TB Control Measures: From development and endorsement to adoption and implementation

1. TB Control Measures:From development and endorsement to adoption and implementation Léopold Blanc TBS Stop TB department WHO Christy Garcia University of Connecticut School of Medicine

2. Overview • Background • Laboratory • Treatment • Drug Resistant TB • TB/HIV • Infection Control • Care Delivery Innovation • Conclusions

3. Background • 2010: Global Plan estimates 16 medicines, 18 diagnostics, 12 vaccines in development • Recent years have seen the launch of several new tools with the recommendation to use Xpert MTB-RIF… conditions to be discussed during the Global consultation end of November • The time is right to evaluate uptake of these tools to adapt promotion for increased uptake in the future

4. Background • Task Force on Retooling • Created by Stop TB Partnership to help programmes implement new technologies • Innovative New Approaches and Tools subgroup • Ensure timely access to information on new tools and technical support for rapid adoption • Track progress in uptake and expansion of new tools

5. Background • Method: • Inventory of major policy changes in the last 10 years • Creation of questionnaire and piloting within HQ • Questionnaire distributed targeting 22 HBC and high MDR-TB countries • 27/40 surveys were returned • Goal: Identify areas of delay for better promotion of new approaches and tools in the future

6. Laboratory • Challenges: • Long delay between seeking care and diagnosis • Expensive technology not available for low-resource settings • Newly endorsed methods: • New case definition smear + (2007) • Liquid culture and rapid speciation (2007) • Line-probe assay (2008) • LED FM (2009) • Xpert MTB-RIF (2010)

7. Laboratory Results

8. Laboratory Results • Significant number of countries utilizing tool prior to WHO endorsement • Most of the uptake occurs within 1st yr • Implementation mainly at national and regional level

9. Treatment • Challenges: • Long duration • Multiple drugs • Recent Policy Changes: 1999: Fixed-dose combination tablets for the treatment of tuberculosis 2003: Treatment of Tuberculosis: guidelines for national programmes 3rd ed. 2010: Treatment of Tuberculosis: guidelines 4th ed.

10. Treatment Results

11. Treatment Results Substantial number of countries with guidelines in place prior to WHO policy:

12. Multidrug Resistant TB • Challenges: • Delayed identification leads to further spread of resistant strains • Recent policy changes: 2006: Guidelines for the programmatic management drug-resistant tuberculosis 2008: Emergency update

13. Multidrug Resistant TB Results

14. Multidrug Resistant TB • Other risk categories in which routine DST is being conducted: • Patients who have failed first line treatment (68%) • Patients who have failed a retreatment regimen (84%) • 7 EURO countries conduct routine DST in all TB patients • 78% intensive phase conducted in hospital; 78% continuous phase as outpatient or community-based • 58% countries have recording and reporting system in place for adverse rxns to second line drugs

15. TB/HIV • Challenges: • Smear microscopy has lower sensitivity • Higher conversion latent to active infection • Interaction between ARVs and antituberculosis drugs • Recent policy changes: 2004: Guidelines for HIV surveillance among tuberculosis patients 2007: Improving diagnosis and treatment of smear-negative pulmonary and extrapulmonary tuberculosis in adults and adolescents 2009: A guide to monitoring and evaluation for collaborative TB/HIV activities

16. TB/HIV Results

17. TB/HIV • Few countries with existing TB/HIV policies in place • Good uptake of policies within 1-2yrs of WHO endorsement • Low uptake of new diagnostic algorithm and IPT

18. TB Infection Control • Challenges: • Respiratory spread person to person • Greater exposure for health care workers, populations in congregate settings • Recent Policies: 1999: WHO guidelines for the prevention of TB in health care facilities in resource-limited settings 2009: WHO policy on TB infection control in health-care facilities, congregate settings, and households

19. TB Infection Control Results

20. TB Infection Control • Long delay between first endorsement of guidelines by WHO and adoption by countries • Implementation mostly at national and regional level • Over half of countries implementing policies only did so in TB care facilities

21. Care Delivery Innovation • Challenges • Lack of infrastructure • Lack of human and financial resources • Engagement of political will • Recent policies and tools 2006: Stop TB Strategy 2006: Engaging all health care providers in TB control 2007: A tool for national situation assessment 2008: Contributing to Health Systems Strengthening

22. Care Delivery Innovation Results

23. Care Delivery Innovation • Area with least uptake of new tools and policies • 41% of countries have advanced planning and preparation for new tools • 33% of countries have INAT component in Global Fund agreement

24. Conclusions • Largest percentage of uptake 1-2yrs after endorsement of policy • Most uptake seen with TB/HIV policies • Both country factors and global factors play a role in delay of uptake

25. Moving Forward… • Continued use of survey instrument and database for broader sampling • Collaboration between TB control areas to learn from examples of successful promotion • More focus on health systems strengthening

26. Thank you