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DTBE in Thailand

map of Thailand

Capital City: Bangkok
Area*:513,115 sq. km. (198,114 sq. mi.);
Population (est.), 2011*: 66.7 million
Estimated TB Incidence, 2010**: 137/100,000
Estimated TB Prevalence, 2010**: 182/100,000
Adult HIV Prevalence Rate, 2009***: 1.3%
Number of people living with HIV (PLHIV), 2009***:530,000
Percent of tested TB patients who were HIV+, 2010**: 16%

*Source: www.state.gov
**Source: WHO Global TB Control Report 2011
***Source: UNAIDS, Report on the Global AIDS Epidemic, 2010

Background

The Centers for Disease Control and Prevention’s Division of Tuberculosis Elimination (DTBE) works with the Thailand National Tuberculosis Program (NTP) and other non-government organization (NGO) partners to improve surveillance and control of TB, multidrug-resistant TB (MDR TB), and TB in persons infected with HIV, including among U.S.-bound refugees.  CDC/DTBE has a Regional TB Technical Advisor (Medical Officer) stationed in Bangkok.  Operational research focuses on answering practical questions about how to improve screening, diagnosis, and treatment of MDR TB and TB/HIV in high-burden settings.

Recent Accomplishments & Ongoing Collaborations

Program Strengthening and Epidemiology

Laboratory Capacity Building:  CDC/DTBE worked with Thailand National TB Reference Laboratory from 2006-2009 to develop standard operating procedures and training curricula for liquid-based culture. CDC/DTBE has supported the reference laboratory to build capacity among Southeast Asia Regional Office (SEARO) countries and provide reference services and technical support for second-line drug-sensitivity testing and rapid molecular tests for MDR TB.  CDC has provided support to Thailand’s Supra-national Reference Laboratory (SNRL) in the following areas: molecular diagnostics, second-line drug sensitivity testing and quality testing, performance and cost-effectiveness comparisons of liquid and solid culture of fluorescent microscopy, and of conventional and new rapid TB identification tests. A set of indicators was developed for monitoring quality and performance of laboratories conducting liquid culture.

Thailand TB Active Surveillance Network-DOTS-Plus Expansion: Since 2003, CDC/DTBE and the Thailand Ministry of Public Health (MOPH) have collaborated on the Thailand TB Active Surveillance Network for TB control in five provinces. The Network’s goal is to expand the foundation of Directly Observed Therapy Short-course (DOTS) to include: enhanced surveillance, monitoring, and evaluation of TB cases treated in the public and private sector; closer integration of TB and HIV services; increased laboratory capacity for TB culture and susceptibility testing; and electronic recording and reporting of TB cases to permit rapid analysis and data dissemination. Data from the network has led to a number of important studies related to TB program management and policy: impact of DOTS on outcomes, comparison of outcomes in public and private care, factors associated with default, MDR TB on the Thai-Burmese border, childhood TB, improving HIV testing rates through provider initiated counseling and testing.  

MDR TB, TB/HIV, and Other At-Risk Populations

Intensified TB Case Finding (ICF) for People Living with HIV (PLHIV):  CDC/DTBE led a cross-sectional study (Improving Diagnosis of TB in HIV-Infected Persons: The ID-TB/HIV Study), enrolling more than 2,000 PLHIV from eight anti-retroviral therapy (ART) clinics in Cambodia, Thailand, and Vietnam to determine the best method for screening and diagnosing TB in PLHIV. The study found that using previously recommended screening approaches failed to detect more than two-thirds of patients with TB disease. However, screening PLHIV for TB using a combination of three symptoms detected almost all cases (93%) among this population.  The presence of one or more symptom (cough, fever, or night sweats) is a positive symptoms screen, whereas absence of all symptoms is a negative symptom screen. Patients with a positive symptom screen need further evaluation to accurately diagnose TB disease. Patients with a negative symptom screen have TB disease reliably ruled-out (97% without TB had no symptoms), allowing isoniazid preventive therapy (IPT) to be started more quickly. In follow up to this study, CDC/DTBE and the World Health Organization (WHO) collaborated on a meta-analysis which led to a change in WHO’s international guidelines for screening for TB among PLHIV.  These updated guidelines are available: WHO Guidelines for ICF and IPT.

TB Screening for People with HIV: In follow up to the intensified TB case finding study described above, CDC is working with MOPH partners to implement the newly recommended TB screening algorithm in selected demonstration sites. The sites will follow the new algorithm for one year and also implement IPT for eligible patients. The performance of the algorithm in a routine program setting will be evaluated, along with its feasibility, and acceptability to clinicians in routine clinical practice. A cost-effectiveness analysis of the new algorithm was completed with Thai partners.

Evaluation of Impact of Using Rapid MDR TB Diagnostics: After validating a new rapid test for MDR TB in two laboratories in Thailand, this test is now being used in all Thailand’s TB Active Surveillance Network sites. CDC and partners are evaluating the change in turnaround time for getting results to clinicians, and the reduction in delays to put patients on appropriate treatment regimens. Enrollment for the rapid test evaluation is complete, with 1,927 tests completed and 72 MDR TB patients enrolled. Preliminary findings have been shared with 197 stakeholders in five sites.  Analysis of stage one of the study will be completed in late 2012.  As a result of the study, the rapid test is being scaled up in eight provinces through the National TB Program.

 
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