DJIBOUTI PROPOSAL

							DJIBOUTI PROPOSAL

   ORGANISATION,
  MANAGEMENT AND
   COORDINATION
 Number of patients planned for
 enrolment and anticipated start
   and duration of the project
• 50 patients will be enrolled in the first year
  of the project. The start of the project is
  due on June 2009, which coincides with
  the start of the GF R6 grant second phase.
  The duration of the project is 3 years, that
  is the duration of phase 2 of the GF R6
  grant.
  Facility of the TB control system that will be
 involved in the treatment of patients with drug
 resistant TB and the roles and responsibilities


• As Djibouti is a small country with low size
  population, the treatment of MDR TB
  patients will be carried out in the TB and
  chest diseases Reference Centre of Paul
  Faure to which Resistant suspected
  patients will be referred by all facilities
  involved in TB treatment.
 Local personnel in the TB control system who will be
  responsible for the treatment of patients affected by
 drug resistant TB, and their training/experience in the
management of such cases and use of second-line anti-
                        TB drugs
• In Paul Faure Centre there are three
  physicians who are dealing with the
  management of MDR TB cases. Among
  these physicians one is trained and has
  experience in such management. The two
  others will need training at national level.
 Local facilities outside the TB control system
  that will be involved in the management of
              patients with MDR TB

• No facility other the reference centre will
  be involved in this management
    Infection control measures

• Like almost all EMRO countries this
  component is very weak. Furthermore the
  global fund project does not foresee such
  important aspect. And so, all required
  steps will be taken before launching the
  DOTS plus project taking advantage of the
  present MDR management course
Plan for the monitoring and supervision of the
project by the project itself and by any external
                 organisations
• The project will be monitored and
  supervised by the NTP and the MDR focal
  point with regular monitoring visits from
  the GLC.
    Training programme for health care personnel,
 laboratory technicians, and information systems/data
                management personnel
• Before the launch of the project, all doctors who
  will be involved in the treatment of MDR TB
  patients will follow a two-day training course on
  treatment of MDR TB according to the national
  guidelines. This training should also include the
  information system. For this purpose national
  guidelines, the recording and reporting system
  will be developed beforehand.
• Besides, laboratory technicians will be trained
  on culture and DST as part of the global fund
  project R6 and French Cooperation project.
Plan for sustainability of MDR TB management
      beyond the DOTS Plus pilot project:

• The management of MDR TB cases will
  continue with the same organisation and
  procedures as during the pilot project and
  it is expected that the number of patients
  will decrease and the MOH can afford to
  buy drugs. However after the withdrawal of
  WHO at the end of the project, ways
  should be found to find pharmaceutical
  firms who will accept to sell drugs for a
  small number of patients.
   Collaboration established with the prison
 system for management of the drug resistant
                      TB
• Collaboration has already been
  established with the prison health system
  on the occasion of a survey on case
  detection in non NTP facilities, which is
  underway. It is expected that all MDR
  cases will be transferred from the prison to
  the hospital for care.
LABORATORY ASPECTS
  Laboratory network and main laboratories that will
                 serve the project

• The only laboratory capable of performing smear
  microscopy, culture and DST is the NRL of Paul Faure
  Centre. The rest of existing laboratories perform only
  smear microscopy.
• The NRL is well staffed with 5 lab technicians and is
  performing the 2/3 of the total smear examinations in the
  country corresponding to 14000 smear examinations.
• Within the laboratory network for TB control all aspects
  concerning specimen collection and transport are
  standardised. Smear microscopy uses Ziehl Nelson
  coloration techniques. Culture is performed with
  Lowenstein Jensen medium. DST uses the proportions
  method (1 % threshold).
  Schedule, frequency, and extent of bacteriological
 evaluation of patients during treatment and follow up

• For non MDR cases, two specimens are
  requested for follow up of treatment in the
  second month, the fifth month and the end
  of treatment.
• For MDR cases follow up smear and
  culture examinations will be performed
  monthly until culture conversion, confirmed
  by two successive negative cultures. Then
  cultures will be done on quarterly basis.
Quality control and quality assurance systems


• Smear microscopy is quality assured
  through an EQA system which was put in
  place since October 2007.
• The laboratory network is supervised by
  the National Laboratories Supervisor, who
  is a member of the NTP central unit, with
  the assistance of the NRL.
 Collaboration with an international laboratory
 and the quality assurance system associated
              with this laboratory

• External Quality assurance of the NRL will
  be carried out through the Supra National
  Reference Laboratory in EMRO, namely
  the Egypt NRL laboratory.
  Process and infrastructure for specimens
      collection, transport and referral

• The NRL is part of the Paul Faure
  Reference Centre and all specimens will
  be collected in the centre.
   Information management (recording and
              reporting) system

• The information system will be integrated
  in the MDR information system.
• The laboratory network performing only
  smear microscopy comprises 16
  peripheral laboratories belonging the
  Ministry of Health, out of which 6 are
  based in the rural districts, and 5
  laboratories outside the Ministry of Health.
FIELD VISIT
                Field visit
• Was beneficial
• Positive points
  – Seperation of MDR patients based on
    bacteriological status
  – Infection control measures
• To be improved
  – Green space for patients or balcony for MDR
    patients