STOP TB LVIV

pilot-project for TB-control in Lviv Oblast

Background

1. The Ukraine belongs to the 18 Eastern European countries where TB has increased in alarming proportions during the last 10 years. While the incidence rate in Western Europe is only 4 new TB-cases per 100'000 inhabitants, the rate in Ukraine is 80. WHO has therefore declared TB in these countries as a threatening epidemic requiring urgent measures (Global Plan to Stop TB in the high-priority countries of the WHO European Region 2007-2015). The reasons of this situation are: -socioeconomic crisis, - deterioration of medical infrastructure (mainly laboratory diagnostics for culture and drug susceptibility testing ), - unreliable and sometimes missing availability of quality assured anti-TB-drugs, mainly the second line drugs, - massive increase of resistance against first line anti-TB drugs (up to 25% MDR-TB),- appearance of resistance against second line anti-TB drugs (so called XDR-TB), - rapid growth of the HIV epidemic, reduced awareness of the TB epidemic by the government, the medical staff and the public.
2. The district of Lviv (Oblast Lviv) counts 2,8 Mio inhabitants. The treatment of TB patients (inpatients and outpatients) takes place in 15 TB hospitals. The phtisio-pulmonological centre in Sychiv , a hospital with 700 beds, is the leading TB centre of the district.
3. The Health Department of Lviv is not able to control the epidemic. The main reasons are:

-          The limited financial resources for a) efficient laboratory diagnosis, b) purchase of second line anti TB drugs, c) effective communication and registration system enabling outcome assessments.

-          The current anti – TB strategy.

-          The progression of HIV

4. The Non Profit Organisation Bear and Lion (Bär und Leu) has created   well functioning partnerships in the field of TB control. The following partners did meet on the TB conference of 28.5.2006 in Sychiv and decided to start a project for the control of TB in the oblast of Lviv :

-          Directorate of Health Department of Lviv Oblast (Prof. Herych)

-          Department of phtisiatry and Pulmonology of Lviv Medical University (Prof. Ladnyi)

-          Lviv Regional Phtisio-Pulmonological Centre Sychiv (700 beds) (Dr. Rak)

-          regional TB hospital Drohobych (Dr. Skurchanskyi)

-          WHO Ukraine (Dr. Miskinis)

-          Swiss Lung Asssociation (Dr. Zellweger)

-          Insitute of Infectiology Iniversity of Berne (Dr. Bodmer)

-          “Bear and Lion” (NGO/NPO) Switzerland (Dr. Vogt,/ Dr. Bischler) + Secretariate Lviv (Alexander Denisenko)

Aim of the Project

-          Implementation of the new WHO STOP TB Strategy  by a subnational Pilot-Project concerning the whole population of 2,8 million inhabitants

-          Reduction of the TB death rate and of new TB cases, especially multiresistant cases

-          Effective Diagnosis by improved quality assured laboratory system

-          free access to and uninterrupted supply of quality assured standardised treatment with first and second line anti TB drugs for all Patients of the Oblast

-          case detection rate of  -at least- 70% of the new smear - positive TB cases

-          treatment success rate of – at least- 85 % of the newly detected TB cases

-          protection of the poor and vulnerable population against TB, TB-HIV and MDR TB

Strategy and Tasks

1. Implementation of DOTS (a-e) and DOTS-PLUS (f-i) Stratetgy of WHO

a)      political commitment

b)      case detection through quality-assured bacteriology

c)      standardised treatment with supervision and patient support

d)      access and uninterrupted supply of quality assured first line anti TB drugs

e)      registration and monitoring system for evaluation and impact measurement

f)       bacteriological diagnosis by culture and drug sensitivity testing

g)      access and uninterrupted supply of quality assure second line anti TB drugs

h)      cooperation with all care providers and health system departments

i)        diagnosis of TB-HIV  and  inclusion of high risk groups

2. Improvement of the laboratory system (equipment, tests, quality assessment, instruction and training of staff) for effective diagnosis
3. enable free access and uninterrupted supply of quality assured first and second line Anti-TB drugs
4. adequate separation of MDR-patients and treatment of them by specialists
5. Installation of an IT-System for communication and registration of patients and data in order to reach an outcome assessment and find exact epidemiological data of the TB situation
6. Training of TB specialists at all levels (physicians, lab-technicians, nursing staff, social workers)  concerning the new strategy
7. Information about the new strategy for the whole population and the medical care providers of the Oblast in order to get a high detection rate by self  reporting method
8. provide high grade protection of personal working with TB infection
9. prevent development of drug resistancy by accurate application of the standardised chemotherapy according the WHO strategy
10. institutionalisation of HIV-test for all TB patients and organisation of cooperation with HIV-specialists.

