Download JOINT REVIEW OF THE NATIONAL TUBERCULOSIS

JOINT REVIEW OF THE NATIONAL
TUBERCULOSIS PROGRAMME OF
LEBANON
Carried out by the World Health
Organization, International Organization for
Migration and the Ministry of Health of
Lebanon
1 – 6 November 2015
Report
Acronyms and abbreviations
AIDS
COPD
Acquired immunodeficiency syndrome
Chronic obstructive pulmonary disease
CXR
DALY
Chest X-ray
Disability-adjusted life years
DOTS
DST
A brand name for the WHO-recommended strategy for TB control; it
constitutes the foundations for the Stop TB Strategy and End TB Strategy
Drug susceptibility test/testing
EMR
Eastern Mediterranean Region
EMRO
WHO Office for the Eastern Mediterranean Region
EPTB
FNSR
Extra-pulmonary tuberculosis
Foreigners who are Not Syrian Refugees
Gross domestic product gross domestic product
Global Fund
GDP
GF
HIV
Human immunodeficiency virus
IOM
International Organization for Migration
IPT
MDR-TB
MOPH
Isoniazid preventive therapy
Multidrug-resistant tuberculosis
Ministry of Public Health
NAP
National HIV/AIDS Program
NGO
NRL
NSP
NTP
Nongovernmental organization
National reference laboratory
National strategic plan
National Tuberculosis Programme
PAL
Practical approach to lung health
PHC
PLHIV
PMDT
Primary health care
People living with HIV
SOP
SNPTB
SPPTB
SR
Programmatic management of drug-resistant tuberculosis
Standard operating procedures
Smear-Negative Pulmonary Tuberculosis
Smear-Positive Pulmonary Tuberculosis
Syrian Refugee
TB
TST
UNHCR
Tuberculosis
Tuberculin Skin Test
United Nations High Commissioner for Refugees
UNRWA
United Nations Relief and Works Agency for Palestine Refugees in the
Near East
WHO
World Health Organization
INTRODUCTION AND BACKGROUND INFORMATION
Lebanon is located in Middle-East and has a size of 10,400 squared kilometres. It has
a border of 709 kilometres with Syria in North and East, Israel in South and
Mediterranean Sea in West. The size of its population is 6.2 million inhabitants who
belong to more than 15 religious entities. There are also 1.1 million UNHCRregistered Syrian refugees and nearly 500,000 Palestinian refugees; in addition, it is
believed that there are 500,000 other Syrian refugees who are not registered. The
national territory of Lebanon is administratively divided into six governorates which,
all together, include 26 districts. Each district is also divided into sub-districts or
municipalities. Eighty eight percent of the total population lives in urban areas and
approximately one third in the Capital City Beirut. The gross domestic product (GDP)
is estimated at 18,100 US$ (2014 estimates).
Approximately 25% of the population is aged less than 15 years, 42% less than 25
and 44% between 25 and 54; the median age is 29.4 years. The population growth
rate is estimated at 0.9% in 2015. The crude mortality rate is 4.9 deaths per 1,000
population per year (2015 estimate). The maternal mortality is 15 deaths per
100,000 live births while the infant mortality 7.8 deaths per 1,000 live births (2015
estimates). The life expectancy is 80 years regardless of gender; it is 82 years in
females and 78 in males (2015 estimates).
Lebanon has a long tradition of free-market economy and does not restrict foreign
investment. The Lebanese economy is service-oriented with strong banking and
tourism sectors. The 1975-90 civil war seriously damaged Lebanon's economic
infrastructure, cut national output by half, and derailed Lebanon's position as a
Middle Eastern banking hub. Following the civil war, Lebanon rebuilt its
infrastructure by borrowing heavily, mostly from domestic banks, which resulted in
an important national debt. The ongoing conflict in the neighboring country of Syria
has led to an influx of Syrian refugees, an increase in internal tension and a slow
economic growth to the 1-2% range in 2011-13, after a four-year growth of 8% per
year on average. Chronic fiscal deficits have made Lebanon’s debt-to-GDP ratio the
third highest in the world.
It is estimated that approximately 28% of Lebanese population lives under poverty
level. The Government has developed and implemented since 2006 actions to
alleviate poverty in the framework of programs, such as the National Poverty
Targeting Program.
POPULATION HEALTH STATUS
Lebanon is in epidemiological transition. Communicable diseases have been
decreasing for the last 20 years but still remain relatively frequent in socially
disadvantaged groups of population, migrants and refugees. The data of the Ministry
of Public Health (MOPH) established for the year 2011 showed that the morbidity
related to: i) water- and food-born illnesses was only 0.04% (31% of the cases were
associated with viral hepatitis A), ii) vaccine-preventable diseases 0.06% (74% of
them were viral hepatitis B) and iii) the other infectious diseases 0.07% (meningitis
accounted for 52% of them). Non communicable diseases constitute a major
problem of public health in the country. Nearly 10,000 cases of cancer are identified
every year through the services of the existing health care system; the incidence of
cancer is estimated at 197 cases per 100,000 population for the year 2014. Mental
health issues are one the main causes of demand of care; the lifetime prevalence of
at least one mental disorder is estimated at approximately 25%. Among people aged
more than 18 years, the prevalence of diabetes is estimated at 13% and that of high
blood pressure at 22%. Thirty seven percent of Lebanese aged more than 15 years
are tobacco smokers (44% among males and 30% among females). Obesity is high;
27% of adults aged 25 years and above are obese. Road accidents contribute
significantly to the burden of health problems in Lebanon. According to the Lebanese
Red Cross, 11,161 car accidents, needing first-aid interventions, occurred in 2011.
The data collected in 2010 by Internal Security Forces suggest that there were 1.4
injury per accident which resulted in a case fatality rate of 8.4%. World Health
Organization (WHO) estimates the number of physically disabled persons at
approximately 277,000; nearly 45% of them are aged between 6 and 34 years and 30%
between 35 and 65.
The age-adjusted rates of mortality from communicable diseases, non
communicable diseases and injuries in 2011 were respectively 30, 385 and 41 deaths
per 100,000 population. Therefore, death from non communicable diseases is 13 and
9 times more likely to occur than from communicable diseases and injuries
respectively.
The proportional mortality rates established for the year 2012 (WHO) shows that
ischemic heart diseases accounted for 31% of deaths, strokes for 9% and road
injuries for 4%; most of the other leading causes of deaths are chronic illnesses such
as cancer, diabetes and chronic obstructive pulmonary disease (COPD). Chronic
diseases have the highest disability-adjusted life years (DALY); among them,
cardiovascular diseases rank first. Infectious illnesses, including tuberculosis (TB)
have the lowest DALYs.
HEALTH SYSTEM DESCRIPTION
In 2013, the total expenditure on health was estimated at 1,092 US$ per capita and
accounted for 7.2% of GDP. The Government expenditure on health accounts for
nearly 11% of the total Government expenditure.
Lebanon has significant geographic discrepancies in health care, but the recent
health sector reform has focused on trying to balance access to healthcare across
the country and to provide universal health care services through the use of public
funds.
The MOPH has revised the national health policy after the 2006 war. The goal of this
policy is to “improve the health status of the population by: i) ensuring equitable
accessibility to high quality health services through fairly financed universal coverage
and ii) addressing economic and social determinants of health through transsectorial policies”.
To this end, a National Health Plan was established in 2007 with the following six
objectives: i) reducing the regional discrepancies, ii) improving the overall quality of
health service delivery, iii) sustaining health care financing reform, iv) providing and
rationalizing cost-effective prescription of quality-assured medicines, v)
strengthening national health programs and vi) strengthening the regulation
capability of MOPH. Most of the health work is decentralized at governorate, district
and sub-district or municipality levels. This decentralization allows for responsibility
and oversight to be spread and places primary authority for inspections and health
programs’ implementation as local activity.
There are, in Lebanon, 168 hospitals with all together nearly 13,000 beds and among
which 28 public hospitals. Most of the hospitals are private and run by charitable or
religious organizations, or private physicians’ groups. The MOPH is the only
accrediting body for hospitals. It also contracts with hospitals (public and private),
creating annual budget with a fixed financial ceiling. The contract is based on quality
and accreditation, therefore placing incentive on performance and sound investment
practices. Despite the MOPH maintaining financial control, public hospitals have
some degree of autonomy via autonomous administration boards. The utilization of
public hospitals by population, in the recent years, has increased and attracted more
than 40% of hospitalized patients.
In addition, there are 960 dispensaries and primary health care (PHC) centres among
which 216 are accredited by the MOPH and constitute a PHC network. Seventy PHC
facilities are operated by the Ministry of Social Affairs, 47 by MOPH and the rest by
NGOs. There are more than 320 laboratories, which are either hospital-based or
free-standing. Approximately half of the free-standing laboratories are licensed by
the MOPH. Most of the laboratories are concentrated in urban areas, contributing to
the unequal distribution of access to health care. The MOPH controls the pricing of
pharmaceutical drugs.
