Strengthening and Aligning TB Diagnosis and Treatment Joint GLI/GDI Partners Forum April 27-30, 2015 Geneva REGIONAL GLC EXPERIENCES… DAUNTING CHALLENGE(S) IN WPRO Lee B. Reichman, MD, MPH Chair: WPRO rGLC Rutgers, The State University of New Jersey
PNG rGLC Site Visit and Meeting in Papua New Guinea, May 11-15, 2015 ToR • To review and provide feedback on – progress and quality of TB integration of PMDT with the health system; – use of rapid diagnostics tests as part of the laboratory network; – the minimum requirements for country preparedness and planning for introduction of new anti-TB medicines
PNG Back to the basic XDR-TB, MDR-TB, and drug-sensitive tuberculosis are all the same disease . The only difference is that MDR-TB is drug- sensitive tuberculosis modified by inappropriate treatment or drug taking, and XDR-TB is MDR-TB thus modified . In other words, every person with MDR-TB or XDR-TB was not treated properly, did not take their drugs properly, or were infected by somebody who was not treated properly or did not take their medicines properly. Reichman, LB The Lancet 373, 2009 (emphasis added)
TB snapshot in PNG 2013/14 32 000 Prevalent 25000 incident 24000 notified 1100 MDR-TB 220 notified
PNG Impressive scale up in case notification 2008-2014 Case notification 30000 25000 24860 22496 20000 17113 15989 15000 12297 10000 6357 5000 0 2007 2008 2009 2010 2011 2012 2013 2014
PNG But then poor treatment outcome, 2013: high loss to follow up New ReTx Transfer Transfer 1% 0% Cured 10% LTFU LTFU 24% 32% Cured 48% Failed 6% Completed Died 53% 7% Failed 1% Completed 15% Died 3%
PNG Active transmission in the community (cumulative 2008-12)
PNG DRS data from the recent survey in 4 provinces in 2014 • MDR overall – among new cases is 3.2% – among previously treated cases is 23% • The highest rate of MDR is in Western province. – Among new cases: 17% – among retreated cases: 61%
PNG MDR-TB case notification increased as rapid Dx scaled up MDR-TB case notification 250 221 200 150 145 100 82 60 50 0 2010 2011 2012 2013 2014 17 Xpert MTB-Rif
PNG MDR-TB treatment outcome is very poor MDR-TB treatment outcome 2011 cohort as reported to WHO successful 14% Died Not 22% evaluated 61% Loss to follow up 3%
PNG XDR-TB notification increased even among new cases DRTB No Resistance profile Outcome Location Previously Current Months on Regimen treatment (most recent DST resistance treated with profile) SLD (since SLD started) 1 DH0911 XDR Y 20 (40) Failure / On DGH (HRZKmAkCmOfxEto) treatment isolation Mfx Cs PAS AMC Cfz 2 DH1712 XDR 27 Previously Mx Cs PAS Failure / On DGH (HREZKmAkCmOfxEto) Amox Cfz treatment isolation treated with FLD 3 DH1513 XDR 17 previously Mfx Cs PAS Failure / On DGH (HREZSCmOfxEto) AMC Cfz treatment isolation treated with FLD 4 DH6512 XDR 21 Community previously Lfx Cs PAS Failure / On (HREZSCmOfxEto) Amx/Clv Cfz treatment treated with FLD 5 DH6913 XDR 9 (26) New case z Am Mfx Cs Probable DGH (HREZSKmCmOfxEto) (contact) PAS Lnz isolation failure / On treatment 6 DH7013 XDR Y 9 (58) E Mfx Cs PAS Failure / On DGH (HRZSKmAkCmOfxEto) treatment isolation Amx/clv Cfz Lnz 7 DH2913 XDR Y 17 (36) Community Failure / On Mfx Cs PAS (HRZSKmAkCmOfxEto) treatment Amx/Clv Cfz Lnz (bedaquiline) 8 DH2014 preXDR Y 5 (17) On treatment DGH Z Km Lfx Cs (HRS OfxEto) isolation PAS Amx/Clv Cfz Lnz
PNG Current laboratory capacity • 113 functional smear microscopy laboratory (1.6/100 000 population) • External Quality Assurance system in place • National Reference laboratory refurbishment to PC 3 lab started • Xpert MTB/Rif: 16 (?) • Supra National Reference Laboratory: QMRL, Queensland, Australia
