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Follow-up of Berlin declaration and
Consolidated Action Plan to prevent
and combat M/XDR-TB 2011-2015
Dr Masoud Dara, Programme Manager
TB and M/XDR-TB
WHO Regional Office for Europe
Wolfheze 2013, NTP manager’s meeting
29 May 2012
Outline of presentation
• Berlin Declaration and Consolidated Action
Plan to Prevent and Combat M/XDR-TB
(MAP) in a nutshell
• TB and MDR-TB epidemiological situation
• Status of MAP core indicators
• Achievements and challenges
• Conclusions
• Next steps
Berlin declaration October 2007
Ministers of Member States in WHO European Region:
1. Note with concern that TB has re-emerged as an increasing threat to
health security in the WHO European Region
2. Despite some achievements over the past decade, TB control and efforts
towards elimination of the disease in the Region need to be improved
3. Recognize that many countries have national plans for TB control and
national and international funding and support for TB activities in the
European Region have grown
4. Note with concern the gaps to be bridged in order to fully implement the
Stop TB Strategy for effective TB control
5. Commit themselves to strengthen political will, adopt the Stop TB
Strategy in all its components, to secure sustainable financing
6. Commit themselves to closely monitoring and evaluating the
implementation of the actions outlined in this Declaration every 2 years
starting from 2009
Consolidated Action Plan to Prevent and Combat
M/XDR-TB 2011-2015
• Prompt diagnosis, including newly endorsed
molecular diagnostic techniques
• Equitable access to adequate treatment
• Health system approach to preventing and
controlling MDR-TB
• Emphasis on involving civil society organizations
• Identifying and addressing social determinants
• Working in partnership, twinning of cities and
programmes
• Robust monitoring framework, accountability
and follow-up
• Including neglected aspects (such as palliative
care and surgery)
Expected achievements of MDR-TB Action Plan
(MAP)
• 225 000 people with MDR-TB
diagnosed
• 127 000 people with MDR-TB
treated successfully
• 250 000 MDR-TB and 13 000 XDR-
TB cases averted
• 120 000 lives and 12 US$ billion
saved
75.436 71.478
28.887
60.756
17.913
60.756
10512
45567
2011 2012 2013 2014 2015
Expected achievements due to the implementation of the action plan, 2011– 2015
Estimated MDR-TB cases emerging
MDR-TB cases, detected
MDR-TB patients enrolled on treatment
MDR-TB patients succesifully treated
Full coverage for with DST for detecting 85% of MDR-TB
Full coverage for treatment enrolment
Areas of intervention
Prevent the development of M/XDR-TB
Scale up access to effective treatment
Scale up access to early diagnosis
Infection control
Strengthen surveillance
Expand management capacity of the programmes
Address the needs of special populations
The WHO European Region has the
lowest treatment success rate worldwide
67
58
72
63
75 75
74 7475
7072
7071
7069
67
57
54
60
64 64
69
73
76
80
8385
8486 86 86
87
45
50
55
60
65
70
75
80
85
90
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Tre
atm
en
t su
cce
ss r
ate
(%)
Treatment success for new smear-positive cases (%), WHO European region and globally (1995-2010)
EUR
Global
While globally in
other regions
treatment success
rate steadily is
increasing, in WHO
European region it is
reducing.
