WORLD
HEALTH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION
Elizabeth Rose Hall, 5th Floor United Nations University, UN House Tokyo, Japan 22-24 July 2008
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LO CA TIO N MA P OF (1) TOKYO PRINC
E HO TEL & (2) TH E PRINCE PAR K TO WE R TO KY
O
PRINCE PARK TOWER TOKYO 4-8-1 SHIBAKOEN MINATO-KU TOKYO 105-8563 JAPAN
Tel: 81-3-5400-111 1 Location: Central 55 kms to the airport (narita) 13 kms to the airport (haneda) 2 minute walk to the nearest metro station (akabanebash i(oedo line)) 1 km to the nearest station (jr hamamatsu-ch o station) · 2 minute walk to the nearest bus stop 1 km to the nearest fair site (tokyo international forum) Located in the heart of the city and adjacent to Shiba Park. Well-known landmarks close by include Tokyo Tower and the famous Zojo-ji temple. The hotel is well serviced by subway, the closest stations being the Akabane Bashi Station on the Oedo line, or Shibakoen Station on the Mita line. Hamamatsu-ch o station on the Yamanote line is just a 12 minute walk away, and allows easy access via Monorail to Haneda Airport.
Japan travel information General information for the traveller new to Japan. Visas Visitors to Japan must be in possession of a passport valid for 6 months beyond arrival in the country, with at least one empty page for the visa stamp and a return or onward travel ticket. Some nationalities are entitled to a visa free stay. Anyone not entitled to this must apply for a visa prior to arrival and this can be done through ? Japanese Embassy or Consulate abroad. It is advisable to confirm all current visa information. Tourists who remain in the country for longer than 90 days are required to apply for an Alien Registration Card from the municipal office in the town where they are residing. Should they change their residence, they must re-register within 14 days. Customs The only restriction relating to money is with regards to exporting local currency. The maximum amount that can be taken out of the country is Smillion. Visitors may take the following into Japan duty free: • • Alcohol - 3 bottles (760ml each) of wine or spirits TuiJcccu - 200 cigarettes, 250 grams of tobacco or !:>0 cigars
Penalties for carrying or trafficking illegal drugs are extremely severe. Time Japanese time: GMT
+ 9 hours
Currency Yen ()-Check current exchange rates Notes issued: 10,000, 5,000, 1,000 Coins issued: 500, 100, 50, 10, 5, 1 Language The national language is Japanese. Some English is spoken to varying degrees in major cities. Tipping A 3% consumer tax is levied in respect of restaurant bills exceeding 5,000 and hotel bills over 10,000. Many restaurants and hotels also add 10-20% service charge. Other forms of tipping are not customary. Banking Hours Monday to Friday 9.00 am to 3.00 pm Telephone The international dialling code for Japan is 81 When making international calls from Japan, first dial telephone number Local Telephone Codes Fukuoka Hiroshima Kawasaki Kobe Kyoto Nagasaki Nagoya Narita Okinawa Osaka Sapporo Sendai Tokyo Yokohama Yokosuka 092 082 044 078 075 0958 052 0476 098 06 011 022 03 045 0468
ooi + country code + area code +
Electricity 100 Volt AC (50 cycles) Flat two-pin plugs are used in Japan and it is advisable to carry a plug adapter set. Water Tap water is safe to drink. Health Medical facililie~ 111 JC:Ipan are of a high standard but services are expensive and adequate health insurance covering evacuation is advisable. It is always best to check the current situation and any vaccination requirements with your doctor when planning your trip.
International Airports
•
•
•
• • • • • •
Fukuoka Kyushu - Kagoshima Nagaski Nagoya New Tokyo - Narita Niigata Okinawa - Naha Osaka - Kansai Sapporo
International Airport Departure Tax 2040 at Narita Airport 2650 at Kansai Airport 945 at Fukuoka Airport All other international airports do not charge a departure tax
PROVISIONAL TIMET ABLE SIXTH STOP TB TECHNICAL ADVISORY GROUP MEETING FOR THE WESTERN PACIFIC REGION
WPR/2008/DCC/06/STB(4)/2008/l(b)
22 - 24 July 2008, Tokyo, Japan Time 09:00 09:30 09:50 Tuesday, 22 July Time 09:30 Wednesday, 23 July Time 09:30 Tht:rsday, 24 July
Registration Opening ceremony
(12) Report on the Regional laboratory consultation meeting (13) Global TB laboratory initiative (14) Laboratory capacity in the Western Pacific Region (15) Laboratory perspectives and discussion
09:40
(I) Meeting objectives 10:00 10:10
09:50 10:10
10:30
( 17) Summary of coun!ry plans -Accelerating the implementaticn of the Regional Strategic Plan (18) Feedback from ICC meeting (19) Response to feedtack - Country perspec:ive - Donor perspectiwe (20) Technical assistan.:::e from a country and regional perspecti•e COFFEE I TEA BREAK
10:00 11:00 11:20 11:40
PHOTO- COFFEE/TEA BREAK
11:00
COFFEE I TEA BREAK
11:00 11:30
(2) Global TB control & MDRIXDR response plan (3) Stop TB Partnership: Progress and perspectives (4) Current situation & future perspective - TB control in the Western Pacific Region - HIVIAIDS: Towards universal access (5) Discussion LUNCH BREAK 13:00 11:30 12:00 12:30
(16) Country action plans 2008-2010, focusing on TB-HIV, MDR and laboratories -Cambodia -China -Lao PDR
(21) Conclusions and
r·~commendations
12:15
Closing
12:15 13:00 14:00 14:30 15:00
LUNCH
BREAK
12:30
LUl'-CH
BREAK
(6) Revised regional TB-HIV framework (7) Discussion (8) MDR-TB implementation: -Mongolia - Philippines -China COFFEE I TEA BREAK 14:00 14:30 15:00 15:30 16:00
Country plans (cont'd.) -Malaysia -Mongolia - Papua New Guinea - Philippines -VietNam
16:30 17:00 18:00
16:30 17:00
COFFEE I TEA BREAK
(9) Discussion on MDR-TB Inter-agency Coordinating Committee (ICC) Meeting (10) Urban TB- Introduction -Urban TB in Japan - Urban TB in the Philippines 19:00
18:30 19:00
(11) Discussion on Urban TB Cocktails
Meeting of TAG Members
Secretariat meeting
WORLD
HEALTH
ORGANISATION MONDIALE DE LA SANTE
ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION Tokyo, Japan 22-24 July 2008
WPR/2008/DCC/06/STB(4)/2008/1 (a) 8 July 2008
ENGLISH ONLY
PROGRAMME OF ACTIVITIES Tuesday, 22 July 2008 09:00-09:30 Registration (Reception area, 2nd Floor, UN House)
Presenter
Meeting venue: (Elizabeth Rose Hall, 5th Floor, UN House)
09:30- 09:50
Opening ceremony • • • Speech of the Regional Director Introduction of participants Election of officers Dr P. van Maaren
09:50-10:00 10:00- 11 :00 11:00-11:20
(1) Meeting objectives
Group photo I Coffee/tea break (1 hour) (2) Global TB control, global MDRIXDR response plan (3) Stop TB Partnership: Progress and perspectives (4) Current situation and future perspective • • TB Control in the Western Pacific Region HIV/AIDS: Towards universal access Dr P. Glaziou Dr M Ghidinelli
Dr L. Blanc DrM Espinal
11 :20 - 11 :40 11:40-12:15
12:15-13:00 13:00- 14:00
(5) Discussion (Chair) Lunch (1 hour)
WPR/2008/DCC/06/STB(4)/2008.1(a) Page2
14:00- 14:30 14:30-15:00 15:00-16:30
(6) Revised regional TB-HN framework (7) Discussion
DrK. Osuga Chairperson
(8) MDR-TB implementation (30 minutes each) • • • Mongolia Philippines China
16:30- 17:00 17:00- 18:00 18:00- 18:30
Coffee/tea break (30 minutes) (9) Discussion on MDR-TB (10) Urban TB
• • • 18:30- 19:00
Introduction Urban TB in Japan Urban TB in the Philippines
(11) Discussion on Urban TB
19:00
Cocktails (Reception Hall,
2nd
Floor, UN House)
Wednesday, 23 July 2008 09:30-09:40 (12) Report on Regional laboratory consultation meeting (13) Global TB Laboratory initiative
DrM Ota Dr l Onozaki Dr P. Glaziou
09:40 - 10:00 10:00-10:10
(14) Laboratory capacity in the Western Pacific Region ( 15) Laboratory perspectives
10:10- 11:00 11:00-11:30
DrK. MKam
Coffee/tea break (30 minutes) (16) Country action plans 2008-2010, focusing on TB-HN, MDR and laboratories
DrK. Osuga
11:30-12:00 12:00- 12:30 12:30- 13:00 13:00- 14:00
• • •
Cambodia China Lao PDR
Lunch (1 hour)
WPR/2008/DCC/06/STB(4)/2008.1(a) Page3
Country plans (continued)
14:00- 14:30 14:30- 15:00 15:00-15:30 15:30- 16:00 16:00- 16:30 16:30-17:00 17:00- 19:00 19:00
• •
Malaysia Mongolia
•- Papua New Guinea • • Philippines VietNam
Coffee/tea break (30 minutes) Inter-agency Coordinating Committee (ICC) Meeting • • Meeting of TAG Members Secretariat Meeting
Thursday, 24 July 2008
09:30- 09:50 09:50-10:10 10:10-10:30
( 17) Summary of country plans - Accelerating the implementation of the Regional Strategic Plan (18) Feedback from the ICC Meeting
DrK. Cain
Japan
( 19) Response to feedback - Country perspective - Donor perspective
10:30-11:00
(20) Technical assistance from a country and regional perspective Coffee/tea break (1 hour) Conclusions and recommendations
Dr L. Blanc MrB. Tomas
11:00- 11:30 11:30-12:15
Dr J Broekmans Dr P. van Maaren
12:15-12:30 12:30
Closing Lunch
WORLD
HEALTH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL O,.,.IC!! FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION Tokyo, Japan 22-24 July 2008
WPR/2008/DCC/06/STB(4)/2008/1 8 July 2008
ENGLISH ONLY
PROVISIONAL AGENDA
Opening ceremony 1. Meeting objectives 2. Global TB control, global :MDR/XDR response plan 3. Stop TB Partnership: Progress and perspectives 4. Current situation and future perspective • • TB control in the Western Pacific Region HIV/AIDS: Towards universal access
5. Revised regional TB-HIV framework 6. :MDR-TB implementation 7. Urban TB 8. Report on the Regional laboratory consultation meeting 9. Global TB laboratory initiative 10. Laboratory capacity in the Western Pacific Region 11. Laboratory perspectives 12. Country action plans 2008-2010, focusing on TB-HIV, :MDR and laboratories 13. Summary of country plans- Accelerating the implementation of the Regional Strategic Plan
WPR/2008/DCC/06/STB(4)/2008/IB/2
Page2
14. futer-agency Coordinating Committee (ICC) Meeting 15. Feedback from ICC meeting 16. Response to feedback • • Country perspective Donor perspective
17. Technical assistance from a country and regional perspective 18. Conclusions and recommendations Closing
WORLD
HEALTH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION Tokyo, Japan 22-24 July 2008
WPR/2008/DCC/06/STB(4)/2008/IB/1 15 July 2008
ENGLISH ONLY
INFORMATION BULLETIN NO. 1 (Rev. 1)
This is the first of a series of information bulletins that will be issued between now and the opening of the meeting. 1.
Background information
Following the declaration of the "tuberculosis crisis" in September 1999 by the WHO Regional Committee for the Western Pacific, WHO established the Stop TB Special Project. The Region is the first and so far the only Region to have achieved the 70% case detection rate, 85% treatment success rate and 100% DOTS coverage 2005 targets. In order to achieve the goal to reduce by half the prevalence and mortality due to TB within 10 years ending in 2010, which is in line with the Millennium Development Goals, the Region will need to address the remaining challenges, including multidrug resistant TB and TB-HIV. The TB Technical Advisory Group (TAG) was formed in 2000 as a mechanism to provide policy, strategic and technical guidance and to monitor progress of the Special Project. The sixth TAG meeting will be held with support from the Government of Japan and will review the progress made since the achievement of the intermediate targets in 2005 and discuss issues and challenges with regard to the 2010 goal. TAG members are expected to provide recommendations to WHO and countries on the implementation of the regional and national TB control plans. The Regional Interagency Coordinating Committee meeting will be held during the sixth TAG meeting. 2.
Objectives The objectives ofthe proposed TAG meeting are:
(1) to review progress towards the 2010 Stop TB regional goals, identify issues and challenges, and provide recommendations to address them;
WPR/2008/DCC/06/STB(4)/2008/IB/1 Page2
(2) to review and provide recommendations on the implementation of national TB control plans 2006-2010 of the seven countries with a high burden ofTB; (3) to discuss the revised Regional Framework on TB-HIV and advise on its implementation; and (4) to identify gaps in financial and technical support through the Interagency Coordinating Committee and to mobilize further commitments to address these gaps.
3.
Dates and site
The meeting will be held from 22 to 24 July 2008 in Tokyo, Japan. 4. Language
English only.
5.
Participants
Participants will be national programme managers and senior staff of National Tuberculosis Programme and HIV/AIDS programme managers. 6. Hotel accommodation
Due to unforeseen circumstances, all meeting participants will now be accommodated at: Prince Park Tower Tokyo 4-8-1 Shibakoen, Minato-ku Tokyo 105-8563, Japan Tel. No.: (813) 5400 1111 Fax No.: (813) 5400 1110 Website: www.princehote1sjapan.com/The Prince Park Tower Tokyo
Those who were previously booked at the Tokyo Prince Hotel are now booked at the The Prince Park Tower Tokyo using the old rates of JPY 16 900 for single rooms (with early check-in charge of JPY 13 500) and JPY 24 150 for twin or double-bed rooms (with early check-in charge of JPY 18 000). Check-in time is 12:00 noon while check-out time is 2:00p.m. For those who were previously booked at the Prince Park Tower Tokyo (most TAG members, Secretariat and a number of observers) will be moved from standard single rooms to executive rooms at the same old rate of JPY 23 000 (with early check-in charge of JPY 19 000) The hotel is 1-hour and 30-minute ride by car or airport limousine from the New Tokyo International Airport (Narita).
WPR/2008/DC C/06/STB(4)/2008/IB/1 Page3
7.
Travel arrangements
Economy class or excursion fare air tickets, if applicable, will be delivered by authorized travel agents of WHO . As soon as travel arrangements have been finalized, participants will receive a communication from the Administrative Services Office (ASO), Manila. This Office normally arranges the itineraries of the participants and should there be any cieviRtion in tnwel arrangements, the participant will bear the additional oo9t9. Once the details of arrival are known, participants should contact the Administrative Services Officer, WHO Regional Office for the Western Pacific, fax no. (632) 521-1036, E-mail: ASO@wpro.w ho.int to inform them of the exact date, flight number and time of arrival, so that hotel reservations can be confirmed. All subsequent travel arrangements and reconfirmation of return air bookings will be dealt with during the meeting. Any extended stay in Japan will be the responsibility of each traveller. 8. Visa
Participants are responsible for having in their possession a valid passport. All participants (except those from Australia, France, Malaysia, the Netherlands, Republic of Korea and the United States of America) are required to obtain the visa to enter Japan from the Japanese Embassy in their respective countries. Since an advance clearance is required before the application for a visa is made, participants are requested to advise WHO Manila by fax of their passport number, the date and place issued, and the validity of their passports.
9.
Insurance Participants
WHO does not provide insurance cover for participants or their belongings and participants are expected to make their own arrangements for accident, illness and luggage insurance, if so desired. Temporary advisers Temporary advisers will be covered by accident insurance throughout the period of their attendance and during authorized travel time. 10. Daily allowance, currency and rate of exchange
Participants will be paid a daily subsistence allowance based on the prevailing standard per diem rate in Tokyo at the time of the meeting which is currently at US$ 311 per day. Those residing within commuting distance to the meeting will be paid one-third of that rate. Temporary advisers will be paid a daily subsistence allowance based on the prevailing standard per diem rate in Tokyo at the time of the meeting which is currently at US$ 311 per day, plus US$ 50 per day as supplemental allowance. Those residing within commuting distance to the meeting will be paid one-half of that rate. The monetary unit in Japan is the Yen. The exchange rate is currently JPY 106 to US$ 1.00 (subject to change).
WPR/2008/DCC/06/STB(4)/2008/IB/1 Page4
11.
Airport tax No airport tax is levied on passengers upon embarkation at the airport.
12.
Documents for the meeting
Each participant will be given a folder containing the documenta of the meeting. They should inquire from the Reception Desk Clerk at the hotel whether there are any messages or documents for them. 13.
Climate
The temperature in July is 22.5°C- 29°C. Offices are normally air-conditioned. Business suits are generally worn during meetings or on formal occasions. 14.
Postal address, e-mail and fax no.
