Tuberculosis country work summaries 2013

Tuberculosis country work summaries 2013 Document number: WHO/EURO:2013-8884-48656-72249 © World Health Organization 2013 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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Contents Armenia ................................................................................................................................................... 1 Azerbaijan ............................................................................................................................................... 3 Belarus .................................................................................................................................................... 5 Bulgaria ................................................................................................................................................... 7 Estonia ..................................................................................................................................................... 9 Georgia .................................................................................................................................................. 11 Kazakhstan ............................................................................................................................................ 13 Kyrgyzstan ............................................................................................................................................. 15 Romania ................................................................................................................................................ 17 Russian Federation ................................................................................................................................ 19 Tajikistan ............................................................................................................................................... 21 Ukraine .................................................................................................................................................. 23 Uzbekistan ............................................................................................................................................. 25 Tuberculosis country work summary Armenia Total population (millions): 3.1 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 0.27 (0.22-0.33) 8.8 (7.2-11.0) Estimates among notified TB cases: Prevalence 2.4 (1.1-4.3) 77 (35-139) MDR-TB among new cases 86 (65-110) 9 .4 (7.1-12.0) Incidence 1.7 (1.4-2.0) 55 (45- 65) MDR-TB among previously treated 170 (140-190) 43 (38-49) Case detection rate 74 (63-90)% Notified MDR-TB cases on treatment 79 100 Estimated prevalence of HIV among TB (number, percentage); 55 (38-75), 3.3 (2.4-4.2)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New smear-positive pulmonary cases 71.7 4.4 15.0 8.8 New smear-negative/extrapulmonary cases 85.3 3.4 2.1 9.2 Previously treated cases 67.0 6.0 10.2 16.9 MDR-TB cohort 2009 51.5 7.5 14.2 26.9 *Data provided here are based on the latest WHO global TB database accessed on 26 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html2012 **Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. 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. Following the Extensive Review of TB Prevention, Care and Control Services in Armenia conducted by WHO in 2011, the institutional capacity of the Programme has been substantially strengthened. Status of the NTP within the health system has been improved to 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. Furthermore, the time it takes to get drug susceptibility test results available needs to be reduced. New rapid diagnostic techniques are planned to be implemented; the country is adopting an implementation protocol for pilot introduction of the Xpert MTB/RIF assay. Armenia still 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. Following WHO Regional Office for Europe recommendations for tuberculosis diagnosis and care and supporting financial incentives in the Republic of Armenia, the country is currently revising the financing system of TB services. These measures, along with enhancement of the service delivery at PHC level of care and improvement of infection control standards should contribute to reductions in unnecessary hospitalization. 1 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 and high quality of clinical follow up including DOT. Achievements in collaboration with WHO • Support for updating the structure, mandate and organization chart of the NTP was provided. • Joint Green Light Committee (GLC) and Global Drug Facility (GDF) missions were conducted in 2012, providing support to the country on treatment, drug management and laboratory issues.. • The NTP was supported to develop and finalize the National MDR-TB Response Plan in line with the Regional M/XDR-TB Action Plan. • Recommendations were provided to improve tuberculosis diagnosis and care and the supporting financial incentives in the Republic of Armenia, including suggestions to commence revision and rationalization of hospitalization criteria to reduce excessive hospitalization of patients and TB suspects, and revision of TB financing mechanisms. • Organization of a training of trainers on M/XDR-TB management to improve the capacity of health care providers in M/XDR TB management. • Technical assistance for development of the National TB Infection Control Guidelines and trainings on TB Infection Control for health care providers. • Technical assistance to the management of TB programmes in hospitals. Planned WHO activities • Technical assistance to finalize the National Strategic Plan for TB Control in Armenia. • Further support to the introduction and implementation 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 further strengthen TB infection control. • Assessment of TB services at primary health care facilities and recommendations for their optimization to enhance service delivery at PHC level. • Technical assistance to improve provision of psycho-social support to patients with MDR TB. 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): 9.3 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number (thousands) % Mortality 0.34 (0.24–0.44) 3.7 (2.6–4.7) Estimates among notified TB cases: Prevalence 16 (7.7–28) 172 (83–301) MDR-TB among new cases 0.93 (0.79–1.1) 22 (19–26) Incidence 11 (8.7–13) 118 (93–140) MDR-TB among previously treated 2.5 (2.3 –2.7) 56 (52–60) Case detection rate 59 (50–75)% Notified MDR-TB cases on treatment 592 73 Estimated prevalence of HIV among TB (number, percentage); 160 (110–220), 1.5 (1.1-2.0)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New laboratory confirmed pulmonary cases 76.6 3.3 4.5 15.6 New laboratory unconfirmed /extrapulmonary 70.2 7.1 6.4 16.3 Previously treated cases 62.6 3.2 4.4 29.7 MDR-TB cohort 2009 74.0 8.0 12.0 6.0 * Data provided here are based on the latest WHO global TB database accessed on 27 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html ** Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. Major challenges Azerbaijan is among the 27 high multidrug-resistant (MDR) TB burden countries. The Ministry of Health (MoH) has made good progress towards the implementation of The Global Fund grant, round 7, however models of care, including early diagnosis and treatment of active and latent TB infection should be improved in line with international standards Methods for rapid diagnosis of MDR-TB are available at the National Reference Laboratory and in the penitentiary system, but not routinely accessible in most of the country. The laboratory network therefore needs further strengthening in order to scale up the new diagnostic methods and expansion of culture and drug susceptibility testing. Provision of directly observed therapy (DOT) needs to be improved urgently to cover all TB and MDR-TB patients. In addition, linkages between TB and HIV services need to be further integrated and the recently developed infection control measures in line with the international recommendations need to be implemented. Currently, released prisoners are followed up by nongovernmental organizations, but the management of the continuum of care in this way is not sustainable. . . Achievements in collaboration with WHO • Following a request by the Minister of Health of Azerbaijan, the WHO Regional Office for Europe, in collaboration with key partners, organized a comprehensive external review of the National TB Control Programme. The mission members from WHO, the Green Light Committee (GLC), The Global Fund, the Centers for Disease Control and Prevention (CDC), the United States Agency for International Development (USAID) and representatives of the National TB Programme (NTP), the Medical