Tuberculosis country work summaries 2012

Tuberculosis country work summaries 2012 Document number: WHO/EURO:2012-8642-48414-71874 © World Health Organization 2012 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication 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. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. 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Tuberculosis country work summary Armenia Total population (millions): 3.1 High TB priority country High MDR-TB burden country Epidemiological profile 2010** Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 0.33 (0.22-0.47) 11 (7.0-15.0) Estimates among notified TB cases: Prevalence 3.5 (1.5-5.9) 114 (48-189) MDR-TB among new cases 92 (68-120) 9 .4 (7.0-12.4) Incidence 2.3 (1.9-2.7) 73 (60-87) MDR-TB among previously treated 190 (170-220) 43.2 (37.9-48.7) Case detection rate 62 (52-76)% Notified MDR-TB cases on treatment 154 87 Estimated prevalence of HIV among TB (number, percentage); 31 (17-49); 1.4 (0.8-2.2)%. Treatment outcome 2009 Successfully treated (%) Died (%) Failed (%) Lost to follow up* (%) New smear-positive cases 72.5 7.0 2.7 17.7 New smear-negative/extrapulmonary 81.7 4.5 0.3 13.5 Previously treated cases 63.5 7.6 3.9 25.1 MDR-TB cohort 2008 54.5 2.6 10.4 32.5 *Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. **Data provided here are based on the latest WHO global TB database accessed on 9 December 2011. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html Major challenges Tuberculosis (TB) is one of the major public health problems in Armenia. The treatment success rate of new sputum smear-positive pulmonary TB patients is below the WHO target of 85%. Poor treatment outcome is partly explained by the high prevalence of drug-resistant forms of TB; Armenia is among the 27 high multidrug- resistant (MDR) TB burden countries in the world. To ensure the expansion of the Stop TB Strategy in Armenia, the Minister of Health took over the management of the National Tuberculosis Programme (NTP) in 2010. Nevertheless, there is a need to strengthen the institutional capacity of the Programme. Improving the structure and status of the NTP within the health system will ensure that national and international resources, as well as technical assistance, are effectively utilized. TB treatment is not patient-friendly and often involves unnecessary hospitalization, which contributes to the spread of (MDR) TB due to limited infection control measures. Diagnostic services need to be brought closer to patients at primary health care (PHC) level by finalizing the optimization of the TB laboratory network and improving the sputum and slide transportation system. Another weakness in diagnostic services is the length of time it takes to make drug susceptibility test results available. Furthermore, new rapid diagnostic techniques have not yet been implemented. Armenia practices excessive hospitalization of patients and TB suspects; nearly all regular TB patients and absolutely all MDR-TB patients are hospitalized in specialized TB wards during the intensive phase. An underlying cause of this is the reverse incentive system, which promotes hospitalization of TB patients and discourages ambulatory care. There is a need to reduce hospitalization by enhancing service delivery at the PHC level of care, while also improving infection control standards and restructuring the financing system. Dependency on funding for TB medicines from external sources makes the drug supply system vulnerable. The management of TB/HIV co-infection needs to be strengthened by providing a one-stop service for TB patients living with HIV. TB treatment for ex-prisoners needs to be ensured. The management of MDR-TB needs trained staff. 1 Achievements in collaboration with WHO • The main activity coordinated by WHO was the comprehensive review of the National TB Programme in Armenia conducted during April and May 2011. This review was combined with a Green Light Committee (GLC) mission, as well as drug management and laboratory support to the country. • WHO has also supported the NTP with the development of a draft National MDR-TB Response Plan. • WHO has provided technical assistance with the management of TB programmes in hospitals. Planned WHO activities • The WHO Country Office will take over the Country Coordinating Mechanism (CCM) Secretariat. • Finalization of the National M/XDR-TB Response Plan to align it with the Regional M/XDR-TB Action Plan. • Support for updating the structure, mandate and organigram of the NTP. • Revision and rationalization of hospitalization criteria to reduce excessive hospitalization of patients and TB suspects, and revision of TB financing mechanisms. • Introduction of new diagnostic methods to improve early diagnosis of MDR-TB. • Technical assistance to improve the management of co-infections, particularly TB/HIV, and strengthen collaborative mechanisms between civilian and penitentiary services. • Technical assistance to improve TB infection control. Main partners of WHO • Ministry of Health • The Global Fund to Fight AIDS, TB and Malaria (The Global Fund) • United States Agency for International Development (USAID) • Médecins Sans Frontières (MSF), France • Project HOPE • American University of Armenia • Armenian Red Cross. 2 Tuberculosis country work summary Azerbaijan Total population (millions): 9.2 High TB priority country High MDR-TB burden country Epidemiological profile 2010** Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number (thousands) % Mortality 0.9 (0.6-1.4) 10 (6.6-15) Estimates among notified TB: Prevalence 15 (6.3-26) 166 (69-279) MDR-TB among new cases 1.0 (0.8-1.1) 22 (19-27) Incidence 10 (8.3-12) 110 (90-131) MDR-TB among previously treated cases 1.1 (1.0-1.2) 56 (50-62) Case detection rate 63 (53-77)% Notified MDR-TB cases on treatment 0.29 52 Estimated prevalence of HIV among TB (number, percentage); 140 (74-220); 1.4 (0.8-2.2)%. Treatment outcome 2009 Successfully treated (%) Died (%) Failed (%) Lost to follow up* (%) New laboratory confirmed cases 62 3.1 7.3 27.6 New laboratory unconfirmed /extrapulmonary 67.1 3.1 2.8 27.0 Previously treated cases 53.2 5.7 9.4 31.8 MDR-TB cohort 2008 56.5 8.7 34.8 0 *Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. **Data provided here are based on the latest WHO global TB database accessed on 9 December 2011. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html Major challenges Political support for the National Tuberculosis Programme (NTP) in Azerbaijan is suboptimal. Models of care, including treatment, early diagnosis and treatment of latent tuberculosis (TB) infection should be improved in line with international standards. The laboratory network also needs strengthening. There is insufficient support for directly observed therapy (DOT) for susceptible TB at primary health care level. Azerbaijan is among the 27 high multidrug-resistant (MDR) TB burden countries in the world with the third highest MDR-TB rate worldwide. Released prisoners are followed up by nongovernmental organizations and managing the continuum of care in this way is not sustainable. Achievements in collaboration with WHO • The laboratory network includes the National Reference Laboratory, accredited by the Supranational Reference TB Laboratory in Borstel, Germany, which recently supported the establishment of several second-level regional laboratories based on international standards, with correct infection control measures. • In 2011, WHO coordinated a number of missions for the Green Light Committee (GLC)/Europe and supported the development of national TB and TB infection control guidelines, as well as the preparation of a procurement list for the National Reference Laboratory for rapid molecular diagnosis of TB and MDR-TB. • WHO also supported the organization of training courses for TB laboratories within the Foundation for Innovative Diagnostics (FIND) project for the civil and penitentiary systems, and provided technical assistance with developing an application to the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund). • A WHO TB laboratory mission to strengthen the TB laboratory network has taken place, which aimed to assist with developing/updating a laboratory plan based on an assessment of the TB laboratory network. This included diagnostic algorithms at different levels of the network, and guidelines and training materials for TB laboratory services, in order to review the current policies and practices for QA of laboratory services for smear microscopy, culture and anti-TB drug susceptibility testing. The TB recording and reporting form was revised with the support of WHO experts, approved by the MoH and is in use since January 2012. • A protocol for an anti-TB drug resistance survey is under development. 3 • In collaboration with the MoH and WHO headquarters, a two-day workshop on TB Ethics was organized on 8–9 December 2011 in Baku. The heads of TB facilities from Baku and the regions, representatives from the Ministry of Justice, Public Health and the Reform Centre, as well as the United Nations Educational, Scientific and Cultural Organization (UNESCO), participated in the seminar. Through the second workshop of this kind, awareness was raised of ethical human rights issues based on the recent guidelines. Planned WHO activities • Technical assistance with important measures to reduce the risk of TB transmission, including increasing the awareness and training of health care workers; improving the ability to diagnose TB, including upgrading of laboratories with rapid methods to detect rifampicin-resistant TB; reducing the need for hospitalization of TB patients by strengthening primary health care and improving access to DOT; and strengthening infection control measures. • The National M/XDR-TB Response Plan will be updated in accordance with the Regional M/XDR-TB Action Plan. • Extensive review of the NTP. • Technical assistance with updating the law on TB; improving the monitoring and evaluation system and developing standard tools; strengthening the TB laboratory system; and TB drug management (including capacity building, standard operating procedures for inventory management, registration, calculations, etc.). • Further support for implementation of the FIND project. • Coordination of upcoming GLC missions in support of M/XDR-TB control. • Technical assistance with developing infection control plans for TB facilities in the civilian and prison sectors, including infection control training. • Support for implementation of an electronic surveillance system and a countrywide anti-TB drug resistance survey. • Promoting the Practical Approach to Lung Health (PAL) at primary health care level (developing the strategy and national guidelines). • Management of co-infections; strengthened TB/HIV collaboration; updating the HIV/TB protocol based on the latest WHO recommendations. Main partners of WHO • Ministry of Health; National Tuberculosis Programme (NTP) • Medical Department of the Ministry of Justice • The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) • United States Agency for International Development (USAID) • Abt Associates • Green Light Committee (GLC) • TBTEAM • Nongovernmental organizations (NGOs): “Support to Health” "Hayat", “Assistance of Healthcare Development”, “Azerbaijan Health Communication Association”, Azerbaijan Red Crescent Society • Global Drug Facility (GDF). 4 (8\ World _He�lth� ,JI Organ1zat1on Tuberculosis country work summary �� REGIONAL 0Ft1a FOR Europe Epidemiological profile 2010** Estimates of TB Number burden Mortality 39 (36-46) Prevalence 350 (96-610) Incidence 3 3 0 (290-370) Case detection rate 85 (76-97) % Rate (per 100 000) 2.9 (2.7-3.4) 26 (7-45) 25 (22-28) Estonia Total population (millions): 1.3 High TB priority country High MDR-TB burden country MOR-TB burden Estimates among notified TB cases: MOR-TB among new cases MOR-TB among previously treated cases Notified MOR-TB cases on treatment Estimated prevalence of HIV among TB (number, percentage); 3 4 (25-44); 10 (7.1-13.0)%. Treatment outcome 2009 Successfully treated(%) Died(%) Failed(%) New laboratory confirmed cases 58.8 15.0 2.1 New laboratory unconfirmed/extrapulmonary 77.5 12.4 0.0 Previously treated cases 51.2 14.6 6.1 MDR-TB cohort 2008 46.0 10.8 10.8 Number % 43 (31-57) 18 (13-24) 35 (25-46) 44 (32-58) 63 100 Lost to follow up* (%) 24.2 10.1 28.0 34.4 *Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. **Data provided here are based on the latest WHO global TB database accessed on 9 December 2011. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html Major challenges In Estonia transmission of tuberculosis (TB) occurs mainly among certain vulnerable populations, such as alcohol abusers, intravenous drug users and TB/HIV coinfected patients. The country has one of the highest rates of TB/HIV coinfection prevalence in the EU (10%) and is among the 27 high multidrug-resistant (MDR) TB burden countries in the world. Estonia is at a turning point in terms of TB control, as the country appears to be approaching the low incidence phase in a steady manner. This, however, implies a number of strategic challenges in addition to the epidemiological challenges mentioned above. It will be a hard task to maintain political and financial commitment despite the declining incidence. Furthermore, as a result of emigration, staff who choose alternative careers and the retirement of current staff, it is anticipated that there will be a shortage of doctors, nurses and laboratory staff in Estonia in the near future. Finally, the country does not yet have a formally recognized National Reference Laboratory. Achievements in collaboration with WHO • Estonia represents a model of epidemiological progress in TB control in the context of high MDR-TB prevalence. In particular, there is potential for achieving the 2012 target of an incidence of 20 per 100 000 new cases in 2012, as defined in the current National TB Plan. This would move Estonia towards a low incidence setting. • With the support of WHO, Estonia has achieved favourable conditions for TB control in the last few years, including: political commitment for TB control; the National TB Programme (NTP) is in place with optimal management; existing staff who provide TB services are well trained; outstanding examples of drug procurement and rational use of drugs; a well functioning laboratory network with quality assurance and rapid testing; TB services integrated with health services; and financing of TB control ensures universal coverage and access for the entire resident population, regardless of legal and insurance status. • Successful joint TB country visit (programme review) by the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe, August 2010. • Green Light Committee (GLC) monitoring visit, August 2010. • The TB National Plan reflects and responds to the current epidemiological situation. 5 • Support for the introduction of a one-stop service for methadone, antiretroviral and TB treatment for coinfected patients. • Mid-term evaluation of the Estonian national HIV/AIDS strategy, 2006-2015 and national drug prevention strategy 2012 (with participation of the Regional Office), 19-23 September 2011. • With assistance from WHO, a project on how to deal with TB patients who suffer from alcohol dependence has been initiated. Planned WHO activities In order to make progress towards TB elimination and to avoid a resurgence of the TB epidemic, the following actions are proposed for the coming biennium: • Assistance with implementation and evaluation of a pilot project on TB patients with alcohol dependence. • Support for clear identification of high risk groups, particularly by optimizing the use of epidemiological and molecular data in identifying risk groups/settings. • Assistance with scaling up active case-finding; screening of high risk populations, such as prisoners, is showing clear benefits in curbing transmission. Opportunities for expansion of active case-finding are being considered. • Evaluation of preventive treatment of latent TB in risk groups other than HIV positives. • Case management and support for vulnerable populations will be expanded, particularly through extending social support and rehabilitation. Main partners of WHO • Ministry of Health • Ministry of Social Affairs • Ministry of Justice • Health Board • National Institute for Health Development • T artu University Hospital • North Estonia Medical Centre • West Tallinn Central Hospital • Centre of Infectious Diseases • European Centre for Disease Prevention and Control (ECDC) • Finnish Lung Health Association (Filha) • Green Light Committee (GLC) 6 Tuberculosis country work summary Kyrgyzstan Total population (millions): 5.3 High TB priority country High MDR-TB burden country Epidemiological profile 2010** Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 1.4 (0.9-2.0) 26 (17-38) Estimates among notified TB cases: Prevalence 13 (5.5-22) 243 (103-407) MDR-TB among new cases 530 (440-610) 14 (12-17) Incidence 8.5 (7.0-10) 159 (131-191) MDR-TB among previously treated 380 (350-420) 39 (35-43) Case detection rate 66 (56-81) % Notified MDR-TB cases on treatment 566 100 Estimated prevalence of HIV among TB (number, percentage); 240 (190-290); 2.8 (2.4-3.2)%. Treatment outcome 2009 Successfully treated (%) Died (%) Failed (%) Lost to follow up* (%) New smear-positive cases 82.4 3.3 4.1 10.1 New smear-negative/extrapulmonary 91.7 1.4 0.5 6.4 Previously treated cases 70.9 7.3 5.6 16.2 MDR-TB cohort 2008 49.6 8.0 14.5 27.9 *Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. **Data provided here are based on the latest WHO global TB database accessed on 9 December 2011. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html Major challenges Kyrgyzstan is among the 27 high multidrug-resistant (MDR) TB burden countries in the world. Adherence to MDR-TB treatment is a challenge, and monitoring and evaluation of drug-resistant TB cases needs to be improved. Furthermore, it is necessary to strengthen the management of the TB programme at both hospital and outpatient care levels, and to motivate staff and improve treatment practices for effective TB control. The country has a low MDR-TB detection rate because of limited laboratory capacity. Substantial financial gaps exist, especially with regard to the complex and costly interventions of drug-resistant TB management. About 44% of funds for TB control activities are contributed by foreign aid, including the Global Fund, making Kyrgyzstan dependent on external support and threatening sustainable TB interventions. Data received from the National TB Programme (NTP) is insufficiently analysed, and there is weak coordination of TB data management at institutions within the Ministry of Health and other agencies. There is also insufficient support for directly observed therapy (DOT) at primary health care level. Infection control measures during diagnosis, treatment and isolation of smear-positive MDR-TB patients are inadequate in both the civil sector and the penitentiary system. Achievements in collaboration with WHO • Gradual expansion of MDR-TB treatment coverage within the framework of Green Light Committee (GLC) projects. • Technical assistance for the NTP to prepare a new TB Strategy Plan for 2012–2013. • Technical assistance for the application to the Transitional Funding Mechanism of the Global Fund. • The National Reference Laboratory (NRL) collaborates with the WHO Supranational Reference Laboratory in Gauting, Germany and has successfully passed proficiency testing for drug susceptibility to first-line anti- TB drugs. 