Treatment outcome of laboratory confirmed
new pulmonary TB cases, 2010
Low treatment success rate in
region (67.2%) is explained
- by growing MDR-TB burden,
- growing HIV epidemic
- Interrupted supply of first
line drugs;
- Gaps in management
Only eleven countries reached
the target of 85%
Some countries showed good progress in
reducing default rate
5.8%
6.1% 6.5%6.6%
5%
0%
2%
4%
6%
8%
10%
12%
14%D
efa
ult
rat
e (
%)
Default rate among new laboratory confirmed
TB patients (%), WHO European region, 2010
Baseline
Target
And it is possible…
14 14 12
10 8 7,9
0
2
4
6
8
10
12
14
16
2005 2006 2007 2008 2009 2010
De
fau
lt r
ate
(%
)
Armenia
13
10 9
8 7,5 6,9
0
2
4
6
8
10
12
14
2005 2006 2007 2008 2009 2010
De
fau
lt r
ate
(%
)
Georgia
11 10 10
9 8,1
7,1
0
2
4
6
8
10
12
2005 2006 2007 2008 2009 2010
Russia
5 5 5
4
2,9 2,3
0
1
2
3
4
5
6
2005 2006 2007 2008 2009 2010
Kazakhstan
5
4
3 3
2,3 2,5
0
1
2
3
4
5
6
2005 2006 2007 2008 2009 2010
Turkey
7 6
8
5
3,5 3,1
0
1
2
3
4
5
6
7
8
9
2005 2006 2007 2008 2009 2010
Bulgaria
However, not always reflected on trends
of treatment success rate
72,5
69,3 70,0
73,3 72,5 71,7
60
65
70
75
80
85
2005 2006 2007 2008 2009 2010
Tre
atm
en
t su
ccess
rate
(%)
Armenia
72,6
75,5 77,1
72,7 75,4 76,3
60
65
70
75
80
85
2005 2006 2007 2008 2009 2010
Tre
atm
en
t su
ccess
rate
(%)
Georgia
57,6 58,3 57,7 57,4 55,3
53,1
50
55
60
65
70
75
80
85
2005 2006 2007 2008 2009 2010
Russia
89,3 90,7 91,5 91,6
90,8 91,3
80
85
90
95
100
2005 2006 2007 2008 2009 2010
Turkey
71,1 72,1
68,5
64,0 62,4
60,9
50
55
60
65
70
75
80
85
2005 2006 2007 2008 2009 2010
Kazakhstan
82,0 79,0 78,8
84,8 84,9 86,3
65
70
75
80
85
90
95
100
2005 2006 2007 2008 2009 2010
Bulgaria
Time trends of treatment success rate (green
line) and default rate (red line) in retreated cases
36,7 32,7 29,7
21,3 15,3 12,9
40,7 43,4 46,4 50,9
63,5 67,0
0
10
20
30
40
50
60
70
80
2005 2006 2007 2008 2009 2010
Perc
en
tag
e
Armenia
16,2 12,7
15,4 13,8 12,3 11,7
36,9
47,2
35,7 36,3 33,9 34,1
0
10
20
30
40
50
60
2005 2006 2007 2008 2009 2010
Russia
6,0 6,8 8,9 7,5 5,7 4,8
46,8
36,8
53,0
41,7 48,4 47,2
0
10
20
30
40
50
60
70
80
2005 2006 2007 2008 2009 2010
Kazakhstan
22,6 17,0 14,8 14,4 14,8
11,5
54,5 56,4 55,8 49,6
59,7 61,9
0
10
20
30
40
50
60
70
80
2005 2006 2007 2008 2009 2010
Perc
en
tag
e
Georgia
11,8 10,4 10,1 9,3 8,6 7,4
70,2 75,6 76,1 74,6 73,3
68,7
0
10
20
30
40
50
60
70
80
90
100
2005 2006 2007 2008 2009 2010
Turkey
14,1 13,1 11,6 4,6
8,3
11,8
66,7 71,5 59,1
23,2
70,3
63,8
0
10
20
30
40
50
60
70
80
2005 2006 2007 2008 2009 2010
Bulgaria
Member states with no stock-out of first-
line TB drugs at any level, 2011
23 Member States out of 53
reported on first line drugs
stock-out status;
18 Member states reported
no stock-out;
Stock-out reported in
Romania, Montenegro,
Serbia, Ukraine,
Uzbekistan.
617 942 943 878
6,668
4,347
8,626
16,057 15,860
28,157
33,863 34,204
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Number of MDR patient diagnosed by year in WHO
European region, 2000-2011
Efforts are made for increased access to
diagnose MDR TB…
38% 37% 37%
34.5%
85%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
MDR TB detection rate among notified TB cases, WHO European Region, 2011
Baseline
Target
Notable progress in scaling-up access to MDR
treatment …
28,157
33,863 34,204
17,169
28,336
36,318
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
2009 2010 2011
Number of M/XDR TB patients diagnosed and enrolled on treatment by year, WHO European region, 2009-2011
Diagnosed
Enrolled
Within last 2
years access to
M/XDR
treatment
almost doubled
in the region.