Department of the Ministry of Justice (MoJ), conducted the between 10 and 18 April 2012. The MoH was debriefed on key findings and recommendations shortly after the review and a detailed report was finalized and submitted. • Support to revision of the National MDR-TB Action Plan and in line with the Regional M/XDR-TB Action Plan. • Technical assistance to the development of a protocol for a nationwide anti-TB drug resistance survey (DRS). The survey started in November 2012 and monitoring and quality control of the survey was provided in close collaboration with the Supranational Reference laboratory (SRL). • Assistance to the MoH and the Country Coordination Mechanism (CCM) of The Global Fund in desk review of the country proposal for the transitional funding mechanism (TFM) for continued support by The Global Fund. 3 • In collaboration with Program for Appropriate Technology in Health (PATH) provision of technical assistance to the NTP in preparation and organization of the national workshop on strengthening TB/HIV collaborative activities. • Continuous support to the MoH in implementation of the strategy for Practical Approach to Lung Health (PAL). The technical working group on PAL has been established under leadership of the MoH. In-country assistance was provided to the development of national guidelines on PAL and the organization of a training for general health care practitioners conducted in November 2012. • Assistance to the development of the national guideline on infection control that was endorsed by the MoH at the end of 2012. • Assistance to the NTP in the establishment of a centralised system for procurement and management of first-line anti-TB drugs. The system was established under leadership of the MoH, who ensures the funding from 2011. • Assistance to the start-up of centralized procurement of second line anti-TB drugs started in 2012. • Within the framework of a memorandum of understanding between the Foundation for Innovative New Diagnostics (FIND) and the MoH and the MoJ, WHO provides continuous technical assistance to the implementation of the EXPAND-TB project innovative TB diagnostics technologies. Planned WHO activities • Technical assistance to strengthening TB drug management (including capacity building, standard operating procedures for inventory management, registration, forecasting, etc.). • Continued technical assistance to the implementation of the EXPAND-TB project for expanding and accelerating access to diagnostics for patients at risk of MDR-TB, within the framework of a memorandum of understanding between FIND and the MoH and the MoJ. • Support to finalization of a national plan on strengthening of the TB laboratory network, including rapid molecular diagnosis of MDR-TB. • Coordination of upcoming GLC/Europe and Global Drug Facility (GDF) missions in support of M/XDR-TB control. • Technical assistance to further strengthen TB infection control and implementation of the PAL strategy. • Monitoring and quality control of the nationwide DRS, and assistance with the analysis and interpretation of results of the DRS in close collaboration with the SRL. • Establishment of mechanisms of coordination for detection and care of TB/HIV co-infection and support to development of updated TB/HIV guidelines. • To collaborate with the TB training center in penitentiary system in order for this center to develop into a WHO collaborating center. Main partners of WHO • Ministry of Health 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 • Nongovernmental organizations (NGOs): “Support to Health”, “Hayat”, “Assistance of Healthcare Development”, “Azerbaijan Health Communication Association”, “Azerbaijan Red Crescent Society” and “People living with HIV/AIDS (PLWHA) ” • Foundation of Innovative New Diagnostics (FIND) • Program for Appropriate Technology in Health (PATH). 4 Tuberculosis country work summary Belarus Total population (millions): 9.6 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden*** Number % Mortality 0.79 (0.74-0.84) 8.3 (7.7-8.8) Estimates among notified TB cases: Prevalence 9.6 (4.2-17) 100 (44-178) MDR-TB among new cases 1200 (1100-1300) 32 (30-35) Incidence 6.7 (5.5-8.1) 70 (58-85) MDR-TB among previously treated 810 (780-850) 75 (72-79) Case detection rate 70 (58-85)% Notified MDR-TB cases on treatment 1446 91 Estimated prevalence of HIV among TB (number, percentage); 250 (180-340), 3.8 (3.0-4.7)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New smear-positive pulmonary cases 66.3 8.4 22.5 2.9 New smear-negative/extrapulmonary cases 90.3 5.7 0.3 3.7 Previously treated cases 47.9 10.4 35.6 6.2 MDR-TB cohort 2009 40.2 15.0 11.0 33.8 *Data provided here are based on the latest WHO global TB database accessed on 27 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html **Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. ***Additional data in the text Major challenges Belarus is among the 27 high multidrug-resistant tuberculosis (MDR-TB) burden countries in the world with the highest level ever recorded. In 2010–2011, a countrywide anti-TB drug resistance survey supported by WHO revealed 32% and 76% of MDR-TB among new and previously treated smear/culture-positive TB cases, respectively. The major challenges in addressing MDR-TB are the scale up of rapid diagnostic tests for MDR- TB; reducing hospitalization and poor infection control measures; suboptimal surveillance of MDR-TB; insufficient TB and HIV program collaboration and lack of patient-centred TB care. Considering the recent currency devaluation and the increase in the estimated number of MDR-TB patients in need of treatment, there is a financial gap in securing diagnosis, treatment and patient support for all patients. Achievements in collaboration with WHO • Belarus has made considerable progress in implementing WHO recommendations during the last three - four years. Directly observed therapy (DOT) is implemented by order of the Ministry of Health (MoH). Since 2008, a formal collaboration is ongoing between the National Reference Laboratory and the Supranational Reference Laboratory in Stockholm. Since 2009, Belarus has been revising its national guidelines on TB control and has developed new protocols for treatment of drug-susceptible TB and MDR-TB, as well as new recording and reporting forms, new guidelines on infection control, and a new policy on TB prevention in children, including limiting BCG revaccination and annual screening with tuberculin skin testing. • With financial support from the United States Agency for International Development (USAID), support was provided for the revision of TB national policies and guidelines, as well as capacity building in synergy with the implementation of the Global Fund grants. • Green Light Committee (GLC) missions have monitored the treatment of MDR-TB patients on an annual basis since 2008. • With the technical assistance of WHO, a country-wide anti-TB drug resistance survey (DRS) was conducted and the results were finalized and presented at the international conferences and published in the WHO Bulletin and in the external NTP review report. • An external review of the National TB Programme (NTP) was organized in October 2011 with national and international experts and a comprehensive report was submitted to the MOH and published on the WHO website. 5 • The National M/XDR-TB Response Plan was updated in accordance with the Regional M/XDR-TB Action Plan and prepared for approval at the Inter-agency Coordination Board on TB control. • Technical assistance to the NTP in the development of the new guidelines of “Organization of TB care for the primary care” approved by the order of the MoH in May 2012 enhancing DOTS policies at the primary care level. • In August 2011, a memorandum of understanding was signed between the MoH and the Foundation of Innovative New Diagnostics (FIND) in the framework of an EXPAND-TB/UNITAID project supported by WHO on introducing rapid diagnostic tests at the national reference laboratory level. The first shipment of laboratory equipment was implemented in June 2012. • Support was offered to the development of new guidelines on MDR-TB treatment, incorporating the recommendations of the country-wide DRS, and these guidelines were approved by an order of the Minister of Health (MoH) in August 2012. • Assistance to the MoH in the development of the National Practical Approach to Lung Health (PAL) guidelines that were taken to the piloting phase in Ostrovetz district / Grodno region in accordance with the MoH. Planned WHO activities • Technical assistance to the implementation of the Global Fund Round 9 on TB in Belarus. • Ongoing monitoring of treatment of MDR-TB patients with the support of GLC. • Technical assistance to strengthen TB surveillance on MDR-TB. • Support to capacity building for TB and HIV collaborative activities in the country. • Training on anti-TB drug management. • Support to the development of the national TB laboratory manual. • Implementation of the EXPAND-TB project in Belarus on rapid diagnostics for MDR-TB. Main partners of WHO • Ministry of Health • National TB Programme (NTP) with the leading Republican Scientific and Practical Centre for Pulmonology and Tuberculosis • Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) • United Nations Development Programme (UNDP) as primary recipient of the Global Fund project in Belarus • United States Agency for International Development (USAID), Minsk • Foundation of Innovative New Diagnostics (FIND). 