ISSN 1027 3719 NOVEMBER 2016 The SUPPLEMENT 1 ... · MDR-TB and migration: from infection fundamentals to programme innovations S23 22. Newapproachesto MDR-TB treatment in children:

The Official Journal of the International Union Against Tuberculosis and Lung Disease

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S U P P L E M E N T 1The

InternationalJournal of Tuberculosis

and Lung Disease

A B S T R A C T B O O K

47th World Conference on Lung Health of the International Union Against Tuberculosis and Lung Disease (The Union)

LIVERPOOL • UNITED KINGDOM26–29 OCTOBER 2016

S U P P L E M E N T 1

V O L U M E 2 0 N U M B E R 1 1 N O V E M B E R 2 0 1 6

SYMPOSIATHURSDAY 27 OCTOBER 2016

S1 01. High-dose rifampicin: recovering an old drug in thepost-multidrug-resistant TB era

S2 02. Pneumonia: supportive clinical management wherethere is no intensive care

S3 03. Tackling second-hand smoking: a life courseapproach

S4 04. Active TB drug safety monitoring andmanagement: a transformative approach to limittreatment-related patient harm

S5 05. Addressing healthcare disruption and minimisingdrug resistance development among TB patientsaffected by conflict arising from armed resistance inSyria

S5 06. Tuberculosis and diabetes collaborative activities inthe context of the End TB Strategy and SustainableDevelopment Goals

S7 07. Introducing bedaquiline and delamanid for drug-resistant TB under routine programme conditions:preliminary results from the End TB Initiative

S8 08. Tuberculosis in adolescents: confronting neglect,improving care

S8 09. Screening for latent TB infection among migrants:from controversy to consensus?

S10 10. Policy makers and partnerships: building thepolitical will to end TB

S11 11. Another transnational tobacco company in themaking: the impact of the globalisation of the Chinesetobacco monopoly on tobacco control policies aroundthe world

S12 12. Reframing resistance: research and innovation toimprove patient care and end drug-resistant TB

S13 13. Monitoring progress towards the End TB Strategytarget to eliminate catastrophic costs: findings from thefirst round of surveys

S14 14. Enough is enough: time to end preventablemortality among people living with HIV

S15 15. New approaches and innovations in TB vaccineresearch and development

S15 16. Quinolones: from bench to bedside

S17 17. Driving real-time access to diagnostic data throughconnected diagnostics

S18 18. Ending TB transmission, stepping up TB infectioncontrol: lessons learnt, opportunities in sight

FRIDAY 28 OCTOBER 2016

S20 19. Implementing pillar three of the WHO’s End TBStrategy at the country level: lessons learned from path-finding countries

S21 20. Challenging tuberculosis in urban settings and bigcities in comprehensive TB control programmes

S22 21. MDR-TB and migration: from infectionfundamentals to programme innovations

S23 22. New approaches to MDR-TB treatment in children:from research to evidence-based implementation

S25 23. Magnitude and scope of TB stigma: scale validationand cross-country comparisons

S26 24. Asthma and COPD: a shifting landscape

S27 25. Qualitative research for tuberculosis control: whatlessons can researchers offer to policy makers andimplementers in tackling drug-resistant TB?

S28 26. Best practices and challenges in ending TB incorrectional facilities

S29 27. MDR-TB and XDR-TB treatment service deliverymodels in Africa and Latin America

S30 28. Early warning system to improve patient access toTB medicines: from quantification to decision making

S32 29. Moving towards integrated community andprimary health systems to improve outcomes forwomen and children affected by TB and TB-HIV

S32 30. Resistance to public health policy, the uniquevector: tobacco industry

S34 31. Building research capacity in tuberculosis: theexperience of training programmes and their impact inlow–middle-income countries

S35 32. Should addressing tobacco use in TB and HIVpatients be integral to disease control programmes? Acase for support

S36 33. The growing gender gap in TB: a consequence ofresistance to recognising men’s vulnerability in TBdiagnosis and care?

S37 34. Monitoring TB treatment: alternatives tomicroscopy and culture?

S38 35. E-cigarettes and other electronic nicotine deliverydevices: where are we now? Regulation, opportunitiesand protecting public health

S39 36. Demonstrated need for strengthened national StopTB partnerships

S40 37. Tackling TB in cities: lessons and best practices inurban TB

S42 38. The effectiveness and obstacles for social supportfor TB patients

SATURDAY 29 OCTOBER 2016

S44 40. TB elimination initiative in countries of the LatinAmerican Region

S44 41. It’s time to scale up treatment of TB infection in highTB burden countries

S45 42. Reaching under-served groups to eliminatetuberculosis in England: patient perspectives,technological advances, and the role of themultidisciplinary team

S46 43. Novel quantitative approaches in paediatrictuberculosis

S47 44. Biosafety and tuberculosis infection control:sharing knowledge, challenges and solutions in TBlaboratories

S48 45. Adherence to confront resistance: social andbehavioural interventions in Latin America

S48 46. Low-level M. tuberculosis resistance: a challengefor the laboratory, an opportunity for MDR- and XDR-TB treatment

S49 47. Modelling to overcome resistance to TB drugs andthe End TB Strategy

S50 48. Shortened regimens for the treatment ofmultidrug-resistant tuberculosis

S52 49. TB screening and isoniazid preventive therapy forpregnant and breastfeeding women in resource-limited settings

S53 50. Trials of mice and men: recent advances and thefuture of TB drug development science

S54 51. TB and mental disorders: putting the science intopractice

ABSTRACT PRESENTATIONSTHURSDAY 27 OCTOBER 2016

e-poster sessions

S56 01. Child and adult MDR with modelling

S61 02. From screening and integration to outcomes

S65 03. Childhood MDR-TB, epi, detection, isoniazidpreventive therapy and training

S71 04. Revolution: harnessing mobile technologies tosupport client-centred care

S75 05. Better TB services for better treatment outcomes

Oral abstract sessions

S79 01. Resistance to TB drugs: new moves and what next?

S83 02. Advocacy and community engagement

S87 03. Prisons, slums and the homeless

S91 04. ‘Here, there and everywhere’: how to end TB

S95 05. Improving patient care in MDR-TB

S99 06. Internally displaced indigenous populations andhealth workers

S103 07. TB mortality

S107 08. ‘The long and winding road’: latent TB infectiontesting and treatment

S111 09. The changing landscape of tobacco control

Short oral abstract sessions

S114 01. Drugs, vitamins, valves: the diversity of TB clinicaltrials

S119 02. ‘We can work it out’: understanding andpreventing diagnostic treatment delays

S123 03. Methodologies and models for TB education andtraining

S128 04. SAD to have TB: smoking, air pollution andvitamin D

Poster discussion sessions

S133 01. An intimate relationship: drug resistance and genes

S138 02. Integration of services: attitudes and lessonslearned

S144 03. Childhood asthma and TB: a potpourri

S149 04. New developments in basic science

S154 05. ‘Help!’: no drugs, no programme

S158 06. Raising TB awareness

S163 07. Issues surrounding TB: ‘Medicines make you feelgood though they can also make you feel sick’

S167 08. Knowing the enemy: MDR-TB epidemiology I

S173 09. ‘So sweet’? TB-diabetes screening

S178 10. Supporting MDR-TB patients: mHealth, nutrition,palliation, and health-related quality of life)

S183 11. ‘With a little help from my friends’: understandingand supporting retention and adherence

S189 12. TB transmission

S193 13. Spectrum of TB care in key affected populations

S199 14. Implementing tobacco control strategies

S203 15. Tobacco industry interference

S206 16. TB diagnostic pathways: improving its steps

S212 17. TB among refugees

S217 18. TB modelling, prevalence and surveillance

S222 19. Intensified case finding

FRIDAY 28 OCTOBER 2016

e-poster sessions

S227 06. Community-based approaches for TB

S231 07. TB transmission dynamics

S236 08. ’I need you’: strengthening health systems

S241 09. GenXpert: exciting results from fieldimplementation


S245 10. HIV and TB: lessons from Africa

S249 11. Bacteria, vaccines and immunity

S253 13. Enhanced case finding and contact tracing

S257 14. Challenges in TB diagnostics: an overview ofmethods and issues

S262 15. Tobacco packaging and graphic health warnings

S265 16. Adult lung health: chronic obstructive pulmonarydisease, chronic disease, asthma and oxygen

S269 17. HIV-TB Late-Breaker Session

S273 18. The tide is high: TB and comorbidities

S277 19. Drugs for MDR-TB: challenges and successes

S281 20. TB infection control: too fast, too slow or just right?


