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Thank you for viewing this presentation. We would like to remind you that this material is the property of the author. It is provided to you by the ERS for your personal use only, as submitted by the author. 2012 by the author 23/05/2017 M/XDR-TB: WHAT ARE THE UNRESOLVED PROBLEMS? Jean-Pierre Zellweger, MD Swiss Lung Association Faculty disclosure • I am a clinician caring for patients and fed up by errors and mismanagement of TB and MDR-TB • I have no interest in any organization or industry making profit from MDR-TB (who will anyway?) • Most of the data I will present are from WHO or ECDC reports. I have no personal or secret data to present M/XDR-TB UNRESOLVED PROBLEMS: 1. EPIDEMIOLOGY • The number of M/XDR-TB cases is increasing worldwide • The increase concerns in particular Eastern Europe and Central Asia • In some countries, the proportion of MDR-TB increases in spite of a decrease in the rate of TB • The surveillance and the available data are far from comprehensive. TREND IN TOTAL TB, MDR-TB AND PROPORTION OF MDR-TB IN NEW CASES MDR-TB: GLOBAL BURDEN OF DISEASE M/XDR-TB UNRESOLVED PROBLEMS: 2. DIAGNOSIS • Insufficient diagnostic capacities in many countries • Insufficient use of cultures and DST • Insufficient support of lab networks by local authorities M/XDR-TB UNRESOLVED PROBLEMS: 3. CHOICE OF TREATMENT • Niveau 1 – Niveau 2 • Niveau 3 – Niveau 4 » Niveau 5 M/XDR-TB UNRESOLVED PROBLEMS: 3. CHOICE OF TREATMENT • There are Guidelines but few recommendations are based on a strong evidence • The best Guidelines are useless if the drugs are not available • The best drugs are useless if the patients do not tolerate them • Sotgiu G et al, Eur Respir J 2012:40(2) 500 / 400’000 M/XDR-TB UNRESOLVED PROBLEMS: 3. OUTCOME OF TREATMENT • The outcome of treatment – if known – is still below the expected standards • Patients treated in a GLC-supported programme have a better outcome (because the best drugs are available) TREATMENT OUTCOME BY WHO REGION, 2010 REPORTING YEAR WHO European Region Other WHO Regions 100% 7 90% 80% 6 1 6 1 5 2 4 3 10 5 1 3 3 1 1 2 4.3 6.1 7.3 6.7 11.3 14.1 8 11.3 1 5 9.0 13.0 70% 93 88 88 60% 80 9.3 76 68.7 11.3 50% 56.3 40% AFR AMR Not evaluated EMR SEAR Defaulted New pulmonary lab.confirmed WPR Failed Died Re-treated lab confirmed Successfully treated MDR-TB cohort M/XDR-TB UNRESOLVED PROBLEMS: 4. MANAGEMENT OF ADVERSE EVENTS • Adverse events are frequent and may be severe • Treatment of adverse events means – in the best of cases – the use of further drugs (if available) or interruption of treatment ADVERSE EVENTS DURING TREATMENT OF MDR-TB • 1027 patients with MDR-TB treated in Latvia – Adverse events in 79% • Nausea (58%) • Vomiting (39%) • Abdominal pain (24%) • Serious psychiatric episodes (13%) • Hepatitis (9%) • Real failure (4%) – Change in drug dosage in 20% – Discontinuation of one or more drug in 64% Bloss E, IJTLD 2010;14(3):275 M/XDR-TB UNRESOLVED PROBLEMS: 5. CASE HOLDING • Cas holding is – still –not a tradition in many countries • Even if needed, DOT is frequently not possible because there are no outreach workers to do the job and there are many administrative obstacles MANAGEMENT OF AN OUTBREAK OF MDR-TB: IMPACT OF DOT ON DEATH RATE • The Chuuk experience Brostrom R, AJPH 2011;101(1):14-18 M/XDR-TB UNRESOLVED PROBLEMS: 6. COSTS OF TREATMENT • The treatment of MDR-TB is 10-20 times more expensive than the treatment of drug-sensitive TB • MDR-TB can ruin the budget of TB in countries with weak economy • In many developed countries, the treatment of MDR-TB is more expensive than cardiac transplantation • Who can afford it? M/XDR-TB UNRESOLVED PROBLEMS: 7. INFECTION CONTROL • Hospitals are a perfect place for the transmission of MDR-TB • Implementing all infection control measures can only prevent a part of all cases transmitted in hospital settings • How to prevent the transmission of MDR-TB to other patients, HCW and visitors? • How to manage contacts of MDR-TB cases who have been infected? OUTBREAK MANAGEMENT OF MDR-TB • 2 independent but simultaneous outbreaks of MDR-TB observed in July 2008 in the State of Micronesia • 232 contacts identified, 139 examined: – 15 MDR-TB – 5 drug-sensitive TB – 119 infected • 105 offered preventive therapy with quinolone+E or quinolone +ethio • 93 completed the preventive treatment 0 TB – 28 contacts without preventive treatment (2/14 refusal) developed TB between 2008 and 2012 M/XDR-TB UNRESOLVED PROBLEMS: 8. PALLIATIVE CARE • Back to sanatoria, fresh air, rich meals and morphine (and large graveyards)? M/XDR-TB UNRESOLVED PROBLEMS: 9. PREVENTION • MDR-TB is a problem because errors have been committed and are perpetuated • As long as these errors will not be acknowledged and corrected, there will be no prospect for a decrease M/XDR-TB UNRESOLVED PROBLEMS: 10. LEGAL ISSUES • In many settings, legal issues (laws, regulations and Guidelines) are an obstacle to the adeqate management of TB and MDR-TB • The committment of the governments should start with the updating of the laws and regulations MDR-TB: TURN OFF THE TAP! IF NOT… TRENDS IN M/XDR-TB BY REGION (WHO REPORT 2012)