Tatiana Dabija – Page 4 – Control Tuberculoza

Ensuring the correct, complete and quality treatment for 1000 patients with multidrug resistant and extensively resistant tuberculosis (MDR / XDR TB)

In May 2016, the enrollment of patients continued in the two MDR TB centers in Bucharest and Bisericani, also in TB centers in the country. At the end of April, a total of 531 patients were enrolled in complete, accurate and continuous treatment.
Between May 25th and June 2nd, 2016, monitoring visits took place in Timis, Dolj, Arges, Calarasi and Constanta counties, to discuss cases of MDR TB, assessing the state of enrolled patients and the results of rapid diagnosis activities.

Providing integrated interventions to prevent transmission of TB in poor communities and to increase treatment adherence

From 13th to 14th of May, 2016, at the “Marius Nasta” Institute for Lung Diseases in Bucharest, training of trainers sessions were organized, attended by 12 TB specialists and community health workers. A monitoring visit was made during the training.

This month, 19 information caravans (IEC) took place in several counties: 9 in Calarasi, 3 in Neamt, 6 in Giurgiu and 3 in Dolj. These sessions have been attended by a total of 1,021 people, of which 259 Roma. So far, in the project, a total of 5,479 people were informed, including 495 Roma.
For the July to September 2016 period, were planned other 12 IEC sessions in Gorj counties, besides the 6 previously planned for this period.

By the end of May, 2016, a total of 3,494 food coupons worth 34 940 lei, were distributed to patients. Also, 1,574 food coupons, worth 15 740 lei, were about to be distributed to other patients.

Establishing a network of functional laboratories for early detection of MDR / XDR TB

Of all patients screened in May through rapid diagnosis methods in NPPSCT network of laboratories, 783 were diagnosed with sensitive tuberculosis, 85 with multidrug-resistant TB and one with TB drug resistance.
Overall, between March 2015 and May 2016, 17,671 unique patients were screened through rapid diagnosis methods in the project, of which 6,805 were diagnosed with sensitive TB, 603 with drug resistance (MDR TB) and 21 extremely drug resistant TB (XDR TB).
To ensure the continuity of rapid testing activity in the NPPSCT laboratories within the project 2,896 LPA tests and 5,600 MGIT tests will be purchased.

This month, all 300 desktop computers purchased in project were delivered to TB units in the country. TB dispensaries and laboratories from 165 TB Hospitals have been equipped with desktop computers in the project.
The purchase of two IT servers, necessary for national management software for registration, monitoring and reporting of TB / MDR TB cases was scheduled for the extension period of the project (April 1st, 2016 – March 31st, 2017).

Other activities carried out in May 2016

597 patients met the eligibility requirements to receive food coupons to increase adherence to treatment, of which 100 new patients. To date, a total of 781 patients were reached in the project.

TB units in the country received UV lamps procured under the project. Also, training courses were organized on TB infection control.

WHO Technical assistance missions to improve the NPPSCT management were prepared and will begin in June-July. Discussions were held in this matter with the stakeholders who will be involved in these missions.

Ensuring the correct, complete and quality treatment of the patients with multidrug resistant and extensively resistant tuberculosis (MDR / XDR TB)

In April 2016, the enrollment of patients for treatment continued in MDR centers in Bucharest and across the country. At the end of April, a total of 460 patients were enrolled in complete, accurate and continuous treatment.
Between 29th of March and 1st of April, four monitoring visits took place in the counties of Galati, Neamt, Iasi and Bacau in order to discuss cases of MDR TB, assessments of enrollment and verification of the laboratories equipment and supplies for rapid diagnostic.
Another monitoring visit was organized on April 26 at Leordeni to check the progress of rapid diagnostic testing equipment and discuss MDR TB cases in the county.

