An analysis of multi drug resistant tuberculosis control in Vietnam

Multi-drug resistant tuberculosis is a major global health problem. Viet Nam is 14th among 27 MDR-TB high burden countries with an estimated about 5,100 MDR-TB cases among notified TB cases per year. Management of MDR-TB in Viet Nam is one of the main objectives of the TB control programme. This thesis provides an understanding of the current situation of MDRlXDR-TB in Vietnam and its control policies focusing on case finding strategy, targeting groups for MDR-TB screening. MDR-TB contacts, one of the high risk groups recommended by the WHO is a focus of this thesis. The thesis presents screening practices of household contacts of TB patients, feasibility of TB contact investigations, and to identify challenges and solutions for a successful implementation of an efficient contact investigation among MDR -TB patients in Viet Nam. Since 2009, the programmatic management of drug resistant tuberculosis (PMDT) was piloted in Viet Nam following the development of 2009 country MDR TB guideline. A year after the WHO updated guideline was disseminated, the country revised its guideline and SOP to be in line with WHO's recommendations and contextualized to local capacity and resources. The PMDT has been rolled out and scaled up in the country. However, lack of resources, limited communication on policy changes to lower level, unable to provide screening to all risk groups, inadequate capacity to perform diagnosis of mono and poly resistant TB and second- line DST have posed significant challenges for the NTP to implement their policy. This study found that only about 30% MDR TB cases was detected. through the PMDT system. The possible reasons we identified were: (1) delay in fully rolling out PMDT policies and limited capacity of the system, mostly due to inadequate resources, (2) operational factors, and (3) neglecting high risk groups during MDR- TB screening, particularly close contacts of MDR TB patients. Noteworthy, the NTP strategy relies on "passive case finding" while the proportion of household contacts of smear-positive tuberculosis patients screened for TB under the current passive screening approach of the Vietnam National TB program is very low compared with prevalence of TB among contacts in high burden countries, particularly for contacts under 5 years of age. Although screening of close contacts of MDR-TB patients is recommended by the NTP of Viet Nam, this is generally not done. Therefore, a different approach is needed. This study applied Social network Analysis (SNA), which is a more comprehensive approach than traditional contact tracing. However, with SNA of 99 MDR-TB index patients we were not able to detect new MDR-TB cases. The fact we found no new MDR-TB cases may be explained by reduced fitness of MDR-TB and the short follow up time of our study of 6 months. The results of this study suggest that there are several interventions that could improve the PMDT program in Viet Nam. Firstly, the National TB control Program should standardize and decentralize training on PMDT and provide staff with updated information on policy changes through proper communication channels. Capacity on MDR-TB diagnosis and treatment should be strengthened. PMDT should expand ambulatory care of MDR-TB treatment and expand risk group for MDR-TB screening. MDR TB case finding could be strengthened by provision of information and education of close contacts of MDR-TB patients, with special attention to children; and to perform more research on how active contact investigations should be done for MD-TB to have the best yield. The NTP should allocate more resources to MDRTB control, particularly well-trained staff.