Sorry, this entry is only available in Română.
Sorry, this entry is only available in Română.
Sorry, this entry is only available in Română.
Caravana IEC (WP7) -10 iunie 2016, satul Razvani, oraș Lehliu-Gara, jud. Călărași
Rapid testing of patients for Multidrug Resistant and Extensively Resistant Tuberculosis (MDR TB and XDR TB)
A total of 1,398 people across the country have been tested in the National Programme for Prevention, Surveillance and Control of Tuberculosis to control the TB epidemic (NPPSCT) laboratories network which were equipped within the project with the latest equipment for rapid diagnosis of Multidrug-resistant (MDR TB) and the extremely drug resistant tuberculosis (XDR TB). A number of 295 of them were diagnosed with sensitive tuberculosis, 16 were detected with MDR TB and one person with XDR TB.
From March 2015 to December 2016, a total of 12 815 people have undergone rapid diagnosis, of which 3,160 were diagnosed with TB, 272 with MDR TB and XDR TB 5.
The development of a national laboratories network for early detection of TB MDR / XDR
GeneXpert equipment was purchased and installed in the designated laboratories within the project: Iasi, Timisoara, Leordeni, Craiova, Constanta, Cluj-Napoca, Brasov and Baia Mare. After commissioning of the equipment, laboratory staff has been trained in using the equipment. Also in December, the first batch of kits GeneXpert was delivered to TB laboratories equipped with GeneXpert.
Regarding the acquisition of 44 safety cabinets for laboratories, the centralised procurement procedure is in the bid evaluation stage.
The 10 LED epifluorescence microscopes were purchased this month. The procedure for selecting the supplier was completed, the supply contract was signed and products reception was made and two of the microscopes have been installed in the National Reference Laboratory (NRL) Bucharest. The two microscopes were put into operation and staff of the NRL Bucharest has been trained in their use. The remaining 8 LED microscopes will be installed in the following laboratories: Cluj Napoca, Iasi, Constanta, Timisoara, Bacau, Brasov, Craiova, Leordeni.
Three laboratories from the NPPSCT network – Bucharest, Cluj-Napoca and Galati – were equipped with Versatrek equipment, which were put into operation, and the staff has been trained in their use. The Versatrek supplies were purchased in December: the provider selection procedure was completed, the contract for delivery has been signed and reception of the products was made. For the purchase of IT equipment, the centralised procurement procedure is in the bid evaluation stage.
Strengthening the Capacity of the National Programme for Prevention, Surveillance and Control of Tuberculosis to control the TB epidemic
In December two training courses for staff were organized in Constanta and Baia Mare in order to strengthen the capacity of the NPPSCT. 41 people attended these trainings, and the total number of health professionals trained in the field of respiratory medicine through project has reached 549. Earlier this month, the direct purchase of services assessment ended and the training calendar has been updated for the month of January 2016.
Providing integrated interventions to prevent transmission of TB in poor communities and to increase treatment adherence
In December, three training sessions with the participation of Local Health Assistance services and Health Ministry were organized in Neamt, Botosani and Dolj, attended by a total of 160 people. There were three monitoring visits to these three training sessions.
It has also been prepared the documentation for the purchase of gift vouchers necessary to stimulate community workers who will ensure the support in providing integrated interventions to prevent TB transmission in poor communities and to increase treatment adherence. The procedure is in the stage of bid evaluation.
Ensuring the correct, complete and quality treatment of the patients enrolled and of those who receive incentives for maintaining adherence to treatment
60 medical records were analyzed by the MDR TB commissions doctors, and 25 of the patients received the recommendation to be enrolled in treatment. In December, no new patients were enrolled in treatment. The project team continued the steps to complete the dossier submitted to the National Agency for Medicines and Medical Devices in order to obtain the special needs authorization to import the anti TB drugs in Romania.
This month, from the total of 1837 patients considered eligible to be enrolled in the project, 654 had signed consent sheets until November 10th. Between November 11th and December 31st, 10 new patients sent full consent sheets. There are 647 patients enrolled in the project to receive incentives / social support. So far, 580 unique patients have received social support to maintain adherence to treatment.
Other December activities:
NPPSCT county technical coordinators were requested information about locations to place the UV lamps purchased within the project.
Preparations for next year TA missions of WHO experts continued, by identifying the periods, NPPSCT priorities and the experts to carry out those missions.
