e-TB Manager: g
A Comprehensive Web-Based Tool for Programmatic Management
of TB and Drug Resistant TB of TB and Drug-Resistant TB
Management Sciences for Health Management Sciences for Health
Facts about TB*
TB is contagious and airborne; each untreated person
with active TB can infect ~ 10 to 15 people a year
One third of world population infected with TB (most
vulnerable – people with HIV)
1 8 million died in 2007 (TB is leading killer of people
1.8 million died in 2007 (TB is leading killer of people with HIV ~500,000 in 2007)
9.27 million new TB cases registered in 2007g
TB is a worldwide pandemic: among the 15 countries
with the highest estimated TB incidence rates, 13 are in
Af i hil h lf f ll i i A i
Africa, while half of all new cases are in six Asian
countries (Bangladesh, China, India, Indonesia, Pakistan and the Philippines)
Facts about TB
cont
Facts about TB,
cont.
Multidrug-resistant TB (MDR-TB) is a form of TB that
does not respond to the standard treatments using first does not respond to the standard treatments using first-line drugs – 511,000 new MDR-TB cases in 2007
Extensively drug-resistant TB (XDR-TB) occurs when y g ( ) resistance to second-line drugs develops
WHO’s Stop TB Strategy aims to reach all patients and
achieve the target under the Millennium Development achieve the target under the Millennium Development Goals (MDG): to reduce by 2015 the prevalence of and deaths due to TB by 50% relative to 1990 and reverse the trend in incidence
Required investment to achieve the MDG target is
estimated at US$ 67 billion (there’s a 40 billion gap) estimated at US$ 67 billion (there s a 40 billion gap)
International Response
International Response
Guidance: WHO, StopTB, UNIONGuidance: WHO, StopTB, UNION
TB control is well standardized (consensus on forms, guidelines,
recommendations)
Funding mechanisms: The Global Fund, UNITAID, Bill
Gates, governments (USAID, DfID, etc)
Sources of TB medicines: GDF, GLC
Technical resources: UNION, KNCV, MSF, PIH, ICRC,
MSH t
Information management for TB:
Information management for TB:
•Information tools are required by Global Initiatives (GLC/GDF, Stop TB…)
WHO ERR working group revised formsWHO ERR working group revised forms
Catalogue (existing software)
http://www.who.int/tb/err/catalogue/
But to date there was no tool integrating consistently all programmatic dimensions for management purposes
NTP Challenges
g
Most countries will not reach MDG by 2015
Lack of actual support from governmentspp g
Low detection rate (poor diagnosis, advocacy, education)
Poor compliance with treatment (by providers and patients)
High default rate
Co-infection with HIV
I t ti i d l ( th GDF t i )
Interruptions in drug supply (even the GDF countries)
Spread of MDR/XDR TB (increased length of treatment and
costs = X 1000) costs X 1000)
Lack of proper supervision, recording and reporting
Many of the challenges can be addressed through strengthening MIS
e-TB Manager: Web based system
g
y
Aligned with WHO recommendations for DOTS and DOTS
Plus programs (standard data collection recording and Plus programs (standard data collection, recording and reporting)
Easy online information sharing / consolidation between
different levels and data extraction tool to other interfaces
Rapid response to case and drug management issues
Database protected by a validation process from upper
level
Internal security features and unique patient identification
Developed with open sources technical solutions, no
additional licenses needed
Can be used with a mixed system of online reporting and
paper system at periphery levels
Online notification and follow-up, recording clinical and laboratory results, tracking patient transfers in and out,
providing data on patients regimen schemes, treatment adherence, patient contacts’ evaluation,
consultation agenda
Treatment and case management
First Line medicines management Medicine needs’ forecasting, ordering, distributing, Data extraction Information and surveillance management dispensing, and recording of stock movements + DM indicators at all levels Second Line medicines management tool / Operational and clinical research at all levels
For easy data analysis and export to statistical interfaces
Mapping of TB and MDR/XDR cases,
epidemiological indicators, surveillance reports, previous treatment history, co-morbidities, up-dated information with ready access online
at central and periphery levels at central and periphery levels
For the system to support
the TB program
appropriately, there must be
clear guidelines and core
clear guidelines and core
staff must be experienced in
MDR-TB management
MDR TB management
Diagnosis
Treatment protocols, patient
management management
Consistent flows for
