TB Control Measures:TB Control Measures:

From development and From development and endorsement to adoption and endorsement to adoption and implementationimplementation

Léopold BlancLéopold BlancTBS Stop TB department WHO TBS Stop TB department WHO

Christy GarciaChristy GarciaUniversity of Connecticut School of MedicineUniversity of Connecticut School of Medicine

OverviewOverview

BackgroundBackground Laboratory Laboratory TreatmentTreatment Drug Resistant TBDrug Resistant TB TB/HIVTB/HIV Infection ControlInfection Control Care Delivery InnovationCare Delivery Innovation ConclusionsConclusions

BackgroundBackground

2010: Global Plan estimates 16 2010: Global Plan estimates 16 medicines, 18 diagnostics, 12 vaccines medicines, 18 diagnostics, 12 vaccines in developmentin development

Recent years have seen the launch of Recent years have seen the launch of several new tools with the several new tools with the recommendation to use Xpert MTB-recommendation to use Xpert MTB-RIF… conditions to be discussed during RIF… conditions to be discussed during the Global consultation end of the Global consultation end of November November

The time is right to evaluate uptake of The time is right to evaluate uptake of these tools to adapt promotion for these tools to adapt promotion for increased uptake in the futureincreased uptake in the future

BackgroundBackground

Task Force on RetoolingTask Force on Retooling– Created by Stop TB Partnership to help Created by Stop TB Partnership to help

programmes implement new technologiesprogrammes implement new technologies

Innovative New Approaches and Tools Innovative New Approaches and Tools subgroupsubgroup– Ensure timely access to information on Ensure timely access to information on

new tools and technical support for rapid new tools and technical support for rapid adoptionadoption

– Track progress in uptake and expansion of Track progress in uptake and expansion of new toolsnew tools

BackgroundBackground

Method:Method:– Inventory of major policy changes in the Inventory of major policy changes in the

last 10 yearslast 10 years– Creation of questionnaire and piloting within Creation of questionnaire and piloting within

HQHQ– Questionnaire distributed targeting 22 HBC Questionnaire distributed targeting 22 HBC

and high MDR-TB countriesand high MDR-TB countries– 27/40 surveys were returned27/40 surveys were returned

Goal: Identify areas of delay for better Goal: Identify areas of delay for better promotion of new approaches and tools promotion of new approaches and tools in the futurein the future

LaboratoryLaboratory

Challenges:Challenges:– Long delay between seeking care and Long delay between seeking care and

diagnosisdiagnosis– Expensive technology not available for low-Expensive technology not available for low-

resource settingsresource settings

Newly endorsed methods:Newly endorsed methods:– New case definition smear + (2007)New case definition smear + (2007)– Liquid culture and rapid speciation (2007)Liquid culture and rapid speciation (2007)– Line-probe assay (2008)Line-probe assay (2008)– LED FM (2009)LED FM (2009)– Xpert MTB-RIF (2010)Xpert MTB-RIF (2010)

Laboratory ResultsLaboratory Results

Policy/Policy/

ToolToolPrevious Previous AdoptioAdoptionn

Adopted within:Adopted within: No No adoptioadoptionn

1yr1yr 2yrs2yrs 3yrs3yrs

New New definitiodefinitionn

5/275/27 0/270/27 3/273/27 2/272/27 16/2716/27

Liquid Liquid cultureculture

8/278/27 9/279/27 3/273/27 0/270/27 7/277/27

Rapid Rapid SpeciatioSpeciationn

5/275/27 2/272/27 3/273/27 0/270/27 17/2717/27

LPALPA 2/272/27 8/278/27 2/272/27 NANA 15/2715/27

LED FMLED FM 11/2711/27 1/271/27 NANA NANA 15/2715/27

Laboratory ResultsLaboratory Results

Significant number of countries Significant number of countries utilizing tool prior to WHO utilizing tool prior to WHO endorsementendorsement

Most of the uptake occurs within 1Most of the uptake occurs within 1stst yryr

Implementation mainly at national Implementation mainly at national and regional leveland regional level

TreatmentTreatment

Challenges:Challenges:– Long durationLong duration– Multiple drugsMultiple drugs

Recent Policy Changes:Recent Policy Changes:1999: Fixed-dose combination tablets for the 1999: Fixed-dose combination tablets for the

treatment of tuberculosistreatment of tuberculosis

2003: Treatment of Tuberculosis: guidelines 2003: Treatment of Tuberculosis: guidelines for national programmes 3for national programmes 3rdrd ed. ed.