Lebanon has seven medical schools; four of them are in Beirut. Various categories of
health professionals are available in the country. In order to practise, all health
professionals need to have a working permit from the MOPH and be registered in
their National Order or Professional Union. Besides several categories of health
workers such as physiotherapists or laboratory and radiology technicians, there are,
in Lebanon, approximately 11,200 registered physicians, 7,400 nurses and 9,950
pharmacists. The majority of physicians and dentists practice in the Greater Beirut
Area making the distribution of these categories of health professionals unequal
across the national territory. Also, it is important to highlight that nearly 70% of
physicians are specialists.
Slightly less than 50% of the population is covered by a health insurance in Lebanon.
Many Government not-for-profit and private for-profit financing schemes are
available. The most important are the National Social Security Fund which covers
mainly the employees of private sector and their family members and the Civil
Servants Cooperative which covers the regular government employees and their
families. The National Social Security Fund covers the employees during their
employment period only and not during their retirement. The Government allocates
in the budget of the MOPH special allotments to cover the uninsured population
with the aim of ensuring universal access to health services. Therefore, the MOPH
covers persons who have no health insurance; they account for slightly over 50% of
the population. Despite these efforts, the share of out-of-pocket represents nearly
40% of total health expenditure (2012).
Formal refugee camps or field hospitals are not currently allowed to be established
for Syrian refugees in Lebanon. As a result, the Syrian refugees must use the health
care system that exists in Lebanon. They have access to health centres run by
nongovernmental organizations (NGO) partners of United Nations High
Commissioner for Refugees’ (UNHCR) and the Ministry of Social Affairs. Given the
high costs of medical care in Lebanon and the lack of funding for UNHCR, the Syrian
refugees have limited access to secondary and tertiary health care services. The
Syrian refugees may use the 27 PHC centres of United Nations Relief and Works
Agency (UNRWA) located in 12 Palestinian refugees. There are also health centres
which have their own funding. These health facilities may be funded by private
donors, charitable groups or beneficiaries not registered with UNHCR. Refugees may
only receive secondary or tertiary care from these centers if they have a referral
from a UNHCR registered PHC centres.
In order to meet the needs of the refugees and work with Lebanon’s health care
system, the International Organization for Migration (IOM) in collaboration with the
Al-Kayan Foundation has launched the mobile medical unit. The unit includes a
doctor, nurse and assistants. The team travels to remote communities where access
healthcare is limited and provides free consultations and medications to the
patients.
EPIDEMIOLOGY OF TUBERCULOSIS IN LEBANON
Lebanon is a low burden TB country. The last WHO estimates highlighted that 920
persons were newly affected by TB in 2014 while the incidence was 16 new episodes
of TB per 100,000 population for the same year. The prevalent number of TB cases
was estimated at 1,200 and the prevalence at 21 TB cases per 100,000 population.
According to WHO, 89 people died of TB in 2014, which resulted in a mortality rate
of 1.6 deaths from TB per 100,000 population. The incidence, prevalence and
mortality rate, as estimated by WHO, steadily and sharply declined from 1990 to
mid-2000s; since then, the WHO estimates suggest, in contrast, a slight increase in
these three indicators.
TB care and control are organized in the framework of the National TB Programme
(NTP). The NTP adopted the WHO DOTS Strategy in 1998 and established an
information system that has generated useful data on TB epidemiology and TB
control. The number of TB cases, all forms, notified between 2010 and 2014
increased from 513 to 676 (32% increase). In fact, the number of notified TB patients
who are Lebanese remained more or less stable between these 2 years (300 to 340).
The increase of notified TB cases was at the expense of patients who are foreigners.
Indeed, the number of TB cases increased until 2012 among foreigners who are not
Syrian refugees (FNSR) and among Syrian refugees (SR); in 2013 and 2014, the
number of FNSR with TB declined slightly but that of SR with TB increased
significantly (see Graph 1). Among notified TB cases, the proportion of Lebanese with
TB declined from 66.7% in 2010 to 49.4% in 2014, that of FNSR with TB oscillated
between 31 and 41% (41.1% in 2012) and that of SR with TB increased from 1.6% in
2010 to 16% in 2014 (see Graph 2).
Among the 676 TB cases (regardless of the nationality) notified in 2014, 46.2% had a
smear-positive pulmonary TB (SPPTB), 18.7% a smear-negative pulmonary TB
(SNPTB), 35.2% an extra-pulmonary TB (EPTB) and 0.9% a TB relapse. This
distribution varies according to the nationality. The proportion of EPTB is much
higher among Lebanese while that of SPPTB is significantly higher in FNSR (see Table
1).
In 2014, 59.3% of the 676 notified TB cases were females. However, this proportion
varies in function of the form of TB and the nationality status of the patient. The
proportion of females accounted nearly for 86% in FNSR with any form TB and even
more (91%) in those with EPTB (Table 2). This high proportion may be explained by
the high number of women among migrant workers.
It is important to highlight that among all the women notified with any form of TB in
2014, 50.1% were FNSR; among women with SPPTB, 61.2% were FNSR (versus only
39.4% for EPTB).
Table 1: Distribution, in percent, of the form of TB by nationality status of patient
Form of TB
Regardless of Lebanese Foreigners who Syrian refugees
the nationality
are not Syrian
status
refugees
SPPTB
46.2%
36.4%
57.3%
48.6%
SNPTB
17.8%
20.5%
13.2%
20.0%
EPTB
35.2%
41.6%
28.6%
31.4%
TB relapse
0.9%
1.5%
0.9%
0.0%
Overall
100.0%
100.0%
100.0%
100.0%
SPPTB: smear-positive pulmonary tuberculosis;
SNPTB: smear-negative pulmonary tuberculosis;
EPTB: extra-pulmonary tuberculosis;
TB: tuberculosis.
Table 2: Proportion of females among notified cases by form of TB and nationality
status
Form of TB
Regardless of Lebanese Foreigners who Syrian
the nationality
are not Syrian refugees
status
refugees
Any for form of
59.3%
44.9%
85.9%
46.7%
TB
By form of TB
58.7%
38.0%
83.6%
43.1%
 SPPTB
50.8%
39.7%
87.1%
33.3%
 SNPTB
65.1%
53.6%
91.0%
60.6%
 EPTB
 TB
33.3%
40.0%
50.0%
-----relapse
SPPTB: smear-positive pulmonary tuberculosis;
SNPTB: smear-negative pulmonary tuberculosis;
EPTB: extra-pulmonary tuberculosis;
TB: tuberculosis.
The average of age of TB cases notified in 2014, irrespective of the form of TB and
the nationality status, was 33.2 years. However this average varies according to the
gender and the nationality status; women are younger in all the nationality groups.
Lebanese are the eldest (37.4 years on average with 35.1% years for females and
39.2 years for males) while FNSR are the youngest (28.6 years on average with 27.6
for females and 34.9 years for males).
The 2014 data show that 78% of notified TB cases were aged less than 45 years and
86% less than 55 years. However, these percentages vary according to gender and
the nationality status of patient. They are higher in females than in males regardless
of the nationality status. These percentages are much higher for FNSR and SR than
for Lebanese (Table 3); for instance, among female FNSR with TB, 56.6% were aged
25-34 years and 99% were less than 45 years (see Graph 3). It is important to
highlight that still more than 70% of Lebanese who developed TB in 2014 are aged
less than 55 years. This suggests that TB is affecting persons who belong to the
productive age groups of the Lebanese population.
Table 3: Proportion of TB patients aged less than 45 years and less than 55 years
according to the nationality status and gender in Lebanon, 2014
Nationality status of
< 45 years
< 55 years
patients
Regardless of the
nationality status:
78.3%
85.8%
 Males and females
66.8%
79.9%
 Males
86.1%
89.9%
 Females
Lebanese:
62.7%
73.4%
 Males and females
60.0%
72.8%
 Males
66.0%
74.1%
 Females
FNSR:
96.5%
98.7%
 Males and females
80.0%
93.3%
 Males
99.0%
99.5%
 Females
Syrian refugees
87.2%
96.3%
 Males and females
81.0%
94.8%
 Males
94.1%
98.0%
 Females
TB: tuberculosis
FNSR: foreigners who are not Syrian refugees.
Lebanon has a very low HIV/AIDS burden; UNAIDS estimates, for the year 20014, the
prevalence of HIV infection at less than 0.1% in population aged 15 to 49 years and
the number of deaths from AIDS at less than 100. Among the 109 new HIV/AIDS
cases reported to the National HIV/AIDS Program (NAP) in 2011, 93% were males
and 28% associated with travel to or migration from endemic areas.
Conclusion: Lebanon has a low TB burden. However, TB notification significantly
increased to more than 670 cases in 2014 (32% increase since 2010). This increase
was made at the expense of foreigners in whom TB detection significantly
progressed, including among Syrian refugees. The number of Lebanese identified
with TB remained stable around 340 every year and accounted for approximately
50% of TB cases notified across the country. Women who are FNSR constituted a
significant proportion of notified TB cases particularly among SPPTB patients. TB is
still affecting the most productive age groups in Lebanese population since 70% of
TB cases notified in 2014 are aged less than 55 years. Given that HIV/AIDS burden is
low in the country, HIV infection is unlikely to contribute, for the time being, to
fuelling TB transmission in general population.
