Progress in implementing the Stop TB Strategy and the Global Plan to Stop TB, 2006-2015

Update of the Working Group on MDR-TB

Thelma Tupasi, Chair of Working Group on MDR-TB

From DOTS to the Stop TB StrategyBuilding on Achievements for Future Planning

Meeting of 22 High Burden Countries and Core Groups of the Stop TB Partnership30 October 2006, La Maison des Polytechniciens, Paris, France

Outline

• Goal of the Global Plan 2006-2015 – Launched Jan, 2006

– To enroll on treatment 800,000 MDR-TB patients from 2006 to 2015

• MDR-TB in the new Stop TB strategy – Launched March 2006)

– To mainstream management of MDR-TB in TB control programmes ensuring access to rational treatment for ALL cases diagnosed with MDR-TB

Outcome of the Fifth Working Group meeting, May 12, 2006, Atlanta, US

Four major challenges to scale up MDR-TB management were identified

-Political commitment at country level and resource mobilization-Human resources-Capacity to diagnose all cases of MDR-TB-Drug management of second-line TB drugs

Challenge 1: Increased and sustained political commitment

to scale-up sound TB control programmes

Two growth projections for scaling up MDR-TB management

0

50

100

150

200

250

300

350

400

2000 2001 2002 2003 2004 2005 2006 2007 2008

Nu

mb

er

of

ap

pli

cati

on

s

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

Nu

mb

er

of

pati

en

ts

GLC-reviewed applications Applications: Scenario 1 - Steady growth

Applications: Scenario 2 - Rapid growth GLC-reviewed patients

Patients: Scenario 1 - Steady growth Patients: Scenario 2 - Rapid growth

Challenge 2: Human resources

•Limited number of consultants trained and Limited number of consultants trained and experienced in assisting on MDR-TB experienced in assisting on MDR-TB

managmentmanagment

•Quantity of properly trained human resources Quantity of properly trained human resources needed for scaling up MDR-TB management needed for scaling up MDR-TB management

at country level is unknownat country level is unknown

Challenge 3: Laboratory capacity

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Cases estimated detected with MDRTB

with estimated 45% case detection rate

with estimated 45% case detection rate

with estimated 5% DST coverage

with estimated 5% DST coverage

Source: WHO/STB/THD

•

Challenge 4: Drug management

Limited quantity of quality-assured manufacturers and products

High cost of second-line TB drugs

Market of second-line TB drugs needs to become more robust

Outcome of the Fifth Working Group meeting, May 12, 2006, Atlanta, US

Revitalize the Working Group in order to face these challenges:

-To create several subgroups within the WG:- Resource mobilization and advocacy- Research - Drug management- Focal person on laboratory needs for MDR-TB management- Infection control (created in October 2006, after the meeting of the WHO Global Task Force on XDR-TB).

-To produce an operational plan to scale up MDR-TB according to the Global Plan and the emerging challenge of XDR-TB (underway)

Progress in addressing the challenges for operationalizing the Strategic Plan of the WG

• Sustained commitment to scale up– Business plan for the GLC developed by WHO

Working Group Secretariat thanks to generous support of USAID

– Board of the GFATM agreed to fund GLC operations under a cost-sharing scheme. First disbursement expected in 2007.

– UNITAID gave green light for funding second-line TB drugs for MDR-TB management, operationally through GFATM and directly through GLC

Major progress in the political commitment to manage MDR-TB in several HBCs

• China: GFATM approved pilot project for 4,000 patients

• India: • WHO Guidelines for programmatic management of drug

resistant TB adapted• First application for MDR-TB management in two states

reviewed by GLC 1st November, 2006 • Plan of at least one MDR-TB project in 20 states by 2010

• Russia: • Project to treat 7,500 MDR-TB patients in 12 oblasts

approved by GFATM. • Ten applications under review/ to be approved by the GLC. • Major progress in laboratory capacity to diagnose drug

susceptibility testing.