Note: Simulation Data for Demo Note: Simulation Data for Demo
Slide 24
lh25 this doesn't show much--you could just use the next slide and talk about administration
Name displayed in the system
Address (where to send orders to) Region and locality (also used in user view)
Checked if the unit is a treatment health unit (case management) Checked if the unit stores medicine (medicine management module)
Enables the unit to use the medicine receiving module
Select who is going to deliver medicine orders to this unitg g
Used to calculate the quantity estimated when creating a new order If checked, the user may change the quantity estimate when creating a new Check it if the unit y g
order
If the order has to be authorized before delivering, select the unit that authorizes it
If the unit registers medicine dispensing enter the delivers medicine to
other units (order delivery)
If the unit registers medicine dispensing, enter the dispensing registration frequency (daily, weekly or monthly)
Online tools for medicines forecasting,
ordering, distribution, and dispensing
Tracks stocks positions at
central and periphery level;
p
p
y
;
Calculates upcoming needs
for medicines dispensing at
p
g
treatment centers / sites
Controls estimated and real
consumption
Provides reports and
indicators
Distribution flow:
S Central Warehouse Sources: GLC/GDF MoH GFRegional Regional Regional
Regional Warehouse Regional Warehouse Regional Warehouse District District District District District Treatment Center Treatment Center Treatment Center Treatment Center Treatment Center Treatment Center TS TS TS TS TS TS TS TS TS TS TS TS TS
Epidemiological Reports
p
g
p
Incidence/incidence
Co-morbidities
rate
Prevalence/prevalence
t
Previous treatments/
treatment history
C
t
i
ti
i i
rate
Demographic
characteristics
Contamination origin
Contacts identification
and evaluation
characteristics
Resistance patterns
Clinical/X-rays patterns
and evaluation
Adverse reactions
Treatment outcomes/
Clinical/X rays patterns
HIV/AIDS(diagnosis/
co-infection rate)
Treatment outcomes/
cohort analysis
Operational Reports
p
p
Suspects or cases search/identification
L b
t
t
l
(
ti
t
h t)
ith
Laboratory exams at a glance (patient or cohort) with
conversion rates
Treatment history/regimens at a glance (patient or
Treatment history/regimens at a glance (patient or
cohort)
Case management agenda (dates for exams
Case management agenda (dates for exams,
appointments, defaulters list, etc.)
Mapping case transfers
Mapping case transfers
Treatment adherence/medicines dispensing reports
Resistance Profile
Jan. 1994 – Mar. 2009 (n= 3,798)
Brazil or States City of Residence Month/Year Begins Month/Year Ends Residence Treatment Health Facility Nº of treatments for DR-TB Generate Report Probably DR-TB Confirmed DR-TB Resistance Profile Probably DR TB Confirmed DR TB Sensitive to R Sensitive to H Sensitive to RH Sensitive to all drugs tested Other combinations of resistanceEvaluation of Contacts (Pará State)
Jan. 1994 – Mar. 2009 (n= 1,218 identified)( , )
City of Residence Identified Examined with TB
e-TB Manager
: Where Are We Today ?
Currently adopted as national TB surveillance MIS for DR-TB in Brazil
(including all re-treatment cases for better prevention of MDR-XDR (including all re treatment cases for better prevention of MDR XDR emergence)
Integrated with the national DR-TB MIS in Romania and Moldova
Active field pilot testing in the Philippines, Dominican Republic and
Uk i ( MOH )
Ukraine (on MOH server)
Being adapted for: Armenia, Georgia, Azerbaijan, Uzbekistan
Requests from countries: Namibia
Collaboration with WHO – a possibility for e-TBM to become a
WHO-recommended MIS tool
Challenges and Lessons Learned
E-TBM cannot just be installed and used:
Need for extensive TA to streamline the existing MIS for
Need for extensive TA to streamline the existing MIS for
TB (procedures, SOPs, data forms)
Need for adaptation to country requirements
Training of users, TOT
Lack of clear national treatment guidelines for TB
and MDR TB, and SOPs for lab and drug
management
WHO is constantly changing data forms
Lack of infrastructure: must develop PC-based
i
i l d t b
Challenges and Lessons Learned cont
Challenges and Lessons Learned, cont.
Need to sign a MOU:
NTP may lack authority, bureaucratic procedures
Engaging stakeholders – national working groups
Competition (most NTPs already have some
electronic tools in place)
V
li it d f
di
f
TBM i
l
t ti
Very limited funding for e-TBM implementation
Partnering with other projects in the field is crucial
(b t
t l
h
t f
li
l ti
)
(but not clear how to formalize relations)
Endorsement from major players is important
(WHO KNCV UNION GDF/GLC UNITAID etc )
(WHO, KNCV, UNION, GDF/GLC, UNITAID, etc.)