Participants may use the following address for personal mail for the duration of the meeting: Postal address: (name of participant) (attending the SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION) Tokyo Prince Hotel 3-1, Shibakoen 3-chome, Minato-ku Tokyo 105-8560, Japan Tel No.: (813) 3432 1111 Fax No.: (813) 3434 5551 Website: www. princehotelsj apan.com/The PrinceParkTowerTokyo
WORLD
HEALTH
ORGANISATION MONDIALE DE LA SANTE
ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION Tokyo, Japan 22-24 July 2008
WPR/2008/DCC/06/STB(4)/2008/IB/2 16 July 2008
ENGLISH ONLY
INFORMATION BULLETIN NO.2
PROVISIONAL LIST OF TAG MEMBERS, RESOURCE PERSONS, REPRESENTATIVES/OBSERVERS AND SECRETARIAT
1. TAG MEMBERS
Dr Jaap Broekmans Former Executive Director KNCV Tuberculosis Foundation Koningin Emmakade 174 2518 JN The Hague The Netherlands Tel.: (31)703352696 Fax: (31) 65 390 6054 E-mail: broekmansj@tbconsult.nl Dr Donald Enarson Director Scientific Activities International Union Against Tuberculosis and Lung Diseases (The Union) 68, boulevard Saint-Michel 75006 Paris France Tel.: 33 1 44 320360 Fax: 33 1 43 299087 E-mail: denarson@iuatld.org
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page2
Dr Michael Iademarco Captain, U.S. Public Health Service Health Attache Office of Global Health Affairs Office of the Secretary Department of Health and Human Services United States Embassy HaNoi VietNam Tel. No.: (84 4) 850 5053 Fax No.: (84 4) 831 4604 E-mail: iademarcoMF@state.gov Dr Sang Jae Kim Laboratory Consultant International Union Against Tuberculosis and Lung Diseases (The Union) 101-703 Mabuk Ssaryong Apartment, Gihunggu, Y onginsi Kyeonggido 446-560 Republic of Korea Tel.: 82 31 287 4301 Fax: 82 31 304 4301 E-mail: SJKim@iuatld.org Dr Vicki Krause Director Centre for Disease Control NT Department of Health and Community Services P.O. Box 40596 Casuarina, N.T. 0810 Australia Tel.: 61 (0) 8-8922 8510 Fax: 61 (0) 8-8922 8310 E-mail: Vicki.Krause@nt.gov.au Dr Tamami Umeda Director Tuberculosis and Infectious Disease Control Division Health Services Bureau Ministry of Health, Labour and Welfare 1-2-2, Kasumigaseki, Chiyoda-ku, Tokyo 100-8916 Japan Tel.: (81 3) 5253 1111 ext. 2370 Fax: (81 3) 3581 6251 E-mail: Dr Xiao Donglou Deputy Director-General Bureau of Disease Control and Prevention Ministry of Health 1 Nanlu, Xizhimenwai, Xicheng District Beijing 100044 China Tel.: (86-10) 68792050 Fax: (86-1 0) 68792514 Email: xiaodl@moh.gov.cn
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page3 Dr Nobukatsu Ishikawa Director The Research Institute of Tuberculosis 3-1-24 Matsuyama Kiyose Tokyo 204-8533 Japan Tel.: (81) 424 92 4767 Fax: (81) 424 92 4600 Email: ishikawa@jata.or.jp
2. PARTICIPANTS CAMBODIA Dr Mao Tan Eang Director National Center for TB and Leprosy Control (CENAT) Ministry of Health No. 1, Str. 278-95, Boeung Keng Kang 2 Khan Chamkar Mom Phnom Penh Tel: (855) 12 916 503 Fax: (855) 23 218090 E-mail: mao@online.com.kh Dr Mean Chhivun Director National Center for HN I AIDS, Dermatology and STD (NCHADS) No. 266, St 1019, SK Phnom Penh Thmey Khann Roesseykeo Phnom Penh Tel.: (855) 16 830241 Fax: (855) 16 830 241 Email: mchhivun@nchads .org Dr Huot Chan Yuda Deputy Director National Center for TB and Leprosy Control (CENAT) Ministry of Health Street Comer 278-95, Sangkat Boeung Keng Kang II Khan Chamkar Mom Phnom Penh Tel.: (855) 12 976781 Fax: (855) 23 218090 Email: hyuda@camnet.kh Dr Tieng Sivanna Vice Chief, Technical Bureau National Center for TB and Leprosy Control (CENAT) Ministry of Health Street 278-95, Boeung Keng Kang 2 Khan Chamkar Mom Phnom Penh Tel.: (855) 12 863 811 Fax: (855) 23 218 090 Email: tsivanna@camnet.com.kh
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page4
CHINA, PEOPLE'S REPUBLIC OF
Dr Wang Wenjie Division Director Division ofTB Control and Prevention Bureau of Diseases Control Ministry of Health 1 Xiwai Nanlu Beijing 100044 Tel.: (8610) 6879 2363 Fax: (8610) 6879 2514 E-mail: wangwj@moh.gov.cn Dr Wang Lixia Director Center for TB Prevention and Control, China CDC 27 Nanwei Road, Xuanwu District Beijing 100050 Tel.: (8610) 8313 6116 Fax: (8610) 8313 7006 E-mail: wanglx@chinatb.org Dr Zhao Yanlin Director National Tuberculosis Reference Laboratory China CDC No. 97 Machang, Tongzhou Distict Beijing 101149 Tel.: (8610) 6954 3261/6359 Fax: (8610) 6954 6819 E-mail: zhaoyanlin@tb123.org Dr Wang Weizhen Deputy Division Director Division ofHIV/AIDS Prevention and Management Bureau of Diseases Control Ministry of Health No. 1, Nanlu, Xizhimenwai Beijing 100044 Tel.: (8610) 6879 2344 Fax: (8610) 6879 2362 E-mail: treatment@chinaids.org.cn Dr Zhong Qiu Director Guangdong Research Center for TB Prevention & Control West 485 Huangpu Street Guangzhou, Guangdong Beijing 510630 Tel.: (8620) 3890 5657 Fax: (8620) 3890 6142 E-mail: zhongqiu@vip.163 .com
JAPAN
Dr Yasuo Sugiura Deputy Director International Affairs Division Ministry of Health, Labour and Welfare 1-2-2, Kasumigaseki, Chiyoda-Ku Tokyo 100-8916 Tel.: 81 3 3595 2404 Fax: 81 3 3501 2532 E-mail: yasugiura@hotmail.com
WPR/2008/DCC/06/STB(4)/2008/IB/2 PageS
Dr Shinsuke Miyano Medical Officer, Tuberculosis Tuberculosis and Infectious Disease Central Division Health Service Bureau Ministry of Health, Labour and Welfare 1-2-2, Kasumigaseki, Chiyoda-Ku Tokyo 100-8916 Tel.; 813 5253 1111 (ext. 2931) · Fax: 81 3 3501 6251 · E-mail: miyano-shinsuke@mhlw.go.jp LAO PEOPLE'S DEMOCRATIC REPUBLIC Dr Phannasinh Sylavanh Director National Tuberculosis Centre Dr Chanmy Sramany, Global Fund Unit Hygiene and Prevention Department Ministry ofHealth Vientiane Tel.: (856) 21 9078/020 222 2076 Fax: (856) 45 2855 E-mail: psylavanh-ntcplao@laopdr.com Dr Soth Bounmala Chief, Planning and Budgeting Division Coordinator, Global Fund ofTB Center National Tuberculosis Center Ban Thongtoum, Chanthabury District Vientiane P.O. Box 2209 Tel.: (856) 21 217955 Email: sothbounmala@laopdr.com Dr Phouthone Southalack Deputy Director, Center for HIV/AIDS/STI (CHAS) Km 3 Thadeua Road, Ban Phoxay Sisattanak District Vientiane Telefax.: (856) 21315500 Email: pt_soth@yahoo.com MALAYSIA Dr Sha'ari bin Ngadiman Senior Principal Assistant Director AIDS/STD Section Disease Control Division Ministry of Health Level 4, Block E 10, Parcel E Federal Government Administrative Centre 62590 Putrajaya Tel.: (603) 8883 4271 Fax: (603) 8883 4285 E-mail: drshaari@moh.gov.my
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page6
Dr Badrul Hisham bin Abd. Samad Principal Assistant Director (TB and Leprosy Control) Office of the Director of Johor State Health Department Ministry of Health Malaysia Level3, Block B, Wisma Persekutuan Jalan Ayer Malek 80590 Johor Bahru, Johor Tel.: (607) 224 5188/89/90 Fax: (607) 227 7577 E-mail: drbadrul2001@yahoo.com badrul@dr.com Dr Teng Khoon Koay Principal Assistant Director TB-Leprosy Sabah State Health Department Ministry of Health Malaysia 1st Floor, Federal House Jalan Mat Salleh Kota Kinabalu Sabah Tel.: (6088) 245 105 I 088 247 105 Fax: (6088) 245 107/088 217 740 E-mail: koaytk@pc.jaring.my MONGOLIA Dr Naranbat Nyamdavaa Deputy Director National Center for Communicable Diseases (NCCD) NCCD Campus, Nam-Yan-Su Street Ulaanbaatar 210648 Telefax.: (976) 11 450492 E-mail: ntpml@mongol.net Dr Rentsenmyagmar Tsogtoo Deputy Director for Medical Services National Center for Communicable Diseases (NCCD) Nam-Yan-Su Street Ulaanbaatar 210648 Tel.: (976) 11 450443 E-mail: tsrenomzul@yahoo.com PAPUA NEW GUINEA Dr Paul Aia Acting Director Disease Control Branch National Health Department P.O. Box 807, Waigani Port Moresby Tel.: (675) 301 3738 Fax: (675) 301 3604 E-mail: paul-aia@health.gov.pg
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page7 Dr Joseph Bana-Koiri Specialist Medical Officer- TB (Curative) Department of Health TB Clinic, Port Moresby General Hospital PMB,P.O. Boroko, NCD Tel.: (675) 323 5570 Fax: (675) 325 0342 Email: joebana-koiri@dalton.com.pg Ms Osana Mera TB/DOT Coordinator Hope Worldwide (Papua New Guinea) P.O. Box 3478 Boroko, NCD Tel.: (675) 325 6901 Fax: (675) 323-0419 Email: osanamera@yahoo.com.au PHILIPPINES Dr Jaime Lagahid Director III National Center for Disease Prevention and Control Department of Health Sta. Cruz Manila Telefax: (632) 711 6808; 743 8301 ext 2350/2352 E-mail: drlagahid@yahoo.com Dr Rosalind Vianzon Medical Specialist IV Center for Infectious Disease Office National Center for Disease Prevention and Control Department of Health Sta. Cruz Manila Telefax: (632) 711 7808 E-mail: rgvianzon 1O@yahoo.com VIETNAM, SOCIALIST REPUBLIC OF Professor Dinh Ngoc Sy Director, National Hospital ofTB and Respiratory Diseases Ministry of Health 463 Hoang Hoa Tham Ba Dinh District HaNoi Tel.: (844) 761 3728 Fax: (844) 761 4901 E-mail: ngocsy@bvlaobp.org Vnntp463@hn.vnn.vn Dr Tran Ngoc Buu Chief, National Tuberculosis Programme Department
Phan Ngoc Thach Hospital 120 Huuang Vuong Street District 5 Ho Chi Minh City Tel.: (848) 855 0189 Fax: (848) 574 264 Email: bvpwt@vnn.vm buueam@yahoo.com
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page 8 Dr Do Thi Nhan Deputy Chief Care and Treatment Unit
VAAC 13513 Nui True, Badinh HaNoi Tel.: (844) 869 0022 Fax: Email: dothinhhan@gmail.com
3. RESOURCEPERSONS
Dr Kai Man Kam Medical Microbiologist Tuberculosis Reference Laboratory Public Health Laboratory Centre Rm. 731, 7/F 382 Nam Cheong Street Shek Kip Mei Kowloon, Hong Kong Tel.: (852) 2319 8303; 2776 1901 Fax: (852) 2776 1446 E-mail: kmkam@dh.gov.hk; kmkam@email.com Dr Kevin Cain Medical Epidemiologist Division of Tuberculosis Elimination US Centers for Disease Control and Prevention 1600 Clifton Road, MS E-1 0 Atlanta, Georgia 30333 United States of America Tel.: (1-404) 639 8120 Fax: (1-404) 639 1566 E-mail: kcain@cdc.gov
4. REPRESENTATIVES OF PARTNER AGENCIES AND OBSERVERS DAMIEN FOUNDATION BELGIUM (DFB) Mr Alex Jaucot DFB Representative for South-East Asia Beijing Representative Office Room 060 1, Guangming Hotel Liangmaqiao Road Beijing 100125
China Tel.: 8610 8451 2250 Fax: 8610 6463 7144 E-mail: alex.jaucot@damien-bel.org.cn
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page9 Dr Liu Zbentian Medical Advisor for China DFB- China Room 0601, Guangming Hotel Liangmaqiao Road Beijing 100125 China Tel.: 8610 6467 8020 Fax: 8610 8451 2250 E-mail: liu.zhentian@damien-bel.org.cn GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA (GFATM) Dr Elmar Vinh-Thomas Team Leader, East Asia and the Pacific GFATM Chemin de Blandonnet 8 1214 Vernier Geneva Switzerland Tel.: (41-22) 7911700 Fax: (41-22) 7911701 E-mail: elmar. vinh-thomas@theglobalfun d.org Dr Kishio Ono Executive Technical Advisor to the Director General Human Development Department JICA Headquarters Shinjuku Maynds Tower Building 2-1-1 Yoyogi, Shibuya-ku Tokyo 151-8558 Japan Tel. no.: (813) 5352 5202 Fax no.: (813) 5352 5320 Email: Dr Mitsuo Isono Visiting Senior Advisor Human Development Department JICA Headquarters Shinjuku Maynds Tower Building 2-1-1 Yoyogi, Shibuya-ku Tokyo 151-8558 Japan Tel. no.: (813) 5352 5202 Fax no.: (813) 5352 5320 Email: Mr Tomoyuki Odani Programme Officer Infectious Disease Control Division JICA Headquarters Shinjuku Maynds Tower Building 2-1-1 Y oyogi, Shibuya-ku Tokyo 151-8558 Japan Tel. no.: (813) 5352 5202 Fax no.: (813) 5352 5320 Email:
JAPAN INTERNATIONAL COOPERATION AGENCY (JICA)
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page 10
KOREAN INSTITUTE OF TUBERCULOSIS (KIT)
Dr Hee Jin Kim Director Department of Epidemiology Korean Institute of Tuberculosis 14 W ooMeyeonDong Seochogu Seoul137-140 Republic ofKorea Tel.: (822) 575 1547 I 576 4982 Mobile: (019) 9150 9439 E-mail: hatchingbird@yahoo.co.kr Dr Joel Keravec Senior Programme Associate Management Sciences for Health Rua Timoteo da Costa 777 -Apt204 Rio de Janerio Brazil Tel.: ((55) 21 2448 6805 Fax: (55) 21 2448 6810 Email: jkeravec@msh.org Dr Hajime Inoue Director Office of International Cooperation Ministry ofHealth, Labour & Welfare Tokyo Japan Tel.: (81-3) 3595 2494 Fax: (81-3) 3502 6678 Email: inoue-hajime@mhlw.go.jp
MANAGEMENTSCffiNCESFOR HEALTH (MSH)
MINISTRY OF HEALTH, LABOUR AND WELFARE, JAPAN
(attending the ICC Meeting only) Dr Keiko Yamamoto Deputy Director International Affairs Division Ministry of Health, Labour & Welfare Tokyo Japan Mr Kei Tsutsumi Intern International Affairs Division Ministry of Health, Labour & Welfare Tokyo Japan MINISTRY OF HEALTH, WELFARE AND FAMILY AFFAIRS, REPUBLIC OF KOREA (to be determined later)
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page 11 RESEARCH INSTITUTE OF TUBERCULOSIS (RIT) I JAPAN ANTI-TUBERCULOSIS ASSOCIATION (JATA) Dr Seiya Kato Vice Director RIT/JATA 3-1-24 Matsuyama, Kiyose Tokyo 204-8533 Japan Tel.: 81-424-93-5711 Fax: 81-424-92-4600 Dr Norio Yamada Director Department of International Cooperation RIT/JATA Dr Satoshi Mitarai Head, Bacteriology Division Mycobacterium Reference Centre RIT/JATA Dr Akihiro Ohkado Senior Research Officer Department of Research RIT/JATA Dr Tatsuo Sugiyama Head, Human Resource Development Department of International Cooperation RIT/JATA Dr Jintana Ngamvithayapon-Yanai Deputy Head Human Resource Development RIT/JATA Dr Kuniko Murakami Medical Officer Department of International Cooperation RIT/JATA SECRETARIAT OF THE PACIFIC COMMUNITY Dr Axel Wiegandt Medical Officer TB Control Section/Public Health Programme Secretariat of the Pacific Community BPD5, 98848 N oumea Cedex New Caledonia Tel.: (687) 26 0142 Fax: (687) 26 3818 Email: AxelW@spc.int Dr Tan Sai Tiang Medical Director Singapore Anti-Tuberculosis Association 3 51 Chai Chee Street Singapore 468982 Republic of Singapore Tel.: (65) 6244 6714 Fax: (65) 6244 1770 E-mail: saitiang.tan@sata.com.sg
SINGAPORE ANTITUBERCULOSIS ASSOCIATION
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page 12
THE BILL & MELINDA GATES FOUNDATION
