Stop TB Partnership's

MDR-TB Working Group Meeting 2007

Dr Mario RaviglioneDirector, Stop TB Department

Tbilisi, Georgia, 20 September 2007

From Dream to Reality CheckOn MDR-TB Management Scale-up

Latest global TB estimates - 2005

Estimated number of cases

(in million)

Estimated number of deaths

(in million)

1.68.8

116,000424,000

All forms of TB

Multidrug -resistant TB (MDR-TB)

Extensively drug-resistant TB (XDR-TB)

27,000 16,000

(Zignol M et al. Global Incidence of Multidrug-Resistant Tuberculosis, JID 2006:194)

MDR-TB prevalence in new TB cases, 1994-2003

Estonia

Russia (Ivanovo)

Latvia

China (Henan)

China (Liaoning)

Dominican Rep

Russia (Tomsk)

Israel

Ivory Coast

Ecuador

Kazakhstan

Uzbekistan

Lithuania

Iran

4.9

7.8

10.4

6.6

12.2

5.0

14.2

5.3

14.2

9.3

9.4

9.0

13.7

13.2

Eastern Europe,

65,853

Africa high HIV

incidence, 48,141

Latin America,

11,301

Eastern

Mediterranean

Region, 18,330

Central Europe,

1,462

Established Market

Economies, 1,681

South-east Asia,

114,967

Western Pacific

Region, 152,018

Africa low HIV

incidence, 10,449

Global burden:

424,203 cases

Estimated number of MDR-TB cases by regions, 2005

XDR-TB – Extensive Drug ResistanceThe new threat

XDR = Resistance to at least INH and

RIF (MDR) PLUS resistance to any

fluoroquinolone, AND any one of the

second-line injectable drugs (amikacin,

kanamycin, or capreomycin)

Of 17,690 isolates from 49 countries

during 2000-2004 20% were MDR

and 2% were XDR

XDR found in:

USA: 4% of MDR

Latvia: 19% of MDR

S Korea: 15% of MDR

XDR found in South

Africa associated with

HIV

Czech Republic

The boundarie

s and names shown and th

e designations used on th

ismap do not im

ply th

e expression of a

ny opinion

whatsoever o

n th

e part o

f the W

HO concerning th

e legal status ofany country

, territo

ry, city

or a

rea or o

f its

authoritie

s, o

r concerning th

e delim

itatio

n of its

frontiers or b

oundarie

s. D

otte

d lin

es on m

aps re

present a

pproximate

border lin

es fo

r which th

ere m

ay not y

et b

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ll agreement.

WHO 2005. A

ll rights re

served

Ecuador

Georgia

Argentina

Bangladesh

Germany

Republic of Korea

Armenia

Russian Federation

South Africa

Portugal

Latvia

Mexico

Peru

USA

Brazil

UK

Sweden

Thailand

Chile

Based on information provided to WHO Stop TB Department 13 September 2007

SpainIslamic Republic of Iran

China, Hong Kong SAR

France

Japan

NorwayCanada

Italy

Netherlands

Estonia

Lithuania

Ireland

Romania

Israel

Azerbaijan

Poland

Slovenia

India

Australia

Mozambique

Vietnam

Countries with XDR-TB confirmed cases as of September 2007

Treating MDR-TB in the bush of Swaziland – St Philip's, 8-2007

Observed and expected spread of MDR-TB

0

2

4

6

8

10

12

14

0 10 20 30

years of drug use

MDR (%)

RelativeFitnessOf MDR-TB

Will drug-resistant strains replace drug-susceptible ones?

Dye C. et al. Science 2002; 295:2042-6

Can MDR-TB case management generate additional XDR-TB?

Message: the higher the % of MDR-TB managed

with current poor outcomes,

the higher the % of XDR-TB generated

Blower S, Supervie V. Predicting the future of XDR tuberculosis. Lancet 2007

The Stop TB Strategy to achieve the 2015 MDGs

What needs to be done to addressMDR-TB and XDR-TB effectively?