S285 20. ‘Help!’ Identifying TB education and training needsand outcomes from selected interventions

S290 21. Adult lung health in Africa and Asia

S294 22. Childhood TB clinical and outcomes

S299 23. Childhood TB around the world

S304 24. Knowing the enemy (better): MDR epidemiology II

S309 25. ‘With a little help from my friends’: linking thepublic-private sectors

S312 26. Tuberculosis and diabetes outcomes: not always ‘sosweet’

S317 27. MDR drugs: access, supply and cost

S322 28. ‘Getting better’: service delivery reforms toenhance patient centred-care

S327 29. Community-based, decentralised MDR care

S333 30. Tobacco control: policy legislation

S336 31. Tobacco epidemiology

S341 32. Second-line TB drugs: new drugs, new resistance,new challenges

S346 33. Expanding the diagnostic landscape: lookingbeyond sputum samples

S351 34. Prisons: the smoking gun

S356 35. From TB data collection to TB data use for decisionmaking

S361 36. TB testing: a bouquet of approaches

S366 37. TB mortality and recurrence

S371 38. Alternative diagnostics: from biomarkers, serologyto X-ray

SATURDAY 29 OCTOBER 2016

e-poster sessions

S376 10. Eyes, ears and kidneys: MDR drug toxicity

S381 11. ’How do you do it?’ Using e-health to improve TBprogramme outcomes

S385 12. Got the bug? Basic science

S389 13. Smoke-free environment

S394 14. Latent TB infection: something for everyone


S401 21. The Union/CDC Late-Breaker Session on TB

S404 22. Priorities in finding the missing cases

S409 23. Interplay of tobacco control and broader healthagenda

S410 24. The Union student Late-Breaker Session on lunghealth

S415 25. Childhood TB, MDR and pharmacokinetics

Short abstract session

S420 05. Improving diagnostics implementation: challengesand new solutions


S426 39. The ‘rocky road’ of screening and treatmentoutcomes

S431 40. Childhood TB diagnosis and care detection

S436 41. Latent TB infection testing: who and how

S441 42. Infection control: knowledge and interventions

S447 43. Media engagement in TB interventions

S453 44. Extra-pulmonary TB

S457 45. ‘Do you want to know a secret?’ The risingincidence of non-tuberculous mycobacteria

S461 46. Optimising drugs for resistant TB

S466 47. MDR- and isoniazid-resistant TB: outcomes

S471 48. MDR treatment outcomes

S477 49. Mental health, diabetes and other comorbidities inTB

S481 50. Media communication: for or against tobacco usestrategies

S486 51. Drug resistance assessment: methods, feasibilityand results

S491 52. Key populations: all in

S496 53. Cost: socio-economic impact on TB

S501 54. TB programme implementation and effectiveness

S508 55. TB contact tracing and latent TB infection

S517 56. As a team everybody achieves more: innovations tostrengthen TB case finding

S517 57. Tobacco dependence and cessation

The Official Journal of the International Union Against Tuberculosis and Lung Disease

AIMS AND SCOPE. The International Journal of Tuberculosis and Lung Disease is an official journal of The Union. The Journal’smain aim is the continuing education of physicians and other health personnel, and the dissemination of the most up-to-date infor-mation in the field of tuberculosis and lung health. It publishes original articles and commissioned reviews not only on the clinicaland biological and epidemiological aspects, but also—and more importantly—on community aspects: fundamental research andthe elaboration, implementation and assessment of field projects and action programmes for tuberculosis control and the promo-tion of lung health. The Journal welcomes articles submitted on all aspects of lung health, including public health-related issuessuch as training programmes, cost-benefit analysis, legislation, epidemiology, intervention studies and health systems research.

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ROGELIO HERNANDEZ PANDO

(Mexico)

ANNEKE HESSELING (South Africa)

DAVID HUI (China)

MICHAEL IADEMARCO (USA)

WANIS IBRAHIM (Qatar)

S K JINDAL (India)

PETER KAZEMBE (Malawi)

WON-JUNG KOH (Korea)

UMESH LALLOO (South Africa)

CHRISTOPH LANGE (Germany)

CHI-CHIU LEUNG (China)

KEIR LEWIS (UK)

ROBERT LODDENKEMPER (Germany)

CARL LOMBARD (South Africa)

KNUT LÖNNROTH (The Netherlands)

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MARY REICHLER (USA)

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AKOS SOMOSKOVI (Switzerland)

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TIM STERLING (USA)

JASON STOUT (USA)

WEI-JUIN SU (Taiwan)

WAN CHENG TAN (Canada)

CHARLES THOEN (USA)

ARNAUD TRÉBUCQ (France)

MUKUND UPLEKAR (India)

SUSAN VAN DEN HOF

(The Netherlands)

ARMAND VAN DEUN (Belgium)

FRANK VAN LETH (The Netherlands)

ANNELIES VAN RIE (USA)

VERONICA WHITE (UK)

ROBERT J WILKINSON (UK)

PAN-CHYR YANG (Taiwan)

JAI-JOON YIM (Korea)

YING ZHANG (USA)

ALI ZUMLA (UK)

Expert statistical review panel Larry Moulton (USA), Brian Williams (Switzerland)Ex-officio members (The Union) President of The Union, E. Jane Carter (USA); Past Editors-in-Chief: Michael Iseman (USA),

Nulda Beyers (South Africa), Moira Chan-Yeung (China), Donald Enarson (Canada),Wing-Wai Yew (China), Martien Borgdorff (Kenya)

Editors-in-Chief Tuberculosis Peter Davies, Consultant Chest Physician, University of Liverpool, Liverpool, UKKathryn DeRiemer, Division of Epidemiology, Department of Public Health Sciences,University of California, Davis, Davis, CA, USA

Lung Disease Guy Marks, Woolcock Institute of Medical Research, Sydney, NSW, Australia

Manuscripts and correspondenceMANAGING EDITOR CLARE PIERARD DIRECTOR OF PUBLICATIONS JOSE LUIS CASTRO

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EDITORIAL OFFICE The International Union Against Tuberculosis and Lung Disease (The Union)68 boulevard Saint Michel, 75006 Paris, FranceTel: (þ33 1) 44 32 03 60 Fax: (þ33 1) 43 29 90 83 e-mail: [email protected] website: www.theunion.org

INT J TUBERC LUNG DIS 00(00):S000–S000Q 2016 The Union

47th World Conference on LungHealth of the International Union Against Tuberculosisand Lung Disease (The Union)Liverpool, UK, 26–29 October 2016

SYMPOSIA: THURSDAY27 OCTOBER 2016

01. High-dose rifampicin: recovering anold drug in the post-multidrug-resistantTB era

High-dose rifampicin in pulmonary TB

G Davies1 1University of Liverpool, Liverpool, UK. e-mail:[email protected]

Early dosing recommendations for rifampicin were basedlargely on cost considerations. Current efforts to re-evaluate dosing of rifampicin are aimed at improvingefficacy by increasing doses, based on promising resultsin in vivo models. We will report the results of twopharmacokinetic-pharmacodynamics studies that as-sessed exposure, efficacy, and safety of current formula-tions of rifampicin at 1.5 and 2 times standard doses.Results will be pooled across the two studies HIRIF andHIGHRIF2, conducted respectively in Peru and Tanza-nia, to increase the power to detect differences in safetyand efficacy endpoints and to increase the generalizabil-ity of findings. These results will be discussed in thecontext of other rifampicin-optimization efforts andplans for a Phase III trial of shorter rifampicin-basedtreatment.

Drug-drug interactions with rifampicin andimplications for its use with new anti-TB drugsand in HIV-coinfected TB patients

K Dooley1 1Johns Hopkins University, Baltimore, MD, USA.e-mail: [email protected]

Description: Rifampicin has unique activity against semi-dormant ‘persisters’. To date, no drug has provensterilizing activity equal to that of rifamycins. There isa clear relationship between drug exposure and micro-biologic activity; thus, high dose rifampicin holdspromise for treatment shortening. However, rifampicinis a potent inducer of drug metabolizing enzymes anddrug transporters, and rifampicin can reduce concentra-

tions of companion anti-TB drugs and drugs used to treatcommon comorbidities, such as HIV infection ordiabetes mellitus. In this talk, the speaker will presentcurrent knowledge about clinically-meaningful druginteractions with rifampicin, the potential impact thathigher rifampicin doses may have on metabolic druginteractions, and, how these interactions influence TBregimen development and the overall goal of developingtreatments that will benefit all patients.

High-dose rifampicin in TB-meningitis

R Aarnoutse1 1Radboud University Nijmegen MedicalCentre, Nijmegen, The Netherlands. e-mail:[email protected]

Tuberculous meningitis (TBM) is the most severe form oftuberculosis, resulting in death or neurological disabilityin 50% of patients. Rifampicin is pivotal in the treatmentof TBM as shown by the high mortality in patients withrifampicin-resistant TBM, but the penetration of thisdrug into cerebral spinal fluid is limited. A small clinicaltrial on high dose, intravenously administered rifampicinshowed a strong decrease in mortality in patients withTBM, but a large trial with a moderate rifampicin doseincrease showed no benefit. Several pharmacokineticstudies are ongoing. This presentation will provide anoverview of data on efficacy, safety/tolerability andpharmacokinetics of higher doses of rifampicin in adultsand children with TBM. The merits of other TB drugs asalternatives to rifampicin, means of enhancing deliveryof TB drugs into the central nervous system, and the wayforward will be discussed.

Adjunctive therapies and other approaches toextending the useful life of rifampicin

T Gumbo1 1Baylor Institute of Immunology Research, Dallas,TX, USA. e-mail: [email protected]

Based on pharmacokinetic/pharmacodynamic studies,simulations, and clinical data, we have proposedlowering the rifampicin susceptibility breakpoints fromcurrent 1 mg/L to 0.125 mg/L. This could increasenumbers of patients with rifampicin-resistance by up tofour-fold. In the hollow fiber system and in clinicalstudies, artificial intelligence algorithms have alsoidentified AUCs and peak/MICs above which microbial

kill can be effected. We have also identified efflux pumpinduction and mutations central to rifampicin resistance,even in the presence of rpoB mutations. These can beovercome by use of a three step program: 1) Bayesian-feedback optimized dosing that achieves concentrationsabove the PK/PD target thresholds, 2) use of efflux pumpinhibitors to lower the MIC and disrupt the ‘antibioticresistance arrow of time’ in conjunction with step 1, and3) enhancing the intracellular concentration of therifampicin. Computer-aided clinical trial simulations willbe presented to demonstrate the feasibility.