Dr Peter M. Small Senior Programme Officer Global Health Programme The Bill and Melinda Gates Foundation P.O. Box 23350 Seattle, Washington 98102 United States of America Tel.: (1-206) 709 3301 Fax: (1-206) 709 3170 Email: peter. small@gatesfoundation.org Professor Lee Shiu Hung Vice-President The Hong Kong Tuberculosis, Chest and Heart Diseases Association 266 Queen's Road, East Wanchai Hong Kong Tel.: (852) 2572 3466 Fax: (852) 2834 0711 E-mail: antitb@ha.org.hk Ms Chan Ying Yee, Babe Executive Secretary The Hong Kong Tuberculosis, Chest and Heart Diseases Association 266 Queen's Road, East Wanchai Hong Kong Tel.: (852) 2572 3466 Fax: (852) 2834 0711 E-mail: antitb@ha.org.hk
THE HONG KONG TUBERCULOSIS, CHEST AND HEART DISEASES ASSOCIATION
UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT (USAID)
Dr John MacArthur Infectious Diseases Team Leader Office of Public Health US AID Regional Development Mission/Asia Diethelm Towers A, 3rd Floor 93/1 Wireless Road Bangkok 10330 Thailand Tel.: (66-2) 263 7411 Fax: (66-2) 263 7499 Email: jmacarthur@usaid.gov Dr Sri Chander Regional Health Advisor Asia Pacific Regional Office World Vision International 10 Anson Road #13-08 International Plaza Singapore 079903 Republic of Singapore Tel.: (65) 62211-040 Fax: (65) 62211 390 E-mail: sri_chander@wvi.org
WORLD VISION INTERNATIONAL
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page 13 Dr Jaruwaree Snidwongse Senior TB Programme Manager Asia Pacific Regional Office World Vision Foundation of Thailand 582/18-22 Soi Ekkamai Sukhumvit 63 W atthana District Bangkok 10110
Thailand Fax: (662) 381-4923 E-mail: Jaruwaree_ Snidwongse@wvi.org
5. SECRETARIAT WHO WESTERN PACIFIC REGIONAL OFFICE (WHO/WPRO) Dr Shigeru Omi Regional Director WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9903 Fax: (632) 521 1036 E-mail: omis@wpro.who.int Dr Pieter van Maaren (Responsible Officer) Regional Adviser Stop TB and Leprosy Elimination WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9706 Fax: (632) 521 1036 E-mail: vanmaarenp@wpro.who.int Dr Philippe Glaziou (Co-Responsible Officer) Medical Officer Stop TB and Leprosy Elimination WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9708 Fax: (632) 521 1036 E-mail: glazioup@wpro.who.int Dr Massimo Ghidinelli Regional Adviser HNI AIDS and STI WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9714 Fax: (632) 521 1036 E-mail: ghidinellim@wpro.who.int
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page 14
Dr Takuya Sugie Medical Officer Programme on Technology Transfer WHO/WPRO U.N. Avenue 1000 Manila Philippines
Tel.: (632) 528 9933 Fax: (632) 521 1036 E-mail: sugiet@wpro.who.int
Dr Katsunori Osuga Medical Officer Stop TB and Leprosy Elimination WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9709 Fax: (632) 521 1036 E-mail: osugak@wpro.who.int Dr Masaki Ota Medical Officer Stop TB and Leprosy Elimination WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9726 Fax: (632) 521 1036 E-mail: otam@wpro.who.int Mr Bernard Tomas Technical Officer Stop TB and Leprosy Elimination WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9727 Fax: (632) 521 1036 E-mail: tomasb@wpro.who.int WHO/WPRO COUNTRY OFFICES Dr Cornelia Hennig Medical Officer, Tuberculosis Office of the WHO Representative in China 401, Dongwai Diplomatic Office Building 23, Dongzhimenwai Dajie Chaoyang District Beijing 100600 China Tel.: (8610) 6532 7189 Fax: (8610) 6532 2359 Email: hennigc@chn.wpro.who.int
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page 15
Dr Liu Yuhong National Professional Officer, Tuberculosis Office ofthe WHO Representative in China 401, Dongwai Diplomatic Office Building 23, Dongzhimenwai Dajie Chaoyang District Beijing 100600 China Tel..: (8610) 6532 7189 Fax.: (8610) 6532 2359 E-mail: liuy@chn.wpro.who.int Dr Giampaolo Mezzabotta Medical Officer, Tuberculosis Office of the WHO Representative in VietNam 63 Tran Hung Dao Street Hoan Kiem District HaNoi Socialist Republic of VietNam Tel.: (844) 943 3734 Fax: (844) 943 3740 Email: mezzabottag@vtn.wpro.who.int Dr Michael Voniatis Medical Officer, Stop TB and Leprosy Elimination Office ofthe WHO Representative in the Philippines P.O. Box 2932 Manila Philippines Tel. No.: (632) 5289767 Fax No.: (632) 7313914 E-mail: voniatism@phl.wpro.who.int Dr Rajendra Prasad Yadav Medical Officer, Tuberculosis Office of the WHO Representative in Papua New Guinea 4th Floor, AOPI Centre W aigani Drive Papua New Guinea Tel. No.: (975) 325 7827 Fax No.: (975) 325 0568 E-mail: yadavr@png.wpro.who.int Dr Jamhoih Tonsing Medical Officer Office of the WHO Representative in Cambodia No. 177-179 comer Pasteur (51) and 254 Phnom Penh Cambodia Tel.: (855) 23 216610 Fax: (855) 23 216211 E-mail: tonsingj@wpro.who.int
WPR/2008/DCC/06/STB(4)/2008/IB/2 Page 16
Dr Jacques Sebert WHO Consultant, Tuberculosis Office of the WHO Representative in Laos Ban Phonxay, 23 Singha Road Vientiane Lao People's Democratic Republic Tel.: (856) 21413 431 Fax: (856) 21 413 432 .b-mail: sebertj@wpro.who.int WHO HEADQUARTERS Dr Marcos Espinal Executive Secretary Stop TB Partnership Secretariat HIVIAIDS, TB and Malaria Cluster World Health Organization Avenue Appia 20 CH -1211 Geneva 27 Switzerland Tel.: 4122 791 2708 Fax: 4122 791 4886 E-mail: espinalm@who.int Dr Leopold Blanc Coordinator TB Strategy and Health Systems Stop TB Department World Health Organization Avenue Appia 20 CH- 1211 Geneva 27 Switzerland Tel.: 4122 791 4266 Fax: 4122 791 4268 E-mail: blancl@who.int Dr Ikushi Onozaki Medical Officer TB Strategy and Health Systems Stop TB Department World Health Organization Avenue Appia 20 CH - 1211 Geneva 27 Switzerland Tel.: 4122 791 2583 Fax: 4122 791 4268 E-mail: onozakii@who.int WHO CENTRE FOR HEALTH DEVELOPMENT Dr Jacob Kumaresan Director WHO Centre for Health Development/ (WHO Kobe Centre) I.H.D. Centre Building, 91h Floor 5-1, 1-chome, Wakinohama-Kaigandori Chuo-ku, Kobe 651-0073 Japan Tel.: (81 782303100 Fax: 81 78 230 3178 Email: kumaresanj@who.int
(attending the ICC Meeting only)
WORLD
HEALTH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING .FUR THE WESTERN PACIFIC REGION
Tokyo, Japan 22-24 July 2008 ENGLISH ONLY
COUNTRY ACTION PLANS 2008-2010 • • • • • • • • CAMBODIA CHINA LAO PEOPLE'S DEMOCRATIC REPUBLIC MALAYSIA MONGOLIA PAPUA NEW GUINEA PHILIPPINES VIETNAM
WORLD
HEALTH
ORGANISATION MONDIALE DE LA SANTE
ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION
WPR/2008illCC/06/STB(4)/2008.2 11 July 2008 ENGLISH ONLY
Tokyo, Japan 22-24 July 2008
COUNTRY ACTION PLAN 2008-2010 CAMBODIA
MDRTB Cambodia -Current Situation• 1st National TB Drug Resistance Survey (2001): - PltNaltliiCt:lralt% or druy resistance to I, R, E and s among new cases were 6.4%, 0.6%, 0.2%, and 5.0% respectively. - MDR-TB: 1.5% in new cases, 3.1% in previously treated.
Action Plan 2008-2010 Fcx;u~ina
on
MDRTB, TB-HIV, and laboratory capacity strengthening
22-24 July, 2008 6th Stop TB Technical Advisory Group Meeting for the Westem Pacific Region Tokyo, Japan
• 2nd National TB DRS (2006-2007) - Preliminary results: 1.3% MDR-TB among combined cases
• Pilot projects for MDR-TB implemented through NGOs - >50 patients enrolled on treatment so far
MDRTB -Current Situation• Plans for programmatic management of MDRTB - Funding secured through GF R7, starting Oct 2008 -Technical working Group on MDR-TB formed - Guidelines under development -Training on management of SLD held in July, GLC monitoring cum TA scheduled for August 2008 - GLC application in 2009
MDR-TB: Plans for 2008-2010 Program Activities Development of Standard Operational Procedure Oeveklpment of Application to Green Ught Cammittl!e Development of Operational Guideline
HW"e Consultant for writing ~lication end guideline Orientation workshop
MDR-TB: Plans for 2008-2010 Program Activities Training on MDR Management for staff of 3 Intensive care centers ( CENAT in Y1, Kg Cham in Y2, and Battambang in Y3 ) Training on Continuation phase care for
MDR-TB: Plans for 2008-2010 Program Activities Refetral fee for MDR-TB suspect to DST center
MDR-TB Patient support during intensive phase 6months Supervision from PHD and 00 to continuation phase ConstrucUrenovate the builcfmg for Isolation room Renovation of space to create BSL-3 laboratOf'(
MOR-TB case for Provincial and 00 SUpervisors Training on Continuation phase care for MOR-TB case for HC Staff and community
Vclunteer Dev~op
th!: Training CUrricu1um for MDR-TB
trmlng
Local training, Pasteur lnstiMe, Cambodia
1
TB/HIV 2001 First TBIHIV Clinic (CENAT/JICA} 2002 Framework for TB/HIV collaboration in Cambodia 2003 1st National HIV sere-prevalence among TB patients, thereafter at 2 year interval. TBIHIV Pilot Projects at 4 sites 2004: ~lational Wi on Tlii/HIV Co morbidity 2005: Development ofTB/HIV joint statement by CENAT and NCHADS 2006: TB/HIV training started Networking between community groups and health facilities Integrated TB/HIV data into the current R&R system TB/HIV IEC material development
HIV sera-prevalence trend among TB cases
2007: -1st National TB/HIV Workshop -Regular TB/HIV WG meetings under CENAT/NCHAD joint ooordination -Joint statement by NTP & NAP for strengthening traatment & care strategies & clarifying responsibilities of the two national centres
2008: - TB/HIV clinical guidelines and training materials developed
2003
2005
2007
Principles for Collaborative efforts for diagnosis & treatment TB Control Programme HIV Control Programme
SOP for prompt testing of TB/HIV TB services/DOT centers with no VCCT services ~ Tll _ poHoo!!l n><civing DO'!' should be supp9rted with fundo for
~.ac~lon to the ni!::illn!St: VCCT G'lh! m on::ir:r to nave-a tes ~ for
I'ICJEDH w.ilh the C.pocity-to provide~~ nnd post:tesl coun_ s eling and draw bloc~ s·ampfes_ kom TB p~tients volunteermg fen: HIVf.AIDS testing should s end ~peomens to the ncarost Veer .
~ Option3
veer stall visit HC/FDH where TB patients have been groupCIIUI\5eled ;md _gather"" bt he•ltl:'i pOFSOrmel in < .oU..liaration.with HBC teams. veer staff will provide pre-teot-oouuselin!l> tnke blllod to dor.opid test iit the fudllties visited and provide'Post-lelit
co11115eling
HIV testing in TB 2006 (340Ds) 2007 (all ODs)
Intensified TB case finding 2006 HIV+ Registered at VCT HIV+ clients screened for TB TB diagnosed BK+ BKEPTB IPT (3 sites only) 4,270 2,225 1,035 (47%) 208 349 478 53 2007 11,641 5,318 1,801 (34%) 501 625 686 77 36,066 30,801 13,391 (44%) 11,676 476 (4%) 1,091 608
Total TB cases registered Unknown HIV+ after TB registered Referred to VCT HIVtested TB/HIV under CPT TB/HIV under ART
11,156 9,870 3,871 (39%) 3,547 954 385
HIV positive 342 (10%)
2
TB/HIV -Major Challenges- Sustainability of the support for transportation of patients or blood samples to VCCT centres - Human resources: limited staff, capacity for counseling (esp TB HC staff and Home Care Team) - Stigma and discrimination causes patient resistance - R&R system: inconsistencies, data not included in Health Information System, limited capacity to analyze and use data for improving performance at provincial and OD levels - Joint supervision by TB and HIV programmes - Lack of harmonization in incentive provision between programmes and partners
TB/HIV -Updated Plan of Activities 2008-2010- Appoint TB-HIV coordinators at PHD and OD levels - Fund and implement the policy for prauider-initiated HN
tacting - Expand HIV counseling & testing (sending blood vs. onsite testing) at HC level - Ensure transfer of patient data between facilities - Fund CXR for screening of TB in HIV - Introduce liquid culture sytems - Expand HIV reporting to include TB data - Develop a policy on infection control - Develop script for pre-counseling - Improve quality of data collection and accountability for reported data
Laboratory capacity strengthening -Current SituationNational strategic plan for TB laboratories for 2007-201 0 developed Quarterly based EQA decentralized to 11/24 provinces Performance of blinded cross-checking of slides in 2007 - False positive: 4 .6% - False negative: 2.5% - Overall agreement rate: 97.3%
Laboratory capacity strengthening -Major ChallengesEnsuring adequate supply of laboratory consumables Capacity of HC staff (non-LT) to prepare good smears Human resources: numbers, capacity and motivation ( low salary) Strengthening the NTRL to perform culture and DST with good performance on proficiency testing Addressing bio-safety issues in laboratories performing culture and DST
Culture and DST (first line drugs) services in in NTRL, culture capacity in 2 regional laboratories
Laboratory capacity strengthening -Updated Plan of Activities 2008-201 0Procurement of adequate laboratory supplies with funds from the GF Decentralize quarterly based EQA to all provinces • EQA for culture and DST and later for Fl. microscopy Develop/revise TB laboratory guidelines, SOP, training modules including that for EQA, DST, infection control and waste disposal Introduce LED FM and liquid culture systems with support from partners and GF RS ( if approved) Training of HC staff to strengthen capacity for smear preparation, training for new initiatives Improve physical infrastructure of laboratories performing C & DST to comply with appropriate BSL
Core national targets by 2010 MDRTB • Enrol at least 80% of estimated MDR-TB patients on treatment (GFR7) TB Laboratory • % of well performing laboratories in smear microscopy EQA TB!HIV (Strategic Plan for TB control 2006-201 0) Atleast 80% ofTB patients referred for HIV testing • >90% of eligible TBIHIV patients on ART "The core national targets may be adapted to better renect local epidemiology, and need not be the same as Regional core targets.
3
Financial plan Provide a rough estimate of the costs of the Action Plan 2008-2010 for the three areas and indicate the funding
gap. Describe how this gap can be filled, and indicate anticipated available resources.