Providing integrated interventions to prevent transmission of TB in poor communities and to increase treatment adherence

The team continued the work on the gathering, verification and centralization of consents signed by patients who were already enrolled and those enrolled in April and updated lists of patients who are given treatment under direct observation (DOT) in the six counties involved in the project.
For the period July to September 2016, 55 information-education-communication (IEC) caravans were planned in counties of Botosani, Gorj, Calarasi, Neamt, Giurgiu and Dolj. In the caravans organized by the end of April, 4458 people in the communities were informed regarding TB.
A total of 320 patients were enrolled to receive DOT, of which 17 Roma.
By the end of April, social vouchers worthing 26.650 lei were distributed to a total of 2,665 patients and other 520 food coupons worthing 5,200 lei were being distributed.

Establishing a network of laboratories for early detection of MDR / XDR TB

In April, the testing by rapid techniques for diagnosing MDR / XDR TB took place in 20 laboratories in the NPPSCT network: NRL Bucharest, NRL Cluj-Napoca, TB laboratories in Bacau, Brasov, Constanta, Craiova, Sibiu, Timisoara, Iasi, Baia Mare, Leordeni, St. Stefan Hospital Bucharest, Leamna, Calarasi, Galati, Targoviste, Drajna, Deva, Tg. Mures and Focsani.
In April 2016, through the rapid testing methods, 3124 patients have been tested, of which 529 were detected with sensitive TB and 31 with MDR TB. In total, between March 2015 and April 2016 in the laboratories of network NPPSCT 24 726 rapid tests were carried out, with the following results: 5871 patients were diagnosed with TB, 522 with MDR TB and 23 with XDR TB.
Up to 31st of March, 2016 a total of eight laboratories were provided with the GeneXpert equipment within the project: Cluj-Napoca, Iasi, Constanta, Craiova, Timisoara, Brasov, Leordeni, and Baia Mare. For the extended period of the implementation of the project (April 1st, 2016 – March 31st, 2017) further equipment shall be purchased: 2 GeneXpert, 1 MGIT equipment and 6 centrifuges, for which centralized procurement procedure will be organized. Also, to ensure continuity of rapid testing in TB laboratories, another 2896 LPA tests and 5.600 MGIT tests will be purchased.
In the project, 28600 GeneXpert tests were procured for nine TB laboratories: Cluj-Napoca, Bucharest, Iasi, Constanta, Craiova, Timisoara, Brasov, Leordeni and Baia Mare and 44 safety cabinets will be delivered to the laboratories.
Versatrek supplies were purchased and necessary kits were delivered to those 14 TB laboratories nominated by NPPSCT: NRL Cluj-Napoca, NRL Bucharest, laboratories TB Hospital at St. Stefan Hospital Bucharest, Iasi, Craiova, Leamna, Bacau, Calarasi, Galati, Targoviste Drajna, Deva, Focsani and Targu Mures.

Providing directly observed treatment (DOT) and incentives for TB patients treated in ambulatory in order to increase adherence to treatment

One year after the start of granting social vouchers, the situation is as follows: 682 unique patients were enrolled in the project to increase adherence to treatment and approximately 50% of them receive food coupons since the first month of enrollment. About 18% of all patients enrolled, 120 patients, were declared cured or complete treatment.

Other activities carried out in April 2016

The project implementation team has organized weekly training in TB infection control with participants from Marius Nasta Institute.
Assessment mission of the National TB Control Program was prepared, as well as the mission for reviewing the strategic documents developed for the laboratories, and the reorganization plan for bacteriology laboratories in Romania.
In terms of providing information about TB to the patients, vulnerable groups and the general population, the main activities undertaken in April were the completion of the leaflet, organizing a workshop to pretest the brochure for patients (9 -10 of April, 2016) and training outreach workers (11-12 of April, 2016), attended by 32 participants.

