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Control of MDR-/XDR-TB and elimination of TB in Europe: status update Dr Masoud Dara Programme Manager TB and M/XDR-TB WHO Regional Office for Europe

I have no, real or perceived, conflicts of interest that relate to this presentation.

Outline of presentation An overview of TB and M/XDR-TB situation Global and European Response Current status of TB care and control Progress so far Process ahead

Estimated TB burden; world, 2010 www.worldmapper.org 8.8 million in the world 420 000 in Europe Global tuberculosis control: WHO report 2011. Geneva: WHO, 2011 (WHO/HTM/TB/2011.16)

Burden of TB in WHO Europe, 2010 19 April 2017 Main figures 420,000 new TB cases per year (47 per 100,000 pop, <1 – 206 in Monaco – Tajikistan) 81,000 (73-90,000) MDR-TB cases 60,000 (48-75,000) deaths Incidence peak in 2000, then falling by 2% per year; MDG target on track Prevalence falling, MDG target not on track Mortality falling, MDG target on track 18 high priority countries: Armenia, Azerbaijan, Belarus, Bulgaria, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Romania, Russian Fed, Tajikistan, Turkey, Turkmenistan, Ukraine, Uzbekistan Global tuberculosis control: WHO report 2011. Geneva: WHO, 2011 (WHO/HTM/TB/2011.16) 6 6

Global Progress 46 million patients cured, 1995-2010 On track to target 1990 2015 40% decline since 1990 Rate peaked in 2002 2010 Falling 1.3% per year Cases falling since 2006 46 million patients cured, 1995-2010 7 million lives saved compared to 1994 care standards 2015 MDG target on track: global TB incidence rate peaked in 2002, cases in 2006 BUT, TB incidence declining too slowly and 1.4 million people still dying unnecessarily Mortality

Percentages of notified MDR among TB cases, WHO European Region, 2005-2010 EUR have the highest MDR-TB rates in the world Even the best MDR detection in the world, we still miss the 66% (100-34) from the overall MDR cases emerged and 52% (100-48) from TB notified in the Region. In the framework of the WHO/Europe MDR-TB special project; a Consolidated Action Plan to Prevent and Combat M/XDR-TB is to be endorsed in September 2011 (RC in Baku) 8

MDR-TB Rates Belarus; DRS finalized recently: New: 32.3% (95% CI:29.7-35%) Previously treated: 75.6% (72.1-78.9%) 9

Percentages of TB cases with HIV infection among all TB cases tested to HIV, WHO European Region, 2006-2010 increasing by 20% per year in the last 5 years During the last 5 years TB/HIV co-infection increased, from 5 336 to 15 954 10

Percentages of notified TB cases of foreign origin among all TB cases, WHO European Region, 2010 Determinants of TB TB is particularly linked to migration, and imprisonment Identification of the geographic origin of patients was significantly better in western countries Identification of the imprisonment status of patients was significantly better in eastern countries Overall TB notification rate (all TB) per 100,000 inmates, the WHO European Region, 2010 Average = 280/100000 Two determinants play an important role for TB in our Region, one is migration and the other one is prison On this slide you can see two maps, the darker areas show importance of the above two determinants, on the above map you see in some countries particularly in the West up to 50% of TB cases are among migrants. On the below map you can notice the TB rate among prisoners, in the Eastern Europe and in some countries of the Region up to 2000 TB cases in every 100,000 prisoners (2%) have had TB. You can also notice some countries does not report TB cases among prisoners.

Treatment outcome by WHO Region, 2010 reporting year Other WHO Regions WHO European Region 12

Treatment outcome, new laboratory-confirmed pulmonary TB cases, European Region, 2001 - 2009 This slide shows the trends in treatment success of new pulmonary TB cases which are laboratory confirmed either by sputum smear or culture. You can see that the there has been a continuous decrease in treatment success rate with increase in failure (parallel to increase in MDR-TB rate). The death rate has also increased due to increase in MDR-TB and TB/HIV co-infection.

