MDR-TB management in EMR updates from rGLC

Dr. Essam Elmoghazy

Chairman of rGLC-EMR

TB and MDR TB Burden in EMR 2014

AFR28%

AMR

3%

EMR

8%EUR4%

SEAR

41%

WPR

17%

Graph 1: EMR Contribution to estimated TB incidence % 2014

EMR has 117 per 100,000 population as estimated TB incidence rate.EMR is ranking 4 among other regions and is responsible about 8 % of estimated incident TB cases and 5% of MDR-TB cases incident globally. The estimated number of MDR-TB cases was 15900 in 2014

AFR11%

AMR2%

EMR5%

EUR24%SEAR

33%

WPR24%

Graph 2: EMR contribution to estimted MDR-TB in-cidence among notified PTB % 2014

AFR AMR EMR EUR SEAR WPR Global

2.1 2.4 3.2

15

2.2 4.4 3.3

11 1118

48

1622 20

est-rate MDR-TB among new PTBest-rate MDR-TB among prv trt PTB

Reporting from Countries

• In EMR few countries (Bahrain, Jordan, Oman, Kuwait, and Qatar) apply DR TB surveillance (culture and DST) for all newly diagnosed TB cases.

• 14 countries had done at least one drug Resistance survey (Afghanistan, Djibouti, Egypt, Iraq, Iran, Jordan, Lebanon, Morocco, Pakistan, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, and Yemen).

• Djibouti, and Sudan results will be incorporated in 2016 GTB report.

• Bahrain, Djibouti and Libya did not report on 2014 data (GTB report 2015).

Estimated number of MDR-TB cases among notified pulmonary TB cases 2014

• During 2014, the top 5 countries in the region (based on estimated number of MDR-TB cases among new and previously treated PTB) were Pakistan, Afghanistan, Somalia, Sudan and Morocco.

• Those 5 countries were responsible of 93% of MDR-TB cases in the region.• Pakistan alone was shouldering 76% of MDR-TB burden among new and 55%

among previously treated in the region in 2014.

12000

1100770 540 340 250 160 150 140 130 72 48 31 21 19 11 10 6 3 2 2 1

15806

MDR-TB detection• During 2014, EMR countries notified 4% of globally

confirmed RR/MDR-TB cases. The overall case detection in the region was 28% of all 15800 estimated MDR-TB cases.

• The total number of RR/MDR-TB cases confirmed was 4348 cases (WHO Global TB Report 2015) among 30519 tested as per the table below.

AFR21%

AMR3%EMR4%

EUR34%

SEAR

27%

WPR11%

PAK IRQ SOM MOR AFG EGY SUD SAA YEM IRN SYR TUN LEB JOR KWT OMN QTR UAE PAL BAH DJI LIB

3043

196 176 115 88 86 82 67 53 48 31 14 10 9 9 8 2 1 0

• The top 4 countries that reported confirmed RR/MDR-TB cases were: Pakistan, Iraq, Somalia, and Morocco

Progress in MDR-TB detection in EMR 2009-2014

2009 2010 2011 2012 2013 2014

2

5.9

5.1

12

22

28

Detection rate

Enrolment on treatment 2014During 2014• 4348 confirmed RR/MDR-TB• 3423 (79%) MDR-TB cases put

on treatment in 2014. • No information on cases treated

outside NTP. • Consequently, during 2014 there

were 925 patients on waiting list or treatment was not received due to several reasons.

• This list is always changing. Some of the patients are enrolled on treatment, and others die while waiting the treatment. Estimated Detected Enroled on treatment

100

28 22

2014 (%)

Estimated Detected Enroled on treatment

15800

4348 3423

2014 (Number)

Treatment outcomes • The treatment success rate reached (2012

cohort) was 65% for MDR-TB, and 33% for XDR-TB cases (GTB report 2015).

• Compared to other regions the success rate in EMR is the highest with less unfavourable results

• During 2007-2012 Treatment success rate was increasing while cases lost to follow up and/or not evaluated are decreasing.

Regional challenges/risks foreseen • Enhance the diagnostic capacity, and PPM to improve case detection.

• Management of side effects and pharmacovigilance needs further enhancement especially when planning to introduce new medicines.

• Limited human resources at country and regional level is still critical.

• Maintaining uninterrupted supply of quality-assured second-line anti-TB drugs.

• Unstable situation in the region mainly in (Afghanistan, Lebanon, Libya, Iraq, Pakistan, Somalia, Syria, Tunisia and Yemen)resulted in several challenges as follows:– Huge population movement including MDR-TB patients and health staff– Huge staff turn over – Destruction of infrastructure– Limited movement in the field– Sever loss of drugs and equipment– Restricted options for monitoring and evaluation, conduct meetings and receive

participants due to visa obstacles almost in all countries that are reasonable secure/stable.

The strategic directions of the work of EMR_GLC 2016

The main strategic directions of the work in EMR_ GLC from 2014-2015 were continued in 2016 as follows:

• Improve planning for PMDT (support planning at country level), including use of new medicines and short regimen

• Support implementation of high quality ambulatory based model based on global documents and country experience,

• Scale up R&R for MDR (standardized tools and reports preferably on line, data quality and analysis),

• Promote utilization of new diagnostics • Establish/strengthen pharmacovigilance systems • Scale up infection control at all levels, • Build national HR capacity • Support operational research in the field of MDR-TB.