Strengthening the capacity of the National Programme for TB Control to control the TB epidemic

In March 2016, the testing activity using rapid techniques for diagnosing TB MDR / XDR took place in 20 laboratories of the NPPSCT network: Bucharest, Cluj-Napoca, Bacau, Brasov, Constanta, Craiova, Sibiu, Timisoara, Iasi, Baia Mare, Leordeni, St. Stefan Hospital Bucharest, Leamna, Calarasi, Galati, Targoviste, Drajna, Deva, Focsani and Targu Mures.

This month, 3108 patients were tested in labs within the project. Of these, 700 were diagnosed with sensitive TB and 64 with MDR TB. In March no pacient was detected with extensively drug resistant TB patients (XDR TB).

In total, since the beginning of the project, 21 296 patients participated in rapid testing, of which 5163 were diagnosed with sensitive TB, 463 with MDR TB and 13 TB with extensive drug resistant TB (XDR).

Establishing a network of laboratories for early detection of MDR / XDR TB

GeneXpert equipment were purchased, installed and commissioned in TB laboratories nominated by NPPSCT. All 8 laboratories equipped in the project continued GeneXpert TB diagnostic work: Cluj-Napoca, Iasi, Constanta, Craiova, Timisoara, Brasov, Leordeni, and Baia Mare.

This month, another order for kits was submitted to the GeneXpert supplier contracted within the project, to be used in all 8 laboratories equipped with GeneXpert equipment to diagnose MDR TB.

Regarding the acquisition of the safety cabinets for laboratories, the centralized procurement procedure was finalized and the supply contract had been signed.

Versatrek supplies were purchased. The first orders were shipped to the 14 TB laboratories nominated by NPPSCT: Cluj-Napoca, Bucharest laboratories at St. Stephen TB Hospital Bucharest, Iasi, Craiova, Leamna, Bacau, Calarasi, Galati , Targoviste, Drajna, Deva, Focsani and Targu Mures.

Regarding the purchase of IT equipment, the centralized procurement procedure was completed. Supply contracts were signed for 15 laptop computers, 300 desktop computers, printer, scanner, copier. Of all, there were received 15 laptop computers and 25 desktop computers for PNF units in Bucharest. The reception and delivery of the remaining computers procured under the project has been scheduled for next month.

Ensuring the correct, complete and quality treatment of the patients with MDR / XDR TB

In March 2016, the enrollment in two MDR TB centers in Bucharest and Bisericani resumed, and it will be extended across the country starting from April 2016. At the end of March, a total of 336 patients were enrolled in the treatment completely, accurately and continuously.

Also in March, there were four monitoring visits in Galati, Neamt, Iasi and Bacau counties.

Regarding the provision of integrated interventions to prevent TB transmission in poor communities and to increase treatment adherence, three monitoring visits were organized in Botosani, Piatra Neamt and Giurgiu, during which food coupons were distributed for patients enrolled in treatment within the project.

The team continued the work on the gathering, verification and centralization of consents signed by patients who will receive treatment under direct observation (DOT). This month, 18 IEC caravans were organized in 6 counties: 4 in Botosani, 12 in Gorj, 16 in Calarasi, 9 in Neamt, 6 in Giurgiu and 6 in Dolj. A total of 879 people attended these sessions. Until now, within the project, 979 people were informed and other 53 IEC caravans were planned for April-June 2016 period: 4 in Botosani, 12 in Gorj, 16 in Calarasi, 9 in Neamt, 6 in Giurgiu and 6 in Dolj.

In total, at the end of this reporting period, 231 patients were enrolled for DOT, of which 10 Roma ethnics.

Providing directly observed treatment (DOT) and incentives for TB patients treated in ambulatory in order to increase adherence to treatment

In March 2016, of the total number of 1946 patients considered eligible to be enrolled in the project, 732 had signed consent sheets up to February 10^th. Between February 11^th – March 31^st, 2016, 11 patients sent their consent sheets.

