What, Where, How and Action Steps… XDR-TB Extensively Drug-Resistant Tuberculosis What, Where, How and Action Steps…

Confirmed cases to date Countries with XDR-TB Confirmed cases to date Argentina Armenia Bangladesh Brazil Canada Chile 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 WHO 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 2005. All rights reserved China, Hong Kong SAR Czech Republic Ecuador France Portugal Georgia Republic of Korea Germany Russian Federation Islamic Republic of Iran Italy South Africa Japan Spain Latvia Sweden Mexico Thailand Norway UK Based on information provided to WHO Stop TB Department March 2007 Peru USA

Emergence of XDR-TB March 2006 XDR = Multidrug-resistant TB (MDR-TB) plus resistance to (i) any fluoroquinolone, and (ii) at least 1 of 3 injectable second-line drugs capreomycin, kanamycin, amikacin (new definition agreed October 2006) MDR-TB = resistance to at least isoniazid and rifampicin, the two most powerful first-line anti-TB drugs Of 17,690 isolates from 49 countries during 2000-2004, 20% were MDR-TB and 2% were XDR-TB XDR-TB found in: USA: 4% of MDR-TB Latvia: 19% of MDR-TB S Korea: 15% of MDR-TB

Given the underlying HIV epidemic in Africa, XDR-TB in Southern Africa August 2006 Church of Scotland Hospital, Tugela Ferry, KwaZulu-Natal Province, South Africa 53 of 544 patients defined as XDR-TB cases 52 of the 53 patients died on average within 25 days, including those on antiretroviral therapy Further investigations being carried out XDR-TB likely in bordering African countries Given the underlying HIV epidemic in Africa, drug-resistant TB could have a major impact on mortality and requires urgent action on care and prevention

WHO Stop TB Strategy addresses drug resistance by strengthening TB control 14

The Stop TB Strategy & The Global Plan However, Even at maximum DOTS coverage, case detection seems to remain below the 70% target level in most settings (Dye et al 2002) So we need innovative approaches to case detection. The DEWG is a mechanism to do whatever it needs to be done We need to ensure we make good use of it. The 2nd ad hoc Committee produced some recommendations for action, the DEWG is a tool to facilitate/implement some of them. The Stop TB Strategy strengthens TB control, preventing the emergence of drug-resistant TB… …and underpins the Stop TB Partnership's Global Plan to Stop TB 2006-2015, to treat 50 million patients and save 14 million lives

WHO Global Task Force on XDR-TB, October 2006 International response to the XDR-TB emergency WHO Global Task Force on XDR-TB, October 2006 "Priority for the immediate strengthening of TB control in countries" Accelerate access to rapid tests for rifampicin resistance Ensure adherence to WHO drug resistance guidelines, improve programme management, access to MDR-TB drugs under proper conditions including direct observation. Ensure all patients with HIV are adequately treated for TB and started on antiretroviral therapy Accelerate implementation of infection control measures to reduce transmission especially among those HIV positive Strengthen laboratory capacity to diagnose, manage and survey drug resistance. Commence rapid survey so that the size of the XDR-TB epidemic can be determined Initiate information-sharing strategies that promote prevention, treatment and control of XDR-TB

to respond to the XDR-TB emergency Resources needed in 2007 to respond to the XDR-TB emergency Estimated needs for 14 Southern African Development Community countries from November 2006 to end 2007 US$ Costs in the 14 countries: $35m: Strengthening XDR-TB response: human resources development, lab strengthening, infection control, surveillance, monitoring and evaluation, community health, cross border collaboration, communication and health education etc. $40m: Second line anti-TB drugs to 9,000 MDR-TB and XDR-TB patients $ 5m: Rapid diagnostic tests to 154,000 MDR-TB and XDR-TB suspects $80 million Technical assistance costs (coordinated by WHO and provided by WHO and partners): $9,460,000: Strengthening of general TB and TB/HIV control in countries most affected by XDR-TB by provision of technical assistance by international organizations and human resource development $ 450,000: Revision of the Global Plan to Stop TB to reflect XDR-TB (not restricted to Africa) $1,230,000: Support for management of persons suspected of having MDR-TB or XDR-TB $1,200,000: Laboratory strengthening: development/revision of global and country strategic plans, strengthening of the global Supranational TB Reference Laboratory Network $ 375,000: Infection control: updating of guidelines, training of consultants $1,700,000: XDR-TB surveillance: establishment of regional reference laboratories in the African Region, support to countries by the Supranational Reference Laboratory Network, rapid XDR-TB surveys $ 285,000: Advocacy, communication and social mobilization: communication support, advocacy materials, health education tools etc. $ 100,000: Planning and resource mobilization support and coordination of partners $ 200,000: Research and Development Strategy: meeting with TB diagnostics, drugs and vaccine working groups and partners $15 million TOTAL $95 million

XDR-TB The Facts Drug-resistant TB poses a grave public health threat especially in populations with high HIV rates XDR-TB occurs as a result of poorly-managed TB control programmes XDR-TB, if identified early, can be treated and cured in some cases under proper TB control conditions, based on the experiences in a few successful programmes where HIV prevalence was low Infection control measures must be strengthened everywhere, and especially where HIV prevalence is high, to protect the vulnerable and those at risk of XDR-TB XDR-TB strains have been found in all regions of the world, although still thought to be uncommon  XDR-TB underlines the need for investment in the development of new TB diagnostics, treatments and vaccines, since the current tools are outdated and insufficient

World Health Organization Leading the fight against TB and XDR-TB "We will build greater momentum to control malaria, TB and neglected diseases" Dr Margaret Chan WHO Director-General Elect Acceptance speech to the World Health Assembly "WHO is absolutely committed to supporting country efforts to fight TB in all forms" Dr Anders Nordström WHO Acting Director-General Address to the Global Task Force on XDR-TB "WHO Stop TB, with full resources in place, will ensure the response to the XDR-TB emergency is effective and robust" Dr Mario Raviglione WHO Director Stop TB Department

XDR-TB For more information: WHO Stop TB: Stop TB Partnership: for latest XDR-TB data, country reports, monthly updates, guidelines, FAQs, www.who.int/tb Email: thomasg@who.int Stop TB Partnership: for information on XDR-TB activities of the Partnership's Working Groups and its 500 partners www.stoptb.org Email: stoptbinfo@who.int