Global MDR-TB Update Paul Nunn, MA, FRCP(UK) Director, Global Infectious Disease Consulting London, UK
Acknowledgements Matteo Zignol Mario Raviglione All the WHO staff in drug resistance surveillance and MDR-TB management Ariel Pablos-Mendes Kitty van Weezenbeek Ernesto Jaramillo Eva Nathanson
Learning goals understand recent developments in MDR TB epidemiology understand the strategies of the international community in response to MDR TB epidemic changes and the new guidelines produced understand the risk of MDR in any patient presenting with TB from another country
Contents How did we do, 2006-2015? Surveillance Diagnosis and treatment Policy guidance Future directions where are we headed in 2016-2035? Surveillance Diagnosis and treatment Policy guidance
How did we do, 2006-2015? Surveillance
20 years of anti-tb drug resistance surveillance Since 2006 Key WHO publications on drug-resistance surveillance (DRS), 1994-2014
Global coverage of anti-tb drug resistance surveillance has expanded yearly DRS data now available from countries with 95% of the MDR-TB burden
Strong network of TB supranational reference laboratories fundamental to progress The Supranational TB Reference Laboratory network (SRLN), 2014
The burden of MDR-TB is low globally and in many countries 16% Trend analysis now available for the first time: an estimated 3.5% of new cases has MDR- TB and this has not changed in recent years Previously treated TB patients have a significantly higher risk of MDR-TB compared to new cases, 20.5% Percentage of new TB cases with MDR-TB
Some countries have serious MDR-TB epidemics - extensively drug-resistant (XDR) TB has been detected in 100 countries TOP TEN COUNTRIES RANKED BY SIZE OF MDR-TB BURDEN 16% 16% 95%
More than half of the global burden of MDR-TB is in three countries - India, China and the Russian Federation 16% Estimated number of MDR-TB cases among notified TB patients, 2013
Some lessons learnt from surveillance Routine testing gives a much better understanding of resistance levels and trends than repeated surveys Many more countries need to build capacity for routine surveillance The use of molecular tests is growing They are faster, easier and cheaper The former Soviet Union was, and still is, home to the highest rates of MDR-TB While social and economic conditions of 1990s are blamed, they are unlikely to have been the cause then, or now Control efforts should be focused on India, China and Russian Federation
Diagnosis and treatment
There is significant progress in MDR-TB detection but treatment challenges compromise gains 480,000 total estimated cases of MDR-TB 9% of these have XDR-TB But 55% of the estimated cases are not detected, lowest detection rates in W Pacific 5 high MDR-TB countries, Ethiopia, Myanmar, Kazakhstan, Pakistan & Vietnam have treatment success >70% XDR-TB treatment success only 22%
Diagnosis and treatment targets v. the reality
Constraints to treatment of MDR-TB Insufficient trained staff and inadequate facilities in countries Non-NTP providers insufficiently involved Insufficient diagnostic capacity Insufficient ambulatory treatment Insufficient drugs Too costly Market too small
Policy guidance
MDR-TB response is guided by WHO policies 95%
Optimistic financing for TB and MDR-TB but for how long? GLOBALLY, FUNDING GAP FOR TB AND MDR-TB PREVENTION, DIAGNOSIS AND TREATMENT ABOUT US$ 2 BILLION PER YEAR Funding for TB prevention, diagnosis and treatment by intervention area, 2006-2014 (constant 2014 US$ billions)
How did we do, 2006-2015? A lot of progress, but targets mostly missed MDR-TB management remains a complex intervention for lowincome countries Countries mostly not prepared infrastructure, staffing, logistics Treatment policies in many countries are out-dated Slow initiation of relevant research Large increases in funding, but insufficient for the needs
Where are we headed in 2016-2035?
Surveillance Routine drug susceptibility testing of every case Better collection and analysis of data Routine use of molecular methods Better understanding of the relationship of drug resistant genotypes and phenotypes Better diagnostic tools
Diagnosis and treatment Greater routine use of molecular tests for resistance Point of care test for TB and MDR-TB Simpler, less toxic regimens of shorter duration, using new drugs developed especially for MDR-TB Ambulatory treatment routine
Five priority actions to address the global MDR-TB crisis How will the treatment success rate be raised from 86% where it has been for years? ACTIONS NEEDED ON ALL FRONTS FROM PREVENTION TO CURE Cost is key - how will drug prices be further reduced? Do we first need easier regimens? What must be done to get China to diagnose and treat more than 8% of its MDR-TB cases? How can policies and practice in Russia be improved? Neglected problem but who exactly will do what to address it?
Further issues to be addressed, 2016-2035 Diagnostic: treatment gap and waiting lists for treatment Lack of follow up, enablers and support Limited patient centred care How will the TB community address health system constraints? Will the drive for Universal Health Coverage improve health systems? How should countries that are under-performing be addressed, eg China, Russia? Ensuring the End TB strategy is implemented with enthusiasm, motivation, discrimination, diplomatic, advocacy and technical skills