NTP Centers and Services

The National Tuberculosis Program (NTP), under the Ministry of Public Health of Lebanon, operates through the Tuberculosis (TB) central unit at Karantina and 9 TB control centers across the country:

1 center located in Beirut (Karantina), 1 in Mount Lebanon (Barouk), 2 in Bekaa (Zahleh and Hermel), 2 in the North (Tripoli and Halba), and 3 in the South (Nabatieh, Saida and Tyre).

NTP is committed to providing equitable, quality services for the diagnosis and treatment of TB to all notified cases residing in Lebanon, regardless of the geographical region, economic status and country of origin.

The following services are provided FREE of charge at the TB centers falling under the NTP:

• TB diagnostics and laboratory services (Chest Radiography, Direct Smear Microscopy, Gene Xpert testing, Culture and Drug Sensibility testing for first and second line drugs)
• TB cases management and treatment (first and second line treatment regimens provided for drug-susceptible and drug-resistant TB cases)
• Treatment follow-up and Support through Directly Observed Treatment (DOT) and Video Observed Treatment (VOT)
• TB Contacts investigations and Screening
• TB Prevention through the provision of preventive treatment for Latent TB cases in high risk groups when recommended (TB-HIV patients, TB Contacts, Immunocompromised patients, Migrants from high TB burden countries)

Furthermore, MOPH contracted the Sanatorium at Azounieh-Mount Lebanon for TB cases that require hospitalization and isolation.

MOPH also nominated and contracted Laboratoire Rdolphe Merieux (LRM) as the National Reference Laboratory (NRL) for TB in Lebanon as of June 2018. The following diagnostic tests are performed by the NRL as per the national TB guidelines:

• Culture
• Phenotypic and Genotypic Drug Susceptibility Testing for first and second line drugs
• Gene Xpert for extra-pulmonary specimens 

 
NTP Activities NOT FINALIZED

Community Based TB Activities

In the past few years, the NTPs workplan emphasized on raising public awareness about TB in line with the National Strategic Plan. Therefore, the program, with the support of national and international organizations, established a diverse network of partners who helped in accessing and gathering vulnerable groups for awareness raising sessions (refugees, migrants from high TB burden countries, people living in poverty…).

The objectives of the sessions were to:

• Provide basic knowledge about TB, its common signs and symptoms, its mode of transmission, the importance of treatment adherence and methods of disease prevention.
• Modify perceptions/ misconceptions in the community regarding the disease in order to reduce TB stigma.
• Inform participants about the NTP centers across the country and the services provided by the center. 

Screening and active case-finding activities

TB Contacts
Contact Investigation is an important process which helps in the early identification of active TB and thereby decreases disease severity and transmission of MTB, and aids in the detection and treatment of latent TB infection. Therefore, NTP healthcare workers put a lot of effort into TB contact investigation. Investigations are done in 2 phases:

1. Contact Identification & Prioritization: systematic process to identify contacts with or at increased risk for development of TB. An interview with the index case as soon as possible after diagnosis (generally within 1 week) to obtain the names and ages of contacts. The focus should be on household members, but people in the workplace and other settings in which there is exposure should not be ignored.
2. Contact Clinical Evaluation: A systematic process for the diagnosis or exclusion of active TB among contacts. Clinical evaluation is undertaken if the results of contact identification and prioritization indicate a risk for having or developing TB. Follow the algorithm for LTBI (in National guidelines).

Migrants
One of the objectives of the National Strategic Plan “Toward Tuberculosis elimination in Lebanon” was to decrease by half the burden of TB among migrant workers by 2021. And so, a decree was issued by MOPH and MOL in 2017 aiming to do systematic TB screening in governmental hospitals for all migrants upon entry to Lebanon. Should we add numbers??

Furthermore, NTP put major efforts to reach undocumented migrants by mapping gathering points such as religious sites, clubs and other meeting points and conducting screening activities to these communities.
 