Data from interviews of the TB patients about their information needs were collected and centralized, in order to accomplish a booklet about TB who will address TB patients, vulnerable groups and the general population. Also, the procurement procedure of an audit firm was organized.
Strengthening the Capacity of the National Programme for Prevention, Surveillance and Control of Tuberculosis to control the TB epidemic
Four training courses were organized in November for the medical staff in order to strengthen the capacity of the National Programme for Prevention, Surveillance and Control of Tuberculosis (NPPSCT) epidemic. The courses were organized in Bacau, Tg. Mures, Galati and Bucharest, and were attended by 85 participants. Overall, by the end of November, 508 health professionals were trained within this project. There were two monitoring visits, with courses organized at Galati and Bucharest, and the course planning was updated for the November 2015 – January 2016 period.
Documents were drafted for the procurement of services for training program evaluation and the panel of experts who will be invited to send their bid was selected.
Rapid testing of patients for Multidrug Resistant and Extensively Resistant Tuberculosis (MDR TB and XRD TB)
Two new TB laboratories – in Iasi and Leordeni – have started their activity of rapid testing within the project, completing the NPPSCT network of laboratories that have rapid diagnostic techniques for MDR TB and XDR TB in Bucharest, Cluj, Bacau, Brasov, Constanta Craiova, Sibiu, Timisoara. In November, in these modern equipped laboratories, 1,760 people have been tested, of which 484 have been detected with sensitive TB and 52 people with MDR TB.
In total, from March until the end of November, 11,406 patients have been tested in NPPSCT labs. A quarter of them (2,853 people) were detected with TB, 258 with MDR TB, and 4 with XDR TB.
Continue the work for the development of a functional laboratory network for early detection of MDR / XDR TB
The contract for the GeneXpert equipment procurement was signed and the laboratories in the country where it will be put into use were designated: Iasi, Timisoara, Leordeni, Craiova, Constanta, Cluj-Napoca, Brasov, Baia Mare. The persons responsible to work with the new equipment will be trained in this regard in December, 14th to 21st.
Regarding the acquisition of the 44 safety cabinets for laboratories, the centralised procurement procedure is in the bid evaluation stage. For the procurement of the 10 LED laboratory microscopes, the supplier selection procedure was completed, and the winner company was named. Next, the supply contract will be signed.
This month, the 9 vehicles procured under the project for transporting samples to rapid diagnosis laboratories were registered and sent to the designated TB units: Timisoara, Craiova, Calarasi, Constanta , Iasi, Bacau, Cluj-Napoca and Leordeni. One vehicle was assigned to NRL Bucharest, at the “Marius Nasta” Institute for Lung Diseases.
Three laboratories – NRL Bucharest, NRL Cluj-Napoca and LRR Galati – will receive Versatrek equipment, as stipulated in the contract signed in November with the company that won the procurement procedure. The equipment was received and shall arrive in laboratories between 3rd and 10th of December, when it will be put into operation and the staff will be trained to use it.
Ensuring the correct, complete and quality treatment of the patients enrolled and of those who receive incentives for maintaining adherence to treatment
Three more MDR TB patients were enrolled in treatment in November, and the total number of MDR patients enrolled since the beginning of the project is 292. Other 63 patients received the recommendation to be enrolled in treatment, after doctors from MDR TB committees analysed and discussed 111 new medical records.
In November, out of the 1,799 patients considered eligible to be enrolled in the project to receive incentives, 614 had signed consent forms until October 10th. In addition, 23 new patients had signed consent forms between October 11th and November 30th. Overall, 628 patients are enrolled to receive incentives within the project.
By the end of November, 561 unique patients had received social support to maintain adherence to treatment, as confirmed by the treating doctors.
Providing integrated interventions to prevent transmission of TB in poor communities and to increase treatment adherence
In November, the centralizing of the databases of TB patients from the six counties involved in the project was finished. 680 patients were identified for enrollment, as follows: 206 in Botosani County, 115 in Giurgiu County, 112 in Calarasi County, 107 in Gorj County, 79 in Neamt County and 61 in Dolj County.
Also, work has been done to prepare three meetings with the participation of Local Health Assistance services and Health Ministry. They are about to take place during December in Botosani, Neamt and Dolj.
Other November activities
The procurement procedure of the UV lamps continued.