7 • A comprehensive WHO review of the NTP in Kyrgyzstan was conducted in July–August 2010. This mission concentrated on evaluation and follow-up of the programmatic issues of TB control, including trends in TB epidemiological indicators, political commitment, funding and coordination, health system strengthening, TB case-finding and diagnosis, activities at PHC level, drug management, integration of TB and HIV activities, TB monitoring and evaluation, PAL strategy, operational research, and publications and educational activities. • In 2011, a Global Drug Facility (GDF) mission provided technical support for programme, case and drug management, as well as determining the needs for anti-TB drugs and preparing a request for anti-TB drugs for the coming year. Planned WHO activities • Updating the National M/XDR-TB Response Plan to align it with the Regional M/XDR-TB Action Plan. • Collaboration on the implementation of an integrated electronic surveillance system. • Technical assistance to enable and promote operational research. • Technical assistance with development and implementation of the national strategic plan for TB infection control. • Support for strengthening the capacity of NTP management. • Organization of joint Global Fund/GDF/GLC missions. Main partners of WHO • Ministry of Health • Association of Phthisiologists • German Development Bank (KfW) • Global Drug Facility (GDF) • Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) • Grant Management Solution Project • Green Light Committee (GLC) • International Committee of the Red Cross (ICRC) • KNCV Tuberculosis Foundation • Médecins Sans Frontières (MSF) • Project HOPE • TBREACH • United Nations Development Programme (UNDP) • United States Agency for International Development (USAID). 8 Tuberculosis country work summary Latvia Total population (millions): 2.1 High TB priority country High MDR-TB burden country Epidemiological profile 2010** Estimates of TB burden Number Rate (per 100 000) MDR-TB burden Number % Mortality 74 (59-89) 3.3 (2.6-4.0) Estimates among notified TB cases: Prevalence 970 (250-1 700) 43 (11-75) MDR-TB among new cases 76 (59-96) 10 (8-13) Incidence 890 (780-1 000) 39 (34-45) MDR-TB among previously treated cases 26 (17-36) 24 (16-33) Case detection rate 100 (91-120)% Notified MDR-TB cases on treatment 87 100 Estimated prevalence of HIV among TB (number, percentage); 89 (69-110); 9.5 (7.5-12.0)%. Treatment outcome 2009 Successfully treated (%) Died (%) Failed (%) Lost to follow up* (%) New laboratory confirmed cases 74.8 8.6 0.5 16.0 New laboratory unconfirmed/extrapulmonary 83.2 11.8 0.8 4.2 Previously treated cases 44.6 14.2 0.0 41.2 MDR-TB cohort 2008 61.7 18.8 4.7 14.8 *Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. **Data provided here are based on the latest WHO global TB database accessed on 9 December 2011. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html Major challenges Latvia is among the 27 high multidrug-resistant tuberculosis (MDR-TB) burden countries in the world. Social and economic changes following the economic crisis have had a negative impact on TB control in recent years. The number of people belonging to social groups at risk of TB is increasing. Moreover, the simultaneous changes in the health system have not contributed to TB control. There has been a reduction in the number of staff, which has limited access to TB care in remote areas, and primary health care (PHC) services are not prepared to take on these responsibilities. The development and implementation of the National TB Programme (NTP) is the biggest challenge, including the quality of DOTS with all its components, management of drug- resistant TB cases, TB/HIV, and strengthening of collaboration with PHC services. TB/HIV collaborative activities are not sufficiently integrated. There is a need to strengthen MDR-TB/HIV management, with intensified case-finding of patients with TB symptoms, active screening using radiological examinations for people living with HIV (PLHiV), implementation of isoniazid preventive therapy for PLHiV, and the development of home-based care for TB/HIV patients. Active screening of vulnerable populations, for example PLHiV and in congregate settings such as prisons, is not fully developed. Contact tracing and examinations are also suboptimal in these populations. Achievements in collaboration with WHO Latvia has a well-established TB and MDR-TB control programme, which is used as an example for other countries. • Rolling out the country experience in TB control in other regions. • The WHO Collaborating Centre of Latvia for Research and Training on MDR-TB Management organizes international training courses on drug-resistant TB. • The National Reference Laboratory, assigned as the Supranational Reference Laboratory to Ukraine, contributes to international multidrug- and extensively drug-resistant (M/XDR) TB control. • Experts on MDR-TB management participate in the TB roster and contribute to TB control in the Region. • National TB/MDR-TB guidelines for TB specialists and PHC doctors, as well as other health care providers, have been developed. • A working group has been established for the development of the NTP. 9 Planned WHO activities • Finalization of the National M/XDR-TB Response Plan to align it with the Regional M/XDR-TB Action Plan. • Development and implementation of the National TB Programme, 2012–2015. To ensure adequate monitoring and evaluation of the progress achieved and gaps in TB and M/XDR control, a monitoring and evaluation unit and plan will be developed. • Technical assistance through monitoring missions. • Distribution of the national TB/MDR-TB guidelines for TB specialists and primary health care (PHC) doctors, as well as other health care providers, and provision of relevant training in these guidelines. • Expansion of the Stop TB Strategy through collaboration with PHC to provide more patients with treatment under direct observation by family doctors close to patients’ homes. • Technical assistance for the country to ensure that TB infection control is included in general infection control and the hygiene programme at country level, and that contact tracing, contact investigations and active screening are expanded, particularly among vulnerable populations. • Technical assistance to establish an algorithm for the rapid detection of MDR-TB, using Xpert MTB/RIF and enrolment of MDR-TB patients on treatment. • Support for continuing participation in clinical trials for new anti-TB drugs and new drugs for compassionate use. • Support for the WHO collaborating centre to share the country experience of MDR-TB management. • Support for professional experts in Latvia to provide technical assistance in other countries. Main partners of WHO • Ministry of Health • European Centre for Disease Prevention and Control (ECDC). 