Increasing tuberculosis case detection in the Republic of Moldova

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Increasing tuberculosis case detection in the Republic of Moldova
 

– Reported, February 03, 2012

 

The Republic of Moldova undertook reforms in tuberculosis (TB) control and health care consistent with international recommendations and advanced towards the global target for case detection. The number of TB cases notified increased overall by 50% during 2001–2005. Expansion of the DOTS strategy and full coverage coincided with a greater role for primary health care (PHC) in TB control and the advent of national insurance for TB diagnosis and treatment. These developments and improvements in laboratories, surveillance, medical personnel skills, and public awareness contributed to increased case detection. The Republic of Moldova addressed both demand and supply sides in these efforts. It increased effective demand for TB services by dispersing diagnostic capability, instituting financing mechanisms and saturating the public with information on symptoms, transmission and treatment. It increased the supply of TB services by upgrading the laboratory network, revamping surveillance and training practitioners. The Republic of Moldova’s experience offers lessons for other countries: TB–PHC integration allowed more suspect cases to be diagnosed at nearby PHC clinics, contributing to more cases being notified. Innovative TB communications reached the general public, vulnerable groups, practitioners and the media. TB control projects built on each other and national coordination mechanisms served to identify funding for the most pressing needs. There are challenges remaining for TB control in the Republic of Moldova, not least the stable treatment success rate, but the country can list valuable lessons and achievements.

The Republic of Moldova adopted the DOTS strategy in 2001 and committed to reaching the global tuberculosis (TB) targets of 70% case detection and 85% treatment success.1 At the same time, the Republic of Moldova initiated health system reforms, reorienting towards primary health care (PHC) and introducing national health insurance. International donors supported TB control and reforms designed to increase the demand for, and supply of, services. This paper reviews TB case notification in the context of interventions during 2001–2005 to extract early lessons of the Republic of Moldova’s experience. Detection of new smear-positive cases increasing from 37% in 2001 to 65% in 2005.

The National Programme for Tuberculosis Control in the Republic of Moldova for 2001–2005 reoriented the Republic of Moldova’s TB system to the WHO-recommended DOTS strategy. In November 2001, the NTP initiated a civilian DOTS pilot programme, preceded by initiation of DOTS in penitentiaries in November 2000. As Fig. 1 shows, DOTS expanded rapidly and 100% coverage was achieved in January 2004. The full coverage of DOTS coincided with the introduction of obligatory national health insurance, which finances a package of health-care services, including tuberculosis diagnosis and treatment. For TB diagnosis, the insurance system contracts with PHC practitioners on a per capita basis and covers laboratory tests and personnel. For TB treatment, the insurance system contracts with hospitals per treated case and covers patient stays, laboratory tests and drugs for treatment of chronic cases and latent infection. Most anti-TB drugs were provided during 2001–2005 through Global Drug Facility (GDF) and Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) grants.
PHC began to be developed in the Republic of Moldova in 1998, when the Department of Family Medicine was established at the State Medical and Pharmaceutical University. In 2001, the first PHC clinic opened; with the World Bank’s assistance, the PHC concept was elaborated and physician retraining started. Integration of separate TB and PHC services was shaped by defining diagnostic and referral protocols and training practitioners beginning in 2004. A three-day TB training module was added to an ongoing four-week PHC retraining programme for physicians and nurses.

Multidrug-resistant tuberculosis (MDR-TB) and TB/HIV are threats to the Republic of Moldova’s efforts to reach global targets. An ongoing study is estimating the extent of drug-resistant TB in the Republic of Moldova. Primary MDR-TB increased from 6.3% to 13.4%, and acquired MDR-TB increased from 36.7% to 49.6%, from 2001 to 2005. This phenomenon is explained by a large number of MDR-TB patients without proper treatment, and contributes to increased numbers of relapse and new resistant cases. It also contributes to the low rate of treatment success, which was 62% for new smear-positive cases and 42.3% for retreatment cases in 2005. DOTS-Plus projects are elucidating the effect of drug-resistance on prevalence and treatment outcomes. In the city of Balti, which has a high HIV prevalence, preliminary data indicate the effect of HIV co-infection. TB/HIV co-infection increased from 7.4% in 2001 to 24.5% in 2005; and TB mortality related to HIV co-infection increased from 10% of total TB mortality in 2001 to 31.6% of total TB mortality in 2005.13 Effective action to address TB/HIV, including collaboration between the national HIV/AIDS and the national TB programmes, remains a challenge for the Republic of Moldova.

Credits: Viorel Soltan,Asma Khalid Henry,Valeriu Crudu and Irina Zatusevski

More Information at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647358/?tool=pubmed

 

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