Educational materials for TB infection control course for TOT have been prepared and the training was organized.
In November, the discussions with the WHO for programming the technical assistance missions for next year started by identifying and prioritizing NPPSCT periods and experts to carry out those missions.
Between 18 and 21 November the communications training session for health workers was organized, attended by 21 health professionals from NPPSCT network.
The non-reimbursable grants from public funds represent a real opportunity for the beneficiary countries, to address specific problems of the vulnerable communities, for which the country policies haven’t yet succeed, in some situations, to establish concrete measures. Furthermore, the development of several projects in public-private partnerships allows, through the non-reimbursable grants for the support and improvement of the measures included in the national strategies for the control or eradication of some diseases or for the improvement of the life quality of some groups at risk of social exclusion.
Until now, in Romania, only in the fields of human resources, health, and human rights, the non-reimbursable public funds supported the development and piloting, at national level, of some infrastructure of services specific for the people affected by diseases difficult to cure or chronic (diagnosis, specialized interventions etc.), gave way to the implementation of some training programs for different professional categories, were the basis of several research programs and the development of studies in fields uncovered in Romania (such as autism) or allowed the development of some information campaigns addressed to the general population on different diseases, non-discrimination campaigns or advocacy campaigns to improve the existing legislation regarding the rights of the people with disabilities and those affected by TB, HIV/AIDS, etc.
The benefits of the European funding or those granted by the government of some European countries are priceless.
Maybe that is exactly why their management at national level and the reporting systems for the reimbursement of the expenditure might try to complete this balance that the external funding re-establishes in countries like Romania. The modern technology and the electronic systems of data storage allow today to replace the paper support with electronic support which is without any doubt equally ecologic and durable. More and more campaigns try nowadays to educate the population in the spirit of a proper use of electronic devices, avoiding hard storage of the information.
The current systems of reporting to the national management authorities for the international funding, related to expenditure reimbursement, is based largely on data presentation and storage on paper, leading to impressive quantities of files, ring-binders and paper sheets for each monthly report, for each project, everything in up to 3 copies for each document. Only for the project “Improving the Health Status of the Romanian Population in Romania by Increasing Tuberculosis Control”for the January – April 2015 reporting, the data storage needed 70 ring-binders, each having an average 400 A4 sheets of paper. Considering that each A4 sheet of paper weighs 5 grams (80 gr/sqm), after doing the math we conclude that only the content of 70 ring-binders, for one periodical reporting, weighs 140 kg of paper (without adding the weight of the ring-binders).
Of course, at a first glance the situation might create opportunities to access new financing lines for solutions to protect the forests and local ecosystem.
Nonetheless, at a more realistic assessment of the situation, there is a need to reconsider and change the reporting system (regarding data storage), with higher focus on using modern filing technology and information storage. No doubt, it’s a win-win situation, for the national management authorities, project implementers and general population who, although far away from these details, breathe the air which Romanian forests help to breath.
The change can come from the first decision maker who understands its benefits.
Marian Istrate is 41 years old, lives in Bucharest and in April 2015 was hospitalized at the “Marius Nasta” Pulmonology Institute in Bucharest, with the diagnostic of multidrug resistant tuberculosis. He left at home his wife and their 19 years old daughter who just had the bachelor degree exam, worried that there are chances he would have given them the Koch bacillus. In an interview conducted in his room from “Marius Nasta” Institute, Istrate told us how he ended up being diagnosed with tuberculosis and what his hopes for the future are.
“I don’t know, I have several problems, and the most important is Crohn’s disease, which I have been fighting for 10 years now. (ed.: Chron’s is a chronic inflammatory disease, localized in the digestive tract wall). Because of this disease I had a stroke, trombophlebitis, there were several things linked to each other. Then some biologic treatments for the Chron’s disease appeared and the doctors proposed to follow them.
Thus, as I ended up doing all sorts of investigations in hospitals, in 2007 they discovered I had pleurisy. Then, in 2013, they noticed a spot on the right superior lobe of the lungs and the doctors told me I had TB. I followed 1st line treatment, except that the spot didn’t become larger, but it didn’t shrink also. And I thought to myself: if I cut my finger, then it swallows, it gets infected or it heals. But in my case the spot remained there, even after the treatment.