ORGANIZATION OF TUBERCULOSIS CONTROL IN LEBANON
There is a NTP in charge of organizing TB control in Lebanon. Its role is to implement
TB prevention, care and control interventions and activities and to ensure the
coordination with the relevant stakeholders such as the private medical sector, the
NAP or the hospital network. The NTP adopted DOTS Strategy in 1998 and Stop TB
Strategy in 2006 as national policies to fight TB in the country and deployed efforts
to implement the programmatic management of drug-resistant TB (PMDT) and to
initiate the practical approach to lung health (PAL). However, the NTP does not
establish national strategic plans (NSP) to develop and implement strategic
interventions and activities to achieve clear goal(s) and objectives.
The NTP is included in the Directorate of Preventive Health Care of the MOPH. It
has, at national level, a Central Unit headed by a manager who is medical officer.
This unit
is responsible for the organization, implementation, supervision, monitoring and
evaluation of TB prevention, care and control activities as well as for the
management of NTP resources. The Central Unit is assisted by a National TB
Committee in: i) developing national guidelines, ii) supervising, monitoring and
evaluating NTP activities and iii) facilitating the coordination with the key
stakeholders and partners.
TB prevention, care and control interventions and activities are developed and
implemented through a network of eight TB centres located in the six governorates.
Four governorates have one TB centre each (Beirut, Mount Lebanon, North and
Nabatiyeh) and the remaining two governorates two each (Bekaâ and South). Each
TB centre is under the responsibility of a chest physician who supervise a team
including one to three nurses, clinical workers, a laboratory technician in charge of
TB sputum smear microscopy, DOT workers; the TB centre equipped with X-ray
machine has an X-ray technician. The NTP Central Unit is located in the TB Centre of
Beirut (Karantina Centre) and the NTP manager is also responsible for the care
activities undertaken in this centre.
Patients are referred from the private medical facilities, PHC centres or hospitals
(public and private) to the TB centres for the provision of TB diagnosis and treatment
services. Each TB centre covers a part or the totality of a governorate, depending on
the number of TB centres available in the governorate. All the TB centres are
assumed to ensure chest X-ray (CXR) and sputum smear examinations to the patients
with presumable TB who are referred. All TB patients who need hospitalization in
Lebanon are hospitalized in Armenian Azounieh Sanatorium. The treatment of
patients with multidrug-resistant (MDR) or extensively drug-resistant TB is initiated
and monitored in this health facility. The Sanatorium has a TB laboratory ensuring
sputum smear microscopy and X-ray equipment.
The laboratory network of the NTP includes the TB microscopy laboratories of chest
centres and a National Reference Laboratory (NRL) hosted at the Bacteriology
Laboratory of American University Beirut Medical Centre. Culture, Xpert testing and
drug susceptibility tests (DST) are performed in the NRL. Xpert testing is also carried
out in the Karantina TB centre of Beirut. In addition, seven Xpert machines are
available in the private health sector. Besides the NRL, DST is performed in two other
laboratories: one public and one private.
The NTP has adopted the WHO requirements for the implementation of its
information system regarding TB epidemiology and control in Lebanon. A case-based
data set has been developed and is hosted in the NTP Central Unit.
TB prevention, care and control activities are fully funded by the MOPH through the
Directorate of Prevention Health Care. However, no budget is specifically allocated
to the NTP per se. NTP activities have been recently supported by Global Fund (GF)
funding through IOM; this support focuses on improving and strengthening TB care
and control services for Syrian refugees.
NTP developed a network of partners mainly from universities, medical professional
associations and societies and private health sector.
According to the WHO estimates, 73% of incident TB cases that appear in Lebanon
population were detected in 2014 and only 71% of TB patients, who were put on
treatment, were successfully treated in 2013.
OBJECTIVES OF THE REVIEW
The joint review of the NTP of Lebanon was undertaken by the MOPH, IOM and
WHO-Eastern Mediterranean Region (EMR). The objectives of this review were:
 to assess the level of development and implementation of the approaches
adopted by the NTP to control TB in the country, including those targeting
Syrian refugees;
 to evaluate the managerial capacities and the strategic orientations of the
NTP;
 to provide guidance to strengthen TB prevention, care and control services;
 to recommend strategic actions in order to accelerate the decrease in TB
burden toward the elimination of TB in Lebanon.
DESCRIPTION OF THE REVIEW IMPLEMENTATION
The review was undertaken on 2 to 6 November 2015. It was carried out by one
team which included four international TB experts, one international and one
national staff from IOM Office in Lebanon, one international staff from the WHO
Office in Jordan, one senior epidemiologist from Lebanese University and the NTP
manager of Lebanon. After briefing meetings held in the WHO Office of Lebanon and
NTP Central Unit, the review team made field assessments and met relevant staff
and stakeholders in 14 sites across the six governorates. The field visits took place in
a PHC facility, TB centers, Syrian refugee communities, hospitals and laboratories; a
full session was devoted to meet the board of the Lebanese Pulmonary Society
during the review.
OBSERVATIONS MADE IN THE REVIEW
1. Political commitment
1.1. Strengths
A national program for TB control was established few decades ago and has been
maintained to date despite other competing health priorities such as chronic
diseases that constitute a major problem of public health in Lebanon. TB prevention,
care and control services are financed with public funds through the general budget
allocated by the Government to the MOPH. The public funding covers the anti-TB
drugs’ supply, some equipment and running costs. All TB patients, including
foreigners, are treated and followed free of charge all over the national territory.
The NTP is structured; it has: i) a Central Unit whose role is to organize the
implementation of TB control interventions and ii) TB centres which ensure the
provision of TB prevention, care and control services to population across national
territory. The salaries of all the staff of the Central Unit and TB centres are covered
by the budget of MOPH.
1.2. Challenges
Because of the demographic and epidemiologic transitions, many chronic diseases
are emerging in Lebanon. Some of these illnesses, such as cardiovascular diseases,
diabetes, cancer or COPD, are major problems of public health. Chronic diseases
constitute the first cause of death and, therefore, have received significant attention
from health policy makers. Interventions to control the burden of these diseases and
conditions, such as smoking and obesity, are presently included in the top priorities
of the national health policy and are promoted and politically supported by various
and powerful medical professional associations as well as by academies. Given the
important burden of chronic diseases and their high visibility within the medical
communities of Lebanon, much more attention may be given, in terms of funding
and priority in the national health agenda, at the expense of TB control. As matter of
fact, in the last National Strategic Health Plan developed in 2007, TB control is not
specifically mentioned among the interventions to meet the Objective 5 entitled
“Strengthen the MOPH Preventive Programs” while Enlarged Program of
Immunization, NAP, Non-Communicable Disease Program and registries for cancer
and heart diseases are clearly identified.
There is no earmarked budget allocated to the Central Unit of NTP to cover the costs
of training, supervision, monitoring missions and meetings.
The role of the PHC network in TB care and control services’ provision is not defined.
2. Management of NTP
2.1. Strengths
The managerial functions of the Central Unit of the NTP focus on: i) the
establishment of the national policy to prevent and control TB in Lebanon, ii) the
development of norms and standards for TB prevention, care and control at national
level, iii) the implementation of strategic interventions and activities in line with
these norms and standards, iv) the management of TB drugs, vi) the coordination
with the eight existing TB centres, the Armenian Azounieh Sanatorium and the NRL,
v) the monitoring of the implementation of NTP interventions and activities and the
evaluation of their outcomes, vi) the collaboration with the other health sectors,
especially with the private medical sector and vii) the coordination with the TB
National Committee as well as with national and international partners, such as
Lebanese Respiratory Society, IOM, UNHCR or UNRWA.
There are TB Centres available in all the six governorates. They are the referral
facilities for patients who need to be assessed and managed for TB. Therefore, they
constitute the main providers of TB prevention, care and control to population. They
ensure a communication and relation with the PHC network, the private medical
sector, hospitals and the other health sectors. TB centres are the health facilities
where information on TB epidemiology and control is collected for the NTP.
The NTP adopted DOTS strategy in 1998 and Stop TB Strategy in 2006. In
collaboration with the TB National Committee, the NTP developed treatment
guidelines in 2006 and PAL guidelines in 2009. More recently, a new TB guidelines’
document has been prepared and is in process of finalization in collaboration with TB
National Committee and Lebanese Respiratory Society.
The NTP has developed an adequate work relation with IOM; this has created a
good momentum which focuses on the provision of TB services for Syrian Refugees.
2.2. Challenges
The Central Unit of NTP, which is hosted in Karantina TB Centre of Beirut, is staffed
with 11 health professionals under the leadership of the NTP manager. Most of their
work deals with the provision of TB diagnosis and treatment services to patients who
are referred from the private and public health facilities located in Beirut
Governorate. The Central Unit does not devote enough time to the programmatic
management of TB control in Lebanon; only the NTP manager, the monitoring and
evaluation officer and the pharmacist are ensuring, on part time basis, some
managerial activities for the NTP.
The existing TB treatment guidelines were developed 10 years ago; they are
outdated and not available for the staff working in the health facilities visited during
the review (as highlighted above, new guidelines’ document is in the process of
finalization).
The Central Unit is not used to establish work plans; therefore, the NTP has no NSP
with clear goal(s) and operational objectives which should be targeted by strategic
interventions.