6 Tuberculosis country work summary Bulgaria Total population (millions): 7.4 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 0.2 (0.2-0.2) 2.5 (2.5-2.6) Estimates among notified TB cases: Prevalence 3.3 (1.3-6.3) 44 (17-85) MDR-TB among new cases 28 (16-46) 2.0 (1.1-3.2) Incidence 2.6 (2.3-3.0) 35 (31-40) MDR-TB among previously treated cases 91 (66-120) 26 (19-33) Case detection rate 84 (72-96)% Notified MDR-TB cases on treatment 42 76 Estimated prevalence of HIV among TB (number, percentage); 8 (2-17), 0.3 (0.1-0.7)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New laboratory confirmed pulmonary cases 86.3 7.9 1.6 4.2 New laboratory unconfirmed/extrapulmonary cases 88.0 8.5 0.1 3.4 Previously treated cases 63.8 13.2 5.7 17.2 MDR-TB cohort 2009 18.6 34.9 11.6 34.9 *Data provided here are based on the latest WHO global TB database accessed on 16 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html **Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. Major challenges Bulgaria is among the 18 high priority countries for tuberculosis (TB) control in the WHO European Region. Challenges for the National Tuberculosis Programme (NTP) include the lack of efficient TB infection control and the low level of engagement of TB care providers, especially primary health care providers, in early detection and follow-up of TB patients. TB services, especially access to directly observed treatment (DOT) in the continuation phase, are not delivered equally countrywide. A major concern is the sustainability of financing of provision of anti-TB drugs, health promotion and outreach interventions by nongovernmental organizations to vulnerable groups (e.g. Roma communities) after the end of the grants from The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund). Achievements in collaboration with WHO Major achievements in the last year include: • The national TB guidelines were updated with guidelines on HIV counselling and testing and on programmatic management of drug-resistant TB, in line with international standards. • The treatment of multidrug-resistant (MDR) TB patients continued in the Lung Diseases Hospital in Gabrovo with technical assistance and monitoring of the Green Light Committee (GLC). • The first national representative survey of anti-TB drug resistance in Bulgaria was completed. The results of the survey showed much lower MDR-TB levels than previously estimated, demonstrating the Ministry of Health commitment in addressing the problem of drug resistant TB. • In 2011, for the first time, the National TB Reference Laboratory (NRL) was certified in second-line anti-TB drug susceptibility testing by the WHO Supranational TB Reference Laboratory in Milan, Italy. • The National M/XDR-TB Response Plan was finalized and is in line with the Regional M/XDR-TB Action Plan. 7 Planned WHO activities • Technical assistance to procurement of third-line anti-TB drugs for treatment of patients with extensively drug-resistant (XDR) TB, and their management in a new facility for palliative care. • Ongoing monitoring of treatment of MDR-TB patients with the support of GLC (visit planned for June 2013). • Technical assistance to further increase the involvement of health care providers and nongovernmental organizations’ workers in TB and MDR-TB prevention and control. Main partners of WHO • Ministry of Health • Country Coordinating Mechanism to Fight AIDS and Tuberculosis • National Centre of Infectious and Parasitic Diseases • Regional TB treatment facilities • Medical universities • Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) • Nongovernmental organizations (NGOs). 8 Tuberculosis country work summary Estonia Total population (millions): 1.3 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number Rate (per 100 000) MDR-TB burden Number % Mortality 36 (36-37) 2.7 (2.6-2.8) Estimates among notified TB cases: Prevalence 380 (160-710) 28 (12-53) MDR-TB among new cases 56 (43-72) 23 (17-29) Incidence 330 (290-380) 25 (22-28) MDR-TB among previously treated cases 44 (33-54) 58 (43-71) Case detection rate 89 (78-102) % Notified MDR-TB cases on treatment 75 96 Estimated prevalence of HIV among TB (number, percentage); 50 (36-66), 15 (11-19)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New smear-positive pulmonary cases 67.5 10.5 1.6 20.4 New smear-negative/extrapulmonary cases 60.0 18.5 1.5 20.0 Previously treated cases 39.5 11.1 2.5 46.9 MDR-TB cohort 2009 41.2 17.6 5.9 35.3 *Data provided here are based on the latest WHO global TB database accessed on 26 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html. **Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. Major challenges In Estonia transmission of tuberculosis (TB) occurs mainly among certain vulnerable populations, such as alcohol abusers, intravenous drug users and TB/HIV co-infected patients. The country has one of the highest rates of TB/HIV co-infection prevalence in the EU (15%) 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 target of an incidence of 20 per 100 000 new cases, 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; a National TB Programme (NTP) in place with optimal management; -trained staff who provide TB services ; 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 other health services; and a financing system of TB control that 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. 9 • Support for the introduction of a one-stop service for methadone, antiretroviral and TB treatment for co- infected 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 MDR-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 scale up of 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. • Organization of a workshop on MDR-TB and alcohol dependence to present the results of the demonstration project. • The WHO Regional Office for Europe, the Special Programme for Research and Training in Tropical Diseases (TDR) and partners are jointly organizing the first training programme on operational research within the framework of the project “Support for Operational Research and Training IniTiative (SORT IT) in Eastern Europe, 2013-2014”. The SORT IT project intends to help the countries and the Region with evidence which can be used for programme decision making and inform policy recommendations to improve tuberculosis programmes. The workshops for the first SORT IT course will be hosted by the National Institute for Health Development in Tallinn, Estonia, on 6-10 May 2013, 13-17 May 2013, 31 March-4 April 2014 Main partners of WHO • Ministry of Health • Ministry of Social Affairs • Ministry of Justice • Health Board • National Institute for Health Development • Tartu 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) 10 Tuberculosis country work summary Georgia Total population (millions): 4.3 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 0.16 (0.14-0.19) 3.7 (3.2-4.4) Estimates among notified TB cases: Prevalence 6.9 (2.8-13) 159 (65-300) MDR-TB among new cases 340 (300-390) 11 (9.6-12) Incidence 5.4 (4.8-6.1) 125 (111-141) MDR-TB among previously treated 420 (370-460) 32 (28-35) Case detection 84 (75-95)% Notified MDR-TB cases on treatment 612 129** Estimated prevalence of HIV among TB (number, percentage); 80 (58-110), 1.5(1.1-1.9)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up*** (%) New smear-positive pulmonary cases 76.3 2.8 11.5 9.3 New smear-negative/extrapulmonary cases 83.4 2.0 2.1 12.5 Previously treated cases 61.9 5.1 17.5 15.6 MDR-TB cohort 2009 53.7 7.6 6.0 32.8 *Data provided here are based on the latest WHO global TB database accessed on 16 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html **The percentage of notified MDR-TB cases on treatment exceeds 100% because of TB programme backlog. ***Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. Major challenges Georgia is among the 27 high multidrug-resistant (MDR) TB burden countries in the world. The context for TB control is changing as Georgia is fundamentally reforming its health system. The majority of both primary health care facilities and hospitals have been privatized, and insurance coverage has expanded. In 2012, most TB dispensaries were absorbed into private general medical