drug resistant tuberculosis in southeast asia-status report

7/28/2019 Drug Resistant Tuberculosis in Southeast Asia-Status Report

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Drug Resistant Tuberculosis in the

South-East Asia Region

Status Report

December 2011


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Drug Resistant Tuberculosis i n the South-East Asia Region

Magnitude of Multidrug-resistant TB in the Region

In 2010, there was an estimated prevalence of 650,000 cases of multidrug-resistant TB(MDR-TB), and in 2008 it was estimated there were 150,000 MDR-TB deaths annually.While more people are being treated for MDR-TB in 2010. Although the absolute numbers ofTB cases tested for drug resistance, diagnosed with MDR-TB and started on appropriatetreatment remain low, they are increasing. The reported number of patients enrolled ontreatment for MDR-TB reached 45, 553 in 2010, equivalent to 16% of the estimated 290,000cases of MDR-TB among TB patients notified in 2010 (Ref: Global TB Report 2011)

In the South-East Asia Region, well-functioning national TB control programmesachieving high cure rates has resulted in maintaining the slow but steady decline in TBincidence rates during the past decade. It is estimated that 88,000 cases of MDR-TB amongnotified cases of pulmonary TB in 2010 (Range: 68,000- 110,000). The notified case ofMDR-TB is 4.3 among all notified cases of pulmonary TB in 2010. The number of MDR-TBcases enrolled for treatment is 3,937 in 2010. However, given the large numbers of TBcases, nearly one third of the worlds MDR-TB cases are in the SEA Region, with Indiaestimated to have the highest number globally. Extensively drug resistant TB (XDR-TB) hasalso been reported from 5 countries in the Region. MDR-TB could potentially replace drug-susceptible TB, and constitutes a threat to global public health security. In areas of high HIVprevalence, the potential for increased transmission of MDR-TB, is high. The estimatedMDR-TB cases and rates in SEAR Member Countries, 2010 is shown below in Table 1.

Table 1: Estimated MDR-TB cases and rates in SEAR Member Countries, 2010

Country Source ofestimates

% MDR amongnew TB cases(95% CI)

% MDR amongpreviously treatedTB cases (95%CI)

Number of MDR-TBamong incident total TBcases (95% CI)

Bangladesh model 2.2 (0.05.6) 14.7 (0.039.6) 9 800 (1 00019 000)

Bhutan model 2.2 (0.05.6) 14.7 (0.039.6) 33 (461)DPR Korea model 2.2 (0.05.6) 14.7 (0.039.6) 3900 (6587 200)India DRS,a 2005 2.3 (1.82.8) 17.2 (14.919.5) 99 000 (79 000120 000)Indonesia DRS,a 2004 2.0 (0.56.9) 14.7 (0.039.6) 9 300 (021 000)Maldives model 2.2 (0.05.6) 14.7 (0.039.6) 3 (06)Myanmar DRS, 2007 4.2 (3.25.6) 10.0 (7.114.0) 9 300 (6 40012 000)Nepal DRS, 2007 2.9 (1.94.3) 11.7 (7.617.6) 1 700 (9902 300)Sri Lanka DRS, 2006 0.2 (0.01.0) 0.0 (0.010.2) 63 (0130)Thailand DRS, 2006 1.7 (1.12.6) 34.5 (28.241.5) 2 900 (2 1003 800)Timor-Leste

model 2.2 (0.05.6) 14.7 (0.039.6) 130 (6260)

a Estimates based on subnational drug resistance data. DRS = drug resistance surveillance or survey data;CI = confidence interval; MDR-TB = multidrug-resistant TB

DRS Survey in Indonesia was completed for Mimika District (2004) and Central Java province (2006).Mimika district: MDR TB in newly diagnosis TB cases: 2.0 %.Central Java province: preliminary result; MDR TB in newly diagnosis TB cases was: 1.8 % and amongpreviously treated TB cases was: 16.7 %.Source: 2010 Global Report on Surveillance and Response

The subclass of MDR-TB known as extensively drug resistant tuberculosis (XDR-TB),defined as Mycobacterium tuberculosis isolates resistant to at least isoniazid, rifampicin, anyfluoroquinolone, and at least one of the three injectable drugs (amikacin, kanamycin, orcapreomycin), has been isolated in samples from 5 countries in the Region. Considerableeffort will be required to expand capacity for quality assured drug susceptibility testing in the


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Region in order to more accurately estimate the extent of MDR and XDR TB in the Region.Given the widespread availability and use of second-line drugs, and as laboratory capacity toconduct second-line drugs susceptibility testing increases, additional numbers of patientswith XDR-TB are likely to be identified.

Laboratory Capacity for the Detection of MDR and XDR-TB in the Region

The national reference laboratories at the Tuberculosis Research Centre, Chennai, India,and at the Bureau of TB at Bangkok, Thailand, are the two designated supra-national TBreference laboratories in this Region. These two laboratories are part of a global network of26 supra-national reference laboratories.

National Reference Labs (NRLs) in all Member countries (with the exception ofMaldives and Timor-Leste) have capacity for mycobacterial culture. However this capacity isquite limited even in these countries. In Nepal, culture and DST facilities are being providedthrough an NGO-run laboratory, quality-assured by the SNRL at Gauting, Germany. Anational reference laboratory is in the process of being established. The national referencelaboratories in Bangladesh, Indonesia, and Myanmar have recently been accredited forquality assurance for culture and drug susceptibility testing, while Sri Lanka is in the processof upgrading the national reference laboratory for TB.

As a result, NRL in some countries are linked up to SRLs outside the region:Bangladesh to the SRL in Antwerp, Belgium; DPR Korea to the SRL in Hong Kong;Indonesia and Timor- Leste to the laboratory at Adelaide, Australia, and Nepal to theGauting laboratory in Germany.

The national reference laboratories in India and Thailand are currently undertakingDST for second-line anti-TB drugs to determine the extent of XDR-TB. Referencelaboratories in Bangladesh, Indonesia, Myanmar and Nepal are also engaged in rapidsurveys for XDR-TB among mycobacterial isolates from patients who have failed re-treatment regimens, through linking with the SRNLs in the global network.

Resource mobili zation and cross-cutt ing issues

The costs of containment of already existing multi-drug resistant TB, however, if notaddressed at this stage, will be beyond the capacity of national health systems and worse;epidemic proportions of multi-drug resistance could emerge over a period of time. Thepriorities are to establish quality-assured culture and drug susceptibility testing facilities,expand drug resistance surveillance to monitor trends in MDR-TB and then to establish andrapidly scale-up services to treat TB patients with drug-resistant forms of TB.