In the project, a total of 642 unique patients received social support (vouchers) to maintain adherence to treatment, status confirmed by the treating doctors and MDR coordinators. Of all patients who received social support, 77 declared themselves Roma. Between May 2015 and February 2016, vouchers were distributed to 4513 patients. At the end of March, of the 172 patients enrolled in the first month of the project, 77 successfully completed the treatment (44.76%), 11 died (6.39%), 2 were declared to abandon the treatment (2.77% ) and 73 patients are still in treatment and are adherents since April (42.44%).

In March, a joint event has been organized by „Marius Nasta” Institute and it was attended by county TB coordinators, physicians working with laboratories, and 40 coordinating MDR TB doctors.

Other activities carried out in March 2016

Weekly training in TB infection control were organized, attended by participants from Marius Nasta Institute.
The documentation related to distribution of UV lamps in TB units and the documentation for the reception committee of the UV lamps were prepared.
The organization of technical assistance mission started, aiming to review strategic documents developed for the laboratories and the bacteriology laboratories in Romania reorganization plan. The mission is scheduled in early May 2016.
Between 9^th and 12^th of March, the fourth training for health communication was organized in Oradea.
The work on the draft of the brochure for patients with tuberculosis continued, and also the preparation training for outreach workers.
The second press conference of the project was organized.

Strengthening the capacity of the National Programme for TB Control to control the TB epidemic

In February, three courses for health professionals in the field of respiratory medicine were organized in Bucharest, attended by a total of 71 students. In total, by the end of this month, 687 specialists were trained within the project. For these courses, monitoring visits took place.

Rapid testing of patients for Multidrug Resistant and Extensively Resistant Tuberculosis (MDR TB and XDR TB)

This month, no patient was found with XDR TB among patients tested in the laboratories of the National Programme for Prevention, Surveillance and Control of Tuberculosis to control the TB epidemic (NPPSCT) equipped through the project. Of the 2630 patients tested between February 1st to 29th in these laboratories, 524 were diagnosed with sensitive TB and 42 with MDR TB. In total, from March 2015 until the end of February 2016, a number of 17 943 patients were screened, of which 4301 were diagnosed with TB sensitive, 397 with MDR TB and 13 with XDR TB.

Establishing a network of laboratories for early detection of MDR / XDR TB

Nine new labs began testing activity through rapid diagnostic methods (Versatrek), being equipped within the project with test kits for use of such equipment. The nine new TB laboratories are at the St. Stefan Hospital Bucharest, Leamna, Calarasi, Galati, Targoviste, Drajna, Deva, Tg. Mures and Focsani. Thus, since February 2016, the NPPSCT network has 20 laboratories carrying out testing activity by rapid techniques for diagnosing MDR / XDR TB: NRL Bucharest, NRL Cluj-Napoca, laboratories TB in Bacau, Brasov, Constanta, Craiova Sibiu, Timisoara, Iasi, Baia Mare, Leordeni and the nine new laboratories.

Other 8 GeneXpert equipments were purchased, installed and commissioned in TB laboratories nominated by NPPSCT.

To purchase 44 safety cabinets for laboratories, the centralized procurement procedure was finalized and the purchase contract with the selected firm was signed. The 10 LED epifluorescence microscopes were also purchased and received. Two of them were installed and commissioned in the NRL Bucharest, the other 8 were installed this month in the NRL Cluj Napoca, RL Iasi, RL Constanta, RL Timisoara, RL Bacau, RL Brasov, RL Craiova and RL Leordeni.

Versatrek supplies were purchased. The first orders were shipped to the 14 TB laboratories nominated by NPPSCT: NRL Cluj-Napoca, Bucharest NRL laboratories at TB Hospital St. Stephen Bucharest, Iasi, Craiova, Leamna, Bacau, Calarasi, Galati , Targoviste, Drajna, Deva, Tg. Mures and Focsani.

Ensuring the correct, complete and quality treatment of the patients with MDR / XDR TB

In February 2016, 4 more patients were enrolled, leading to a total of 309 patients under treatment in the project. Another 75 medical records were analyzed and discussed by the MDR TB commissions doctors, and 46 patients received the recommendation to be enrolled into treatment as soon as anti TB are in store UNIFARM warehouse will receive authorization for exemption from the labeling. According to consent sheets received by the end of January, the number of Roma patients rose to 48.