Implementation Plan

Phase 1 : Planning and Preparation  (till 30.6.2007)

-          Constitution (incorporation) of the coordinating council and the council board  including its partners  (responsibility, working stratetgy, documentation)

-          creation of the protocol on implementation of the project

-          planning and start of training programs for TB specialists, laboratory staff, nursing staff, social workers, communication personnel (incl. IT-specialists) : in DOTS (Warsaw), DOTS-PLUS (Riga) and local instruction courses

-          planning of laboratory network, laboratory equipment, laboratory tests and laboratory quality assessment

-          compiling main data about current TB management, number of patients, drug resistancy, multi-drug resistancy, chronic cases ..... according to WHO Global TB Control Program

-          organisation of a communication system

-          organisation of drug supply

-          plan for separation of MDR patients

-          set up of a budget

-          application to the Global Fund

Phase 2 : Purchase and installation (1.7.2007 – 31.12.2007)

-          of new laboratory systems, IT-Systems (and , if financial resources are available,  X-Ray equipment) with the aim of optimised diagnostics, data collection and communication

Phase 3 : Registration and Classification (1.1.2008 – 31.12.2008)

-          registration of all TB patients under treatment, using the new laboratory procedures

-          registration of all TB staff, using the new laboratory procedures

-          Classification of the diagnostic categories, separation of MDR patients

-          list up the amount of second line anti TB drugs needed

Phase 4 : Treatment (1.1.09 – end of 2011) of all TB patients according to DOTS and DOTS PLUS strategy following WHO manuals : “Treatment of Tuberculosis, Guidelines for National Programs” (2003/4), “Guidelines for the programmatic management of drug resistant TB” (2006), “International standards of TB care (diagnosis, treatment, public health) 2006”

The whole project will last 5 years

The new strategy will be continued by the local health department of Lviv thereafter.

Budget planning

For phase 1 :                            Application to “Lotteriefond” Berne (CH)  by Bear und Lion

For phase 2 and 3                     Application to B&M Gates Foundation

For Phase 4                                         Application to B&M Gates Foundation, Global Fund, Green Light Committee

Financial self-contribution by the different partners

-          Directorate of Health Protection of Lviv : all the present performance of the Health Department including working capacity, supply of first line anti TB drugs for free, part of training expenses for local courses

-          Swiss Lung Association: all expenses for the consulting activities of Dr. Zellweger

-          Institute of Infectious Diseases University Berne : The consulting work of Dr. Bodmer does not create expenses to the project.

-          Bear and Lion : the coordinating and supporting functions are done mainly honorary. Expenses for travelling, transports, secretary work, humanitarian aid  are paid by the budget of the organisation as far as possible. The extensive size of the pilot project will however exceed the financial possibilities of the organisation. Therefore Bear and Lion will need support by the donors of the project.

-          Deza ( Swiss agency for development and cooperation ) subsidizes certain additional food supply

Realisation of the project

-          The project is realised mainly by the Health Department of  Lviv Oblast together with WHO

-          The management is done by the coordinating council and the council board

-          The consulting partners are the Swiss Lung Association, the Institute of Infectiology of University of Berne and the NGO/NPO Bear and Lion CH

-          The Project is similar to an ongoing TB project in the Oblast of Donetsk, realised also in cooperation with WHO

Bär und Leu : Functions and  Aid support

The NGO and NPO B&L is functioning as coordinator, communicator, mediator for donors and can be called catalyser of the project.

B&L supports:

-          intellectual company, seeing problems , providing steps for solutions

-          Translation by its secretary in Lviv

-          expanding its humanitarian aid program including

-          1. IT-Installation

-          2. Hospital equipment

-          3. Hospital laundry

-          4. Additional food

-          5. social aid (financial support for poor persons)

                                                                                                           Ringgenberg, 1.2.2007 U.Bischler