1. Progress in implementing the Stop TB Strategy and the Global Plan to Stop TB, 2006-2015 Update of the Working Group on MDR-TB Thelma Tupasi, Chair of Working Group on MDR-TB From DOTS to the Stop TB Strategy Building on Achievements for Future Planning Meeting of 22 High Burden Countries and Core Groups of the Stop TB Partnership 30 October 2006, La Maison des Polytechniciens, Paris, France

2. Outline Goal of the Global Plan 2006-2015 –Launched Jan, 2006 –To enroll on treatment 800,000 MDR-TB patients from 2006 to 2015 MDR-TB in the new Stop TB strategy –Launched March 2006) –To mainstream management of MDR-TB in TB control programmes ensuring access to rational treatment for ALL cases diagnosed with MDR-TB

3. Outcome of the Fifth Working Group meeting, May 12, 2006, Atlanta, US Four major challenges to scale up MDR-TB management were identified -Political commitment at country level and resource mobilization -Human resources -Capacity to diagnose all cases of MDR-TB -Drug management of second-line TB drugs

4. Challenge 1: Increased and sustained political commitment to scale-up sound TB control programmes Two growth projections for scaling up MDR-TB management

5. Challenge 2: Human resources Limited number of consultants trained and experienced in assisting on MDR-TB managmentLimited number of consultants trained and experienced in assisting on MDR-TB managment Quantity of properly trained human resources needed for scaling up MDR-TB management at country level is unknownQuantity of properly trained human resources needed for scaling up MDR-TB management at country level is unknown

6. Challenge 3: Laboratory capacity with estimated 45% case detection rate with estimated 45% case detection rate with estimated 5% DST coverage with estimated 5% DST coverage Source: WHO/STB/THD

7. Challenge 4: Drug management Limited quantity of quality-assured manufacturers and products High cost of second-line TB drugs Market of second-line TB drugs needs to become more robust

8. Outcome of the Fifth Working Group meeting, May 12, 2006, Atlanta, US Revitalize the Working Group in order to face these challenges: -To create several subgroups within the WG: - Resource mobilization and advocacy - Research - Drug management - Focal person on laboratory needs for MDR-TB management - Infection control (created in October 2006, after the meeting of the WHO Global Task Force on XDR-TB). -To produce an operational plan to scale up MDR-TB according to the Global Plan and the emerging challenge of XDR-TB (underway)

9. Progress in addressing the challenges for operationalizing the Strategic Plan of the WG Sustained commitment to scale up –Business plan for the GLC developed by WHO Working Group Secretariat thanks to generous support of USAID –Board of the GFATM agreed to fund GLC operations under a cost-sharing scheme. First disbursement expected in 2007. –UNITAID gave green light for funding second- line TB drugs for MDR-TB management, operationally through GFATM and directly through GLC

10. Major progress in the political commitment to manage MDR-TB in several HBCs China : GFATM approved pilot project for 4,000 patients India: WHO Guidelines for programmatic management of drug resistant TB adapted First application for MDR-TB management in two states reviewed by GLC 1 st November, 2006 Plan of at least one MDR-TB project in 20 states by 2010 Russia: Project to treat 7,500 MDR-TB patients in 12 oblasts approved by GFATM. Ten applications under review/ to be approved by the GLC. Major progress in laboratory capacity to diagnose drug susceptibility testing. Eight high burden TB countries: GLC-supported Programmatic MDR-TB management

11. Scaling up of Programmatic MDR-TB treatment through the GLC Oct 2006 – 40 projects Almost 23'000 patients approved for enrolment

