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Advocacy, Communication,and Social Mobilization

to Fight XDR TB

Wanda Walton, PhD, MEdCommunications, Education, and Behavioral Studies Branch

Division of Tuberculosis Elimination

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ACSM to Address Key Challengesto TB Control at Country Level

Improving case detection and treatmentadherence

Combating stigma and discrimination

Empowering people affected by TB Mobilizing political commitment and

resources for TB

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Framework for ACSM to AddressKey Challenges to TB Control

at Country Level Building national and subnational ACSM capacity Building inclusion of patients and affected

communities

Ensuring political commitment and accountability Building country-level ACSM partnerships Learning, adapting, and building on good ACSM

practice

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Advocacy, Communication,and Social Mobilization for XDR TB

Communication to exchange information aboutXDR TB, informing and creating awareness

Advocacy to place XDR TB control high on the

political agenda, foster political will, increasefinancial and other resources, e.g., humanresources

Social mobilization to bring together allies to raiseawareness and demand for program needs, assist

in delivery of resources and services, createsustainable change

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XDR TBExtensive (or Extreme) Drug Resistant TB

XDR TB extensive (or extreme) drug resistant TB

MDR TB - defined as TB resistant to at least the 2most potent anti-TB drugs, isoniazid and rifampicin(first-line drugs)

XDR TB* - defined as MDR TB that is also resistantto at least 3 of the 6 classes of second-line drugs

*Definition may change based upon recommendations

of expert panel

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Drugs for the Treatment of TB

1. Isoniazid2. Rifampicin

3. Pyrazinamide

4. Ethambutol

5. Aminoglycosides

6. Capreomycin

7. Quinolones

8. Thioamides

9. Cycloserine

10. PAS

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First-line drugs and treatment ofdrug-susceptible TB

1. Isoniazid

2. Rifampicin

3. Pyrazinamide

4. Ethambutol

5. Aminoglycosides

6. Capreomycin

7. Quinolones

8. Thioamides

9. Cycloserine

10. PAS

Standardized treatment of routinedrug-susceptible TB

4 drugs, 6-9 months Safe, effective, inexpensive

95% cure, $20 (drug costs) Based on solid scientific evidencefrom ~ 30 years of drug discovery andcontrolled clinical trials, 1943-72

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Second-Line Drugs and Treatment ofMultidrug-Resistant TB

1. Isoniazid2. Rifampicin

3. Pyrazinamide

4. Ethambutol

5. Aminoglycosides

6. Capreomycin

7. Quinolones

8. Ethionamide

9. Cycloserine

10. PAS

Treatment based on laboratorydrug-resistance testing andepidemiology information

4-6 drugs, 2 years

Less effective, more toxic,expensive - 65%-75% cure - $3500 (drug costs)

No clinical trials evidence toguide treatment or prevention

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Drug Susceptible Multidrug

resistance

Extensive drugresistance

Isoniazid Isoniazid Isoniazid

Rifampicin Rifampicin Rifampicin

Pyrazinamide Pyrazinamide Pyrazinamide

Ethambutol Ethambutol Ethambutol

Aminoglycosides Aminoglycosides Aminoglycosides

Capreomycin Capreomycin Capreomycin

Quinolones Quinolones Quinolones

Thioamides Thioamides Thioamides

Cycloserine Cycloserine CycloserinePAS PAS PAS

Resistance by definition Resistance possible or likely

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XDR TBAwareness and Emergency Response

Oral and poster presentations at IUATLD conference,November 2005

CDC report on Emergence of Mycobacterium tuberculosiswith Extensive Resistance to Second-Line Drugs ---Worldwide, 2000--2004, March 24, 2006

16th International AIDS Conference presentation, August2006

Global alert issued by WHO on emerging threat of highlylethal strains of drug resistant TB (XDR TB) on September 5,2006

Emergency experts meeting (MRC, WHO, CDC) inJohannesburg, SA on September 7-8 Call for Global XDR TB Task Force in Geneva, first meeting

October 2006

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XDR TB in KwaZulu-NatalProvince (KZN), South Africa

Reports of high mortality from TB in ARV treatment programin KZN in 2005

Team of collaborators invited to identify problem Investigators preformed cross-sectional study of TB

suspects attending rural hospital

1539 patient isolates, 544 diagnosed with M.tb Of these, 221 (41%) MDR TB

Of these, 53 (24%) XDR TB

Of these patients, 26 had no h/o TB treatment;

44 of 44 tested were HIV infected;

52 (98%) died; 15 were on ARVs

XDR TB now documented in 28 health care institutionsthroughout KNZ

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Expert Consultation on DrugResistant Tuberculosis

Expert Consultation organized by Medical Research Council(MRC) to strategize steps forward in Southern Africa

Development Community (SADC) countries to address

problem of drug resistance, September 7-8, 2006

Convened by Medical Research Council, Republic of SouthAfrica (RSA) Department of Health

Key stakeholders with experience in drug-resistant TBresponse WHO, CDC (DTBE and RSA GAP), KNCV