In this regard updated guidelines need to be implemented and treatment in line withinternational standards for TB care (ISTC) should be in place in all sectors, particularly theprivate sector. The guidelines should include control strategies, such as tracing andtreatment of close contacts of MDR-TB patients, particularly for people at high risk, like

children and HIV-infected people and cross-border TB control strategies.

Strategies to prevent defaults before and during the treatment need to be carefullydesigned, including large scale integration of community-based treatment of MDR-TB intonational programmes. Regardless the model of treatment delivery in place, infection controlmeasures have to be adequately and urgently implemented.

With the exception of Thailand, all countries identified laboratory capacity as a majorconstraint to scaling up diagnosis and treatment of MDR-TB cases. Considerable effort willbe required to expand capacity for quality assured DST in the Region in order to more


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accurately estimate the extent of MDR and XDR TB in the Region. Given the widespreadavailability and use of second-line drugs, the majority of which are prescribed outside ofnational programmes, in the absence of treatment protocols for MDR-TB patients, additionalnumbers of patients with XDR-TB are likely to occur and need to be identified.

Adequate quantities of quality assured first and second-line anti-TB drugs foruninterrupted treatment of the planned number of MDR-TB cases should be secured andlegislative measures to ensure rational use of drugs need to be strengthened. Thepharmaceutical sector should be encouraged to provide competitively priced high qualitysecond-line drugs.

Substantial amount of additional resources required to provide adequate trainingscreate a pool of skilled personnel and to provide quality infrastructures for diagnosis, patientmanagement and surveillance. Sustainable financial support should be guaranteed throughapplication to global initiatives and funds and establishing domestic funding mechanism.Technical assistance required for MDR-TB control should be provided through wellcoordinated partnership and in-country capacity building.

Resolut ion WHA 62.15

The Sixty-Second World Health Assembly (WHA 62.15) in May 2009 urged Member Statesto develop and implement long-term plans for tuberculosis including M/XDR-TB preventionand control, in line with the Global Plan to Stop TB 20062015. The Beijing Call for Action onTuberculosis Control and Patient Care earlier in April 2009, and the resolution onPrevention and Control of Multidrug-resistant Tuberculosis and Extensively Drug-resistantTuberculosis endorsed at the sixty-second WHA reiterated the need for urgent action toaddress M/XDR-TB. Delays will result in greater numbers of TB including M/XDR-TB cases,deaths, reversing progress made so far towards achieving the TB targets. Managing drugresistant tuberculosis requires much stronger TB control. This in turn requires addressingkey weaknesses of the health systems through which TB services are delivered. A numberof interventions are proposed in this regard-

To achieve universal access to diagnosis and treatment of multidrug-resistantand extensively drug-resistant TB as part of the transition to universal healthcoverage, thereby saving lives and protecting communities by- developing acomprehensive framework for management and care of multi drug resistant andextensively drug resistant TB; strengthening health information and surveillancesystems; aiming to ensure the removal of financial barriers to allow alltuberculosis patients equitable access to tuberculosis care; making availablesufficiently trained and motivated staff; strengthening laboratory systems;engaging all relevant public and private health care providers; ensuring thatnational air borne infection-control policies are developed; ensuring uninterruptedsupply of first-and-second line drugs; ensuring that tuberculosis medicines aresold on prescription only; undertaking effective advocacy, communication andsocial mobilization and establishing national targets in order to accelerate access

to treatment according to WHO guidelines for multi drug-resistant and extremelydrug-resistant TB.

To enhance quality and coverage of DOTS in achieving 70% detection rate and85% success rate of tuberculosis treatment, thereby preventing secondarily multi-drug resistant tuberculosis.

To use all possible financing mechanisms to fulfill the commitments made inresolutions WHA 58.14 and WHA 60.19, including the commitment to ensuresustainable domestic and external financing, thereby filling the funding gapsidentified in the Global Plan to Stop TB 2006-2015.


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To increase investment by countries and all partners substantially in operationresearch and development for new diagnostics, medicines and vaccines toprevent and manage tuberculosis including multidrug-resistant and extensivelydrug-resistant tuberculosis.

Action in Member countries to contain MDR-TB and XDR-TB

The first priority in dealing with MDR-TB remains prevention of acquired drug resistancethrough continuing to ensure higher case detection and cure rates through high quality ofDOTS services. Secondly, attention needs to be discussed on developing comprehensivenational plans for the urgent scale-up of diagnostic and case management capacity forMDR-TB, conforming to internationally recommended protocols, including good infectioncontrol measures.

In the context of both of the above, the priorities in the Region are:

Securing adequate quantities of quality assured first and second-line anti-TB drugsfor uninterrupted treatment of the planned number of MDR-TB cases;

Ensuring treatment in line with international standards for TB care in all sectors,

particularly the private sector, and strengthening legislative measures to ensurerational use of drugs; Urgent attention to building health systems capacity: skilled personnel and quality

infrastructure, focusing on the weakest areas, i.e., laboratory capacity for diagnosis,and surveillance;

Securing adequate external as well as domestic funds, (including from localgovernments under decentralized systems);

Increasing the number of manufacturers in the Region meeting WHO pre-qualification or national drug regulatory standards, equivalent to internationalstandards.

During the past two years, steady progress has been made in the Region in initiatingMDR-TB cases on treatment. The Green Light Committee had approved the case

management of patients with MDR-TB under national programmes in nine countries.Bangladesh, India, Indonesia and Myanmar are in the process of expanding these services,while Nepal has already established ambulatory case management services for MDR-TBthroughout the country. Maldives continues to treat the few cases that occur on a case-by-case basis. Bhutan, Sri Lanka and Thailand began enrolling cases in 2011, while DPR Koreato establish MDR-TB case management under their respective national programmes in 2012.Until the end of 2010, a total of over 3000 patients with MDR-TB had been registered fortreatment in the Region. Initial treatment success rates of above 55% have been reported.

