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.
165 doctors and nurses from the pulmonology wards countrywide have attended training courses on tuberculosis epidemiology, rapid diagnostic methods for multidrug-resistant tuberculosis and the correct treatment, by the end of June 2015. Seven courses were organised in Timişoara, Sibiu, Ploieşti, Constanţa, Piteşti and Cluj, and 20 more training sessions shall be organized in other cities of the country by the end of the project.
The trainees had the chance to learn new things about the disease incidence and modern diagnosis, “information they don’t have access to in day to day medical activity”, as Dr Florin Sologiuc says, consultant at the Centre for Health Policies and Services Foundation, one of the organizations in charge with the training. One of the trainers, Doctor Marilena Crişan, specialized in paediatric tuberculosis, also stated that the added value of the trainings is given by the fact that they provide the doctors and nurses the opportunity to thoroughly discuss the news in the area of tuberculosis. “Although tuberculosis seems like a simple disease, it has been constantly surprising for more than 200 years. The trainings are very interesting because they are interactive, and the participants have access to the new technologies. We intend to discuss with the doctors about the cases and none of the training participants is marginalized; we want them to be engaged.”
The pulmonology network in Romania is made of more than 700 doctors and over 2000 nurses. A series of training courses on tuberculosis was organized during 2004 – 2014, especially within the projects funded by the Global Fund to Fight against HIV/AIDS, Tuberculosis and Malaria, but now, due to the increase of multidrug-resistant tuberculosis cases at global level and following the revision of the World Health Organization (WHO) guidelines on treatment and patient management, the training of the pulmonology doctors became a priority.
“I am not as strong as before, yet I drag myself along”
Ioana (45) comes from Mediaș and she suffers from extensive resistant tuberculosis. In March, she was hospitalized along with her daughter (14) also a MDR suspect. Should the suspicion be confirmed, her daughter will become one of the patients included in the project “Improving the Health Status of the Romanian Population through the Increase of the TB Control Capacity”.
“Last year I spent 9 months here. I am unfit to work, but I am glad I can cook, clean and help my daughter. We can barely make ends meet from my pension and her survivor’s benefit. We limit ourselves to what we have. We live in a studio where we have what we need. We are poor, but we can afford to pay for the heating and to buy food.
When I was 19 years old, I suffered from drug-sensitive tuberculosis. I have had two relapses since then and, in the third, the doctors diagnosed me with MDR. When I was little, I had once a sore throat so severe that I could no longer speak, and when I enrolled at the university, they did some X-rays. ‘No file, no university – the hospital’, they told me. After me and my husband divorced, I had a relapse, my immune system was weakened, and I keep telling myself it was nerve-related.
My eldest boy’s father, who also has TB, died in 1995 of TB and we still do not know what kind of TB it was. One of my husband’s brothers also died of TB. His mother and sister had no idea what drugs he was taking. When the doctor learned that I had MDR-TB, he told me that I got it from my husband.
He hardly followed his treatment.
I had a 12 hours a day job and I neglected my diet. I worked as a clothes manufacturer. I finished post-secondary school, I was in the Technical Quality Control for a while and then I was somewhat of a shift manager. I have not worked since 2007. Until 2008, I was on first-line therapy. It was in 2008 that the doctors in Mediaş considered testing me to see whether I was resistant to drugs. The tests showed I was resistant to two drugs and they kept me there for another 4 months. When my child got sick, I did not leave him in Mediaş, instead I took him to Sibiu and later to Bucharest.
His condition is improving.
I am feeling so-so now. I am not as strong as before, yet I drag myself along. My daughter is in the 8th grade and she wants to go to the military high school so she had to do some tests. There was something wrong with her lungs. The doctors still do not know what it is, but they suspect she got it from us.
We were not alarmed because she was feeling well and ate well. She is a good student and she wants to study mathematics and computer science, however she can no longer enrol at the military high school. We have been in hospital for almost a month now, but we are to go home soon.
When I was ill and I could not manage on my own, my mother and my daughter would help me, and we would help each other. We are used to living on our own, just the two of us.
“Everything starts with you”
Simona (37) is an economist in Bucharest and she was told she has MDR-TB almost two months ago. She has been in hospital ever since.
“I got TB from my brother-in-law, who is also hospitalized here.
It started with pneumonia – I started coughing, so I went to the doctor and he told me I had an untreated pneumonia. I underwent treatment with antibiotics; then the doctor did an X-ray and told me it looked better. I told him I had come for my pneumonia but also because I had a case of TB in the family. He said that if I had had TB, the antibiotic he had given me would not have had any effect.
The next time I came for an X-ray, the doctor told me he had the impression there was something else there, that it was no longer pneumonia. One week later, I got a call from the clinic and I was told to come urgently. The DST had come out with tuberculosis.