The NTP has no training modules and programs for the health workers who should
be involved in TB prevention, care and control. In fact, there is no budget line for
training on TB prevention, care and control.
The role of the PHC system in the development and implementation of NTP
activities is not well defined. The NTP did not develop standard operating procedures
(SOP) which can be used on routine basis by PHC workers. Some sensitization
sessions are organized on ad hoc basis for health staff practising at PHC level.
The supervision of NTP activities’ development and implementation is not organized
and not undertaken at any level. There is no national guidelines nor checklist to carry
out a supervision visit. In addition, there is no budget line for supervision activities.
There is no quality control for TB laboratory activities organized and carried out on
routine basis under the supervision of the NRL.
Except for collecting data on TB detection, notification and treatment, the TB
centres are not developing nor involved in any programmatic activities for NTP such
as the establishment of annual operational plans for their governorate or the
capacity building of the health professionals practising in the PHC network.
3. Management of patients with TB symptoms and TB detection
3.1. Strengths
Patients with presumptive TB are usually identified in the private medical sector,
PHC facilities or hospitals and referred to the TB centres of Governorates for TB
assessment; some of the patients are directly referred to Armenian Azounieh
Sanatorium. The process of TB assessment usually includes CXR and tuberculin skin
testing (TST) as a first step; if there is any radiological lesion, three sputum smears
are examined by microscopy. Significant number of patients with EPTB are also
identified in TB centres; the diagnosis of EPTB is based most often on
histopathological evidence.
TB patients are also identified through TB contact investigation and systematic
screening of Syrian refugees.
All retreatment TB cases who are identified are assessed for drug-resistant TB
through Xpert testing and DST.
3.2. Challenges
In practice, there is no working definition of presumptive TB which can be used by
health workers to identify the patients who need to be evaluated for TB. The
interviews of health workers during the review showed that they use confusing and
non standardized definitions. In addition, the definition of presumptive TB is not
clearly identified in the national treatment guidelines’ document, even in the new
one which is on the process of finalization (see “Recommendations” in paragraph “X”
entitled “Diagnosis of TB”). In the draft of the new guidelines’ document, the process
of diagnosis TB is confusing, not in line with the WHO guidelines and not clearly
prescriptive.
Most of the TB centres are not equipped with X-ray machine (ex.: TB Centres of
Tripoli and Zahlé) and, therefore, CXRs are made in hospitals or in private medical
sector and for which the patients should pay at least 10 US$. In not all TB centres
(ex.: TB centre of Zahle), TB laboratories are not functioning and, therefore, sputum
smear microscopy is carried in private sector or hospital and for which patients
should pay. These payments (CXR and smear microscopy) in private sector or
hospital are directly made by Lebanese while it is ensured by IOM for Syrian
refugees. It is not clear to which extent the PHC facilities are contributing to the
identification of patients with presumptive TB. Most of the health workers practicing
in this category of health facilities have not been trained on the identification and
management of patients with symptoms compatible with TB. For instance, the PHC
facility called Taal Abaya Health Center (Zahle), visited during the review, which
usually deals on average with 2,000 care seekers every month has nearly no linkages
with the local TB centre.
There are no data collected systematically on the process of identification and
management of patients with presumptive TB, except for those specified in the TB
microscopy registers.
NTP data for the year 2014 show that bacteriological confirmation by smear
microscopy was 64, 71 and 81% for pulmonary TB in, respectively, Lebanese, SRs and
FNSRs. These percentages may suggest that the process of TB diagnosis is unequal
according to the nationality. The high percentage of smear-positive cases among
FNRSs may indicate that foreign workers may have more extensive pulmonary
lesions than Lebanese; this may also suggests that FNSRs have some obstacles to
access TB diagnosis services. In addition, the smear microscopy confirmation of
pulmonary TB is relatively low in Lebanese citizens. This observation points out that
the clinically established diagnosis of TB might be doubtful in some of these patients.
Like many other countries of WHO EMR, the proportion of EPTB cases among
notified TB patients is high, especially among Lebanese (41%); however, the NTP has
not yet defined and standardized procedures to establish the diagnosis of EPTB.
4. TB laboratory
The private sector ensures a significant proportion of TB laboratory services,
including microscopy, conventional culture, DST and tests using molecular methods
(ex.: Xpert testing).
Functional TB microscopy laboratories are currently available in five TB centers and
in Armenian Azounieh Sanatorium (for hospitalized patients).
In line with the NTP policy, specimens taken from all previously treated patients and
selected new patients (people living with HIV (PLHIV), prisoners, MDR contacts,
patients from high MDR countries, patients who are still smear-positive at the end of
intensive phase of treatment, history of treatment with unknown quality drugs) are
sent to Karantina TB Centre of Beirut for Xpert testing and, if needed, culture and
DST. Liquid culture and first-line DST are conducted in the NRL (American University
of Beirut) in line with an outsourcing agreement. An Xpert machine has been
recently implemented in Karantina TB Centre of Beirut where samples are tested for
preliminary evaluation.
4.1. Strengths
There is a functional microscopy laboratory network with a centralization at
Karantina TB Centre. Effort has been made to increase the number of microscopy
laboratories within NTP network. The procurement of equipment and supplies are
under the responsibility of and ensured by the NTP Central Unit.
There are appropriate capacities to detect TB and resistance to rifampicin using
molecular technology are available in country (ex.: Xpert testing).
The transportation system of specimens taken from patients is ensured across the
country.
There is a policy established by the NTP to initiate Xpert testing and conventional
culture/DST.
4.2. Challenges
In general, the sputum smear examinations are carried out in poor conditions in the
existing microscopy laboratories. There is no standardized TB laboratory registers.
There is nearly no external quality assurance system for smear microscopy. External
quality assurance procedures are occasionally proceeded in some workshops. NTP
needs of culture and DST are ensured by one site only at the national level. There is
no linkages with a supra-national reference laboratory. There is no attempt of
bacteriological confirmation of EPTB using Xpert testing and/or culture.
Sustainability of laboratory services is of special concern as six of the ten laboratory
technicians are recruited under the GF grant through IOM.
5. TB treatment
5.1. Strengths
The TB treatment regimens used in the NTP network are in line with the WHO
recommendations. Most of the TB treatments are prescribed in the TB centres of
NTP. The indications of the treatment regimens tend to be respected by the
physicians of TB centres; most of the physicians of TB centres are chest specialists.
Treatments are provided to patients in TB centres only. In some TB centres, the TB
drugs’ intake is directly supervised for pulmonary TB during the intensive phase of
chemotherapy; this supervision is ensured by a health staff called “DOT Worker”.
The TB medicines are provided to patients on regular basis (ex.: weekly basis) during
the continuation phase of treatment and when patients are treated for EPTB. In
some TB centres, the TB treatment is regularly monitored, during its continuation
phase, using CXR and sputum smear microscopy (ex.: Tripoli TB centre; monitoring
every 1-2 months). Some of the patients are hospitalized and treated in Armenian
Azounieh Sanatorium, their treatment is directly supervised by health staff on daily
basis and their sputa are examined with microscopy every week; they are discharged
from hospital when they become smear-negative at the microscopy examination. It
is important to highlight that some patients are also treated in the private medical
sector in coordination with the relevant TB centre.
The treatment of Syrian refugees is, whenever possible, directly supervised by
volunteers in the refugee shelters. In some settings, mobile phones are used by
health workers to strengthen TB treatment adherence.
All TB patients, including migrant workers and refugees, are diagnosed, treated and
followed free of charge. The migrants workers who developed TB are not deported
outside the country.
TB drugs are appropriately and closely managed by NTP from the Karantina TB
Centre of Beirut; a pharmacist is appointed to ensure all the necessary tasks.
There has been no shortage of TB drugs for the last 12 months. The presentations,
formulations and dosages of TB medicines used in the NTP network are in line with
the WHO and Global Drug Facility requirements; paediatric fixed-dose combinations
are available and provided through NTP services.
TB drugs are available in the private pharmacies but not sold without any medical
prescription.
5.2. Challenges
The indications of TB treatment regimens may not be in line with the WHO
recommendations in some TB centres (ex.: Zahle TB Centre). The treatment
regimens included in the draft of the new TB treatment guidelines document are not
prescriptive enough; in many instances, they are not clearly specific for the duration
of treatment. In addition, the description of the retreatment TB cases’ management
in this draft is not in line with the WHO recommendations.
Challenge TB treatment is used to establish the diagnosis of TB in some TB centres
(ex.: Tripoli TB Centre); therefore, the diagnosis of TB may not be established on
bacteriological and/or clinical evidence.
The provision of TB treatment is not decentralized in the PHC facilities which are the
closest health units to patients in their communities. The TB treatment services are
still centralized in the TB centres of governorates; this may constitute an obstacle for
TB patients to access treatment services.
In many TB centres, the direct supervision of TB treatment is not implemented; the
conditions under which it needs to be undertaken are not clear. Also, the monitoring
process of TB treatment administration during the continuation phase is often not in
line with the WHO recommendations. In one TB centre visited during the review, the
monitoring is quasi absent. In addition in the draft of the new treatment guidelines
document, there is no clear indications on how to ensure the monitoring of TB
treatment in patients.
