1. World Health Organization Regional Office for the Western Pacific Drug-resistant tuberculosis in the WHO Western Pacific Region Tauhid Islam Stop TB and Leprosy Elimination World Health Organization Regional Office for the Western Pacific NINTH TECHNICAL ADVISORY GROUP (TAG) AND NATIONAL TB PROGRAMME MANAGERS MEETING FOR TB CONTROL WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC 9-12 December 2014, Manila, Philippines

2. World Health Organization Regional Office for the Western Pacific MDR-TB patients speak Courtesy: MDR-TB working group, Stop TB Partnership

3. World Health Organization Regional Office for the Western Pacific Content highlights Coverage of DRS Estimated MDR-TB burden Burden over time DST coverage: FLD &SLD Notifications and enrolment Treatment outcomes Financing Cascade of PMDT Way forward - Group work

4. World Health Organization Regional Office for the Western Pacific Data source Data source: Global TB database Acknowledgements: All countries of the Region who submitted data and Tom Hiatt Nobuyuki Nishikiori Cornelia Hennig Matteo Zignol Anna Dean

5. World Health Organization Regional Office for the Western Pacific Coverage of DRS Drug resistance data available from 25 of the 36 countries and areas –Routine surveillance - 19 –Periodic surveys - 6 National DRS data - 5 out of 7 priority countries At least two national representative survey data points - Cambodia, Mongolia, Philippines and Viet Nam 2 countries with pending DRS data: Papua New Guinea and Lao People’s Democratic Republic Malaysia's 1997 data originated from non-representative geographical areas

6. World Health Organization Regional Office for the Western Pacific Estimated MDR-TB MDR-TB among new cases MDR-TB among previously treated TB cases Total MDR-TB cases CountryData type and yearn % N % n Australia Surveillance (2013) 16(9–27) 2(1–4) 1(0–7) 4(< 1–21) 17(8–26) Cambodia Survey (2007) 320(160–580) 1(< 1–3) 180(68–370) 11(4–22) 510(270–740) China Survey (2007) 45 000(35 000–55 000) 6(5–7) 9 200(7 800–11 000) 26(22–30) 54 000(48 000–61 000) Hong Kong (China) Surveillance (2012) 34(21–52) < 1(< 1–1) 9(3–20) 3(< 1–6) 43(26–59) Macao (China) Surveillance (2013) 7(2–16) 2(< 1–5) 4(1–10) 12(2–30) 11(4–18) Japan Surveillance (2002) 110(63–160) < 1(< 1–1) 100(72–130) 10(7–13) 200(150–260) Lao People’s Democratic Republic Model† 160(96–230) 5(3–6) 65(56–75) 24(20–27) 220(160–290) Malaysia Survey (1997) 19(0–120) < 1(0–< 1) 0(0–340) 0(0–17) 19(0–57) Mongolia New: Survey (2007) Previously treated TB : surveillance (2013) 33(16–59) 1(< 1–3) 210(180–240) 34(29–38) 240(210–280) New Zealand Surveillance (2012) 1(0–5) < 1(< 1–3) 2(0–5) 17(2–48) 3(0–6) Papua New Guinea Model 560(340–800) 5(3–6) 570(480–650) 24(20–27) 1 100(890–1 400) Philippines Survey (2012) 4 400(3 100–6 000) 2(1–3) 4 100(3 000–5 500) 21(16–29) 8 500(6 900–10 000) Republic of Korea Surveillance (2004) 780(600–980) 3(2–3) 1 200(850–1 600) 14(10–19) 1 900(1 600–2 300) Singapore Surveillance (2013) 17(8–30) < 1(< 1–2) 3(0–12) 3(< 1–9) 20(9–31) Viet NamSurvey (2012) 3 000 (1 900–4 100) 4(3–5) 2 100(1 500–2 600) 23(17–30) 5 100(4 100–6 100) Western Pacific Region 53 000(31 000–75 000) 4(3–6) 18 000(15 000–21 000) 22(18–26) 71 000(47 000–94 000)

7. World Health Organization Regional Office for the Western Pacific Estimated MDR-TB

8. World Health Organization Regional Office for the Western Pacific Estimated MDR-TB Intercept 0.08%, coefficient 3.1%, F-statistics 3.84, p=0.123

9. World Health Organization Regional Office for the Western Pacific Trends in drug resistance

10. World Health Organization Regional Office for the Western Pacific Trends in drug resistance

11. World Health Organization Regional Office for the Western Pacific Trends in drug resistance

12. World Health Organization Regional Office for the Western Pacific DST coverage Notified cases with DST resultsCases confirmed by Xpert among MDR-TB and RR-TB * New Ret. TotalNew Ret. Total n% n% n%n% N% n% Cambodia–– –– –––– –– –– China20 0803 7 15320 27 233324415 24610 49012 Lao People’s Democratic Republic 11< 1 7126 8220– 00 00 Malaysia2 70214 1819 11 1105200 00 00 Mongolia28912 53185 838281523 3821 5322 Papua New Guinea–– –– 93< 1–– –– 3372 Philippines25< 1 2 63114 2 6561–– –– –– Viet Nam353< 1 3 95545 4 53153792 80180 84181 Western Pacific Region 36 1033 16 05720 60 765529612 1 08519 1 41717