I have never been ill, neither have I taken drugs, underwent treatment or been admitted to any hospital. I had a good immune system, I eat healthy, I do not smoke and I do not drink coffee or alcohol. In 37 years, I have never been in hospital. If I felt ill, I would let the system fight on its own, and I would not take drugs.
Sunday before I left for the hospital, I cried a lot. Everything was new for me: from an active and healthy person, suddenly I had to be hospitalized.
At first, it was difficult in the hospital; I would wake up in a state of panic in the morning, when I had to take the medication. I felt fear and rejection inside. It is not easy because there are days when I simply cannot walk and I can barely articulate words. There are days and days…
I have to be strong and take it easy. You need to encourage yourself and learn to do things on your own. Everything starts with you.”
One thousand patients detected with multidrug resistant tuberculosis receive quality treatment, starting with March. At the same time, once they go home, they, together with other 500 patients (who receive treatment through governmental financing) shall be monitored by the doctors from the local TB dispensaries, so that they don’t discontinue the therapy. In order to help them cope with the new situation which involves many costs (from those related to healthy nutrition, to support the body, to those related to regular checks which imply travelling to the doctor), all the 1500 patients shall receive, starting with May 2015, monthly social tickets of 80 lei, the main goal being to help them follow the correct administration of anti-TB treatment.
Last year in Romania there have been diagnosed 14,938 TB cases; 12,562 new patients, and 2,376 patients were relapse cases. 449 were cases of multidrug resistant TB (MDR – when two anti-TB drugs cannot generate a response from the illness) and 36 extensive resistant (XDR – when more than 4 anti-TB drugs cannot fight the disease).
One of the biggest challenges of the multidrug resistant TB, either MDR or XDR, is the treatment, taken continuously and consistently. Some of the sensitive tuberculosis relapses can turn into multidrug resistant TB, if the patient didn’t take the drugs according to the treatment regimen and on the duration prescribed by the doctor. The treatment side-effects can be various: from vomiting, bone aches and headaches, up to hearing impairment. There are days, towards the end of the treatment, when some patients feel good and decide on their own to give up the medicines or start taking them irregularly. Thus, the few months of treatment become useless and the risks to relapse or to turn into a more aggressive form increase.
Cristina Popa, pulmonology doctor at the “Marius Nasta” Pulmonology Institute in Bucharest says that “the patients should know that they must continue the treatment, if not for them, then for those around them, to prevent spreading the disease to others”.
This time, the treatment is associated with a control system. In each county there will be one coordinator who shall collaborate with the doctors in all TB dispensaries in the county who are responsible for the MDR patients. “The DOT supporters are the medical staff or any other person trained in the administration under direct observation of the complete and correct anti-TB treatment. These can be nurses, community nurses or even the legal representatives of the patients”, says Iuliana Sîrbu, Romanian Angel Appeal Foundation, coordinator of one of the work packages within the project “Improving the Health Status of the Romanian Population through the Increase of the TB Control Capacity”.
In the MDR ward of the “Marius Nasta” Pulmonology Institute in Bucharest, about 30 patients have been enrolled since the beginning of March, while in Bisericani MDR Centre another 20 patients who receive treatment and who shall be monitored once they are discharged. This activity can be considered the most important of the project because, beside the TB treatment provided, there was a need to supervise its administration, but also for social incentives for the patients, support without which there is a risk to decrease the adherence to this difficult and long-term treatment.
The activities of the project are developed in line with the international TB control strategies, of which we mention: addressing the multidrug resistant tuberculosis in poor and vulnerable groups and ensuring standardized treatment, with the monitoring and support for the patients during the treatment.”
Between 19 and 22 March, in Bucharest, over 20 pulmonology doctors were trained in TB control, within the project “Improving the Health Status of the Romanian Population through the Increase of the TB Control Capacity”, financed through the Norwegian Grants 2009-2014 within the Program RO 19 – Public Health Initiatives, developed by the Ministry of Health.
The doctors participating at the course held on mid-March were trained in rapid diagnosis and received information on TB epidemiology (worldwide and in Romania) and epidemiology survey. After this course, they will become trainers and shall train, starting with April, 600 doctors and nurses in the country.
Adriana Socaci, a medical doctor from Timişoara and coordinator of the National TB Program in Timiş county, says that the notions learned at the training sessions bring news regarding rapid diagnosis methods which, during last year, reduced the time for TB diagnosis from a few months to a few hours. Mr. Florin Sologiuc, MD, consultant for the Centre for Health Policies and Services Foundation, one of the training organisers, told us that he wishes that, at the end of the 30 training sessions in the country, the doctors and nurses “will be informed about the new diagnostic and treatment methods, will know how to use them, who to investigate and who not, so that the new equipment procured within the project can be efficiently used.”