Panel discussion on the future of rifamcyins forTB treatment in the face of resistance

P Phillips1 1MRC CTU at UCL, London, UK. e-mail:[email protected]

This discussion will be moderated and guided by one ofthe session organizers who will both prepare questionsand solicit questions from the audience. Questions willbe addressed by the panel, comprising speakers andchairs. It will consider the larger question of whetherefforts to preserve rifampicin are warranted in the face ofgrowing resistance globally. Additional Topics willinclude the risks and opportunities afforded by rifamy-cins in TB treatment; discussion of higher doses ofrifampicin than those presented in the talks, and if/howthey should be further evaluated; and the prospectsafforded by and lessons learned from clinical studies ofthe other rifamycins (rifapentine and rifabutin).

02. Pneumonia: supportive clinicalmanagement where there is no intensivecare

How can risk stratification benefit childrenwith pneumonia?

E McCollum1,2 1Johns Hopkins University School ofMedicine, Pediatrics, Eudowood Division of PediatricRespiratory Sciences, Dhaka, 2Johns Hopkins BloombergSchool of Public Health, Department of International Health,Dhaka, Bangladesh. e-mail: [email protected]

Mortality amongst children in low-income countriesfrom pneumonia is high, and frequently complicated byhypoxemia, HIV, and malnutrition. Evidence of declin-ing child pneumonia case fatality in countries such asMalawi are cause for hope, but mortality remainselevated and largely unchanged amongst high-riskgroups. This talk discusses potentially innovative strat-egies for identifying high-risk patients and how suchidentification may feed into improved case managementat referral health facilities and in rural communities oflow-resource settings.

How can risk stratification benefit adultpatients with pneumonia?S Aston1 1Royal Liverpool University Teaching Hospital,Tropical and Infectious Diseases Unit, Liverpool, UK. e-mail:[email protected]

The ability to accurately triage patients with pneumoniais key to improving the management of respiratoryinfection. Underestimating disease severity may lead todelays in starting appropriate treatment and increasedmortality. By contrast, overestimating severity results inunnecessary hospitalisation and broad-spectrum antibi-otic use. Several severity assessment tools (e.g. CURB65,IDSA/ATS criteria) have been developed to supportclinicians to make early management decisions inpneumonia. In well-resourced settings, these tools havesuccessfully been used to both identify patients at highrisk of deterioration to target for early aggressivetreatment and also to safely increase the proportion oflow-risk patients managed in the community. However,all existing validated severity assessment tools have beenderived in high-resource settings. When examined inlow-resource settings - where patient populations aretypically younger and have a different pattern ofcomorbid illness including high rates of HIV and TB -these tools have been found to perform poorly. Thispresentation will describe the process and challenge ofdeveloping accurate and practical severity assessmenttools for use in low-resource settings. The performanceof existing tools will be reviewed and then recent effortsto derive alternative tools better adapted for use in low-resource populations discussed. Finally, suggestions ofhow severity assessment tools may be incorporated intopneumonia management pathways and then evaluatedwill be presented.

Biomarkers of pneumonia: are new diagnosticson their way, or far away?

E Carrol1 1University of Liverpool, Institute of Infection andGlobal Health, Liverpool, UK. e-mail:[email protected]

Pneumonia is the major cause of death in childrenthroughout the developing world especially in childrenunder the age of 5 years. Most deaths attributable toacute respiratory infection are caused by pneumonia andbronchiolitis. The differentiation of bacterial and viralaetiologies is difficult on clinical grounds alone. Char-acterising biomarkers of severe bacterial infections couldlead to rapid diagnostic tests with high discriminatoryvalue. Individual biomarkers frequently fail to reach thethreshold for clinical usefulness, but biomarker panelsderived from disease related biological processes arelikely to improve classification. This will help guideantibiotic management and decisions on referral tohospital.

S2 Symposium abstracts, Thursday, 27 October

03. Tackling second-hand smoking: a lifecourse approach

Prevalence of second-hand smoke exposureduring pregnancy: a secondary analysis ofdemographic and health surveys in 30 low- andmiddle-income countries

S Reece,1 M Kanaan,1 K Siddiqi1 1University of York, York,UK. e-mail: [email protected]

Second-hand smoke (SHS) exposure during pregnancy isan important and avoidable risk factor for perinatalmorbidity and mortality. Presently, there are no globalestimates of the prevalence and attributable diseaseburden of SHS exposure in pregnancy. We used datafrom Demographic and Health Surveys to determine themagnitude of SHS exposure in pregnancy and its relationto maternal age, educational status, occupational status,wealth index, and characteristics of household smokers.Data was collected from 37,427 pregnant women from30 low- and middle-income countries between 2008 and2014. On average, 33% of pregnant women wereexposed to SHS, reaching 72% in some countries, and28% on a daily basis. The attributable risk of SHSexposure in pregnancy is likely to be higher than activesmoking, where global prevalence is comparatively lower(2.6%) highlighting the importance of focused publichealth strategies to protect maternal and child health inthis area.

Interventions to reduce home exposure tosecond hand smoke in pregnant women:findings from a systematic review andmodified Delphi survey

M Dherani,1 V Satyanarayana,2 R Huque,3 P Chandra,4

C Jackson,5 K Siddiqi,6 A Rahman,1 IMPRESS StudyGroup 1University of Liverpool, IPHS, Liverpool, UK;2NIMHANS, Clinical Psychology, Bangalore, India; 3ArkFoundation, Dhaka, Bangladesh; 4NIMHANS, Psychiatry,Bangalore, India; 5University of York, Clinical Trials, York,6University of York, Health Sciences, York, UK. e-mail:[email protected]

Background: Exposure to second-hand smoking (SHS)among non-smoking pregnant women is high in severallow and middle income countries (LMIC) and isassociated with adverse pregnancy and infant healthoutcomes. There is a paucity of research on use andeffectiveness of behaviour change interventions (BCI) inSHS exposure reduction in LMICs. We plan to develop acomprehensive BCI package using available literatureand expert consensus, and carry out a feasibility RCT inIndia and Bangladesh.Methods: 1) Systematic review (SR): Two reviewerssearched and extracted literature derived from eightdatabases for research published between 2000 and 2015in ’English’ language. Population: Pregnant womanassisting her spouse change smoking habit; Interventions:BCI used at home; Comparison: No intervention;Outcomes: Reduced SHS exposure at home or quitting

smoking or increased awareness. 2) Modified Delphisurvey (MD): 30 experts were asked to rank a list of 21BCIs in the order of priority based on their past researchexperience. Rankings from 17 experts across threerounds of consensus building were examined.Results: Very stringent criteria yielded 327 citations ofwhich 35 were reviewed and 6 were extracted. All thestudies were health facility based and included 4 RCTand 2 before-and-after without control. Two studies usedHealth Belief Model and two used Trans-TheoreticalModel. The common intervention used included infor-mation booklet, motivational interviews (telephone/in-person), health-professional advice, and videos. After thethird round of modified Delphi, a modest but significantconsensus among experts was achieved (Kendall’sw¼0.61; P, 0.001). The highest-ranked interventionswere cotinine feedback, providing information on theconsequences of SHS, salience of consequences andbarrier identification.Conclusion: There is a dearth of literature and the qualityof studies was moderate to low. The BCIs appear to beuseful but limited to self-reported SHS reduction. Basedon SR and modified Delphi survey findings we developedan intervention package entailing letter from unbornfoetus to father, cotinine feedback, pictorial booklet andvoice call to father. This BCI package is currently beingpiloted in India and Bangladesh. The findings will haveimportant implications for scalability and sustainabilityof BCIs in reduction of SHS during pregnancy in LMIC.

Second-hand smoke exposure in children in alow-income countries with smoke free laws: aschool-based survey in Bangladesh

K Siddiqi,1 S Shah,1 M Kanaan,1 R Huque,2 A Sheikh31University of York, York, UK; 2The ARK Foundation, Dhaka,Bangladesh; 3University of Edinburgh, Edinburgh, UK. Fax:7970544872. e-mail: [email protected]

We report on second-hand smoke (SHS) exposure basedon saliva cotinine levels among children in Bangladesh - acountry with laws against smoking in public places. Asurvey of primary school children from two areas ofDhaka, was conducted in 2015. Participants completed aquestionnaire and provided saliva samples for cotininemeasurement to assess SHS exposure with a cut-off rangeof 70.1 ng/mL. 481 children aged 9-15 years wererecruited from 12 schools. Of these, 479 saliva sampleswere found sufficient for cotinine testing, of which 95%(453/479) were positive for SHS exposure. Geometricmean cotinine was 0.36 (95%CI: 0.32-0.40); 43% (208/479) of children lived with at least one smoker in thehousehold. Only 21% (100/479) reported completesmoking restrictions for residents and visitors; 87%(419/479) also reported being exposed to SHS in publicspaces. Living with a smoker and number of tobaccoselling shops in the neighbourhood had positive associ-ations with SHS exposure. Despite having a ban onsmoking in public places, SHS exposure among childrenin Bangladesh remains very high. There is an urgent needto reduce exposure to SHS in Bangladeshi children.