4
WORLD
HEALTH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION
WPR/2008illCC/06/STB(4)/2008.3 11 July 2008 ENGLISH ONLY
Tokyo, Japan 22-24 July 2008
COUNTRY ACTION PLAN 2008-2010 CHINA
• CHINA Action Plan 2008-201 0 Focusing on MDR- TB, TB-HIV, and laboratory capacity strengthening
•
MDR-TB -Current Situation• MDR-TB control has been incorporated into National TB Control Programme implementation plan (2006-2010) -To develop the framework and implementation plan for MDR-TB control -To carry out pilot study on MDR-TB cases treatment and management in pilot area v'By 2010, 90% MDR-TB patients detected in pilot area will be treated -To conduct DRS
22-24 July, 2008 61h Stop TB Technical Advisory Group Meeting for the Western Pacific Region Tokyo, Japan
•
MDR-TB -Current Situation• Developed the national framework for MDR-TB control with following principles : - To maintain and strengthen quality DOTS strategy implementation for preventing MDR-TB -To implement MDR-TB control programmatic management based on high DOTS quality -To engage TB special hospitals into MDR-TB prevention and control network - To strengthen international cooperation
•
MDR-TB -Current Situation• Implementing the national baseline survey of DR-TB - Duration of field work: Apr. 2007 - Dec. 2008 - Scope: 70 counties in 31 provinces -Sample: 4,617 smear positive PTB cases - Results : will be obtained in early 2009 The impact of national baseline survey of DR-TB - Improved the capability of culture and DST -Will provide the evidence for MDR-TB control policy making
•
MDR-TB -Current SituationOngoing international cooperation • GFS -Duration: Oct. 2006- Sep. 2011 - Coverage: 31 DOTS-Plus sites in 6 provinces -Target: to find and treat 4,470 MDR-TB cases • GF7 -Duration: Jul. 2008- Jun. 2013 -Coverage: 50 DOTS-Plus sites in 10 provinces - Target: to find and treat 11 ,000 MDR-TB cases
•
MDR-TB -Current SituationOther international cooperation • New diagnostics technical study - Foundation Merieux -GATES Foundation • Relevant training - Lilly project
•
MDR-TB -Major Challenges-
•
MDR-TB -Updated Plan of Activities 2008-2010 • To maintain high quality DOTS to prevent drug resistant TB • To summarize the experience from pilot study • To push forward TB legislation, seek policy support on MDR-TB prevention and control • To strengthen capacity building on: -Strategic planning - Programmatic management -Technical capacity
• Free MDR-TB programmatic services are limited in pilot areas • Insufficient capacity - Strategic planning - Programmatic management -Technical capacity
•
TB/HIV -Current Situation• TB/HIV Epidemiological situation - High TB burden - HIV remains low prevalence overall, geographic distribution is highly varied
•
TB/HIV -Current Situation• Set up the National TB/HIV coordination group and working group with effective mechanism • Developed and issued the National TB/HIV Framework and the technical guidelines • NTP provides free diagnosis and treatment on TB; NAP provides free VCT and ART
• TB/HIV Surveillance report of the 14 provinces with 134 high HIV prevalence counties by the end of 2007 - TB rate among HIV/AIDS was 6.7% - HIV (+) rate among TB was 0.6%
•
TB/HIV -Current SituationHuman resources • Established the expert group on TB/HIV control in National Advisory Committee • Established the TB/HIV control department in NCTB with full-time staff • Assigned person to be the coordinator of TB/HIV in 14 provinces with high HIV prevalence • Strengthened the training for TB/HIV control person by international and national training r:ourse
•
TB/HIV -Major Challenges• Collaboration mechanism between TB and HIV control institutes needs to be improved • TB/HIV control activities are limited in the pilot areas • Tangible activities essential in TB/HIV to be addressed • Technical difficulties on TB diagnosis among HIV/AIDS
•
€9 -Updated Plan of Activities 2008-2010TB/HIV • To strengthen the collaboration mechanism • To update the national TB/HIV framework • To strengthen the capacity building on TB/HIV • To strengthen the operational research
•
Lab capa'ci ty strengthenin~ -Current Situation• Laboratory system are integrated into NTP • Naliuuald~vt!lupment plan on TB laboratory has been developed (2008-2013) • National Laboratory network has been established with function at each level • EQA for microscopy in place • Standardized operational procedure for smear, culture and DST has been drafted
•
Lab
cap~~ity strengthening ~ -Current Situation-
•
{~7.75_1
TB laboratory network of ChinF"'" National Reference Laboratory (NRL)(1) ~
• Supervision checklist • Standardized training material for microscopy has been developed • DRS at provincial level has been conducted in 13 provinces • Nationwide anti-TB drug resistance survey is ongoing, and 7 provincial DRS are being prepared
Provincial Reference Laboratory (PRL)(31) ~
Prefecture Laboratory (PL)(333) ~
County Laboratory (CL) (2876) ~
Township sputum smear examination sites (11000)
•
L ~oC.17<d Lab capacity strengthening ~
•
Lab capacity strengthening -Major Challenges• Human resource Proficient and stable staff shortage in some laboratories
-Current Situation• Policy: • • • • • • • •
~
NTP guideline Expanding culture facility gradually Nationwide laboratory network developing plan Update microscopy EQA guideline Develop the essential requirements for laboratory at each level Bio-safety guideline is being reviewed Supervision checklist has been drafted Posters for microscopy1 culture and DST have been disseminated in point laboratories
• Guidelines:
• Bio-safety issues The gap between the requirement of bio-safety regulation and current situation exists in most county laboratories
• Pilot lab project: • 3 Provincial DRS will be conducted in 2008
• Financial issues Financial input on laboratory still needs to be increased Infrastructure of laboratories needs to be improved
~:cfF~~~~~it~~\f~~!~!~~y5 ~~J"~~~~n~~~ATES Foundation
•
Lab capacity strengthening • Strengthening the laboratory network
~
• Targets by 2010 MDR-TB 90% of MDR-TB patients will be treated in the pilot areas TB/HIV 80% of HIV-infected TB patients who qualified ART can receive ART during TB treatment in the pilot areas TB Laboratory 97% EQA coverage for smear microscopy 90% the EQA coverage for culture and DST. Increase the coverage of bio-safety cabinet to 30%
-Updated Plan of Activities 2008-2010To fulfill the National Development Plan on TB laboratory To establish the regional reference laboratory To Increase eligible starts To strengthen training
• Technical To expand culture at county level gradually To introduce the new diagnostics at different level To scale up the EQA coverage for culture and DST
• Financial To increase financial input on laboratory to improve the environment and facilities
• Financial plan • Technical: - MDR-TB: drug, hospitalization fee, infection control, lab, etc.
•
• Strategic planning : -Capacity building with the priority of budget planning, and the capacity of case management which would be the basis of policy and budget
Thank you
WORLD
HEALTH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUl' (TAG) lVlKKl'lNt; FOR THE WESTERN PACIFIC REGION Tokyo, Japan 22-24 July 2008
WPR/2008/DCC/06/STB(4)2008.3.1
ENGLISH ONLY
MDR-TB IMPLEMENTATION
CHINA
MDR-TB Control Implementation in China • ,. • •
Contents
22-24 July,2008 6'h Stop TB technical Advisory Group Meeting for the Western Pacific Region Tokyo, Japan
Key actions taken in TB control Achievements of TB control Progress in MDR-TB control Next step
-"'i Key Actions Taken Strong government commitment Developed Niltion;ll TB Control Programme (2001·20:1.0} Incre<~sing
Total Available Funding for TB Control in China (10,000 RMB)
goverment financial input
Providing the free diagnosis & drug for 0111 active pulmonary TB c.ases Established incentin mechanism for health worker in gr<~~uroot
health facilities
Improving TB control system, strengthening human resource development A professional team is available at national, provincial and loaf levels Established and improving TB laboratory network Strengthening collilboration between hospitals and TB dispe nsaries Training the TB control staffs at
an levels
Harmonized all available source to service for NTP
i
Achievements • Achieved the mid-term target of "National TB Control Programme(2001-2010) • Achieved the three global targets for TB control set by WHO
Achievements of TB control from 1991 to 2007 ~
/ -
I
/ • The case-detection rate still maintained 79% in 2006 and 2007 • DOTS strategy lays a solid foundation for MDR-TB prevention
l 1':' ~ I
I I I_ 1.1
I.
DOTS coverage rate •cure rate •detection rate
"'"* Progress in MDR-TB control {1) • MDR-TB control has been incorporated into National TB Control Programme implementation plan (2006-2010) - To develop the framework and implementation plan for MDR-TB control - To carry out pilot study on MDR-TB cases treatment and management in pilot area - By 2010, 90% MDR-TB patients detected in pilot area will be treated - To conduct DRS 7
i
Progress in MDR-TB control (2) Developed the nattonal framework for MDR-TB control with following principles: To maintain and strengthen quality DOTS strategy implementation for preventing MDR-TB To implement MDR-TB control programmatic management based on high DOTS quality To engage TB special hospitals into MDR-TB prevention and control network To strengthen international cooperation
j
Progress in MDR-TB control (3) • Implementing the national baseline survey of DR-TB Duration of field work: Apr. 2007 · Dec. 2008 Scope: 70 counties in 31 provinces Sample : 4,617 smear positive PTB cases Results : will be obtained in early 2009 • The impact of national baseline survey of DR-TB Improved the capability of culture and DST - Will provide the evidence for MDR-TB control policy making
i
Progress in MDR-TB control (4) Ongomg International cooperation • GFS Duration: Oct. 2006- Sep. 2011 . Coverage: 31 DOTS-Plus sites in 6 provinces . Target : to find and treat 4,470 MDR-TB cases . GF Funds: 12 million USD
• GF7 Duration: Jul. 2008- Jun . 2013 Coverage : 50 DOTS-Plus sites in 10 provinces Target: to find and treat 11,000 MDR-1ll cases Funds: 64 million USD
--=* Progress in MDR-TB control (5) Other international cooperation • New diagnostics technical study - Foundation Merieux -GATES Foundation • Relevant training - Lilly project
:)
Next Step
• To maintain high quality DOTS to prevent drug resistant TB • To summarize the experience from pilot study • To seek policy support on MDR-TB prevention and control • To put forward TB legislation including MDR-TB • To strengthen capacity building on: - Strategic planning - Programmatic management -Technical capacity II
11
Thank you for your attention !
WORLD
HEALTH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROU.P (l'AG) lVlli.Kl'lNt; FOR THE WESTERN PACIFIC REGION Tokyo, Japan 22-24 July 2008
WPR/2008/DCC/06/STB(4)/2008.4 11 July 2008 ENGLISH ONLY
COUNTRY ACTION PLAN 2008-2010 LAO PEOPLE'S DEMOCRATIC REPUBLIC
MDRTB -Current SituationLAO PDR
Action Plan 2008-201 0 Focuiino on MDRTB, TB-HI V, and laboratory capacity strengthening
6th
22-24 July, 2008 Stop TB Technical Advisory Group Meeting for the Western Pacific Region Tokyo, Japan
• Estimated 3.7% MDR rate among never treated cases and 19% among previously treated cases tWHO, LAO PDR country profile, 2006) • No DRS conducted • 3.5% failure among re-treatment TB cases (category 2) reported by NTP (30/864, in cumulated cohorts 2000-2006) • No MDR policy, guidelines • No culture, DST
MDRTB -Major Challenges• • • • • • • Start culture, DST Need full time microbiologist Apply to GLC Elaborate MDR policy, guidelines Conduct first DRS Training staff on management of MDR Manage second line drugs Technical assistance
MDRTB -Updated Plan of Activities 2008-20102008 Develop culture, DST in NRL First DRS Apply to GLC Establish one MDR-TB unit Culture for all chronic cases Culture for re-treatment cases Treat MDR patients Technical Assistance for MDR case management X X X X X X 10 6 mo 2009 2010
TB/HIV -Current Situation- (2 TB units, 2007) 0.1% HIV prevalence in 15-49 population and 2% in high risk groups (CHAS, 2005) 292/100,000 prevalence ofTB all forms (WHO, 2006) 7.5% of TB patients newly HIV tested (302/4013) 9.6% HIV + among newly HIV tested (29/302) 196 TB-HIV cases (4.9% of all TB cases) including 167 PLA and 29 newly tested HIV+ - 7% (14) PTB smear positive, - 74% (146) PTB smear negative, - 18% (36) EPT
TB-HIV co-infection, Lao PDR HIV +/
2ll
O~PIA
newly tested
:m ~ 1~
-;;
........... 1-- 1"'" 2tl:ri':'=Z042JlMllf:ml
.-......
[]~ r-
.--
2001 2002 2003 2004 2005 2006'
2!70 4/55
I
PLA
I
Total
8 37
10 8
6/1 40 81210 10/1 91 161304 29/302
•
43 78 84 112 196
70 74 96 167 114
CPT and ARV but no IPT TB-HIV guidelines and M&E not finalised
= :, .•-11
,..
2007 2008 (6 Mol
51132
I
119
• Start 2d TB unit
1
TB/HIV -Major Challenges-
TB/HIV -Updated Plan of Activities 2008-20102008 2009 2010
Finalise M&E system for TB-HIV Finalise TB-HIV guidelines Scale-up rapid HIV testing in more TB units Training staff on counselling , testing and management of TB-HIV
Finalili& MB,E liylit&m TB-HIV Guidelines Training on HIV counselling and testing and management of coinfection % TB patients tested for HIV (GF round 7 targets) TA on management of coinfection
X X X X
10%
20% 130% X
X
Laboratory capacity strengthening -Current SituationExisting NTP laboratory manual on microscopy and EQA No manual for culture • EQA of microscopy since 2004 • No panel testing No culture/DST NRL bio safety to be upgraded • Prevalence survey (8000 cultures in 6-8 months) in 2008-2009
Laboratory capacity strengthening -Current Situation- (2007) [1] No, of TB microscopy units [2] having had at least one round of blinded-rechecking (EQA) (average 2007) [3] with poor performance (average 2007) [4] on site visit if poor performance found during last EQA ( 2007): [5] Total number of culture units [6] Total number of DST units 154 150 98%
15
10%
18/62 29% 0
I
0
Laboratory capacity strengthening -Major ChallengesLack of coordination and consensus in use of laboratory network (policy, technical choices, SOP, laboratory management, quality control) Upgrade NRL and 2 regional laboratories HR for culture/OST in NRL and culture in 2 regional labs Technical Assistance Conduct prevalence survey Conduct DRS
Laboratory capacity strengthening -Updated Plan of Activities 2008-201 02008 Upgrade NRL and 2 regional laboratories X X X X X X
2009
2010
Prevalence survey First DRS Culture all failure and re-treatment cases Microbiologist in NRL Additional laboratory staff
12 me 2
12mo
4 3 me
4 3 me
Technical Assistance 11
,
2
Targets by 2010 MDRTB • Fir~t nRfl r.nnrtur.tP.rt • Culture for all chronic and re treatment cases Treatment of 10 MDR cases TB/HIV • 30% of new TB patients tested for HIV TB Laboratory • Capacity for culture and DST
Action Plan 2008-2010 for MDRTB, TB-HIV, and laboratory Global Fund (US$) 2008 Upgrade laboratories
2009
2010 07,01!0 134,400
300 ,000
97 ,550 87,0.i:!O
R.vDg9f\h:1Runnioa vvm fvr h1b1t Send samples Quality assurance Upgrade 3 TB units (for TB-HIV} Upgrade one MDR unit
75,5;1:0 124,896 21,513 29,000 39,585
134,400
21,573 29,000 35,000
21 .573 29,000
DRS 2d line drugs and GLC Human resources
82,450 239,098 263,600 346,430 1.439,702 260,119 274,600 341 ,107
281,989 251 ,200 347,903 1,236,435
Technical Assistance
Tnalnlng Total
a n-d-~IM!rviDon
1,;!81 .269
,.