Representatives from all 9 provinces of RSA Representatives from 10 SADC countries

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Expert Consultation 7-Point Plan:Short Term Response

Improve function and performance of national TBprograms to strengthen treatment adherence andachieve high rates of treatment completion for allTB patients

Develop national emergency response plan forMDR/XDR TB within 3 months Conduct rapid surveys of MDR TB and XDR TB

within the next 3-6 months

Strengthen and expand current national TBlaboratory capacity

Urgently implement broad infection control practicesin health care facilities with special emphasis onthose facilities providing care for PLWHA

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7-Point Plan: Long Term Response

Establish capacity for clinical public healthmanagers to effectively respond to MDR/XDR TB

Promote universal access to ARVs for all TBpatients through collaboration with HIV/AIDStreatment and care programs

Support an increase in research for anti-TB drugdevelopment and rapid diagnostic test developmentfor MDR/XDR TB

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XDR TB is a significant threat to the major

gains made in global TB control.World Health Organization

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Individuals with TB, including XDR TB, arehuman beings with human rights. We musttreat all people with TB with respect,preserve their dignity, and save their lives.

There is no role for stigma anddiscrimination in managing TB.

Professor Gavin Churchyard

Director, Aurum Institute for Health Research

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TBDisease

Latent TBInfection

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XDR TB

MDR TB

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First global report of highly drug resistant TB, which shows widespreadpresence of virtually untreatable TB

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Critically important totake steps now to prevent

further spread of highly-

resistant TB.

MDR TB in 1990s signaled thebeginning of a global epidemic

Ensure adequate treatment of bothdrug-susceptible and drug-resistant TBo Ensure patients complete TB and

MDR TB treatment through DOTSprograms

o Strengthen lab capacity fordiagnosis of MDR TB and second-line drug susceptibility testing

o Use of quality-assured TB drugs

Expand surveillance to determinetrends and better evaluate XDR TB

XDR TB

MMWR 3/24/06

p y

Survey of global network of supranational TB reference laboratories, consisting of top-performing TB labs located on 6 continents

2% of the isolates (347 out of nearly 18,000) were identified w/ extensive drug resistance (MDRTB that is also resistant to 3 of the 6 classes of second-line drugs that are used to treat TB)

o XDR TB was ID-ed in all regions, but was most frequent in the countries of the formerSoviet Union and in Asia

o While global trend data is limited, available data may indicate some increases in XDRTB

Because reference labs are more likely to receive data f/ complex TB cases,looked at population-level data from selected countries to further understand

the prevalence of XDR TB and trendso In U.S., found 4% of MDR TB cases were highly drug resistant

XDR cases increased slightly, but not significantly, f/ 3.9% ofMDR cases in early 90s to 4.5% by end of 2004o In Latvia, a country w/ one of the highest rates of

MDR TB, 19% of MDR TB cases were highlydrug resistant.

CDC is partnering to raiseawareness and enhance strategies for

TB prevention worldwide

CDC is a member of the Green Light Committee, which was created to increase accessto quality-assured, lower cost second line drugs while ensuring their proper use toprevent increased drug resistance.

CDC is urging more accurate and rapid detection and treatment of drug-resistant TB,

including the development of international standards for second line drug susceptibilitytesting, new anti-TB drug regimens, and better diagnostic testing

Must build capacity of frontline providers to diagnose and ensure completion of treatment,which will help avert drug resistance

Worsening drug resistancearound the world poses aserious threat to our ability to

treat & control TB

Treating patients with drug-resistant TB is costly,and drugs are toxic and expensive

Because drug resistant TB requires 4-5 drugs totreat, this level of resistance precludes effectivetreatment in many areaso While places with more resources, such as the

U.S. or Latvia, may have greater access toadditional effective drugs, the majority of TBcases occur in places unlikely to have access

o Limited drugs mean that patients with XDR TBare virtually untreatable according tointernational TB treatment guidelines in mostcountries

Patients with drug-resistant TB have worsetreatment outcomes (death or treatmentfailure)o Compared to patients with MDR

TB, those with XDR TB were 64%more likely to die duringtreatment in the U.S.

o In Latvia, patients w/XDR TB were 54%more likely to dieor have txfailure

XDR TB M

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XDR TB MessagesFirst global report of highly drug resistant TB, which shows

widespread presence of virtually untreatable TB

Survey of global network of supranational TBreference laboratories, located on 6 continents

2% of the isolates (347 out of nearly 18,000) wereidentified w/ extensive drug resistance

XDR TB was ID-ed in all regions, but was mostfrequent in the countries of the former Soviet Unionand in Asia

While global trend data is limited, available datamay indicate some increases in XDR TB

In U.S., found 4% of MDR TB cases were highlydrug resistant In Latvia, MDR TB, 19% of MDR TB cases were

highly drug resistant

XDR TB Messages

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XDR TB MessagesWorsening drug resistance around the world poses a serious

threat to our ability to treat & control TB

Treating patients with drug-resistant TB is costly,and drugs are toxic and expensive