Symposium abstracts, Thursday, 27 October S3

What can be done with schools to protectchildren from second-hand smoke exposure?R Huque1,2 1University of Dhaka, Economics, Dhaka, 2ARKFoundation, Research and Devlopment, Dhaka, Bangladesh.Fax: (þ880) 2 861 5583. e-mail: [email protected]

We tested a school-based intervention designed tosupport families in implementing smoking restrictionsat homes in Bangladesh in a two-arm pilot clusterrandomised controlled-trial, conducted in 12 primary-schools and with 481 children. Outcomes includedchildren’s exposure to SHS measured by salivary cotinineconcentration before-and-after the intervention. Ourpilot trial findings suggest potential in the interventionto reduce children’s exposure to SHS. There was a slightreduction in the mean cotinine concentration from 0.34ng/mL (95%CI 0.30-0.39) at baseline to 0.30 ng/mL(95%CI 0.26-0.35) at follow-up in the intervention armand from 0.38ng/mL (95%CI 0.33-0.43) to 0.36 ng/mL(95% 0.31-0.43) in the control arm. Compared to havingpartial or no restriction, complete smoking restriction athome was associated with a reduction in cotinineconcentration. While the observed effect was in the rightdirection, the difference was not statistically significantas expected from a pilot trial. This warrants a definitivetrial to study its effectiveness.

04. Active TB drug safety monitoring andmanagement: a transformative approachto limit treatment-related patient harm

Limitations and problems of current MDR-TBtreatment adverse event reportingD Menzies1 1Montreal Chest Institute, McGill University,Montreal, QC, Canada. e-mail: [email protected]

Current MDR-TB treatment adverse event data fromboth randomized clinical trials and observational studiesare sparse and challenging to work with. A recentlycompleted systematic review of 74 studies reportingMDR-TB treatment outcomes published since January2009 demonstrated that outcomes were much morecompletely and consistently reported than AE reporting -which was non-standardized, and incompletely reportedin almost all of the publications. Problems reporting AEsincluded varying definitions, methods of ascertainment,and judgement of severity making pooling of resultsacross studies difficult. In this session we will look at howuncertainties associated with poor quality or sparse datalimits our understanding of toxicity and hence makes itvery difficult to compare possible drugs to use whendesigning treatment regimens.

Reporting adverse events within theframework of aDSM: parameters andapproaches

D Falzon1 1World Health Organization / Global TBProgramme, Laboratories, Diagnostics and Drug ResistanceUnit, Geneva, Switzerland. e-mail: [email protected]

The unsatisfactory treatment outcomes associated withcurrent regimens for multidrug-resistant (MDR-TB) andextensively drug-resistant TB (XDR-TB) have motivatedthe introduction of new and repurposed medicines totreat patients with these conditions. This has at timeshappened ahead of the completion of trials. This trendposes some concern about the safety of medicines andnovel regimens which have as yet only been used inlimited contexts. The monitoring of adverse events (AEs)has not been one of the standard parameters which TBprogramme staff have monitored systematically whenfollowing up patients on TB treatment. This presentationwill describe the rationale behind active TB drug-safetymonitoring & management (aDSM) as a new pro-gramme activity, how it is being implemented, and theassociated efforts to standardise the reporting of seriousand other AEs in order to generate comparable country-level indicators and contribute to the global aDSMdatabase.Background information: http://www.who.int/tb/areas-of-work/

drug-resistant-tb/treatment/pharmacovigilance/en/

Adverse events reporting for anti-tuberculosismedicines in the Philippines: current situation,experiences and lessons learnt

AMC Garfin1 1National TB Control Program, Department ofHealth, Manila, The Philippines. e-mail:[email protected]

Philippines is one of the 30 high TB burden countries inthe world based on the listing of the World HealthOrganization. The initiative to address drug resistant TBstarted in the private sector in 1999 and was main-streamed to the National Tuberculosis Control Program(NTP) in 2008. Treatment regimen is standardized andduration is for at least 18 months. Treatment success rateis low due to high loss to follow-up. Study was done andshowed that the common causes of loss to follow-upwere due to adverse drug reactions, need to work,personal challenges, geographic barriers and the durationof the standard regimen. With these challenges and theinformation of the successful use of the 9-monthtreatment regimen (9MTR) under operations researchcondition, the NTP decided to implement the 9MTR in2015. With the use of the 9MTR and the use ofbedaquiline, the NTP needs to have pharmacovigilancein place to ensure early detection and timely reporting ofadverse events. In the Philippines, the Food and DrugAdministration (FDA) is the agency that is mandated toimplement the national Pharmacovigilance Program.Currently, the FDA utilizes only a spontaneous reportingsystem for most medicines. With the introduction of9MTR and the use of bedaquiline, the NTP together withpartners and the FDA is working towards an active drug


safety monitoring and management system. Currentlypaper based reporting system is used to report adverseevents. To facilitate reporting and analysis of data, theNTP in collaboration with Systems for Improved Accessto Pharmaceuticals and Services and the FDA is workingon the use of Pharmacovigilance Monitoring System.Collaborative meetings were done to identify andharmonize the needs of the NTP and FDA. Reportingof adverse events for anti-TB drugs is challenging butbased on the experience of NTP, it can be done with thecoordination and cooperation of the different stakehold-ers. It is important that everybody in the systemunderstands the significance of the initiative, roles andthe responsibilities are well defined, and are informedand capable of the given tasks.

Improving TB patient safety and management:the Georgia experienceN Lomtadze1 1National Center for Tuberculosis and LungDiseases, Head of TB Surveillance and Strategic PlanningDepartment, Tbilisi, Georgia. e-mail: [email protected]

Georgia was the first country to start MDR-TB patientson treatment through the USAID/Janssen bedaquilinedonation program. In response to the WHO aDSMstrategy, and to optimize safety of the patients onbedaquiline, Georgia established a system for collection,collation, and analysis of adverse event data in line withthe core package requirements of aDSM. To enforcereporting using this system by TB facilities, a Ministerialorder was issued mandating all serious adverse events forMDR-TB patients to be reported to the national center ofTB and Lung Diseases. This session will present ourexperiences, results, and challenges implementing thesystem and will describe a web-based application tocollect, analyze, report, and publish adverse event datacaptured while monitoring patients treated with new TBmedicines in Georgia.

05. Addressing healthcare disruption andminimising drug resistance developmentamong TB patients affected by conflictarising from armed resistance in Syria

Public health strategy for tuberculosis amongSyrian refugees in JordanA Elton1 1World Health Organization, Amman, Jordan.e-mail: [email protected]

This talk will outline the multipartner strategy developedwith the goal ’To reduce susceptible and resistanttuberculosis transmission, morbidity, and mortalityamong Syrian refugees residing in Jordan’. The imple-mentation and current statues, including successes andsetbacks, will be discussed.

The impact of the Syrian civil war on TB caredelivery and the role of the internationalcommunity

A Sparrow1 1Mount Sinai Global Health Center at MountSinai School of Medicine, New York, NY, USA. e-mail:[email protected]

The partisan nature of aid delivery has left an estimated96% of civilians living in besieged areas without healthassistance. The United Nations Office for the Coordina-tion of Humanitarian Affairs has been unable to hold thegovernment accountable for increasing attacks on healthworkers and hospitals, creating a dire health situation.The unavailability of drugs, constant migration ofSyrians and breakdown of infrastructure, make apotential outbreak of tuberculosis and MDR-TB aserious threat.

Conflict and the interruption of TB treatmentamong Syrians

MZ Sahloul1 1University of Illinois, Chicago, IL, USA. e-mail:[email protected]

The confluence of a decimated healthcare system, athriving pharmaceutical industry brought to its knees,and the loss of healthcare workers have created an idealenvironment for TB to spread, and the even uglier MDR-TB is likely gaining ground. The deliberate andaccidental interference with the healthcare system hascaused interruptions in the treatment regimens, which isa known risk factor for MDR-TB. As Syria empties of itspeople, they carry with them their TB across the region inwhat will likely be a serious setback in the fight againstthis disease.

06. Tuberculosis and diabetescollaborative activities in the context ofthe End TB Strategy and SustainableDevelopment Goals

Update on the global progress in implementingTB-diabetes collaborative activities

A D Harries1 1The Union, Winchester, UK. e-mail:[email protected]

The main objective of this presentation is to give furtherguidance to the global audience on how best to deliverintegrated services for TB and Diabetes Mellitus(DM).The interaction between Diabetes Mellitus andtuberculosis (TB) has been known for many years now. Inresponse to the growing global threat of TB and DM, theWorld Health Organization together with partnerspublished the first global framework in 2011 followingwhich countries started to translate the global recom-mendations into action. Based on the review of the globalliterature and limited country experiences, WHO issueda call to action in 2014. In this presentation, we willdiscuss global progress in terms of translating existing


global recommendations in to action and will suggest theway forward for further roll out at global level.

TB and diabetes: promising scalable models ofTB and diabetes integration in resource-poorsettings with dual burden. Lessons from WorldDiabetes Foundation (WDF)

A Kapur1 1World Diabetes Foundation, Gentofte, Denmark.e-mail: [email protected]

World Diabetes Foundation (WDF) has been in theforefront in an effort to generate evidence that alignswith the World Health Organization - collaborativeframework for care and control of tuberculosis anddiabetes with innovate and scalable models of TB anddiabetes integration in resource-constrained settings withdual burden of TB and diabetes. Towards that end, WDFhas piloted different models and also conducted a varietyof operation research in the Americas, Africa, LatinAmerica as Well as South East Asia. The objectives of thispresentation is to share evidence of these existing andpromising integration models and discuss steps thatneeds to be taken to move these models from pilot toscale.