10 Tuberculosis country work summary Lithuania Total population (millions): 3.3 High TB priority country High MDR-TB burden country Epidemiological profile 2010** Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 0.37 (0.24-0.56) 11 (7.1-17) Estimates among notified TB cases: Prevalence 3.1 (1.1-5.3) 94 (34-159) MDR-TB among new cases 140 (120-170) 11 (9-13) Incidence 2.3 (2.0-2.7) 69 (59-80) MDR-TB among previously treated cases 190 (170-210) 52 (47-57) Case detection rate 76 (66-89) % Notified MDR-TB cases on treatment 310 100 Estimated prevalence of HIV among TB (number, percentage); 10 (5-16); 0.4 (0.2-0.7)%. Treatment outcome 2009 Successfully treated (%) Died (%) Failed (%) Lost to follow up* (%) New laboratory confirmed cases 73.4 9.7 1.7 15.2 New laboratory unconfirmed/extrapulmonary 85.6 6.8 0.5 7.1 Previously treated cases 29.7 24.3 4.7 41.3 MDR-TB cohort 2008 NA+ NA+ NA+ NA+ *Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. + NA; not available. **Data provided here are based on the latest WHO global TB database accessed on 9 December 2011. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html Major challenges Despite the decline in tuberculosis (TB) incidence in recent years, the TB epidemiological situation in Lithuania is still serious, with high rates of multidrug-resistant (MDR) TB and TB/HIV co-infection. The country is among the 27 high MDR-TB burden countries in the world. The mechanisms for effective follow-up of patients to prevent them from defaulting from treatment are underdeveloped for all patients. The default rate is particularly high among MDR-TB patients. In addition, treatment outcome monitoring of MDR-TB cases is inadequate. Infection control measures in TB service facilities are also inadequate, which results in nosocomial TB infection. Achievements in collaboration with WHO • Support for the preparation of a national programme for TB prevention and control, 2011–2014 and for the development of a national plan to control multidrug- and extensively drug-resistant (M/XDR) TB. • The international tender for procurement of second-line anti-TB drugs is on track. Several pharmaceutical companies, including the International Dispensary Association through the Green Light Committee (GLC), took part in the tender. • A training workshop for pulmonologists on MDR-TB treatment, management, surveillance and infection control was conducted. Planned WHO activities • Finalization of the National M/XDR-TB Response Plan in line with the Regional M/XDR-TB Action Plan. • Technical assistance for the implementation and expansion of outpatient TB case management. • Support for activities to improve TB patient adherence, such as patient education and social support for TB patients. • Technical assistance for primary health care facilities with directly observed therapy (DOT) and social support for TB patients during the continuation phase of treatment in order to prevent default and thus improve treatment success rates. 11 • Support for implementation of the national programme for TB prevention and control, 2011–2014. • Support for implementation of the national plan to control M/XDR-TB. • Technical assistance to develop the algorithms for rapid diagnosis of TB and drug resistant TB for optimal use of the available rapid diagnostic technologies. Main partners of WHO • Ministry of Health • Ministry of Justice • Local nongovernmental organizations (NGOs) • Green Light Committee (GLC) • Rotary National and International. 12 13 14 Tuberculosis country work summary Romania Total population (millions): 21.5 High TB priority country Epidemiological profile 2010** Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 1.5 (1.5-1.5) 7.0 (7.0-7.0) Estimates among notified TB cases: Prevalence 34 (12-59) 159 (58-275) MDR-TB among new cases 370 (240-550) 2.8 (1.8-4.2) Incidence 25 (20-30) 116 (95-138) MDR-TB among previously treated cases 560 (410-750) 11 (8.0-14.6) Case detection rate 74 (62-90)% Notified MDR-TB cases on treatment 502 100 Estimated prevalence of HIV among TB (number, percentage); 530 (310- 810); 2.1 (1.3-3.3)%. Treatment outcome 2009 Successfully treated (%) Died (%) Failed (%) Lost to follow up* (%) New laboratory confirmed cases 85.4 4.4 3.9 6.4 New laboratory unconfirmed/extrapulmonary cases 88.3 7.0 0.3 4.3 Previously treated cases 57.4 10.5 12.3 19.8 MDR-TB cohort 2008 16.4 18.7 32.7 32.3 *Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. **Data provided here are based on the latest WHO global TB database accessed on 9 December 2011. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html Major challenges Political commitment in Romania is limited and needs to be strengthened in order to ensure proper support for the National Tuberculosis Programme (NTP). Laboratory capacity is suboptimal because of the weak laboratory network structure and limited availability of culture on liquid media and rapid tests for anti-tuberculosis (TB) drug resistance. Drug susceptibility test results are available for only 50% of reported TB cases. Challenges with regard to treatment/follow-up of TB patients and anti-TB drug management include inadequate treatment regimens for multidrug-resistant (MDR) TB patients; decentralized drug procurement for first- and second-line anti-TB drugs, which is dependent on the local availability of each anti-TB drug; weak provision of directly observed therapy (DOT); and the absence of social support. The recording and reporting system is outdated and needs to be improved to include all necessary MDR variables. The NTP has a central management team that lacks a clear mandate, does not supervise the lower levels adequately, and is not involved in drug procurement. Furthermore, infection control measures in TB service facilities are inadequate. Achievements in collaboration with WHO • Support for the development of the National MDR-TB Strategic Plan, 2011–2015, which was submitted for approval to the Ministry of Health in September 2011. • Technical assistance with the development of two other strategic documents: the mid-term National TB Strategy and the Infection Control Strategic Plan. • A Green Light Committee (GLC)/Europe monitoring visit was carried out in June 2011. • A monitoring mission by the WHO Regional Office for Europe was carried out in December 2011. • Assistance with a new application to Transitional Funding Mechanism (TFM) of the Global Fund. 15 Planned WHO activities • Finalization of the National M/XDR-TB Response Plan in line with the Regional M/XDR-TB Action Plan. • Support to the implementation of the Global Fund project. • WHO expert mission on infection control, focusing on laboratories. • High-level WHO/ECDC joint mission to increase awareness and commitment for TB control. Main partners of WHO • Ministry of Health • National Public Health Institute • National Health Insurance House • National Institute for Lung Diseases “Marius Nasta” where the NTP is located • Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) • Centre for Health Policies and Services: a nongovernmental organization (NGO) active in public health and implementing Global Fund projects • Romanian Angel Appeal (NGO), the principal recipient of the Global Fund • Salvati Copiii (Save the Children Romania): an NGO active in children’s rights and implementing Global Fund projects • Romanian Red Cross, implementing Global Fund projects • Association of TB patients • European Centre for Disease Prevention and Control (ECDC). 