But…still far below to reach target of 75% of
successful MDR treatment outcome
Failed
Defaulted, lost to
follow-up
Treatment success varied
from 16% to 74% among
MDR-TB patients started
on treatment in 2009 in
the 12 MDR-HB countries
of European region.
Treatment outcome of MDR TB patients started
treatment in 2009, European region (n=12110)
Fourteen countries reported no data on outcomes.
Core indicators for monitoring the implementation of the
M/XDR-TB action plan, WHO European Region, 2011
• 78 000 people estimated to fall
sick with M/XDR-TB yearly
• Only 30 000 M/XDR-TB
patients diagnosed
• Fewer than 50% of MDR-TB
patients successfully treated
Numbers talk
Leading killer among people living with HIV
• Fewer than 13 000 TB cases with HIV co-infection were
detected in the Region, or 56.5% of the estimated total.
• Only 70% of them were offered antiretroviral treatment.
Percentage of TB
cases with HIV co-
infection among all
HIV-tested TB cases
increased by 20% a
year in 2006–2011.
49% 48% 50%
57.4%
75%
15%
25%
35%
45%
55%
65%
75%
85%
Trea
tmen
t suc
cess
rate
(%)
Treatment success rate in MDR TB patients (%), European region, 2009
Baseline
Target
Closer look by HPC countries:
25% 25% 25%
21.3%
5.0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Def
ault
rate
(%)
Percentage of MDR TB patients lost to follow-up (default, transfer out, not evaluated), European region, 2009
Baseline
Target
Treatment interruption is the main reason of
poor MDR TB treatment outcome
MAP indicators
Baseline2009 2011 2015 Target
1.2.1. Default rate among new laboratory-
confirmed TB patients (%)
6.6% 5.8% 5%
2.1.8. Coverage of first-line drug susceptibility
testing among notified previously treated TB
patients (%)
41.1% 31.4% 100%
3.4.5. Percentage of MDR among retreated TB
cases
37% 46% 29%
3.4.2. MDR-TB detection rate among notified TB
cases
34% 38% 85%
MAP core indicators (cont.)
Baseline
2009
2011
2015 Target
3.4.8. Treatment success rate of MDR-TB patients 57.4% 48.5% 75%
3.4.9. Death rate in MDR-TB patients cohort 10.3% 16.2% 10%
3.4.10. Failure rate in MDR-TB patients cohort 11.0% 9.9% 10%
3.4.7. Percentage of M/XDR-TB patients enrolled in
treatment to all M/XDR-TB patients detected
61.8% 100.4%
but quality
unknown
Close 100%
5.2.1. Number of Member States with electronic
case-based data management at national
level, at least for MDR-TB patients
N/A 46 53
Financing TB and MDR-TB interventions
• Assisting and revising the financing mechanism in several
countries and providing support on budgeting their TB prevention
and control interventions to improve programme efficiency.
• Assisting the countries eligibility to apply to GFTAM and other
donors.
• However, cancellation of round 11 of GFATM and delay in
announcing the new funding mechanism was a challenge.
• Financial crisis and budget cuts: achieved results may be
endangered in some of the countries of the European Union
1. Prevent the development of M/XDR-TB cases
• Assessing reasons for defaulting from treatment.
– Social determinants in the drug resistance surveillance system;
– TB/MDR-TB health system assessment tool developed;
– In several MS including the Baltic States the MDR-TB rates are
stabilized.
• Emergence of drug resistant forms with inadequate treatment still prevail
in some MS including EU
– unnecessary hospitalization in the absence of adequate airborne
infection control;
– Ambulatory services and other models of care are still not fully
functioning in some MS.
• lack of evidence on prophylactic treatment for contacts of M/XDR-TB
patients.
2. Scale up access to testing for resistance to
first- and second line drugs and to HIV status
• European TB Laboratory Initiative;
• Scaling up diagnostic capacities and embark on the
rapid molecular diagnosis of TB and MDR-TB and
improve biosafety;
• However, the financial crisis will slow this down.
• Collaboration in TB/HIV activities.