Implementation steps in a new country: May take
from 2-3 months to one year
from 2 3 months to one year
Recon-• Present e-TBM main features
• Understand country’s health system structure, operation, standards for TB
d/ DR TB d d
• On-site pilot on selected TB units to evaluate system
ff ti fit ith
naissance visit
and/or DR-TB, and needs
• Define necessary system customization • Define working group, responsibility
matrix and MoU
On-site pilot
effectiveness, fit with current flows and
procedures and acceptance by end users
System customization
• Customize e-TBM functionalities and interfaces to address country needs
Final system adjustments
• Adjust system based on pilot outcome
Remote testing
• Remotely test initial e-TBM version to identify potential bugs and need for further adjustments
Implementation/ training
• Implement system on country’s proprietary server and train IT personnel
• Train potential trainers or end users (depends on number of
System adjustments
• Adjust system based on remote testing outcome
Maintenance
sites)
• Guarantee remote on-going support to country`s IT team and end users
adjustments
System cost to USAID/MSH, from customization to implementation
and maintenance, ranges from US$50-70k ESTIMATIVE
Estimates based on a
comprehensive cost model designed for e-TBM
System cost to USAID/MSH
PROJECT SCHEDULE AND CHARACTERISTICS COST (USD)
System cost $70.112
Duration
PHASES weeks Programmer MSH Other
1. Reconnaissance visit 1 2 2 1 $10.928
2. System customization 4 6 2 0 $14.400
3. Remote testing 1 0 $0
4. System adjustments 1 2 1 0 $5.200
5. On-site pilot 1 1 1 1 $7.728
6. Final system adjustments 1 2 1 0 $5.200
7. Implementation/training 1 1 1 2 $12.256
Total to implement 10 14 8 0 $55.712
Time required (weeks FTE per phase) Number of intl. trips
Intl.*
Weeks FTE* Weeks FTE* Intl.*
p
8. Maintenance/support 52 6 2 0 $14.400
Monthly
Infrastructure MONTHLY cost $6.194
IT infrastructure Number required
Server 1 $283 Computers 40 $1.111 Internet access 40 $1.600 Helpdesk FTE required 1 $3.200 1. Reconnaissance visit 2. System customization 1 -1 4 1 1 trips Prog. MSH 1 -2 6 2 2 trips Prog. MSH 3. Remote testing 4. System adjustments 5. On-site pilot
6. Final system adjustments 7 I l t ti /t i i -1 -1 -1 1 1 1 -½ 1 ½ 1 -1 -2 2 1 2 1 1 1 1 1 7. Implementation/training 8. Maintenance/support 1 -1 4** 1 1** 2 -1 6** 1 2** 60
* FTE: Full Time Equivalent; Intl.: International ** Within the total phase duration (52 weeks)
Ongoing operational and maintenance costs for host country
depend on number of sites and infrastruture required ESTIMATIVE
Monthly maintenance/operational cost to host country
Estimates based on a comprehensive cost
model designed for e-TBM
PROJECT SCHEDULE AND CHARACTERISTICS COST (USD)
System cost $70.112
Duration
PHASES weeks Programmer MSH Other
1. Reconnaissance visit 1 2 2 1 $10.928
2. System customization 4 6 2 0 $14.400
3. Remote testing 1 0 $0
4. System adjustments 1 2 1 0 $5.200
5. On-site pilot 1 1 1 1 $7.728
6. Final system adjustments 1 2 1 0 $5.200 $
Time required (weeks FTE per phase) Number of intl. trips 7. Implementation/training 1 1 1 2 $12.256
Total to implement 10 14 8 0 $55.712
8. Maintenance/support 52 6 2 0 $14.400
Monthly
Infrastructure MONTHLY cost $6.194
IT infrastructure Number required
Server 1 $283 Computers 40 $1.111 Internet access 40 $1.600
Helpdesk
FTE required 1 $3.200
• Number of total sites*
• Number of servers required
• Number of IT** infrastructure
required (computer + internet)
20 1 20 60 1 20 10 0 1 50
required (computer internet) 50
61
* Influences number of support staff required. Model assumes 1 helpdesk FTE can support up to 50 sites ** Information technology
