Download ppt - Stop TB Partnership

Advocacy, Communication,
and Social Mobilization
to Fight XDR TB
Wanda Walton, PhD, MEd
Communications, Education, and Behavioral Studies Branch
Division of Tuberculosis Elimination
ACSM to Address Key Challenges
to TB Control at Country Level
• Improving case detection and treatment
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adherence
Combating stigma and discrimination
Empowering people affected by TB
Mobilizing political commitment and
resources for TB
Framework for ACSM to Address
Key Challenges to TB Control
at Country Level
• Building national and subnational ACSM capacity
• Building inclusion of patients and affected
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communities
Ensuring political commitment and accountability
Building country-level ACSM partnerships
Learning, adapting, and building on good ACSM
practice
Advocacy, Communication,
and Social Mobilization for XDR TB
• Communication to exchange information about
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XDR TB, informing and creating awareness
Advocacy to place XDR TB control high on the
political agenda, foster political will, increase
financial and other resources, e.g., human
resources
Social mobilization to bring together allies to raise
awareness and demand for program needs, assist
in delivery of resources and services, create
sustainable change
XDR TB
Extensive (or Extreme) Drug Resistant TB
XDR TB extensive (or extreme) drug resistant TB
• MDR TB - defined as TB resistant to at least the 2
most potent anti-TB drugs, isoniazid and rifampicin
(first-line drugs)
• XDR TB* - defined as MDR TB that is also resistant
to at least 3 of the 6 classes of second-line drugs
*Definition may change based upon recommendations
of expert panel
Drugs for the Treatment of TB
1. Isoniazid
2. Rifampicin
3. Pyrazinamide
4. Ethambutol
5. Aminoglycosides
6. Capreomycin
7. Quinolones
8. Thioamides
9. Cycloserine
10. PAS
First-line drugs and treatment of
drug-susceptible TB
1. Isoniazid
2. Rifampicin
3. Pyrazinamide
4. Ethambutol
5. Aminoglycosides
6. Capreomycin
7. Quinolones
8. Thioamides
9. Cycloserine
10. PAS
• Standardized treatment of “routine”
drug-susceptible TB
• 4 drugs, 6-9 months
• Safe, effective, inexpensive
• 95% cure, $20 (drug costs)
• Based on solid scientific evidence
from ~ 30 years of drug discovery and
controlled clinical trials, 1943-72
Second-Line Drugs and Treatment of
Multidrug-Resistant TB
1. Isoniazid
• Treatment based on laboratory
2. Rifampicin
drug-resistance testing and
epidemiology information
3. Pyrazinamide
4. Ethambutol
5. Aminoglycosides
6. Capreomycin
7. Quinolones
8. Ethionamide
9. Cycloserine
10. PAS
• 4-6 drugs, 2 years
• Less effective, more toxic,
expensive
• - 65%-75% cure
• - $3500 (drug costs)
• No clinical trials evidence to
guide treatment or prevention
Drug Susceptible
Multidrug
resistance
Extensive drug
resistance
Isoniazid
Isoniazid
Isoniazid
Rifampicin
Rifampicin
Rifampicin
Pyrazinamide
Pyrazinamide
Pyrazinamide
Ethambutol
Ethambutol
Ethambutol
Aminoglycosides
Capreomycin
Aminoglycosides
Capreomycin
Aminoglycosides
Capreomycin
Quinolones
Quinolones
Quinolones
Thioamides
Thioamides
Thioamides
Cycloserine
Cycloserine
Cycloserine
PAS
PAS
PAS
Resistance by definition
Resistance possible or likely
Extensive Drug Resistance Among MDR TB
Isolates Submitted to 14 Supranational
Reference Labs, by Region 2000–2004
Geographic Region
Total MDR TB
isolates (n)
Industrialized nations
821
Latin America
543
Eastern Europe
406
Africa and Middle East
156
Asia
1,572
Total
3,418
XDR TB
n (%)
53 ( 6 )
32 ( 6 )
55 ( 14 )
1 ( <1 )
204 ( 13 )
345 (10)
XDR TB
Awareness and Emergency Response
• Oral and poster presentations at IUATLD conference,
November 2005
• CDC report on Emergence of Mycobacterium tuberculosis
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with Extensive Resistance to Second-Line Drugs --Worldwide, 2000--2004, March 24, 2006
16th International AIDS Conference presentation, August
2006
Global alert issued by WHO on emerging threat of highly
lethal strains of drug resistant TB (XDR TB) on September 5,
2006
Emergency experts’ meeting (MRC, WHO, CDC) in
Johannesburg, SA on September 7-8
Call for Global XDR TB Task Force in Geneva, first meeting