2010: Treatment of Tuberculosis: guidelines 2010: Treatment of Tuberculosis: guidelines 44thth ed. ed.

Treatment ResultsTreatment Results

PolicyPolicy PreviouPrevious s adoptioadoptionn

Adopted within:Adopted within: No No adoptioadoptionn

1yr1yr 2yr2yrss

3yr3yrss

4yr4yrss

5yr5yrss

6yr6yrss

7yr7yrss

8yr8yrss

FDCsFDCs 10/2710/27 2/22/277

1/21/277

2/22/277

1/21/277

2/22/277

2/22/277

1/21/277

1/21/277

4/274/27

Daily Daily Rx Rx entirelentirelyy

13/2713/27 0/20/277

2/22/277

1/21/277

2/22/277

1/21/277

1/21/277

0/20/277

NANA 6/276/27

2HRZE2HRZE/4HR /4HR

SmearSmear++

17/2717/27 1/21/277

1/21/277

1/21/277

1/21/277

3/23/277

1/21/277

0/20/277

NANA 2/272/27

2HRZE2HRZE/4HR/4HR

Smear Smear --

15/2715/27 0/20/277

1/21/277

1/21/277

1/21/277

3/23/277

2/22/277

0/20/277

NANA 3/273/27

Treatment ResultsTreatment Results

PolicyPolicy Overall Overall AdoptionAdoption

Prior Prior AdoptionAdoption

FDCsFDCs 86%86% 37%37%

Daily RxDaily Rx 71%71% 58%58%

6 month 6 month

smear +smear +93%93% 63%63%

6 month 6 month

smear -smear -89%89% 56%56%

Substantial number of countries with guidelines in place prior to WHO policy:

Multidrug Resistant TBMultidrug Resistant TB

Challenges:Challenges:– Delayed identification leads to further Delayed identification leads to further

spread of resistant strainsspread of resistant strains

Recent policy changes:Recent policy changes:2006: Guidelines for the programmatic 2006: Guidelines for the programmatic

management drug-resistant management drug-resistant tuberculosistuberculosis

2008: Emergency update2008: Emergency update

Multidrug Resistant TB ResultsMultidrug Resistant TB Results

PolicyPolicy Previous Previous AdoptionAdoption

Adopted within:Adopted within: No No adoptionadoption1yr1yr 2yrs2yrs 3yrs3yrs 4yrs4yrs

DST in new DST in new case areas prev case areas prev >3%>3%

6/276/27 0/270/27 1/271/27 0/270/27 0/270/27 20/2720/27

DST in MDR-TBDST in MDR-TB

exposureexposure7/277/27 3/273/27 4/274/27 2/272/27 0/270/27 11/2711/27

DST DST retreatmentretreatment

7/277/27 4/274/27 4/274/27 3/273/27 1/271/27 8/278/27

DST in sputum DST in sputum + pts at 3mos+ pts at 3mos

8/278/27 4/274/27 5/275/27 2/272/27 0/270/27 8/278/27

MDR risk MDR risk assess.assess.