facilities. Some of the responsibilities for the national TB program have been transferred from the National Center for TB and Lung Diseases (NCTBLD) to the National Center for Disease Control and Public Health (NCDC), and currently both centers are partially responsible for TB surveillance, key parts of the TB laboratory network, and the of initiation of TB contact investigations. The different levels of expertise and experience of the current players in TB control and the lack of clarity in the roles and responsibilities of these players cause challenges to and weaknesses in the TB control system, including e.g. delay in sputum transportation to laboratories. Intensive consultations are ongoing to overcome these problems and strengthen TB control at all levels. Further to these health system and institutional reforms, the national clinical practice guidelines and protocols need to be finalized and introduced, as well as a TB monitoring plan to assure accountability of the new TB service providers. One of the major challenges remains MDR-TB and TB/HIV co-infection. TB and HIV control activities are not very well integrated. Analysis of the 2009 cohort of MDR-TB patients showed a high default rate. Georgia has implemented diagnostics for rapid detection of TB and drug resistance, enabling Georgia to identify 63% of the estimated MDR-TB cases among notified TB cases in 2011. However, this suggests that about one third of the MDR-TB cases were not detected and, hence, continues to transmit this drug resistant form of disease. Currently a number of essential TB control functions are largely depending on The Global Fund project and the United States Agency for International Development (USAID) TB Prevention Project, which both end in 2015, after which country has to sustain TB control through domestic resources. 11 Achievements in collaboration with WHO • Assistance with sustaining countrywide universal access to quality diagnosis and treatment of all forms of TB, including M/XDR TB. • Strengthening of the TB laboratory capacity through the EXPAND-TB project since 2010. Within the framework of the project, the Tbilisi and Kutaisi reference laboratories were provided with laboratory equipment and supplies. • Technical revision of the draft National TB Strategic Plan for Georgia for 2013-15. • Technical assistance in completion of The Global Fund Phase II proposal development. • Capacity building through ensuring participation of Georgian specialists in different WHO TB Control related events in 2012 (Joint ECDC/WHO Surveillance Network for TB meeting; National TB Program Managers’ Meeting; Meeting of the European Tuberculosis Laboratory Initiative; Regional Workshop on National Strategic Planning for Tuberculosis Control).Monitoring of treatment of MDR-TB patients and quality of anti- TB drugs through a joint Green Light Committee (GLC)/Global Drug Facility (GDF) mission in June 2012. Planned WHO activities • Support for improving the diagnosis of TB, including M/XDR-TB, through implementation and expansion of rapid diagnostic tools, such as introduction of the Xpert MTB/RIF assay. • Technical assistance to finalize the National TB Strategic Plan for Georgia for 2013-15.Continued monitoring of treatment of MDR-TB patients and quality of anti-TB drugs (next Joint GLC/GDF mission in July 2013). • Capacity building through participation of Georgian specialists in different forthcoming WHO TB-related events. Main partners of WHO • Ministry of Labour, Health and Social Affairs (MoLHSA) • National Center for TB and Lung Diseases (NCTBLD) • National Center for Disease Control and Public Health (NCDC) • The Global Fund to Fight AIDS, Tuberculosis and Malaria • United States Agency for International Development (USAID), through TB Prevention Project • Médecins Sans Frontières France (MSF). 12 Tuberculosis country work summary Kazakhstan Total population (millions): 16.2 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number (thousands) % Mortality 2.2 (2.0-2.5) 14 (11-14) Estimates among notified TB cases: Prevalence 27 (11-51) 167 (68-315) MDR-TB among new cases 3.8 (3.6-3.9) 30 (29-32) Incidence 21 (18-24) 130 (111-148) MDR-TB among previously treated cases 4.5 (4.3-4.6) 51 (50-53) Case detection rate 87 (76-101) % Notified MDR-TB cases on treatment 4.7 63 Estimated prevalence of HIV among TB (number, percentage); 330 (270-390), 1.6 (1.4-1.7)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New smear-positive pulmonary cases 61 3.2 6.7 2.4 New smear-negative/extrapulmonary cases 85 1.4 2.5 1.7 Previously treated cases 47 8.7 4.5 4.8 MDR-TB cohort 2009 73 6.5 7.2 5.3 *Data provided here are based on the latest WHO global TB database accessed on 16 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html **Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. Major challenges Kazakhstan is among the 27 high multidrug-resistant (MDR) TB burden countries in the world. TB control, and especially combating MDR and extensively drug-resistant TB (M/XDR-TB), is a priority in the Health Care Development Programme 2011–2015 and the national budget for TB control has been increased several folds to enable rapid scale up of treatment for MDR-TB patients. Despite these efforts, universal access to treatment is not yet achieved. The country also lacks laboratory capacity for culture, drug susceptibility testing and early diagnosis of MDR-TB cases. Kazakhstan 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. Although Kazakhstan has made progress in recent years, infection control is still suboptimal in many TB-related health care facilities. There is a need to reduce hospitalization of TB patients and improve service delivery at the primary level of health care, while at the same time improving infection control standards and restructuring the financing system. Cross-border TB care for external migrants remains a challenge. Discussions to address this problem have started, but effective coordination with neighbouring countries to ensure cross-border TB control and care has yet to be established. Within the country, continuity of care between the penitentiary system and the community health care service is not fully ensured. Achievements in collaboration with WHO • Technical assistance with the Global Drug Facility (GDF) review of anti-TB drug procurement, October 2011. • Organization of a subregional workshop on laboratory diagnosis of TB, including the Xpert MTB/RIF assay, Almaty, November 2011. • Organization of a subregional workshop on migrants and cross-border TB control and care, Almaty, December 2011. 13 • Upon request of the Minister of Health (MoH) of Kazakhstan, an extensive programme review to TB prevention, control and care was organized on 9-18 May 2012. A team of 15 international experts conducted the country programme review. All technical reports, surveillance data, national reports and epidemiologic data were reviewed and institutes and organizations involved in TB control were visited and their respective staffs interviewed. The review mission was grouped into four teams visiting Almaty city, Almatinski Oblast, Akmolinski Olbast and South Kazakhstan Oblast. The MoH was debriefed on key findings and recommendations shortly after the review and a detailed report was finalized and submitted. • Update and finalization of the National M/XDR-TB Response Plan in line with the Regional M/XDR-TB Action Plan. • Support to development of a national plan on infection control and strengthening of the national programme to implement infection control in TB-related health care facilities. • Organization of a review of infection control recommendations and technical assistance with the development of a national infection control plan. • Assistance with the development of mobile units with the GeneXpert MTB/RIF assay for detection of MDR- TB in remote rural areas and prisons. • Technical assistance with strengthening the laboratory capacity for culture and Xpert MTB/RIF assay testing. Planned WHO activities • Development of a mechanism of coordination to improve subregional cross-border TB control. • Development of guidelines for treatment of TB/HIV co-infection. • Organization of national workshops on infection control, and development of relevant legal background documents that will enable monitoring of infection control measures by the Sanitary Epidemiological Station (SES). • Development of guidelines on palliative care for patients with chronic TB. • Analysis of the impact of social determinants on TB control, and monitoring the impact of the social support package of measures for TB patients, including better treatment compliance. Main partners of WHO • Ministry of Health • United States Agency for International Development (USAID); TB Care • Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) • German Development Bank (KfW) • Abt Associates • Project HOPE • Centers for Disease Control and Prevention (CDC) • KNCV Tuberculosis Foundation • AIDS Foundation East-West • International Federation of Red Cross and Red Crescent Societies (IFRC). 