PPM SUBGROUP MEETING Cairo, 3-5 June 2008

Involving all health care providersin the MDR and XDR-TB response

Matteo Zignol

Stop TB DepartmentWorld Health Organization

• What is the problem?

• What are the causes? (the role of private health sector)

• What are the possible solutions?(the role of private health sector)

How to approach the problem of anti-TB drug resistance

What is the problem?

Drug susceptible TB*

*or limited resistance

Manageable with 4 drug regimen

Cure rate: virtually 100%

Resistance to H&R

Treatable with 2nd line drugs

Cure rate: up to 80%

MDR-TB

1990

XDR-TB

2006

Resistance to (R, H, Fqs) and (Km or Am or Cm)

Treatment options seriously restricted

Cure rate: up to 35%

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there

may not yet be full agreement. WHO 2006. All rights reserved

< 3%

3-6 %

> 6 %

No data

MDR-TB among new TB cases, 1994-2007

XDR-TB among MDR-TB cases, 1994-2007

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< 3% or less than 3 cases in one year of surveillance3 - 10%

> 10%

No data

Report of at least one case

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for

which there may not yet be full agreement. WHO 2006. All rights reserved

XDR-TB in South Africa

Study characteristics (53 patients) No. (%)

• No prior TB Treatment 26 (51) • Prior TB treatment

• Cure or Completed treatment 14 (28)• Treatment Default or Failure 7 (14)

• HIV-infected (44 tested) 44 (100)• Dead (Includes 34% on ARV) 52 (98)• Identical M. tb spoligotype 26/30

Lancet 2006; 368:1575-80

What are the causes?Role of private health sector in creation of DR-TB

Drug resistance is man made

- Treatment regimens prescribed by health care providers: no data on DR-TB but plenty of papers on mismanagement of TB in the private sector

- Quality of drugs: absence of tender market for SLD and wider use of SLD outside NTPs

- Patient's adherence to treatment: high default rates (>15%) if no patient support measures in place

Role of private health sector in prevention & management of DR-TB: the Makati model

• 1999: privately initiated Private-Public Mix DOTS (PPMD) at Makati Medical Center (MMC) DOTS Clinic

• 2000: Green Light Committee (GLC) Pilot project for 200 patients (MMC PPMD unit)

• 2003: 100% DOTS coverage in the Philippines (case detection rate: 75%, 2005; success rate: 87%, 2004)

• 2003: expansion of GLC Pilot to faith-based organizations; start of Round 2 GF(500 patients)

• 2004: decentralization of MDR services to public health centers (hospital and public health centers)

• 2006: “formal” mainstreaming of MDR TB management into the NTP: Round 5 GF (2,500 patients)

6 15 84 100191

70 92 94184

396

640 640 640

6 21 105 161 183283

474

728

1950

2590

21 (14 GF)

55

3230

1216

0

500

1000

1500

2000

2500

3000

3500

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

pre GF/GF2 GF 5 Cumulative

TDF-MMC DOTS Clinic (private PPMD)

KASAKA Housing Facility (private)

LCP DOTS Center (gov’t PPMD)

Tala, Tayuman , MM South,CebuPhases in PMDT implementation

Faith-based orgs

Public health centers

PPMD units

TDF, Philippines

Pilot Expansion Mainstreaming to the NTP

Role of private health sector in diagnosis of DR-TB

• South Africa has 16 labs capable of performing culture and 14 capable of performing drug susceptibility testing (DST)

• All the rest of Africa has only 13 laboratories capable of performing culture and only 11 that can do DST

Crucial role for private/university/research labs!

II Meeting of the WHO Task Force on XDR-TB 9-10 April, Geneva, Switzerland

Recommendation:

Countries to involve all health care providers in

the global response to MDR-TB and XDR-TB

The way forward for PPM MDR-TB

• Creation of "Joint group on PPM-MDR TB" representing PPM Subgroup and MDR-TB Working Group.

Possible areas of work:• Assessment of the problem in key settings• Documentation of best practices and models• Development of framework for PPM MDR-TB based on WHO guidelines• Pilot testing of PPM MDR-TB in key settings

Conclusions

• No success in TB control without success in MDR-

TB and HIV control

• No success in MDR-TB control without involvement

of all health care providers

• Collaborative work needed with all health care

providers to:

- support and improve the Global Response Plan

- coordinate efforts to address all bottlenecks

Acknowledgments

Ernesto Jaramillo

Berthollet Kaboru

Kitty Lambregts

Mamel Quelapio

Mukund Uplekar

THANK YOU!