The work on centralizing databases of TB patients in the six counties involved in the project continued, in conjunction with community workers associated communities with TB cases. They were collected, verified and centralized signed consent by patients who are to receive DOT.

Enrollments to ensure DOT were made for 160 patients from Botosani, Neamt, Dolj, Gorj, Giurgiu and Calarasi. In January, DOT has been granted for 36 patients, and in February for 114 unique patients. In total, to date, 150 unique patients received DOT, of which five Roma patients, according tos the community workers who were monitoring those patients.

They were planned and prepared to be held in March 2016 a number of 18 IEC caravans: four in Botosani county, 4 in Gorj county, 3 in Calarasi county, 3 in Neamt county, 2 in Giurgiu county and 2 in Dolj county.

Providing directly observed treatment (DOT) and incentives for TB patients treated in ambulatory in order to increase adherence to treatment

In February 2016, of the 1,930 patients considered eligible to be enrolled in the project, 691 patients had signed consent sheets until January 10. Between 11 January and 29 February 2016, a total of 47 new patients have sent consent sheets. To date, of the 1930 eligible patients to be enrolled, 613 have received social support for adherence to anti TB administered, of which 76 declared themselves Roma. Cumulatively, in the period May 2015 – January 2016, vouchers were distributed to a total of 4036 patients.

Of the 172 patients enrolled in the first month of the project, 73 completed treatment successfully (42.44%), 10 died (5.8%), two patients were declared abandonment (2.77%), and 81 patients are still in treatment and are adherents of April (47 %%).

Other activities carried out in February 2016:

The documentation for service contracts for TB infection control trainers was prepared, the courses were scheduled and lists of participants in training courses at the Institute Marius Nasta were prepared.

In terms of technical assistance by the World Health Organization (WHO) to improve the NPPSCT management, the technical assistance missions plan was carried and the mission objectives were detailed. The plan is consistent with the one of the missions of technical assistance funded by the FG.

For providing information about TB to patients, vulnerable groups and general population, the project team is working on organizing the fourth communication training for health. The third workshop for health communication has been established that will be held in Baile Felix, March 9^th to 12th. Also, the preparation for the brochure for TB patients were conducted.

The theme established by the World Health Organisation for the World Tuberculosis Day (WTBD) this year is “Unite to End TB,” and one of the four sub-theme is “Together we test, treat and cure more effectively.”

Through its activities, the project entitled “The Improvement of the health of the Romanian population through enhanced tuberculosis control” falls perfectly in line with this sub-theme by providing TB laboratories with advanced equipment and by ensuring rapid diagnosis services. We have talked about this with Mr Răzvan Vulcănescu, Undersecretary of State with the Ministry of Health, coordinator of RO_19.01 – “Public Health Initiatives” Programme

What is the contribution of the project “The Improvement of the health of the Romanian population through enhanced tuberculosis control” to the results of the Programme RO_19.01 – Public Health Initiatives, managed by the Ministry of Health?

The Ministry of Health was designated as the operator of the Programme RO 19.01 – “Public Health Initiatives,” and its objective is “to improve public health and reduce healthcare inequalities.” Two of the expected outcomes of the programme are the improvement of the prevention and treatment of contagious diseases (including TB) and the development of resources at all the levels of the healthcare system. This project seeks – and the results have already begun to show – to consolidate the institutional capacity of the National Tuberculosis Prevention, Surveillance and Control Programme PNPSCT) with a view to controlling the TB epidemic in Romania, as well as to ensure the early detection of cases of multidrug-resistant tuberculosis (MDR TB) and of extensively drug-resistant tuberculosis (TB XDR). The project also aims at ensuring full, continuous and quality treatment with second-line drugs for MDR/XDR TB patients, as well as at developing an integrated community support model for the treatment and prevention of TB in poor and vulnerable groups. The project was prepared based on the thorough understanding of the current social factors associated to TB and of the interventions from outside the healthcare sector, in particular in relation to social support and the prevention of the disease in vulnerable groups.