The TB treatment success rate was 71% only in 2013, which is far below the 85%
minimal rate required by WHO.
6. Information system
6.1. Strengths
The NTP has developed and implemented a standardized information system. TB
treatment registers are available in the health facilities (Governorates’ TB Centres
and Armenian Azounieh Sanatorium) where the diagnosis and treatment are
undertaken. Treatment cards are widely available. The definitions of TB cases and
treatment outcomes are adequately used by health staff in some of the TB centres
visited during the review. The information on the bacteriological monitoring and
follow-up of TB patients is available and included in the TB treatment registers in
some of the TB centres. In some TB centres, the registers and the treatment cards
are appropriately completed and the information they include is consistent.
Each governorate TB centre sends, every month, to the NTP Central Unit the list of
TB patients who have been newly registered in the TB treatment register as well as
follow-up information on TB patients who are already treated. The lists received
from all the Governorate Coordination Units are compiled in the NTP Central Unit.
All the information on each TB patient is entered in a data set using a computer
programme. The collection and compilation of the information on the treatment
outcome of each patient follow the same process.
6.2. Challenges
There is no standardized information system on the identification and management
of patients with presumable TB. Therefore, the data on the process of TB detection
are not systematically collected nor analysed in TB centres and NTP Central Unit.
In contrast to other TB centres, the definitions of TB cases and treatment outcomes
are not correctly used and TB treatment registers appropriately completed in some
of the TB centres visited. Some on the physicians working in the TB centres do not
have a full knowledge of the WHO definitions and TB treatment regimen categories.
In addition, the definitions of TB cases and treatment outcomes, the description of
the NTP information system and the instructions on how to use this information
system are not clearly specified in the draft of the new treatment guidelines’
document of NTP.
In some TB centres, there is a discrepancy between the data registered in the TB
register and the data forwarded to the NTP Central Unit.
Given that data are forwarded to the NTP Central Unit every month, no quarterly
reports are established in the Governorates’ TB centres; no data analysis is carried
out on quarterly basis to assess the progress made in TB detection and treatment
outcomes.
The cohort analysis of the patients “transferred in” is not carried out at national
level; therefore, its integration in the overall cohort analysis, is missed.
Furthermore, there is no information system on TB contact investigation activities
well established in the NTP network. The information available on the contribution
of TB contact investigation to TB detection is not quite reliable. The draft of the new
treatment guidelines’ document includes a section on this intervention but does not
specify any indications on how to monitor its implementation and evaluate its
outputs.
The case-based data set established in the NTP Central Unit is not usually analysed
in depth; in general, the analysis made at this level is not well focused. Moreover,
the case-based data set does not include further information on social, behavioural,
environmental and health factors that are inherent to TB patient. The available data
are not used to raise hypotheses for operational research to help NTP improve its
performance.
No annual report on TB epidemiology and TB control situation in Lebanon is
prepared and produced by NTP Central Unit to inform decision and policy makers
and partners.
7. TB/HIV collaborative activities
7.1. Strengths
The HIV/AIDS control in Lebanon is organized in the framework of a national
program: the NAP. TB patients who are identified HIV-positive are referred to NAP
sites for the provision of HIV care package. All co-infected TB/HIV patients are
treated and followed for their TB in the governorates’ TB centres. Isoniazid
preventive therapy (IPT) in PLVIH is included in the national policy.
7.2. Challenges
In the draft of the new NTP guidelines’ document, there is no description of the
measures that must be taken through the NTP services for HIV.
There is still no clear coordination body established between the NTP and the NAP
that would facilitate the integration of activities of the two programmes.
It seems that most of TB patients identified in the TB centres are not systematically
screened for HIV infection. For instance, there is almost no information on HIV
screening of TB patients in the treatment registers of TB centres visited during the
review.
There is no information on the systematic TB screening in PLHIV as well as on IPT in
PLHIV with no active TB.
There are almost no data available on TB/HIV collaborative activities in the TB
centres visited during the review.
8. Multidrug-resistant tuberculosis
8.1. Strengths
WHO estimates the number of patients with MDR TB at 10 among notified
pulmonary TB and retreatment TB cases for the year 2014. The laboratory capacities
to identify MDR TB are available in the country, namely nine Xpert machines (one in
Karantina TB Centre of Beirut, one in the NRL and seven in private laboratories) and
DST in two laboratories. The indications to undertake Xpert testing are clearly
specified in the national policy.
All MDR-TB cases identified through NTP network are treated free of charge. Indeed,
the treatment with 2nd line anti-TB drugs was initiated for 5 patients within the year
2014. All patients with MDR TB are hospitalized and receive their medications in
Armenian Azounieh Sanatorium until they become bacteriologically negative; then,
there are discharged and referred to the relevant TB centre where their treatment is
continued. On the day of the review visit to Armenian Azounieh Sanatorium, three
MDR TB patients were hospitalized and on treatment with 2nd line anti-TB medicines.
8.2. Challenges
There is no clear strategy to develop and strengthen the capacities of the NTP to
manage MDR-TB patients. There is no clear guidance on how to identify potential
MDR-TB cases during the monitoring of TB cases who are administered 1st line antiTB drugs. There is no clear guidelines on how to manage patients with MDR-TB.
9. Infection control
9.1. Strengths
Nearly all the TB centres visited are well ventilated; many of them are well designed
for air-flow. The renovation of laboratories (Hermel, Zahle and Saida), that were
dilapidated, has been initiated and is presently ongoing; this renovation includes the
installment of hood with exhaust fan. The process of construction of the new TB
centre of Halba is progressing and taking into account the administrative measures
of airborne infection control. Isolation measures are applied in Armenian Azounieh
Sanatorium where TB and MDR-TB patients are usually hospitalized. Most of the TB
laboratories have hoods with exhaust fans. All the required health workers have
access to personal protective equipment. WHO-recommended sputum collecting
cups are available in most of health facilities visited during the review. Plastic bags
and ice boxes are used for the transport of specimens to the NRL.
9.2 Challenges
The NTP has not yet developed a national guide on TB infection control; therefore,
no clear infection procedures are available for health workers and no training has
been undertaken for them. There is no focal person within the NTP Central Unit
team for TB infection control.
Hand washing facilities are not easily accessible to health staff in most of the TB
laboratories and centres visited. The disinfectant used by health workers is not
internationally recommended. In most of the TB laboratories (except for that of
Armenian Azounieh Sanatorium), there are no clear procedures applied for waste
management.
The ventilation system with exhaust fans is weak and not well adapted to some
health settings; for example, the ventilation is not sufficient in the MDR TB ward of
Armenian Azounieh Sanatorium and in the TB centre of Tripoli.
The personal protective equipment is not widely used by health staff of TB centres
visited. The health staff has no clear knowledge on how to use respirators. In some
health facilities, sputa are collected from patients under sub-opitimal conditions in
inappropriate environment.
10. TB contact investigation
10.1. Strengths
TB contact investigation is included in the national policy to control TB. A specific
chapter is devoted to this intervention in the draft of the new NTP guidelines’
document. TB case index and contacts who need to be systematically and actively
screened are clearly identified in this chapter and are consistent with the WHO
recommendations. TB contact investigation is assumed to be implemented in all the
chest centres visited in the review. The contacts are systematically screened by CXR
and TST, regardless of the presence of symptoms. Contacts who have radiological
lesions are, then, assessed by sputum smear microscopy. Contacts with active TB are
registered and treated in line with the NTP policy. In principle, children, PLHIV and
persons with immune-deficiency who have no active TB receive IPT. The dosage of
isoniazid and duration of IPT are in line with the WHO recommendations.
10.2 Challenges
There are no clear national guidelines for TB contact investigation with clear SOPs
and algorithm to carry out TB contact investigation (even in the draft of the new NTP
guidelines’ document).
The index cases for whom TB contact investigation should be undertaken are
different across the TB centres; for instance, TB index cases are: i) in Tripoli TB
Centre, those who have any form of TB and ii) in Zahle TB Centre, those who have
pulmonary TB. In all TB centres visited during the review, it seems that not all index
TB cases, as defined locally, are investigated.
There is no clear information system on TB contact investigation activities carried
out in the NTP network. No indicators to monitor and evaluate this intervention are
identified in the draft of the new NTP guidelines document.
The dosage, duration and indications of IPT vary across the TB centres. There is no
information on IPT; as a result, the number of contacts who are treated with IPT is
unknown and the number of those who completed it is unknown as well.
11. Involvement of all care providers
11.1 Strengths
It is estimated that 60 to 80% of notified TB cases in Lebanon are identified through
the private medical sector. Some TB patients are treated and followed by private
physicians; the NTP supplies these physicians with anti-TB drugs to ensure the
treatment administration of TB patients. In general, there is a good collaboration
between the NTP and the private sector, NGO and faith-based organizations.
The NRL belongs to the private sector (American University of Beirut) and ensures
many laboratory activities for the NTP such as culture, DST or genotyping.
In addition, the Lebanese Pulmonary Society closely collaborates with the NTP in: i)
developing national guidelines, ii) promoting NTP strategy in the curricula of the
medical schools and post-graduate courses, iii) devoting special sessions on TB
prevention, care and control in professional conferences and iv) participating actively
in the events organized every year on World TB Day.