Charting the course for integrative care: fiveyears of TB-diabetes programme progress forthe PacificR Brostrom1 1Centers for Disease Control and Prevention,Honolulu, HI, USA. e-mail: [email protected]

In 2014, 57% of adult Pacific Islanders with TB werealso found to have diabetes. Six years ago, in parallelwith the WHO Collaborative Framework for Care andControl of TB and Diabetes, seven Pacific nationsadopted a common set of TB-DM Standards that provideguidance for bidirectional screening, a list of clinicalreminders for TB clinicians, methods for optimizingglucose control during TB treatment, and suggestions fortargeted latent TB screening as an opportunity for TBprevention. A recent meeting for Pacific TB Programswas held in conjunction with the 2015 APR Meeting inSydney to mark our progress, identify best localpractices, and chart a course for further implementationof TB and DM activities. This talk focuses on the paceand the progress for TB-DM implementation milestonesin the Pacific. Challenges germane to all TB programs arehighlighted.

Using TB and HIV platforms for prevention andcontrol of diabetes mellitus: successfulexample from EthiopiaD Jerene,1 N Hiruye,2 I Jemal,3 W Kiros,4 T Anteneh,2

P Suarez,5 G Sangiwa5 1Management Sciences for Health,Addis Ababa, 2Management Sciences for Health, HEAL TB,Addis Ababa, 3Oromia Regional Health Bureau, Addis Ababa,4Amhara Regional Health Bureau, Bahir Dar, Ethiopia;5Management Sciences for Health, Arlington, VA, USA.e-mail: [email protected]

Background: Whether disease prevention and controlplatforms created under the TB and HIV programs couldbe used to address the growing threat of non-communi-cable diseases such as diabetes remains unanswered. Ourobjective was to demonstrate the feasibility of providingintegrated clinical care for DM, TB, and HIV in generalpublic hospitals in Ethiopia.Methods: Between February-June 2015, trained healthworkers from TB, HIV, and DM clinics screened TBpatients for HIV and DM; HIV patients for DM and TB;and DM patients for TB. A fasting plasma glucose (FPG)7 126 mg/l or Random Plasma Glucose (RPG) 7 200mg/dl was considered suggestive of DM. Patients in TBclinics received FPG tests because they take their anti-TBmedications before taking breakfast while those in ARTclinics received RPG tests. We used screening checklistswhich also served as data collection tools. Analysesincluded descriptive statistics of the baseline character-istics; calculating proportion of patients with diabetes,TB, or HIV among those screened; and binary logisticregression for adjusted analyses.Results: Of 3439 study participants, 888 were from DMclinics, 439 from TB units, and 2, 112 were from HIVclinics. Six of the DM patients had TB of which five werealready on treatment; the overall yield being 676 per 100000 population. FPG was determined in 435 of the 439TB patients. 141 (32.4%) TB patients had FPG 7 126mg/dl, of which only five were known diabetic patientson follow up. Of 392 (89.5%) who knew their HIVstatus, 12.5% were co-infected with HIV. Symptomaticpatients and those with risk score of 5 or more wereabout 2.8 times more likely to have abnormal bloodglucose level. Of 2,072 HIV patients with randomplasma glucose (RPG) determined, only 1.5% had RPG7 200 mg/dl.Conclusions: The yield of TB among DM patients wasabout three times the prevalence estimate for the generalpopulation. The integrated screening approach helpeddetect .90% of TB patients with abnormal bloodglucose. Strengthening integrated screening practicescan serve as entry point for addressing the growingthreat of co-morbidities.


The TANDEM programme: understandingtuberculosis and diabetes through field studiesand basic sciencesR van Crevel1 1Radboud UMC Nijmegen, Nijmegen, TheNetherlands. Fax: (þ31) 24 354 1734. e-mail:[email protected]

TANDEM (Tuberculosis and Diabetes Mellitus), is amultidisciplinary EU-consortium which started its activ-ities in 2013 (www.tandem-fp7.eu). TANDEM evaluatesways of screening TB patients for diabetes and vice versain Romania, Peru, South Africa and Indonesia. Beyondscreening, TANDEM studies clinical management of TB-DM patients, also looking at costs. In addition,consortium members in Germany, UK, South Africaand the Netherlands explore possible mechanisms of theassociations between TB and diabetes. This is done at agenetic, transcriptomic and cellular level, using patientsamples, in-vitro studies with macrophages and adipo-cytes, and animal experiments. This presentation willinclude some of the progress of TANDEM.

07. Introducing bedaquiline anddelamanid for drug-resistant TB underroutine programme conditions:preliminary results from the End TBinitiative

Organising MDR-TB treatment withbedaquiline and delamanid: End TB in ArmeniaA Hayrapetyan1 1National TB Control Center, Abovyan,Armenia. e-mail: [email protected]

Armenia began providing MDR-TB treatment regimensthat contain bedaquiline and/or delamanid to eligiblepatients under compassionate use in 2013 and in thecontext of the End TB initiative in April 2015. This EndTB project is a collaboration between Médecins SansFrontières and the Armenian Tuberculosis ControlCentre and makes treatment with bedaquiline ordelamanid available to MDR-TB patients in the country.We will report the number of patients, in civilian andprison populations, who initiated an MDR-TB regimencontaining either bedaquiline or delamanid through May2016 and the distribution of indications for receipt ofthese drugs. The frequency of two-month cultureconversion and incidence of serious adverse events willbe reported. We will discuss special challenges, innova-tions in treatment delivery including video DOT anddecentralized treatment, and any advances and challeng-es arising from the introduction of the new drugs in thecountry.

Bedaquiline for the treatment of XDR-TB andpre-XDR-TB: End TB in Peru

L Lecca1 1Socios En Salud, Lima, Peru. e-mail:[email protected]

Peru began providing MDR-TB treatment regimens thatcontain bedaquiline and/or delamanid to eligible patientsin February 2016. This End TB project is a collaborationbetween Socios En Salud and the National HealthStrategy for Tuberculosis Prevention and Control ofPeru. Patient eligibility is determined by a nationalcommittee of pulmonologists with expertise in treatmentof DR-TB. Patient care is administered in homes or in adecentralized network of primary care facilities. We willreport the number of patients who initiated an MDR-TBregimen containing either bedaquiline or delamanidthrough May 2016 and the distribution of indicationsfor receipt of these drugs. The frequency of two-monthculture conversion and incidence of serious adverseevents will be reported. We will also describe thedecision-making process, associated delays to treatment,and the transition from hospital to community-basedcare with continued intensive monitoring.

Bedaquiline and delamanid for MDR-TB in asetting of high HIV coinfection: End TB inLesotho

OJ Alakaye1 1Partners In Health, Maseru, Lesotho. e-mail:[email protected]

Lesotho began providing MDR-TB treatment regimensthat contain bedaquiline and/or delamanid to eligiblepatients in November 2015. This End TB project is acollaboration between Partners In Health and theNational Tuberculosis Program of Lesotho. HIV coin-fection is present in approximately 75% of M/XDR-TBpatients in Lesotho. We will report the number ofpatients who initiated an MDR-TB regimen containingeither bedaquiline or delamanid through May 2016 andthe distribution of indications for receipt of these drugs.The frequency of two-month culture conversion andincidence of serious adverse events will be reported.Results will be stratified by HIV serostatus. And, we willreport the frequency of ART regimen adjustments amongthose coinfected. We will discuss special challenges andany advantages arising from the management of HIV andtreatment with the new drugs.

Bedaquiline and delamanid for MDR-TB in asetting of high HCV coinfection: End TB inGeorgia

T Kotrikadze1 1Médecins Sans Frontières, Tbilisi, Georgia.e-mail: [email protected]

Georgia began providing MDR-TB treatment regimensthat contain bedaquiline and/or delamanid to eligiblepatients through compassionate use in 2012 and in thecontext of the End TB project in April 2015. This End TBproject is a collaboration between Médecins SansFrontières and the National Center for Tuberculosis


and Lung Diseases of Georgia. HCV coinfection ispresent in approximately 16% of M/XDR-TB patientsin Georgia. We will report the number of patients,including those coinfected with HCV, who initiated anMDR-TB regimen containing either bedaquiline ordelamanid through May 2016 and the distribution ofindications for receipt of these drugs. We will report onprison and civilian populations. The frequency of two-month culture conversion and incidence of seriousadverse events will be reported. We will discuss specialprogrammatic and clinical considerations for use of thenew drugs in patients who are coinfected with HCV.

Panel discussion: next steps for bedaquilineand delamanid for drug-resistant TB in End TBcountriesF Varaine1 1Paris, France. e-mail:[email protected]

Session chairs will moderate and contribute to a paneldiscussion on themes emerging from the presentations,questions from the audience, as well as additionalopportunities for innovation with the new drugs. Thisincludes use of new drugs in pediatric populations as wellas in combination, through compassionate use. And,panelists will discuss the End TB clinical trials, whichwill test all-oral shortened regimens containing at leastone new drug in two different studies: one in patientswith fluoroquinolone-susceptible MDR-TB and thesecond in patients with fluoroquinolone-resistantMDR-TB.

08. Tuberculosis in adolescents:confronting neglect, improving care

Global epidemiology of adolescenttuberculosisK Snow1 1 University of Melbourne, Melbourne, VIC,Australia. e-mail: [email protected]

The epidemiology of tuberculosis changes significantlyacross the life-course. In endemic areas, TB incidence islowest among children aged 5-9 years, and risesmarkedly through adolescence before stabilizing at ahigh peak. This suggests that early adolescence may bethe key time-point for preventative interventions for TBwithin the lifetime of any given generation. With novelTB vaccines in development and significant advances intherapy for latent TB infection, intervening effectivelywith the current generation of adolescents could changethe course of the global TB epidemic. In order toascertain the potential impact of preventative interven-tions aimed at adolescents, it is necessary to understandthe current epidemiological situation in this group. Thistalk will present estimates of the current incidence of TBamong adolescents globally, and will also provide adetailed description of the epidemiology of TB amongadolescents in a high TB transmission setting (SouthAfrica’s Western Cape Province).

