Moving Forward in Diagnosis of Infectious Diseases in Developing Countries - A focus on Tuberculosis - 1st Meeting of the Global Laboratory Initiative (GLI) 1st Meeting of the Global Laboratory Initiative (GLI) World Health Organization & Fondation Mérieux MDR and XDR-TB: the new challenge f di i for diagnosis Paul Nunn on behalf of Kitty Lambregts Chair MDR Working Group Paul Nunn on behalf of Kitty Lambregts, Chair, MDR Working Group Les Pensières, Veyrier-du-Lac, France, 8 - 9 May 2008
26
Embed
MDR and XDR-TB: the new challenge fdi ifor diagnosis...XDR-TB in Tugela Ferry, South AfricaSouth Africa 544 Culture +ve, of which 221 MDR-TB (41%) and 53 XDR-TB Study characteristics
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Moving Forward in Diagnosis of Infectious Diseases in Developing g g p gCountries
- A focus on Tuberculosis -1st Meeting of the Global Laboratory Initiative (GLI)1st Meeting of the Global Laboratory Initiative (GLI)
World Health Organization & Fondation Mérieux
MDR and XDR-TB: the new challenge f di ifor diagnosis
Paul Nunn on behalf of Kitty Lambregts Chair MDR Working GroupPaul Nunn on behalf of Kitty Lambregts, Chair, MDR Working Group
Les Pensières, Veyrier-du-Lac, France,8 - 9 May 20088 9 ay 008
Latest global TB Estimates - 2006
Estimated number of
cases
Estimated number of
deathscases deaths
1.65 million1.65 million9.15 million9.15 millionAll forms of TB Greatest number of cases in Asia;
120 000489 000
Greatest number of cases in Asia; greatest rates per capita in Africa
MDR-TB among new cases 1994-2007g* Sub-national averages applied to China, Russia, Indonesia
< 3%3-6 %> 6 %> 6 %No data MDR-TB is resistance to isoniazid and rifampicin
Drug susceptible TB Cure rate 95+%MDR-TB Cure rate 67%
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or
boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2006. All rights reserved
% MDR among new and retreatment cases (1994-2006)
Baku, Azerbaijan
Arkhangelsk Oblast, RF
Kaliningrad Oblast, RF
Tomsk Oblast, RF
Donetsk, Ukraine
Pskov Oblast, RF
Estonia
Kazakhstan*
Tashkent, Uzbekistan
Latvia
Ivanovo Oblast, RF*
Mary El Oblast, RF
Armenia
Lithuania
Liaoning Province, China*
Latvia
I M li P i Chi
Henan Province, China*
Orel Oblast, RF
Armenia
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0
Heilongjiang Province, China
Inner Mongolia Province, China
0.25
0.30
0.35
80
100
120
200
250
300
350
0.05
0.10
0.15
0.20
0.25
p=0.0750
20
40
60
Arkhangelsk oblast
56 59 69 85
0
50
100
150
200
0.001997 1999 2001 2003 2005
p 0.075
0.35
01998 2000 2002 2004 2006
01999 2000 2001 2002 2003 2004 2005
400 120
0.15
0.20
0.25
0.30
150
200
250300
350
40
60
80
100
0.00
0.05
0.10
1997 1999 2001 2003 2005
p=0.0068
10 11 19 23 28
0
50100
1999 2000 2001 2002 2003 2004 2005 20060
20
40
1998 2000 2002 2004 2006
Orel oblast
0 25
0.30
0.35
400
500
600
100