There are unique challenges to incorporating of the management of MDR-TB intonational TB programmes. Developing comprehensive costed national plans for the urgentbut feasible scale-up of diagnostic and case management capacity for MDR-TB, conforming

to internationally recommended protocols, including good infection control measures, is apriority. The challenges facing countries in the Region may be summarized as below:

a. Gaps in basic TB control :

funding, drugs, supplies, and skilled personnel to ensure early diagnosis,treatment and care for all TB patients

sub-optimal access to quality first-line drugs through all sectors and providers


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ISTC not yet widely in use by all providers; links between hospitals/ medicalschools and community-based providers for treatment follow-up not yet wellestablished

b. In managing MDR-TB:

In the absence of substantive evidence from national DRS in many countries,the understanding of the burden of MDR/XDR-TB is based on best estimates

limited laboratory capacity for diagnosis of drug resistant cases and for DRS difficulties In procuring quality second-line drugs; long lead times for

procurement of drugs limited capacity, experience in managing MDR-TB cases under programmes lack of infection control measures in most health facilities, including hospitals challenges to introducing new diagnostic tools/ technology substantial additional resources to manage relatively small number of patients

(including training, drugs, service delivery, etc)

Action taken at regional level

Assistance to all countries (excepting Maldives given very few cases) to establishsound programmes and access to concessional priced second-line drugs;

Support for the development of costed national plans and guidelines for the treatmentof drug-resistant tuberculosis;

Assistance with drug procurement and supply management of second-line anti-TBdrugs in collaboration with GDF;

Missions together with the GLC in countries undertaking MDR-TB case management(Bangladesh, Bhutan, DPR Korea, India, Indonesia, Myanmar, Sri Lanka, Thailandand Timor-Leste);

Training of staff of national programmes and participating NGOs in the management

of drug-resistant tuberculosis; Promoting the adoption and widespread dissemination of the International Standards

of TB Care (ISTC) at country level, among private and un-linked public providers, toprevent further the emergence of drug-resistance;

Establishment of a Regional expert group on M/XDR-TB to review and provideguidance on implementation of interventions for M/XDR-TB;

Initiative to establish Regional GLC in the Regional Office.

Laboratory strengthening

Supporting capacity of the two regional supra-national reference laboratories fortrainings, external quality assurance of national reference laboratories;

Organizing Regional training workshops and laboratory consultative meetingssupporting in-country training for national reference laboratory staff on qualityassurance, culture and drug susceptibility testing and laboratory networkmanagement;

Supporting DRS protocol development for implementation of drug resistance surveysin selected countries;


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Assisting in evaluating and deploying newer diagnostics (liquid culture, moleculartests for rapid diagnosis of MDR-TB, Gene Xpert MTB/RIF) together with FIND(Foundation for Innovative New Diagnostics) and UNITAID.

WHO Regional Office Act ivi ties for MDR-TB/XDR-TB for 2010-2011

A Regional response plan has been developed. The objectives of the Regional responseplan for MDR and XDR-TB are to: (1) sustain and improve the quality of DOTS; (2) expanddrug resistance surveillance; (3) strengthen laboratory capacity for diagnosis and follow-upof drug resistant cases and deploying new diagnostics at field level; (4) build capacity forprogrammatic management of MDR-TB and XDR-TB, including through other sectors (5)assist countries in establishing infection control measures in health facilities; (6) promoteresearch, including field testing of new diagnostics, drugs and regimens.

In order to fully achieve these objectives, considerable additional technical andfinancial resources will require to be mobilized.

Activi ties have been planned for 2012-2013

Plans at regional level

While the prevention of drug resistance through effective DOTS remains the key objective,several steps require to be taken to simultaneously engage in diagnosis, treatment andsurveillance of MDR and XDR-TB. A rapid scale-up of laboratory capacity is crucial both todiagnose MDR-TB cases and conduct surveillance. Improved technical and managerialcapacity within national programmes, additional funding, greater attention to effectivelyinvolving providers in other sectors, extending community-based care, and new tools tobetter diagnose and more effectively treat patients are required.

a. In-country Technical assistance

Assistance for assessment and evaluation missions for countries initiating andimplementing MDR-TB case management;

Support for updating national guidelines for the treatment of drug-resistanttuberculosis;

Support for developing national plans and guidelines to introduce infection controlmeasures at health facilities where MDR-TB and HIV-TB cases will be managed;

Assistance with cross-border TB control in the context of MDR-TB (eg., Myanmar-Thai cross-border disease control project);

Promoting the widespread dissemination and adoption of the InternationalStandards of TB Care (ISTC) at country level, among private and un-linked publicproviders, to help prevent further emergence of drug-resistance to both first and

second-line anti-TB drugs.

b. Scaling up Capacity for treatment

Assist countries in monitoring progress and developing and/or revising expansionplans and targets for MDR-TB case management, based on the assessments ofperformance and outcomes from established treatment sites;


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Building capacity for drug procurement and supply management of second-lineanti-TB drugs in collaboration with GDF;

Ensure shorter lead times for procurements of increasingly larger requirements forsecond-line drugs in collaboration with GDF;

Promote and facilitate technology transfer and pre-qualification of smallermanufacturers, particularly of generic drugs, in this Region who have capacity;

Liase with the Global Drug Facility to organize a meeting of second-line drugmanufacturers in the Region to pre-qualify suitable manufacturers to augmentcapacity for the manufacture of these drugs.

c. Human Resource Development

Supporting country level workshops for the management of drug-resistanttuberculosis, in association with the introduction of national guidelines for thediagnosis and management of drug-resistant TB, and infection control;

Training of national programme staff and participating NGOs in the managementof drug- resistant tuberculosis and establishing measures for infection control;

Developing and disseminating materials on standard clinical management to allhealth care providers;

Supporting in-country training of laboratory staff to field test and deploy newerdiagnostics that are now becoming available;

Training of SNRL and NRL laboratory staff on second-line DST.

d. Laboratory strengthening

Assist countries in assessing requirements and developing plans for the requiredlaboratory infrastructure and technical capacity, as appropriate, for expandedquality-assured culture and DST for first- and second-line drug testing;

Assist countries in identifying additional laboratories within medical teaching,

established private facilities and research facilities and accredit these throughinclusion within the quality assurance network coordinated by the SNRL network;

Organizing Regional training workshops for NRL staff on quality assurance,culture and drug susceptibility testing and laboratory network management,including infection control;

Building NRL capacity to respond to the needs of national TB control programmes,including through involvement of laboratories with capacity for MDR-TB diagnosisin the private sector and medical teaching institutions;

Evaluating the operational use of liquid culture, molecular tests for rapid diagnosisof MDR-TB, as a means of speeding the detection and referral of patients eligiblefor MDR-TB treatment.

e. Supporting development of newer diagnostics/treatment modalities

Provide NTPs with updated information on the feasibility and cost-effectiveness ofnewer diagnostics and drug regimens to guide programme decisions on adoptingnewer case management and diagnostic modalities;

Facilitate the participation of institutions and national programmes in the Region inglobal operations research and field testing of newer diagnostics and treatmentmodalities to help generate the evidence base, and in the application of researchfindings to guide policy and strategy formulation for the management of MDR-TB.


