Hello Dr. Singh,
Eli Lilly & Co. actively works with partners to eradicate MDR-TB in 60 countries, particularly the high burden countries. Please consult www.lillymdr-tb.com for more information.

Laurel Vogelsang
International Government Affairs
Eli Lilly & Co.
Washington, DC

Thank you Dr. Laurel for this useful information. I will visit this site and
contact the concerned officials.

In New Delhi we are planning to participate in MDR TB control as main
supplementary partner to Govt, so I am looking for models that are tested
successfully in other countries.

Best regards,

Dr. Singh

On Thu, Dec 4, 2008 at 1:24 AM, GHDonline (Laurel Vogelsang) <
> wrote:

> Reply to: community MDR TB models
>
> Hello Dr. Singh,
> Eli Lilly & Co. actively works with partners to eradicate MDR-TB in 60
> countries, particularly the high burden countries. Please consult
> www.lillymdr-tb.com for more information.
>
> Laurel Vogelsang
> International Government Affairs
> Eli Lilly & Co.
> Washington, DC
>
> --
> **Your reply will be sent to the entire community and posted as is.**
> See also:
> http://www.ghdonline.org/drtb/discussion/community-mdr-tb-models/
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Dear Dr. Singh,

Please see below a brief list of resources related to Partners In Health’s model for community-based MDR-TB treatment. To all members: please feel free to share resources and links here regarding your community models of care for MDR-TB.

1. Treatment supporters and treatment literacy: Lessons from Lesotho http://www.ghdonline.org/drtb/resource/treatment-supporters-and-treatment-literacy-lesson/

This presentation looks at accompaniment/treatment supporters in a socio-economic context, and discusses adherence issues in Lesotho.

Accompaniers, or Community Health Workers/Treatment Supporters, have been a core component at Partners In Health Lesotho from the inception of the project. They help programs to ensure that the patient will complete an adequate course of treatment while facilitating the prevention and management of side effects. Full adherence to treatment results in a shorter infectious phase for the patient, which leads to reduction in transmission.

2. Principles of out-patients MDR-TB Treatment & Management http://www.ghdonline.org/drtb/resource/principles-of-out-patients-mdr-tb-treatment-manage/

This presentation includes several cases from Tomsk, Peru, and Lesotho which illustrate the core principles of MDR-TB out-patient treatment.

Some information from this presentation:

Directly Observed Therapy (DOT) is more than just observation:

- It is the direct observation of patients taking their medicines
- It is the documentation of the visit
- It allows a daily rechecking of the patient medications
- It is the control of side effects
- It involves home visits if patients do not come to the clinic
- It involves looking for patients who are non-adherent or are defaulting
- DOT is an extension of the clinic into the patients community
- The system of DOT can be used to find programmatic solutions to patient barriers
- Food assistance for patients
- Choice of treatment site
- Improved side effect management (provision of ancillary medications)
- Improvement of working hours at medical facilities to make it more convenient for patients
- Treatment at home for patients who are unable to ambulate or who live too far
- Use of volunteers (e.g. neighbors) for DOT
- Rapid search for non-adherent patients and defaulters
- The use of enablers and incentives

Incentives for patients:

- Improved nutrition in the hospital with snacks
- Hot meals at the day hospital
- Food packets monthly for adherent patients
- Travel vouchers (government provided)
- Small gifts for adherence
- Help with passports, access to pensions, etc.

Incentives for staff:

- Hot meals at the day hospital
- Food packets monthly for rural health workers and nurses

3. Article in the New England Journal of Medicine: Comprehensive Treatment of Extensively Drug-Resistant Tuberculosis http://www.ghdonline.org/drtb/resource/comprehensive-treatment-of-extensively-drug-resist/

This article offers a description of the management of extensively drug-resistant tuberculosis and treatment outcomes among patients who were referred for individualized outpatient therapy in Peru.