In more than one year and a half since its inception, this project has determined considerable improvements: we have ten laboratories fitted with ultra-advanced equipment which can cover the entire territory of the country, we have trained pulmonologists all over the country, we have an integrated community support model for the treatment and prevention of TB in poor and vulnerable groups. How do these results look from the perspective of the WHO, in the context of the World TB Day (24 March)?

The theme of the World TB Day (WTBD) this year, as announced by the WHO, is “Unite to End TB,” with reference to government, communities, the civil society in the field and the private sector, therefore addressing all stakeholders that can contribute to this goal. One of the four sub-themes that the WHO promotes in 2016 for the WTBD is “Together we test, treat and cure more effectively,” and the project “The Improvement of the health of the Romanian Population through enhanced tuberculosis control” falls perfectly in line with this sub-theme, through the provision of TB laboratories with advanced equipment and through the rapid testing services which they now can offer patients. As such, the project contributes to the international effort to stop this disease and follows the lines of the WHO Stop TB Strategy, aimed at eradicating the TB epidemic by 2030. Among others, this means that the activities of all stakeholders should focus on the patient and on assuming ambitious changes in the public health system.

During the last year, more than 10,000 persons have been tested using rapid diagnostic methods in the laboratories that were provided with equipment under this project. This means that, in time, there will be less new cases of disease in the communities and, ultimately, the overall number of TB cases will also decrease. What is the impact of this project on a social level?

The impact of this project translates into better diagnostic services, better treatment, directly-observed treatment (DOT), social support and preventive interventions for epidemiologically-relevant and vulnerable groups, which in time will lead to the reduction of economic and social differences caused by TB in Romania and in the European Economic Area.

Ensuring early diagnostic, followed by continuous, complete and quality anti-TB treatment DOT and incentives in the form of food for the patients in order to increase treatment adherence will lead to a better treatment success rate among TB patients who will in this way be able to return to work, becoming productive citizens again. Moreover, preventive interventions in the poor rural communities, including in the Roma communities, will contribute to better targeting of these populations in the primary healthcare services, to the decrease of the number of new TB cases, the reduction of stigma and of the discrimination of TB patients and their families, as well as to an improved social and economic status of the members of the community.

Tuberculosis is no longer a disease of poverty but many Romanians are not yet aware of this and do not expect to become ill. The diagnostic is hard to accept for a bank manager, for example, or for a lawyer. Cătălina Constantin, the President of the Association for the Support of Patients with Multidrug-Resistant Tuberculosis, talked to us about the social and psychological problems faced by tuberculosis patients, but also about the importance of the permanent training of the medical staff working with TB patients.

What are the problems, beyond the disease, the problems that are determined by the disease and are complementary to it?

There is a context, before the disease; tuberculosis is no longer a disease of poverty. The main vulnerability is a weak immune system. The general context is that there are many cases of tuberculosis in Romania and low immunity always exposes people to the risk of contracting the disease. Tuberculosis affects people in all the dimensions of their lives: psychological, social and medical.

What happens when someone finds out the diagnostic?