16 Tuberculosis country work summary Tajikistan Total population (millions): 6.9 High TB priority country High MDR-TB burden country Epidemiological profile 2010** Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 2.8 (2.1-3.7) 41 (31-53) Estimates among notified TB cases: Prevalence 26 (12-43) 382 (177-619) MDR-TB among new cases 710 (470-1 000) 17 (11-24) Incidence 14 (12-17) 206 (169-247) MDR-TB among previously treated cases 610 (520-690) 62 (53-70) Case detection rate 44 (37-54) % Notified MDR-TB cases on treatment 245 92 Estimated prevalence of HIV among TB (number, percentage); 370 (280-470); 2.5 (2.0-3.0)%. Treatment outcome 2009 Successfully treated (%) Died (%) Failed (%) Lost to follow up* (%) New smear-positive cases 81.3 4.4 8.1 6.1 New smear-negative/extrapulmonary 90.5 2.8 1.4 5.3 Previously treated cases 72.0 10.7 10.2 7.1 MDR-TB cohort 2008 NA+ NA+ NA+ NA+ *Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. + NA; not available. **Data provided here are based on the latest WHO global TB database accessed on 9 December 2011. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html Major challenges Tajikistan is among the 27 high multidrug-resistant tuberculosis (MDR-TB) burden countries in the world. Although the country has committed to the Stop TB Strategy, there is a lack of drug supply management and problems with the procurement of quality-assured anti-TB drugs. The TB detection rate is very low and the TB information system is weak and does not supply reliable information to decision-makers. The majority of TB hospitals do not meet internationally-recognized infection control requirements. There is still a lack of human resource capacity to manage TB control, especially in rural areas at primary health care level because of poor motivation and low salaries. About 85% of funds for TB control activities are contributed by the Global Fund and other donors. Despite the annual increase in the state budget on TB, there are insufficient government funds to cover the basic needs of the National TB Programme (NTP), making Tajikistan dependent on external support and threatening sustainable TB interventions. Achievements in collaboration with WHO • Technical assistance to develop national MDR-TB control guidelines and a national protocol on TB management in the penitentiary system. • Technical assistance to draft national Practical Approach to Lung Health (PAL) strategic guidelines and national PAL clinical protocols. • Technical assistance to revise the national protocol on TB drug management. • Certification for the National Reference Laboratory to conduct anti-TB drug susceptibility testing. • Gradual expansion of MDR-TB coverage within the framework of Green Light Committee (GLC) projects. • Technical assistance to strengthen the TB information system. The Ministry of Health/National TB Programme in partnership with WHO, the United Nations Development Programme (UNDP) and the International Research & Development Organisation (IRDO), has started piloting an electronic recording and reporting system for MDR-TB. • Technical assistance to conduct an operational research study comparing hospitalization with ambulatory TB treatment outcomes. 17 • An assessment of barriers to the integration of TB and HIV services was conducted according to the key health system blocks and the report was shared with the Ministry of Health. • Tajikistan was enrolled in the EXPAND-TB project; laboratory equipment and reagents were supplied to the National Reference Laboratory. • Technical assistance for a community-based pilot project that was started to improve the quality of DOTS and the TB detection rate. Planned WHO activities • Finalization of the National M/XDR-TB Response Plan to align it with the Regional M/XDR-TB Action Plan. • Follow-up of the recommendations of the health system assessment of barriers to the integration of TB and HIV services. • Technical assistance to improve the quality of DOTS through continuing capacity building. • Addressing MDR-TB: adaptation of the National MDR-TB Response Plan based on the Regional M/XDR-TB Action Plan. Step-by-step expansion of the MDR-TB programme. • Introduction of the PAL Strategy in order to improve the TB detection rate and DOT at primary health care (PHC) level. Tajikistan started piloting PAL in three districts under the Global Fund TB project and based on the results is planning its expansion in the coming years. • Technical assistance to strengthen the TB information system. Based on the results of the pilot study, a plan of action to expand the electronic TB database will be developed. An electronic reporting and recording system will be developed for the DOTS part and incorporated into the MDR-TB part. Work is ongoing on the development/revision of evidence-based protocols, instruction and practices on different aspects of TB management. • Operational research will be carried out in 2011–2012 to compare TB treatment outcomes (including the social and financial burden) at ambulatory and hospital levels. • Technical assistance to address TB through health systems strengthening and primary health care. Main partners of WHO • Ministry of Health • Ministry of Justice, department of correctional affairs • Ministry of Education • National and regional TB centres • National and regional HIV/AIDS centres • Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) through the United Nations Development Programme (UNDP) • Project HOPE • United States Agency for International Development (USAID) through the Health Quality Project • German Development Bank (KfW) • Deutsche Gesellschaft für Internationale Zusammenarbeit • AIDS Foundation East-West • Red Crescent Society of Tajikistan • Caritas Luxemburg • Aga Khan Foundation • Finnish Lung Health Association (Filha). 18 Tuberculosis country work summary Turkmenistan Total population (millions): 5.0 High TB priority country Epidemiological profile 2010** Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 1.0 (0.7-1.9) 20 (13-37) Estimates among notified TB cases: Prevalence 3.9 (1.0-6.9) 77 (19-137) MDR-TB among new cases 100 (29-50) 4 (1-10) Incidence 3.3 (2.7-4.0) 66 (54-80) MDR-TB among previously treated cases 15 (9-23) 18 (11-28) Case detection rate 96 (80-120) % Notified MDR-TB cases on treatment NA+ Estimated prevalence of HIV among TB; NA+ Treatment outcome 2009 Successfully treated (%) Died (%) Failed (%) Lost to follow up* (%) New smear-positive cases 83.8 4.7 6.2 5.3 New smear-negative/extrapulmonary NA+ NA+ NA+ NA+ Previously treated cases NA+ NA+ NA+ NA+ MDR-TB cohort 2008 NA+ NA+ NA+ NA+ *Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. + NA; not available. **Data provided here are based on the latest WHO global TB database accessed on 9 December 2011. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html Major challenges The quality of tuberculosis (TB) services needs to be improved and infection control in TB facilities is poor. There is a lack of effective diagnosis of TB due to the absence of clear criteria for sending sputum for culture examination and drug susceptibility testing. The system of recording and reporting on anti-TB drugs is not unified. No strategy has been implemented for the diagnosis and treatment of patients with multidrug-resistant (MDR) TB. The management of anti-TB drugs at central level is still under development. Although a national drug coordinator has been formally appointed, most of the functional responsibilities are still distributed among different employees at the National Centre of TB Prevention. As a consequence, anti-TB drugs lack quality assurance and can be obtained without a doctor’s prescription. The laboratory network in Turkmenistan lacks capacity to perform culture and anti-TB drug susceptibility testing and rapid diagnostics. Furthermore, there are currently 55 peripheral laboratories that perform Ziehl-Neelsen microscopy for the diagnosis of TB, but the workload in some of these laboratories is too low. Therefore the TB laboratory network needs to be rationalized. Achievements in collaboration with WHO • There is strong political commitment to TB control at all levels in the country and the TB programme is supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund). • Technical assistance to introduce elements of DOTS countrywide, including 100% coverage of the penitentiary system. • Technical assistance to optimize the TB laboratory network and introduce new methods for laboratory diagnosis of TB. • Technical assistance to integrate primary health care with anti-TB services across the country, including training of family doctors and nurses. • Technical assistance to develop a protocol for a nationwide anti-TB drug resistance survey. • Technical assistance to develop treatment protocols and a diagnostic algorithm for MDR-TB patients. • An electronic TB register has been established. • A Green Light Committee (GLC) mission and an infection control assessment mission were conducted. • Technical assistance to revise recording and reporting forms. 19 Planned WHO activities • Finalization of the National M/XDR-TB Response Plan to align it with the Regional M/XDR-TB Action Plan. • Technical assistance to improve the quality of the Stop TB Strategy throughout the country, including laboratory diagnosis of TB. • Technical assistance to introduce appropriate infection control in TB facilities. • Development and implementation of a nationwide anti-TB drug resistance survey protocol in cooperation with the Supranational Reference Laboratory. • Health system strengthening mission to increase the capacity of the National TB Programme (NTP) central team. • Two months’ in-country technical assistance to support the programmatic management of MDR-TB patients in line with WHO recommendations and infection control requirements. • Technical assistance to further strengthen the TB laboratory network. Main partners of WHO • Ministry of Health • United Nations Development Programme (UNDP), the principal recipient of the Global Fund Round 9 TB grant • United States Agency for International Development (USAID) • National Red Crescent Society. 20 Tuberculosis country work summary Ukraine Total population (millions): 45.5 High TB priority country High MDR-TB burden country Epidemiological profile 2010** Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number (thousands) % Mortality 8.6 (5.2-12) 19 (11-27) Estimates among notified TB cases: Prevalence 60 (25-100) 132 (54-223) MDR-TB among new cases 4.5 (3.8-5.2) 16 (14-19) Incidence 46 (38-55) 101 (84-121) MDR-TB among previously treated cases 2.3 (2.0-2.5) 44 (40-49) Case detection rate 73 (62-89)% Notified MDR-TB cases on treatment 3.9 73 Estimated prevalence of HIV among TB (number, percentage); 6 000 (5 000-7 100), 13 (13-13)%. Treatment outcome 2009 Successfully treated (%) Died (%) Failed (%) Lost to follow up* (%) New laboratory confirmed cases 59.7 13.1 15.9 11.4 New laboratory unconfirmed/extrapulmonary cases NA+ NA+ NA+ NA+ Previously treated cases 47.1 14.3 22.0 16.6 MDR-TB cohort 2008 NA+ NA+ NA+ NA+ *Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. + NA; not available. **Data provided here are based on the latest WHO global TB database accessed on 9 December 2011. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html Major challenges Ukraine is among the 27 high multidrug-resistant tuberculosis (MDR-TB) burden countries in the world. Despite the adoption of the Stop TB Strategy by the National TB Programme (NTP), its components have not been sufficiently implemented. Financing of TB control activities mainly depends on the commitment and capacity of the oblast health administrations. Laboratory capacity is limited and case detection efforts mainly focus on mass screenings of the general population. Priority is given to hospital-based treatment and appropriate treatment depends on the local capacity to purchase the drugs. Provision of directly observed therapy (DOT) is lacking and patient support is limited. There is a need to reduce hospitalization of TB patients, while improving service delivery at the primary health care (PHC) level, as well as infection control standards, and restructuring the financing system. MDR-TB control activities are inadequate, as are efforts to address TB/HIV co-infection. There is a lack of anti-TB drugs in the country because of inadequate drug supply management and problems with the procurement of quality-assured drugs. The recording and reporting system is suboptimal, and expansion of the application software for a nominal electronic database is slow. Achievements in collaboration with WHO • A review of the NTP took place from 10 to 22 October 2010, involving 13 international and 23 national experts; the report of the review is available on the WHO web site and it has been translated into Ukrainian for the local authorities. • The WHO Country Office in Ukraine actively participated in the development of the new NTP 2012–2016 and the revision of the National MDR-TB Plan. The new programme is based on the Stop TB Strategy and the main recommendations from the NTP review. • In January 2011, the National Reference Laboratory successfully passed the external quality assurance and sent panels for testing to 27 biosafety level III laboratories in the framework of the national quality assurance programme. • Review missions were organized, which resulted in recommendations to optimize the laboratory network, infection control measures and MDR-TB control. • A Green Light Committee (GLC) mission took place in Donetsk. 