13. World Health Organization Regional Office for the Western Pacific DST coverage Among patients tested in 2013 – 8% were resistant to isoniazid only –2% were resistant to rifampicin only –11% were resistant to both The Xpert MTB/RIF test was used to identify 17% of MDR-TB patients –highest for Viet Nam at 81%

14. World Health Organization Regional Office for the Western Pacific DST coverage

15. World Health Organization Regional Office for the Western Pacific Notifications and enrolment EstimatedNotified % notified among estimated Enrolled on treatment New Ret. TotalNew Ret. Total a New Ret. Totaln % among detected Cambodia320 180 510– – 121– – 24121 100 China45000 9200 54 0001612 2571 41834 28 82184 52 Lao People’s Democratic Republic 160 65 2200 7 70 11 34 57 Malaysia19 0 80 5 277421 NA 1 45849 18 Mongolia33 210 24064 177 257194 84 107192 75 Papua New Guinea 560 570 1 100– – 119– – 11145 122 Philippines4400 4100 8 50010 1349 3962< 1 33 472262 57 Viet Nam3000 2100 5 10040 997 12041 47 24948 79 Western Pacific Region 53000 18000 71 0002379 5664 111534 31 166926 62

16. World Health Organization Regional Office for the Western Pacific Notifications and enrolment

17. World Health Organization Regional Office for the Western Pacific Treatment outcome

18. World Health Organization Regional Office for the Western Pacific Second line DST & XDR-TB 2nd-line DSTResistance to FQ Resistance to 2nd-line injectible XDR-TB number % of enrolled number % of tested number % of tested number % of tested Australia 12552171800 Hong Kong Special Administrative Region (China) 261182831214 Macao Special Administrative Region (China) 788000000 Lao People’s Democratic Republic 41001250000 Malaysia 1132311211221< 1 Mongolia 1135965151354 New Zealand 2100000000 Papua New Guinea 73501123–– Philippines 927415963845< 1 Republic of Korea 8388815819112138510 Singapore 1280000000 Viet Nam 1992129152312105 Western Pacific Region 2 326342701219681075

19. World Health Organization Regional Office for the Western Pacific Financing for MDR-TB

20. World Health Organization Regional Office for the Western Pacific AT A GLANCE 71 000 11 153 6 926 52% Patients of MDR-TB estimated among reported TB patients by national TB programmes in Western Pacific Region in 2013 16% of the estimated patients with MDR-TB (11 153 out of 71 000) were detected and reported in 2013 62% detected MDR-TB were started on second –line treatment for MDR-TB in 2013, leaving many patients untreated Of MDR-TB patients of 2011 cohort had a successful treatment outcome

21. World Health Organization Regional Office for the Western Pacific Cascade of patient centred PMDT (1) step-wise increase of the proportion of TB patients who receive drug susceptibility testing (DST) (2) all diagnosed patients are promptly notified and enrolled in treatment (3) all enrolled patients complete their treatment with effective patient-centred support.

22. World Health Organization Regional Office for the Western Pacific Major issues Low DST coverage Laboratory capacity Slow roll out of rapid diagnostic Screening policy and practise Human and financial resource Burden of MDR-TB among new Mis- alignment: Notification- enrolment Poor treatment outcome/high loss to follow up Lack of access Lack of communicatio n Non- availability of drugs Lack of psycho social support Lack of enabling environment

23. World Health Organization Regional Office for the Western Pacific PRIORITY ACTIONS

24. A public health crisis Even if most TB patients in the world are not drug-resistant (5% of total TB burden), the burden of MDR-TB in the world poses a formidable challenge to the prospect of controlling TB Drug susceptible strain may be replaced by drug resistant strain Overall treatment success rate less than 50% complicated long treatment catastrophic expenditure (200-400 times costly than drug susceptible TB) huge burden on existing human resource and technical capacity

25. World Health Organization Regional Office for the Western Pacific ‘How to’ plan Guiding questions: –How to improve cascade of care in each country by the next 2 years? Expected outcome –Group or country specific presentation

26. World Health Organization Regional Office for the Western Pacific ‘How to’ plan Group work: Group 1: Philippines; Viet Nam, PNG Upper lounge Facilitators: Lee Reichman, Chen-Yuan Chiang) –Group 2: Cambodia, Lao PDR, Mongolia Room 212 Facilitators: Jacques van den Broek, Takashi Yoshiama –Group 3: China, Malaysia Room 210 Facilitators: Wing-Wai Yew, Richard Lumb

27. World Health Organization Regional Office for the Western Pacific Courtesy: MSF access campaign – test me – treat me “We have to make this people’s fight. Each one has a name and a family. They are not just numbers.”