4/274/27 2/272/27 0/270/27 0/270/27 0/270/27 21/2721/27

Empiric MDR RxEmpiric MDR Rx 3/273/27 0/270/27 3/273/27 1/271/27 0/270/27 20/2720/27

DST in PLHIVDST in PLHIV 7/277/27 2/272/27 1/271/27 NANA NANA 17/2717/27

Multidrug Resistant TBMultidrug Resistant TB

Other risk categories in which routine DST is Other risk categories in which routine DST is being conducted:being conducted:– Patients who have failed first line treatment (68%)Patients who have failed first line treatment (68%)– Patients who have failed a retreatment regimen (84%)Patients who have failed a retreatment regimen (84%)– 7 EURO countries conduct routine DST in all TB 7 EURO countries conduct routine DST in all TB

patientspatients

78% intensive phase conducted in hospital; 78% intensive phase conducted in hospital; 78% continuous phase as outpatient or 78% continuous phase as outpatient or community-based community-based

58% countries have recording and reporting 58% countries have recording and reporting system in place for adverse rxns to second line system in place for adverse rxns to second line drugsdrugs

TB/HIVTB/HIV

Challenges:Challenges:– Smear microscopy has lower sensitivity Smear microscopy has lower sensitivity – Higher conversion latent to active infectionHigher conversion latent to active infection– Interaction between ARVs and antituberculosis Interaction between ARVs and antituberculosis

drugsdrugs Recent policy changes:Recent policy changes:

2004: Guidelines for HIV surveillance among 2004: Guidelines for HIV surveillance among tuberculosis patientstuberculosis patients

2007: Improving diagnosis and treatment of smear-2007: Improving diagnosis and treatment of smear-negative pulmonary and extrapulmonary negative pulmonary and extrapulmonary tuberculosis in adults and adolescentstuberculosis in adults and adolescents

2009: A guide to monitoring and evaluation for 2009: A guide to monitoring and evaluation for collaborative TB/HIV activitiescollaborative TB/HIV activities

TB/HIV ResultsTB/HIV Results

PolicyPolicy PreviouPrevious s AdoptioAdoptionn

Adopted within:Adopted within: No No adoptioadoptionn

1yr1yr 2yr2yrss

3yr3yrss

4yr4yrss

5yr5yrss

6yrs6yrs

HIV testing in HIV testing in TBTB

patientspatients

7/277/27 9/29/277

3/23/277

1/21/277

1/21/277

2/22/277

0/270/27 4/274/27

TB screening in TB screening in PLHIVPLHIV

4/274/27 9/29/277

4/24/277

2/22/277

4/24/277

0/20/277

1/271/27 2/272/27

IPTIPT 0/270/27 3/23/277

3/23/277

3/23/277

2/22/277

1/21/277

4/274/27 11/2711/27

CPTCPT 2/272/27 7/27/277

2/22/277

3/23/277

4/24/277

2/22/277

1/271/27 3/273/27

New diagnostic New diagnostic algorithmalgorithm

1/271/27 2/22/277

2/22/277

0/20/277

NANA NANA NANA 11/2711/27

ART regardless ART regardless of CD4 countof CD4 count

0/270/27 4/24/277

NANA NANA NANA NANA NANA 21/2721/27

TB/HIVTB/HIV

Few countries with existing Few countries with existing TB/HIV policies in placeTB/HIV policies in place

Good uptake of policies within 1-Good uptake of policies within 1-2yrs of WHO endorsement2yrs of WHO endorsement

Low uptake of new diagnostic Low uptake of new diagnostic algorithm and IPTalgorithm and IPT

TB Infection ControlTB Infection Control

Challenges:Challenges:– Respiratory spread person to personRespiratory spread person to person– Greater exposure for health care workers, Greater exposure for health care workers,

populations in congregate settingspopulations in congregate settings Recent Policies:Recent Policies:

1999: WHO guidelines for the prevention of 1999: WHO guidelines for the prevention of TB in health care facilities in resource-TB in health care facilities in resource-limited settingslimited settings

2009: WHO policy on TB infection control in 2009: WHO policy on TB infection control in health-care facilities, congregate settings, health-care facilities, congregate settings, and householdsand households