3
WORLD
HEALTH
ORGANISATION MONDIALE DE LA SANTE
ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION
WPR/2008/DCC/06/STB(4)/2008.5 11 July 2008 ENGLISH ONLY
Tokyo, Japan 22-24 July 2008
COUNTRY ACTION PLAN 2008-2010 MALAYSIA
TB/HIV
Country: Muluysiu Action Plan 2008-2010 MDRTB, TB-HIV, and Laboratory Capacity Strengthening
Current Situation No. ofTB, HIV and TB/ HIV Cases, Malaysia 1986- 2007 wH rl w"l'JIHty a n
"""' 22-24 July, 2008 6'h Stop TB Technical Advisory Group Meeting for the Western Pacific Region Tokyo, Japan TB/Leprosy Control Unit & AIDS/STD Seer/on Disease Control Dwision, Ministry of Health Malaysia
JJJJJJJJ~~~J ~ MDRTB Major Challenges D MDRTB surveillance • • lab based 0 routine OST, no 2nd line drugs testing clinical based D enhancement in present TB reporting system & MOR registry High risk TB ward Drugs Addict Defaulter Reviewing of CPG
MDRTB Current Situation D D 0 0 0 D
Patient management in the CPG but not XDRTB Managed by Chest Physicians as in·patients All anti-TB drugs including free 2"d line drugs free No fund received from donor DST is done routinely for non-conversion PTB 55+ at the end of 2-month intensive phase and all re-treatment TB cases Sensitivity test results : 2004 No. of isolates tested
0
Adherence to treatment • • •
2005 5,493 472 17
2006 6,386 539 42
2007 6970 456 37
D D
Standardisation of 2"d line drugs •
4,147 NA
HRD • Increase number of skilled physicians and dedicated team • Incorporate MDRTB management In presen t training curricula
No. of monoresistant No. of MDR-TB
13
D
Costs • Alternative access to 2 11d line drugs ~ ? GLC
MDRTB Updated Plan of Activities 2008-2010 0 Improve documentation and reporting system for DST/MDRTB/XDRTB - to link data between TB laboratory and NTP Increase early detection of MDR·TB using new diagnostic tool Central procurement of 2nd line TB drugs Specially trained MDRTB team to be established Involve private sector in standard TB treatment and care Propose research opportunity
TB/HIV Current Situation No. of TB, HIV and TB/HIV Cases, Malaysia 1986- 2007 •HIV •TB/H!V •TB
0 0 0 0 0
"""'
"""'
-
I
JJJJJJJJ~~~J ~
TB/HIV Current Situation 0 Joint collaborative mechanism • TB & HIV programmes under Disease Control Division, Ministry of Health Malaysia • All TB & HIV activities including prevention, treatment care and support are funded by the government • separate steering committees on TB and HIV programmes • non governmental organisation (NGO) involvement in HIV and TB promotional activities • 19 March 1997- Issuance of policy on routine HIV screening among TB patients (option out) • 2002 - Guidelines on TB screening among HIV patients • 2005 - Guidelines on TB & HIV screening in prisons and drug rehabilitation centres • TB & HIV screening and treatment services are provided by primary health care (PHC) & hospital with specialist • H o oPT is pro"ided tree in go"emmes:~t facility
TB/HIV Major Challenges 0 0
---------------------------
TB & HIV collaborative activities between TB and HIV programmes Commitment by non health sector Prison and drug rehabilitatio n centre authorities 0 Segregation between TB 11nd HfV tillses
0
DOT implementation
•
D Post-release continuation of TB and HIV treatment Immigration department 0 Deportation
or TB 6. HJV case to
country of origin
0 0 0
Immigrants • •
(documented&. non documented) Health education In the country of origin Continuation of care
Involvement of NGOs in TB/HIV co-infection Community participation e.g . as DOT supervisors
TB/HIV Updated Plan of Activities 2008-2010 0 0 • • • Priorities on TB & HIV in 9'" Malaysia Plan towards achieving MDG Strengthen TB & HIV collaboration at national level to form the National Committee for TB-HIV implementation of joint TB/HIV strategic plan development of National AIDS Registry with TB data management component Strengthen TB-HIV infection control in congregate settings Improve universal access among TB-HIV patients especially on ART Propose policy on TB prophylaxis for HIV positive patient Strengthen multi-sectoral approach Other agencies, orivate sector. NGOs and community D D D 0 D 0
Laboratory Capacity Strengthening Current Situation National Public Health Laboratory (NPHL) in Sungai Buloh, Selangor is the TB National Reference Laboratory IPR and Johor Bahru Hospital are preparing to carry out DST for anti-TB drugs
~~~i~i;~{j~~o~~~t~~~IJ~~i~gJ~~'f f~~h{,~)li~~da~~~~~~er~~ 5Respiratory 2nd
line
o 0 0 0 •
~~~;~~~~~~~~ ~i~~f~~~t~~9~) b~~a~:~ rechecking on {055) Services are fully funded by the Malaysian government Performances ·
6
Smear microscopy_l Culture No. of laboratory Laboratory with EQA Laboratory with non EQA
DST
656 277
_l
14 4
3 3
1
l
I
Laboratory Capacity Strengthening Major Challenges 0 Coordination between NTP laboratory services (NPHL) and pathology services Upgrading and maintenance of TB laboratory infrastruture National guidelines on culture, DST, occupational safety & health for laboratory workers currently specific to each hospital but not standardised at nationa level. Hospital laboratory Competency and human resource development
Laboratory Capacity Strengthening Updated Plan of Activities 2008-2010 o Laboratory quality assurance (QA) programme- to 0 0 0 0 expand EQA blinded rechecking for DSS to other states Utilization of new diagnostic tools for DST Proposal on regional pathology centres for microbiology (including TB) services Capacity building 1 human capital development Expansion of data collection for improved monitoring e.g. reJected & contaminated samples; Non Tuberculous Mycobacterium (NTM) results ; mono-, MDR-, XDRreslstant rates Laboratory data access at NTP
o 0
o ~~;'b~t~7~~~t~~sr;~,?J~';;~;id~i~ii~gho~rt~~'¥~ 0
0
Core National Targets by 2010 MDRTB Patients under second line drugs
Core National Targets by 2010 TB/HIV No. HIV-positive TB patients on ART HIV-positive TB patients eligible for ART Target: 90% Rationale: High mortality among HIV-positive TB patients (~20%)
Identified MDR-TB patients in DOTS+ programs Target: 90%
Rationale: DST for diagnosis should be implemented where second line drug regimens are available Expected result: Expansion of the coverage of
DOTS+ 10% of treatment Failures (cat 1 and cat 2)
with DST by 2010
Core National Targets by 2010 TB Laboratory 0 DSS Overall Agreement Rate > 90% 0 MTB Culture Growth Rate > 90% 0 MTB Culture Contaminated Rate < 2.5%
Financial Plan 0 0 Rough estimate costs for Action Plan 2008-2010 in 3 areas - TBHIV, MDRTB and Laboratory Funding gap • HIV screening, 2nd line drugs and lab (supply & equipment) using operation budget • No long term budget planning focusing on 3 specialised
areas
• HRD for dedicated team in 3 activities
0
Overcoming gap • central purchasing and supply • annual budget allocation and review • alternative access to 2nd line drugs
0 Monodrug Resistant Rates 0
Anticipated available resources • Annual HIV programme budget • Multi-sectoral approach
Thank You
WORLD
HEALTH
ORGANISATION MONDIALE DE LA SANTE
ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION
WPR/2008/DCC/06/STB(4)/2008.6 11 July 2008 ENGLISH ONLY
Tokyo, Japan 22-24 July 2008
COUNTRY ACTION PLAN 2008-2010 MONGOLIA
MONGOLIA
Political commitment An official order was issued by the Health Minister in 2003,2005 mandating DOTS and MUK-1 t:; management • The Government supports the DOTS and MDRTB operational costs, food for patient and salary staff Developed Plan for procurement of drug, 20082009. First-line drugs are allocated in government budget since 2008
Action Plan 2008-2010 Focusing on MDRTB, TB-HIV, and laboratory capacity strengthening
Dr. N. Naranbat MD, PhD 22-24 July, 2008 61h Stop TB Technical Advisory Group Meeting for the Western Pacific Region Tokyo, Japan
SURVEY OF
M. TUBERCULOSIS DRUG RESISTANCE IN MONGOLIA
MDR-TB CASES in Mongolia YEAR 2003- 2008 .MAY
n~::;n. l)'i oii!I~J ~
-~ P1il l;!.fi.OI(I , 2000 56 55.4% 5.4%
.....
llt»! rt:~ltmn~l
'-"11.: 2005
N,.,.CII_.. 2007 (N~t~n;~U
R~1 t uimenl IIOU.I'i~ 2D07
jN.-!iiJI'IOII I)
Total Number ANY RESISTANCE
405 29.4% 24.2%
125 62.4%
405 25,2 Ufl
190
42.6% 37.4% 38.9% 23.4% 37.7% 28.9%
s H E
R MDRTB
15.3% 1.7% 1.2% 1.0
10.7% 0.0% 0.0% 16.1% 26_4%
16.8% 14,3% 2.5% 4%
2.2%
MDRTB Major Challenges 1400
MDRTB -Updated Plan of Activities 2008-2010-
• Lack of human resource • Lack of knowledge and capacity in counseling and side effect of SLD • Stigma and discrimination causes patient MDR-TB, especially general population • Lack of management of SLD • Lack of patient support from family, the government
1200 1000
800 600 400 200
Jun.Oeo: '06 Jan-Du 07 Jan.Oec'OB
Jan-Oee'09
Jan-OK '10 Jan.Oec'11
Jan-Oec'12 Jan-Oec: '13
IRound 4- GFATM
II RCC-GFATM
1
TB/HIV -Current Situation-
TB/HIV -Major Challenges-
• Reported 41 HIV/AIDS patients (1982Jun 2008) • 8 patients died, HIV/TB 2 (25%) cases • 5 (12.3%) HIV/TB patients reported • 2 cured TB, 1 Tx ongoing • Now 33 HIV positive patients living, every 3 month counted CD4, x-ray • IPT now started
• Insufficient collaboration between NTP ond NAr (No joint coordination body, no joint planning and monitoring) • Weak information system of TB/HIV • Lack of capacity of health care providers in managing HIV/TB • Counselling before HIV test • Community participation
TB/HIV -Updated Plan of Activities 2008-201 0Establish joint coordination body (Joint Technical Committee)- (2008) Establish reporting system of HIV!TB- (2008) Develop, adopt WHO guidelines on management of TB/HIV- (2009) • Improve capacity of health care providers on management of HIV!TB co-infection -(20082010) HIV testing of all TB cases -(2008)
Laboratory capacity strengthening -Current SituationDescription Units Microscopy Culture
DST 1 1185
36 75257 36 units I 7556
1 7525
Examination
EQA of smear microscopy On site visit
1 lab. Staff In the International lab training
1 1 staff in TB meeting
11 aimags, 13 times 8 districts, 24 times
Laboratory consultant S.Mitarai came on Jan, 2008
Training lab J ech
Basic training -4
lab.tech
Laboratory capacity strengthening -Major ChallengesActivities Major problems and constraints to strengthen laboratory capacity >-Weak of relationship the laboratory networlc
Laboratory capacity strengthening -Uodated Plan of Activities 2008-2010 Duration I. Strengthening the laboratory network 11 National seminar for lab technicians 1.2 Five-day training worshop for new laboratory technicians L3 Re-training workshop for laboratory technicians (2 days) 1 4 Advance international laboratory training (RIT course) 1 5 Technical assistance by supra national lab II. Implementing laboratory quality assurance system 1.6 Developing a quality control (QC) mQ/!i.l~ fO( labcr.lkl!le;s (adaptation, translation and printing) 1.7 Onsite evaluation and corrective action 1 8 Conduct blinded slide rechecking (no GF cost) Ill , Establishing Specimen Transport System(STS) 1,9 Review workshop of existing pilot specimen transport system, and refine protocol, policies, and guidelines 1.10 Three-day TOT of aimag STS coordinators (HD officer), TB officers and lab officers (8 aimags) 1,11 Training for health workers (aimags and scums)
0 2. 2009 03-04 2008 2 times in year In 2009 yearly
- Turnaround times feedback of the EQA -Lad af r: ommun/coaJlon blltWHn lillltiV~ labOr.i lDrlM ';>Lack of Implementation laboratory quality assurance system -insufficient corrective action in poor performance of microscopy units -in sufficient on site visit to provincia/laboratory
-lack of quality assured culture and DST );>Un established Specimen Transport System (STS) in the peripheral level
03 .2008 Quarterly 2008-2010 Quarterly.2008-201 0
- weak of devolopment communication system at soum to aimag -Lack of supply and transportation cost of specimen transpott - lack of knowledge about infectious materials transportation of health workers in soum level
03. 2008 03·04 2008 01-04 2009.2010
2
Targets by 2010 MDRTB 90% DOTS plus treatment coverage of MDR- TB patients - Conducting national MDR-TB sutvey 2007 -
Stop TB Plan 2006-2010: Estimated costs (million USD) 2006 Needed Government
2007 2.98 1.50 0.98 0.50
2008 2.98 1,60 1 03
2009 2.89 1.70 0.74 0.45
2010 2.M 1.80 0 1.00
-
All failure cases tested by DST 2006-2010 J~.;drul.l up OOT'!-J.J/u1 .!01)(1-J:O 10 o~~l.:IIIJt:'
11•~
LUll:!
tldUUII.:!IIldtyt!IJ,-
:3.00 1.50 1.01 0.25
TB Laboratory Case detection rate beyond 70% - national programme review (2008-) - guideline for diagnosis and treatment of smear negative TB {2008) - 10% of cases notified under pro-poorTB initiatives TB/HIV At least 80% ART coverage of HIV+ TB patients 70% of TB patients tested for HIV 2006-2010 80% of HJV+ TB patients provided ART 2006-2010
GFATM Gap RCC
0.35 1
3
WORLD
HEALTH
ORGANISATION MONDIALE DE LA SANTE
ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION Tokyo, Japan 22-24 July 2008
WPR/200RffiC.C./06/STR(4)200R.6.1
ENGLISH ONLY
MDR-TB IMPLEMENTATION
MONGOLIA
DOTS plus= DOTS first MDR TB implementation in Mongolia 22-24 July, 2008 61h Stop TB Technical Advisory Group Meeting for the Westem Pacific Region Tokyo, Japan
Trend of TB mortality
t.•lllllllllll ITreatment outcome of re- treatment case, Mongolia I M99&.2006 0111 SURVEY OF
M. TUBERCULOSIS DRUG RESISTANCE IN MONGOLIA
80,------ - -- - - - - New COd.
60 Total Number
,,.
.... WQSII
~t:. tr~l
pr1 1M IIIIIUI , 20D0
.. M
{Nnlonll~
405 29.4%
56
125
-
N_.~H II,
i Nilllwl•ll
'''"
c-.. n , 2007 jN.UMI")
405 25.2% 16.8 '.4 14.3%
190 42.6%
40
ANY
RESISTANCE
55,4%
62.4%
20 or--.-.--.--.-.-~-~--
s H E R MORTB
24.21/a 15.3% 1.7%
5.4% 10,7% 0.0% 0.0%
37.4% 38.9% 23.4%
1.2% 1.0
2.5% 4% 26.4% 2.2 %
37.7% 28.9 %
16.1%
1999
2003
2004
2005
2006
-- 1 After defaulted I
1
TB control in Prisons DOTS cohort analysis 4-LtJrea .· completeo IJied-~alled
Political commitment An official order was issued by the Health Mini!ter in 2003,200!i mandating DOT3 and MDR-TB management • The Government supports the DOTS and MDRTB operational costs, food for patient and salary staff
90 80
70 60
so 40 30 20
/ ~ -:O:l::::ii;; -
--------
Oetaulted....,...Transout
--
--
10 · -
0-
==:;::::::::~::::::::::=-':::::~ ~~ 2004 2005 2006
-
2003
Developed Plan for procurement of drug, 20082009. First-line drugs are allocated in government budget since 2008
MDR..TB: no defaulter; transfers are well coordinated through Prison doctor, supervisor and WV volunteer
Background Apr '05: GFATM Reference laboratory renovated Mar '06: GFATM Reference laboratory renovated Apr '05: GFATM-Round 4 started implementation - Objective 3: to provide services for 375 MDR-TB patients (improve laboratory capacity to support DOTS-Plus and monitor drug resistance) 18 Nov '05: MOH submitted an application to the Green Light Committee (GLC) 17 Jan '06: GLC approval 29 Jun '06: First MDR-TB patient was enrolled on Total of 132 patients started on treatment (Jun '06- 20 May '08) May '08: signing of the Rolling Continuation Channel (RCC): extension of Round 1 = 790 patients (TOTAL= 1,165 patients)
Background: Implementation of MDR-TB Management in Mongolia: GFATM 1400 1200 1000 100 600
IRound 4- GFATM
II Rcc-GFATM
MDR-TB CASES In Mongolia YEAR 2003-2008 MAY
Detected
Treated 102 (49%)
Treatment Outcome: early analysis N=132 (Jun '06-May '08) Cured Com pi
UB Aimags
207
Died
Defaulted
Failed
eted
Transf erred out
Tx
ongoing
Prison
18 332
Overall MDR Ward/Dispe nsanes n=112
7 4
1 1
10
3
5 3
3 0
106 17 lnW; 79 ln Disp
TOTAL
3inW;7 3 in Olsp
Prison Hospital n::o16 MDRTx Unit n=2
3
0
0
0
2
3
B
NIA
N/A
0
0 Jun-Oec 83%
NIA
0
2 Apr-Jun '07 53% 5% 32%
6-montlllnterim ~Ius Cut1ure (-) Culture{+) Culture missed
·os
Jan-Mar ' 07 83% 11 %
8% 8%
6%
2
Case report on patients who died while treated for MDR-TB Jul,2008
Major Challenges • Lack of human resource • Lack of knowledge and capacity in counseling and Tx side effect of SLD • Stigma and discrimination causes patient MDR-TB, especially general population • Lack of management of SLD • Lack of patient support from family, the government
,...__._. 0111 11 "'M -.do
...
r,._. ll
Average 11.4 month
Major Challenges
Stop TB Plan 2006-2010: Estimated costs (million USD) 2006 Needed Government
Infection control plan need Guidance on appropriate administrative, engineering controls and proper use of personal protective equipment High default (13%) among the homeless patients discharged from E:nerel; no civil registration, no health insurance Ward and Prison patients are transferred to dispensaries Defaulter mechanism needs to be ensured
2007 2.98 1.50 0.98 0.50
2008 2.98 1.60 1.03 0.35
2009 2.89 1.70 0.74 0.45
2010 2.80 1.80 0 1.00
3.00 1.50 1.01 0.25 1
GFATM Gap RCC
3
WORLD
HEALTH
ORGANISATION MONDIALE DE LA SANTE
ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION
WPR/2008/DCC/06/STB(4)/2008. 7 11 July 2008
Tokyo, Japan 22-24 July 2008
ENGLISH ONLY
COUNTRY ACTION PLAN 2008-2010 PAPUA NEW GUINEA
MDRTB Papua New Guinea -Current Situation• Category II failures considered as 'MDR-TB' • No laboratory diagnosis of MDR-TB yet - Occasionally, samples sent to Australia for testing
Action Plan 2008-2010 Focusing on MDRTB, TB-HIV, and laboratory capacity strengthening
Number of 'MDR-TB' cases treated in country: Dr Joseph Bana Koiri 22-24 July, 2008 61h Stop TB Technical Advisory Group Meeting for the Western Pacific Region Tokyo, Japan - About 10 treated per year in national hospital - About 5-10 treated per year in other hospitals
• WHO treatment regimens for MDR-TB are used • Dne_ siucly_conducted in 2006-07 in Madang - 5/64 (8%) new cases tested MDR-TB+, in Australia - 1/5 (20%) re-treatment cases tested MDR-TB+
MDRTB -Major Challenges and PlansNo laboratory diagnosis available in country yet - Work is now in progress to upgrade National Lab
TB/HIV -Current Situation 1• PITC is being promoted more widely (2008) - 27/221 (12%) TB+/HIV+ in two pilot areas, in 6 months
Erratic supply of second-line drugs, expensive - Country may submit proposal to GLC in 2009
• TB screening in people living with HIV (2006) - 715/42733 (1 .7%) screened for TB - 108/42733 (0.3%) were found to have active TB - 183/42733 (0.4%) were started on IPT
• No isolation ward for 'MDR-TB' cases - Country may submit a proposal to AusAID in 2009
No MDR-TB protocol yet - This is now being drafted, along with NTP protocol
No proper monitoring and evaluation system - Tech assistance required for training, protocol, M&E
TB/HIV -Current Situation 2TB/HIV included in both Country Plans TB/HIV policy drafted in 2005, not yet published TB/HIV being piloted in two biggest cities Position of TB/HIV coordinator being considered Quarterly meetings of national committee occurs TB/HIV included in new reporting formats
TB/HIV -Major ChallengesLack of a TB/HIV coordinator to focus attention Inadequate number of VCT sites for PITC • Difficulties arising from 'outdated' HAMP Act Infection control inadequate because less space INH prophylaxis therapy still not widely used
• • • • •
1
TB/HIV -Updated Plan of Activities 2008-2010• Technical assistance most urgently needed for: Rt:~vit:~w
Laboratory capacity strengthening -Current Situation• Coverage with external quality assurance (EQA) - LaiJ~ cuvl:!rl:!tJ IJy ~upl:!rvl~lurr . 11no ( 1~%) -Labs covered by blinded rechecking: 19/70 (27%) - Labs covered by annual panel testing: 30/70 (43%)
u[ t:~xi~lirry TB/HIV ~lcrlu~ .