I took the TB treatment for 6 months, plus the biologic treatment for my disease and it went ok. I used to go to Fundeni, but I wasn’t hospitalized, I was going twice a month and get a dose every two weeks. And at the end of last year they changed my treatment with an intravenous one. I had only two doses and during New Years Eve, in December 2014, I had fever, chills. It passed after 2-3 days or so and, after about half a month, I thought I should go to the hospital to see what’s going on.
I had an X-ray and they told me I had a tumour. And I had to have a bronchoscopy done afterwards and it didn’t turn out to be TB, cancer, or any tumour, but some sort of pneumonia. I was put for 20 days on Cefort iv treatment, and in the sputum sample didn’t appear anything. In March, they put me on 1st line treatment, but the spot remained. By end of April, a lady doctor calls me, telling they did the drug sensitivity test and that it turned out multidrug resistant tuberculosis. “Wouldn’t I better go and buy a coffin?” I said to myself.
On 29 April I was hospitalized. It is suspected that I took it (ed. the bacillus) from somewhere in a hospital. At least 2 month I’ll stay here at “Nasta”. To my surprise, I coped with the treatment, although I was afraid I couldn’t do it. As a patient here, one begins to get used with the idea of the disease, of tuberculosis, of severe diagnostic. I still have bad nausea, sometimes I even feel sick to drink water. It has to pass, you end up saying to yourself.”
Marian Istrate is only one of the thousands of patients with multidrug-resistant tuberculosis in Romania, to whom the lack of high performance methods of rapid and correct diagnosis of the disease made loose precious time. Two years – the time when Marian was incorrectly treated for sensitive tuberculosis – represent a period when multidrug resistant tuberculosis would have been cured, with the proper and timely initiated medication.
Access to rapid diagnostic, thanks to the high-end equipment procured through the project “Improving the Health Status of the Romanian Population in Romania by Increasing Tuberculosis Control” allows receiving the diagnostic in very short time (from few hours up to few days) and beginning the correct treatment, offering the patients like Marian Istrate the chance to be cured and have a normal life.
*Marian Istrate is a fictional name; we decided to change it at the patient’s request.
Starting with March 2015, 1,000 people with multidrug resistant tuberculosis shall receive complete, continuous and quality treatment. By the end of June, 139 MDR TB patients were enrolled countrywide and receive treatment within the project “Improving the Health Status of the Romanian Population in Romania by Increasing Tuberculosis Control”.
The doctors in the local tuberculosis dispensaries monitor the health status of the patients enrolled in the program, thus helping them not to give up the treatment. We asked Dr Ariadna Petronela Fildan, MDR coordinator in Constanţa county, which are the advantages of this integrated system of patients treatment. Medical sciences PhD and associated professor at the Faculty of Medicine of the Ovidius Univerity, Dr. Fildan has been a pulmonology doctor at the Constanţa Pulmonology Clinical Hospital starting with 2008.
In this project, what does patient-centred approach mean?
The core of the project is the patient, everything – from human to material resources –gravitating around him, aiming to heal the patient and contain the spread of the disease. Once the multidrug-resistant tuberculosis diagnostic confirmed, the fight with the disease begins, fight which is based on well established rules. First of all, the patient is informed by the attending doctor about the new diagnostic methods, the therapeutic options, the duration, advantages and possible complications of the therapy, concurrently underlying the fact that the disease can be defeated if the treatment if followed on a continuous basis, without interruption for the entire duration indicated by the doctor. One shall try to motivate the patient in order to enter the program, bringing as supreme argument the cure and the chance to a normal life. Each patient represents a specific case; they don’t come only with a diagnostic and a disease we must treat, but with an emotional, cultural and social background which we must consider when trying to motivate the patient. We try to answer to all the questions related to the disease and treatment, to provide them as much information as possible, in a clear way, tailored to the personal level of understating.
How important is the medical care accompanied by psychological care, how does this actually take place in hospitals? Which are the advantages and what is the difference between the new possibilities and what was done before?