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f. Establishing infection control measures

Raise the issue of the need for greater attention to infection control within nationalhealth systems at the highest-level policy forums for greater attention to thisneglected area;

Mobilize a roster of experts and train additional staff at higher levels withinministries of public health trained to help disseminate internationallyrecommended guidelines and prepare sound infection control plans in countries.

g. Mobilizing resources

Assist countries in developing detailed plans of action for MDR-TB surveillance,diagnosis and case management, including plans for human resource andinfrastructure development and involvement of private sector and medicalteaching and research facilities;

Provide the necessary technical assistance to countries on a continuous basis,consistently undertaking technical support missions at least once a year so as tomaintain continuity and consistency in the advice provided to effectively build the

capacity of national programmes and reference laboratory networks; Assist countries in developing advocacy and media engagement strategies to

augment the political and financial support required for wider implementation ofMDR- and XDR-TB prevention, care and control.

h. Monitoring, evaluation, and operational research

Assisting countries to evaluate MDR-TB case management, in collaboration withthe Global Green Light Committee;

Providing forums to review and propose steps to improve implementation, anddisseminate best practices in countries;

Supporting DRS protocol development for implementation of drug resistancesurveys;

i. Strengthening of Regional Office Capacity to provide technical assistance

Developing and updating of a roster of laboratory experts and technicalconsultants to support laboratories and provide technical assistance to nationalprogrammes for the management of MDR-TB;

Continued support to SNRLs and NRLs in the Region, through a full-time RegionalTB laboratory and MDR-TB coordinator based at SEARO.


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Country situation in SEA Region

Bangladesh

There are no representative data on drug resistance in the country. As per GlobalTuberculosis Report -2011 of WHO estimates 5900 (CI: 4400-7400) MDR-TB cases (allforms) in 2010. MDR-TB estimated rate among new cases was 2.1% (CI:1.7- 2.5) and 28% (CI: 25-32) among the previously treated in 2010. More realistic information on drug-resistantTB in the country is expected from the countrys first nationwide drug resistance surveywhich was started in September 2010 and expected to be published by 2nd Q of 2012. DRSis implemented by National TB Reference Laboratory with support from National TB ControlProgram and technical assistance from WHO.

The exact extent of anti-TB drug resistance in Bangladesh is not known. Table 1shows drug resistance data from limited surveys carried out in the past ten years.

Table 1: Multidrug-resistant tuberculosis (MDR-TB) rate in new and resistant cases

Survey

NewCases

Re-

treatmentcases

ICDDR,B/Shyamoli CDC 2001-03(n=647)

3.3% 27.3%

ICDDR,B/Shyamoli CDC 2004-05(n=106)

3.0% 15.4%

Damien Foundation 1995 (n=645) 0.7% 6.8%

Damien Foundation 2001 (n=1041) 0.4% 3.0%

NTP/NIDCH 2005-06 Cat.2 failures(n=96)

88%

MDR-TB guidelines have been developed in 2007. A standardized regimen of6ZKmOfxEtoCs/18ZOfxEtoCs (Z=pyrazinamide, Km=kanamycin, Ofx=ofloxacin,Eto=ethionamide, Cs=cycloserine) has been adopted for management of MDR-TB patientsas per WHO recommendations. Intensive phase is at least 6 months provided 4 months ofconsecutive culture and smear negativity were reached within the period of time. Thecontinuation phase will continue at least for 13 months. The total treatment duration will be atleast 18 months after first culture conversion (not followed by any positive culture). Intensivephase is hospital-based and continuation phase is community based Treatment is givenunder daily DOT.

In 2006, the National TB Program (NTP) of Bangladesh was approved by the Green

Light Committee to implement programmatic management of drug-resistant TB (PMDT) for700 patients as a pilot project over 5 years (2006-2011) in collaboration with the NationalInstitute for Diseases of the Chest and Hospital (NIDCH) as a pilot site. Patient enrollmentwas started in August, 2008. GLC approved management of additional 1000 MDR-TBpatients. In addition to NIDCH; Chittagong Chest Diseases Hospital is also initiatedenrollment of MDR-TB patients as second treatment site since March 2011. A DOTS-PlusCoordination Committee has been providing direction in the overall implementation.Observing the current country capacity (eg: Human , facility resource), the country hasadopted the target to enroll 270 cases within June 2011 to July 2012 and 360 cases in June2013 to July 2014 under PMDT with support from GFATM.


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The National TB Reference Laboratory, quality assured by the Antwerp (Belgium)

Supranational Reference Laboratory, has been providing support for diagnosis and follow-upsince its establishment in 2007. The NTRL is performing mycobacterial cultures onLwenstein-Jensen media. DST is performed at NTRL by the proportion method. The NTRLprovides primary culture; identification of M. tuberculosis complex and non-tuberculousmycobacteria (NTM), and testing for susceptibility to Isoniazid, Rifampicin, Ethambutol andStreptomycin. Clinical laboratory services including basic haematology, biochemistry,serology and urine analysis are also performed by NTRL. Two Regional Referencelaboratories (RTRL) are functioning in the two cities, Chittagong and Rajshahi .Oneadditional RTRL is in the process of operation in Khulna.

Capacity building and drug management are jointly managed by the NTP andNIDCH. Several orientations were done for field level GO and NGO managers andcommunity health workers. A clinical management and social support committees wereestablished in 2007 for programmatic management of MDR-TB patients. Training of trainersfrom National Institute for Diseases of the Chest and Hospital (NIDCH) and otherimplementing partners were organized in 2008 and 2010. Social support for patients such astransportation costs, vocational training, etc has been established. A mechanism forcontinuation of treatment after discharge from hospital has been developed throughproviding training for the community health providers for provision of DOT and referral. Total674 MDR TB patients were registered till the end of October 2011. In 2008 and 2009 (As ofend of Sept), confirmed MDR-TB patients were 104 and 120 respectively among whichTreatment Success rate were 63% and 60 % respectively.

