1. TB Control Measures: From development and endorsement to adoption and implementation Léopold Blanc TBS Stop TB department WHO Christy Garcia University of Connecticut School of Medicine

2. Overview Background Background Laboratory Laboratory Treatment Treatment Drug Resistant TB Drug Resistant TB TB/HIV TB/HIV Infection Control Infection Control Care Delivery Innovation Care Delivery Innovation Conclusions Conclusions

3. Background 2010: Global Plan estimates 16 medicines, 18 diagnostics, 12 vaccines in development 2010: Global Plan estimates 16 medicines, 18 diagnostics, 12 vaccines in development Recent years have seen the launch of several new tools with the recommendation to use Xpert MTB-RIF… conditions to be discussed during the Global consultation end of November Recent years have seen the launch of several new tools with the recommendation to use Xpert MTB-RIF… conditions to be discussed during the Global consultation end of November The time is right to evaluate uptake of these tools to adapt promotion for increased uptake in the future The time is right to evaluate uptake of these tools to adapt promotion for increased uptake in the future

4. Background Task Force on Retooling Task Force on Retooling –Created by Stop TB Partnership to help programmes implement new technologies Innovative New Approaches and Tools subgroup Innovative New Approaches and Tools subgroup –Ensure timely access to information on new tools and technical support for rapid adoption –Track progress in uptake and expansion of new tools

5. Background Method: Method: –Inventory of major policy changes in the last 10 years –Creation of questionnaire and piloting within HQ –Questionnaire distributed targeting 22 HBC and high MDR-TB countries –27/40 surveys were returned Goal: Identify areas of delay for better promotion of new approaches and tools in the future Goal: Identify areas of delay for better promotion of new approaches and tools in the future

6. Laboratory Challenges: Challenges: –Long delay between seeking care and diagnosis –Expensive technology not available for low- resource settings Newly endorsed methods: Newly endorsed methods: –New case definition smear + (2007) –Liquid culture and rapid speciation (2007) –Line-probe assay (2008) –LED FM (2009) –Xpert MTB-RIF (2010)

7. Laboratory Results Policy/Tool Previous Adoption Adopted within: No adoption 1yr2yrs3yrs New definition 5/270/273/272/2716/27 Liquid culture 8/279/273/270/277/27 Rapid Speciation 5/272/273/270/2717/27 LPA2/278/272/27NA15/27 LED FM 11/271/27NANA15/27

8. Laboratory Results Significant number of countries utilizing tool prior to WHO endorsement Significant number of countries utilizing tool prior to WHO endorsement Most of the uptake occurs within 1 st yr Most of the uptake occurs within 1 st yr Implementation mainly at national and regional level Implementation mainly at national and regional level

9. Treatment Challenges: Challenges: –Long duration –Multiple drugs Recent Policy Changes: Recent Policy Changes: 1999: Fixed-dose combination tablets for the treatment of tuberculosis 2003: Treatment of Tuberculosis: guidelines for national programmes 3 rd ed. 2010: Treatment of Tuberculosis: guidelines 4 th ed.

10. Treatment Results Policy Previous adoption Adopted within: No adoption 1yr2yrs3yrs4yrs5yrs6yrs7yrs8yrs FDCs10/272/271/272/271/272/272/271/271/274/27 Daily Rx entirely 13/270/272/271/272/271/271/270/27NA6/27 2HRZE/ 4HR Smear+17/271/271/271/271/273/271/270/27NA2/27 Smear - 15/270/271/271/271/273/272/270/27NA3/27

11. Treatment Results Policy Overall Adoption Prior Adoption FDCs86%37% Daily Rx 71%58% 6 month smear + 93%63% 6 month smear - 89%56% Substantial number of countries with guidelines in place prior to WHO policy:

12. Multidrug Resistant TB Challenges: Challenges: –Delayed identification leads to further spread of resistant strains Recent policy changes: Recent policy changes: 2006: Guidelines for the programmatic management drug-resistant tuberculosis 2008: Emergency update

13. Multidrug Resistant TB Results Policy Previous Adoption Adopted within: No adoption 1yr2yrs3yrs4yrs DST in new case areas prev >3% 6/270/271/270/270/2720/27 DST in MDR-TB exposure7/273/274/272/270/2711/27 DST retreatment 7/274/274/273/271/278/27 DST in sputum + pts at 3mos 8/274/275/272/270/278/27 MDR risk assess. 4/272/270/270/270/2721/27 Empiric MDR Rx 3/270/273/271/270/2720/27 DST in PLHIV 7/272/271/27NANA17/27