TB Infection Control ResultsTB Infection Control Results

PolicPolicyy

PreviouPrevious s adoptioadoptionn

Adopted within:Adopted within: No No adoptioadoptionn1yr1yr 2yr2yr

ss3yr3yrss

4yr4yrss

5yr5yrss

6yr6yrss

7yr7yrss

8yr8yrss

>9yr>9yrss

AdmAdm 0/270/27 2/22/277

0/20/277

1/21/277

1/21/277

0/20/277

3/23/277

0/20/277

3/23/277

11/211/277

3/273/27

EnvEnv 1/271/27 1/21/277

0/20/277

1/21/277

2/22/277

0/20/277

2/22/277

0/20/277

3/23/277

9/279/27 6/276/27

PPEPPE 1/271/27 2/22/277

1/21/277

1/21/277

2/22/277

0/20/277

3/23/277

0/20/277

3/23/277

10/210/277

2/272/27

PlanPlan 3/273/27 8/28/277

3/23/277

1/21/277

NANA NANA NANA NANA NANA NANA 8/278/27

HCWHCW 8/278/27 5/25/277

NANA NANA NANA NANA NANA NANA NANA NANA 11/2711/27

TB Infection ControlTB Infection Control

Long delay between first endorsement Long delay between first endorsement of guidelines by WHO and adoption by of guidelines by WHO and adoption by countriescountries

Implementation mostly at national and Implementation mostly at national and regional levelregional level

Over half of countries implementing Over half of countries implementing policies only did so in TB care facilitiespolicies only did so in TB care facilities

Care Delivery Care Delivery InnovationInnovation ChallengesChallenges

– Lack of infrastructureLack of infrastructure– Lack of human and financial resourcesLack of human and financial resources– Engagement of political willEngagement of political will

Recent policies and toolsRecent policies and tools2006: Stop TB Strategy2006: Stop TB Strategy2006: Engaging all health care providers in TB 2006: Engaging all health care providers in TB

controlcontrol2007: A tool for national situation assessment2007: A tool for national situation assessment2008: Contributing to Health Systems 2008: Contributing to Health Systems

StrengtheningStrengthening

Care Delivery Innovation Care Delivery Innovation ResultsResults

Policy/ ToolPolicy/ Tool PreviouPrevious s AdoptioAdoptionn

Adopted within:Adopted within: No No adoptioadoptionn

1yr1yr 2yrs2yrs 3yrs3yrs 4yrs4yrs

Adoption Adoption ISTCISTC

0/270/27 10/210/277

6/276/27 2/272/27 1/271/27 2/272/27

Adoption PALAdoption PAL 3/273/27 2/272/27 1/271/27 2/272/27 0/270/27 18/2718/27

Patient Patient CharterCharter

0/270/27 4/274/27 5/275/27 3/273/27 1/271/27 13/2713/27

Guidelines Guidelines PPMPPM

5/275/27 1/271/27 2/272/27 2/272/27 0/270/27 16/2716/27

NSA for PPMNSA for PPM 6/276/27 2/272/27 1/271/27 1/271/27 NANA 16/2716/27

HSS HSS frameworkframework

7/277/27 8/278/27 0/270/27 NANA NANA 9/279/27

Care Delivery Care Delivery InnovationInnovation Area with least uptake of new tools Area with least uptake of new tools

and policiesand policies

41% of countries have advanced 41% of countries have advanced planning and preparation for new planning and preparation for new toolstools

33% of countries have INAT 33% of countries have INAT component in Global Fund agreementcomponent in Global Fund agreement

ConclusionsConclusions

Largest percentage of uptake 1-2yrs Largest percentage of uptake 1-2yrs after endorsement of policyafter endorsement of policy

Most uptake seen with TB/HIV Most uptake seen with TB/HIV policiespolicies

Both country factors and global Both country factors and global factors play a role in delay of uptakefactors play a role in delay of uptake

Moving Forward…Moving Forward…

Continued use of survey instrument and Continued use of survey instrument and database for broader samplingdatabase for broader sampling

Collaboration between TB control areas Collaboration between TB control areas to learn from examples of successful to learn from examples of successful promotionpromotion

More focus on health systems More focus on health systems strengtheningstrengthening

Thank you Thank you