Regardless of the form of tuberculosis, it is always a shock for the person concerned. Most of the times, the diagnostic of multidrug-resistant tuberculosis (MDR TB) is not established from the start, because there are only a few places in the country where we have the appropriate equipment to make this kind of determination rapidly. Things are still like this: you find out that you have tuberculosis and after one or two months of treatment you can find out that you have MDR or extensively drug-resistant tuberculosis (XDR TB). But all patients go through the shock of that moment when they find out the diagnostic, the long duration of the disease, the fact that they have to fully reconsider the following six months or two years of their lives and put everything else on hold and follow the treatment. There are many who are unable to do this, they lose their jobs, lose opportunities, stop going to school or give up going abroad to work, they postpone their wedding or leave their girlfriend or boyfriend. However, the most important thing is losing one’s job because not all patients are employed under an employment agreement or under other legal work contracts and, if they are employed, the contract does not reflect the total amount of money they receive and then one of the major problems is that their income decreases dramatically. On top of this, the needs increase. For example, if the parent who became ill was taking care of the children, he or she can no longer do this, they must hire someone (our note – the hospitalisation period for MDR or XDR TB cases may last between three and ten months or more, until the patient becomes negative, meaning until the patient no longer transmits the disease). Because they take the tuberculosis treatment, there is a high probability to develop adverse reactions to the medication and other amounts of money are needed to take other medicines to reduce the intensity of these adverse reactions. These additional drugs are not free, some are partly compensated by the state, others are not. Some patients experience pain because of the anti-TB treatment, others develop liver conditions which means another treatment, other expenses. The patients need rest and food, and food also costs. Before tuberculosis, they could eat anything, now they need meat every day, rich food, rest and quiet.

Another social problem is that many patients have to change profession or their job. Many times, this is costly or impossible. If they work in constructions and one of their lungs was affected, if they were exposed to environments that lower their immunity or to stressful environments, they must give up that job.

At psychological level, anxiety-related conditions, psychotic manifestations and hallucinations may appear. I remember one patient who said that she was feeling a sharp pain in her head, as if someone had stuck a knife there. Hallucinations are complex and real, in the sense that another patient, when she was taking her treatment, believed that she was a canned paprika and could not understand what she was doing in bed instead of being in a jar.

Are they obsessed by the question “Where did I take the disease from”?

Of course, they are obsessed by the question “Why?” because they are blamed for having contracted the disease. This is what they are told by people who are afraid, from physicians to their own families. “Why me?” they ask themselves. And then come periods of fury, depression and, in the end, acceptance, if they are lucky and receive support. When they accept the situation, they can understand that the treatment is the way to be cured and that it is accompanied by a multitude of unpleasant things.

How important is the communication between the patient and the physician?

In this relationship, both parties are responsible, the patient and the medical practitioner alike, whether the latter is a physician or a nurse. The tuberculosis patients consider that the person taking care of them is very important and then they do not ask only for the diagnostic and the treatment, but also for many other things: acceptance, understanding, empathy, advice in matters that are not related to the specialisation in question. They do not necessarily receive these and this happens for various reasons, because the physician and the practitioner also have their own needs: time, training and support, because many of them are burned out. If we want efficient medical staff we have to make sure that they are provided with regular training sessions, to remind them what it means to maintain communication with the patient, we need motivational intervention but also to teach them to strike the right balance in their work.

How did the association you lead appear?

In 2011, I was working as a volunteer with the Red Cross and I was coordinating a psychotherapy and social support programme for patients with multidrug-resistant tuberculosis during their treatment sessions. But I have been working in the field of tuberculosis for about 20 years. I was a nurse at the “Marius Nasta” Institute, then a psychologist from din 2005, and when I started my volunteer work with the Red Cross I was providing psychological support to the patients in sector 5 in Bucharest. I saw many patients – too few of them were diagnosed with multidrug-resistant tuberculosis at that time – and they had very difficult situations in their lives. The shock was when I had a therapy group of 20 people with multidrug-resistant tuberculosis, a group where they felt secure because they were surrounded by others with the same kind of problems.

I was helping them increase their self-esteem and maintain their motivation to remain adherent to a treatment that was causing them a lot of problems. There was however one dimension that I had no answer to and which pertained to their relationship with their families. When, as part of the therapy, I asked them to draw their families, one patient drew his family but he was not in the drawing. Another one had come with his wife, who also had MDR. He drew himself, his wife, their child and the cat, but they were enclosed within a high fortress wall inside of which no one else had access. They felt humiliated each time they went to the Assessment Committee and I used to prepare an entire intervention to deal with this aspect alone. I would help them vent and project themselves with some sort of power that would make it OK to ignore and think that the others were the problem, not them. These experiences gave me the idea to start the association.

