JSI Strengthens Oblast Concilium for Better Tuberculosis Treatment Monitoring in Kyrgyz Republic

Drug-resistant tuberculosis (DR-TB) can develop when patients interrupt their treatment for TB. Resistant cases of TB take a very long time to treat, and require many different drugs which cause serious side effects for patients. Patients need to be monitored regularly during treatment to ensure they are making progress towards being cured, and to manage any adverse events from the drugs to help them adhere to treatment.

Kyrgyzstan has some of the highest rates of drug-resistant TB in the world. To better manage these complicated cases, a medical council called a Concilium operates in each of the seven regions of the country, as well as at the national level to coordinate treatment. Concilia serve as a multi-disciplinary advisory body that make collective decisions about individual DR-TB cases. They are important to ensure decisions are made consistently in all cases, and to apply the same standards nationwide, especially in the context of the rollout of new drugs and treatment regimens.

The USAID Cure Tuberculosis project worked to strengthen the Chui Oblast DR-TB Concilium on a pilot basis to make it more effective. A baseline assessment of the Concilium revealed a lack of membership roles and responsibilities, low decision-making capacity of Concilium members, and unclear rules and procedures for discussing DR-TB cases. All of this led to delays in treatment and prescribing inappropriate regimens. For a TB patient, it is crucial to start effective treatment as soon as possible in order to hold a chance of being cured.

Cure Tuberculosis reformed the structure of the Concilium by expanding membership to include rayon TB doctors, who rotate every 1.5 months as Chair of the Concilium. This enables all rayon doctors to participate in decision-making and build their capacity. The project also established clear guidelines for presenting cases at the Concilium, including obtaining all necessary clinical tests and lab results beforehand. The Chui Oblast Concilium also switched to more frequent meetings in order to facilitate more regular monitoring of TB cases. Cure Tuberculosis also gave the Chui Concilium access to the Laboratory Data Management Information System (LDMIS), previously developed with USAID support. Thanks to the LDMIS, Concilium members now have access to patients’ test results in real time. The Ministry of Health (MOH) approved the Chui Oblast DR-TB Concilium’s new rules and procedures with Order No. 79 of the Ministry of Health (MOH) on February 29, 2020.

Before the restructuring, the Concilium only met on a monthly basis and discussed 76 DR-TB cases during the last quarter of 2019. After the restructuring, in the first quarter of 2020 (January-March), the Concilium met on a weekly basis and discussed 249 cases – a more than three-fold increase. Overall, during the first quarter, the Concilium held a total of 497 discussions about individual DR-TB cases, both for treatment initiation purposes and for regular monitoring of treatment and adverse events.

Cure Tuberculosis also focuses on building physicians’ expertise in DR-TB treatment. Project specialists developed an advanced curriculum in DR-TB management, which was approved by the post-graduate institute. The specialized training contains 4 practical modules on TB diagnosis, treatment, case management, and prevention, and can be accomplished in six months. It is mandatory for all Concilium members to meet the required standards.

When the COVID-19 epidemic emerged in late March and the Kyrgyz Government introduced a state of emergency in Bishkek and some parts of the country, restrictions on movement made it difficult for TB specialists to attend weekly Concilium meetings. Cure Tuberculosis immediately responded by proposing videoconferencing. Project specialists developed a MOH order on the provision of TB services under emergency conditions, which allowed for online Concilium meetings. The project provided technical assistance to the Chui Concilium to transition all their proceedings online. On March 30, the first online Concilium meeting took place, connecting health care workers from the Chui Oblast TB Center and rayon TB specialists.

“All rayons can participate in the Concilium remotely via video-conferencing. They can remotely see test results and X-ray images of patients. [During the lockdown], Concilium meetings were held regularly, fully or partially online with the help of Skype, WhatsApp, e-mail, and the LDMIS. Digitalization of the work of the Concilium was a positive outcome in the [COVID-19] emergency,” says Ilgiz Abdyrasulov, Secretary of the Chui Oblast DR-TB Concilium.

Thanks to online meetings, in the second quarter of 2020 (April to May), not only did the work of the Concilium not cease — the Concilium was able to conduct even more case reviews than during the previous quarter, with a total of 514 discussions of individual DR-TB cases. The volume of discussions decreased slightly during the third quarter at the height of the COVID-19 epidemic due to many doctors being tasked with treating COVID-19 and unable to attend Concilium meetings. However, the rotation system still allowed other rayon doctors to participate in place of the Deputy Chair, as necessary, and the work of the Concilium was able to continue. By September 30, despite the COVID-19 crisis, the Chui DR-TB Concilium managed to hold 901 discussions of DR-TB cases over the 6-month period since the beginning of the epidemic.

The new structure of the Concilium and training opportunities for Concilium members have strengthened the capacity and confidence of Concilium members. The new guidelines for presenting cases at the Concilium, coupled with the help of digital technologies, have allowed Concilium members to share data online and hold fruitful discussions leading timely treatment decisions. The encouraging experience of the Chui Oblast Concilium will be replicated in Year 2 in Jalal-Abad, Talas, and Naryn Oblasts to standardize the work of the regional Concilia and ensure the quality of treatment and monitoring of adverse events.