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TB Control Measures: From development and endorsement to adoption and implementation. Léopold Blanc TBS Stop TB department WHO Christy Garcia University of Connecticut School of Medicine. Overview. Background Laboratory Treatment Drug Resistant TB TB/HIV Infection Control
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TB Control Measures:From development and endorsement to adoption and implementation Léopold Blanc TBS Stop TB department WHO Christy Garcia University of Connecticut School of Medicine
Overview • Background • Laboratory • Treatment • Drug Resistant TB • TB/HIV • Infection Control • Care Delivery Innovation • Conclusions
Background • 2010: Global Plan estimates 16 medicines, 18 diagnostics, 12 vaccines in development • Recent years have seen the launch of several new tools with the recommendation to use Xpert MTB-RIF… conditions to be discussed during the Global consultation end of November • The time is right to evaluate uptake of these tools to adapt promotion for increased uptake in the future
Background • Task Force on Retooling • Created by Stop TB Partnership to help programmes implement new technologies • Innovative New Approaches and Tools subgroup • Ensure timely access to information on new tools and technical support for rapid adoption • Track progress in uptake and expansion of new tools
Background • Method: • Inventory of major policy changes in the last 10 years • Creation of questionnaire and piloting within HQ • Questionnaire distributed targeting 22 HBC and high MDR-TB countries • 27/40 surveys were returned • Goal: Identify areas of delay for better promotion of new approaches and tools in the future
Laboratory • Challenges: • Long delay between seeking care and diagnosis • Expensive technology not available for low-resource settings • Newly endorsed methods: • New case definition smear + (2007) • Liquid culture and rapid speciation (2007) • Line-probe assay (2008) • LED FM (2009) • Xpert MTB-RIF (2010)
Laboratory Results • Significant number of countries utilizing tool prior to WHO endorsement • Most of the uptake occurs within 1st yr • Implementation mainly at national and regional level
Treatment • Challenges: • Long duration • Multiple drugs • Recent Policy Changes: 1999: Fixed-dose combination tablets for the treatment of tuberculosis 2003: Treatment of Tuberculosis: guidelines for national programmes 3rd ed. 2010: Treatment of Tuberculosis: guidelines 4th ed.
Treatment Results Substantial number of countries with guidelines in place prior to WHO policy:
Multidrug Resistant TB • Challenges: • Delayed identification leads to further spread of resistant strains • Recent policy changes: 2006: Guidelines for the programmatic management drug-resistant tuberculosis 2008: Emergency update
Multidrug Resistant TB • Other risk categories in which routine DST is being conducted: • Patients who have failed first line treatment (68%) • Patients who have failed a retreatment regimen (84%) • 7 EURO countries conduct routine DST in all TB patients • 78% intensive phase conducted in hospital; 78% continuous phase as outpatient or community-based • 58% countries have recording and reporting system in place for adverse rxns to second line drugs
TB/HIV • Challenges: • Smear microscopy has lower sensitivity • Higher conversion latent to active infection • Interaction between ARVs and antituberculosis drugs • Recent policy changes: 2004: Guidelines for HIV surveillance among tuberculosis patients 2007: Improving diagnosis and treatment of smear-negative pulmonary and extrapulmonary tuberculosis in adults and adolescents 2009: A guide to monitoring and evaluation for collaborative TB/HIV activities
TB/HIV • Few countries with existing TB/HIV policies in place • Good uptake of policies within 1-2yrs of WHO endorsement • Low uptake of new diagnostic algorithm and IPT
TB Infection Control • Challenges: • Respiratory spread person to person • Greater exposure for health care workers, populations in congregate settings • Recent Policies: 1999: WHO guidelines for the prevention of TB in health care facilities in resource-limited settings 2009: WHO policy on TB infection control in health-care facilities, congregate settings, and households
TB Infection Control • Long delay between first endorsement of guidelines by WHO and adoption by countries • Implementation mostly at national and regional level • Over half of countries implementing policies only did so in TB care facilities
Care Delivery Innovation • Challenges • Lack of infrastructure • Lack of human and financial resources • Engagement of political will • Recent policies and tools 2006: Stop TB Strategy 2006: Engaging all health care providers in TB control 2007: A tool for national situation assessment 2008: Contributing to Health Systems Strengthening
Care Delivery Innovation • Area with least uptake of new tools and policies • 41% of countries have advanced planning and preparation for new tools • 33% of countries have INAT component in Global Fund agreement
Conclusions • Largest percentage of uptake 1-2yrs after endorsement of policy • Most uptake seen with TB/HIV policies • Both country factors and global factors play a role in delay of uptake
Moving Forward… • Continued use of survey instrument and database for broader sampling • Collaboration between TB control areas to learn from examples of successful promotion • More focus on health systems strengthening