The practice showed that some TB patients might abandon the treatment after the first month of administration, because they begin to feel better, or continue to take only a part of the compulsory medication, discarding those with unpleasant adverse reactions (nausea, vomiting, bone aches, etc.). The pneumologists say all the time: these moments favor the development of the Koch bacilli (Mycobacterium tuberculosis) resistant to the existing anti-TB drugs, and the patients become a source of resistant TB infection. In this context, the treatment under direct observation (DOT) by community nurses and community health workers (called DOT supporters) is extremely important. The project Coordinator, Florin Sologiuic, working with the Center for Health Policies and Services (CHPS), partner in the project ”Improving the health of the population in Romania by increasing TB control” explains the role of the Center in implementing the directly observed treatment (DOT) in communities.

In how many communities in Romania the TB directly observed treatment is implemented by DOT supporters?

In the project ”Improving the health of the population in Romania by increasing TB control”, we have 82 communities in 6 counties: Botoșani, Neamț, Gorj, Dolj, Călărași and Giurgiu. Those 50, as we initially began, were not enough, because we realized we have patients in several towns and we wanted to cover as much as possible.

How were the DOT supporters selected in these communities?

Based of the communities having TB patients. This was the selection criterion for the DOT supporters. In the communities with patients, the health mediators and community nurses of the local social care authorities were included in the project. Some of the employees leave, they go to work abroad or find another job, some take maternity leave. At present we have 89 DOT supporters, out of which 4 are Roma health mediators.

What has to do a DOT supporter in this project?

Initially, the worker contacts the patients following to be enrolled in the project, those who receive financial incentives which must ensure an additional support for the medication.

In each county we have also one coordinator of the DOT supporters and, based in the data he or she provides, the supporter gets in touch with the patients, explains them what is all about and give them a file explaining her rights and obligations. If the patients agree to enter the program, signs a consent form in order to receive the directly observed treatment. Afterwards, the supporter goes to the family doctor in the community or to the TB ambulatory in the catchment area of the community and administers them three times a week to each patient. The DOT supporters also encourage the villagers to participate at the medical caravans, information sessions about TB which are organized in these communities.

How do the directly observed treatment process is taking place?

So far, in this project, 150 patients receive directly observed treatment. In average, a DOT supporters has 1 up to 3 patients. It is not very simple, because the treatment implies travel in 3 different days to the patient, so one cannot have many patients, otherwise one wouldn’t have time to do all the work. In each of the 3 days in which the patient has to take the treatment, the worker watches the patient taking each pill in the list of treatment. Because the reactions are sometimes difficult for the patient, from vomiting to headaches or deafness, it is a good thing that the patient to be encouraged and monitored when taking the treatment, to avoid the relapse with aggravated form of multidrug resistant tuberculosis.

What else does the DOT supporter has to follow at the patients?

Being in close contact with the patient, in case he or she declares the change of the health status or tells the worker that something with impact on the disease or treatment happened, the DOT supporter communicates with the family doctor or the TB ambulatory that the status has worsened or the new situation the patient informed him about. It is possible that, at some patients, other diseases appear, ant this fact should be notified.

Sorry, this entry is only available in Română.

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Improving the health of the population in Romania by increasing TB control

Project’s status update by 31st of May (1.05 – 31.05.2016 period)

Project’s status update by 30th of April (1.04 – 30.04.2016 period)

Project’s status update by 31st of March (1.03 – 31.03.2016 period)

Project’s status update by 29th of February (1.02 – 29.02.2016 period)

(Română) 24 Martie 2016 – ZIUA MONDIALA DE LUPTA IMPOTRIVA TUBERCULOZEI