• Strengthen basic TB and HIV/AIDS control, to avoid creation of MDR-TB and XDR-TB

• Scale-up programmatic management of MDR-TB and XDR-TB

• Strengthen laboratory services for adequate and timely diagnosis of MDR-TB and XDR-TB

• Expand MDR-TB and XDR-TB surveillance • Introduce infection control, especially in

high HIV prevalence settings• Strengthen advocacy, communication and

social mobilization (e.g., Response Plan)• Pursue resource mobilization at global,

regional and country levels• Promote research and development into

new diagnostics, drugs and vaccines

2007-2008 XDR & MDRTuberculosis Global Response Plan

MDRMDR--TB projects in 48 countries approved by GLCTB projects in 48 countries approved by GLC

27 of them GF27 of them GF--supportedsupported

A total of 30'000 cases to be treatedA total of 30'000 cases to be treated

1.1.1.1. BangladeshBangladeshBangladeshBangladesh2.2.2.2. IndiaIndiaIndiaIndia3.3.3.3. NepalNepalNepalNepal4.4.4.4. TimorTimorTimorTimor----LesteLesteLesteLeste1.1.1.1. Burkina FasoBurkina FasoBurkina FasoBurkina Faso2.2.2.2. DR CongoDR CongoDR CongoDR Congo3.3.3.3. GuineaGuineaGuineaGuinea4.4.4.4. Kenya Kenya Kenya Kenya 5.5.5.5. LesothoLesothoLesothoLesotho6.6.6.6. RwandaRwandaRwandaRwanda7.7.7.7. UgandaUgandaUgandaUganda1.1.1.1. BelizeBelizeBelizeBelize2.2.2.2. BoliviaBoliviaBoliviaBolivia3.3.3.3. Costa RicaCosta RicaCosta RicaCosta Rica4.4.4.4. Dominican RepublicDominican RepublicDominican RepublicDominican Republic5.5.5.5. EcuadorEcuadorEcuadorEcuador6.6.6.6. El Salvador El Salvador El Salvador El Salvador 7.7.7.7. GuatemalaGuatemalaGuatemalaGuatemala8.8.8.8. HaitiHaitiHaitiHaiti9.9.9.9. HondurasHondurasHondurasHonduras10.10.10.10. MexicoMexicoMexicoMexico11.11.11.11. NicaraguaNicaraguaNicaraguaNicaragua12.12.12.12. ParaguayParaguayParaguayParaguay13.13.13.13. PeruPeruPeruPeru14.14.14.14. UruguayUruguayUruguayUruguay

1.1.1.1. EgyptEgyptEgyptEgypt2.2.2.2. Jordan Jordan Jordan Jordan 3.3.3.3. LebanonLebanonLebanonLebanon4.4.4.4. SyriaSyriaSyriaSyria5.5.5.5. TunisiaTunisiaTunisiaTunisia

1.1.1.1. AzerbaijanAzerbaijanAzerbaijanAzerbaijan2.2.2.2. ArmeniaArmeniaArmeniaArmenia3.3.3.3. Estonia Estonia Estonia Estonia 4.4.4.4. GeorgiaGeorgiaGeorgiaGeorgia5.5.5.5. KazakhstanKazakhstanKazakhstanKazakhstan6.6.6.6. KyrgyzstanKyrgyzstanKyrgyzstanKyrgyzstan7.7.7.7. Latvia Latvia Latvia Latvia 8.8.8.8. LithuaniaLithuaniaLithuaniaLithuania9.9.9.9. Moldova Moldova Moldova Moldova 10.10.10.10. RomaniaRomaniaRomaniaRomania11.11.11.11. Russia Russia Russia Russia 12.12.12.12. UkraineUkraineUkraineUkraine13.13.13.13. UzbekistanUzbekistanUzbekistanUzbekistan1.1.1.1. CambodiaCambodiaCambodiaCambodia2.2.2.2. ChinaChinaChinaChina3.3.3.3. MongoliaMongoliaMongoliaMongolia4.4.4.4. PhilippinesPhilippinesPhilippinesPhilippines5.5.5.5. VietnamVietnamVietnamVietnam

MDR-TB Projects approved by GLCSeptember 2007

Gap between requests to GLC and revised Global Plan, 2006-2015

30,000

1,6000,000

328

548

766

979

1,187

1,389

1,582

1 2 3 7 10 12 25 3066

176

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Thousands

Response Plan

GLC

Conclusions

• XDR-TB is a powerful and threatening alarm call for all of us. Status quo or slow pace are no options.

• Scaling-up of interventions must be massive, well-thought, and rapid. Governments and donors must react now

• GLC is now ready to accommodate more proposals, but all depends on demand from national TB control programmes

• Response Plan is for 2007-8 only. WG needs to think now about the future

• True bottlenecks must be addressed systematically: drug regulations, drug procurement, pre-qualification, lab capacity, and overall human resource capacity of programmes, including community engagement