October 2006
XDR TB in KwaZulu-Natal
Province (KZN), South Africa
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Reports of high mortality from TB in ARV treatment program
in KZN in 2005
Team of collaborators invited to identify problem
Investigators preformed cross-sectional study of TB
suspects attending rural hospital
1539 patient isolates, 544 diagnosed with M.tb
– Of these, 221 (41%) MDR TB
– Of these, 53 (24%) XDR TB
» Of these patients, 26 had no h/o TB treatment;
» 44 of 44 tested were HIV infected;
» 52 (98%) died; 15 were on ARVs
XDR TB now documented in 28 health care institutions
throughout KNZ
Expert Consultation on Drug
Resistant Tuberculosis
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Expert Consultation organized by Medical Research Council
(MRC) to strategize steps forward in Southern Africa
Development Community (SADC) countries to address
problem of drug resistance, September 7-8, 2006
Convened by Medical Research Council, Republic of South
Africa (RSA) Department of Health
Key stakeholders with experience in drug-resistant TB
response – WHO, CDC (DTBE and RSA GAP), KNCV
Representatives from all 9 provinces of RSA
Representatives from 10 SADC countries
Expert Consultation 7-Point Plan:
Short Term Response
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“Improve function and performance of national TB
programs to strengthen treatment adherence and
achieve high rates of treatment completion for all
TB patients”
Develop national emergency response plan for
MDR/XDR TB within 3 months
Conduct rapid surveys of MDR TB and XDR TB
within the next 3-6 months
Strengthen and expand current national TB
laboratory capacity
Urgently implement broad infection control practices
in health care facilities with special emphasis on
those facilities providing care for PLWHA
7-Point Plan: Long Term Response
• Establish capacity for clinical public health
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managers to effectively respond to MDR/XDR TB
Promote universal access to ARVs for all TB
patients through collaboration with HIV/AIDS
treatment and care programs
Support an increase in research for anti-TB drug
development and rapid diagnostic test development
for MDR/XDR TB
XDR TB is a significant threat to the major
gains made in global TB control.
World Health Organization
Individuals with TB, including XDR TB, are
human beings with human rights. We must
treat all people with TB with respect,
preserve their dignity, and save their lives.
There is no role for stigma and
discrimination in managing TB.
Professor Gavin Churchyard
Director, Aurum Institute for Health Research
TB Disease
Latent TB
Infection
XDR TB
MDR TB
First global report of highly drug resistant TB, which shows widespread
presence of virtually untreatable TB
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Survey of global network of supranational TB reference laboratories, consisting of topperforming TB labs located on 6 continents
 2% of the isolates (347 out of nearly 18,000) were identified w/ extensive drug resistance (MDR
TB that is also resistant to 3 of the 6 classes of second-line drugs that are used to treat TB)
o XDR TB was ID-ed in all regions, but was most frequent in the countries of the former
Soviet Union and in Asia
o While global trend data is limited, available data may indicate some increases in XDR
TB
Worsening drug resistance
Critically important to
 Because reference labs are more likely to receive data f/ complex TB cases,
around the world poses a
take steps now to prevent
looked at population-level data from selected countries to further understand
serious threat to our ability to
further
spread of highlythe prevalence of XDR TB and trends
treat & control TB
resistant TB.
o In U.S., found 4% of MDR TB cases were highly drug resistant –
XDR cases increased slightly, but not significantly, f/ 3.9% of
 Treating patients with drug-resistant TB is costly,
 MDR TB in 1990s signaled the
MDR cases in early 90s to 4.5% by end of 2004
and drugs are toxic and expensive
beginning of a global epidemic
o In Latvia, a country w/ one of the highest rates of
MDR TB, 19% of MDR TB cases were highly
 Because drug resistant TB requires 4-5 drugs to
 Ensure adequate treatment of both
drug resistant.