12. Countries with GLC approved projects Domestic or other donor support Armenia Belize Burkina Faso Costa Rica Estonia Guinea Haiti India* Jordan Cambodia* Lebanon Lithuania Latvia Mexico Nepal Rwanda Syria Tunisia GFATM support Azerbaijan Bangladesh* Bolivia DR Congo* Dominican Republic Ecuador Egypt Georgia Honduras Kenya* Kyrgyzstan Mongolia Moldova Nicaragua Peru Philippines* Paraguay Romania Russia* El Salvador Timor-Leste Uzbekistan Total: 40 countries – 22 working with GFATM = More than 23,000 MDR-TB patients GLC applications under review 6 regions in Russian Federation (GFATM) China (GFATM) Kazakhstan (non GFATM) Uganda (non GFATM) India (both GFATM, other donors and domestic resources)

13. Status of GLC collaboration in high TB burden countries as of October 2006. GLC approved: National TB Programs: Bangladesh DR Congo Kenya China Russian Federation The Philippines Non-NTP India Cambodia GLC under consideration National TB Program: India Non-NTP Uganda GLC application underway Myanmar

14. Status of PMTM in high TB burden countries as of October 2006. NTP: Brazil, DR of the Congo,* Mozambique, Philippines,* South Africa, Russian Fed* Thailand GLC approved NTP: India China Bangladesh Kenya Operational Study Cambodia Not NTP Uganda India in New Delhi

15. Status of PMTM funding in high TB burden countries as of October 2006. The three major obstacles weak laboratories, lack of funding lack of qualified staff GFATM funded DRS Cambodia, Nigeria Zimbabwe GFATM funded MDR-TB management Kenya Philippines GFATM has approved funding for both DRS and MDR-TB control in 7 HBCs Bangladesh, China, DR of Congo, India, Indonesia, Mozambique Russia..

16. Progress in addressing the challenges for implementing the Global Plan and new Stop TB strategy Human resources –Second course of MDR-TB consultants, Latvia, Nov, 2006 –First MDR-TB training workshop in Africa, Dar-es Salaam, Oct, 2006. –Generic training modules for case finding and management under development in the Philippines –Online training module for MDR-TB management produced by World Medical Association, based on WHO Guidelines with Eli Lilly support –SEARO MDR course Feb 2007 –country training courses: Philippines, Korea –the PIH course

17. Progress in addressing the challenges for implementing the Global Plan and new Stop TB strategy Laboratory capacity –To be reported by the DOTS expansion Working Group –expansion of the SRL –planned training courses for FLD/SLD DST in conjunction with the SCLS –Drug Resistance Survey

18. no data estimates sub-national surveys countrywide surveys Coverage of Anti-Tuberculosis Drug Resistance Surveillance 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 2006. All rights reserved

19. Drug Resistance Survey in HBCs 11 had carried out nationwide DRS by 2006 –Philippines –Ethiopia –Tanzania Six high burden countries are expanding regional coverage of drug resistance surveys –India, China and Russia have all made major progress –China is planning a nationwide survey in 2007 Indonesia has its first drug resistance survey underway Afghanistan, Nigeria, Bangladesh and Pakistan have no DRS and except Afghanistan plan to carry out surveys.

20. Cumulative DRS population coverage by WHO region - expected 2007

21. Progress in addressing the challenges for implementing the Global Plan and new Stop TB strategy Drug supply –UNITAID agreed to fund the WHO prequalification programme, including all TB drugs –Three major meetings, funded by BMGF, held with manufacturers in Russia and China to promote WHO prequalification, –Update on WHO Prequalification project 7 seven manufacturers applied 13 dossiers submitted 1 manufacturer WHO GMP approved no product yet WHO approved

22. Subgroup on Research Officially established in July 06 Several institutions involved: –KNCV (Chair), CDC, PIH, MRC-South Africa, University of Alabama-US, TRC-India –Secretariat in WHO/STOP TB 4 meetings by teleconference and 1 in person (this week) First task: to develop a new prioritized research agenda on drug resistant TB –first draft ready and circulated for comments

23. Acknowledge The work of the Working Group and the WHO Secretariat has been possible thanks to the generous funding of: –BMGF –Eli Lilly Inc –DFID –USAID