Drug-resistant tuberculosis in adolescents andinterventions to improve outcomes

P Isaakidis1 1MSF, OR, Mumbai, India, Fax: (þ91) 99 30534211. e-mail: [email protected]

Treatment outcomes among adolescents with drug-resistant TB (DR-TB), with or without HIV-infection,are depressingly poor. The presentation will draw fromMédecins Sans Frontières (MSF) data from variousprogrammatic settings in Africa and Asia and frompublished literature, and will discuss patient outcomesand associated factors. We will present selected casestudies to highlight challenges that adolescents face withtreatment adherence but also with their life goals whileon DR-TB treatment. Interventions to support adoles-cents to stay on treatment will also be presented andexperiences from piloting such interventions will bediscussed.

Adherence issues in adolescent TB and HIVtreatment

E Lowenthal1,2 1University of Pennsylvania School ofMedicine, Pediatrics and Epidemiology, Philadelphia, PA,2Children’s Hospital of Philadelphia, Philadelphia, PA, USA.Fax: (þ1) 267 426 2306. e-mail: [email protected]

Outcomes among TB- and HIV-infected adolescents inhigh-prevalence, low-resource settings are consistentlyworse than those for adults. Both perinatally andbehaviorally HIV-infected individuals are especiallyvulnerable to TB-related morbidity and mortality duringtheir adolescent years. Diagnosis of adolescents is oftendelayed and adolescents face greater challenges main-taining adherence to their medications. This talk willexplore some of the challenges to monitoring andsupporting treatment adherence among adolescents withTB and HIV. We will discuss some of the developmentaland behavioral characteristics of adolescents that shouldbe recognized by practitioners in order to facilitate bettertreatment outcomes.

09. Screening for latent TB infectionamong migrants: from controversy toconsensus?

Screening migrants for LTBI: review of theevidence on effectiveness and cost-effectiveness

A Matteelli,1 S Capone1 1University of Brescia, WHOCollaborating Centre for TB-HIV and TB Elimination, Brescia,Italy. e-mail: [email protected]

Immigrants contribute disproportionately to the num-bers of notified cases and represent over a half of totalnotified cases in low incidence countries. The majority ofTB episodes are the result of the reactivation of non-recent infection acquired in the home country. This is therationale to promote a strategy for systematic testing andtreatment of latent tuberculosis infection (LTBI). Over-


all, gaps of knowledge exist throughout the wholecascade of LTBI management. Testing requires selectionof effective tests or combination of tests. The sequentialuse of tuberculin skin test (TST) followed by interferonrelease assays for those who are TST positive, followedby treatment of double positive individuals is proposedas the best choice in this population; however, cost-effectiveness and impact studies are limited. Moreover,the threshold of TB incidence in the home country abovewhich the intervention is cost-effectiveness is stillunknown. The development of a new generation ofdiagnostic tests that target incipient TB rather thanpersistent infection could be a game-changer in this area.Ensuring high treatment initiation and completion ratesfor LTBI regimens is an unsolved challenge. There isevidence that shortening the duration of treatment andreducing the rate of adverse events facilitates treatmentcompletion. Isoniazid should be replaced by rifamycin-containing regimens. Ultra-short treatment based ondaily rifapentine and isoniazid for one month is beinginvestigated in persons living with HIV and couldrepresent a significant advancement in this population.Overall, there are uncertainties on the impact ofpreventive therapy on TB incidence among asylumseekers at population level. Cost-effectiveness of thewhole strategy has been investigated in several studies,but the large variability in assumptions prevent general-ization of conclusions. Ultimately, LTBI managementshould be implemented as a public health strategy andsupported by an efficient system for monitoring andevaluation. LTBI should become a notifiable conditionand electronic-based tools for data collection andanalysis should be established. The critical step to startscale up of implementation is the development of astrong advocacy campaign to generate political consen-sus and allow for the allocation of significant human andfinancial resources.

Guidance on programmatic management oflatent TB infection: applicability for TB controlin migrants

M van der Werf,1 N Beer,1 SJ de Vlas,2 T Noori,1

M Vonk Noordegraaf-Schouten3 1European Centre forDisease Prevention and Control, Stockholm, Sweden;2Erasmus MC, University Medical Center Rotterdam,Department of Public Health, Rotterdam, 3Pallas HealthResearch and Consultancy BV, Rotterdam, The Netherlands.e-mail: [email protected]

Individuals with latent tuberculosis infection (LTBI) are areservoir of Mycobacterium tuberculosis in a populationand as long as this reservoir exists, elimination oftuberculosis (TB) disease will not be feasible. Manage-ment of LTBI requires the identification of infectedindividuals and adequate treatment of those identified.Migrants and other risk groups have been identified asrelevant target groups for TB elimination activities. Insome migrant groups a high proportion of individualstest positive for LTBI and migrant groups may thusbenefit from programmatic management of LTBI. In2013, the European Centre for Disease Prevention and

Control (ECDC) started the development of guidance onprogrammatic management of latent TB infection in theEuropean Union and European Economic Area (EU/EEA) countries. In a first step, experts from the EU/EEAcountries, candidate countries, and representatives frominternational and national organisations reached con-sensus on the components to be included in the guidancedocument. The main components identified were:diagnostic tests for LTBI; preventive treatment regimens;risk group specific interventions; and combining LTBIcontrol with other health programmes. This step wasfollowed by collection of the scientific evidence baseusing literature reviews, accompanied by mathematicalmodelling and cost-effectiveness studies. ECDC is alsodeveloping evidence-based guidance on the assessmentand prevention of infectious diseases among newlyarrived migrants in the EU/EEA. This guidance willinclude options for the prevention of HIV, hepatitis B andC, vaccine preventable diseases, and intestinal parasites,as well as options for the prevention of active TB andLTBI. In October 2016, the evidence base collection forboth guidance documents will be far advanced orcompleted. This evidence will permit the assessment ofoptions for programmatic management of LTBI inmigrants and the assessment of whether there are gapsin the knowledge base.

Screening migrants for LTBI in Italy,Netherlands, Sweden and the UK: acomparative analysis

K Lönnroth,1 G de Vries,2 I Abubakar3 1WHO, Geneva,Switzerland; 2KNCV TB Foundation, The Hague, TheNetherlands; 3Public Health England, London, UK. e-mail:[email protected]

This talk will present a comparison of policies, practicesand M&E systems across four European countries, aspart of a new EU project. This innovative project aims topool data across countries to analyze LTBI screeningcoverage and results among migrants and the patientpathway from screening to diagnosis to treatment totreatment completion. It also includes policy analysis andqualitative studies to map interaction between healthsector and migration authorities. The presentation willcompare policies between countries and present earlydata on coverage and outcome of screening.

Intergovernmental Immigration and RefugeeHealth Working Group perspectives: pre-migration screening and the potential role ofLTBI screening

P Douglas,1 D Zenner,2 D Posey3 1Immigration HealthBranch, Department of Immigration and Border Protection,Australia, Sydney, NSW, Australia; 2Public Health England,London, UK; 3Centre for Disease Control and Prevention(CDC), Atlanta, GA, USA. e-mail:[email protected]

Health and migration authorities in low TB burdencountries including Australia, the UK and the USA are


part of an Intergovernmental Immigrant and RefugeeHealth Working Group together with Canada and NewZealand. This group fosters intergovernmental collabo-ration and provides technical and programmatic guid-ance on pre-migration screening for refugees andimmigrants. This joint presentation from representativesof Australia (Paul Douglas), the UK (Dominik Zenner),and the USA (Drew Posey) provides an analytic andcomparative overview of pre-migration active and latentTB screening programmes of their countries including therange of different approaches and methods used andoutline lessons learned, current initiatives and the wayforward. Recent developments, such as the developmentof a common intergovernmental TB screening specifica-tion and other aspects such as role of migrant TBscreening within their national TB strategy, evidence onpriorities for TB screening and treatment amongmigrants, and monitoring and evaluation, will becovered. With the new emphasis from the World HealthOrganization through the End TB strategy, the impor-tance of how these screening programs address the issueof latent TB and prevent future reactivation in low andmedium incidence countries will be explored. Theoutcomes will demonstrate that premigration screeningfor active TB is successful in decreasing the incidence ofTB in receiving countries but on its own will not meet therequirements to eliminate TB and must be used inconjunction with LTBI screening either before or afterarrival.

10. Policy makers and partnerships:building the political will to end TB

Getting our attention: engaging policy makerson TB

N Herbert1 1House of Commons, London, UK. e-mail:[email protected]

Building political support is key to ending TB, but it ishard to know where to start. The Rt Hon Nick Herbert,co-founder of the Global TB Caucus, will share how hebecame involved in the fight against TB and discussopportunities to approach and engage busy policymakers.

Building champions in the Kenyan Parliament:how grassroots support led 100þMPs to takeaction on TB

R Mwaniki1 1Kenya AIDS NGO Organization (KANCO),Nairobi, Kenya. e-mail: [email protected]

On World TB Day 2015, MP Stephen Mule led a chargeon the floor of the Kenyan Parliament that led to over100 MPs to sign the Barcelona declaration, pledging toend TB in their lifetime. This presentation will explorehow KANCO engaged MP Stephen Mule on TB issues,the tactics KANCO used to build broad bipartisansupport, and how the collaboration between MPs and

civil society laid the foundation for over one hundredMPs to take action on an often forgotten disease.