Children with TB, WHO European Region, 2010 About 10 000 children with TB This shows the concentration of TB cases reported among children. Every child counts, and if we plot every child as one dot, this is the picture we get on the map of the Region. Some countries, even in the western part of the Region, have reported many TB cases among children. In some of the countries in the western part of the Region, half the TB cases among children are among those younger than five years old. one dot = one child

Stop TB Strategy & Global Plan The global response: Stop TB Strategy & Global Plan To save lives, prevent suffering, protect the vulnerable, and promote human rights

European Response Berlin Declaration EU and WHO EURO action plans for TB and MDR-TB control EU and WHO EURO monitoring frameworks

Key challenges in prevention and control of M/XDR-TB Health system failure to prevent emergence and spread of drug resistance TB Late diagnosis of TB and M/XDR-TB Inadequate treatment of TB and subsequent acquired resistance Poor infection control and contact tracing Insufficient capacity to treat M/XDR-TB patients Models of care not cost effective, nor patient friendly Difficult access to expensive second line drugs Lack of new medicines Emergence of MDR-TB in our Region is a sign of health system failure. TB treatment success rates for new sputum smear positive patients has passed the WHO target of 85% in all Regions in the world except WHO Europe: Our treatment success rate is only 70% treatment success.   Treatment success rates among laboratory conformed TB patients in the EU countries are 78.1%  which is good but for MDR TB only 32%! A recent ECDC survey performed in selected clinical settings in EU including Germany and Italy revealed sub optimal practices in treatment regimens Evidence based treatment protocols are still not followed in the many countries in the Region, both west and east! That is why our collaboration with organizations as the European Centers of Disease Control and the European Respiratory Society is so crucial. With these partners, we are working on the development of European Standards of TB Care, which we will present at the Annual Conference of the European Respiratory Society in Amsterdam in 2 weeks. We need involvement of both high level policy makers to endorse the evidence based protocols and of national medical associations. With conventional method, it takes up to 1.5 to 2.5 months to diagnose MDR-TB in the lab and this adds to physician delay (several months often) and patients delay of several months leading to spread of the disease before it is finally diagnosed, in addition patients may be hospitalized or use health services undiagnosed with TB or undiagnosed with MDR-TB

Consolidated action plan to prevent and combat M/XDR-TB, 2011-2015 Goal : To contain the spread of drug resistant tuberculosis by achieving Universal Access to prevention, diagnosis and treatment of M/XDR-TB in all Member States of the WHO European Region by 2015 18

Targets MDR Action Plan 2011-15 To decrease by 20 percentage points MDR-TB proportion among previously treated patients by end 2015 To diagnose at least 85% of estimated MDR-TB patients by 2015 To successfully treat at least 75% of estimated number of patients suffering from MDR-TB by 2015 Universal Access is defined as evidence-based practices and quality services which are available, accessible, affordable and acceptable by people irrespective of their age, sex, sexual orientation, religion, origin, nationality, socioeconomic status or geographic background. The 62nd World Health Assembly on May 2009 has adopted a resolution on MDR-TB and XDR-TB (Agenda item 12.9): to achieve universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis as part of the transition to universal health coverage, thereby saving lives and protecting communities Target audiences The primary audience of the Plan is the Member States in WHO European Region. The Plan urges the involvement of civil society, communities affected by the disease, professional societies and national and international technical agencies and donors. The MDR-TB Action Plan calls for consolidated and coordinated action by the World Health Organization Regional Office for Europe Universal Access is defined as internationally accepted quality services which are available, accessible, affordable and acceptable by people irrespective of their age, sex, religion, origin, nationality, socioeconomic status or Geographic background.

What is new in MAP? Prompt diagnosis including newly endorsed molecular diagnostic techniques Equitable Access to adequate treatment Health System approach to MDR-TB prevention and control Emphasis on involvement of civil society organization Identifying and addressing social determinants Working in partnership, twinning of cities/programmes Robust monitoring framework, accountability and follow-up Promoting development of new drugs and tools With GeneXpert endorsed in December 2010, TB and Rifampicin resistance (MDR-TB proxy) can be diagnosed with a high sensitivity and specificity in most of our settings in 90 minutes (comparing to 1.5 months by conventional methods of culture and drug susceptibility testing) MAP facilitates development and introduction of new drugs and tools by engaging European research institutes in TB and M/XDR-TB

Expected Achievement of MAP 225 000 MDR-TB patients diagnosed 127 000 MDR-TB patients treated successfully; 250 000 MDR-TB cases averted; 13 000 XDR-TB cases averted; 120 000 lives saved; and 7 billion US $ is saved by averting further emergence of M/XDR-TB