21 • Assistance with the development of a protocol for a countrywide survey of the level and patterns of anti-TB drug resistance. Planned WHO activities • Finalization of the National M/XDR-TB Response Plan in line with the Regional M/XDR-TB Action Plan. • Technical assistance with the implementation of Global Fund Round 9 grant activities. • Coordination of a nationwide anti-TB drug resistance survey. • Support to improve policy for the programmatic management of drug-resistant TB. • Support to improve the management of TB/HIV. Main partners of WHO • Ministry of Health • State Services on HIV/AIDS and other socially dangerous diseases • All Ukrainian TB Centre • State Penitentiary Services • National Yanovsky TB and Pulmonology Institute • Rinat Akhmetov Foundation “Development of Ukraine” • United States Agency for International Development (USAID) • Program for Appropriate Technology in Health (PATH) • The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) • World Bank • Management Sciences for Health (MSH) • Médecins Sans Frontières (MSF) • Global TB Drug Facility (GDF) • Green Light Committee (GLC) • All-Ukrainian Network of People Living with HIV • International HIV/AIDS Alliance in Ukraine • National Society of Red Cross • Nongovernmental organizations working in HIV/AIDS, TB and other related areas. 22 Tuberculosis country work summary Uzbekistan Total population (millions): 29.5 High TB priority country High MDR-TB burden country Epidemiological profile 2010** Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number (thousands) % Mortality 5.4 (3.9-7.1) 20 (14-26) Estimates among notified TB cases: Prevalence 62 (29-100) 227 (104-371) MDR-TB among new cases 1.6 (1.2-2.1) 14 (11-19) Incidence 35 (29-42) 128 (105-153) MDR-TB among previously treated cases 2.3 (1.9-2.6) 49 (42-56) Case detection rate 48 (40-58)% MDR-TB cases on treatment 0.628 61 Estimated prevalence of HIV among TB (number, percentage); 710 (560-870); 2.1 (1.9-2.3)%. Treatment outcome 2009 Successfully treated (%) Died (%) Failed (%) Lost to follow up* (%) New smear-positive cases 81.4 6.0 5.4 7.2 New smear-negative/extrapulmonary 88.4 3.4 0.8 7.4 Previously treated cases 68.9 11.2 6.6 13.3 MDR-TB cohort 2008 65.7 5.1 6.1 23.1 *Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. **Data provided here are based on the latest WHO global TB database accessed on 9 December 2011. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html Major challenges Uzbekistan is among the 27 high multidrug-resistant tuberculosis (MDR-TB) burden countries in the world. The management of anti-TB drugs is suboptimal and as a consequence, first-line anti-TB drugs can be obtained without a doctor’s prescription. Children are not treated according to international standards, neither with regard to the combination and dosage of anti-TB drugs, nor with regard to the duration of treatment and hospitalization. The staff in the new culture laboratories is insufficiently trained. Furthermore, the country lacks coordination with neighbouring countries to ensure cross-border TB control and care. Achievements in collaboration with WHO • A nationwide anti-TB drug resistance survey was carried out in 2010-2011 and finalized in 2011. • An extensive review of the National TB Programme was carried out and formed the basis of the approval of the governmental programme on TB control for the period 2010–2015. • WHO provided assistance with an assessment of TB recording and reporting, which led to the implementation of e-TB manager in collaboration with Management Sciences for Health (MSH). • The WHO Country Office (CO) is coordinating the implementation of the Practical Approach to Lung Health (PAL) Strategy in line with the United Nations Trust Fund for Human Security (UNTFHS) project framework in Karakalpakstan. • Organization of a Green Light Committee/Global Drug Facility (GLC/GDF) mission, 16–25 May 2011. • The following educational activities were organized by the TB Programme at the WHO CO in Uzbekistan: - During the last two years, all general practitioners and nurses at primary health care facilities have been trained in the PAL Strategy, and WHO has provided the necessary medical equipment to improve case detection and management of respiratory diseases in Karakalpakstan. - The 3rd central Asian regional workshop on TB laboratory diagnosis, 31 March – 2 April 2010. - An international conference on “M/XDR-TB, call for action” for the national TB programmes of central Asian countries was organized in Dushanbe, Tajikistan, 27–28 April 2010. 23 - A special topic seminar on the management of drug-resistant TB in the prison system in central Asia was held in Tashkent, 15–17 September 2010. This seminar was organized by the WHO TB programmes in the central Asian republics, and the Ministries of Health and Internal Affairs of Uzbekistan. Planned WHO activities • Revision of national TB and MDR-TB guidelines (2011–2013). • Updating and endorsing the M/XDR-TB Response Plan in line with the Regional M/XDR-TB Action Plan. • Regular routine assessment of the implementation of the Stop TB Strategy. • Coordination of the activities of partners. • Assistance with the analysis and reporting of the nationwide anti-TB drug resistance survey. • Development of a mechanism of coordination to improve subregional cross-border TB control and care. • Technical assistance in collaboration with the TB Coalition (TB CARE) on TB in prisoners, migrants, children and other vulnerable groups (2012–2014). • Establishment of a working group on the development of a national protocol on infection control, and finalization of the draft national protocol on infection control (during first half of 2012). • Technical assistance to expand countrywide MDR-TB case management (2011–2014). • Technical assistance to establish new culture and drug susceptibility methods in the laboratory network at oblast level (2011–2012). • Development of a laboratory module within the e-TB manager software will be finalized and tested. Main partners of WHO • Ministry of Health • National TB Programme (NTP) • Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) • German Development Bank (KfW) • United States Agency for International Development (USAID); TB Care • Médecins Sans Frontières (MSF) • Project HOPE • Quality Health Care Project • Management Sciences for Health (MSH). 24