irr[t:~r.:liurr
r.:urrlrul
-Drafting of country framework on the lines ofWPRO - Training of national and key-provincial coordinators
• TB/HIV pilots to expand as follows : - Five (of 20) capital cities by end of 2008 - Nine (of 20) capital cities by end of 2009 - 14 (of 20) capital cities by end of 2010
• Performance of labs as per EQA results: - Labs with major errors in blind recheck: 7/17 (41 %) -Labs with major errors in panel testing: 15/35 (43%)
• Written feedbacks to 100% of labs with EQA • Number of EQA Coordinators (SSAs): Three
Laboratory capacity strengthening -Major ChallengesNot enough lab technicians in the country • Ongoing training of sputum microscopists slow • Spare population creates problems with access • Supervision has been poor, although improving
Laboratory capacity strengthening -Updated Plan of Activities 2008-201 0• Training schools will conduct more LT courses • Expansion plan: - EQA to be expanded to at least 80% labs - Initially, aim to strengthen existing labs (quality) - Thereafter, aim to increase no. of labs (quantity)
• Ensure uninterrupted supply of lab kits (GDF) • Steps to start culture/DST: - First, ensure infection control in culture/DST lab - Then, start culture/DST services for 'failures' - Finally, start using new molecular diagnostics
Targets by 2010 MDRTB Start quality-assured culture/DST services • Conduct one sub-national drug resistance survey TB Laboratory At least 80% labs should be covered by EQA • At least 80% of those covered by EQA should 'pass' TB/HIV At least 50% of TB cases undergo PITC in capital cities • At least 25% of TB/HIV cases receive DOTS and ART
Financial plan • All resource needs are well documented in the Country Strategic Plan, and fully supported by: - Global Fund (for peripheral lab strengthening) - AusAID (for central lab strengthening) -WHO (for technical assistances)
2
WORLD
HEALTH
ORGANISATION MONDIALE DE LA SANTE
ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION
WPR/2008/DCC/06/STB(4)/2008.8 11 July 2008
Tokyo, Japan 22-24 July 2008
ENGLISH ONLY
COUNTRY ACTION PLAN 2008-2010 PHILIPPINES
MDRTB
PHILIPPINES Action Plan 2008 - 2010 Focusing on MDRTB, TB-HIV and Laboratory Capacity Strengthening
• National DR5 (200J • 2004): 21% (Previously Treated) 4.4% (New) • 2009 - proposed schedule of 2nd DRS (based on RCC o
A.O. No. 2008-0018 " Guidelines for the Implementation of the Programmatic Management of Drug-Resistant TB (PMDT)"
22-24 July, 2008 61h Stop TB Technical Advisory Group Meeting For the Western Pacific Region Tokyo, Japan
• DOTS Facilities (Public, Private/PPMDs) • Communities (Decentralization) • NTRL, Public, Private hospitals (Laboratory)
MDRTB o
PMDT Training Modules (WHO assistance) Central, Regional, Provincial/City - Trainers Technical Support- Private partner (TDFI)
1,110 cases: 1999 to May2008
ICure Rate n =474 1 100 80 60
o
Area Expansion (Outside Manila; Region 7 and 4A) Government Procurement and Distribution of SLDs Initial Government procurement
P--
./"'"
o
40
/ 1999 2000
""
= 120 cases
20 0
2001
2002
2003
2004
2006
MDRTB - Major Challenges Prevent MDRTB: Sustaining quality DOTS implementation o • Engaging all care providers on DOTS especially the private sector Cure Existing Cases: • Maintaining a network of quality laboratory services Need for rapid and accurate diagnosis Assurance on the availability of 2nd line drugs • Development of human resources (technical and managerial capacities)
MDRTB Updated Plan of Activities 2008-2010 • Expansion of PMDT implementation Other regions: Luzon, Visayas, Mindanao PMDT Facilities: Public and Private/PPMDs Technical assistance on infection control activities Joint monitoring and evaluation of PMDT Drug management, Data management • Conduct of the 2nd DRS Support from RCC In Partnership with NTRL, TDFI, WHO
1
TB- HIV • Estimated prevalence of HIV in TB cases = 0.1% (WHU global report 2008)
3,000 2,500 2,000 1 , ~uu
_ = __ 1--
~
1 ,000
3,061 HIV seropositive reported cases (1984- 2007) Transmission : 88% sexual intercourse 35% of cases among the 8 million OFWs National TBIHIV Collaborating Committeero.o. No.1869 • Capacity building activities (Training) : - Health Staff on PICT - MedTechs on HIV Testing Proficiency - TB and HIV Coordinators on TB-HIV collaboration
500 0
-
- -
- - 1--
== --
8 Reactive O Tested
--
-
I-I--
DCou n~t!d
0TB _R.~t.steled
4th Q2007
1st Q 2008
2nd Q 2008
"Guidelines in the Collaborative Approach of TB and HIV Prevention and Control" - Screen all TB cases including MDRTB - Provider-Initiated Counseling & Testing (PICT) - Use of Rapid HIV Screening Kits - Provision of TB-DOTS treatment, ART and IPT
TB-HIV MAJOR CHALLENGES • Slow implementation of TB-HIV policies (Casefinding activities to include MDRTB cases) Availability of Trainers for PICT and for HIV Proficiency Testing • Skills of Health Staff on performing PICT • Infection Control in DOTS facilities Weak referral mechanisms • Limited data gathered during TB-HIV monitoring
TB-HIV Updated Plan of Activities 2008- 2010 • Scale-up the TB-HIV implementation Intensify implementation of 3 "l's" • Technical assistance to strengthen infection control measures (Harmonize with MDRTB activities) • Develop monitoring tool on TB-HIV (Include key indicators on 3 "l's'')
LABORATORY CAPACITY STRENGTHENING 1 - - - - - - - - · - -- ----,-·-----..,-------- --·-·!YPE~
LABORATORY CAPACITY STRENGTHENING • Capacity building of laboratory Staff (Training) -Basic Sputum Smear Microscopy - Quality Assurance System Certification/Accreditation of DOTS Laboratories
of 11/TP-DOTS Laboratories I 1) DOTS Microscopy Centers
2) Validation Centers ~.!! ·-' ProvlncialfCity level 3) CHD TB Refer!:!lce Labs. jj_ 7 ~j R~cfl!l level . ~-Cultur~ Ce~~r~J!£: PMD 7l 4 j.2 obllc:,._2 ~ivate 5) DST Centers (for PMD !2__ ' 2 1 e~blic , 1 E_riVate 6) National TB Reference Lab. f 1 , In M ~tro M ~ni ~
-·+-
~ ""ij~~de : Pubi~<:._J:fCs, PP:Y~~
No.
t.
R~m_~rks
(Developmental/Ongoing process) Monitoring and Supervision
• Policies on NTP-DOTS laboratory network Culture and DST in PMDT Guidelines Policies on EQAS for Sputum Microscopy
• National Consultative Lab Management Workshop
2
LABORATORY CAPACITY STRENGTHENING MAJOR CHALLENGES • Maintaining quality of laboratory services DSSM, Sputum culture and DST • Various concerns on expansion of lab services: - Human resources: # of Staff, skills, risk protection - Physical infrastructure - Infection control measures - Engagement of private lab facilities - Cost for expansion Integration with other laboratory services - HSS
Laboratory Capacity Strengthening Updated Plan of Activities 2008 - 201 0 • Ensure the proficiency of NTRL • Technical support to strengthen infection control Technical support to introduce rapid diagnostics Install additional culture centers -phased manner NTRL to finalize the policies on certification/ accreditation of culture centers Technical support to NTRL -conduct of 2"d DRS
TARGETS BY 2010 MDRTB (PMD T Implementation): • Treatment Centers installed = 32 • MDRTB cases under PMDT = 1,760 TB-HIV fPICT lmplemenfallon) : Total facilities • Total Health Staff trained • %New TB tested for HIV LAB STRENG THENING: • EQA implementation • Diagnostic tools available • Culture Centers installed DST Centers installed
FINANCIAL PLAN (for Activities in 2008- 2010) Components MDRTB TB-HIV Estimated Cost($) 3 million 750,000 Existing Source(s) Anticipated Source(s)
= 61 (w/ trained MTs)
= 1,328 (MD,PH(IJ,RHM) = 50 % of area coverage = still nationwide = DSSM,culture,DST = 29 (public, private) = 8 (public, private)
NTP, GF 5, WHO (T.A.) RCC NTP, GF 5 WHO (T.A.)
Laboratory 2.5 million NTP, GF 5, WHO (T.A.) RCC, USAID Strengthening
3
WORLD
HEALTH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION
W ¥W:lUU8/1Jl:l:/Ub/STH( 4):.ZUU8.8.1
Tokyo, Japan 22-24 July 2008 ENGLISH ONLY
MDR-TB IMPLEMENTATION
PHILIPPINES
r
Programmatic Management of Drug-Resistant Tuberculosis (PMDT}
Magnitude of MDRTB in the Philippines Local Studies/ Data Sources New Previously treated 14.5%
the Philippine Experience
Phil. National Survey 1997, Tupasi, eta! National Drug Resistance Survey (DRS) 2003-2004,
1.4%
ROSALIND G. VIANZON, MD, MPH NTPManager Department of Health Philippines
4.4% 21% (Global ave: 1.2%) (Global ave: 7.7%)
NTP, JICA, WHO
Success and Failures (New & Re-Treatment Smear +'s)
Treatment Failure Rate Smear +s, MMC DOTS Unit NEW
I 1999
Total
Failure+ MDR(%)
Re-Treatment Total Failure+ MDR(%)
I I
2000 2001 2002 2003 2004 2005 2006 Total
New
Re-Tx
New
Re-Tx
New
Re -Tx
2003
2003
2004
2004
2005
2005
30 23 28 12 27 37 11 10 178
1 (3.3) 1 (4.3) 0 0 0 1 (2.7) 0 0 3 (1.7)
9 15 14 13 7 15 15 7 9S
6 (66.7) 11 (73.3) 0 2 (15.4) 1 (14.3) 4 (26.7) 9 (60) 5 (71.4) 38 (40)
PPMD Unit at MMC (Privately-Initiated)
Evolution of a PPMD Unit into a DOTS-Plus unit
1
DOTS
is
STILL the OVERARCHING FRAMEWORf Sustained political commitment.
Types of PMDT Facilities
Political :=11. c!immltm<mtQ ality
~~ 2. Diagnosis of drug resistance
m c r~sco py s rv•ce R gular a allablilty or 1"11ne drugs
through quality-assured culture and drug susceptibility testing (DST).
I
I
f eatme nt Centers: ljreatment Sites: Culture Centers: DST Sites:
LJJ
• . r ore comprehensive/specialized management
D.O.T
P i
=JI3. Uninterrupted supply of .I quality assured second-line anti-TB drugs. 4. Ensuring treatment adherence through supervised treatment/D.O.T. trained Treatment Partners
EiJ ~.::.',:~~
I I
- fewer patients ( <10) being treated at a time
- perform microscopy and culture services
Standardized records and reports
~ 5. Records and reports designed for PMDT BUT anchored on the NTP data system
~=~~
- perform microscopy, culture, DST; with EQA functions
Mainstream into the Public DOTS
MDR-TB Priority Countries - 25 countries carry 85% of the estimated global MDRTB burden based on the following criteria: v" highest estimated MDRTB burden in absolute numbers (> 4 ,500 estimated cases) and/or v" highest proportion of MDRTB among all cases (> 10% of MDR-TB)
Philippines: - 131h of 25 high MDRTB priority countries - contributes to the 85% of the global burden
• 13 , U t h ... nh
DR·TB PRIORITY COUNTRIES
",.
£ ot onl o
lat ....
. ~
2 L I<:,yrcyutan
zo _ Cure t• 11 , Altrb ..J.., liS , :o.fyonmar
" "
T•Jlkht.., Moldava
... " "' ,.,
DR Co nco
.. 2 j
c
~
" 11 . Ethi o pia
14 Vl~t Nom Phlllpplnu
S,O 6
0
t, Ba11cluhsh Ulln ln•
.
7 NIE Uia
• RIIH
S o ul ~ I I II
f •••.-.HII•
A frfta
~ 20,000 40,000
I 60,000 80 ,000 100,000 120,000 140,000
Global Plan to STOP TB: * Treat 1.8 million MDRTB cases (2006- 2015) ~' 60% of cases in the 25 prioritized countries should be treated Programmatically in 10 years By 2015, there should be universal access to at least 80% of cases
~JTr~1<11l c - v Fo~"d~IID!I
2
GUidelines for the
oroe•Pmmatir. nmnHar.mRnt a! drug.resistant tube•culosis
New Guidelines Launched in 2006 World Health Organization
IThe Scale-up I
• Department of Health: (NCDPC) • CHD-MM
DOTS Elements: • Political commitment ./Acceptance of patients for decentralization ./Trained Staff complement: MD, Nurse(s), MT, Community Tx Partners • Quality-assured microscopy • Good practice of drug management is in-place • D.O.T. is done WITH defaulter-tracing mechanism(s • Maintains Quality data (TB records and reports) m
Tropical Disease Foundation
• Local Chief
Critical Requirements for PMDT Scale-up Establishment of Laboratory Network Supranational Laboratory
t. City Health Officers
D
r=:::=~> Le.velll/ lntermedia_ te
Level Ill/ Central
DST; Monitoring and supervision of culture laboratories Culture laboratories
1
PPMD Heads
\c:=:::::=>
1
CHD-MM
3
Critical Requirements for PMDT
Scal~-up
Metro Manila 2006 ,Valenzuela
"caloocan (Nor1h)
-
~
Metro Manila '~~ooc -:,_ by 2008 @ North) \ Valenzuela
HR capadty-~i~#.i.n~ ~·,· · ~· ·
.
·~
Quezon Ctty
l i;J\IOt,o:. Ma!aboo
Ma11tJna
Calooca~
Quezon City
Maflktna
_.:'/
·, . . . - - - = ' " "
·•.......\ Manil8 SanJuan Mar.da:uyong Pa s ~g~
1
~a ''1
SanJuan
·,
----lYJ • 'L' Pasay
~i
----l'\rl.
Manda:uyong Pasig l:
Pa ter os
n...
~1
Taguig
Pasay
T~
eros
Parat'laque
P<!rar'.aque ~~P~as
~.!sPmas
D. ~
·~"~-~.. ' v
O l>llO!!!l!!
lAGUNA
Critical Requirements for PMDT ~l
Scale-u~
Community involvement to facilitate a 8ecentralized approach * Treatment Centers * Treatment Sites Public-Private Partnership- en9.aging PPMD unrts.
I
Drug Cycle for znd Line Drugs
~
Private physidans need to be harnessed tv the DOTS strategy to prevent them from proliferating MDRTB.
BULACAN
Critical Requirements for PMDT nzueta 2 N ovoiHJt Malabo
R I ZA
f'l''' '' '"'''
Decentralization to the Community • Patients who are culture(-) are endorsed back to the health center, PPMD unit or faith-based group
·~ Standardized information/data system * Records and Reports * Within NTP system e.g. TB-MIS- pilot phase)
Scale-u~ I
* Monitoring, Supervision and Evaluation *Internal MSE *External MSE - GLC, WHO, GDF/MSH
h
''"''·· /_-' ••
4
PMDT Expansion under GF 5 And RCC
MDRTB Patient Accrual from Pilot to Mainstream to Scale-up 5000
4000
• New 0 Cumulative
3000
2008-2014
2000
1000
Milestones on PMDT 1999: DOTS-Plus Project (DOH, TDFI) 2002: GF 2 Approval 2003: MOU signing PMDT Mainstream (LCP) 2004: QI/PTSI partnership (KASAKA) 2005: Atimonan RHU (Community-based pilot site) GF 5 Approval 2006: MOU signing for Scale-up in Metro Manila (LCEs) 2007: NTRL strengthening for quality lab network 2008: A.O. 0018 s.,2008 "Guidelines for the Implementation of the PMDT"
Lessons Learnt <t· Quality DOTS is STILL the framework for managemen '!i7 Addressing MDRTB needs a stepwise approach
I+PMDT can be complex but is feasible ~ Partnerships
play part in the various stages of PMDT implementation needed resources
I* Opportunities should be optimize to generate the ·<fi The Global Response Plan emphasizes the need for
Training Modules on PMDT (thru W.H.O.)
good basic DOTS AND scale up of the PMDT: • DOTS decreases the generation of MDR-TB • PMDT breaks the ongoing transmission
5
WORLD
HEALTH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
SIXTH STOP TB TECHNICAL ADVISORY GROUP (TAG) MEETING FOR THE WESTERN PACIFIC REGION
WPR/2008/DCC/06/STB(4)/2008.9 11 July 2008 ENGLISH ONLY
Tokyo, Japan 22-24 July 2008
COUNTRY ACTION PLAN 2008-2010 VIETNAM
5th
Stop TB Technical Advisory Group Meeting for the Western Pacific Region 22-24 July, 2008- Tokyo, Japan
MDRTB - Current Situation - (1) • National Drug Resistance Survey 2005/2006 (3rd DRS): - MDR-TB among newly detected patients:
2.7%
- MDR-TB among previously treated patients: 19.3%
VIETNAM TB CONTROL PROGRAM
Action Plan 2008-2010 Focusing on MDRTB, TB-HIV, and laboratory capacity strengthening
• Estimated MDR-TB incidence: 6421 cases (2006) • Plans for 2010-2011 : 4th DRS cat. IV notification SLD surveillance ad-hoc survey
Prof. Dinh Ngoc Sy, MD. PhD. Director of Vietnam National Tuberculosis Control Program
MDRTB - Current Situation - (2) • Piloting PMDT project Phased implementation in 5 provinces in five years
MDRTB -Major Challenges• Shortage of staff: new activity, work in a potentially dangerous environment, hard to assure adherence to treatment. • Infrastructure for in-patients with MDR-TB: should meet requirement for infection control • SLDs management: procurement plan must be approved annually- risk of interrupted supply • Private sector: poor compliance with NTP guidelines may generate new MDR-TB cases
• Standardized regimens: Cat IVa : 6ZEKm(Ofx)PtoCs/12ZEMfx(Ofx)l'toCs Cat IVb: 6ZECm(Km)Mfx(Ofx)PtoCs/12ZEMfx(Ofx)PtoCs
• Intensive treatment phase given in hospitals and community-based continuation phase. • Free of charge for TB patients
MDRTB -Updated Plan of Activities 2008-2010Upgrading in-patients ward in PNT Hospital (HCMC) Upgrading in-patients ward and laboratory in Hanoi TB Hospital Upgrading laboratory in Da Nang and Can Tho TB Hospitals (2009-2010) Piloting DOTS plus project:
TB/HIV
2008 2009 2010
""' ""' ""'
"'"" ~ ~
2011
""'
...,.