PNG Major achievements (1) • High political commitment – Strong resource mobilisation efforts at the NDOH level: • government budget for TB increasing 9 million USD allocation for Y1 of NSP • successful applications to GFATM 18 million USD for three years (2015-2017)
PNG Major achievements (2) • Quality assured 1 st and 2 nd line anti TB medicines procured by government from the GDF • DOTS expansion of DOTS from 2 provinces in 2008 to 22 provinces in 2012 • National TB protocol, PMDT guidelines, and TB/HIV collaborative activities guidelines developed/updated • 9 G-Xperts procured; 7 are waiting to be rolled out • Quarterly and annual reports produced by NTP • PMDT core WG established and regular meetings held • DRS completed
PNG Major issues • Lack of integration PMDT and comprehensive TB care • Weak DOTS • Weak laboratory capacity • Weak PMDT • Lack of HR
PNG Way forward (1) • Improved coordination to strengthen DOTS – All partners should have a common work plan to implement National Strategic Plan 2015-20 – All stakeholders should work on comprehensive TB control – PMDT should be considered as part of comprehensive TB control activities
PNG Way forward (2) • PMDT – Develop standardised SOP – Training on SOP – All R resistant cases will be treated following standardised SOP – Joint supervision and monitoring involving all partners • Treatment – Drug regimen – New drugs – possibly including USAID BDQ donation programme
PNG Way forward (3) • Laboratory Network – Explore option of deployment of further Xpert – Xpert as an initial diagnostic test in high MDR-TB burden areas – Develop capacity of culture laboratory – Strengthen transport mechanism for DST • Human Resource – Partner coordination – Involvement of community partner/volunteer
PNG Take home message We need to recognize that there are more than 9,000,000 new active drug-sensitive cases of tuberculosis globally and 25,000 in PNG that could be feeding drug resistance. It might be a less sexy concept, but they all must be appropriately treated with current strategies (as well as new diagnostics, drugs, vaccines, and proper infection control measures) to avoid preventable MDR-TB and XDR-TB, which are always lurking. Preventing active, drug- sensitive tuberculosis, or treating it properly, should be everybody’s priority: it is the only way to prevent MDR-TB and XDR-TB. modified from Reichman, LB The Lancet 373, 2009 (emphasis added)
but it is not just PNG…
China Minghui et al The Lancet, Feb.2015
China But challenges remain monumental • Maintaining case detection and enrollment (after GF closure) • Maintaining infrastructure, human resources and skills developed during the GF supported project • Laboratory services and new diagnostics capacity is not being fully utilized - slow progress in development of national algorithm • Catastrophic expenditure for patients – Reimbursement rate remains insufficient – Indirect costs (nutritional, travel and loss of productivity) are not considered in the package
China Policy Suggestions • To immediately review the drastic decline in enrolment following GF closure • Develop and implement a strategic plan for establishing a laboratory system that combines the use of Xpert, LPA, and culture and optimizes the efficient use of all diagnostic methods • Continue to explore options to eliminate out of pocket expenses and provide social protection • Under the ongoing public hospital reform, to define roles and responsibilities of hospitals in delivering TB control, as a public good, and how it will be financed
Acknowledgements • Tauhid Islam, MD • Shalala Ahmadova, MD • Chuck Daley, MD
INFORMATION LINE 1-800-4TB-DOCS (482-3627) globaltb.njms.rutgers.edu
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