120
0 05
0.10
0.15
0.20
0.25
p=0.00557 48 57 73 59
95 77100
200
300
400
20
40
60
80
Tomsk oblast
0.00
0.05
1997 1999 2001 2003 2005
p 0.0055
27 48 5 5
0
100
1999 2000 2001 2002 2003 2004 2005
New DST, New MDR TB notification rate % MDR among new
01998 2000 2002 2004 2006
300350400450
0 20
0.25
0.30
0.35
0 20
0.25
0.30
0.35
40
50
60
70
53
75
50 53 64 51 51 4250100150200250
0 00
0.05
0.10
0.15
0.20
p=0.62130 00
0.05
0.10
0.15
0.20
p=0.621310
20
30
40
Estonia0
1998 1999 2000 2001 2002 2003 2004 20050.00
1997 1999 2001 2003 2005
9001000
0.001997 1999 2001 2003 2005
01997 1999 2001 2003 2005 2007
90100
0.35
400500600700800900
405060708090
0.15
0.20
0.25
0.30
71 86 83 99 95 80 114
91
0100200300
1998 1999 2000 2001 2002 2003 2004 20050
102030
1997 1999 2001 2003 2005 2007
Latvia0.00
0.05
0.10
1997 1999 2001 2003 2005
p=0.3260
700800900
1000
0.25
0.30
0.35
60708090
100
64 61 75 84 86 104 12
7
100200300400500600
0.05
0.10
0.15
0.20
p=0.0169102030405060
Lithuania
0100
1999 2000 2001 2002 2003 2004 2005
0.001997 1999 2001 2003 2005
p
New cases tested, New MDR % MDR among new
01997 1999 2001 2003 2005
TB notification rate
2006: eXtensively Drug Resistant Tuberculosis XDR TB
XDR = Resistance to at least INH and
Tuberculosis - XDR-TB
RIF (MDR) PLUS resistance to fluoroquinolones, AND one of the second-line injectable drugs (amikacin, kanamycin, or capreomycin)
Of 17,690 isolates from 49 countries d i 2000 2004 20% MDR during 2000-2004 20% were MDR and 2% were XDR
XDR found in: XDR found in: USA: 4% of MDRLatvia: 19% of MDRS Korea: 15% of MDRS Korea: 15% of MDR
MMWR Morb Mortal Wkly Rep 2006; 55:301-5
Denmark
Croatia
Armenia
Lithuania
Poland
Norw ay
Tomsk Oblast, RF
Rep. Georgia
Armenia
UK
Belgium
Sw itzerland
Baku Azerbaijan
Latvia
Kaliningrad Oblast, RF
Netherlands
France
UK
Donetsk, Ukraine
Pskov Oblast, RF
Baku, Azerbaijan
Israel
Romania
0.0 20.0 40.0 60.0 80.0 100.0
Estonia
Ireland
Spain, Barcelona
Sw eden
% XDR-TB among MDR in Europe n = 27
Spain, Aragon
Czech Republic
Ireland Europe n = 27* Reporting periods vary generally 3 year average
0.0 20.0 40.0 60.0 80.0 100.0
Slovenia
TB Treatment Outcomes, by Selected Drug Resistance Patterns, Latvia, 2000-2003*
Cure Completion Death Default Failed Continue Tx HIV+
HR+AG+FQ
Cure Completion Death Default Failed Continue Tx HIV+
HR+INJ+FQ
HR+3SLD
MDR-TB All
0 10 20 30 40 50 60 70
Percent
* Leimane V, et al. First Global XDR TB Task Force Meeting. Oct 9, 2006(from N = 820 evaluated)
Percent
What no amount of congressional lobbying
could have achieved. And in the end – no harm
done.
Estimated HIV prevalence in new TB cases, 2006
No estimate
HIV prevalence in TB cases, (%)
0–4
20–49
50 or more
5–19
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2006. All rights reserved
MDR-TB & HIV in institutions in the WestWest
Patients with MDR-TB
T l Di dReference
Totalno.
