MDR-TB GLOBALLY AND IN THE REGION 2013Dr Samiha Baghdadi

Medical officer – STB

WHO – EMRO

Cairo March 2014

The structure of the presentation• MDR-TB burden globally and in the region• MDR-TB notification• MDR – TB treatment outcomes• Regional challenges and strategic directions• Ambulatory care for MDR-TB

Global coverage of data on DR-TB 1994-2013

MDR-TB rate among New TB cases

JOR SYR SOM IRN AFG IRQ LIB PAK EGY BAH KWT UAE OMN KSA YEM QTR LEB DJI SUD TUN MOR PAL EMR

6.36.2

5.25

2.9 2.9 2.9 2.9

2.32.2 2.2 2.2 2.2

1.81.7

1.21.1

0.9 0.9 0.82

0.5

3.5

Graph 2: MDR rate among new

MDR-TB rate among previously treated TB cases

LEB IRN SOM AFG IRQ LIB PAK SYR JOR EGY KSA YEM DJI SUD MOR TUN BAH KWT QTR UAE OMN PAL EMR

67

48.2

41

35.4 35.4 35.4 35.4

3129

25

1615 14.4 14.4

12.2 1210.8 10.8 10.8 10.8

8.3

32

Graph3: MDR rate among previously treated

Estimated MDR-TB among TB cases by WHO region

Contribution of WHO regions to MDR-TB burden 2012

AFR13%

AMR2%

EMR6%

EUR25%

SEAR30%

WPR25%

Graph 1: Contribution of WHO regions to MDR-TB burden 2012

Countries notified at least 1 XDR case

MDR-TB cases 2012Estimated, notified and enrolled on treatment

Estimated Number of MDR-TB cases among notified TB cases 2012

PAK AFG SOM IRN SUD IRQ EGY MOR SSUD YEM SYR SAA DJI LIB TUN JOR LEB OMN QAT BAH UAE W&G KWT

11000

1100770 750

580 420 330 300 250 150 97 84 81 36 19 15 10 6 6 3 2 1 0

Graph 3: Estimated number of MDR-TB cases among notified TB cases

Confirmed MDR-TB cases among notified TB cases 2012

PAK IRQ EGY SUD DJI MOR IRN AFG SAA TUN JOR SYR YEM LEB OMN BAH SSUD QAT UAE KWT SOM W&G LIB

1602

420

116 116 96 8050 31 20 15 13 13 8 6 6 4 3 2 2 0 0 0

Graph 5: Confirmed MDR-TB cases 2012

Contribution to MDR-TB notification by region 2012

AFR22%

AMR4%

EMR3%

EUR44%

SEAR23%

WPR5%

Treatment outcomes

Treatment success rate by country 2011

Afghanistan Egypt Iraq Lebanon Morocco Pakistan Sudan Syria Tunisia Total

86

6772

100

27

70

5358

6966

Treatment success rate of MDR_TB cases 2011

Regional challenges/risks foreseen • Unstable situation in many countries in the region, namely (Afghanistan, Egypt,

Lebanon, Iraq, Pakistan, Somalia, Syria, Tunisia and Yemen). This situation resulted in several challenges as follows:

• Huge population movement across the region• Huge staff turn over • Destruction of infrastructure• Limited movement in the field• Sever loss of drugs and equipment

• Limited lab capacity • Culture and DST are not available in Somalia and South Sudan. DST is not available in Afghanistan. • Most of the countries in the region did not widely apply the new diagnostics. • DR survey and surveillance:

• Updated survey is ongoing in Iraq, Iran, Pakistan, Sudan, and needed in Syria.• There is a need to document/report results of DR surveillance that is ongoing in GCC countries, and expand

the continuous surveillance in the remaining 15 countries.• Libya is still the only country in the region without proper management of MDR-TB management.

Regional challenges/risks foreseen

• Expected financial gap to support scaling up MDR-TB activities in most countries, mainly (Djibouti, Egypt, Lebanon, Jordan, Iran, Pakistan and Syria).

• Limited human resources at country level (MDR local support on continuous basis is needed in Afghanistan, Iraq, Pakistan and Sudan mainly).

• Limited consultancy capacity in the region in general ( a team of 5 consultants was established last year to support countries)

The strategic directions of the work of EMR_GLC• Improve planning for PMDT (update the regional plan

and support planning at country level),• Develop regional high standard ambulatory based

model • Develop Regional framework and guidance about the

utilization of New diagnostics and lab support,• Scale up R&R for MDR, infection control at all levels, HR

capacity,• Promote prequalified regional companies; develop

mechanisms for joint proposals, drugs grants.• Operational research

Promote using ambulatory model in MDR-TB careJustification:• Limited country capacity (infrastructure: hospitals,

infection control) and financial.• New diagnostics increase case detection (X-Pert).• Long waiting list of detected cases.• Global experience is encouraging

However :

Ambulatory care does not exclude hospitalization

What do we need for ambulatory model

• Networking:• Diagnosis, • Treatment, • Treatment follow up, • Side effect management, • Daily observation and care, • Social support

Some basic items for provincial profile1. Population

2. Admin areas

3. Geographical description

4. Notified cases/notification rate ( TB type, Age and gender)

5. Treatment outcomes ( TB type, Age and gender)

6. Estimated MDR-TB cases among new and previously treated

7. Infection control

8. Lab coverage

9. EQA for DSM

10. C/DST coverage

11. PPM coverage

12. PHC coverage

13. Hospitals available

14. Referral system

15. Community support

16. Provincial map (PHC facilities, hospitals, laboratories, TB facilities, PPM facilities, patient distribution, MDR cases distribution) and community support points.

17. Security issues

18. MDR focal person

RO support to countries for AT• Briefing about ambulatory model 2012• Training on planning 2013• Follow up planning process 2013

Future plans 2014• Monitoring missions and evaluation• Lesson learnt

SWOT analysis

Stakeholder analysis/matrix

Provincial profile

Provincial map

Strategic frame work

OP plans