3. Scale up access to effective treatment for all
forms of drug-resistant TB
• National Action Plans adapted in line with the Regional one;
• Increased access to second line anti-TB drugs for treatment of M/XDR-
TB patients;
• Regional Green Light Committee established (provides technical assistance on
clinical and programmatic management of drug resistant TB.)
• electronic consilium (e-health) launched in collaboration with ERS (clinical
management of difficult to treat patients).
• Outside the supported projects, the treatment success rate of MDR-TB
patients is extremely low (31% in some settings).
• incomplete treatment regimen and lack of full access to second line
TB drugs.
• some of the Western Europe countries face long delays in diagnosis,
lost expertise, poor management and inadequate follow-up of
patients.
4. Scale up TB infection control
• Finalization of the national TB infection control action plans integrated in
national TB plans or national health strategies;
• Procurement specification for TB infection control developed;
• Airborne infection control measures are not yet scaled-up in some MS
• lack of administrative,
• environmental and
• respiratory protection measures.
• Health care facilities and congregate settings continue to contribute to
further spread of TB and drug resistant TB.
• Some MS deport migrants with TB without considering human and public
health right issues and infection control measures.
5. Strengthen surveillance, including recording
and reporting of drug-resistant TB and
treatment outcome monitoring
• Monitoring framework for follow-up the Berlin Declaration developed and
assistance in improving monitoring and evaluation and using data for
improving programmes’ performance was provided;
• Nation wide drug resistance surveys in the remaining countries with
inadequate routine drug resistance surveillance;
• Annual meetings of TB surveillance focal points for coordination of
surveillance in the Region;
• Data on second line drug susceptibility testing is still limited and nation-
wide electronic data management is lacking in several countries,
• Some countries in Western Europe still don’t monitor treatment outcome,
some in East they don’t report on time or according to international
standards.
6. Scaling up the management of DR-TB,
including advocacy, partnership and policy
guidance
• National MDR-TB response plans and National TB Strategic Plans
incorporating MDR-TB;
• TB Governance assessment tool and assisted to improve the structure
of the national programmes;
• External programme reviews (Armenia, Azerbaijan, Belarus, Hungary, Norway and
Ukraine).
• Launch of the Regional Interagency Collaborating Committee on TB
Control and Care.
• Revising the frameworks for ethics and human rights for TB.
• Except for a few countries, there are limited civil society organizations
involved in TB control.
• Palliative care is not available in many countries.
7. Address the needs of special
populations
• Revision of national TB/HIV policies to address the needs of special populations
and
• Health in prison guidelines updated including TB control in prisons.
• However, there is a lack of functioning TB/HIV coordinating mechanism and
inadequate collaboration of prison and civilian health services.
• Task Force on Childhood TB established (document the current practices and adapt international
recommendations to the Regional context)
• lack of qualified human resources for Childhood TB in most Member States.
• Regional consensus document on Minimum Package of Cross Border TB Control
and Care published.
• Urgent need for research and development for new medicines and vaccine for TB
and M/XDR-TB.
• Two new drugs are expected to be introduced in 2013 and 2014
• Vaccine trials are ongoing.
Conclusions
• There is a substantial progress in the
recruitment of MDR TB patients in the
treatment programs, however, treatment
success rate of MDR TB is far below the
threshold envisaged for 2015 by the
Consolidated Action Plan.
• Lack of full treatment regimen and stock-out of
second-line drugs pose challenges for TB
control in most of high MDR-TB burden
counties in the region.
Next steps
• Continuously and closely support the Member States in
implementation of the Consolidated Action Plan;
• Prepare compendium of Best Practices
• Identify and address the social determinants of TB and M/XDR-
TB
• Scale up the best practices and patient-centred ambulatory care;
• Strengthen country capacity in surveillance for producing reliable
estimates of MDR-TB figures;
• Introduce rational use of new TB drugs;
• Develop interventions to move toward TB elimination in low TB
incidence countries;
• Defining the role of surgery in TB and M/XDR-TB.
Acknowledgements
Dr Arax Hovhannesyan, my team members in Copenhagen
particularly Dr Andrei Dadu and WHO country offices
Member States, NTP managers and partners
35
Thank you very much for your attention
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