14 Tuberculosis country work summary Kyrgyzstan Total population (millions): 5.4 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 0.67 (0.59-0.76) 12 (11-14) Estimates among notified TB cases: Prevalence 9.4 (3.9-17.0) 174 (72-315) MDR-TB among new cases 970 (830-1.100) 26 (23-31) Incidence 6.9 (5.7-8.2) 128 (106-152) MDR-TB among previously treated 550 (490-620) 52 (45-58) Case detection rate 80 (67-97) % Notified MDR-TB cases on treatment 492 61 Estimated prevalence of HIV among TB (number, percentage); 120 (87-160), 1.7 (1.4-2.2)%. Treatment outcome 2009*** Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New smear-positive pulmonary cases 82.4 3.3 4.1 10.1 New smear-negative/extrapulmonary cases 91.7 1.4 0.5 6.4 Previously treated cases 70.9 7.3 5.6 16.2 MDR-TB cohort 2009 35.4 9.7 8.8 46.1 *Data provided here are based on the latest WHO global TB database accessed on 16 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html **Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. ***Treatment outcomes represent data from 2009 cohorts, since no data was reported for 2010 cohorts. Major challenges Kyrgyzstan is among the 27 high multidrug-resistant (MDR) TB burden countries in the world. Currently the main sources of infection transmission in the community are undefined TB cases including late diagnosis and those being diagnosed as having MDR-TB, but not being treated due to current constraints in second line TB Drugs. In addition, a poor infection control (IC) measures within the health care facilities add to the burden of disease transmission. This is especially of concern in the hospital sector as duration of hospitalization is long and IC measures are poor, increasing the chance of re-infections. Similarly, there are IC concerns at primary health care (PHC) facilities: as integration of TB services poses additional requirement of airborne IC, to create a safe environment for all service providers as well as patients. 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. Epidemiological data is insufficiently analyzed, and there is weak coordination of TB data management at institutions within the Ministry of Health (MoH) and other agencies. There is also insufficient support for directly observed therapy (DOT) at PHC 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. Adherence to MDR-TB treatment is a challenge, and monitoring and evaluation of drug-resistant TB cases needs to be improved. Due to an inefficient drug management system, some of the second line drugs have been running out and were replaced by other second line drugs. First and second line anti-TB drugs are available over-the- counter in pharmacies and this fuels non-compliance to the guidelines of the National TB Programme (NTP) by health providers and patients and leads to further amplification of the drug resistance epidemic in the country. The access to TB laboratory testing in the Kyrgyzstan is limited, and this is the main reason for the low TB case detection rate (66%) and even lower culture and drug susceptibility testing coverage (25%). In the Kyrgyzstan, TB REACH, Médecins Sans Frontières (MSF) and the Quality Health Care Project currently implement Xpert MTB/RIF using different strategies and approaches. Within the implementation of Xpert MTB/RIF for patient diagnosis, the NTP has faced challenges related to changes in screening and diagnostic algorithms, shifts in laboratory organization and workload, and requirements for increased supply-chain management. The interim diagnostic algorithm is adapted to country needs and is based on WHO recommendations. 15 A substantial financial gap exists for effective TB control, 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. Achievements in collaboration with WHO • Technical assistance to the NTP in preparation of a new TB Strategy Plan for 2012–2016. • Technical assistance to develop a TB Infection Control Strategy with an accompanying action plan. • TB guidelines and clinical protocols have been developed to ensure effective and qualitative TB prevention, diagnosis, treatment and care on pediatric TB management, MDR-TB, out-patient management of TB, and TB infection control. • Support to implementation of the Xpert MTB/RIF assay for simultaneous detection of TB and rifampicin resistance. • Technical assistance to finalize the National M/XDR-TB Response Plan in line it with the Regional M/XDR- TB Action Plan, which has been approved by the MoH in February 2013. • Upon request of the Minister of Health of Kyrgyzstan, an evaluation of various aspects of the tuberculosis control programme was conducted in December 2012 and January 2013. The aspects evaluated included the use of rapid molecular diagnostics for tuberculosis, tuberculosis surveillance, TB and M/XDR-TB treatment and care, and governance and management of national TB control programme. At the end of the mission the Minister of Health was debriefed on the findings and recommendations of the evaluation team. Planned WHO activities • Collaboration on the implementation of an integrated electronic surveillance system. • Technical assistance to enable and promote operational research. • Technical support for strengthening the governance and the capacity of NTP management. • Technical assistance to evaluate the implementation of Xpert MTB/RIF in the country and to assess the needs for expansion of the Xpert MTB/RIF technology and development of the laboratory network to ensure early diagnosis of TB and MDR-TB. • Technical assistance to assess the current systems for TB epidemiological surveillance, monitoring of program performance, field supervision and identification of gaps in the performance of the epidemiological reporting system and provision of recommendations to MoH and NTP. • Ongoing monitoring of treatment of MDR-TB patients and ensuring provision of quality-assured MDR-TB treatment through Green Light Committee (GLC)/Europe and Global Drug Facility (GDF) missions (mission in March 2013). Main partners of WHO • Ministry of Health • Association of Phthisiologists • German Development Bank (KfW) • Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) • Grant Management Solution Project • International Committee of the Red Cross (ICRC) • KNCV Tuberculosis Foundation • Médecins Sans Frontières (MSF) • Project HOPE • United Nations Development Programme (UNDP) • United States Agency for International Development (USAID). 16 Tuberculosis country work summary Romania Total population (millions): 21.4 High TB priority country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 1.3 (1.3–1.3) 6 (6–6) Estimates among notified TB cases: Prevalence 31 (13–56) 145 (61–261) MDR-TB among new cases 340 (220–500) 2.8 (1.8-4.2) Incidence 22 (18–26) 103 (84–121) MDR-TB among previously treated cases 510 (380–680) 11 (8-15) Case detection rate 74 (65-94)% Notified MDR-TB cases on treatment 485 92 Estimated prevalence of HIV among TB (number, percentage); 350 (240-490), 1.6 (1.2-2.2)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New smear-positive pulmonary cases 83.8 4.7 4.0 7.5 New smear-negative/extrapulmonary cases 84.8 7.8 0.3 7.0 Previously treated cases 54.6 11.1 11.8 22.5 MDR-TB cohort 2009 16.3 17.0 36.5 30.1 *Data provided here are based on the latest WHO global TB database accessed on 16 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html **Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. Major challenges Political commitment in Romania has been renewed recently to strengthen the National Tuberculosis Programme (NTP), but various bottlenecks need to be addressed in order to strengthen the capacity of the programme. Bottlenecks being addressed include: a weak laboratory network structure and limited availability of culture on liquid media and rapid tests for anti-tuberculosis (TB) drug resistance; performance of the drug susceptibility test for only 50% of reported TB cases; inadequate treatment regimens for multidrug-resistant (MDR) TB patients; inadequate infection control measures in TB facilities; decentralized drug procurement for first and second line anti-TB drugs; inadequate provision of directly observed therapy (DOT) and absence of social support; an outdated recording and reporting system; and an NTP central management team that lacks a clear mandate. Achievements in collaboration with WHO • Finalization and approval of the National MDR-TB Strategic Plan, 2011–2015. • Technical assistance to 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 in April 2012. • A high-level visit by the WHO/Europe Regional Director and the European Commissioner for Health and Consumer Policy, who met with the Prime Minister and the Minister of Health on 4 October 2012. • Assistance with the successful application to the Transitional Funding Mechanism (TFM) and the Bridge Funding Mechanism of The Global Fund to Fight AIDS, TB and Malaria (The Global Fund). • Assistance to the Ministry of Health with establishment and initiation of a centralised procurement system for key areas including procurement of medicines for TB and HIV programmes. • Evaluation of the use of BCG vaccination which resulted in WHO´s support to the decision of the Ministry of Health to continue with BCG vaccination of newborns. 