treat, this level of resistance precludes effective
drug-susceptible and drug-resistant TB
treatment in many areas
o Ensure patients complete TB and
o While places with more resources, such as the
MDR TB treatment through DOTS
U.S. or Latvia, may have greater access to
programs
XDR TB
additional effective drugs, the majority of TB
o Strengthen lab capacity for
MMWR 3/24/06
cases occur in places unlikely to have access
diagnosis of MDR TB and secondo Limited drugs mean that patients with XDR TB
line drug susceptibility testing
are virtually untreatable according to
o Use of quality-assured TB drugs
international TB treatment guidelines in most
countries
 Expand surveillance to determine
trends and better evaluate XDR TB
 Patients with drug-resistant TB have worse
treatment outcomes (death or treatment
CDC is partnering to raise
failure)
awareness and enhance strategies for
o Compared to patients with MDR
TB prevention worldwide
TB, those with XDR TB were 64%
more likely to die during
treatment in the U.S.
 CDC is a member of the Green Light Committee, which was created to increase access
o In Latvia, patients w/
to quality-assured, lower cost second line drugs while ensuring their proper use to
XDR TB were 54%
prevent increased drug resistance.
more likely to die
 CDC is urging more accurate and rapid detection and treatment of drug-resistant TB,
or have tx
including the development of international standards for second line drug susceptibility
failure
testing, new anti-TB drug regimens, and better diagnostic testing
 Must build capacity of frontline providers to diagnose and ensure completion of treatment,
which will help avert drug resistance
XDR TB Messages
First global report of highly drug resistant TB, which shows
widespread presence of virtually untreatable TB
• Survey of global network of supranational TB
reference laboratories, located on 6 continents
• 2% of the isolates (347 out of nearly 18,000) were
identified w/ extensive drug resistance
• XDR TB was ID-ed in all regions, but was most
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frequent in the countries of the former Soviet Union
and in Asia
– While global trend data is limited, available data
may indicate some increases in XDR TB
In U.S., found 4% of MDR TB cases were highly
drug resistant
In Latvia, MDR TB, 19% of MDR TB cases were
highly drug resistant
XDR TB Messages
Worsening drug resistance around the world poses a serious
threat to our ability to treat & control TB
• Treating patients with drug-resistant TB is costly,
and drugs are toxic and expensive
• Because drug resistant TB requires 4-5 drugs to
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•
treat, this level of resistance precludes effective
treatment in many areas
While places with more resources, such as the U.S.
or Latvia, may have greater access to additional
effective drugs, the majority of TB cases occur in
places unlikely to have access
Limited drugs mean that patients with XDR TB are
virtually untreatable according to international TB
treatment guidelines in most countries
XDR TB Messages
Worsening drug resistance around the world poses a serious
threat to our ability to treat & control TB (2)
• Patients with drug-resistant TB have worse
treatment outcomes (death or treatment failure)
• Compared to patients with MDR TB, those with
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XDR TB were 64% more likely to die during
treatment in the U.S.
In Latvia, patients w/ XDR TB were 54% more likely
to die or have tx failure
In KZN, 98% of patients with XDR TB and HIV
infection died, despite adequate response to
ARVs
XDR TB Messages
Critically important to take steps now to prevent further spread
of highly-resistant TB
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MDR TB in 1990s signaled beginning of a global epidemic
Ensure adequate treatment of both drug-susceptible and
drug-resistant TB
– Ensure patients complete TB and MDR TB treatment
through DOTS programs
– Strengthen lab capacity for diagnosis of MDR TB and
second-line drug susceptibility testing
– Use of quality-assured TB drugs
Expand surveillance to determine trends and better evaluate
XDR TB
Must have adequately functioning TB programs to
address problem
Implement broad infection control precautions
Additional resources (human and financial)
XDR TB Messages
CDC is partnering to raise awareness and enhance strategies
for TB prevention worldwide
• CDC is a member of the Green Light Committee,
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created to increase access to quality-assured, lower
cost second line drugs while ensuring their proper
use to prevent increased drug resistance
CDC is urging more accurate and rapid detection
and treatment of drug-resistant TB, including the
development of international standards for second
line drug susceptibility testing, new anti-TB drug
regimens, and better diagnostic testing
Must build capacity of frontline providers to
diagnose and ensure completion of treatment,
which will help avert drug resistance
XDR TB Messages
CDC is partnering to raise awareness and enhance strategies
for TB prevention worldwide (2)
New messages
• Participation in expert consultation with WHO
and MRC
• Consensus plan of action
• Strengthen the laboratory
• Train the health care workers
Media Quotes in U.S.:
March 24, 2006
• Dr. Kenneth Castro, director of the CDC's division of
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TB elimination, said emergence of a super-resistant
strain is a potent reminder that tuberculosis remains
a formidable threat. "It is widely distributed
geographically, including in the United States, and
renders patients virtually untreatable," Castro said.
