Mongolia Progress Report

Dr. D. Otgontsetseg, Head of recording and reporting unit, TB surveillance and research department,

NCCD

The ninth Technical Advisory Group and National TB Programme Managers meeting for TB control in the

Western Pacific Region

Manila, Philippines9 -12 December 2014

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

0

1000

2000

3000

4000

5000

6000

0

50

100

150

200

250

300

All form TB cases Notification rate

Year

Nu

mb

er

of T

B c

ase

s

No

tific

atio

n r

ate

pe

r 1

00

’00

0

Notified all form TB cases, In Mongolia, 1962-2013

GF project started

DOTS implemented

Nationwide screening

Number of smear positive TB cases, in Mongolia, 1962-2013

19631966

19691972

19751978

19811984

19871990

19931996

19992002

20052008

20110

500

1000

1500

2000

2500

0%

20%

40%

60%

80%

100%

Sputum smear positive TB casesPercent of pulmonary TB casesPercent of SS+ TB cases among pulmonary TB

Year

Nu

mb

er

of S

S+

TB

ca

ses

Pe

rce

nta

ge

Age distribution of all forms of TB cases, in Mongolia, 2009-2013

0-1 2-7 8-14 15-24 25-34 35-44 45-54 55-64 65+0

400

800

1200

1600

0.0

30.0

60.0

90.0

120.0

2009 2010 20112012 2013 Average rate

Age group

Num

ber

of a

ll fo

rm T

B c

ases

Ave

rage

not

ifica

tion

rate

per

100

’000

Cure rate among smear positive pulmonary cases Mongolia, 2009-2013 year

2009 2010 2011 2012 201377

78

79

80

81

82

83

84

85

86

84.284.5

8382.6

80.1

cure rate target WHO

Failure and default rate among smear positive pulmonary patients Mongolia, 2009-2013 year

7.1 7.28.1

7.1

9

2.2 2.42.9

44.8

0

2

4

6

8

10

2009 2010 2011 2012 2013

per

cen

t

year

failure default

Major successes The global Millennium Development goal and regional

targets for TB control are likely to be met Increasing Government funding for TB control Revised National TB care guidelines approved by Health

Ministerial order WHO revised definition and reporting framework for

tuberculosis introduced in all levels of TB care – pilot in 2014, starting 2015- will be reported officially

Nationwide TB prevalence survey started in Apr 2014 and field data collection completed in urban areas

Introduction and roll out of GeneXpert

Major challenges

Dependence from external funding – sustainability of the National TB programme after the end of the GF grant

Diagnosis and management of EPTB and TB in children

Early detection and treatment of TB among high risk groups (homeless, alcoholics, migrants)

Increasing rates of default and failure among TB patients in the last two years, especially in Ulaanbaatar city

Lack of awareness of the public about TB

National TB Strategy/Policies

• Timeframe: 2010 - 2015• Targets: by 2015, reduce TB prevalence to 154 per 100

000 and by 2015, reduce TB mortality to 15 per 100 000 • Alignment with WHO End TB strategy: The new National

Stop TB strategy will be developed in 2015• National Health Sector Plan will be end in 2015. National

Strategic Plan to Stop TB 2010-2015 is aligned. • Budgeted• 70% - GF supported project, 30% - government

Laboratory strengthening•LED 2 LED: NRTL and 1 province

A prison hospital and 3 provinces received in Nov 2014

•Xpert 3 GeneXpert –NRTL and 2 provinces

NRTL: Total tested 2659, MTB detected 50.2%, error 3.1%, rif resistance detected 18.6%

•Quality assuranceEQA SSM 36 ZN, 1 LED labs, EQA DST, SSM from RIT, Japan

•Laboratory information management system

Internet-based system www.tubis.mn•TA partners

SRL –RIT, Japan since 2005

Reach the unreached• Active case finding: among high risk populations – prisoners,

homeless, medical workers, pregnant women, people living with HIV

• Passive case finding: adults by smear examination and X-ray, children tuberculin skin test and X-ray

• Contact investigation: family members of smear positive patients, children, MDR-TB – target 100%, in practice – 86%

• TB-HIV: screening of people living with HIV for TB by Gene Xpert, all new and relapse TB cases (16 years old and above) tested for HIV. So far 181 HIV cases are reported, out of them 31 are co- infected

• Child TB: Operational research on contact investigation, strategy on child TB will be developed in 2015

Surveillance• Quality of surveillance system

–Use of national unique ID –Paper and internet based reporting: on time by paper; some difficulties using internet-based system due to internet connection

• New case definition roll out– WHO revised definition and reporting

framework for tuberculosis introduced in all levels of TB care – pilot in 2014, starting 2015- will be reported officially

Surveillance• e-R&R

– Internet based reporting – ‘tubis’; – Update of the system based on WHO new

definitions– 90% of TB reporting units use ‘tubis’ platform

• Analysis and usage of data at national and sub-national levels– Analysis data at the national level on monthly,

quarterly and annual basis – Limited capacity at the sub-national level

Notified (n=1375) and died (n=325) MDR-TB cases Mongolia, 2003-2013

0

50

100

150

200

250

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

nu

mb

er

year

notified died

started GF supported MDRTB + pilot project

Treatment success for MDRTB patients Mongolia , 2006-2010

2007 2008 2009 2010 20110

10

20

30

40

50

60

70

80

90

75

85.1

71.677.2

68

success death failure WHO target

Number of XDR-TB cases

XDRTB Pre XDRTB 2009 3 22010 10 12011 6 272012 12 92013 3 132014 6 6

total 40 58

out of them:

Died 30

Address unclear 4

Refused 2

Waiting on treatment 2

2 nd line treatment continued 1

Cured 1

PMDT

•Plan vs universal coverage–In 2014 planned 219 MDR-TB and 81 PDR patients to enroll in treatment

•Barriers–Lack of social support for MDR-TB patients–Lack of experienced health providers ( high turn over of staff)–Lack of management of side effects–Some MDR-TB patients refuse to receive treatment due to various reasons (religious, co-morbidities etc.)

PMDT: Priority actions–Strengthening management of MDR-TB patients (counseling, follow up of patients, capacity building of TB providers)–Establishment of patient support groups in collaboration with MATA –Treatment of XDR-TB patients with financial support of the GF–DRS planned in 2015–TB prevalence survey results to be analyzed–Advocacy to include MDR-TB drugs in Government budget

Bold policies and supportive systems

•TB care financing and social protection–TB care financed by the Government–No health insurance coverage for TB services–No specific social protection services for TB patients–Within general social protection system TB patients (especially employed) may receive disability benefits for certain period

•Strengthening notification mechanism–An estimated 15-20% of diagnosed TB cases are not notified –Supportive supervision should be strengthened–Strengthen internet based reporting and recording

•Drug regulations – Progress since drug regulation meeting in March 2014

–New drugs for MDR-TB were included in national essential drug list–Drug information is in the process of revision in internet-based system

Patient centred care: involvement of patients and civil society

• Community mobilization activities– Patient support groups will be established by

MATA with financial support of Stop TB Partnership

• CBO involvement and their role– MATA: lunch DOT and home DOT– World vision: TB services for prisoners,

homeless – TB Coalition: advocacy for local governments

Patient centred care: involvement of patients and civil society

• Involvement of patient groups in TB control – In the process of establishment

• Forms of social support to TB patients (incentives? TB Pension? Reimbursement of costs related to care like transportation costs?)– Transportation cost only for MDR-TB patients (GF)– Within general social protection system TB patients

(especially employed) may receive disability benefits for certain period

Thank you for your attention