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

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) How to approach the problem of anti-TB drug resistance

What is the problem? Drug susceptible TB* *or limited resistance Manageable with 4 drug regimen Cure rate: virtually 100% Resistance to H&R Treatable with 2 nd line drugs Cure rate: up to 80% MDR-TB 1990 XDR-TB 2006 Resistance to (R, H, Fqs) and (Km or Am or Cm) Treatment options seriously restricted Cure rate: up to 35%

Based on 138 settings surveyed in 116 countries between ,000 incident cases in 2006 (95% CI: 455,000–614,000) 4.8% of all cases notified in 2006 (95% CI: 4.6%–6.0%) Global estimate of MDR-TB

MDR-TB among new TB cases,

XDR-TB among MDR-TB cases, 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 All rights reserved

XDR-TB in South Africa Study characteristics (53 patients)No. (%) No prior TB Treatment26 (51) Prior TB treatment Cure or Completed treatment14 (28) Treatment Default or Failure7 (14) HIV-infected (44 tested)44 (100) Dead (Includes 34% on ARV)52 (98) Identical M. tb spoligotype26/30 Lancet 2006; 368:

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)

TDF-MMC DOTS Clinic (private PPMD) KASAKA Housing Facility (private) LCP DOTS Center (gov’t PPMD) Tala, Tayuman, MM South,Cebu Phases in PMDT implementation Faith-based orgs Public health centers PPMD units TDF, Philippines Pilot ExpansionMainstreaming 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 MDR- TB 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!