Damien Foundation (a NTP NGO partner) is providing MDR-TB services as anoperational research project in designated geographical areas following a 9 months regimen:4KPthCGHZE/5CGZE. The Damien Foundation has its own reference laboratory capable ofperforming cultures and DST for first-line drugs. The first regional reference laboratory wasestablished by NTP in May 2008 in Rajshahi in collaboration with the Damien Foundation(DF). This laboratory performs slide cultures and DST.DF enrolled 181 and 147 MDR-TBcases in 2009 and 2010 respectively and success rate of 2009 cohort was 79%.

Bangladesh developed an expansion plan for the programmatic management of Drugresistant Tuberculosis (2010-2015) in 2010.This expansion plan aims at achieving universalaccess which the Global plan to Stop TB defines as diagnosis and treatment of 80% of theestimated number of smear+ and/or culture+ cases of MDR-TB by 2015, in programsfollowing the international guidelines for the management of drug-resistant TB.

Bangladesh has been selected by EXPAND-TB project for introduction of new rapiddiagnostic tools; e.g: Liquid culture, Line probe Assay . The MoU between NTP andEXPAND TB Project is under process of signing. Bangladesh also planned to procure fourXPERT MTB/RIF (Gene Xpert) machine for rapid diagnosis of TB and DR-TB.

Bhutan

Culture and DST facilities have been established at the National TB Reference Laboratory(NTRL) of the Public Health Laboratory Thimphu. There is a plan to upgrade the existingCulture and DST facilities by introducing liquid culture and newer diagnostictools/equipments subject to the approval of funds. Once this newer diagnostic tool isintroduced at the National TB Reference Laboratory of the PHL, the country will require totrain lab staff from NTRL to perform the tests. However, the national TB ReferenceLaboratory will continue to send the samples from MDR patients to Regional ReferenceLaboratory in Bangkok for 2nd line DST testing. NTCP is also planning to establish culturefacilities at the national referral and two regional referral hospitals to support diagnosis of TBin children and follow up of MDR-TB patients.


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As of today, there is no representative data on levels of drug resistance. However,

WHO estimates (2008), 0.6% MDR-TB among newly diagnosed smear positive TB cases.Currently, NTRL, Public Health Laboratory is conducting the Drug Resistance Surveillance inthe country to study the drug resistance pattern of 1st line anti-TB drugs. The drug rsistancepattern of this country will only be known upon completion of this surveillance which isexpected to be completed within next few months time. The national TB control programmewas approved by the Green Light Committee for management of MDR-TB cases in 2009.The National TB control program then initiated procuring the second line anti-TB drugsthrough GLC and the enrollment of patients had already begun from 2010.

In 2010, the National TB Control Program through the financial and technicalassistance from WHO has developed the MDR-TB guideline for the management of MDR-TB cases in the country. Following that, training on MDR-TB management was conducted tothe selected Medical Officers of the district hospitals with high burden TB cases. Thistraining program was also facilitated by the technical assistance from WHO.The diagnosis and management of MDR-TB cases will be done by the National ReferralHospital and the two regional referral hospitals and these three hospitals have beenidentified as reporting center for MDR-TB since 2011.

DPR Korea

Patients with possible drug resistance are currently not being systematically diagnosed andsecond-line drug are not available through the programme. There is no reliable data on theextent of MDR-TB in the country. However, re-treatment cases comprise 17% of all notifiedcases. A preliminary survey of drug resistance among patients failing Category I and IIregimens carried out with the assistance of the supranational reference laboratory in HongKong showed high levels of resistance. A representative Drug Resistant Survey is proposedto be undertaken in 2012 for which protocol is under development.

A programmatic Management of DR-TB guideline in line with WHO

recommendations has been developed in 2011. Expansion Plan for DR-TB managementhas also been prepared through a wide consultative process. Second line drugs are beingprocured through Global Fund support and by mid 2012 fifty new cases are expected to beinitiated with MDR-TB treatment and subsequently more MDR-TB patients will be put on thetreatment. Infection control plan and guidelines has been developed and essentialrenovations are expected to be carried out in the DR-TB treatment facilities.

The central TB Institute in Pyongyang is being developed to function as the NationalReference Laboratory with capacity to do culture and DST. All necessary equipment for thecentral lab in Pyongyang to undertake quality assurance of smear microscopy and to doculture, has been procured and is being installed in the renovated premises of the Centralreference laboratory at the Central TB Institute in Pyongyang with support from the Stanfordgroup and WHO. Laboratory staff from this laboratory has recently undergone training on

culture and drug susceptibility testing, assisted by the technical consultants from supra-national reference laboratory in Hong Kong.

India

Data from two recent state representative drug resistance surveillance (DRS) surveys inIndia show that multi drug-resistant TB (MDR-TB) amongst new cases is relatively low( 3%), but is significantly higher (14-17%) among re-treatment cases. Due the very largenumber of TB patients in India, it is estimated that MDR-TB cases in India represent over20% of the global burden of MDR-TB, with an estimated 99,000 cases emerging in 2009.


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Extensively drug resistant TB (XDR-TB) has been reported in India, but numbers are as yetuncertain. However high levels of fluoroquinlone resistance among MDR-TB cases havebeen documented in the DRS survey in Gujarat and the initial cohorts of patients enrolledunder RNTCP Category IV treatment.

India has prioritized prevention of MDR-TB and XDR-TB through improved DOTSimplementation, and through increasing engagement of medical colleges and the privatesector. National guidelines for MDR-TB management were developed in 2006. The nationalprogramme provides DST to all patients who have failed an initial first line drug treatment(Category I), all patients who remain smear positive after 4 months or more of Category IItreatment, and contacts of MDR-TB cases who are found to have smear positive PTB. MDR-TB treatment using the standardized regimen is started after DST results confirm MDR-TB.The first MDR-TB suspects were enrolled under RNTCP in March 2007 in the states ofGujarat and Maharashtra. By June 2011, diagnostic services for MDR-TB were establishedin seventeen states and treatment services in nine states. These states providepredominantly community-based MDR-TB treatment, integrated into the routine TB controlprogramme activities at the district level, with case-management supported by a specialityclinical facility at the state level. By the end of September 11, about 5000 MDR-TB patientshad been initiated on RNTCP Category IV treatment.

Diagnostic services are currently available through an expanding laboratory network.Currently, 31 C-DST labs are accredited under RNTCP to provide services for the diagnosisand follow up of MDR TB patients. These include 4 NRLs, 17 IRLs and 10 other labs frommedical colleges, private sector, NGOs and ICMR. A network of at least 43 accreditedlaboratories (offering C&DST and line probe assay testing) is planned to be in place by2012-13. A public-private collaboration mechanism is already in place in order to extend thenetwork through inclusion and accreditation of existing laboratories in medical colleges andin private hospitals. RNTCP will also access culture and DST services through accreditednon-public sector laboratories.