How to engage your colleagues on TB: creatinga national TB caucus in Georgia

G Khechinashvili1 1Parliament of Georgia, Kutaisi, Georgia.e-mail: [email protected]

With the highest rate of drug-resistant TB in the world,the Eastern Europe and Central Asian region is a keybattleground in the fight against TB. As a medical doctor,former National TB Program Manager, and currentMember of Parliament, Dr. Khechinashvili used hispolitical platform to create a national TB Caucus inGeorgia’s parliament. In this presentation, Dr. Khechi-nashvili will outline the steps taken to create a nationalcaucus in the Georgian Parliament and identify oppor-tunities for MPs to work together with civil society tocreate a TB-free world.

Building parliamentary support at a regionallevel: the Asia Pacific TB caucus

S Kirk1 1RESULTS Australia and the Asia Pacific TB Caucus,Sydney, NSW, Australia. e-mail: [email protected]

Almost 6.2 million cases or two-thirds of the global TBburden are estimated to be in Asia, with 40% in just threecountries: India, Indonesia, and China. The region is alsothe home of both established and fast growing econo-mies, and countries that are transitioning out from donorsupport. In September 2015, members of the Global TBCaucus from India, Vietnam, the Philippines, Indonesia,Papua New Guinea, New Zealand and Australia formedthe first parliamentary regional network under theGlobal TB Caucus; the Asia Pacific TB Caucus. TheCaucus was formed with the intention of developingregional solutions to TB, which is a significant regionalissue in the Asia Pacific. First, the Caucus focused onsmall, achievable asks that any individual anywherecould take. This gave a common objective for the TBcommunity to support and helped to engage parliamen-tarians on the issue of TB, and provided a broad base ofpolitical support upon which the Asia Pacific TB Caucushas been built. There is a divide between political leadersand decision-makers, and those who know the diseasebest: those who work on TB, and those who have beenaffected by TB. By leveraging the engagement ofcolleagues in regional countries, the Caucus has beenable to close that gap. Since the founding, Parliamentar-ians around the region have worked with each other toraise the attention given to TB, new comprehensive TBlaws have been passed and are now being replicated, anddonors Governments are now starting coordinate theirTB investments. In addition to this, new regional andlinguistic caucuses have been launched in the Americas,Africa, Europe, and Francophone regions. Each regionalcaucus has their own goals and achievements, but all arefounded on one principle - Tuberculosis is in everycountry in the world, and we need the world to cometogether to address it. As the Caucus grows, it will focus


on strengthening the ties between political leaders andthe TB community, and in doing so help unlock theresources and the policy changes needed to accelerateprogress against the TB epidemic.

Engaging policymakers on TB in emergencysettings: the case of NepalBK Parajuli1 1Volunteers for Development Nepal (VFDN),Program Management, Bhaktapur, Nepal. Fax: (þ977) 15133191. e-mail: [email protected]

While tuberculosis had always been a major challengefacing Nepal. Each year, approximately 45 000 peopledevelop tuberculosis and around 35 000 get registered inNTP recording and reporting system. 10 000 new casesalways missed out from being reported each year.Though NTP is planning to carry out a prevalencesurvey to unveil the real status of tuberculosis in thecountry, the current situation became more complicatedin the wake of the devastating earthquakes of April 25th

and May 12th 2015. The earthquakes affected thirty-oneof the country’s 75 districts. Approximately 9000 peoplelost their lives; more than half a million houses collapsedincluding government buildings, health facilities andprisons and almost 2.8 million people were displaced.The health and population sector was severely affectedcausing losses to health infrastructure and disruption ofhealthcare service delivery. As a result, the ability ofhealth facilities to respond to health care needs had beenaffected and service delivery was disorganized. Conse-quently, vulnerable populations, including disaster vic-tims, were further disadvantaged in accessing healthservices including DOTS in remote and affected areas.The disaster brought forward few challenges - mainte-nance of the disrupted services of national TB program(NTP) in the affected areas and engagement of policy-makers in advocacy for both regulating existing servicesand high level support to NTP in the post disastersituation. Volunteers for Development Nepal (VFDN), anational NGO working in TB engaged along with otherstakeholders in reorganizing the services and tracking ofmissed out patients in earthquakes hit districts as well asengaged with the members of parliament in foundationof Nepal TB Caucus to support and strengthen NTPinitiatives at policy making level. As a result, 42parliamentarians signed on the Barcelona Declarationand founded Nepal TB Caucus, giving TB a politicalstatus for the first time in Nepal. During emergencysituation, VFDN finds partnership between civil societyand policymakers would be essential in enhancingadvocacy and maintaining disrupted services at differentlevels ultimately strengthening NTP in achieving the goalof Global TB to End TB by 2030 in the country and in theregion.

11. Another transnational tobaccocompany in the making: the impact ofthe globalisation of the Chinese tobaccomonopoly on tobacco control policiesaround the world

History, aims and aspirations of the ChinesemonopolyQ Gan,1 X Gao2 1The Union, Beijing, China; 2MacalasterCollege, St Paul, MN, USA. e-mail: [email protected]

The Chinese National Tobacco Corporation is theworld’s largest manufacturer of tobacco products interms of revenues. This session puts spotlight on thehistory of the tobacco business monopoly in China. Italso talks about the aims of the China Tobacco Industryto monopolise the world’s tobacco trade, with specialinterest in LMICs.

China’s monopoly role in tobacco agriculturalsectors in BrazilT Cavalcante1 1National Committee for WHO-FCTCImplementation (CONICQ), Rio de Janeiro, RJ, Brazil. e-mail:[email protected]

China Tobacco is expanding its reach to Latin-Americancountries like Brazil in a big, aggressive way by formingjoint ventures with the local tobacco exporters. Thesejoint ventures have integrated countless tobacco farmersin the exploitative process to make more profits.

Impact on demand and supply side measuresfor tobacco control under expanding ChinesemonopolyD Adam1 1International Union against Tuberculosis and LungDisease (The Union), N’Djamena, Chad. e-mail:[email protected]

Before the United States and the European Union, Chinais the largest trading partner of Africa. Bilateral tradebetween China and Africa exceeded $ 210 billion. Apartfrom the bilateral trade agreements China signed withmany African countries, China is also recognized as apartner in development and cooperation for many ofthese countries. Major African countries have ratified theFramework Convention on Tobacco Control (FCTC).The presentation aims to provide examples from Africabased on the experiences faced due to the expandingstrategies undertaken by China Tobacco Industry and itsimpact on farmers’ livelihood and/or others interventionin tobacco control policy making by China Tobacco.


Impact on demand and supply side measuresfor tobacco control under expanding Chinesemonopoly

V Schoj1 1InterAmerican Heart Foundation, Buenos Aires,Argentina. e-mail: [email protected]

This session aims to provide examples from LatinAmerica based on the experiences faced due to theexpanding strategies undertaken by China Tobacco.

12. Reframing resistance: research andinnovation to improve patient care andend drug-resistant TB

Progress and challenges on the road to auniversal regimen

E Nuermberger1 1Center for Tuberculosis Research, JohnsHopkins University, Baltimore, MD, USA. e-mail:[email protected]

Today’s treatment for drug-resistant TB is toxic, expen-sive, and can be as long as 24 months or more with lessthan 50% of patients cured. Faster-acting and simplifiedall oral TB drug regimens containing three or four newdrugs with no pre-existing resistance and less toxicitywould be a game-changer. This presentation discusses theprogress and challenges towards an enhanced TB drugregimen(s) that can address both drug-sensitive and drug-resistant disease, as well as the strategy over the next 5years to drive the momentum in TB drug developmenttoward the targets of the End TB Strategy with specialfocus on creating a more robust and sustainable pipelineof TB drugs.

Towards universal drug susceptibility testing:how could next generation sequencingsupport this goal

D Dolinger1 1FIND, Geneva, Switzerland. e-mail:[email protected]

Since 2002 there has been a gradual 1.3% per yeardecrease in the incidence of tuberculosis worldwide.Though this is an encouraging statistic it is beinghampered by the growing incidence of drug resistanttuberculosis. One key to effectively controlling tubercu-losis and the spread of multi-resistant strains is accurateinformation on drug resistance and susceptibility. Phe-notypic solutions, although the current ‘gold standard’,are cumbersome, prone to error and time-consuming.Detection of resistance conferring mutations by molec-ular methods is an alternative which has been shown towork but it is only the beginning of a holistic solution forguiding patient treatment. With the introduction of newdrug combinations and patients with potentially morecomplex resistance profiles, it is imperative to provide amore panoramic view of tuberculosis resistance patternsin order to allow for the implementation of correct,guided therapies and to fight further spreading of multi-resistant strains. An important set of genetic resistance

markers is already known, while at the same time awealth of new genetic information is evolving with theidentification of additional putative genes, intergenicnon-coding regions and mutations associated with drugresistance. The rapid evolution of knowledge on thegenetic foundations of tuberculosis drug resistance isindicating that sequencing will become the most appro-priate and versatile technology platform to providerapid, accurate and actionable results for treatment ofthis disease. Reductions in sequencing costs and opera-tional complexity over the past years have brought NGSinto use in clinical laboratories in high-income countriesand expanded its utility as a public health and clinicaltool. Harnessing NGS for LMICs will require acomprehensive analysis to understand the current coun-try specific situations, potential end-to-end solutions andthe right applications. Currently there are no ‘plug-and-play’ solutions for reference labs in the most affectedcountries. However, a program can be envisioned whichwill overcome the limitations and facilitate access to acomprehensive drug resistance genotyping solution forhealth authorities, tuberculosis treatment centres andpatients in low- and middle-income countries.

