DAUNTING CHALLENGE(S) IN WPRO Lee B. Reichman, MD, MPH Chair: WPRO - - PowerPoint PPT Presentation

Rutgers, The State University of New Jersey

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

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

• r drug taking, and XDR-TB is MDR-TB thus modified. In
• ther 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)

PNG

TB snapshot in PNG 2013/14

32 000 Prevalent

25000 incident

24000 notified

1100 MDR-TB

220 notified

Impressive scale up in case notification 2008-2014

6357 12297 15989 17113 22496 24860 5000 10000 15000 20000 25000 30000

2007 2008 2009 2010 2011 2012 2013 2014

Case notification

PNG

But then poor treatment outcome, 2013: high loss to follow up

Cured 10% Completed 53%

Died 3% Failed 1% LTFU 32%

Transfer 1%

New

Cured 48% Completed 15% Died 7% Failed 6% LTFU 24% Transfer 0%

ReTx

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

60 82 145 221 50 100 150 200 250 2010 2011 2012 2013 2014

MDR-TB case notification

17 Xpert MTB-Rif PNG

MDR-TB treatment outcome is very poor

successful 14% Died 22% Loss to follow up 3%

Not evaluated 61%

MDR-TB treatment outcome 2011 cohort as reported to WHO

PNG

XDR-TB notification increased even among new cases

DRTB No Resistance profile (most recent DST resistance profile) Previously treated with SLD Current Regimen Months on treatment (since SLD started) Outcome Location 1 DH0911 XDR (HRZKmAkCmOfxEto) Y Mfx Cs PAS AMC Cfz 20 (40) Failure / On treatment DGH isolation 2 DH1712 XDR (HREZKmAkCmOfxEto) Previously treated with FLD Mx Cs PAS Amox Cfz 27 Failure / On treatment DGH isolation 3 DH1513 XDR (HREZSCmOfxEto) previously treated with FLD Mfx Cs PAS AMC Cfz 17 Failure / On treatment DGH isolation 4 DH6512 XDR (HREZSCmOfxEto) previously treated with FLD Lfx Cs PAS Amx/Clv Cfz 21 Failure / On treatment Community 5 DH6913 XDR (HREZSKmCmOfxEto) New case (contact) z Am Mfx Cs PAS Lnz 9 (26) Probable failure / On treatment DGH isolation 6 DH7013 XDR (HRZSKmAkCmOfxEto) Y E Mfx Cs PAS Amx/clv Cfz Lnz 9 (58) Failure / On treatment DGH isolation 7 DH2913 XDR (HRZSKmAkCmOfxEto) Y Mfx Cs PAS Amx/Clv Cfz Lnz (bedaquiline) 17 (36) Failure / On treatment Community 8 DH2014 preXDR (HRS OfxEto) Y Z Km Lfx Cs PAS Amx/Clv Cfz Lnz 5 (17) On treatment DGH isolation

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 1st and 2nd 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)

PNG

but it is not just PNG…

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 China

Acknowledgements

• Tauhid Islam, MD
• Shalala Ahmadova, MD
• Chuck Daley, MD

INFORMATION LINE 1-800-4TB-DOCS (482-3627) globaltb.njms.rutgers.edu