There is some information on community health workers, notably in the “Methods > Drug-Susceptibility Testing and Treatment” section as copied below:

“Comprehensive treatment included other standard elements. Community health workers supervised daily ambulatory treatment.20 Hospitalization was available, if medically indicated. Patients requiring hospitalization were transferred to outpatient care once their condition had stabilized and they had been discharged. Baseline screening and ongoing monitoring are detailed elsewhere. 19 Monthly sputum samples were collected for smear microscopy and culture, which was performed at local laboratories.”

The discussion section may also be helpful.

4. Training: MDR TB Curriculum, Facilitators' and Participants' Materials http://www.ghdonline.org/drtb/resource/mdr-tb-curriculum-facilitators-and-participants-ma/

This is a set of interactive training materials on MDR-TB treatment. These materials were created by Partners In Health in partnership with the Lesotho Ministry of Health. The Ministry has since adopted them as their official training curriculum for TB coordinators, TB officers, ART nurses and doctors.

Structured for presentation in three four-day sessions, the curriculum covers a number of topics, including MDR-TB diagnosis and treatment; case discussions; infection control; and referral system plans. Short pre- and post-training tests are included to evaluate the effectiveness of the training.

Some additional materials may also be helpful, notably:

Training plan for a new DOTS-Plus treatment supporter: http://model.pih.org/files/mdr-tb/Training-plan-new-DOTS-Plus-treatment-supporter-Sept-2007.pdf

Session 2, Day 2: Community-based Care for MDR-TB http://model.pih.org/files/mdr-tb/day-2-training.zip

5/ DOT-Plus Handbook: Guide to the Community-Based Treatment of MDR TB

The chapters can be downloaded independently in PDF format at this link: http://www.pih.org/inforesources/pihguide-dotstb.html

6/ Article: Community-based therapy for children with multidrug-resistant tuberculosis by Drobac PC, Mukherjee JS, Joseph JK, Mitnick C, Furin JJ, del Castillo H, Shin SS, Becerra MC Pediatrics. 2006;117(6):2022-2029 http://www.pih.org/inforesources/Articles/Pediatrics%202006%20Drobac%20et%20al.pdf

7/ There is also the Training Manual on TB and MDR-TB published in May 2008 by the International Hospital Federation which addresses community participation in MDR TB treatment.
http://www.ghdonline.org/drtb/resource/ihf-training-manual-on-tb-and-mdr-tb-2/

Best Regards,

Tom Nicholson

In addition, I would like to share excerpts from a post by Shelly Batra, MD, on Operation ASHA's work bringing treatment for tuberculosis to communities in North India and their model - see below.

"Right from the beginning of our work in TB, which started 2 years ago, we have focused on Advocacy, Communication and Social Mobilization (ACSM) activities. We are addressing the problem of ignorance and superstition in various communities. We are using the persons belonging to the community we serve, who speak the same language and belong to the same socio-religious group so that our message is accepted. One of the biggest problems that patients face is that DOTS centres are few and far between so they do not want to miss a day’s wages in order to get the treatment. We have tackled this problem by involving the community in delivery of DOTS, so that no patient has to spend time and money to get the medicine.

Another problem is of default. Many TB patients stop taking their medicine as soon as they start feeling better, this leads to default and drug resistance. We have brought down our default rate to less than 1% by adequate counseling before starting treatment, and again at 6 weeks, when the patient starts feeling better and is likely to default. Our fulltime counselors visit every patient who has missed a dose, and repeat the counseling to the whole family, and bring the patient back into the system.

Our methods:

1. The first and foremost is the involvement of councilors of the local municipality and members of state legislatures. They wield tremendous power over the local bureaucracy. They can ensure that the benefits of National Tuberculosis Programme are delivered to the people in their constituencies. This helps them capture votes at the time of elections. With one election or the other, for various bodies like the municipality, state legislature and the parliament, taking place practically every year, the councilors and legislators are more than willing to lend their help. Their education and sensitization to the utter lack of accessible DOTS centers in the slums goes a long way in convincing them of the need and ultimate establishment of DOTS centers that deliver therapy at a time and place that is convenient to patients in disadvantaged areas.