17 Planned WHO activities • Organization of an expert mission on drug supply and management, NTP governance, national MDR-TB clinical guidelines, infection control, laboratory network, and monitoring and evaluation. • Technical assistance to the finalization of two strategic documents: the mid-term National TB Strategy and the Infection Control Strategic Plan. • Technical assistance to develop a protocol for a nationwide anti-TB drug resistance survey. • Training on anti-TB drugs management. • Continued technical support to implement The Global Fund project. Main partners • Ministry of Health • National Public Health Institute • National Health Insurance House • National Institute for Lung Diseases “Marius Nasta” where the NTP is located • The Global Fund to Fight AIDS, TB and Malaria (The Global Fund) • Centre for Health Policies and Services – a nongovernmental organization (NGO) active in public health and implementing The Global Fund supported projects • Romanian Angel Appeal (NGO), the Principal Recipient for The Global FundFund • Salvati Copiii – NGO active in child rights and implementing The Global Fund supported projects • Romanian Red Cross – implementing The Global Fund supported projects • Association of TB patients • European Centre for Disease Prevention and Control. 18 Tuberculosis country work summary Russian Federation Total population (millions): 142.8 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number (thousands) % Mortality 22 (22-23) 15 (15-16) Estimates among notified TB cases: Prevalence 180 (72-330) 126 (50-231) MDR-TB among new cases 19 (17-21) 20 (18-22) Incidence 140 (120-160) 98 (84-112) MDR-TB among previously treated cases 25 (23-29) 46 (41-52) Case detection rate 81 (71-94) % Notified MDR-TB cases on treatment 18.9 137*** Estimated prevalence of HIV among TB (number, percentage); 9 300 (7 400-11 000), 6.7 (5.7-7.7)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New laboratory confirmed pulmonary cases 53.1 11.7 23.1 12.1 New laboratory unconfirmed/extrapulmonary cases 72.7 4.5 9.3 13.5 Previously treated cases 34.1 12.0 33.4 20.5 MDR-TB cohort 2008**** 50.9 8.1 14.1 26.9 *Data provided here are based on the latest WHO global TB database accessed on 28 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html **Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. ***The percentage of notified MDR-TB cases on treatment exceeds 100% because of TB programme backlog. ****Treatment outcomes of the MDR-TB cohort represent data from 2008, since no data was reported for the 2009 cohort. Major challenges The Russian Federation is among the 27 high multidrug-resistant tuberculosis (MDR-TB) burden countries in the world. Despite rapid scale up of diagnostic and treatment coverage, there are challenges in TB and M/XDR- TB control in the country. The national TB control strategy is following WHO recommendations for TB control but treatment practices do not always follow international standards and infection control measures in some of the health care facilities are inadequate. The management of anti-TB drugs and the monitoring of anti-TB drug supplies needs to be strengthened to avoid stock-outs of quality assured drugs. Nation-wide data on drug resistance is lacking and a national drug resistance survey is needed. The TB laboratory network needs strengthening for rapid and quality assured diagnosis of TB and MDR-TB. It is also in need of coordination and standardization through designation of a national reference laboratory by the Ministry of Health. TB/HIV co-infection is increasing, which requires intensified collaboration and joint action by the HIV and TB control programmes. In addition, there is a challenge of aging and retiring of specialist staff for the diagnosis, treatment and care of TB patients. Achievements in collaboration with WHO • Support to the development of a draft National M/XDR-TB Response Plan. • The development of the national TB control strategy was supported through the mechanism of the High- Level Working Group (HLWG) and its Thematic working groups. • Technical support was provided to introduce rapid methods of TB laboratory diagnosis, strengthening of the laboratory network and establishment of a national reference laboratory. • Experts of the National TB Programme (NTP) developed new concepts on TB chemotherapy and TB laboratories, incorporating WHO recommendations on TB treatment and promotion of rapid methods for TB diagnostics. • Comprehensive training courses on MDR-TB management and TB laboratory diagnostics for postgraduate medical education were developed by the NTP in collaboration with partners and with technical advice from WHO. • Development of National guidelines for drug-resistant TB surveillance and supported the work plan development for the nationwide drug resistance survey 19 • Development of the new draft order on TB surveillance and monitoring, including surveillance and monitoring of M/XDR-TB. • National guidelines on infection control in TB control settings have been finalised and prepared for publication. • The annual Analytical Review on TB in Russia for 2010 was published both in Russian and in English, and the new Review was developed for 2011 in collaboration with the Ministry of Health and leading NTP experts. • Training Centres of the WHO Collaborating Center (Central TB Research Institute) in Moscow continued efforts to develop human resources for MDR-TB control through training courses on MDR-TB management (Orel) and Infection Control (Vladimir) • The regulatory documents on TB/HIV care were reviewed to define the areas for further technical support by WHO • A comprehensive advocacy, communication and social mobilization (ACSM) campaign devoted to World TB Day was organized. • WHO facilitated effective collaboration and coordination of national and international partners involved in TB control. • The two WHO collaborating centres on TB control (Central TB Research Institute in Moscow and Novosibirsk TB Research Institute) continued to actively support implementation of the Stop TB Strategy. Planned WHO activities • Technical support to finalize the National M/XDR-TB Response Plan in line with the Regional M/XDR-TB Action Plan. • Technical support to strengthen the national health system for effective TB control through activities of the High Level Working Group and Thematic Working Groups lead by the Ministry of Health in collaboration with the NTP. • Technical assistance to improve the TB/MDR-TB surveillance and monitoring system to ensure complete reporting to the Global TB Report and annual analysis of the TB control situation in the country. • Technical assistance for development and implementation of national guidelines for DR TB surveillance • Advocacy and promotion of WHO endorsed rapid methods for the laboratory diagnosis of TB and MDR-TB. • Technical assistance to the WHO Collaborating Centers for TB and MDR-TB Training in Moscow and Novosibirsk to strengthen the human resource capacity for MDR-TB control • Coordination of international partners involved in TB control activities in the Russian Federation. • Dissemination of the best practices and experiences to other countries of the WHO European Region. Main partners of WHO • Ministry of Health and Social Development of the Russian Federation • National TB Programme, including: - Chief TB specialist of the Ministry of Health and Social Development, St. Petersburg Research Institute of Phthisiopulmonology - Research Institute of Phthisiopulmonology, 1st Moscow State Medical University named after I. M. Sechenov - Central TB Research Institute, Russian Academy of Medical Sciences - Novosibirsk Research Institute of Phthisiopulmonology - Ural Research Institute of Phthisiopulmonology • Federal Correctional Service of the Ministry of Justice of the Russian Federation • Central Research Institute of Public Health Organization and Informatization • Federal System for External Quality Assurance • Russian Red Cross Society • Partners in Health • Finnish Lung Health Association (Filha) • Norwegian Heart and Lung Patient Organization (LHL) • International Organization for Migration (IOM) • International Union Against Tuberculosis and Lung Disease (The Union) • Medecins Sans Frontieres (MSF), The Netherlands • Eli Lilly MDR-TB Partnership • The World Bank • Koch-Metschnikov Forum 20 Tuberculosis country work summary Tajikistan Total population (millions): 7.0 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number % Mortality 1.1 (0.76– 1.5) 16 (11-21) Estimates among notified TB cases: Prevalence 24 (12-41) 344 (172-588) MDR-TB among new cases 540 (420-670) 13 (9.8-16) Incidence 13 (11-16) 186 (158-229) MDR-TB among previously treated cases 500 (450-550) 54 (48-59) Case detection rate 48 (39-57) % Notified MDR-TB cases on treatment 376 62 Estimated prevalence of HIV among TB (number; percentage); 250 (190-320) , 1.8 (1.5-2.2)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New smear-positive pulmonary cases 80.1 4.8 10.7 1.3 New smear-negative/extrapulmonary cases 89.9 3.5 1.4 5.2 Previously treated cases 71.8 10.9 11.4 5.9 MDR-TB cohort 2009 71.2 13.5 11.5 3.8 *Data provided here are based on the latest WHO global TB database accessed on 16 November2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html **Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. 