Main activities 2015-2016

• Laboratory international training• Monitoring missions• Technical Assistance• Briefing to countries on new medicines and

short regimen• Training workshops on updates in MDR-TB

diagnosis and treatment

New diagnostics International courses

• The regional office supported 6 countries (Afghanistan, Pakistan, Iraq, Iran, Sudan and Tunisia) to strengthen their TB laboratory staff capacity through attending International high level TB diagnostics courses (Milano and Tunisia). The total Number of staff trained was 9 TB Laboratory technical staff.

• Similar support is in process 2016 to further enhance laboratory capacity.

JOINT WHO AFRO – EMRO - HQ "New DR−TB drug introduction and experience exchange workshop for the WHO AFR and EMR"

• This workshop took place in Kenya, Nairobi during 4-5 November 2015, were members of two rGLCs from EMR and AFR met to be briefed about new updates in WHO policies regarding utilization of new medicines.

• The WS was prepared by GDI, AFR and EMR rGLC secretariat.

Way Forward for r-GLC EMRO • Arrange briefing meeting to MDR−TB focal persons and partners in the countries. This will

cover all aspects of introducing new medicines. Planned for June 2016 • rGLC members and secretariat will support countries for refreshing their PMDT plans through

missions, on-line support and other means are requested throughout 2016. • Briefing will also be included in consultant training planned for May 2017.

The regional GLC committee 6th meeting (side meeting during Kenya WS)

The objectives of the 6th meeting were to:• Review the situation of PMDT during the first

half of 2015, the implementation of the EMR-GLC plan of action 2015, and the recommendations of the previous meeting.

• Discuss the work plan of 2016 (monitoring missions, training, meetings, planning).

• Discuss the preparation steps for promoting use of new TB medicines in MDR-TB treatment.

• Discuss the idea of establishing local GLC in high burden countries in the region.

• Finalize the proposed changes of the committee membership.

Main recommended actions:• EMR_GLC secretariat will finalize the 2016

operational plan and share it with all members.

• EMR_GLC secretariat will send thanking letters to the members mentioned above.

• EMR_GLC will circulate the call for new members indicating new areas that should be represented in the committee such as nursing, drug management, clinicians, patients, NGOs.

• EMR_GLC members will rethink the options and possibilities to establish local GLC/MDR-TB working group mainly in Pakistan, Sudan, Egypt and Iraq.

Support for NFM proposals

EMR_GLC secretariat supported several countries to include MDR component in NFM proposals for GF during 2014-2015 such as – Djibouti (TA mission), – Egypt (Identify consultant, and support EPI

analysis, NSP), – Pakistan (Identify consultant and support NSP),

Sudan (TA mission and consultant), – Syria (Online support),– Yemen (Desk review, and online support or NSP).

DRS analysis workshop (April 2015-GVA)

• Iran, Iraq, Morocco contributed to the Inter-Regional Drug Resistance Workshop that was conducted in 28-30 April 2015 in GVA to analyse the results of the DR surveys in several countries in EMR and AFR.

• The results of the DRS are ready for Iran, Morocco, and Iraq.

Sudan inter-country MDR-TB meeting 9-11 May 2016

Participants: • One MDR focal point from (Djibouti, Egypt, Iran, Iraq, Jordan, Lebanon,

Morocco, Oman, Syria, Tunisia). Yemen did not participate• Two MDR focal points from (Afghanistan, Pakistan, Sudan and Somalia).

Monitoring and technical assistance missions 2015

• M&E missions were conducted to Afghanistan, Djibouti, Lebanon, Jordan, Pakistan and Sudan.

• The reports were peer reviewed by rGLC members and queries were shared with both countries and consultants to ensure quality of the report.

• Most of the mission included lab and Drug Management consultant or at least benefited from recent related missions in the country.

• At the time of the missions, the forms for rGLC monitoring mission agreed by rGLC were used.

Monitoring and TA mission 2016

• Afghanistan: 18-23 July• Djibouti: not decided yet• Egypt: Done . Report under peer review• Jordan: Done. Report under peer review• Lebanon: Done. Report shared with country (not under

TGF)• Morocco: Done. Report not received yet• Pakistan: under planning• Sudan: 31 July – 4 August• Somalia: 25-27 July• Tunisia: Done. Report not received yet

Plans for training 2016

Location Participants from(1) Lebanon Participants from 4countries:

Jordan (8), Iraq (8), Lebanon (3) and Syria (6)(2) Egypt Participants from 7countries:

Egypt (8), Kuwait (1), Libya (2), Morocco (4), Oman(1), Sudan (6) and Tunisia (3)

(3) Pakistan Participants from 3countries:Afghanistan (6), Iran (6) and Pakistan (10)

(4) Djibouti Participants from 3countries:Djibouti (3), Somalia (8) and Yemen (4)

Four Training WS on MDR TB management including short regimen, new medicines and ambulatory model of the Programmatic Management of Drug Resistant Tuberculosis

Objectives: Train staff working on MDR-TB at national and subnational level on:• Selecting, enrolling and follow up of eligible MDR-TB patients on standardized or

short regimen. • Implementing ambulatory model of management of MDR TB cases, to enhance

compliance using community involvement and social support.

Second Call for nomination

• The committee membership is due to change on half board basis.

• A call for 5 members was circulated among countries in the region.

• Deadline was extended to 25 July

Thank You