Sensitizing the law makers is the first step to harnessing their goodwill and power. This eliminates the usual apathy the bureaucracy has for disadvantaged areas. Education of the community leads to reduction in social stigma against TB. Millions of illiterate urban slum dwellers and village folk still think that TB in incurable: that anyone who contracts TB is likely to die just as their grandfather died or their mother died. Death due to TB is still not an uncommon occurrence with 400,000 persons dying of the disease in India every year. With an educational campaign that is scientifically designed, it is possible to convince the community that TB is not only treatable, many patients (like those suffering from extra-pulmonary TB and sputum smear negative patients) do not infect others. Furthermore, simple precautions can eliminate the chances of infection even from an ‘active’ (infective) patient. Introducing a (willing) person who has been fully treated and has since been living a productive life is of immense help, more so if the person belongs to that or a neighbouring community. Once the stigma is reduced, it is possible to find a treated patient or a socially-inclined person to support a DOTS center from her shop or home. Such involvement garners long term community support for the DOTS programme and leads to success of NTP. We have already experienced the power of this approach and have a municipal councilor in Chandralok in East Delhi running a DOTS center from her house. Similarly, a treated patient in Mazdoor Kalyan Kendra runs a center from the small shop he runs.

Another important constituency is the children. Their minds are impressionable. Educated scientifically, they ‘often become the most educated in the family and begin educating their parents. They become the activists and advocates. Unilever in India used this strategy to great advantage. They educated children on the cause of disease and how to prevent it, creating in the process a new market for their products and reaping new profits.’ (Ref from The Fortune at the Bottom of the Pyramid, by CK Prahalad, Wharton School Publishing, 2005). There are many municipal schools in the vicinity or within disadvantaged localities. Our project will focus on educating the children of these schools to the cause, symptoms, prevention and treatment of TB and the availability of comprehensive services under the NTP in which the patients does not have to pay a fee for any service. Not only that, ill effects of not completing the DOTS therapy and the chances of drug-resistance and consequent ill-effects will be discussed, so that children understand and become advocates of utilization and completion of DOTS therapy, striking at the root of drug-resistance.

2. Sensitization of policy makers/ municipal councillors and state legislators spurs them to take up the matter of proper implementation of NTP and expansion of DOTS and DOTS PLUS with public health officials. Education of patients and communities about their entitlement under NTP helps the community raise these issues with the local politicians and other leaders, especially when the leaders approach the community for support at the time of elections. The education of community, patients and children have substantial impact in accepting that TB is treatable like any other disease and reduction in social stigma. Giving a voice to the community and educating the policy makers goes a long way in implementing NTP intensively and combating the scourge of TB at both local and national levels.

3. Many communities have been educated about TB in general and about NTP, the benefits like free physicians’ services, diagnostics, medicines and cash incentive under this programme. Over 1,000 poor patients who were going untreated now have access to medicines at their doorstep at a time of their convenience. Operation ASHA has been conducting three meetings every month in the neglected communities and schools, many times with the involvement of municipal councilors and other leaders. These meetings have been attended by 50-300 persons.

Other Awareness Activities

1. We have been regularly conducting 3 TB education camps every month. These are held in urban slums, schools, temples, religious places, community weekly bazaars, community canters, factories, and we are able to meet people from different professions, religions, and social strata.

2. Our counsellors visit a total of 30 to 50 families every day, within the areas they serve, to carry out TB education. These are just families who live in the vicinity of our centres, where our counsellors are well known, and their words carry weight. These may or may not have a TB patient in the family.

3. We are sensitising other nonprofits especially those working at grassroots level eg. microfinance organisations, to spread our education about TB."