PMDT expansion is first of all expansion of DR-TB detection services

Workshop on the development and implementation of supervision and patient support approach in Drug Resistant programme in Nepal organized by HERD

Kathmandu - April 30, 2014

Giampaolo MezzabottaMedical Officer / TuberculosisWorld Health OrganizationCountry Office for Nepal

Fresh from HQs

• http://www.who.int/tb/laboratory/xpert_launchupdate/en/

Overview of DR-TB in Nepal MDR−TB burden (from WHO Global TB Report 2013)

Estimated total burden: 990 (among notified TB cases)

Total confirmed cases: 354 (35.8% of estimated)

Enrolled on treatment: 288 (81.4% of confirmed)

Treatment Success Rate (from NTP Annual report 2014)

61.3%, reaching a peak of 72% in the cohort enrolled in March – July 2010*

Key features of PMDT in Nepal• standard treatment protocol for all MDR-TB cases; individualized Tx for pre- and XDR-TB • treatment administered by DOT at DR-TB centres and sub-centres throughout its duration; • two NRL, supervised by SRL (Gauting, Germany), both of them located in Kathmandu;• supply of quality-assured SLD from GDF; • no stock-out of SLD so far; • travel & nutrition bonus (NPR 1500 (~ 15US$)/month) provided to patients.

* = In the second quarter of 2013-14 the TSR reached 80%.

From field to lab to Tx

From: “Screening retreatment tuberculosis patients for drug resistance in mid-west Nepal: how well are we doing?”, MB Tharu et al, PHA 2014; 4(1): 60-65

Diagnostic pathway to MDR-TB in 431 retreatment cases reported in Mid-West Region from July 2011 to July 2012

-62%

-60%

-5%

-38%

-38%

Has the situation improved ever since?

• NTC and partners are currently running 22 GeneXpert machines, one of them in MWDR; 7 more machines in the pipeline for 2014.

• Guidelines and algorithms on the rational use of GeneXpert have been developed;

• WHO 2013 policy recommendations: “Xpert MTB/RIF should be used rather than conventional microscopy, culture and DST as the initial diagnostic test in adults suspected of having MDR-TB or HIV-associated TB (strong recommendation, high-quality evidence)”

• Strategic positioning of GeneXpert across the country, along with adequate logistic for sputum transport, should ensure equitable and early access to DR-TB diagnosis.

Realistic targets?

Based on current estimates, notification data, projections and case-finding strategy (Xpert C/DST), in the year 2014 NTP should aim at detecting:

710 MDR-TB cases among notified DR-TB suspects(1) 185 MDR-TB cases among initially SS- patients(2)

125 MDR-TB cases among DR-TB contacts(3) 100 XDR-TB and pre-XDR cases(4)

TOTAL = 1120 DR-TB cases

Notes(1): considering as DR-TB suspects the 2800 expected relapse, failure and defaulter cases; (2): assuming to test with GeneXpert all 8400 expected new SS- cases;(3): assuming 5 contacts per current DR-TB case and a prevalence of 5% among them;(4): estimating an incidence of XDR equivalent to 10% the incidence of MDR-TB

Conclusions

Even if the target of 1120 DR-TB cases enrolled on treatment in 2014 will not be achieved, we can certainly forecast a substantial increase in the number of DR-TB patients.

Adopting new treatment approaches, tapping the huge potential for community-based PMDT in Nepal, is more of a “must” than a choice.

Thank you for the attention