11.2 Challenges
Even though significant efforts are made to inform the private physicians, the
process of identifying and managing patients with presumable TB in the private
medical sector is not fully known. It is still not known to which extent the private
physicians are following NTP guidelines when they manage TB patients.
12. TB care and control in Syrian Refugees
12.1 Strengths
TB prevention, care and control services for Syrian refugees are fully supported by a
specific GF grant through IOM. IOM shows a strong commitment to organize and
ensure, in close collaboration with the NTP and UNHCR, these services for the Syrian
Refugees. Tremendous support is provided by IOM, through its network, to ensure
TB diagnosis and treatment for all Syrian refugees who are residing in 1,748 shelters
or living in communities. IOM hired four health staff and involves many TB
volunteers who are dealing with Syrian refugees on daily basis. In addition, IOM is: i)
ensuring the salaries of 29 newly recruited staff who are working, as clinicians,
laboratory technicians or nurses, in the NTP network and ii) equipping with digital X–
ray machines the TB centres of Beirut (Karantina), Tripoli and Zahle. Adequate
linkages have been established between IOM and the NGOs and faith-based
organizations that are ensuring health care services to Syrian refugees. All costs
inherent to TB care and management for Syrian refugees, such as hospitalization and
CXR in private sector, are covered by IOM. IOM with its staff and volunteers initiated
important actions of systematic screening for TB and acute flask paralysis in Syrian
refugees using a questionnaire; the refugee who reports any symptom compatible
with TB is then assessed for TB through CXR and, if needed, sputum smear
microscopy. Between June and October 2015, 70,000 Syrian refugees were actively
screened for TB symptoms and, among them, 17 patients with active were identified
(0.02%).
Approximately 15% of TB cases that are notified in Lebanon are detected among
Syrian refugees.
12.2 Challenges
The outstanding work that has been undertaken in TB care and control in Syrian
refugee settings and the significant support provided to NTP by IOM depend
substantially on GF funding.
Tremendous efforts were made to identify 17 TB cases among 70,000 Syrian
refugees using a questionnaire and then further evaluation; this means that the
number of refugees needed to be screened to identify one TB cases was 4,117.
13. Operational research
13.1. Strengths
There are many academic institutions in Lebanon which can develop operational
research for programmatic purpose in order to guide NTP towards TB elimination.
13.2 Challenges
Given the weak capacities of the NTP to undertake in depth analysis of the data
collected, the information system of the NTP does not generate hypotheses for
operational research that would help the NTP address TB control issues identified
through the analysis of the data.
No plan has been yet established for operational research regarding TB prevention,
care and control in Lebanon.
RECOMMENDATIONS
These recommendations aim at: i) strengthening the visibility of TB prevention, care
and control among the national health priorities of Lebanon, ii) addressing the
managerial and programmatic issues identified in the NTP services during the review
and iii) paving way to implementing a sound national policy to eliminate TB in
Lebanon.
The recommendations specified below are intended to the MOPH, NTP, IOM and
WHO/EMRO.
Recommendations to the Ministry of Public Health
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TB elimination should be included in the political health agenda of the MOPH.
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The political commitment to control TB in Lebanon needs to be strengthened.
The MOPH should continue to fund the NTP.
In addition, the funding needs to be significantly increased in order to
develop and implement a policy to eliminate TB in Lebanon.
TB control needs to be promoted and included in all the governorate and
national initiatives to alleviate poverty, especially in the National Poverty
Targeting Program, Community Social Development Program and the local
programs established by Social Development Centres.
TB prevention, care and control services should remain free of charge,
including for foreign workers and refugees, as it is presently.
TB care services’ provision should remain free of charge, even in any process
of health insurance implementation and during the retirement, particularly
for those who were ensured through National Social Security Fund.
A specific budget should be allocated to the NTP Central Unit to undertake
and organize activities such as training, supervision, monitoring, partnership
building or ensuring a strong collaboration and coordination with important
stakeholders, especially with the private medical sector.
Recommendations to the National TB Programme
1. Overall management
 The role of the Karnatina TB Centres of Beirut, as Central Unit of NTP must be
clearly defined regarding the programmatic management of TB control. Its
role in ensuring TB care services for the population of Beirut Governorate
needs to be clearly specified and separated from its managerial role.
 The job description of the staff working in the NTP Central Unit and TB
centres should be clearly defined in order to avoid confusion and overlapping
in the assignments to carry out tasks for the programmatic management of
TB control and TB care services.
 The draft of the new TB guidelines document of NTP needs to fully revised in
line with the various new WHO recommendations and finalized. These new
guidelines should be widely distributed and their utilisation by the health
workers promoted and evaluated.
 The NTP Central Unit must develop a NSP for TB prevention, care and control
for the coming years (ex.: 2016-2020). This new NSP should focus, besides
maintaining sound TB care services, on: i) improving the managerial and
programmatic activities of NTP and ii) initiating interventions for TB
elimination in Lebanon. To this end, the NSP should have well defined goals
and operational objectives and include consistent strategic interventions
along with their inherent activities; in addition, it should include a wellestablished budget, a clear description of the process of monitoring and
evaluation, a description of how the plan will be operationalized and an
identification of the technical assistance needs. The NSP should also include a
preparedness plan.
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Based on the NSP, the NTP Central Unit should issue an operational plan for
every year in order to specify the interventions and activities that will be
undertaken during that year. This operational plan must be shared with the
relevant departments of the MOPH, the Health Directors of Governorates,
the heads of TB centres and the relevant partners.
A staff should be appointed within the NTP Central Unit to appropriately
organize and monitor training and supervision activities to be undertaken for
TB control across the country.
The NTP central Unit should develop a standardized training material in order
to strengthen basic TB care and control services in TB centres and PHC
facilities. It should be widely distributed and used in the training sessions
organized in the Governorates.
Education and training of all doctors, nurses and other health professionals
practising in PHC and general hospital outpatient clinics need to be
undertaken and carefully planned in order to reach a high degree of
awareness and increase the identification of patients with presumptive TB.
This training should target selected general practitioners and chest physicians
of the private sector.
The annual budget of NTP must include the cost of the training that will be
undertaken.
The staff knowledge on TB prevention, care and control should be regularly
assessed.
The NTP Central Unit should clearly define the procedures that need to be
undertaken to carry out supervision visits at governorate level and in each
category of health facility. A supervision checklist needs to be established and
a model of report on supervision visit prepared. The observations included in
the supervision reports need to be compiled and analysed to orient the
trainings programs and agendas established by NTP.
A team of national supervisors should be established by the Central Unit.
The cost of the supervision visits that will be planned and undertaken must
be estimated and included in the budget of NTP.
The NTP Central Unit needs to establish an information system to monitor
and evaluate the training and supervision activities carried out in the
Governorates.
NTP Central Unit must organize, for the staff working in the Governorate TB
centres, a training course on the management of a TB control programme,
including operational planning, in a governorate. The cost of this training
must be included in the budget of NTP.
The NTP Central Unit must work with the NRL to establish a functional
external quality control system for TB laboratory activities.
2. Management of patients with TB symptoms
 The definition of presumptive TB must be clearly specified and identified in
the new guidelines’ document of NTP.
 A significant emphasize must be given to the utilisation of the presumptive
TB definition in the training sessions that will be organized for health staff
working in TB Centres and PHC facilities.
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Specific SOPs and algorithms on the identification and management of
patients with presumptive TB should be developed and implemented
specifically in PHC facilities.
All TB centres must be equipped with digital X-ray and Xpert machines; their
access for all patients attending TB centres must be free of charge.
The cost of CXR and sputum examinations, still carried out in private sector
for Lebanese patients who have no health insurance, must be covered by
National Poverty Targeting Program, Community Social Development
Program or the local programs of Social Development Centres.
The NTP should collect data on the number of patients with presumptive TB
who are identified and assessed for TB in the TB centres. In the supervision,
the process of identification and management of patients with presumptive
TB must be evaluated through the TB centre register, CXR register and TB
laboratory register.
Physicians practising in TB centres need to meet on regular basis the health
staff working in the PHC facilities of their governorates to promote NTP
services and provide technical assistance.
TB identification services must be promoted in the health departments
dealing with migrant workers.
Algorithms need to be established in order to use Xpert testing in improving
the quality of TB diagnosis.
NTP Central Unit should define standardized procedures to establish the
diagnosis of EPTB, including when histopathological evidence is used.
3. TB laboratory
3.1. Microscopy laboratories
 Laboratory facilities should be upgraded. An extensive rehabilitation program is
planned in Halba; it is supervised and financially supported by IOM through the
GF grant. However, other laboratory facilities need refurbishment to provide a
clean environment with renovated masonry and new painting of room walls.
These laboratories should have easy-to-clean benches and chairs adapted to
bench work.
 The supervision of microscopy laboratories must be strengthened. During NTP
supervision visits that will be carried out in TB Centres, more time should be
given for laboratory issues. The supervision should highlight and correct
irrelevant practices such as the utilization of non-adequate containers for
sputum collection while suitable containers are available.
