Advocacy, Communication, and Social Mobilization to Fight XDR TB Wanda Walton, PhD, MEd Communications, Education, and Behavioral Studies Branch Division.

Advocacy, Communication, and Social Mobilization

to Fight XDR TB

Wanda Walton, PhD, MEdCommunications, 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 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 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 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

2. Rifampicin

3. Pyrazinamide

4. Ethambutol

5. Aminoglycosides

6. Capreomycin

7. Quinolones

8. Ethionamide

9. Cycloserine

10. PAS

• Treatment based on laboratory drug-resistance testing and epidemiology information

• 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 Aminoglycosides Aminoglycosides

Capreomycin Capreomycin 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)

XDR TBn ( % )

Industrialized nations

Latin America

Eastern Europe

Africa and Middle East

Asia

821

543

406

156

1,572

53 ( 6 )

32 ( 6 )

55 ( 14 )

1 ( <1 )

204 ( 13 )

Total 3,418 345 (10)

XDR TBAwareness and Emergency Response

• Oral and poster presentations at IUATLD conference, November 2005

• CDC report on Emergence of Mycobacterium tuberculosis 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

• 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

• 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

“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 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

Critically important to take steps now to prevent further spread of highly- resistant TB.

MDR TB in 1990s signaled the beginning of a global epidemic

Ensure adequate treatment of both

drug-susceptible and drug-resistant TB o Ensure patients complete TB and

MDR TB treatment through DOTS programs

o Strengthen lab capacity for diagnosis of MDR TB and second-line drug susceptibility testing

o Use of quality-assured TB drugs Expand surveillance to determine

trends and better evaluate XDR TB

XDR TB

MMWR 3/24/06

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, consisting of top-

performing 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 Because reference labs are more likely to receive data f/ complex TB cases, looked at population-level data from selected countries to further understand the prevalence of XDR TB and trends

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 MDR cases in early 90s to 4.5% by end of 2004

o In Latvia, a country w/ one of the highest rates of MDR TB, 19% of MDR TB cases were highly drug resistant.

CDC is partnering to raise awareness and enhance strategies for

TB prevention worldwide

CDC is a member of the Green Light Committee, which was 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

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

treat, this level of resistance precludes effective treatment in many areas o 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

o Limited drugs mean that patients with XDR TB are virtually untreatable according to international TB treatment guidelines in most countries

Patients with drug-resistant TB have worse

treatment outcomes (death or treatment failure) o Compared to patients with MDR

TB, those with XDR TB were 64% more likely to die during treatment in the U.S.

o In Latvia, patients w/ XDR TB were 54% more likely to die or have tx failure

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 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 MessagesWorsening 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 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 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

• 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 MessagesCDC is partnering to raise awareness and enhance strategies

for TB prevention worldwide

• CDC is a member of the Green Light Committee, 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 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

XDR-TB Coverage from international broadcasters:

'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-TBInternational press coverage:

XDR-TBInternational headlines:

Deadly TB strain spreading across globe

Global alert over deadly new TB strains

Africa: "Extreme" TB Bug Prompts Calls for Rapid Action

South Africa: Action plan developed to combat drug resistant TB

TB strain with extreme resistance to drugs creates nightmare scenario

WHO urges South Africa to curb TB killer super-bug

TB experts will grapple with deadly new strains: WHO

Experts call for urgent steps to battle virulent TB strain

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