Developing a vaccine to prevent all forms of TB

M Hatherill1 1University of Cape Town, South AfricanTuberculosis Vaccine Initiative (SATVI), Cape Town, SouthAfrica. e-mail: [email protected]

Drug-resistance mechanisms are distinct from vaccinetargets, and therefore an effective vaccine is expected toprotect against all forms of TB, including drug-sensitiveTB, multi-drug-resistant (MDR) and extensively drug-resistant (XDR) TB. A safe, effective vaccine will becrucial in stopping the spread of TB and drug-resistance.This presentation will discuss progress and challenges indeveloping new TB vaccines, and key areas of focus overthe next 5 years toward the development of new, moreeffective TB vaccines as identified in the Global Plan toStop TB 2016-2020, which include continuing toadvance the clinical pipeline, enhancing knowledgethrough experimental medicine, increased emphasis onearly-stage research, improving animal models, layingthe foundation for adolescent and adult vaccinationcampaigns, and strengthening community engagement invaccine R&D.

Intensified TB research is essential for re-centring care around the needs of TB patients

M Frick1 1Treatment Action Group, New York, NY, USA.e-mail: [email protected]

Eleven years of data on TB R&D funding collected byTreatment Action Group demonstrates that TB R&D isgravely underfunded; a situation that imposes significantcosts on health systems and carries direct consequencesfor patient-centered care. This presentation will demon-strate how intensified support for research and innova-tion is essential for improving patient-centered care inTB. The presentation will review efforts to ensure that


research reflects patient needs and priorities, and makethe case that governments should see support for TBresearch as necessary for promoting dignity and meetingtheir obligations under international human rights law.

13. Monitoring progress towards the EndTB Strategy target to eliminatecatastrophic costs: findings from the firstround of surveys

Findings from the first national TB patient costsurvey in Ghana

D Pedrazzoli,1 D Boccia,1 F Bonsu,2 N Nortey Hanson,2

R Houben1 1London School of Hygiene and TropicalMedicine, London, UK; 2Ghana National Tuberculosis ControlProgramme, Accra, Ghana. e-mail:[email protected]

Even when tuberculosis (TB) care is free, impoverishedpatients, and their households, continue to incurunmanageable costs due to seeking and staying in carefor the full duration of anti-tuberculosis treatment. In2013, Ghana undertook a national TB prevalence surveywhich showed a generalised epidemic that is four timeshigher than previously estimated. This survey alsohighlighted barriers to accessing and adhering to TBcare. Investigating and addressing these barriers, includ-ing direct non-medical costs (such as costs for travel andfood during health seeking) is therefore imperative inorder to inform the design of policies and interventions toensure effective delivery of TB care, mitigate theeconomic impact of diagnosed TB for patients and theirfamilies, and ultimately contribute to reduction inburden of disease. This presentation will report on theprocess of establishing a nation-wide survey to assess themagnitude and main drivers of patient costs in Ghana.Preliminary findings will also be presented conditionalon completion of data collection.

Findings from the first national TB patient costsurvey in East Timor

S Nery,1 C Lopes,2 M Monteiro,3 A Siroka,4,5

I Garcia Baena,4 K Lönnroth,4,6 K Viney7 1AustralianNational University, Research School of Population Health,Canberra, ACT, Australia; 2Ministry of Health, National TBProgramme, Dili, 3Ministry of Health, Communicable DiseaseControl Department, Dili, Timor-Leste; 4Global TBProgramme, WHO, Geneva, Switzerland; 5UCLA, FieldingSchool of Public Health, Los Angeles, CA, USA; 6KarolinskaInstitutet, Stockholm, Sweden; 7Australian NationalUniversity, Canberra, ACT, Australia. e-mail:[email protected]

Tuberculosis (TB) remains an issue of public healthimportance in the Asia-Pacific region. Timor-Leste(South East Asia) reports an extremely high incidencerate of TB (498 per 100 000 population); much higherthan the global rate, suggesting that further actions areneeded to reduce the burden of TB. These actions should

address patient and household level issues which act asbarriers to effective TB prevention and care, includingthe cost of health care seeking and TB care to patients.The proportion of households incurring catastrophiccosts related to TB diagnosis and care is a new indicatorin the End TB Strategy. It will be used to monitorprogress towards TB elimination and therefore there is aneed to establish baseline information on the economicburden of TB in each country. Here we report the initialresults of a study that aims to estimate TB patient costs inTimor-Leste. A cross-sectional health-facility survey(with retrospective data collection and projections) wasconducted in all but one health facilities that serve as TBDOTS centres. We aimed to recruit 445 TB patients (ofall ages and all types of TB) sequentially as they attendedthe 16 participating DOTS centres, provided that theyhad undergone two weeks or more of TB treatment. Onehealth care worker was trained in each facility to conductface to face interviews with TB patients at the end of theirroutine clinic visits. Data collection was initiated inAugust and was planned to last approximately 2 months.We will calculate mean out-of-pocket medical and non-medical payments and indirect costs, before TB treat-ment starts and during TB treatment and will determinethe proportion of TB patients who incur catastrophiccosts and the amount of dissaving incurred. This researchwill be used to advocate for policies and interventions to:1) minimise barriers in accessing and adhering to TBtreatment and care, and 2) mitigate the economic impactof TB for patients and their families.

Findings from the 2016 national TB patient costsurvey in Viet NamBH Nguyen,1 N Nguyen Viet,1 T Hoang TT,1 K Lönnroth,2

GB Ines2 1Viet Nam National TB Program/National LungHospital, Ha Noi, Viet Nam, 2World Health Organization,Geneva, Switzerland. e-mail: [email protected]

This presentation will summarize findings from the firstnationally representative survey of costs faced by TBpatients and their households in Viet Nam (2016). Thepresentation will have 6 objectives: 1) To presentrationale and backgrounds for this work in the contextof Vietnam and the End TB strategy; 2) To present studyobjectives and methodology in line with WHO method-ology; 3) To describe the adaptation of the surveyinstrument and electronic data collection tool experi-ence; 4) To present the study process from fund raising toresult dissemination; 5) To present preliminary resultsand findings; 6) To describe results dissemination processwithin and beyond the TB community.


Field testing the generic protocol for patientcost surveys: lessons learnt and way forward

I Garcia Baena,1 K Lönnroth,1,2 A Siroka1 1Global TBProgramme, World Health Organization, Geneva,Switzerland; 2Karolinska Institutet, Solna, Sweden. e-mail:[email protected]

This presentation will summarize the emerging work tomeasure costs faced by TB patients and their householdsthrough periodic nationally-representative surveys in linewith WHO methodology (2015). The presentation willhave three objectives: 1) To present an outline of thegeneric protocol and instrument for measuring patientcosts and the proportion experiencing catastrophic costs;2) To share the experience from first implementingcountries that have presented data in this symposium andfrom other countries that have completed or startedsurveys in 2016; 3) To provide advice to countries thatare planning future surveys.

14. Enough is enough: time to endpreventable mortality among peopleliving with HIV

HIV-associated TB mortality: an irreversibletruth?

N Ford1 1World Health Organization, Geneva, Switzerland.e-mail: [email protected]

One third of all HIV-associated deaths were due to TB in2014, and HIV autopsy studies show TB prevalence ratesas high as 40%. Case fatality rates show PLHIV threetimes more likely to die than HIV-negative patientsduring TB treatment. Despite this, evidence has alsoshown that if given ART, HIV-positive TB patients canhave outcomes comparable with HIV negative TBpatients. This presentation will provide an overview ofthe evidence on mortality from HIV-associated TB andMDR-TB, highlighting the opportunities in the cascadeof care through from early case detection to timelytreatment to end preventable mortality.

The role of presumptive TB treatment forimproving survival in severely ill patients withHIV

W Katagira1,2 1Makerere University - University of CaliforniaSan Francisco Research Collaboration, Kampala, 2MakerereUniversity Lung Institute, Kampala, Uganda. e-mail:[email protected]

Background: In 2007, World Health Organization(WHO) issued emergency recommendations on empirictreatment of sputum acid-fast bacillus smear-negativepatients with possible tuberculosis (TB) in HIV-prevalentareas, and called for operational research to evaluatetheir effectiveness. We sought to determine if early,empiric TB treatment of possible TB patients withabnormal chest radiography or severe illness as suggested

by the 2007 WHO guidelines, is associated withimproved survival.Methods: We prospectively enrolled consecutive HIV-seropositive inpatients at Mulago Hospital in Kampala,Uganda, from 2007 to 2011 with cough for 72 weeks.We retrospectively examined the effect of empiric TBtreatment before discharge on 8-week survival amongthose with and without a WHO-defined ‘danger sign,’including fever .398C, tachycardia .120 beats perminute, or tachypnea .30 breaths per minute. Wemodeled the interaction between empiric TB treatmentand danger signs, and their combined effect on 8-weeksurvival,

ISSN 1027 3719 NOVEMBER 2016 The SUPPLEMENT 1 ... · MDR-TB and migration: from infection fundamentals to programme innovations S23 22. Newapproachesto MDR-TB treatment in children:

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