• Eight high burden TB countries: GLC-supported Programmatic MDR-TB management

Scaling up of Programmatic MDR-TB treatment through the GLC

0

5

10

15

20

25

30

35

40

2000 2001 2002 2003 2004 2005 2006

Projects approvedOct 2006 – 40 projects

Almost 23'000 patients

approved for enrolment

Almost 23'000 patients

approved for enrolment

Countries with GLC approved projects

Domestic or other donor support• Armenia• Belize• Burkina Faso• Costa Rica• Estonia• Guinea• Haiti• India*• Jordan• Cambodia*• Lebanon• Lithuania• Latvia• Mexico• Nepal• Rwanda• Syria• Tunisia

GFATM support• Azerbaijan• Bangladesh*• Bolivia• DR Congo*• Dominican Republic• Ecuador• Egypt• Georgia• Honduras• Kenya*• Kyrgyzstan• Mongolia• Moldova• Nicaragua• Peru• Philippines*• Paraguay• Romania• Russia* • El Salvador• Timor-Leste• Uzbekistan

Total: 40 countries – 22 working with GFATM

= More than 23,000 MDR-TB patients

GLC applications under review• 6 regions in Russian

Federation (GFATM)

• China (GFATM)

• Kazakhstan (non GFATM)

• Uganda (non GFATM)

• India (both GFATM, other donors and domestic resources)

Status of GLC collaboration in high TB burden countries as of October 2006.

GLC approved:National TB Programs:

• Bangladesh• DR Congo• Kenya• China• Russian Federation• The PhilippinesNon-NTP• India• Cambodia

GLC under consideration

National TB Program:• India

Non-NTP• Uganda

GLC application underway

• Myanmar

Status of PMTM in high TB burden countries as of October 2006.

NTP:• Brazil, • DR of the

Congo,*• Mozambique, • Philippines,*• South Africa, • Russian Fed*• Thailand

GLC approved NTP:• India• China• Bangladesh• KenyaOperational Study• CambodiaNot NTP• Uganda• India in New Delhi

Status of PMTM funding in high TB burden countries as of October 2006.The three major

obstacles • weak laboratories, • lack of funding • lack of qualified staffGFATM funded DRS • Cambodia, • Nigeria • Zimbabwe GFATM funded MDR-TB

management • Kenya • Philippines

GFATM has approved funding for both DRS and MDR-TB control in 7 HBCs

• Bangladesh, • China, • DR of Congo, • India, • Indonesia,• Mozambique • Russia..

Progress in addressing the challenges for implementing the Global Plan and new Stop TB strategy

• Human resources– Second course of MDR-TB consultants, Latvia, Nov,

2006– First MDR-TB training workshop in Africa, Dar-es

Salaam, Oct, 2006.– Generic training modules for case finding and

management under development in the Philippines – Online training module for MDR-TB management

produced by World Medical Association, based on WHO Guidelines with Eli Lilly support

– SEARO MDR course Feb 2007

– country training courses: Philippines, Korea – the PIH course

Progress in addressing the challenges for implementing the Global Plan and new Stop TB strategy

• Laboratory capacity– To be reported by the DOTS expansion

Working Group

– expansion of the SRL

– planned training courses for FLD/SLD DST in conjunction with the SCLS

– Drug Resistance Survey

no data

estimates

sub-national surveys

countrywide surveys

Coverage of Anti-Tuberculosis Drug Resistance Surveillance

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

Drug Resistance Survey in HBCs

• 11 had carried out nationwide DRS by 2006– Philippines – Ethiopia – Tanzania

• Six high burden countries are expanding regional coverage of drug resistance surveys – India, China and Russia have all made major progress – China is planning a nationwide survey in 2007

• Indonesia has its first drug resistance survey underway• Afghanistan, Nigeria, Bangladesh and Pakistan have no

DRS and except Afghanistan plan to carry out surveys.

Cumulative DRS population coverage by WHO region - expected 2007

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0.9

1.0

AFR AMR EMR EUR SEAR WPR

WHO region

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ulat

ion

cove

rage

Progress in addressing the challenges for implementing the Global Plan and new Stop TB strategy

• Drug supply– UNITAID agreed to fund the WHO prequalification

programme, including all TB drugs – Three major meetings, funded by BMGF, held with

manufacturers in Russia and China to promote WHO prequalification,

– Update on WHO Prequalification project• 7 seven manufacturers applied• 13 dossiers submitted • 1 manufacturer WHO GMP approved• no product yet WHO approved

Subgroup on Research• Officially established in July 06

• Several institutions involved:– KNCV (Chair), CDC, PIH, MRC-South Africa,

University of Alabama-US, TRC-India– Secretariat in WHO/STOP TB

• 4 meetings by teleconference and 1 in person (this week)

• First task: to develop a new prioritized research agenda on drug resistant TB– first draft ready and circulated for comments

Acknowledge

• The work of the Working Group and the WHO Secretariat has been possible thanks to the generous funding of:

– BMGF– Eli Lilly Inc– DFID– USAID