-
"'"' ~
IS10pla
~
1-
I
TA: KNCV & IMVS (Adelaide) -laboratory str<ngthening and upgrading UNITAID Grant to implement rapid molecular test to detect MDR~TB
1
AFB (+)Notification trend 1997-2004 8 16000
HIV among TB patients Sentinel survey on 40 provinces
-Total Pts tested -Ptsw~h
HIV(+)
--%
~
~ c 4
J
14000 12000
"' ~ ~ 0
u ...
I
" .i c
...
1i -4
J 4 u4 ~ ~ r
rHfT+l ~
n
10000 8000 6000
I 65+
u total Total
I/
4000 2000
-8
15-24
25-34
• 35-44
~ 45-54
[ I 'I'
I/
v
1/
"'
v
~·
l/
55-64 Men
0
Years
l=:-:--::-:-----;--:----:--,--o=~=-,.,-,..,..,--~·0 Jn.fl work.rhop on data Blla/y:il of 'flN NTP, Nov' 2005
0
Women
0
1994 1996 1996 199719!18 1999 2000 2001 2002 2003 2004 2006 2006 ~l 20f?!O)!!!lc.. 1~1 40!l<ovU!ces I
•
Data from VAAC
TB/HIV - Current Situation!. Mechanism for NTP-NACP collaboration established • TBIHIV collaboration protocol developed • Joint TBIHN planning, co-ordination, M&E
TB/HIV -Major Challenges• Human resource limited in TB and HIV facilities Unmet need of ARV for all TBIHIV patients • Unmet need of HIV test kits for all TB patients • Diagnosing S- and E/P TB in PLWHA at district level
2. Surveillance imd Research • Sentinel surveillance ~ routine surveillance (WHO R&R formats being adopted countrywide)
3. Decrease the burden ofTB among PLWHAs • TB screening examination at OPCs, HIV/AIDS units • Piloting INH preventive therapy
4. Decrease the burden oflUV in TB patients • Provide HN testing and counseling at PITCNCT • Introduce CPT in 27 provinces
High proportion ofiDUs among TBIHIV patients makes difficult to reach and keep them on treatment • Social stigma against HIV/AIDS and TB
5. Human Resource Development • Training materials developed; • Training conducted: PITC, ICF, referral
TB/HIV -Updated Plan of Activities 2008-201 0Nation-wide implementation Guidelines at all levels Expansion ofPITC in TB system Apply 3 I's at HIV/AIDS system Improve early detection of TB/HIV cases for TB and HIV care and treatment (including IC, ART and CPT) Adopt revised Rec&Rep system in both HIV and TB sites Strengthening referral system between TB and HIV units of TB/HIV Collaborative
Laboratory capacity strengthening
2
Laboratory capacity strengthening -Current Situation1 National Reference laboratory and 1 Regional laboratory with smear, culture and DST capacity At least one laboratory in each district with sputum smear examination ~opacity and under iiQ/\ ~yctom (- 700 lobo) LQAs method successfully piloted in 4 provinces, all provincial staff now trained, full nationwide implementation by 04/2008 Culture-perfonming laboratories: 33, Only 5 of them assessed by EQA DST labs: 2 (Hanoi & HCMC) Recent agreement with IMVS (Adelaide) to become SRL VietNam among the first 16 beneficiaries of UNITAID grant for MDR-TB rapid molecular test
Laboratory capacity strengthening -Major Challenges-
• Shortage of lab-technicians at district level • Inadequate laboratory capacity in provinces • Slow implementation of EQA for culture • Upgrading of bio-safety level for culture/DST
Laboratory capacity strengthening -Updated Plan of Activities 2008-2010• Training and retraining for technicians at district level • Nation-wide expansion ofLQAs • Plan for expanding more laboratory with culture capacity at provincial level (45), DST capacity (4) • EQA and T A by supranational referral lab (IMVS) • Lab strengthening and infection control in MDRIHIV high prevalence settings by PEPFAR funding (through KNCV) • Piloting of rapid molecular test for MDR-TB (UNITAID) MORTS
Targets by 2010
• Number of labs with culture & DST service: • Number of Tx sites established & functioning:
4 4
• Number of MDR TB pts enrolled on treatment: 915 Percentage of patients enrolled in a cohort becoming culture negative after 6 mo. of treatment: 65% • Percentage of MDR-TB patients registered in specific period that were cured plus number that completed treatment (treatment success rate): 70%
Targets by 2010 TB/HIV - No of provinces with coordinating TBIHIV body:
Targets by 2010 TB Laboratory 50
• Suspects examined/population:
1%
- No of provinces offering HIV testing to TB patients: 50
-Percentage of known HIV!TB pts receiving CPT: 100%
• Number and percentage of microscopy centers adequately equipped: 688 (95%}
• Number of provincial laboratories which can perform culture: 45
3
Financial plan AREAS MDRTB (include laboratory) TB Laboratory 2008-2010 GAP?
$4mil
???
$2,7mil
??? -ARV - HIV test kit - ???
TB/HIV
$ 1,4 mil
4
Rapid Molecular Screening for Multidrug -Resistant Tuberculo sis in a High-Volu me Public Health Laborator y in South Africa Marinus Barnard\ Heidi Albertz, Gerrit Coetzee 3 , Richard O'Brien 2 , and Marlein E. Bosman 1 1
Genev<~. Switzerland; and 3National TB RP.fP.r~>nrE' I ahnratnry, NHI
National Health Laboratory Services (NHLS), Greenpoint, Cape Town, South Africa; 2 Foundation for Innovative New Diagnostics {FIND), S. Sanrlrinaham. JnhilnnP,hllrCJ, ~n11th Afrir~
Rationale: The dual challenges to tuberculosis (TB) control of HIV infection and multidrug resistance are particularly pressing in South Africa. Conventional methods for detecting Mycobacterium tuberculosis drug resistance take weeks to months to produce results. Rapid molecular testing for drug resistance is available but has not been implemented in high-TB-burden settings. Objectives: To assess the performance and feasibility of implementation of a commercially available molecular line-probe assay for rapid detection of rifampicin and isoniazid resistance. Methods: We performed the assay directly on 536 consecutive smearpositive sputum specimens from patients at increased risk of multidrug-resistant (MDR) TB in a busy routine diagnostic laboratory in Cape Town, South Africa. Results were compared with conventional liquid culture and drug susceptibility testing on solid medium. Measurements and Main Results: Overall, 97% of smear-positive specimens gave interpretable results within 1-Zdays using the molecular assay. Sensitivity, specificity, and positive and negative predictive values were 98.9, 99.4, 97.9, and 99.7%, respectively, for detection of rifampicin resistance; 94.2, 99.7, 99.1, and 97.9%, respectively, for detection of isoniazid resistance; and 98.8, 100, 100, and 99.7%, respectively, for detection of multidrug resistance compared with conventional results. The assay also performed well on specimens that were contaminated on conventional culture and on smearnegative, culture-positive specimens. Conclusions: This molecular assay is a highly accurate screening tool for MDR TB, which achieves a substantial reduction in diagnostic delay. With overall performance characteristics that are superior to conventional culture and drug susceptibility testing and the possibility for high throughput with substantial cost savings, molecular testing has the potential to revolutionize MDR TB diagnosis.
AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Molecular assays for diagnosis of drug-resistant tuberculosis (TB) are available but not widely used. There is no information on their performance in multidrug-resistant (MDR) TB screening in high-burden settings. What This Study Adds to the Field Molecular assays for MDR TB diagnosis from sputum specimens can be implemented in high-burden settings. The high accuracy, large reduction in reporting time, and high-volume capacity suggest the assay may revolutionize MDR TB diagnosis.
Keywords: tuberculosis; MDR TB; molecular diagnosis.
The dual epidemics of HIV infection and multidrug-resistant (MDR) tuberculosis (TB) threaten global TB control, especially in sub-Saharan Africa. These problems are especially severe in South Africa, which has nearly 20% of the world's reported HIV-associated TB cases (1) and the second largest reported number of MDR TB cases in the world (2, 3). Extensively drugresistant (XDR) TB, defined as MDR TB (i.e., resistance to rifampicin (RIF] and isoniazid (INH]) with additional resistance to a fiuoroquinolone antibiotic and at least one of three injectable drugs used for MDR TB treatment (capreomycin, kanamycin, and am.ikacin) (4, 5), has heightened the challenge faced in controlling the dual epidemics of TB and HIV. In the much publicized outbreak of XDR TB among HIV-infected patients
(Received in original form September 27, 200 7; accepted in final form january 15, 2008) Correspondence and requests for reprints should be addressed to Richard O'Brien, M.D., Foundation for Innovative New Diagnostics, 71 av Louis-Casai, 121 6 Cointrin, Swit2erland . E-mail: rick.obrien@finddiagnostics.org Am J Respir Crit Care Med Vol 177. pp 787-792, 2008 Originally Published in Pre" as 001: 10.1164/ rccm .200709·14360C on january 17,2008 Internet address: www.atsjournals.org
in KwaZulu-Natal, South Africa, 52 of 53 patients died, with a median survival time of 16 days from the date of diagnosis (6). The diagnosis of MDR and XDR TB is based on mycobacterial culture and drug susceptibility testing (DST) on liquid or solid media, with results available in weeks to months. However, mycobacterial culture and DST capacity is severely limited, especially in resource-poor countries. In response to the growing problem of MDR TB and the threat of an epidemic of virtually incurable XDR TB, the World Health Organization (WHO) and the Stop TB Partnership have issued a call for significant expansion of mycobacterial culture and drug susceptibility testing capacity (7) . The Stop TB Partnership's Global Plan to Stop TB 2006-2015 is being revised to include a provision of universal access to diagnose and treat all patients with MDR TB by 2015 (8). These plans call for accelerated access to rapid testing for rifampin resistance to improve case detection in all patients with suspected MDR and XDR TB. Although rapid molecular methods are available for detecting drug-resistant TB (9), there have been questions surrounding the feasibility of their implementation in high-burden settings in the developing world. To address this concern and to respond to the urgent need for improved MDR and XDR TB diagnosis, the Foundation for Innovative New Diagnostics (FIND) has accelerated large-scale demonstration projects of the Genotype MTBDRp/us assay, a polymerase chain reaction (PCR) amplification and reverse hybridization assay for detecting RIF and INH resistance (10). The assay detects mutations in the rpoB gene for RIF resistance, the katG gene for high-level INH resistance, and the inhA gene for low-level INH resistance directly from smearpositive sputum. Results are available within 1 day (11). As a prelude to the demonstration project in South Africa, a validation of the test was undertaken in one of the National Health Laboratory Service (NHLS) laboratories. The aim of the study was to investigate the feasibility of implementation of the
788
AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
VOL 1 77
2008
assay in a routine diagnostic laboratory in a high-burden setting and to validate its performance compared with conventional culture and DST before the use of assay results for patient management in the demonstration project. Some of the results of this study have been previously reported in the form of an abstract (12).
probes, one katG wild-type and two mutant probes, and two inhA wildtype and four mutant probes (Figure 1). Results were interpreted according to the manufacturer's instructions. Turnaround Time of Results
METHODS Study Setting
Turnaround time was calculated from the specimen collection date and the date of reporting of the conventional DST result (on the computerized laboratory system) or the date of availability of the MTBDRplus result. Statistical Methods
This study took place in the NHLS TB laboratory in Greenpoint, Cape Town, South Africa, a referral laboratory for the Western Cape province, serving a population of approximately 4.25 million people. The estimated TB incidence in the province was 932 per 100,000, with an average TB-HIV coinfection rate of 28.2% in 2001-2002. The estimated MDR rate was 0.9% and 3.9% in new and previously treated cases, respectively (3). The laboratory has an exceedingly high workload for TB diagnostic testing, with approximately 400,000 smears, 150,000 cultures, and 50,000 first-line DSTs performed annually. Testing was performed on residual portions of routine clinical specimens submitted for culture and DST. Results were delinked from patient identifiers, and no patient information was collected. Therefore, informed consent was not required for the study. Sputum Specimens
Statistical tests were performed using lntercooled STATA 8.0 software (Statacorp LP, College Station, TX). Results were considered significant at P < 0.05.
RESULTS GenoType MTBDRp/us Testing from Smear-positive Sputum
All manipulations with potentially infectious clinical specimens were performed in a Class II safety cabinet in a BSL2 laboratory. Sputum specimens were decontaminated with N-acetyl-L-cysteine-sodium hydroxide (13). After centrifugation, the pellet was suspended in 1.0 ml of phosphate buffer (pH 6.8). A concentrated auramine smear was prepared and examined under X500 magnification using a fluorescent microscope and graded according to International Union Against Tuberculosis and Lung Disease (IUATLD) guidelines (14). A 0.5-ml portion of the sediment was cultured using the BACTEC MGIT 960 system (BD Diagnostics Systems, Sparks, MD), including mycobacterial growth indicator tubes (MGITs) with PANTA and OADC. Culturing on solid media was not done. Positive cultures were confirmed as Mycobacterium tuberculosis complex using Ziehl-Neelsen staining and p-nitrobenzoic acid testing (15). Indirect DST was performed using the proportion method on Middlebrook 7Hll agar slants with 1.0 t-Lg/ml RIP and 0.2 t-Lglml INH (13)Specimens with a smear grading of 1 + or greater were selected for MTBDRplus testing. Five hundred thirty-six acid-fast bacilli smearpositive sputum specimens were collected from 528 patients between January 31 and March 1, 2007, consisting of all smear-positive sputum specimens submitted to the laboratory for smear, culture, and DST during that period. In addition, GenoType MTBDRplus assay (Hain Lifescience, Nehren, Germany) (MTBDRplus) testing was performed on 100 randomly selected smear-negative specimens submitted for culture and DST. Rapid Drug Resistance Testing
The MTBDRplus was performed according to the manufacturer's instructions (10). The test is based on DNA strip technology and has three steps: DNA extraction, multiplex polymerase chain reaction (PCR) amplification, and reverse hybridization. A 500-fl.l portion of the decontaminated sediment was used for DNA extraction, a 1-hour process that included heating, sanification, and centrifugation. The amplification procedure that consisted of preparation of the master mix and addition of the DNA also required 1 hour. These steps were carried out in separate rooms with restricted access and unidirectional workflow. Hybridization was performed with the GT Blot 48 (Hain Lifescience), which is an automated hybridization machine (10). After hybridization and washing, strips were removed, allowed to air dry, and fixed on paper. All tests were performed independent of culture and DST and before the culture and DST results were available. Interpretation of Results
Each strip consists of 27 reaction zones (bands), including six controls (conjugate, amplification, M. tuberculosis complex, rpoB, katG, and inhA controls), eight rpoB wild-type (WT) and four mutant (MUT)
Table 1 is a summary of MTBDRplus results of all smear-positive specimens tested (n = 536). Eight patients submitted two smearpositive specimens for MTBDRplus testing. Identical results were achieved in each case. Fifteen specimens (2.8%) were culture negative, and therefore no conventional DST result was available. Of these 15 culture-negative specimens, 13 (86.7%) gave interpretable results by the MTBDRplus method. A further two specimens lost viability during RIF DST, and therefore no results were available (one of these specimens gave an interpretable RIF MTBDRplus result). Six specimens lost viability during INH DST, and therefore no results were available (five of these specimens gave an interpretable INH MTBDRplus result). Of the specimens with conventional DST results, 88 (19.2%) were MDR, 9 (2.0%) were RIF monoresistant, 34 (7.4%) were INH monoresistant, and 327 (71.4%) were RIF and INH susceptible by conventional DST. A further 55 (15.4%) conventional DST results were not performed due to contamination of the primary MGIT culture. Of these, 51 (92.7%) gave interpretable RIF MTBDRplus results, and 52 (94.5%) had an interpretable INH result. Of the specimens that had a reportable DST result, MTBDRplus also had a reportable result in 97.8% (454/464) of specimens for RIF resistance and 98.3% (452/460) for INH resistance. A total of 14 specimens were initially discrepant, with MTBDRplus being INH susceptible and INH DST being resistant. Upon reexamination of DST results, an error was detected in the performance of a batch of results due to faulty INH-containing medium. This batch of tests was repeated, and seven results were reassigned as INH susceptible by conventional DST. The data presented are the repeat INH DST results. Table 2 shows results for detection of multidrug resistance (resistance to RIF and INH). Performance parameters for detection of RIF, INH, and multidrug resistance (Table 3) were calculated from specimens for which rapid and conventional results were available. Overall, a significantly higher proportion of MTBDRplus results (96.8%) was interpretable compared with conventional culture and DST (86.6%) (P < 0.001). There was no significant difference in the proportion of interpretable MTBDRplus results in specimens with 1 + smear grading (94.6%) compared with 2+ (98.2%) and 3+ (97.1 %) smear-positive specimens (P = 0.513 for rifampicin resistance; P = 0.350 for isoniazid resistance). The MTBDRplus test performed well on specimens whose MGIT culture was contaminated, with 92.7% of results from such specimens giving interpretable MTBDRplus results compared with 99.6 and 98.2% interpretable results for MTBDRplus tests performed on specimens with an uncontaminated MGIT culture and a conventional DST result.