HIV infected %
Died%
Time to death, median, weeks
Hospital (Florida), 1988–1990 MMWR 1991;40:585-91 65 93 72 7
Prison system (New York State), 1990–1991 JID 1994; 170:151-6 42 98 79 4
JID 2007;196 Suppl 1:S86-107
Epidemiology of MDR and HIV in AfricaPatients Place Association
between tested for HIV statusbetween tested for HIV status and any R HIV and DR
Githui, 1989 271 Nairobi, Kenya No associationGithui, 1989 271 Nairobi, Kenya No associationChum, 1996 1164 Tanzania No associationKenyon, 1999 240 Botswana No association Churchyard, 2000 1913 South Africa No association Warndorff, 2000 836 Malawi No association Espinal 2001 463 Multicentre No associationEspinal, 2001 463 Multicentre No association Mac-Arthur, 2001 709 Mozambique Association with HSWeyer, unpublished 762 South Africa No association
Association with MDR among retreatments
XDR-TB in Tugela Ferry, South AfricaSouth Africa
544 Culture +ve, of which 221 MDR-TB (41%) and 53 XDR-TB
Study characteristics (53 patients) No (%)Study characteristics (53 patients) No. (%)
Cure or Completed treatment 14 (28) Treatment Default or Failure 7 (14)
HIV infected (44 tested) 44 (100) HIV-infected (44 tested) 44 (100) Health care workers 2 Dead (includes 34% on ARV) 52 (98)
M di i l 16 d Median survival 16 days Number of TB strains 4+
Lancet 2006; 368:1575-80
506070
0k p
opn. 2005
20062007 MDR cases
10203040
case
s/10
0
per 100 000 population
010
hekwini
21 U
gu ndlovu
thuke
la zin
yathi
Amajuba
ululand
yaku
de hungulu
iLembe
Sisonke
ro
vince
MD
R
(top). XDR/MDR
20 eT
he 2
22 U
mgungun23
Uth
24 U
mzin25
Am
26 Zul
27 U
mkhan
ya28
Uthu29
iL43
SisKZN pro (bottom)
(Data for
40%
50%
60%
R
200520062007
(Uthungulu for 2005 excluded)
10%
20%
30%
XDR
/ M
D
0%
10%
hekwini
21 U
gu ndlovu
thuke
la inya
thi maju
ba ululan
d ya
kude
hungulu iLem
be Siso
nke
rovin
ce
20 eT
he 21
22 U
mgungun23
Uth
24 U
mzin25
Am
26 Zul
27 U
mkhan
ya28
Uthu29
iL43
SisKZN pro
Gl b l l lGlobal level response
Coordination of Partnership activities – the MDR Working Group
Global strategy and policies directed at better prevention and control of MDR/XDR-TB
Regional and country support Monitoring and evaluation Advocacy and resource mobilisation for
countries and partners
Partnership activitiesPartnership activities
MDR Working Group Tbilisi meeting, September 2007Tbilisi meeting, September 2007 New Chair and Vice Chair Core Group meetings Core Group meetings Sub-groups
• Drug management• Drug management• Advocacy and resource mobilization• ResearchResearch• Green Light Committee (Expanded and reformed)
NewsletterNewsletter
Challenges posed by MDR/XDR-TBg p y1st Global XDR-TB Task Force, 2006
M ff ti b i TB More effective basic TB management
Expansion of management ofExpansion of management of MDR and XDR-TB
Infection control Laboratory strengthening Expanded surveillance of MDR
d XDR TB i l di HIVand XDR-TB, including HIV Advocacy and resource
mobilisationmobilisation New tools
Notified cases of MDR-TB (2004–2006) and j t d ti t t b t t d (2007 2008)50 GLC
projected patients to be treated (2007–2008)4647
40
50 non-GLCGLC
4647
Global plan target for number of MDR-TB
3023
patients to be enrolled on treatment:2006: 14 thousand2007: 48 thousand2008: 98 thousand
10
20 1818
0
10
2004 (101,25%)
2005 (106,48%)
2006 (108,78%)
2007 (112,80%)
2008 (116,86%)
ConclusionsConclusionsMDR i id d i i d b i MDR is widespread, increasing, and being fuelled now by HIV
XDR-TB is ubiquitous and likely rising XDR-TB is ubiquitous, and likely rising Management of patients with MDR or XDR-TB
requires drug susceptibility testsrequires drug susceptibility tests Rapid tests are life saving in HIV associated
MDR-TB Problem is how to resurrect a stunted, starved,
demoralised, laboratory network and establish a vibrant effective responsive accurate purveyorvibrant, effective, responsive, accurate purveyor of DST data in all the places MDR is found
AcknowledgementsAcknowledgements
Katherine Floyd Chris DyeChris Dye Lynne Harrop Abby Wright Ernesto Jaramillo Ernesto Jaramillo Matteo Zignol Karin Weyer
II Meeting of the WHO Task Force on XDR-TB 9-10 April, Geneva, Switzerland9 10 April, Geneva, Switzerland
Main Recommendation
WHO and Stop TB Partnership to convene aWHO and Stop TB Partnership to convene a meeting with ALL 27 high priority countries early in 2009early in 2009
to increase political commitment at the highest country level,
hi d i th i it t i assess progress achieved in these priority countries, and
agree on actions to tackle the main factors hampering agree on actions to tackle the main factors hampering progress