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 there are 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. Moreover, 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 to Fight AIDS, Tuberculosis and Malaria (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 was provided to the NTP in the development of a successful proposal to The Global Fund through the transitional funding mechanism which enabled the country to continuous provision of quality assured drugs for treatment of MDR-TB and strengthening of the TB laboratory system. • The pilot phase of the implementation of an electronic recording and reporting system for MDR-TB was completed and, based on the results of this pilot project, the country started step by step expansion of this open medical record system (Open MRS). In parallel, the module for electronic recording and reporting system of susceptible TB was developed and incorporated in the existing system. The pilot phase of the implementation of the system for all TB cases started. The work is done in partnership with the NTP, the United Nations Development Programme (UNDP) and the International Research & Development Organisation (IRDO). • Technical assistance to the implementation of the practical approach to lung health (PAL) continued. Together with the Quality Health Care Project and other partners, consultative assistance was provided to the national working group on the development of PAL clinical protocols and training materials on PAL and, in addition, two trainings on PAL for primary health care personnel of pilot districts were conducted. 21 • Annual monitoring and gradual expansion of treatment of MDR-TB patients through the Green Light Committee (GLC)/Europe. • Operational research comparing hospitalization with ambulatory TB treatment outcomes has been finished and the research report with recommendations has been developed and presented to partners. • In this second year of strengthening the TB laboratory capacity in the country within the framework of the EXPAND-TB project, laboratory equipments and reagents were supplied to the National Reference Laboratory. • A memorandum of understanding and cooperation between the UNDP, the Ministry of Health, the WHO Tajikistan Country Office and the Supranational Reference Laboratory for TB in Gauting Germany, was signed. This memorandum supports the collaboration between these partners till the end of 2012 in strengthening the public health laboratory services in the country including TB laboratories and establishment of the National Public Health Reference Laboratory (NPHRL). • A National Operational Plan on TB Infection Control was developed through support by the TB Technical Assistance Mechanism (TBTEAM). This plan is for five years and includes a budget and monitoring and evaluation plan. • The National M/XDR-TB Response Plan, in line with the Regional M/XDR-TB Action Plan, was finalized and endorsed by the Ministry of Health. Planned WHO activities • Mid term review of the National TB Program. • Ongoing monitoring of treatment of MDR-TB patients and ensuring treatment with quality assured TB medicines with the support of the GLC/Europe and Global Drug Facility (GDF) mechanisms. • If funding permits, technical assistance to address TB through health systems strengthening and primary health care. • Technical support to implementation of the TB electronic database management system. • If funding permits, continuation of capacity building for TB Control. • High level advocacy of TB issues through the Country Coordination Mechanism (CCM). • Fund raising and follow-up with national and international TB stakeholders to implement the National TB Infection Control Action Plan. Main partners of WHO • Ministry of Health • Ministry of Justice, department of correctional affairs • 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 and TB Care 1 Project • International Research & Development Organisation (IRDO) • German Development Bank (KfW) • Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) • AIDS Foundation East-West • Red Crescent Society of Tajikistan • Caritas Luxemburg • Aga Khan Foundation • Finnish Lung Health Association (Filha). 22 Tuberculosis country work summary Ukraine Total population (millions): 45.2 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number (thousands) % Mortality 8.1 (7.8-8.3) 18 (17-18) Estimates among notified TB cases: Prevalence 47 (21-84) 104 (46-186) MDR-TB among new cases 4.4 (3.8-5.1) 16 (14-18) Incidence 40 (33-47) 89 (73-104) MDR-TB among previously treated cases 5.1 (4.6-5.6) 44 (40-49) Case detection rate 86 (73-104)% Notified MDR-TB cases on treatment 3.8 89 Estimated prevalence of HIV among TB (number, percentage); 8 100 (6 700-9 600), 20 (20-21)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New smear-positive pulmonary cases 59.8 12.5 16.7 11.0 New smear-negative/extrapulmonary cases 76.2 7.0 5.9 10.9 Previously treated cases 46.3 14.1 22.8 16.7 MDR-TB cohort 2009 27.5 31.2 9.3 32.0 *Data provided here are based on the latest WHO global TB database accessed on 16 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html **Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. 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 • Technical assistance for the implementation of The Global Fund to Fight AIDS, TB and Malaria (The Global Fund) Round 9 TB grant was provided on laboratory, programmatic management of drug resistant TB, TB/HIV, monitoring and evaluation, and advocacy, communication and social mobilization (ACSM). • A comprehensive assessment of the TB programme activities in Donetsk Oblast took place in January- February 2012 in collaboration with WHO experts. • Technical assistance was provided to develop the new TB programme plan 2012-2016 for Donetsk. • A National M/XDR-TB Response Plan was developed with Green Light Committee (GLC)/Europe mission support in April 2012. • A GLC/Europe and Global Drug Facility (GDF) joint mission was organized in August 2012 to provide a gap analysis in connection with the preparation of the proposal for the second implementation phase of The Global Fund Round 9 project. • Additional assistance was provided to the preparation of The Global Fund Round 9 second phase project proposal. 23 • From 18-20 October 2012, technical assistance was provided to revise the draft National TB Programme 2012-2016 (for final approval by the President of Ukraine). • From 21-26 October 2012, technical assistance was provided to design the governance of the National TB Programme based on the newly-established “Center for Control of Socially Dangerous Diseases”. • In October 2012, technical assistance was provided for the development of an oblast TB subaccount in Donetsk as first step for documenting inpatient and outpatient costs. • The protocol for a countrywide anti-TB drug resistant survey was finalized. • TB treatment guidelines and MDR-TB recording and reporting forms were developed in collaboration with the Ministry of Health and other national and international partners. • Research was conducted on TB advocacy communication and social mobilization (ACSM) in Donetsk Oblast. Planned WHO activities • Technical assistance with the implementation of The 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. • Support in Health System Strengthening. Main partners of WHO • Ministry of Health • State Services on HIV/AIDS and other socially dangerous diseases • Ukrainian Center for Control of Socially Dangerous Diseases of the Ministry of Health of Ukraine. • State Penitentiary Services • National Yanovsky TB and Pulmonology Institute • Rinat Akhmetov Foundation “Development of Ukraine” • United States Agency for International Development (USAID) • Strengthening Tuberculosis Control in Ukraine Project (Chemonics) • 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) • 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. 