Monitoring of MDR-TB, European Region 36% MDR-TB detection rate among all emerging 96% MDR-TB treatment enrolment 56% treatment success Target by 2015 85% Close to 100% 75% Estimated MDR burden, among all TB cases, WHO European Region 81 000 cases (73 000 – 90 000) Estimated percentage of MDR-TB Among new TB Among previously treated 13% (12 – 15%) 42% (38 – 47%) Coverage of culture confirmation DST testing 39.3% (152 827) 85.7% (131 007) Notified percentage of MDR-TB 13.7% (11 659) 48.7% (16 587) Detection Rate of all MDR-TB cases 36% (32–39%) (29 059) This slide shows increase of MDR-TB in the Region from 2.2% and 15.1% among new and retreatment cases respectively to 13.7% and 48.7% among new and retreatment cases in 2010 We also see that only about 40% of patients have access to culture and not all the cases who are cultured are checked for drug resistance. Therefore many MDR-TB cases may go undetected. 22

Joint launch of the MDR Action Plan, 2011 High level MDG6 Forum October 2011, Moscow This slide shows the official launch of Consolidated Action Plan to Prevent and Combat M/XDR-TB. The Plan was launched in Moscow during the MDG-6 summit 10 October 2011 by GFATM, StopTB partnership, European Commissioner and Regional Director 23

Primary Health Care, Psycho-social Support, Health Financing Regional Committee resolution on M/XDR-TB Adopts the Consolidated Action Plan and Urges Member States: to harmonize as appropriate their national health strategies and/or TB/MDR-TB response plans based on the Regional Plan to Identify and address determinants and health system challenges leading to emergence of drug resistant TB to provide universal access to early diagnosis and effective treatment of MDR-TB patients to address the needs of special population to closely monitor and evaluate implementation of the actions outlined in the Action Plan Requests the Regional Director: to provide leadership, strategic direction and technical support for implementation of the Action Plan to facilitate the exchange of experiences and know-how among the Member States to establish a platform to strengthen partnership for prevention and control of TB and M/XDR-TB to assess progress in the prevention and control of M/XDR-TB every other year starting from 2013 and report back to the Regional Committee The Resolution also urges civil society organizations, national and international partners and development agencies, in particular GFATM and the European Commission to fully support implementation of the Consolidated Action Plan - Health system self-assessment and/or programme reviews identifying the low hanging fruits and mid to long term key interventions - Round 11 GFATM providing additional fund to countries having sound MDR-TB response plans reviewed by the regional European Green Light Committee And a pro active support to go out to the countries on 6 monthly basis if not enough progress is noted by a small group of top level experts, partners and civil society representatives. I can already tell for example that leading experts like Prof Michel Iceman from .. have committed to join such high level expert missions, but we are even more so looking for our own experts from the Region, as for example Georgia and Russia, as long as the experts closely follow the international recommendations. Once again, let me repeat the following ara’s as top priority: Primary Health Care so that we can bring services closer to the population and patients; Psycho-social Support to stimulate the patient and family to complete treatment : never forget that the real VIP is our most vulnerable TB patients, And Health Financing reform to increase domestic resources by decreasing inefficiencies. All my teams are standby to provide the best possible support in these area’s. Primary Health Care, Psycho-social Support, Health Financing

Achievements after launch of MAP Eight countries (Armenia, Azerbaijan, Estonia, Georgia, Latvia, Switzerland, Ukraine and Uzbekistan) have adopted their National Plans to MAP Other countries are updating their plans with WHO and partners’ assistance EU parliamentarian hearing organized on World TB Day to brief MPs on M/XDR-TB 36 technical assistance mission on infection control, M/XDR-TB clinical, laboratory and programmatic management organized The second line drug forecasting and procurement supply and management elaborated in 18 high priority countries (workshop with GFATM, GLC/Europe and GDF organised) report available HUN, KAZ and AZE programme reviews organized Task Force on HS and MDR-TB established European TB Laboratory Initiative established Regional TB Interagency Coordination Committee is being established to oversee implementation of MAP These plans are either finalized or are being finalized. Switzerland plan is launched and available on internet and on WHO website

Looking beyond 2015: Rationale At the 65th World Health Assembly in May 2012, Member States called upon WHO to develop a new post-2015 TB strategy and targets and present this to Member States at the 67th World Health Assembly in 2014. Some States also urged WHO to start the formal process through the Executive Board and World Health Assembly in 2013.

Thank you very much for your attention With thanks to All 53 Member States Colleagues from WHO/Europe and WHO headquarters Pictures by Misha Friedman, winner of the 2010 Images to Stop TB Award, who travelled to Donestk, Ukraine, to capture difficult but moving instants in the daily lives of people ill with TB and those who care for them. www.euro.who.int/tb tuberculosis@euro.who.int