 Laboratory registers must be implemented and laboratory technicians trained on
their utilization. The importance of laboratory results for a better management
of TB patients must be clearly explained. Staff should evaluate their own data
and make monthly calculations of number of smears, positivity rate, positive
cases detected. These indicators provide an early warning of problems and signal
the need for corrective actions. They contribute to staff motivation and selfreliance.
 Refreshment training in microscopy must be organized for staff. Even though,
the NRL holds a one-day workshop on microscopy with lectures and hands-on
training (IOM-sponsored), additional refreshment training needs to be organized
with a focus on microscopy techniques and on the optimal use of standard
laboratory registers.
 As highlighted above, quality assurance of microscopy must be implemented in
line with the WHO guidelines. First, provide internal quality control using
positive and negative control slides. Control slides should be included in each
day's reading and read before patient smears. Second, implement a closer
external quality control with blind rechecking of all the smear-positive slides and
10% of the smear-negative slides.
3.2. Culture and DST
 A new culture/DST laboratory needs to be implemented in North Lebanon. North
Lebanon is the region with the most important population of Syrian refugees and
is, therefore, likely the area where more DSTs will be needed. The establishment
of a second laboratory performing culture and DST in this region will contribute
to minimizing the time of specimens’ transportation which is a key for optimal
recovery of TB bacilli and high yield of culture positivity. It has to be noted that
for the last 27 DST results released by NRL, 13 were not interpretable due to
absence of growth for 6 samples and contamination of the 7 others.
The Lebanese University of Tripoli offers a platform with a high technological
level (Biosafety cabinets, MGIT automate for liquid culture, Xpert testing) with
extensive experience in culture and DST. Moreover, the director of the
University is willing to create a containment room to meet the WHO biosafety
recommendations.
 A tender should be organized to identify the cheapest supplier for the best
services and reduce the costs of DSTs. The cost is expected to raise with the
increase in number of requests. The present outsourcing agreement should be
revised to anticipate the cost increase. If a facility other than the NRL located in
the American University of Beirut is identified, particular attention should be
paid to safety conditions.
 Linkages need to be established with a supra-national reference laboratory for
the quality control of DST and supervision. The NRL of American University of
Beirut is accredited by the College of American Pathologists. However, the
mycobacteriology survey organized by this College does not meet the WHO
standards for external quality control of DSTs. The two centers covering the
North and South Lebanon should participate in external quality assurance of DST
that will be organized by the supra-national reference laboratory of WHO-EMRO.
 The indications of Xpert testing must be clarified with respect to the indications
of conventional DST.
 The quality control of molecular tests should be implemented in order to check
the quality of the results of Xpert tests carried out in the NTP facilities (Karantina
and the 2 culture/DST centers). This quality control needs to be undertaken in
collaboration with the supra-national reference laboratory.
 Systematic bacteriological investigation (culture/molecular testing) of extrapulmonary specimens needs to be undertaken to establish a bacteriological
confirmation of EPTB. The NTP should forward, to (hospitals, surgeons,
laboratories of the private sector, guidelines addressing the logistics (conditions
of collection of specimens, quality of specimens, transportation conditions, etc)
for a successful culture.
4. TB treatment
 The treatment regimen categories and their indications must be clearly
specified, identified and prescriptive in the new TB guidelines document of
NTP. They should be in line with the WHO recommendations.
 The training that will be undertaken should emphasize these regimen
categories and their indications.
 The challenge treatment to set the diagnosis of TB must be totally banned;
this issue needs to be clearly highlighted in the new TB guidelines’ document
of NTP.
 TB treatment provision to TB patients, who are not hospitalized, needs to be
progressively extended to the network of PHC facilities. PHC workers need to
be trained on ensuring the direct supervision of TB treatment for the patients
whose anti-TB drugs’ intake needs to be directly observed.
 TB treatment should be also provided to patients through the existing
network of social workers whenever and wherever possible to improve the
direct supervision of anti-TB drugs’ intake.
 The monitoring process of TB treatment administration must be carefully and
appropriately described in the new TB guidelines’ document of NTP. This
monitoring process must be urgently applied in the TB centres.
 The cohort analysis must be carried out in every TB centres; this analysis
must be done also separately for Lebanese and non Lebanese patients. The
NTP must identify why the treatment success rate is below 85% (defaulting?,
death?...), where it is low and in which category of TB patients.
5. Information system
 The new TB guidelines’ document must clearly describe the information
system used by NTP in Lebanon. This document must include the definitions
of TB cases and treatment outcomes.
 The training sessions that will be organized must emphasize the utilization of
the NTP information system.
 The supervision visits, that will be organized, should monitor the quality and
comprehensiveness of the data collected.
 As highlighted above, the NTP should organize the collection of data on the
process of identification and management of patients with presumable TB.
These data will be collected in the TB centres and compiled in the Central
Unit. The following indicators need to be monitored to evaluate this process:
i) number of patients referred to TB centres for TB evaluation, ii) number of
patients assessed through CXR, iii) number of patients for whom sputum
examination was performed and iv) the number of TB cases diagnosed.
 On quarterly basis, the number of presumptive TB patients identified should
be compared to the number of patients who were assessed for TB through
the registers of CXR and TB laboratory.
 On quarterly basis, the proportion of patients registered in the TB treatment
register should be calculated among the patients who were assessed for TB.
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The number of smear microscopies, Xpert tests and cultures performed for
TB diagnosis out should be properly recorded, compiled and monitored.
The proportion of patients who have bacteriologically confirmed TB among
pulmonary TB cases should be evaluated on quarterly basis and monitored
over time.
The quarterly reports on TB declaration, TB conversion at the end of the
intensive phase of treatment must be established at Governorate level.
The treatment outcomes should be assessed every quarter, using cohort
analysis, in all the Governorate TB Centres.
The TB Centres should forward to the NTP Central Unit the information on
the treatment outcome of every TB patient who was “transferred in” in the
Governorate. The Central Unit will integrate this information in the national
case-based data set.
The NTP Central Unit must establish an information system for TB contact
investigation, including clear definitions of the relevant indicators.
Data on TB contact investigation activities must be collected and analysed at
all levels. On quarterly: i) the number of contact investigations needs to be
compared to the number of TB index cases registered, ii) the proportion of
contacts screened and assessed for TB among the number of identified
contacts should be evaluated and iii) the proportion of TB cases identified in
contacts needs to be calculated among TB patients registered in TB
treatment register. In addition, the number contacts who received IPT should
be registered and the proportion of those who completed their IPT course
evaluated.
Information on demographic, social, environmental and health factors needs
to be collected for each TB patient who is registered. The NTP Central Unit
will compile this information in the national case-based data set.
The national case-based data set established in the NTP Central Unit must be
analysed in depth in order to identify more specific high risk groups for TB
(other than TB contacts and PLHIV) as well as areas where TB is more
prevalent. This will help to identify target populations or regions for
innovative approaches to prevent and control TB. These innovative
approaches will need to be defined, designed, implemented and monitored.
The in-depth analysis of the national data will help raise hypotheses for
operational research.
The NTP Central Unit needs to prepare and issue an annual report on TB
epidemiology and on TB care and control activities’ results. This report will be
forwarded to those who need to be informed, namely health workers
involved in NTP activities, decision makers and partners.
6. TB/HIV collaborative activities
 NTP Central Unit must develop in collaboration with the NAP a national
guidelines document on the collaborative TB/HIV activities in Lebanon.
 The new TB guidelines’ document of NTP must highlight specifically the joint
TB/HIV activities that need to be undertaken.
 A functional coordination mechanism must be established at ministerial level
between NTP and NAP. This mechanism will help create communication
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channels, at all levels, between the two programmes and will facilitate the
integration of their inherent activities.
The information system of NTP must collect data on HIV activities carried out
within the NTP network.
All TB patients who are identified must be tested for HIV infection.
All co-infected TB/HIV must receive antiretroviral treatment and cotrimoxazol.
In collaboration with the NAP, the NTP should collect data on: i) the number
of TB/HIV who received antiretroviral treatment and co-trimoxazol, ii) the
number and proportion of PLHIV, followed in the NAP sites, who were
systematically screened for TB and iii) the number and proportion of PLHIV
with no active TB who were treated with IPT.
7. Multidrug-resistant tuberculosis
 National guidelines for PMDT must be prepared in line with the last WHO
recommendations.
 The PMDT activities undertaken in Armenian Azounieh Sanatorium should be
maintained and fully supported by the NTP Central Unit.
 Psycho-social support needs to be provided to MDR-TB patients who are on
treatment with 2nd line anti-TB drugs.
 The new TB guidelines’ document of NTP should briefly describe the PMDT
component of the national strategy to control TB.
 In the new TB guidelines’ document, the utilization of Xpert testing, culture and
DST must be clearly described in the process of the monitoring of treatment
regimens using 1st line anti-TB medicines.
 The NTP Central Unit should establish a routine monitoring system on the
process of identification of MDR-TB cases; this system needs to be closely linked
to the monitoring system of culture and Xpert testing requests.
 A national drug resistance survey needs to be undertaken in order to assess
accurately the burden of MDR-TB in Lebanon.
 The NTP Central Unit should explore, in collaboration with the NRL, the feasibility
of continuous drug resistance surveillance.