RNTCP is receiving financial and technical support for the expansion of MDR-TBservices through a number of sources. Financial support is provided by the GF (via and

approved Rolling Continuation Channel agreement), the World Bank (via a credit agreement)and WHO (utilising USAID funds for laboratory strengthening). Technical support is providedby FIND, GLI, PATH and WHO to the laboratory strengthening activities, and GLC and WHOfor the management of MDR-TB cases. In May 2009, UNITAID approved support to RNTCPin relation to laboratory strengthening and procurement of second line anti-TB drugs. Asignificant component (US $130 million) of Indias application to GFATM Round 9 is intendedto support the scale-up of MDR-TB services up till 2015.

RNTCP services for MDR-TB and plans for scale-up were recently reviewed duringthe Joint Government of India / WHO Monitoring Mission of RNTCP in April 2009 and a jointGLC/GLI mission in July/August 2009.

However most MDR-TB cases are still being managed outside of the RNTCP. A

major concern is that unless MDR-TB management scales-up rapidly in the public sector, anincreasing number of MDR-TB cases will be managed by the unregulated private sector,posing risks for increases in XDR-TB in India. The National Consensus Statement on themanagement of MDR-TB in India, which resulted from a consultative meeting held byRNTCP in late 2007, has been widely disseminated to lay down a national minimumstandard for the diagnosis and management of MDR-TB for all public and private providersnationwide treating MDR-TB cases, especially those outside of RNTCP. The programme isclosely working with the office of the Drug Controller General of India in regard to the betterenforcement of the existing regulatory mechanisms related to anti-TB drug prescription and


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usage, and to explore ways to further strengthen such mechanisms to protect the currentlyavailable, and future, anti-TB drugs from misuse and the development of drug resistance.

Indonesia

The drug resistance survey in Central Java has been completed. The MDR-TB rate is 1.9 %among the new cases and 17.1 % re-treatment cases. Another DRS survey is in progress inEast Java province. The national MDR-TB prevalence is estimated to be 2 % of all TBcases, which is lower than the estimated regional average of 4.0%.

Efforts to expand and strengthen the national laboratory network are underway, withassistance from the Supra National Reference Laboratory IMVS, in Adelaide, Australia.Reference laboratories for quality assurance for AFB direct smear microscopy examinationare already established in 26 provinces out of the existing 33 provinces in Indonesia. Thereference laboratories for quality assurance are being established in seven new provinces,for AFB direct smear microscopy examination. Five Laboratories have been quality assuredfor drug susceptibility test (DST) for first line anti TB drugs (FLD) in 2008 and in 2009 forsecond line anti TB drug (SLD). The five quality assured laboratories are the PersahabatanHospital Laboratory in Jakarta, The Microbiology Department of University Indonesia inJakarta, the provincial Laboratory the BLK Bandung in Bandung, the provincial laboratorythe BBLK Surabaya in Surabaya and the Microbiology Department of UniversityHasanuddin, the NEHCRI, in Makassar, South Sulawesi province. The MicrobiologyDepartment University Indonesia and the NEHCRI are using the liquid media method; whilethe other three are using conventional solid media method.

However, not all providers in private sector and hospitals are linked yet with theservices of the NTP; they are not following the DOTS Strategy. TB cases in these settingsusually receive un-standardized treatment and without proper supervised treatment.Treatment success rates among TB patients treated in hospitals, and private clinics/sectorsare generally lower, except for those hospitals which have been successfully linked to NTP.

DOTS expansion to hospitals and private providers remains a challenge and a priority.

A GLC application was approved in September 2007. National programmatic andtreatment guidelines for the management of MDR-TB and training materials for health staffare in place. Two sites of PMDT pilot have started providing service for MDR TB cases inmid 2009. The two pilot sites are the East Jakarta City with Persahabatan Hospital as itsreferral center for MDR TB; and Surabaya city with Dr. Soetomo Hospital as its referralcenter for MDR TB. During the pilot phase in order to speed up the diagnosis, it was agreedthe drug-susceptibility testing (DST) of the pilot sites was to be conducted in MicrobiologyUniversity Indonesia, while the treatment follow up laboratory examination is beingconducted in Persahabatan Hospital for East Jakarta pilot site and the BBLK Surabaya forSurabaya city pilot site. For expansion policy, all five quality assured laboratory will beutilized to conduct DST for diagnosis purposes. The rapid test to diagnosis TB is being

introduced in the country. The line probe assay (LPA), the Hain test, is in operationalresearch phase-2 and the newest rapid diagnostic, the GeneXpert, is being processed forpilot purposes and operational research in 17 sites.

In May 2010, preparation of PMDT expansion was planned for three new sites:Makassar city in South Sulawesi, with Labuang Baji Hospital as the referral hospital for MDRTB; Surakarta city in Central Java with Dr. Muwardi Hospital as the referral hospital for MDRTB and Malang city in East Java with Dr. Saiful Anwar as the referral hospital for MDR TB.The three new sites started treating MDR TB patients by end 2010.


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Cumulatively MDR TB patients intake until end of September 2011 was: 1585 MDR TB suspects were detected. 1109 MDR TB suspects completed laboratory examination. 471 confirmed MDR TB patients.

332 (70 %) are put on treatment. 32 (6 %) pre-enrolment. 10 (2 %) excluded for various reason. 45 (11 %) died while waiting for DST result. 39 (8 %) refused to be enrolled. 13 (3 %) lost.

More than 20 % of the confirmed MDR TB cases were not put on treatment due tovarious reasons as stated. Efforts are being conducted to improve the rate of enrollment.

Preparation for four new sites are in progress: Denpasar city, Bali province, withSanglah hospital as referral hospital for MDR TB; Jogjakarta city, DIY Province with Sardjitohospital as referral hospital for MDR TB, Bandung city, West Java province with HasanSadikin hospital as referral hospital for MDR TB and Medan city, North Sumatra province

with Adam Malik hospital as referral hospital for MDR TB. Hopefully the four new sites will bein function by the end of 2011.