Evidently, the psychological support is very important; a trained person can find the methods adequate to each patient to motivate them not to give up the treatment. In fact, the most important aspects in the success of a treatment are, first and foremost, the compliance and ensuring continuity. Psychological counselling at the initiation of the treatment but also during the entire course, when complications – some quite difficult to deal with and to control – might appear, is a major contributor to the therapeutic success. Unfortunately, not all the hospitals have trained staff and in this situation is our hospital in Constanţa as well. To bridge the gap, the discussions with the patient take place with the participation of the attending doctor, the chief of department or the chief of dispensary (according to the case, if the patient is hospitalized or in ambulatory), the medical director and the program coordinator. The advantages we have at this moment are considerable, starting with the fact that we can have an MDR TB diagnostic in a few hours, compared to a few months, through access to the newest molecular diagnostic methods, continuing with access to modern therapy, ensuring continuity, the treatment regimens being those established by the MDR commission, according to the international guidelines.
Social support: what is the role of the social vouchers?
The role of these vouchers is a motivational one. It has been observed that providing monthly “bonuses” – if the patient came to the doctor and was given the treatment in the presence of the doctor or nurse – increases the treatment compliance rate. As it is very well known, many of the patients face serious material difficulties and thus any help is welcome.
What feedback do you have from your patients, regarding this approach?
The patients are satisfied because they have the continuous treatment ensured, have an additional chance, by being included in this program, and understand the importance of the correct administration, without interruption, of the medication, because this is the only way they can be cured.
How many patients are enrolled in this program in Constanța?
Currently there are five patients enrolled for complete regimens and eleven patients enrolled for social support in order to increase their compliance to treatment. We hope as many as possible will be accepted.
What is the situation in the county regarding tuberculosis?
In Constanţa County, the tuberculosis incidence decreased constantly in the past 10 years, from the 3rd place at national level to the 12th place. Last year 634 cases of tuberculosis, new cases and relapses were notified, representing an incidence of 87.6 versus 89.9 per 100,000 inhabitants, in 2013. 38 cases were notified in children. What we noticed for the first half of this year is the high number of severe cases registered in our hospital, extended, milliary forms, meningo-encephalitis. Until now we had 13 deaths due to tuberculosis, which probably can be explained by the long latent period between the occurrence of the symptoms and the visit to the doctor.
Grațiela Chiriac is the chief of the pulmonology laboratory in Bacău, one of the 8 laboratories equipped with high-end technology through the project “Improving the Health Status of the Romanian Population in Romania by Increasing Tuberculosis Control”. Dr Chiriac is laboratory doctor and member of the Laboratory Working Group of the National Tuberculosis Prevention, Surveillance and Control Program. We asked her what would be the advantages of the new equipment of the laboratory network.
How does rapid diagnosis help the patient?
The patient’s benefit is considerable, since they can receive the diagnostic early, together with conclusive information about the sensitivity of the infectious strain. Thus, the patient has the opportunity of a treatment initiated early and tailored according to the result of the drug sensitivity test. In these circumstances, the doctors take the right decisions regarding the treatment and the development of chemo-resistance is avoided, as it would make the cases difficult to treat. The liquid media diagnostic method implies inoculation in a liquid media tube, with a standardized technique, and placing it in the equipment which shall monitor the culture. The positive result, which basically confirms the disease, is obtained in 7 – 14 days, and the final result in 42 days. Comparing with the method on solid media, the benefit is obvious: the time to obtain the positive culture is of 7 – 14 days, versus 21 – 60 days; a complete result, culture and drug sensitivity test in 21 days, versus 50 days or even 4 months.
What does this new technology mean for the doctors working in the field?
For the clinicians, the purpose of the activity within the tuberculosis network is to initiate an adequate treatment, as soon as possible, and for the doctors in the laboratories to establish a correct diagnostic, as soon as possible. Correct diagnostic means the isolation of the strain which determines the disease, identifying it as belonging to the Tuberculosis Complex, testing and determining the sensitivity to drugs.
How many patients were diagnosed so far, with this new method, in the laboratory you run?
By the end of June 2015, we had processed through this method 151 culture samples and sensitivity tests. Bacău is among the counties with a tuberculosis incidence above the country average and with an increased number of re-treatments (ed.: relapses, defaults or failures to previous treatments). That is why is necessary to do cultures on liquid media, to ensure a rapid result. In 2008, we considered the idea of the semi-automated MGIT, at that moment being a routine method in Europe. It was a really special moment, although the method is quite time consuming (each tube was manually passed through the fluorescence reader). The automated method we use now, which indicates with sound and visual signals the positive state of one tube, is beyond comparison, even if it took 7 years to get to this point.
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