Refugees
IOM, in close coordination with NTP deploys a network of community Health volunteers to conduct a nationwide TB screening campaign in informal settlements and collective shelters in the North, South, Bekaa and Mount Lebanon since 2015. Their main tasks are to raise awareness about TB, identify presumptive TB cases using symptoms screening forms and refer them to the nearest NTP center.

Around 430000 refugees were screened from June 2015 till February 2019.

Other Vulnerable groups:
TB screening is also conducted in other vulnerable populations in Lebanon by the NTP such as in elderly and prisoners
 
Capacity Building (part to be added)
 
WHO Support

WHO continued to provide support to the NTP in 2019 through the following activities:

• Monitoring missions: Regional Green Light Committee mission conducted in September 2019.
• Supporting the NTP in the implementation of the TB Registration System (TRS) for migrants screened for TB upon entry to Lebanon in governmental hospitals.
• Updating the ENRS currently used at the NTP through the development of a new electronic platform, the DHIS2 for TB, currently under progress.
• Supporting the NTP during the World TB day.
• Supporting the NTP in conducting Training sessions and Capacity Building activities. 

 
IOM Support
The International Organization for Migration has been supporting the NTP in Lebanon since 2014.

In 2019, IOM, as the principal recipient of the Global Fund to Fight AIDS, Tuberculosis and Malaria fund, continued to support the prevention, diagnosis and treatment of TB among Syrian, Palestinian and recently, as of 2019, Iraqi refugees under the MER2 project (2019-2021).

IOM support to NTP is in two arms:

• System strengthening: and this includes all necessary resources to provide diagnosis, treatment and follow up at the level of the 9 Tuberculosis Control Centers as well as capacity building.
• Direct services to Syrian and Palestine and Iraqi nationals. 

 
  TB Epidemiology in Lebanon

Lebanon is a low TB burden country with an estimated incidence rate of 11/ 100000 population, an estimated mortality rate of 0.89/ 100000 population and a treatment coverage of 87% in 2018 (WHO Global Tuberculosis Report 2019).

However, TB burden is rising among non-nationals and this is mainly attributable to the increase in cases among the migrant workforce and to the influx of Syrian refugees to Lebanon. In fact, the number of TB cases in the non-Lebanese community has gradually increased since 2006, reaching a proportion of 62% of the total TB cases in 2018 and 2019 (Figure 1.a). Figure1.b represents the trends in notified TB cases by resident status between 2007 and 2019.

Figure 1.a): Trends in notified TB cases-Nationals/ Non-nationals, 2006-2019


Figure 1.b): Trends in notified TB cases by resident status, 2011-2019

*Refugees include Syrian, Palestinian and Iraqi cases
 
 
Moreover, the overall treatment success rate was 81% in all reported TB cases in 2018, and 95% in TB cases among Lebanese and refugees. The low treatment success rate among patients from the migrant workforce (63%) could be attributed to the fact that a large number leave the country before completion of treatment. To overcome this challenge and ensure treatment continuation for migrants who leave Lebanon while still under treatment, the NTP has developed a transfer-out form, which includes information about diagnosis, tests’ results and treatment status, to be sent with patients who leave Lebanon. However further international collaboration is needed to be able to retrieve their treatment outcome from NTP in home-country.

TB Surveillance Data-Year 2019

Distribution of TB Cases by a) Type and b) Site of disease (2019)
    
 
Distribution of TB Cases by Gender and Age Category (2019)


Distribution of TB Cases by Nationality (2019)

 
Distribution of TB Cases by Nationality and Age Category (2019)

 
Distribution of TB Cases by Nationality at District Level (2019)
Beirut


Mount Lebanon


North Lebanon


South Lebanon


Bekaa

 

  What is Tuberculosis?

Tuberculosis (TB) is caused by bacteria (Mycobacterium tuberculosis) that most often affects the lungs and is called Pulmonary TB. It can also affect other organs in the body (such as the bones, lymph nodes, brain…) and is known as Extra-pulmonary TB.

