Reality check: Perspectives from the field on Reality check: Perspectives from the field on

OPPORTUNITIES for technology and innovationOPPORTUNITIES for technology and innovation

Kitty Lambregts, KNCV TB FoundationKitty Lambregts, KNCV TB Foundation

Chair Chair -- MDRMDR--TB WGTB WG

MDRMDRMDRMDR----TBTBTBTB Working GroupWorking GroupWorking GroupWorking Group

ContentsContents

Only 4 years agoOnly 4 years ago

Capacity to diagnose and capacity to treat: the balance is shiftCapacity to diagnose and capacity to treat: the balance is shifting ing

Reality check 1: do we embrace progress made? Reality check 1: do we embrace progress made?

Reality check 2: lab network design and the role of TB Reality check 2: lab network design and the role of TB programmesprogrammes

Reality check 3: are Reality check 3: are programmesprogrammes and partners ready to respond?and partners ready to respond?

The weakest link The weakest link ……....

ConclusionsConclusions

STAG presentation 2005:STAG presentation 2005:STAG presentation 2005:STAG presentation 2005:

Estimated incidence of MDR TB (2003) Estimated incidence of MDR TB (2003) Estimated incidence of MDR TB (2003) Estimated incidence of MDR TB (2003)

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Cases estimated detected with TB diagnosed with MDR-TB

with estimated 45%

case detection rate

with estimated 45%

case detection rate

with estimated 5%

DST coverage

with estimated 5%

DST coverage

ScaleScale--up of MDRup of MDR--TB managementTB management

Countries ranking 1 to 10 of the 27 MDR high priority countriesCountries ranking 1 to 10 of the 27 MDR high priority countries

0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000

Philippines

Nigeria

Uzbekistan

Bangladesh

Pakistan

Kazakhstan

South Africa

Russian Federation

China

India

Number of MDR-TB cases assuming all notified ss pos cases receive DST

Number of MDR-TB cases, 2007

Number of ss+ MDR-TB cases expected to be treated

Symptoms

Smear - 60%

LJ - 40d

LED +10% LAMP+25% Xpert +40%

AG/AB

SensitivitySensitivity

Time to responseTime to response

Point of carePoint of care

Molecular

MGIT 15d MTBDR+ 1d

Enose

FIND deliverables for 3 levels of the health systemFIND deliverables for 3 levels of the health system

Other innovationsOther innovations

Electronic information systems linking caseElectronic information systems linking case--detection, detection,

cohortcohort--analysis and procurement in all sitesanalysis and procurement in all sites

Active caseActive case--finding / contact tracingfinding / contact tracing

Infection control policies / technologiesInfection control policies / technologies

New drugs (and new regimens)New drugs (and new regimens)

Need for trialsNeed for trials

A new global TB control strategy, but the same workforceA new global TB control strategy, but the same workforce

Reality check 1: do we embrace progress made?Reality check 1: do we embrace progress made?

Absolutely, most of us recognize opportunitiesAbsolutely, most of us recognize opportunities

–– Increased TB case detectionIncreased TB case detection

–– Less delay to identify drugLess delay to identify drug--resistanceresistance

–– Diagnosis of smear negative TB Diagnosis of smear negative TB

–– Increased survival of HIV coIncreased survival of HIV co--infected TB patientsinfected TB patients

–– Decentralization of diagnosis of (resistant) TB! Decentralization of diagnosis of (resistant) TB!

–– Less false positive TB diagnosis (HIV related)Less false positive TB diagnosis (HIV related)

–– Easier drug resistance surveillanceEasier drug resistance surveillance

–– Diagnostic platforms (funding, human resources, integration)Diagnostic platforms (funding, human resources, integration)

Reality check 2Reality check 2

Is laboratory network design informed by programmatic Is laboratory network design informed by programmatic

vision (and realities) and epidemiological evidence?vision (and realities) and epidemiological evidence?