8. Infection control
 National guidelines and SOPs on TB infection control must be established.
 Training of health workers on infection control procedures should be organized.
 Dedicated focal person for infection control needs to be assigned within the NTP
Central Unit and in the main health facilities dealing with TB and MDR TB
patients.
 Air ventilation needs to be maximized in indoor waiting areas using exhaust fans
or open window.
 TB Centres need to be supplied by hand washing facilities or, as substation,
alcohol rub.
 Windows should be opened in TB centres and laboratories to maintain
ventilation.
 Specimen collection area should be carried out outdoor in open air.
9. TB contact investigation and IPT
 National guidelines on TB contact investigation must be developed in line with
the WHO recommendations and widely distributed to the users. These guidelines
should clearly define the index cases and contacts, specify the process of TB
screening and assessment in contacts and appropriately define the indicators to
monitor and evaluate TB contact investigation activities.
 An information system to monitor and evaluate TB contact investigation
activities needs to be established in line with the national guidelines.
 TB contact investigation needs to be included in the training program of
health workers.
 The possibility of carrying out TB contact investigation activities from PHC
facilities as well as of ensuring IPT in this health facility category should be
explored and evaluated.
 A specific register on IPT should be designed and implemented in the health
facilities. The outcome of IPT needs to be monitored and regularly evaluated.
10. Involvement of all care providers
 The existing mechanisms of collaboration between the NTP and the private
medical sector and Lebanese Respiratory Society must be maintained and
strengthened.
 The NTP should promote of NTP policy in the curricula of medical schools
and post-graduate courses and in the programs of the conferences of
professional medical associations and societies.
 The new TB treatment guidelines document of NTP needs to be promoted in
seminars that will be organized for private general practitioners and chest
specialists in collaboration with the relevant professional associations or
societies.
 The NTP should monitor the contribution of the private medical sector to TB
case detection in Lebanon and regularly evaluate the level of adherence of
the physicians belonging to this sector to the NTP guidelines.
11. TB care and control in Syrian refugees
 The efforts to ensure TB care and control services for Syrian refugees must be
maintained.
 The successful coordination mechanism between IOM and NTP must be
maintained.
 The experience on the provision of TB care and control services to Syrian
refugees must be analysed in depth, documented and published to inform
international community.
 The cost-benefit of the approach to systematically screen Syrian refugees
using questionnaire needs to be studied and evaluated.
 IOM, WHO and other partners should mobilize funds to maintain the existing
momentum.
12. Operational research
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The operational research must be oriented towards problem-solving for the
NTP.
The in-depth analysis of the data collected by the NTP should identify
hypothesis for operational research.
The NTP Central Unit should establish, in collaboration with the existing
national research institutions and academies, a national agenda for TB
prevention, care and control, with a focus on TB elimination in Lebanon.
The innovative interventions that will be designed will be tested and
evaluated through operational research studies.
The programmatic implementations of these interventions will be monitored
and assessed through the information system of NTP.
13. Other recommendation
 The NTP needs to establish linkages with the National Diabetes Program in
order to promote TB care provision in diabetes settings and improve care
services in diabetic patients with TB.
Recommendation to the International Organization for Migration
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IOM should maintain its successful collaboration with NTP, UNHCR, WHO and
the other partners.
IOM should help in fund raising for TB control in Syrian refugees.
World Health Organization
WHO/EMRO Stop TB Unit should:
1. Support NTP to define and establish a national policy to eliminate TB in
Lebanon; this policy will define and design innovative approaches, including
strategic interventions for active TB case-finding and chemoprophylaxis in
specific groups.
2. Technically assist NTP to develop a new multi-year NSP to address the
managerial and programmatic issues and initiate actions for the
implementation of TB elimination strategy in Lebanon.
3. Provide the technical support to develop the relevant guidelines and training
material and to address the managerial and programmatic issues through the
mobilization of the required technical assistance.
4. Contribute to providing a technical support to improve the activities to be
carried out in the laboratory network of Lebanon.
5. Organize the external monitoring of the multi-year NSP implementation as
well as the evaluation of the outcomes of this plan.
ANNEXES
Review team and sites visited
Review team members:
National reviewer
Dr Mary Deeb, Epidemiology Department, Lebanese University, Beirut, Lebanon
Dr Abdallah Mkanna, Emergency public health specialist, IOM Office, Beirut, Lebanon
Dr. Hiam Yaâcoub, NTP manager, Beirut, Lebanon
International reviewers
Dr. Mohamed Abdel Aziz, RA STB EMRO, Cairo, Egypt
Dr. Novera Ansari, Project coordinator for Jordan and Lebanon Global Fund grant,
Emergency Support Team, WHO, Amman, Jordan
Dr Kaisa Kontunen, Health Coordinator, IOM Office, Beirut, Lebanon
Dr. Salah-Eddine Ottmani, WHO consultant, Geneva, Switzerland
Dr. Amal Salah, Infection Control consultant, Cairo, Egypt
Dr. Veronique Vincent, TB laboratory consultant- HEALEXPERT, Paris, France.
Sites visited
 NTP Central Unit/Karantina TB Centre of Beirut
 National Reference Laboratory (American University of Beirut)
 Plage Noor Shelter (Syrian refugee setting)
 TB Centre of Tripoli
 Shelter of Camp1 Minieh (Syrian refugee setting)
 Office of the Lebanese Pulmonary Society (meeting with the National Board)
 Armenian Azounieh Sanatorium
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Taal-Abaya Health Center, Tahle
TB Centre of Zahle
TB Centre of Halba (infection control assessment only)
TB Centre of Beiteddine (infection control assessment only)
TB Centre of Saida (infection control assessment only)
TB Centre of Nabatieh (infection control assessment only)
TB Centre of Tyre (infection control assessment only).
WHO Recommendations for laboratory waste
Waste management:
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To minimize the risk from waste, all infectious materials should be
decontaminated, (an approved decontaminant or bleach should be added to
sputum cups before discarding).
- Incinerated in an incinerator, or autoclaved.
- Discard bags should be used to segregate waste, broken glasses and sharps
should be discarded in safety boxes up to two third.
- Decontamination by proper disinfectant for TB :
Phenol:
- Used in concentration of 5% in water
- Used for decontamination of equipment and single use items prior to disposal.
- Disadvantage: highly irritant to skin, mucous membrane and eyes, because of its
toxicity and odor phenol derivatives are used.
Chlorine:
- Sodium hypochlorite (domestic bleach) contains 50g/l.
- diluted to 1: 50 or 1: 10 in water, should be prepared daily
- Stored in well ventilated, dark area.
- used as general disinfectants, soaking of contaminated materials
- Because it is highly alkaline it can corrode metals.
Alcohols:
- Ethanol or isopropyl alcohol are used at 70% solution
- Used for routine decontamination of BSC
- Used as hand rub when hand is decontaminated followed by thorough hand wash
with soap and water.
- Disadvantage: alcohol is volatile; flammable should not be used near flames, and
well labeled
Per acetic acid:
- Used at 2% conc. Solution stable for 48 hours
- It has a rapid action against all microorganisms.
- It lacks harmful decomposition product, enhance removal of organic materials and
leaves no residue.
Reference: Tuberculosis Laboratory Biosafety Manual 2012
N.B : Azonieh sanatorium is the ideal way for waste storing which should be
followed
“To incinerate hazardous waste properly requires an efficient means of controlling
the temperature, and a secondary burning chamber. Many incinerators, especially
those with a single combustion chamber, are unsatisfactory for dealing with
infectious materials or plastics. If this type is used, such materials may not be
completely destroyed, and the effluent from the chimney may pollute the
atmosphere with microorganisms, toxic chemicals and smoke. However, there are
many satisfactory configurations for combustion chambers. Ideally the temperature
in the primary chamber should be at least 800°C, and in the secondary chamber at
least 1000°C. In order to achieve the required temperatures, the incinerators must
be properly designed, operated and maintained.(page 18 Tuberculosis Laboratory
Biosafety Manual 2012)”
Specification of UVGI
1- UV-c lamps of wave length 254 nm (253.7nm)
2- The upper-air UV beam protected with pure medically approved stainless
steel, could be used in the presence of patients and staff
3- 8000 working hours
4- covers from 35/75 m²
Special considerations for installing UVGI:
- Using ceiling fans with low speed to ensure the germicidal effect of UV rays
as hot air rises upwards due to its low density and replaced by cold air.
- The room ceiling should be more then 2.4m high
- The lamp should be installed at 2.10 m high so people cannot look into the
lamp.
- The lamp should be of 30w / 18-20m. Square
- Cleaning of the lamp should be done every week by 70% alcohol and annual
maintenance is needed or replacement as the lamp works up to 8000hours
- Efficacy of UV lamp decrease if humidity is around 70%, this should be put in
consideration
Reference
- Riley, R.L., and E.A. Nardell. 1989. Clearing the air-The theory and application
of ultraviolet air disinfection. Am. Rev.Resp. Dis. 139: 1286-1294.
- First M.W., Nardell E.A., Chaisson W., Riley R. 1999 Guidelines for the
Application of Upper Room UVGI for Preventing transmission of Airborne
Contagion. Part I and II. ASHRAE transactions 105