How does it spread?

TB is spread from person to person through the air; a patient with active pulmonary TB releases the germs into the air through coughing, sneezing or spitting; a person needs to inhale only a few of these ­germs to become infected (Latent TB infection).

A patient with Latent TB means he has been infected by TB bacteria but has not (yet) developed active TB disease and cannot transmit it.

People infected with TB bacteria have a 5 to 15% lifetime risk of falling ill with active TB. However, persons with compromised immune systems, such as people living with HIV, malnutrition or diabetes, or people who use tobacco, have a higher risk of falling ill.

Rarely, a person could get infected with TB after the consumption of unpasteurized milk from infected cows.
 
What are the common signs and symptoms of TB

TB bacteria most commonly affects the lungs, and can cause the following symptoms:

• Cough that lasts 2 weeks or longer
• Chest pain
• Fatigue
• Loss of appetite
• Weight loss
• Fever
• Night Sweats 

How is it treated?

Active, drug-susceptible TB disease is treated with a standard 6 months course of 4 antimicrobial drugs that are provided with information and support to the patient. TB disease can be cured when medicines are taken properly. You should inform your doctor of any adverse event that might occur throughout the treatment course.

Drug resistance emerges when anti-TB medicines are used inappropriately (such as when a patient stops treatment prematurely) and can lead to the development of a dangerous, life threatening form of TB disease.
 
DOT-VOT
Directly Observed Therapy (DOT) and Video Observed Treatment (VOT) improve treatment adherence by requiring a health worker or volunteer to observe patients taking each dose of the medicine on a daily basis.

TB is preventable and curable. Keep in mind that compliance to treatment is critical for cure and always follow the instructions of your healthcare provider.
 
How to prevent the spread of TB?

If you have tuberculosis, you should follow a number of preventive measures that help in reducing the transmission and spread of the disease especially to household members and close people.

• Do not spit on the ground
• Do not cough or sneeze in front of others without covering your mouth or nose
• Maintain good ventilation of the house
• Allow natural sunlight into the house

  National Strategic Plan

The National Strategic Plan (NSP) toward TB Elimination in Lebanon 2017-2021 was launched at a press conference held by the Ministry of Health during the World TB day on 24 March 2017. The NSP is designed for five years and describes five objectives which are in alignment with the WHO End TB Strategy.

• Objective 1: By 2021 further decrease the burden of TB to less than 10 cases/100 000 population by increasing the efforts for case detection and improve treatment outcomes through the existing health service network.
• Objective 2: By 2021 decrease by half the burden of TB among migrants and increase case finding activities to all refugee populations newly arrived in Lebanon
• Objective 3: Achieve and sustain accurate surveillance, monitoring and evaluation, adherence to SOPs and obtain better estimates of TB situation for a reliable measurement of progress.
• Objective 4: Increase coordination among all stakeholders involved in TB prevention care and control, public and private, including social support actors by organizing formal meetings with stakeholders.
• Objective 5: Raise TB awareness, decrease stigma through a plan for communication and social mobilization and promote research. 

National TB Guidelines (Links)

• National TB Guidelines 2017-English
• National TB Guidelines 2017-French 

TB Algorithms (Links)

• Algorithm for Latent TB-English
• Algorithm for Latent TB-French
• Algorithm for Active Pulmonary TB-English
• Algorithm for Active Pulmonary TB-French
• Algorithm for Drug Resistant TB-English
• Algorithm for Drug Resistant TB-French 

Annual TB Reports (Links)

• NTP Annual Report – 2017
• NTP Annual Report – 2018
• NTP Annual Report – 2019 

Lebanon TB Country Profile-2018 (WHO Global TB Report 2019) (Link)
TB Reporting Form - إستمارة إبلاغ عن حالة سل (Link) the updated form IEC Materials (Links) Once finalized by Bahij (ask for soft copies) + WHO World TB day IECs + TB Video