During the second part of February 2015, the 2015 – 2020 National Tuberculosis Control Strategy was endorsed by Government Ordinance. The legal document aims at reducing the incidence and mortality through TB, by ensuring prevention, detection, diagnostic, treatment and treatment adherence services, according to the World Health Organization (WHO) recommendations.
The development of the National Tuberculosis Control Strategy as coordinated by the Ministry of Health, with assistance from the World Health Organization, and the working group was formed of experts from national and international institutions and organizations, such as “Marius Nasta” Institute of Pulmonology, “Prof. Dr. Matei Balș” National Institute of Infectious Diseases, Romanian Angel Appeal Foundation, the Association for the MDR TB Patients Support.
Among the specific objectives of the National Tuberculosis Control Strategy to be met by 2020, are the following:
- ensure universal access to rapid diagnosis methods;
- diagnose at least 85% of all estimated drug sensitive TB and multidrug resistant TB cases;
- successfully treat at least 90% of new culture positive TB cases and 85% of all retreatment cases;
- successfully treat 75% of MDR-TB cases;
- reduce overall TB mortality rate to 4.3 per 100 000 population;
- general decrease of the disease incidence;
- general improvement of the health system capacity to control TB.
Other results estimated to be reached after the implementation of the Strategy:
- decrease the global incidence rate of the disease from 72,9 cases per 100.000 population in 2013, to less than 50 cases per 100.000 population in 2020;
- decrease the number of deaths from 5,3 per 100.000 population, in 2013, to less than 5 per 100.000 population in 2020;
- decrease the total number of patients from 15.523 notified cases in 2013, to less than 10.000 cases in 2020.
According to the news published on the Internet website of the Government, “the endorsement of the National TB Control Strategy makes possible to mobilize resources from the European structural funds during 2014-2020 and from other European non-reimbursable funds. It is foreseen that the Strategy shall be funded by: 145 million lei from structural funds from the 2014-2020 fiscal period, 46 million lei from funds donated by Norway, 37 million from the Global Fund to Fight against HIV/AIDS, Tuberculosis and Malaria, allocations from the state budget, other reimbursable and non-reimbursable funds. The total budget of the 2015-2020 Strategy for the diagnostic, treatment, labs equipment, surveillance activities and human resources is up to 1,571 billion lei.”
The National Tuberculosis Control Strategy aims at ensuring the conditions to eradicate TB as a public health problem in Romania, by 2050.
The service procurement procedure for the organization of training courses for the staff of the Technical Assistance and Management Unit of the National Tuberculosis Prevention, Surveillance and Control Programme (PNPSCT) has been completed. The contract with the service provider was signed in December 2014 and now the Romanian Angel Appeal Foundation is working to prepare the training sessions.
In the following period, 15 persons from the PNPSCT Technical Assistance and Management Unit will be trained, so that the National Tuberculosis Control Programme may have better capacity for the management of medicine procurement and distribution, but also for fundraising, project management, monitoring, assessment and reporting.
Four training sessions will be organised in relation to the procurement of medicines from the Global Drug Facility of the WHO/StopTB partnership and the distribution chain management, as well as in relation to financial management, monitoring, assessment and reporting. The professionals who will be trained are part of the medical and management staff of the Marius Nasta Institute of Pulmonology in Bucharest.
Both during the training, and throughout the project period, the Romanian Angel Appeal Foundation, who is the owner of the working package on the capacity-building of the PNPSCT Technical Assistance Unit, will provide permanent assistance and operating support for the UTAM staff.
“We would like that the members of the UATM team, through the courses that we will deliver over the following period, consolidate their knowledge and necessary skills in order to be able to continue to attract projects and the funding needed for the strengthening of the National Tuberculosis Control Programme. Our courses are generally seen as interactive and dynamic and we hope that they will also be a useful and pleasant experience for the PNPSCT UATM team.” Silvia Asandi, Director of the RAA Foundation.
The team of the Centre for Health Policies and Services Foundation (CPSS) is currently preparing a series of training courses for both the medical staff in the national pulmonology network, and the community nurses and sanitary mediators.
“We are very glad that CPSS’ over 10 years of experience in the organisation of training courses in the field of tuberculosis control will be tapped into by this important project! The involvement of community workers and of the communities in the control of tuberculosis is a prerequisite for the success of a national programme.” Dr. Dana Fărcășanu, CPSS Executive Chairperson.
As such, training courses are currently being prepared on medicine management, the control and surveillance of the tuberculosis infection, DOT and tuberculosis prevention education.
The training courses on medicine management, the control and surveillance of TB infection address 600 doctors and nurses all over the country. The training courses begin in March this year and are expected to be conducted until March 2016.