24 Tuberculosis country work summary Uzbekistan Total population (millions): 27.8 High TB priority country High MDR-TB burden country Epidemiological profile 2011* Estimates of TB burden Number (thousands) Rate (per 100 000) MDR-TB burden Number (thousands) % Mortality 1.7 (1.4 -2.0) 6.1 (5.0-7.2) Estimates among notified TB cases: Prevalence 49 (24-84) 177 (86-303) MDR-TB among new cases 2.4 (1.8-3.0) 23 (18-29) Incidence 28 (23-33) 101 (83-119) MDR-TB among previously treated cases 0.67(0.56-0.76) 62 (52-71) Case detection rate 52 (44-63)% MDR-TB cases on treatment 0.855 62 Estimated prevalence of HIV among TB (number, percentage); 960 (780-1 200), 3.4 (3.2-3.7)%. Treatment outcome 2010 Successfully treated (%) Died (%) Failed (%) Lost to follow up** (%) New smear-positive cases 81.1 5.8 5.9 7.3 New smear-negative/extrapulmonary cases 88.2 3.2 0.7 7.9 Previously treated cases 72.5 10.1 5.0 12.3 MDR-TB cohort 2009 61.4 9.3 10.8 18.5 *Data provided here are based on the latest WHO global TB database accessed on 16 November 2012. Extended epidemiological profiles can be found at: http://www.who.int/tb/country/data/profiles/en/index.html **Includes those cases that defaulted from treatment, those that were transferred out and those that were not evaluated. Major challenges Uzbekistan is among the 27 high multidrug-resistant tuberculosis (MDR-TB) burden countries in the world. The increasing MDR-TB rates underline the need for improved diagnosis of TB, better patient and drug management, and infection control measures in line with international standards. The management of anti-TB drugs is suboptimal and as a consequence, anti- TB drugs can be obtained without a doctor’s prescription. In addition, second line anti-TB drugs are not available throughout the whole country. Case management of children with TB, including dosages of anti-TB drugs, and duration of treatment and hospitalization of children with TB, need to be revised and updated. To increase the country’s diagnostic capacity, rapid diagnostics for detection of MDR-TB are being implemented and four new culture laboratories have been established. However, the staff in these new culture laboratories is insufficiently trained and expansion and training is needed for the new diagnostics. Case detection rates are low and primary health care needs to be improved to increase these rates. The measures to prevent nosocomial transmission of TB need to be intensified and the recording and reporting system should be optimized in order to prevent double reporting and better serve surveillance. The country lacks coordination with neighbouring countries to ensure cross-border TB control and care. Within country coordination of activities between the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), the DOTS centre and the National Tuberculosis Programme (NTP) also needs to be strengthened. The Karakalpakstan region has increased rates of TB morbidity, including MDR-TB and mortality rates, and this region therefore needs additional support to strengthen TB control. Achievements in collaboration with WHO • A nationwide anti-TB drug resistance survey coordinated by WHO was carried out in 2010-2011 and finalized in 2012. • An extensive review of the NTP was carried out and formed the basis of the approval of the governmental programme on TB control for the period 2010–2015. • WHO provided technical 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 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. • The National M/XDR-TB plan was developed and submitted to the Ministry of Health (MoH). • The strategy for the implementation of the Xpert MTB/RIF technology, including a diagnostic algorithm, is finalized by the national working group. • The National Guideline on Infection Control was developed and submitted to MoH for approval. 25 • A joint WHO and United States Agency for International Development (USAID) mission took place in October, 2012, to discuss and share the new WHO/USAID “TB Partnership project” with relevant partners from the MoH, the NTP, and other partners working in the field of TB in Uzbekistan. • In December 2012, a mission was organized to support the development of a National Strategy on TB Laboratory Development, in collaboration with the Supranational Reference Laboratory in Gauting, Germany. • The following educational activities were organized: - On 21-25 August 2012, a training of trainers on the implementation of the PAL strategy was held in Nukus for group of trainers from Karakalpakstan. - A workshop on consensus building for staff of the medical department of the prison sector and the NTP was held on 18-20 September 2012. The main objective was to increase political commitment to (MDR-) TB control in prisons and strengthen coordination and collaboration between prison and civil TB services. - A national workshop on infection control at was conducted on 23-25 July, 2012. - In July 2012 and December 2012, national workshops were provided to support the implementation of a rapid test for the diagnosis of MDR-TB (the Xpert MTB/RIF assay). Planned WHO activities for 2013 In line with the WHO/USAID “Partnership Project for TB Control” the following activities are planned: • Establishment of a committee to coordinate TB control activities among prisoners, migrants and children, including technical support to routine intersectoral meetings of this committee on all TB issues, as well as on M/XDR-TB issues. • Development of a National TB Laboratory Plan. • Technical support to revise the national guidelines for drug-resistant TB management. • Technical support to develop a policy for TB control in the prison sector,, as well as a needs assessment and development of a training program for the prison sector. • Organization of the annual National TB conference. • Technical support to develop a set of monitoring and evaluation tools for TB control activities on site and to elaborate national standards and criteria for regular evaluation of data quality. • Technical assistance to roll out the e-TB manager software in 11 regions and development of a program for on site training. • Interactive training material on e-TB Manager will be developed to increase the countrywide capacity on the use of this software. The training will be web-based or supported by electronic data carriers and will be followed by on-the-job training of TB service staff. Under coordination of WHO CO supervision visits will be conducted by the NTP Central Unit team to 14 oblast centers and selected districts within the oblasts: twice a year to follow up expansion of MDR-TB case management countrywide, implementation of Infection Control measures, implementation of e-TB manger and reporting and recording system. • Technical support to the working group on infection control to develop an implementation plan for adequate infection control in TB facilities at the national level. • Technical assistance to the Working Group on Advocacy Communication and Social Mobilization (ACSM). • Analytical review of available guidelines and regulatory documents on pediatric TB management and revision of these documents in line with the most recent WHO recommendations. • Information materials on TB for the general population and for TB patients will be printed. Within the framework of the WHO/TB CARE I project the following activities are planned: • Organization of working meetings for the development of a psycho-social patient support model. • Organization of technical assistance and a round table discussion on the development of a national protocol on outpatient care. • Development and printing of informational materials on TB for prisoners and ex-prisoners. • Procurement of infection control measurement equipment to be used in both the civil and prison sectors. • Printing of the approved infection control guideline. Main partners of WHO • Ministry of Health of the Republic of Uzbekistan • Ministry of Interior • Multisectoral Expert Council for HIV, tuberculosis and malaria control • National tuberculosis Programme (NTP) • United States Agency for International Development (USAID); • Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) • German Development Bank (KfW) • Médecins Sans Frontières (MSF) • Project HOPE (funded by USAID) • Other United Nations agencies (United Nations Development Programme (UNDP), United Nations Volunteers (UNV), United Nations Trust Fund For Human Security (UNTFHS)). 26 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Review of the National Tuberculosis Programme in the Republic of Moldova 4–15 February 2013 World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: contact@euro.who.int Website: www.euro.who.int WHO/EURO:2013-8884-48656-72249