Overview of MDR-TB in SEA Region and response

1. Overview of MDR-TB in SEA Region and response Vineet Bhatia MD Regional Workshop on TB Control Planning, Implementation and Monitoring Jakarta, Indonesia, 29-31 May 2012

2. Background • Global Plan to Stop TB 2006–2015 - The need to scale-up diagnosis and effective treatment of MDR-TB • Global MDR/XDR Response Plan 2007-08 – Integration of MDR/XDR-TB activities with general TB activities and roadmap for scale-up • Ministerial conference in Beijing, April 2009 - Call for Action on the part of governments and international agencies • May 2009, the World Health Assembly resolution WHA 62.15 - “to achieve universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis” • The Global Plan to Stop TB 2011-15 calls for a renewed focus to strengthen fight against M/XDR TB

3. Relevant global targets

4. MDR-TB in the SEA Region • Relatively low levels of multi drug-resistance (2.1%) are reported among newly detected cases but higher rates (18%) are reported among previously treated cases in the Region; • Around a fourth or nearly 105 000 of the world’s MDR-TB cases are estimated to occur annually in the SEA Region; • Extensively drug resistant TB (XDR-TB) reported from five countries in the Region

5. MDR-TB in the SEA Region(Cont.) • A large proportion of patients currently being treated on an ad-hoc basis • Second line drugs freely available in the open market and widely prescribed • NTPs have limited facilities to offer treatment

6. MDR-TB in the SEA Region

7. Progress so far in SEA region

8. MDR-TB case notification % new cases with DST ~0.5% in 2010; % of retreatment case with DST in 2009 ~1.5%; in 2010 ~0.4%

9. Treatment outcome

10. Estimates v/s notifications 4.3% 4.4%

11. MDR-TB case notification - projections 21.6%!!!

12. Challenges

13. Regional challenges • > 1/3 of estimated cases are not registered by NTPs • While the geographical coverage for DOTS in all member countries has reached 100%, there are challenges to access for several pockets of populations • As per studies in the region Private sector is the first contact for 65% TB patients in India; 73% in Myanmar. Study in Indonesia also reveals that majority of people in the rural area preferred private practitioners for treatment of TB. • Despite significant progress the involvement of private and other health sectors in TB control in the region is yet far from being optimal.

14. Regional challenges • Evidence also suggests that Tx success rates in private sector (unless part of PPM initiatives) are usually < 50%. • Less than 5% of the estimated MDR-TB cases are registered for treatment by NTPs. • A huge proportion of cases are either not getting treatment or being treated under unknown conditions with high chance of a non-standardised regimen • Poor drug regulation - TB drugs (both 1st and 2nd line) are available over the counter in several countries in the region • Overburdened health infrastructure specifically overcrowded hospitals with no infection control policy • Several countries in the region face poor housing conditions and specifically overcrowding in urban areas that facilitate spread of infections

15. Regional response plan

16. Purpose of the document • To provide an overview of planned regional response to M/XDR TB • To draw a roadmap for regional contribution to achievement of global targets set forth for M/XDR TB in Global Plan 2011-15 • To act as guidance tool for member countries for developing strategic and operational plans for PMDT • To serve as a reference document and tool of communication for regional priorities for addressing the challenges related to M/XDR TB in the region

17. Goals and objectives • Aligned with the Regional strategic plan for TB control 2006-15 • Goal • overall goal for TB control is to reduce morbidity, mortality and transmission of TB until it is no longer a public health problem in the Region • Objectives • sustain or surpass the 70% case-detection and 85% treatment success rates among TB cases set by the World Health Assembly in 2000 (related to Indicator 24 under the MDGs) in order to then, • Halve TB deaths and prevalence by 2015 (related to Indicator 23 under the MDGs) towards halting and beginning to reverse the incidence of TB as implicitly stated under the Millennium Development Goals set for 2015.

18. Component strategies • Preventing the emergence of resistance through sustained and enhanced efforts to reach all TB patients with quality care • Strengthening basic TB control services to improve case notification and treatment success • Promoting the adoption of International Standards of TB Care (ISTC) by all care providers • Promoting rational use of drugs and pharmacovigilance • Strengthening TB-HIV collaboration

19. Component strategies • Scaling up PMDT • Screening and testing for resistance to first- and second-line drugs, as well as HIV testing among confirmed cases of MDR-TB • Providing access to effective treatment for drug-resistant TB • Providing patient-centric care and promoting adherence

20. Component strategies • Implementing TB-IC in health-care facilities and congregate settings • Strengthening surveillance, including recording and reporting of drug-resistant TB • Strengthening health systems to ensure capacity for PMDT integrated with primary health care • Forging partnerships and ensuring coordination with stakeholders to mobilize the requisite resources • Supporting PMDT through ACSM • Undertaking research

21. New global framework to support PMDT scale-up

22. The previous GLC Initiative - structure and functions • GLC Committee: • Reviews applications from countries that wish to access quality assured second-line drugs - majority of countries funded by GF • Identifies needs for TA to countries from application through to implementation • Monitors and evaluates GLC-approved programmes to assess their progress and continued adherence to WHO guidelines, and advises WHO accordingly • Assists WHO with developing policy to control MDR-TB • GLC Secretariat hosted and administered by WHO • Global Drug Facility procures second-line drugs for GLC-approved programmes • Partners who provide financial and technical assistance

