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…..