated by NTP partners from the private sector which include Medical Colleges and I/NGOs. All partners follow NTP guides and regularly report using standardized forms and formats.

Nepal MDR TB management programme as regional training site:

Nepal MDR TB management programme has been a model of ambulatory treatment in the WHO South East Asia Region. Since inception of this programme several countries have visited the programme for training and field visits, including; Bangladesh, Bhutan, Indonesia and Myanmar. NTP organized orientation sessions and field visits to explain the organization and implementation of the MDR TB management programme.

CONSTRAINTS AND CHALLENGES

Lack of socio-economic support to patients and infection control are key challenges for optimal performance of MDR TB management in Nepal. Lack of focal staff at central level is another key constraint as responsibilities of this important programme are given to existing staff as additional task which has direct implications on programme supervision and monitoring. Similarly, MDR TB management programme is managed through existing staff within PHC who receive no extra remunerations or incentives for this responsibility.

 

 

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