Maldives

The national TB programme in the Maldives has achieved and sustained full coverage withDOTS, fully involving the private sector in the country. Case detection and treatmentsuccess rates of over 90% have consistently been achieved over several years. A few casesof drug resistance have been reported by the programme since 1998. However, MDR-TB iscurrently a growing concern in the Maldives. Drug susceptibility testing (DST) as deemedclinically necessary, is undertaken by sending samples to regional reference laboratories inthe region. Currently the samples are sent to the National Tuberculosis Institute inBangalore, India. Patients diagnosed with MDR-TB are managed clinically at the tertiary

care hospital Indira Gandhi Memorial Hospital (IGMH) in Mal, and treatment is based onindividualized regimens. Eight patients have so far been identified as MDR-TB, of which 3were cured and 2 are on treatment. Second-line drugs for the management of these casesare procured by the Ministry of Health and Family on a case-by-case basis.

Myanmar

Public-public and public-private mix initiatives are being scaled up to increasingly engagegeneral practitioners and specialists in DOTS implementation, in order to avoid the furtherdevelopment of M/XDR-TB. In 2010, almost 15% of TB cases were notified by generalpractitioners though the collaboration with the Myanmar Medical Association and PopulationServices International. Anti-TB drugs are available over the counter including for second-line

drugs kanamycin and the fluoroquinolones.

A nationwide drug resistance survey carried out in 2007-2008, showed an MDR-TBprevalence of 4.2% among newly diagnosed and 10% among previously treated cases. Todate, five XDR-TB case have been confirmed. The third nationwide drug resistance surveywill commence in early 2012.

The national reference laboratory in Yangon performs cultures and first-line DST.Second-line DST is being undertaken at the SNRL at Bangkok. Culture and DST facilitieshave been established at the facility in Mandalay in 2009. The launching ceremony for


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Biosafety level-3 Laboratories for TB Diagnosis (NTRL Yangon and Upper Myanmar TBLaboratory Mandalay) was held in NTRL building in Yangon on 12.7.2010. Since thebeginning of 2011, the two laboratories are performing liquid culture and line probe assay forrapid diagnosis of MDR-TB. As of November 2011, Xpert MTB/RIF is not being used butequipment is being brought in by international NGOs in collaboration with the NTP.

The Ministry of Health has established a National Committee on Drug-Resistant TB,including hospital specialists, staff of the NTP, WHO and implementing partners, to overseethe national response. The Green Light Committee approved DOTS-Plus pilot project startedpatient enrollment in 10 pilot sites in Yangon and Mandalay in July 2009. From July 2009 toend August 2011, 291 MDR-TB patients have initiated treatment. A total of 28 MDR-TBpatients have completed the treatment out of which 71% have been cured. These initialresults are very promising, especially since all enrolled patients were chronic TB patientsthat had been on a waiting list for treatment with second-line anti-TB drugs. With supportfrom WHO, the 2009 MDR-TB management guidelines are being revised. In April 2011, theGreen Light Committee approved the expansion of MDR-TB management to treat anadditional 1,800 patients under Global Fund Round 9 support.

An ambitious MDR-TB scale-up plan has been finalized for 2011-2015. Diagnosis,treatment and care will be offered to an additional 10,000 MDR-TB patients over five years.All States and Regions will have MDR-TB treatment centres with the possibility to hospitalizeMDR-TB patients. Rapid MDR-TB diagnosis will be ensured by Xpert MTB/RIF availability ineach State/Region and a specimen transportation system will allow for additional laboratoryinvestigations at the two existing state-of-the art reference laboratories. MDR-TB diagnosiswill be offered to previously treated TB patients, contacts of MDR-TB patients and HIV-associated TB patients. All confirmed MDR-TB cases will be treated according to WHOguidelines. The NTP will rely on community-based MDR-TB care but patients can behospitalized for about two weeks to ensure that the second-line anti-TB drug treatment istolerated. As a result, community-based organizations and volunteers will have a muchexpanded role for MDR-TB management and national and international NGOs arecommitted to support community-care programmes based on the newly developed NTPcommunity care guidelines. Efforts are now being made to attract financial resources from

Global Fund Round 11, USAID, Three Diseases Fund and UNITAID to support the MDR-TBscale-up plan (funding needs amount to US$ 53 million over five years).

Nepal

Nepal and Thailand are the only two countries reporting trends in drug resistance on anational scale. However, the proportion of MDR-TB among new cases in Nepal hasfluctuated from a little over 1.0% to 3.0%, in the four surveys that have been conductedsince 1996, making it difficult to interpret the trends. The current estimate is 2.9% (1.8-3.2)among new cases and 11.7% (7.1-18.32) among retreatment cases.

MDR-TB management under the national programme commenced in September

2005 following WHO Green Light Committee approval. Currently, culture and DST facilitiesare being provided through a unique public-private partnership with GENETUP (GermanNepal Tuberculosis Project) an NGO-run laboratory, actively supported by the SNRL atGauting, Germany. The national reference laboratory has been accredited by SLR GautingGermany in 2010. NTP has plan to extend culture facilities to all five regions while DSTservice will be available in one additional region.

With WHO support NTP has revised the DR TB Guidelines, training modules andspecific recording reporting forms and registers in 2011.


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MDR-TB management services are available in all five regions of the country. Bymid-July 2011, twelve treatment centers and 54 sub-centers were offering MDR-TBtreatment and follow up services. Treatment progress is monitored with sputum cultureexaminations every month during intensive phase (first 8 to 12 months) and bi-monthlyduring the continuation phase (9 to 24/32 months).

By July 2011, the NTP had registered over 1,150 MDR-TB cases for treatment. Thelargest number of MDR-TB cases registered belong to failures of category 2 (89%) followedby category I failures. Male MDR-TB cases have accounted for almost 64% of all registeredcases. This trend corresponds with ratio of male to female registered under the DOTSprogramme. The largest number and proportion of MDR-TB patient belong to 15-54 agegroup, with almost half of the registered patients in the age group between 15-34 years. Thistrend is also in line with age groups of new TB patients registered under DOTS.

Cure rates among MDR-TB patients registered during first four year of theprogramme (2005 - 2008) was 67%, while 7% of patients failed treatment, 9% died and 17%defaulted. One of the key reason for high default rate is lack of sufficient hospital beds oralternate accommodation. However, default rates have declined as number of MDR-TBtreatment sites were nearly doubled and NTP also managed to provide financial support fortransportation (NRs 300/month) through Government resources. This support hassubsequently been increased to NRs 1,500 through Global Fund support, which has resultedin a significant decrease in default rates at most of the MDR TB management sites.

The Green Light Committee of WHO initially approved the NTP to register 350 MDR-TBpatients for treatment. Following five consecutive international annual reviews by the WHOGreen Light Committee, the NTP has received approval for continuation of the programmetill 2012. During this phase, the NTP plans to treat 300 MDR-TB patients each year up till2015.