Dr. Marcos Espinal, executive secretary of WHO's
TB elimination program, called XDR TB a veritable
death sentence. "If people are failing first- and
second-line drugs and we don't have in the pipeline
a new drug for immediate use, that's a crisis," he
said.
Media Response to XDR TB
in South Africa
XDR-TB
WHO expresses concern
WHO background briefing note
issued prior to XDR-TB Expert
Consultation meeting in South
Africa
'Virtually untreatable' TB
found
A "virtually untreatable" form of TB has emerged,
according to the World Health Organization
(WHO).
Extreme drug resistant TB (XDR TB) has been seen
worldwide, including in the US, Eastern Europe and
Africa, although Western Europe has had no cases.
Dr Paul Nunn, from the WHO, said a failure to correctly
implement treatment strategies was to blame.
XDR-TB
Coverage in major weekly journals
Newsweek Sept. 13, 2006 –
WHO recently issued a warning
that deadly new strains of
tuberculosis appear to be
spreading around the globe…
HIV sufferers are particularly
vulnerable because of their
weakened immune systems.
TB, already the world’s fourth
most fatal infectious disease,
could wreak havoc with AIDS
treatment programs
XDR-TB
Coverage in major weekly journals
XDR-TB
African press coverage:
New TB strain in SA: 'No time
to wait'
07 September 2006
The extreme drug-resistant
tuberculosis (XDR-TB) in
KwaZulu-Natal must be dealt
with urgently, international
health experts said in
Johannesburg on Thursday.
"There is no time to wait before
we embark on decisive action,"
said the World Health
Organisation's Dr Ernesto
Jaramillo, explaining that an
epidemic could have a deadly
impact.
XDR-TB
International press coverage:
XDR-TB
International headlines:
Deadly TB strain spreading across globe
Africa: "Extreme" TB Bug Prompts Calls for Rapid Action
Experts call for urgent steps to battle virulent TB strain
South Africa: Action plan developed to combat drug resistant TB
WHO urges South Africa to curb TB killer super-bug
Global alert over deadly new TB strains
TB strain with extreme resistance to drugs creates nightmare scenario
TB experts will grapple with deadly new strains: WHO
XDR-TB
Editorial in New York Times & Int. Herald Tribune
EXTREME TUBERCULOSIS
SEPTEMBER 14, 2006
TB is outrunning us. In the last few months, 53 patients in the South
African province of KwaZulu-Natal were found to have a form of the
disease resistant to enough existing drugs that it is virtually incurable. All
but one of those patients have died…
Stinginess created this problem. Generosity is needed to fix it.
Stop TB XDR Response
1. Coordination – Develop an appropriate,
coordinated global response to XDR TB
2. Resource mobilization – Raise sufficient funds to
ensure no delays in the global response to XDR
TB
3. Case definitions – Ensure consistency in
surveillance and case management
4. Monitoring and evaluation – Determine
geographical and temporal spread of XDR TB
Stop TB XDR Response (2)
5. Communications – Provide a proactive flow of
information to all stakeholders, including member
states and the global media
6. Case management – Define the optimal way of
rapidly identifying suspect XDR cases and ensuring
appropriate treatment; determine appropriate
infection control measures in health facilities
7. Country support – Ensure a timely and sufficient
response to requests from countries for assistance
This time, I bet you that if the press is
prompted and well prepared, journalists will
come like flies around a cake and other
objects...
Mario Raviglione