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Figure 1. Examples of GenoType MTDBRp/us strips (Hain Lifescience, Nehren, Germany). (Lane 1) Mycobacterium tuberculosis, susceptible to isoniazid (INH) and rifampin (RJF). (Lane 2) M . tuberculosis, JNH monoresistant (katG S31 5T1 mutation). (Lane 3) Multidrug-resistant tuberculosis (MDR TB), rpoB S531 L mutation and katG S31 5T2 mutation. (Lane 4) MDR TB rpoB S531 L mutation and katG 531 5T1 and inhA C1 5T mutations. (Lane 5) M . tuberculosis, RIF monoresistant (mutation in rpoB 530-533 region). (Lane 6) MDR TB, rpoB 051 6V and katG S31 5T1 mutations. (Lane 7) MDR TB, rpoB SS31 L, and katG 531 5T2 mutations. (Lane 8) MDR TB, rpoB, D51 6V, katG S31 5T1 mutation and inhA mutation at -15/-16. (Lane 9) Uninterpretable result, no M. tuberculosis complex (TUB) band. (Lane 70) Negative control.
Conventional culture and DST for smear-positive specimens had a total turnaround time of 42 ± 9 days (mean ± SD) with a range of 23 to 99 days. For MTBDRplus testing, the test took 1-2 days for smear-positive specimens once specimens had been selected for testing based on positive sputum smear results. Turnaround time for smear-negative specimens was also 1-2 days. Table 4 shows the distribution of different banding patterns in drug-resistant isolates, including MDR, INH-monoresistant, and RIF-monoresistant strains. Typical banding patterns obtained on the MTBDRplus strips are shown in Figure 1. For detection of RIF resistance, S531L mutation (MUT3 band) occurred the most commonly, with 70.5% of all RIP-resistant strains (76.4% of MDR- and 37.5% of RIF-monoresistant strains) having the mutation. This difference in prevalence of the S531L mutation
between MDR- and RIF-monoresistant strains was significant (P = 0.0115). One MDR strain had a S531L and a D516V
mutation, whereas one RIF-monoresistant strain had S531L and H26Y mutations. Other mutations in the 530-533 region were common, as detected by the lack of binding to the WT8 probe in the absence of S531L mutation. A significantly higher proportion of RIF-monoresistant strains (18.8%) had a H526Y mutation (MUT2A band) compared with MDR strains (2.2%) (P = 0.0015) . Other mutations occurred at rpoB516 (9.5% overall), and one MDR strain had complete deletion of the rpoB gene. There was no significant difference in the presence of other bands between MDR- and RIF-monoresistant strains. Two "false" RIP-resistant results were obtained compared with the conventional DST result. One strain had the WT2 band missing (Q513L
TABLE 1. SUMMARY OF RESULTS OF RIFAMPICIN AND ISONIAZID RESISTANCE BY GENOTYPE MTBDRp/us COMPARED WITH MYCOBACTERIAL GROWTH INDICATOR TUBE CULTURE AND DRUG SUSCEPTIBILITY TESTING Conventional MGIT Culture and DST Genotype
MTBDRplus Rifampicin Resistant Susceptible Uninterpretable Isoniazid Resistant Susceptible Uninterpretable
Resistant
Susceptible
Not Done (MGIT contaminated)
Not Done (MGIT culture negative)
No Growth on DST Control
94 2 114 7 1
2 357 8 1 330 7
4 47 4 4 48 3
0 13 2 1 12 2
0 1
0 5 1
Definition of abbreviations: DST
= drug
susceptibility testing; MGIT
= mycobacterial growth
indicator tube.
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TABLE 2. SUMMARY OF RESULTS OF MULTIDRUG RESISTANCE BY GENOTYPE MTBDRp/us COMPARED WITH CONVENTIONAL CULTURE AND DRUG SUSCEPTIBILITY TESTING Conventional MGJT Culture and DST RIF Monoresistant 0 8 0 0 INH Monoresistant 0 0 26 6 0 RIF and INH Susceptible 0 2 Not Done (MGIT contam) Not Done (MGIT culture negative) 0 0 No Growth on DST Control 0 0
Genotype MTBDRp/us MDR RIF monoresistant INH monoresistant RIF and INH susceptible Uninterpretable
MDR 85 1 0 0 2
1 318 8 46 4
1 12 2
0 5
Definition of abbreviations: DST =drug susceptibility test; INH =isoniazid; MDR = multidrug resistant; MGIT = mycobacterial growth indicator tube; MGIT contam = MGIT culture contaminated; RIF = rifampicin.
mutation), a rare mutation that had previously only been detected theoretically (in silica). The second strain had a S531L mutation, which is likely to be indicative of true resistance. Of all INH-resistant strains, 64.1% (70.8% of MDR strains and 42.9% of INH-monoresistant strains) had a mutation in the katG gene, and 41.9% (38.2% of MDR strains and 53.6% of INH-monoresistant strains) had a mutation in the inhA gene. This difference in prevalence of mutations in MDR strains compared with INH-monoresistant strains was significant for katG (P = 0.0073) but not for inhA (P = 0.1497). Twelve strains had mutations in both the katG and inhA genes. There was one "false" INH-resistant MTBDRplus result compared with conventional DST. This isolate had an inhA C15T mutation. Twenty-seven percent (24/89) of MDR strains did not have a mutation in the katG gene and were detected as INH resistant by a mutation in the inhA gene. Fifteen of 28 (53.6%) INHmonoresistant strains were detected by the presence of a mutation in inhA only. Genotype MTBDRp/us Testing from Smear-negative Sputum
10 susceptible strains) in the specimens for which both MTBDRplus and conventional DST results were available.
DISCUSSION
The performance of the GenoType MTBDRplus test directly from smear-positive sputum correlated very highly with conventional culture and DST. The sensitivity for detection of rifampicin resistance, isoniazid resistance, and multidrug resistance was 99, 94, and 99%, respectively. The specificity for detection of rifampicin, isoniazid, and multidrug resistance was 99, 100, and 100%, respectively. These performance characteristics suggest that the assay is equivalent to conventional LowensteinJensen medium-based DST performed in quality-assured reference laboratories (16). Considering that the test performs well on specimens that subsequently are contaminated on culture, its overall performance for detection of MDR TB is superior to conventional methods. Detection of mutations in the 81-bp region of the rpoB gene correlated very highly with RIF resistance (17, 18), with 99% of RIP-resistant strains being identified in this study. However,
A secondary part of the study included testing of 100 smearnegative sputum specimens. Of 100 smear-negative specimens tested, 25% (n = 25) were culture positive. Twenty culturepositive specimens were put up for conventional DST (three specimens were contaminated, and two specimens did not have DST requested). Of these specimens, 16 out of 20 (80%) gave interpretable MTBDRplus results for RIF, and 14 out of 19 (74%) gave interpretable MTBDRplus results for INH resistance. Furthermore, MTBDRplus results were available for two specimens in which no conventional DST result was available due to contamination. No MTBDRplus results were interpretable for any of the culture-negative specimens (n = 77). There was 100% correlation in the results for detection of RIF (16/16 sensitive strains) and INH resistance (4 resistant and
TABLE 4. PATTERN OF GENE MUTATIONS IN RESISTANT Mycobacterium tuberculosis STRAINS USING GENOTYPE MTBDRplus ASSAY Gene Band Gene Region or MDR INH Monoresistant RIF Monoresistant Mutation (n = 89*) (n = 28) (n = 16) 506-509 510-513 513-517 516-519 518-522 521-525 526-529 530-533 D516V H526Y H526D S531L 315 S315T1 S315T2 -15/-16 -8 C15T A16G T8C T8A 88 88 78 78 88 88 83 19 8 2 3 68 26 34 31 (99) (99) (88) (88) (99) (99) (93) (21) (9) (2) (3) (76) (29) (38) (35) 55 (62) 89 (100) 32 (36) 1 (1) 0 (0) 0 (0) 28 (100) 28 (100) 28 (100) 28 (100) 28 (100) 28 (100) 28 (100) 28 (100) 0 (0) 0 (0) 0 (0) 0 (0) 16 (57) 10 (36) 3 (11) 13 (46) 28 (100) 15 (54) 0 (0) 0 (0) 0 (0) 16 14 16 16 16 16 14 9 2 3 1 6 16 0 0 16 16 0 0 0 0 (100) (88) (100) (100) (100) (100) (88) (56) (13) (19) (6) (38) (100) (0) (0) (100) (100) (0) (0) (0) (0)
TABLE 3. PERFORMANCE OF GENOTYPE MTBDRp/us IN DETECTING RIFAMPICIN, ISONIAZID, AND MULTIDRUG RESISTANCE FROM SMEAR-POSITIVE SPUTUM SPECIMENS Rifampicin Sensitivity Specificity Overall accuracy PPV NPV 98.9 99.4 99.3 97.9 99.7 Isoniazid Multidrug Resistance 98.8 100 99.8 100 99.7 (93.7-100.0) (99.0-100.0)* (98.8-1 00.0) (95.8-1 00.0)* (98.5-100.0)
(94.3-100.0) 94.2 (88.4-97 .6) (98.0-99.9) 99.7 (98.3-100.0) (98.1-99.9) 98.2 (96.5-99.2) (92.7-99.7) 99.1 (95.3-100.0) (98.5-1 00.0) 97.9 (95.8-99.2)
rpoB WT1 WT2 WT3 WT4 WT5 WT6 WT7 WT8 MUT1 MUT2A MUT2B MUT3 katG WT MUT1 MUT2 inhA WT1 WT2 MUT1 MUT2 MUT3A MUT3B
Definition of abbreviations: NPV = negative predictive value; PPV = positive predictive value. Values are percentages with 95% confidence interval in parentheses. • One-sided, 97.5% confidence interval.
Definition of abbreviations: JNH = isoniazid; MDR = multi drug resistant; RIF = rifampicin. Values are numbers, with percentages in parentheses.
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test sensitivity for RIF resistance may be lower in other settings where mutations outside the 81-base-pair region of the rpoB gene, which are not detected by the assay, are responsible for RIF resistance (19), In agreement with most other studies, we found the most common mutations at codons 531, 526, and 516. We found a higher proportion of RIP resistance due to S531L mutations than that reported in other geographical locations (70.5% in all rifampin-resistant strains in this study compared with between 36.1 and 56.7%). Mutations at codon 526 were kss wmmun than reported In many ather countries (8.6% in all rifampin-resistant strains compared with between 6.8 and 39.3%, with six of nine countries having >20% mutations at codon 526). The rate of mutations at 516 (9.6% in all rifampinresistant strains) was within the range reported elsewhere (20). Twenty-seven percent of MDR strains and 54% of INH monoresistant strains were detected as INH resistant by a mutation in the inhA gene only. These strains would not have been detected as MDR by the previous version of the assay (Genotype MTBDR), which only tested for mutations in the katG gene (20-22). In this setting, the presence of probes for inhA substantially increased the sensitivity for detection of INH resistance (and MDR TB). The prevalence of mutations in the inhA and katG genes seems to vary widely in different geographic locations. For example, katG mutations were found in 97% (77/ 79) and inhA mutations in 24% (19/79) of INH-resistant isolates from KwaZulu-Natal (23), whereas van Rie and colleagues reported katG mutations in 72% of INH-resistant isolates (41/ 57) and mutation in the inhA gene in only 2% (1/57) isolates in the Western Cape province of South Africa (18). Studies from other countries have confirmed this variability in the contribution of different mutations to INH resistance (24, 25). Mutations in inhA were rarely reported in Germany (11). A high prevalence of katG mutations has been reported to account for a high proportion of INH resistance in high-TB-prevalence countries and for a much lower proportion in lower TB prevalence settings, presumably due to ongoing transmission of these strains in highburden settings (25). A high proportion of interpretable results (80%) was obtained from smear-negative, culture-positive specimens tested by the MTBDRplus assay. One hundred percent correlation was seen for specimens in which MTBDRplus and conventional DST results were available. However, because only 25% of smearnegative specimens were culture-positive in this laboratory, the overall yield of interpretable results would be low (14--16%) if routine screening of all smear-negative specimens were implemented. Nevertheless, the ability to obtain rapid MDR screening results on smear-negative sputum specimens in a high-HIVprevalence setting such as South Africa, where a large proportion of patients with HIV who are coinfected with TB (i.e., at risk of MDR TB) are smear negative, is advantageous. Receipt of specimens and decontamination of sputum for conventional culture and DST were performed according to usual NHLS procedures by the main TB laboratory staff. This laboratory is a high-volume facility, with over 600 specimens per day set up for culture and approximately 1,000-1,200 specimens per day received for smear microscopy. The high correlation of the GenoType MTBDRplus results with conventional results reflects well on the performance of the test in this high-volume laboratory. Although a trained molecular biologist was responsible for the molecular testing, the decontamination of specimens and all conventional testing was performed by the general TB laboratory technical staff. The facility for PCR testing was separate from the routine TB laboratory and had strictly controlled and limited access, enabling PCR contamination to be avoided during this study. These results suggest that this test can be successfully implemented in a high-volume
routine TB diagnostic laboratory with well-qualified technical staff. The MTBDRplus assay is rapid, reliable, and easy to interpret. Although the MTBDRplus assay can produce results within 8 hours, in this high-volume facility a longer turnaround time of 2 working days was routinely reported from the time of selection of specimens for testing based on positive smear results because the limitations of general laboratory space for DNA extraction and reading of sputum smears did not permit the whole MTBDRplus procedure to be completed on a single day. Uns equates to a total turnaround time of less than 7 days when specimen transport time, time to perform smear microscopy, and reporting of results is included. This is a substantial reduction compared with conventional culture and DST. Calls from the WHO and other international agencies to urgently expand access to culture and DST in response to the dual challenges that HIV and MDR TB (and XDR TB) pose significant challenges to TB control programs and TB laboratory services (7). The cost and complexity of establishing culture and DST capacity to meet the anticipated need, especially in lowincome countries where these services are not generally available, present overwhelming challenges. Consequently, other diagnostic methods, and in particular molecular testing, should be considered as alternatives. This study shows that it is feasible to perform molecular-based rapid MDR screening with the GenoType MTBDRplus test routinely in a high-volume laboratory with no previous experience of routine implementation of molecular assays. The high degree of accuracy, the substantial reduction in reporting time, and the possibility for high throughput with substantial cost savings suggest that molecular testing has the potential to revolutionize the diagnosis of MDR TB. On the basis of FIND-negotiated prices, the cost of the molecular assay is less than 50% of that for conventional liquid culture and DST for INH and RIF. Simplification of specimen processing for molecular testing may allow for easier referral of specimens to central laboratories and may contribute to large-scale drug-resistance surveillance studies. The impact of such rapid assays on patient outcomes is highly dependent on the quality of the rest of the TB control program, including the specimen transport system, reporting of results, and patient follow-up. Strengthening of the whole program is required if such new technologies are to benefit patients (26). Strengthening the capacity of laboratories is also necessary to enable full benefit to be drawn from emerging new TB diagnostic technologies. Conflict of Interest Statement None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. R.O. is employed by the Foundation for Innovative New Diagnostics (FIND), and H.A. is a paid consultant to FIND, a nonprofit agency that has a contractual agreement with Hain Lifescience GmbH, the manufacturer of the GenoType MTBDRplus assay. This agreement calls on FIND to conduct demonstration studies of this assay. In turn, Hain Lifescience has agreed to provide the assay at a substantially reduced price to the public sector of developing countries. FIND is currently undertaking, in collaboration with NHLS and the South Africa Medical Research Council, a large-scale demonstration project of the MTBDRplus assay in South Africa. Acknowledgment: FIND (Foundation for Innovative New Diagnostics), Geneva,
Switzerland, provided MTBDRplus test kits and the required consumables. Hain Lifescience and Davies Diagnostics provided training and technical support but had no role in the study. The authors thank the NHLS TB laboratory staff, Greenpoint, Cape Town, for their technical assistance.
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