Nepal NTP started XDR TB management in Feb. 2010, since then 26 patients havebeen registered for treatment.

During next five-year plan period (July 2010 July 2015) the NTP plans to increase thenumber of treatment centers/sub treatment centers to 80. This expansion will involvepartners in both the public and private sectors. Currently culture facilities are limited to theKathmandu Valley. The NTP plans to expand culture facilities to at least four additionalregions in the coming five years, while drug susceptibility testing, presently available at onlyone site (GENTUP), will be extended to one additional regional site.

Sri Lanka

Drug resistance survey in 2007 showed exceptionally low rates of drug resistance. The nextnational drug resistance survey is planned to commence in 2012. The protocol for the drugresistance survey has been already developed with the technical assistance from WHO.

Culture and DST is performed for all patients who fail Category I regimens, at thetime of initiation of treatment for all retreatment patients (commencing Category II regimens),contacts of known MDR-TB cases and other high risk groups such as prisoners, drugaddicts, people living with HIV/AIDS, overseas returnees etc. The national referencelaboratory is supported by the designated supranational laboratory at TRC Chennai, and bystaff from WHO/SEARO. Guidelines for Programmatic Management of Drug Resistant TBhave been developed. MDR-TB is diagnosed at the national reference laboratory located atthe premises of the Chest Hospital at Welisara. Patients are treated primarily at this referralhospital, though other hospitals also manage these cases. In addition to the Chest Hospital


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Welisara, there are 12 hospitals throughout the country with wards for patients with chestdiseases. Second-line anti-TB drugs are received as a grant from the Green LightCommittee. Enrolment of patients was started in 2010. No stock-outs have been reported.The success rate among MDR-TB cases is not known since systematic collection of data onMDR-TB patients was commenced only recently.

Thailand

The third national drug resistance survey (DRS) was completed in 2006. The surveyrevealed a low rate of 1.65% multi-drug resistance among newly diagnosed cases and34.5% among previously treated cases, slightly higher than the rate of MDR-TB among newcases reported in the survey conducted in 2002 (0.93%). The fourth DRS is conducting in2010-2011 under the financial support from the GFATM Round 6.

According to the National guideline, five groups of patients are targeted for cultureand drug susceptibility testing (DST) at start of treatment: re-treatment cases, migrantworkers, prisoners, HIV positive patients and close contacts of MDR-TB patients but with thelimitation of budget the NHSO would support funding for culture and DST in patientsmentioned above except the migrant and prisoners. Cultures are performed in 65laboratories of which 15 laboratories are presently accredited for culture and first line DST,including 5 of the 12 regional laboratories. Culture, DST and second line drugs areperformed free of charge for Thai citizens, utilizing funding from the National Health SecurityOffice. But since MDR records and reports have been implemented since 2009, the firstreport should come to the NTP by the end of 2010.

MDR-TB treatment is presently provided at about 100 treatment units throughout thecountry, based on the national guidelines for the programmatic management of MDR-TB,adapted from the WHO guidelines. MDR recording and reporting system was just developednationwide in 2009. In 2009, estimated MDR-TB cases among notified pulmonary TB casesby World Health Organization were 2,300. However, only 376 confirmed MDR cases and189 suspected MDR cases were reported to the central level. These numbers included 23confirmed MDR cases and 68 suspected MDR cases in prison settings. Recording and

reporting system is the most challenging issue because the MDR national guideline hasbeen on the process of revision and the recording and reporting system is not finalized.

Model facilities have been selected based on their performance in DOTSimplementation, the presence of a good referral system and measures for infection control.The selected sites will serve as centres of excellence for the management of MDR-TB. AGLC mission assessed four selected sites in March 2009 and a GLC application wasapproved in May 2009 to enroll 50 cases in Years 1 (2009) and 2 (2010) at the four sites,followed by up to 290 cases by Year 5 at 25 sites. These four sites are the Chest DiseaseInstitute, the Bamrasnaradura Infectious Disease Institute, the Chest clinic at TB Bureau,and the Medical Correctional Institute. This application is funded through the Global FundRound 8, with additional funding received through Round 6 for laboratory strengthening.

Timor-Leste

The Green Light Committee approved project for management of MDR-TB in Timor-Lestewas formally launched in June 2008. MDR-TB guidelines have been developed and anational coordination committee has also been established. Sputum samples of suspectedMDR-TB are transported for culture and drug susceptibility testing to SA Pathology (formallyIMVS), Adelaide, Australia which is the designated supra-national reference laboratory forTimor-Leste. Treatment for MDR TB patients is initiated through an NGO, Klibur Dominwhich supports the NTP for MDR-TB treatment, admitting patients in their facility during


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intensive phase. Continuation phase of treatment is ambulatory. NTP coordinates withPMDT coordination committee and the Cuban Doctors Brigade to ensure regular follow-up ofpatients by expert clinicians.

The results for PMDT in Timor Leste up to March 2011 are as follows:

Culture and DST testing, Timor Leste 2008-2011:

2008 2009 2010 2011 (uptoMarch)

No of cases tested for MDR-TB atIMVS(including DST)

13 14 33 3

No of cases detected to be MDR-TB byIMVS

4 4 3 1

No of cases started on treatment bythe

NTP

3 1 3 0

Three patients are currently undergoing treatment. Support for drugs has been received fromUNITAID and from Global Fund Rd 7 grant.

Milestones for 2011

Regional and national costed plans for MDR-TB and XDR-TB management andinfection control developed in all countries;

MDR-TB sites further expanded in Bangladesh, India, Myanmar, Nepal,Indonesia and Timor-Leste; established in Bhutan, DPR Korea, Sri Lanka and

Thailand;

At least over 3000 MDR-TB patients initiated on treatment by end-2010.

Implications fo r the Regional Offices col laborative activi ties with countries

Intensified technical assistance to Member countries to build laboratory and casemanagement capacity for the diagnosis and case management of M/XDR-TB;

Building capacity at both Regional and country offices to effectively supportcountries in implementing, monitoring performance, and assessing the impact ofthese more complex interventions;

Strengthening linkages with centres of excellence, and identifying additional expertsincluding from WHO Collaborating Centres, to assist countries;

Greater coordination and collaboration with all technical and development partners toharmonize support and to ensure capacity is built in countries, in a sustainable way.

drug resistant tuberculosis in southeast asia-status report

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