The training courses on direct observation treatment (DOT) and tuberculosis prevention education begin in April. 70 community nurses and sanitary mediators will acquire basic knowledge in the field of tuberculosis in order to provide DOT and inform the population regarding tuberculosis. The end beneficiaries of these training courses will be 1000 TB patients from 50 poor rural communities, who will be offered support during their treatment by community nurses and sanitary mediators. Also, 10,000 people from these communities, including Roma, will benefit from information and education sessions on tuberculosis prevention held by the community nurses and sanitary mediators trained through this project.
The rapid diagnosis of a resistant form of tuberculosis is essential for the patient to be able to benefit from the most efficient treatment and to be cured. The classical methods for diagnosis and for testing the susceptibility to anti-tuberculosis medication may take between 21 days and 3 months. During all this time, the Romanian doctors and patients must wait until the patient’s treatment can be determined, and this delay is dangerous for both the patient and the community, because a person suffering from tuberculosis who is not undergoing the correct treatment is contagious and may spread the disease to close persons (family, colleagues, friends). On the other hand, the administration of a treatment that is not appropriate for the form of tuberculosis the patient has may favour the development of an even more resistant form of TB.
At the end of February 2015, the procurement of LPA and MGIT equipment was completed for the endowment of the network of 8 laboratories that are to be modernised under this project, for the rapid diagnosis of multidrug-resistant tuberculosis. Also, supply contracts have already been signed for 3 MGIT systems and, by 10 March they will be installed in the laboratories of the pulmonology units in Bucharest, Cluj and Bacău. The staff in the laboratories where the equipment is to be installed will be trained in the modern diagnosis techniques. The training will take place under the coordination of the Marius Nasta Institute of Pulmonology.
By enabling the diagnosis of MDR TB within a very short time interval (2 to 48 hours), the advanced equipment procured under the project offers patients the chance to immediately receive the treatment appropriate for their form of TB.
Marius, a 27-year old IT manager, has been hospitalised at the Marius Nasta Institute for almost two months. He finds it hard to understand what happened to him and why, all of a sudden, his full and always agitated life seems to have come to a standstill. He is one of the patients suspected of multidrug-resistant tuberculosis who wait for their treatment to be determined. Now, Marius has been given an additional chance because, due to the modern equipment procured under this project, he will benefit from rapid diagnosis and from an appropriate treatment. And, if he observes all the indications given by his doctors, he will be cured.
On 8 August 2014, the “Marius Nasta” Institute of Pulmonology in Bucharest, in partnership with the Romanian Angel Appeal Foundation, the Centre for Health Policies and Services Foundation and the LHL International Tuberculosis Foundation in Norway began the implementation of the project “Improving the health status of the Romanian population through increased tuberculosis control”. The aim of this project is to strengthen the control of tuberculosis in Romania, focusing especially on multidrug-resistant and extensively resistant tuberculosis (MDR/XDR TB) and on poor and vulnerable groups.
“The importance of the implementation of this programme speaks for itself. Romania has the highest tuberculosis and multidrug-resistant tuberculosis incidence in the European Union. Approximately 10,000 patients are to be tested and 1,000 patients will be treated thanks to the Norwegian support in the fight against tuberculosis in Romania. This is an important step in the eradication of tuberculosis, both in this country and in Europe.” Tove Bruvik Westberg, Ambassador of the Kingdom of Norway to Romania.
With a total budget of over EUR 10 million, the project is financed in a proportion of 85% by the Norwegian Financial Mechanism 2009 – 2014, within the Public Health Initiatives Programme, the Programme Operator being the Ministry of Health. 15% of the project’s budget represents co-financing from the state budget.
“Tuberculosis is a public health priority for the Ministry of Health and for the Romanian Government. This is why the Ministry of Health has approved a series of measures for the improvement of the National Tuberculosis Prevention, Surveillance and Control Programme, the most important of which being the increase by over 50% of this year’s budget of the National Tuberculosis Control Programme and the approval of the Strategic Plan for the Control of Tuberculosis in Romania 2015-2020.” Suzana Matei, the manager of the Public Health Initiatives Programme, from the Ministry of Health.
The main activities included in the project concern the endowment of 8 laboratories with modern equipment for the rapid diagnosis of tuberculosis and multidrug-resistant tuberculosis, the continuous treatment with quality medication of a number of 1,000 patients with multidrug-resistant tuberculosis, the support of 2,500 patients during outpatient treatment, the update of the national database of the National Tuberculosis Control Programme, the purchase of 2,000 UV lamps to be provided to the TB units, the training of 960 doctors, nurses and administrative staff in the control of TB infection.
“We are hoping that through this project we will increase the treatment success rate, because we have one of the highest success rates for drug-susceptible tuberculosis, i.e. 85%, but this rate is very poor for multidrug-resistant tuberculosis.” Dr. Gilda Popescu, Technical Coordinator of the National Tuberculosis Control Programme.
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