The reality and needs in the fieldThe reality and needs in the field

–– Coordination at country level often subCoordination at country level often sub--optimaloptimal

–– NTP and lab under different departments ; NTP and lab under different departments ; parastatalparastatal and private labsand private labs

–– Often many international partners, but no coordinationOften many international partners, but no coordination

–– Often little integration between disease Often little integration between disease programmesprogrammes

–– Joint lab network planning crucial to cover and monitorJoint lab network planning crucial to cover and monitor

Estimated MDREstimated MDR--TB caseTB case--load load

Actual notification: smear negative and positive TBActual notification: smear negative and positive TB

DRS data (FL and SLDDRS data (FL and SLD--resistance in patient categories)resistance in patient categories)

Diagnostic algorithm and Diagnostic algorithm and programmeprogramme designdesign

Applications to GF and other donors (diagnose Applications to GF and other donors (diagnose andand manage cases)manage cases)

Private public mix modelsPrivate public mix models

Advocacy for Progress with developments of new technologiesAdvocacy for Progress with developments of new technologies

Consensus on technical requirements : BSL 2+, 3, 2.7 Consensus on technical requirements : BSL 2+, 3, 2.7 ……

Reality check 3: Reality check 3:

Are Are programmesprogrammes and partners ready to respond?and partners ready to respond?

Actions needed:Actions needed:

–– overcome (natural) resistance to change with both countries and overcome (natural) resistance to change with both countries and technical partners : prioritytechnical partners : priority--setting, NTP capacity..setting, NTP capacity..

–– develop new diagnostic algorithms and develop new diagnostic algorithms and programmeprogramme designdesign

–– address HRD implications (human resources, training)address HRD implications (human resources, training)

–– Link up with Link up with ‘‘strangersstrangers’’ ( Flu, HIV, PPM, academic setting)( Flu, HIV, PPM, academic setting)

–– Address global secondAddress global second--line drug supply crisisline drug supply crisis

–– address imbalance between capacity to diagnose and capacity address imbalance between capacity to diagnose and capacity to treatto treat

–– Assist national manufacturers to meet QA requirements Assist national manufacturers to meet QA requirements

Urgent need to set up country DRUrgent need to set up country DR--TB coordinating and TB coordinating and technical assistance mechanismstechnical assistance mechanisms

Resistance Pattern of patients enrolled in first Resistance Pattern of patients enrolled in first

GLC programmesGLC programmes

0%

20%

40%

60%

80%

100%E

sto

nia

La

tvia

Ore

l

Pe

ru

Ph

ilip

pin

es

To

ms

k

Patients resistant to HRES and

second-line drugs

Patients resistant to HRES

Patients resistant to HR only

The weakest link determines pace of scaleThe weakest link determines pace of scale--up to up to

the 2015 Global Plan targetsthe 2015 Global Plan targets

GovernmentsGovernments

–– Funding & Workforce Funding & Workforce

–– Framework elementsFramework elements

lab, DRS: measure!lab, DRS: measure!

quality assured drugsquality assured drugs

public private mixpublic private mix

HIV/TB crossHIV/TB cross--referralreferral

information systemsinformation systems

STB PartnershipSTB Partnership

–– Coordination and M&E !!Coordination and M&E !!

–– Donor mobilizationDonor mobilization

–– Technical support modelsTechnical support models

–– New tools New tools

–– Access to QA drugsAccess to QA drugs

ConclusionsConclusions

Excellent progress, but threat of imbalance !Excellent progress, but threat of imbalance !–– capacity to diagnose capacity to diagnose ≠≠ capacity to treat capacity to treat ≠≠ drugs drugs ≠≠ fundingfunding

–– coordinating mechanism that includes coordinating mechanism that includes An overall coordinating body under the STP Board with involvemenAn overall coordinating body under the STP Board with involvement of the t of the Core Group of the MDRCore Group of the MDR--TB WG and the GLITB WG and the GLI

Coordination within WHO (secretariats of Coordination within WHO (secretariats of WGsWGs and subgroups)and subgroups)

mirrored by coordinating bodies at national levelmirrored by coordinating bodies at national level

New models requiredNew models required–– aggressive technical assistance (learning by doing : need to evaaggressive technical assistance (learning by doing : need to evaluate)luate)

–– involving private providers, public hospitals, private labsinvolving private providers, public hospitals, private labs……

–– funding (global and country levels)funding (global and country levels)

–– GLC procurement and GLC approval for countries that want to procGLC procurement and GLC approval for countries that want to procure ure outside GDF (streams of engagement)outside GDF (streams of engagement)

Show donors and countries that we (can) moveShow donors and countries that we (can) move

Thank you for your attentionThank you for your attention

Looking forward to a lively Looking forward to a lively

discussion.discussion.