Causal Cross-border Migrants: health of the migrant patient Facilitator(s): Rapporteur(s): Organizations represented: *session 1, **session 2, ***sessions 1 and 2 (separate signup sheet will be provided and this information can be added later) General Question From the perspective of the clinician, what, if any, are the key challenges that are specific to controlling TB among migrants compared to the general Thai population? Response How to know who get sick How to health access How to give free of change of treatment cost How to improve quality of care of neighboring countries -Language barrier of migrant -Care attitude of health care workers who have more burden Case detection and diagnosis General question Does the current system promote access to TB screening according to the national guidelines among both registered and non-registered migrants? *+ the current system is hardly functioning at all ++ There are some very limited systems in place +++ There is an adequate system in place, but it is not sustainable ++++ There is a very useful and sustainable system in place Overall rating ++ 1
Specific questions Status Gaps/Challenges Recommendations What case detection activities are - There is only passive in place to identify migrant TB case detection and patients? What is done to promote passive depend on special project screening? Outreach screening on causal migrant activities? What diagnostic tests are available at your facility for diagnosing migrant patients? Culture? Have you utilized Xpert MTB/RIF for migrant patients? Are you able to regularly test newly diagnosed TB cases for HIV in your facility? What is the referral mechanism for HIV+ patients? - Sputum smear (all provinces) - Chest X-ray (all provinces) - Sputum culture (questionable, should be strategized) - Communication gap - Expanding passive case detection throughout into border area. - Establish active case finding by foreign community health volunteer - Sputum culture is questionable. - In some border areas. Should be evaluated for cost effectiveness. - Perform all in Thai and non-thai TB cases. - no gap - - Train and supervise - supported budget - Sputum culture should be strategized Should be evaluated for cost effectiveness. 2
Are you able to regularly test newly diagnosed HIV cases for TB in your facility? What is the referral mechanism for TB+ patients? - Perform in Thai HIV +ve - Perform in non-thai +ve only under NAPHA extension. - + perform in non-thai +ve. - Inadequate ARV treatment in migrants. - Funding for HIV testing and long term treatment. - Referral back to patients countries or setting long term care unit along border. Treatment General question Overall rating* Does the current system support access to TB treatment for casual migrants accordance with the National TB treatment guidelines? ++ Does the current system provide integrated AID and TB treatment for migrant patients? ++ *+ the current system is hardly functioning at all ++ There are some very limited systems in place +++ There is an adequate system in place, but it is not sustainable ++++ There is a very useful and sustainable system in place 3
Specific questions Status Gaps/Challenges Recommendations What has been your experience with compliance among migrants using DOTS? Home/community based care? - DOTS compliance is good and using home/community based care is not good. - -DOTS compliance is not nationwide. Do you have specific materials in the migrants language to explain TB treatment? Who explains the treatment protocol to the migrant patient? What is the first line TB treatment protocol used in your health facility? How do you obtain first line TB drugs for migrants? Are supplies sufficient? How do you obtain second line TB drugs for migrants? Are supplies sufficient? - Migrant s language health education materials -TB clinic personnel and translator who can speak migrant s language. -All public health hospitals follow all NTP guideline. -Sufficient at present -Sufficient at present -Using CHVs/ BHWs are DOTS watchers. - -Standardize talking point for service providers. What are the treatment failure and default rates for migrant patients in your facility? What are the particular issues involved in case management of MDR TB among migrant patients? -treatment failure 3-5% -default rates for casual crossborder migrant patients approx 20-40% (Thai Myanmar border) -Reduce default rates -Low adherence high risk for drop out. -Using DOTS for the more highly mobile groups, and enhancing community-based approach where context allows (e.g. Sankhlaburi). -Establishing MDR TB houses/villages -Active and effective service provision What efforts are in place to include migrant patients under National HIV strategy includes TB integration, can be applied to Resource gaps exist in most locations. Establishing treatment centre along border areas try to 4
the Integrated AIDS and TB Treatment strategy? migrants in some settings where there is large number of migrants and capacity exists (e.g. large number of registered migrants so budget available, e.g. away from borders). Resources limited though, so unregistered do not access and must self-pay. NAPHA extension supports some with limited quota. strengthen services on both sides in border areas. The resource and capacity gaps need to be filled. 5
Follow-up and Referral Specific questions Status Gaps/Challenges Recommendations What is your referral system for migrant TB patients? Some twin city health care centres have referral systems. Not enough locations Need to expand and develop specific protocols for referral. Regional GFATM proposal could be developed for regional Do you have an individual patient card which clearly indicates their drug regimen? Do you have any regular contact with colleagues across the border in Myanmar, Cambodia, or Lao PDR? What % of your migrant TB patients are lost to follow-up? Hospital-level have treatment cards for all patients, e.g. Patient Treatment Card. (In Myanmar the OPD Card is copied and given to patient) Some twin cities have occasional or regular. For cases to refer are contacting and quarterly meetings bilateral. ~10% overall default on average along the three borders, but not always clear which migrant typologies of patients. 15-20% loss to follow-up casual crossborder migrants (Mae Sod) not sure in other locations. This is not sufficient to facilitate referral: not happening everywhere, needs to say drug regimen, Need to have regular contact per set schedule in more locations. Should also have more regular exchange of information. Need to decrease default rate, using DOTS approach perhaps more effective for the more highly mobile groups. collaborative HSS. Need to develop national (or ASEAN-level) multilingual referral card as with malaria doing already. Rx dates and category, personal info, lab results, contact info of service provider (name, email, phone) so provider in home country can f/up with Thai provider. Set regularly scheduled meetings and ensure mechanisms are in place for continuity, e.g. appoint focal points for cross-border collaboration. See recommendation for Question 6 under treatment. Utilize DOTS and where context allows, strengthen communitybased. 6
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