23. New GLC Framework

24. Rationale for the revision • Slow scale up of MDR-TB management • Limited political commitment and capacity of countries • The mandate of the GLC acting as bottleneck • Member states have committed to achieve universal access to diagnosis and treatment of MDR-TB by 2015 (WHA Resolution 62.15) • GLC not completely in conformity to WHO rules and practice Stakeholder consensus to revise the Global Framework to support expansion of MDR-TB services which "should explicitly shift from a controlling to a supporting mode"

25. New global framework Goal Universal Access to DR-TB Management by 2015 Global framework • Focus on strategic concerns • Strengthen MDR-TB-related advocacy • Aim to build up national MDR-TB capacity through increased technical assistance to countries • Increase access to high-quality, affordable SLDs • Regular monitoring and evaluation of country performance • Regularly update international policy and guidelines • Provide advice to funding agencies upon request

26. How new framework will work • GLC "approval" no longer required • Open access to quality assured SLDs • Procurement by GDF on condition of annual monitoring • Increased coordination of TA aimed at nationwide MDR-TB services • Increased provision of TA, including via in-country advisor positions, – proposed, depends on budget • Expanded monitoring and evaluation of country performance annually, with results published in WHO Annual Global TB Control Report • Increased advocacy through coordination with Stop TB Partnership

27. New structure • Establishment of broader based strategic committee ("gGLC") at global level • Dual role: Advising WHO and a sub-group of MDR-TB WG of STP • Members appointed in individual capacity, with all relevant technical areas, constituencies and regions represented • Supported by a Secretariat housed in WHO Geneva • Regional advisory committees (“rGLC”) • Advising WHO ROs and partners • Supported by a Secretariat housed in partner agencies • Phased decentralization to regions (AMRO, EURO & WPRO in Year 1) • Members as above • Review after 1 year for AFRO, EMRO & SEARO

28. What the GLC Framework will do • gGLC • Review global progress • Coordinate technical assistance strategy • Advise WHO and all partners in addressing priority issues in MDR-TB management scale up (see later) • Review secretariats' response to requests for advice from funding agencies • Coordinate with regional GLCs • rGLCs • As above, with regional focus • Coordinate with gGLC • Secretariat • Organize TA • Collate monitoring and evaluation, through global data collection, and national mission reports, and report to GLCs • Prepare bulk of advice for funding agencies, synthesize results for GLCs, discussing in detail difficult cases only

29. Second-line drug supplies • SLDs must be quality-assured but GDF not sole supplier • GDF has proposed an improved approach to drug forecasting needs • WHO will continue to support the Global Drug Facility in its efforts to • negotiate with UNITAID the expansion of the strategic revolving stockpile, • conduct the first bidding process for second-line drugs, • consolidate the public sector market for second-line drugs and reduce existing fragmentation • encourage more manufacturers to become pre-qualified, • recruit regional level technical officers effective Q1 2012 • and strengthen regulatory procedures in key countries

30. Current status • rGLCs • AMRO, EURO WPRO and SEARO selected and functional • gGLC and rGLC collaboration being established • Developing more precise budgets for additional costs • Concise communications with countries in preparation

31. Selection of rGLC members-SEARO • rGLC Selection Committee (CDS SEARO, STP, TB TWG SEARO ) recommended following applicants:

32. ToRs of MDR-TB Advisory Committee • Review and provide inputs to the regional strategies and/or action plans for scale up of programmatic management of drug-resistant TB (PMDT); • Review and analyze GLC monitoring mission reports and surveillance data; • Provide an opinion to donors/funding agencies on their request on country PMDT scale-up plans and the subsequent technical assistance needs addressing identified gaps, via the global GLC secretariat (g-GLC) Secretariat;

33. ToRs of MDR-TB Advisory Committee (Cont.) • Oversee the provision of supportive monitoring missions and technical assistance missions to countries; • Liaise with the g-GLC and exchange information on plans of the GLC South-East Asia 's activities, seek inputs and advice as and when required, and inform the g-GLC of technical and political issues relevant to TB and MDR-TB prevention and control; • In collaboration with WHO Regional Office and Partners, to convene advocacy efforts for PMDT scale up, access to and rational use of quality medicines, and coordinate and report on progress related to data collection in respective regions.

34. The way forward

35. TWG recommendations • The SEA rGLC should start functioning as soon as possible. The members need to develop an operational plan for the purpose • The SEA rGLC consider inviting ad hoc members for specific technical areas for which expertise is not represented among the permanent members of the committee • Member countries undertake clinical audits for management of DR-TB and ensure regular sensitization of practitioners through professional associations on the standards for clinical management of DR-TB cases • Research into shorter treatment regimens for treatment of DR-TB is strengthened

36. TWG recommendations • WHO and partners support NTPs in the member countries to develop and implement PMDT expansion plans at national level addressing identified bottle necks including: • Clear definition of roles and responsibilities of different partners • Advocacy to raise political commitment and adequate resources particularly funding and human resources, through appropriate financial mechanisms • Coordinated support to PMDT expansion plan development and implementation at national level to achieve universal access to timely diagnosis, treatment and care for all MDR-TB patients by 2015 • Identification of technical assistance needs and coordinated action plans to address them following the RDMA consultation. This also implies establishment/ strengthening of local TB TEAMs • Ensuring that no diagnosed patients have to wait for treatment and that sufficient drugs are available to complete treatment

37. TWG recommendations • WHO ensures close collaboration and coordination between the SEA regional GLC (rGLC) and GDF and other regional GLCs • WHO and implementing partners assist countries to strengthen their capacity in all aspects of management of second line anti-TB medicines (e.g. forecasting, quality assurance, storage at all levels, establishment of buffer stocks) including strengthened collaboration with National Regulatory Authorities

38. THANK YOU