1. PMDT expansion is first of all expansion of DR-TB detection services Workshop on the development and implementation of supervision and patient support approach in Drug Resistant programme in Nepal organized by HERD Kathmandu - April 30, 2014 Giampaolo Mezzabotta Medical Officer / Tuberculosis World Health Organization Country Office for Nepal

2. Fresh from HQs http://www.who.int/tb/laboratory/xpert_launch update/en/ http://www.who.int/tb/laboratory/xpert_launch update/en/

3. Overview of DR-TB in Nepal MDR−TB burden (from WHO Global TB Report 2013) Estimated total burden: 990 (among notified TB cases) Total confirmed cases: 354 (35.8% of estimated) Enrolled on treatment: 288 (81.4% of confirmed) Treatment Success Rate (from NTP Annual report 2014) 61.3%, reaching a peak of 72% in the cohort enrolled in March – July 2010* Key features of PMDT in Nepal standard treatment protocol for all MDR-TB cases; individualized Tx for pre- and XDR-TB treatment administered by DOT at DR-TB centres and sub-centres throughout its duration; two NRL, supervised by SRL (Gauting, Germany), both of them located in Kathmandu; supply of quality-assured SLD from GDF; no stock-out of SLD so far; travel & nutrition bonus (NPR 1500 (~ 15US$)/month) provided to patients. * = In the second quarter of 2013-14 the TSR reached 80%.

4. From field to lab to Tx From: “Screening retreatment tuberculosis patients for drug resistance in mid-west Nepal: how well are we doing?”, MB Tharu et al, PHA 2014; 4(1): 60-65 Diagnostic pathway to MDR-TB in 431 retreatment cases reported in Mid-West Region from July 2011 to July 2012 -62% -60% -5% -38%

5. Has the situation improved ever since? NTC and partners are currently running 22 GeneXpert machines, one of them in MWDR; 7 more machines in the pipeline for 2014. Guidelines and algorithms on the rational use of GeneXpert have been developed; WHO 2013 policy recommendations: “Xpert MTB/RIF should be used rather than conventional microscopy, culture and DST as the initial diagnostic test in adults suspected of having MDR-TB or HIV-associated TB (strong recommendation, high-quality evidence)” Strategic positioning of GeneXpert across the country, along with adequate logistic for sputum transport, should ensure equitable and early access to DR-TB diagnosis.

6. Realistic targets? Based on current estimates, notification data, projections and case-finding strategy (Xpert  C/DST), in the year 2014 NTP should aim at detecting: 710 MDR-TB cases among notified DR-TB suspects (1) 185 MDR-TB cases among initially SS- patients (2) 125 MDR-TB cases among DR-TB contacts (3) 100 XDR-TB and pre-XDR cases (4) TOTAL = 1120 DR-TB cases Notes (1): considering as DR-TB suspects the 2800 expected relapse, failure and defaulter cases; (2): assuming to test with GeneXpert all 8400 expected new SS- cases; (3): assuming 5 contacts per current DR-TB case and a prevalence of 5% among them; (4): estimating an incidence of XDR equivalent to 10% the incidence of MDR-TB

7. Conclusions Even if the target of 1120 DR-TB cases enrolled on treatment in 2014 will not be achieved, we can certainly forecast a substantial increase in the number of DR-TB patients. Adopting new treatment approaches, tapping the huge potential for community-based PMDT in Nepal, is more of a “must” than a choice.