A framework for the treatment and care of MDR and XDR-TB 3 … · Harness all public and private...
Transcript of A framework for the treatment and care of MDR and XDR-TB 3 … · Harness all public and private...
A framework for the treatment and care of MDR and XDR-TB3 April 2009
Paul Nunn, CoordinatorStop TB Department
The Problem
500,000 new patients with M/XDR-TB each yearOnly 3% are being properly treated in 2009
The IndicatorNumerator:Number of cases of MDR-TB started on treatmentDenominator:Number of culture +veMDR-TB cases estimated to have occurredin your countryAnnual monitoring, every year, just like DOTS
The ChallengeThe management of MDR-TB is
DemandingComplexCostly
With the exception of the Baltic states, Russian Federation and South Africa, all other high MDR burden countries are at pilot phaseScaling up is therefore the challenge
The bottlenecks to scaling up the treatment and care of M/XDR-TB
Addressed so far in this meeting:Weak basic TB controlInadequate laboratoriesImpact of HIVLow access to affordable drugs for the treatment of MDR-TB Inadequate human resourcesInfection control
To be addressed:Expansion of M/XDR-TB treatment and care
Models of care within a comprehensive frameworkHuman rights and ethicsInvolvement of all health care providersHow to scale up M/XDR-TB management
Note – not all bottlenecks apply to all countries
Pillars of M/XDR-TB treatment and care
Sustained political commitmentCase finding through culture and drug susceptibility testing (quality assured)Treatment with 2nd line drugsUninterrupted supplies of drugs (quality assured)Standardized recording and reporting
Models of Care: hospitalization vs. outpatient
HospitalizationEasier to do in some health systemsDOT easierFacilitates training on clinical managementbut requires:infection controlguaranteed funding and bed capacity ethical issues addressed
Out-patient careSocially acceptableLower costDOT more challenging
but requires:Access to a primary health care network Strong social supportCommunity-based care in many cases
Harness all public and private providers for MDR scale-up
ProblemMany private and public institutions outside NTP already do culture and DST, without quality assurancePrivate providers treat majority of MDR cases in some countries,outside NTP, and without quality assurance. 2nd line drug TB drugs only found in the private sector in several HBCs (e.g. India and Indonesia)
SolutionsSituation assessment - MDR-TB diagnosis and treatment practices and capacities in all sectorsAllocate MDR tasks to appropriate providersAccreditation of all practitioners
There is a role for everyone
Private "village doctor" providing ambulatory MDR treatment (under Damien Foundation Bangladesh) in rural Bangladesh (Picture by Ahmed Shakil)
The scale-up of MDR-TB managementProblem
MDR-TB management is a complex intervention, requiring careful implementationEfficacy of SLDs is a public health good that must be preserved67% of the 27 high MDR-TB burden countries, and 80% of the countries with GLC approved projects are still at pilot stage
Solutions (for countries)
Pilot MDR-TB management according to WHO guidelinesGet technical assistance for piloting from Green Light Committee (GLC)Collect and analyze the evidence for developing local policy (GLC)Get assistance in planning the scale up based on the lessons learned in the piloting phase (GLC)
Establishing strong partnerships is keyChallenges of implementing new diagnostics
Feasibility, contract, development phases
Demonstrationphase
Global Impact
Evaluationphase
Access phase
• Evidence for regulatory approval
• Evidence for making policy
• Evidence for scaling up
• Evidence for measuring impact
Moving from demonstration to access and impact requires that new diagnostic tools are integrated into functional laboratory services
Additional components to ensure quality diagnostic services
Essential instruments, reagents, supplies
• Global Policy
Concluding solutionsUrgently develop strategic M/XDR-TB policies and plans to prevent and manage MDR-TB within national TB control plans, which include,Where patients will be treated,And by whom,With affected communities involved,And all practitioners,And partnerships built,Come and present plans in the 7th MDR WG meeting, Geneva, October 12-13, 2009
And if we do all this then we can smile too…..