14. Multidrug Resistant TB Other risk categories in which routine DST is being conducted: Other risk categories in which routine DST is being conducted: –Patients who have failed first line treatment (68%) –Patients who have failed a retreatment regimen (84%) –7 EURO countries conduct routine DST in all TB patients 78% intensive phase conducted in hospital; 78% continuous phase as outpatient or community- based 78% intensive phase conducted in hospital; 78% continuous phase as outpatient or community- based 58% countries have recording and reporting system in place for adverse rxns to second line drugs 58% countries have recording and reporting system in place for adverse rxns to second line drugs

15. TB/HIV Challenges: Challenges: –Smear microscopy has lower sensitivity –Higher conversion latent to active infection –Interaction between ARVs and antituberculosis drugs Recent policy changes: Recent policy changes: 2004: Guidelines for HIV surveillance among tuberculosis patients 2007: Improving diagnosis and treatment of smear-negative pulmonary and extrapulmonary tuberculosis in adults and adolescents 2009: A guide to monitoring and evaluation for collaborative TB/HIV activities

16. TB/HIV Results Policy Previous Adoption Adopted within: No adoption 1yr2yrs3yrs4yrs5yrs6yrs HIV testing in TB patients7/279/273/271/271/272/270/274/27 TB screening in PLHIV 4/279/274/272/274/270/271/272/27 IPT0/273/273/273/272/271/274/2711/27 CPT2/277/272/273/274/272/271/273/27 New diagnostic algorithm 1/272/272/270/27NANANA11/27 ART regardless of CD4 count 0/274/27NANANANANA21/27

17. TB/HIV Few countries with existing TB/HIV policies in place Few countries with existing TB/HIV policies in place Good uptake of policies within 1-2yrs of WHO endorsement Good uptake of policies within 1-2yrs of WHO endorsement Low uptake of new diagnostic algorithm and IPT Low uptake of new diagnostic algorithm and IPT

18. TB Infection Control Challenges: Challenges: –Respiratory spread person to person –Greater exposure for health care workers, populations in congregate settings Recent Policies: Recent Policies: 1999: WHO guidelines for the prevention of TB in health care facilities in resource-limited settings 2009: WHO policy on TB infection control in health-care facilities, congregate settings, and households

19. TB Infection Control Results Policy Previous adoption Adopted within: No adoption 1yr2yrs3yrs4yrs5yrs6yrs7yrs8yrs>9yrs Adm0/272/270/271/271/270/273/270/273/2711/273/27 Env1/271/270/271/272/270/272/270/273/279/276/27 PPE1/272/271/271/272/270/273/270/273/2710/272/27 Plan3/278/273/271/27NANANANANANA8/27 HCW8/275/27NANANANANANANANA11/27

20. TB Infection Control Long delay between first endorsement of guidelines by WHO and adoption by countries Long delay between first endorsement of guidelines by WHO and adoption by countries Implementation mostly at national and regional level Implementation mostly at national and regional level Over half of countries implementing Over half of countries implementing policies only did so in TB care facilities

21. Care Delivery Innovation Challenges Challenges –Lack of infrastructure –Lack of human and financial resources –Engagement of political will Recent policies and tools Recent policies and tools 2006: Stop TB Strategy 2006: Engaging all health care providers in TB control 2007: A tool for national situation assessment 2008: Contributing to Health Systems Strengthening

22. Care Delivery Innovation Results Policy/ Tool Previous Adoption Adopted within: No adoption 1yr2yrs3yrs4yrs Adoption ISTC 0/2710/276/272/271/272/27 Adoption PAL 3/272/271/272/270/2718/27 Patient Charter 0/274/275/273/271/2713/27 Guidelines PPM 5/271/272/272/270/2716/27 NSA for PPM 6/272/271/271/27NA16/27 HSS framework 7/278/270/27NANA9/27

23. Care Delivery Innovation Area with least uptake of new tools and policies Area with least uptake of new tools and policies 41% of countries have advanced planning and preparation for new tools 41% of countries have advanced planning and preparation for new tools 33% of countries have INAT component in Global Fund agreement 33% of countries have INAT component in Global Fund agreement

24. Conclusions Largest percentage of uptake 1-2yrs after endorsement of policy Largest percentage of uptake 1-2yrs after endorsement of policy Most uptake seen with TB/HIV policies Most uptake seen with TB/HIV policies Both country factors and global factors play a role in delay of uptake Both country factors and global factors play a role in delay of uptake

25. Moving Forward… Continued use of survey instrument and database for broader sampling Continued use of survey instrument and database for broader sampling Collaboration between TB control areas to learn from examples of successful promotion Collaboration between TB control areas to learn from examples of successful promotion More focus on health systems strengthening More focus on health systems strengthening

26. Thank you