Transcript Countries to involve all health care providers in the global response

PPM SUBGROUP MEETING
Cairo, 3-5 June 2008
Involving all health care providers
in the MDR and XDR-TB response
Matteo Zignol
Stop TB Department
World Health Organization
How to approach the problem of
anti-TB drug resistance
• 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)
What is the problem?
Drug
susceptible
TB*
MDR-TB
XDR-TB
1990
2006
*or limited
resistance
Resistance
to H&R
Resistance to (R, H, Fqs)
and (Km or Am or Cm)
Manageable
with 4 drug
regimen
Treatable
with 2nd
line drugs
Treatment options
seriously restricted
Cure rate:
virtually 100%
Cure rate:
up to 80%
Cure rate: up to 35%
MDR-TB among new TB cases,
1994-2007
< 3%
3-6 %
>6%
No data
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 among MDR-TB cases,
1994-2007
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< 3% or less than 3 cases in one
year of surveillance
3 - 10%
> 10%
Report of at least one case
No data
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
• Prior TB treatment
• Cure or Completed treatment
• Treatment Default or Failure
• HIV-infected (44 tested)
• Dead (Includes 34% on ARV)
• Identical M. tb spoligotype
26 (51)
14 (28)
7 (14)
44 (100)
52 (98)
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)
Phases in PMDT implementation
Tala, Tayuman ,
MM South,Cebu
LCP DOTS Center
pre GF/GF2
GF 5
(gov’t PPMD)
Cumulative
KASAKA Housing Facility
3500
(private)
TDF-MMC DOTS Clinic (private PPMD)
3230
3000
2590
2500
2000
1950
PPMD units
Public health centers
1216
Faith-based orgs
1500
1000
728
474
500
6
6
15
105
21 84
55
283
21 183
191
161
100
(14 GF)
640
640
640
2009
2010
396
184
70
92
94
0
1999
Pilot
TDF, Philippines
2000
2001
2002
2003
2004
2005
Expansion
2006
2007
2008
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 MDRTB 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!