Because drug resistant TB requires 4-5 drugs totreat, this level of resistance precludes effective

treatment in many areas While places with more resources, such as the U.S.or Latvia, may have greater access to additionaleffective drugs, the majority of TB cases occur inplaces unlikely to have access

Limited drugs mean that patients with XDR TB arevirtually untreatable according to international TBtreatment guidelines in most countries

XDR TB M

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XDR TB MessagesWorsening drug resistance around the world poses a serious

threat to our ability to treat & control TB (2)

Patients with drug-resistant TB have worsetreatment outcomes (death or treatment failure)

Compared to patients with MDR TB, those withXDR TB were 64% more likely to die during

treatment in the U.S. In Latvia, patients w/ XDR TB were 54% more likely

to die or have tx failure

In KZN, 98% of patients with XDR TB and HIVinfection died, despite adequate response toARVs

XDR TB Messages

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XDR TB MessagesCritically important to take steps now to prevent further spread

of highly-resistant TB

MDR TB in 1990s signaled beginning of a global epidemic Ensure adequate treatment of both drug-susceptible and

drug-resistant TB

Ensure patients complete TB and MDR TB treatmentthrough DOTS programs

Strengthen lab capacity for diagnosis of MDR TB andsecond-line drug susceptibility testing

Use of quality-assured TB drugs

Expand surveillance to determine trends and better evaluateXDR TB

Must have adequately functioning TB programs toaddress problem Implement broad infection control precautions Additional resources (human and financial)

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XDR TB MessagesCDC is partnering to raise awareness and enhance strategies

for TB prevention worldwide

CDC is a member of the Green Light Committee,created to increase access to quality-assured, lowercost second line drugs while ensuring their properuse to prevent increased drug resistance

CDC is urging more accurate and rapid detectionand treatment of drug-resistant TB, including thedevelopment of international standards for secondline drug susceptibility testing, new anti-TB drugregimens, and better diagnostic testing

Must build capacity of frontline providers todiagnose and ensure completion of treatment,which will help avert drug resistance

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XDR TB MessagesCDC is partnering to raise awareness and enhance strategies

for TB prevention worldwide (2)

New messages

Participation in expert consultation with WHOand MRC

Consensus plan of action Strengthen the laboratory Train the health care workers

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Media Quotes in U.S.:March 24, 2006

Dr. Kenneth Castro, director of the CDC's divisionof TB elimination, said emergence of a super-resistant strain is a potent reminder thattuberculosis remains a formidable threat. "It iswidely distributed geographically, including in theUnited States, and renders patients virtuallyuntreatable," Castro said.

Dr. Marcos Espinal, executive secretary of WHO'sTB elimination program, called XDR TB a veritabledeath sentence. "If people are failing first- andsecond-line drugs and we don't have in the pipelinea new drug for immediate use, that's a crisis," hesaid.

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Media Response to XDR TBin South Africa

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XDR-TB

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WHO expresses concern

WHO background briefing note

issued prior to XDR-TB Expert

Consultation meeting in SouthAfrica

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'Virtually untreatable' TBfoundA "virtually untreatable" form of TB has emerged,according to the World Health Organization(WHO).Extreme drug resistant TB (XDR TB) has been seenworldwide, including in the US, Eastern Europe andAfrica, although Western Europe has had no cases.Dr Paul Nunn, from the WHO, said a failure to correctly

implement treatment strategies was to blame.

XDR-TB

http://www.rfi.fr/radiofr/pages/001/accueil.asphttp://news.bbc.co.uk/

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Coverage in major weekly journals

Newsweek Sept. 13, 2006

WHO recently issued a warninthat deadly new strains oftuberculosis appear to be

spreading around the globeHIV sufferers are particularlyvulnerable because of theirweakened immune systems.TB, already the worlds fourthmost fatal infectious disease,could wreak havoc with AIDStreatment programs

XDR-TB

http://www.thelancet.com/home

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Coverage in major weekly journals

XDR-TB

http://www.thelancet.com/home

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African press coverage:

New TB strain in SA: 'No timto wait'07 September 2006

The extreme drug-resistanttuberculosis (XDR-TB) in

KwaZulu-Natal must be dealtwith urgently, internationalhealth experts said inJohannesburg on Thursday."There is no time to wait beforewe embark on decisive action,"said the World Health

Organisation's Dr ErnestoJaramillo, explaining that anepidemic could have a deadlyimpact.

XDR-TB

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International press coverage:

XDR-TB

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International headlines:

Deadly TB strain spreading across globe

Global alert over deadly new TB strains

Africa: "Extreme" TB Bug Prompts Calls for Rapid Action

South Africa: Action plan developed to combat drug resistant TB

TB strain with extreme resistance to drugs creates nightmare scenario

WHO urges South Africa to curb TB killer super-bug

TB experts will grapple with deadly new strains: WHO

Experts call for urgent steps to battle virulent TB strain

XDR-TB

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Editorial in New York Times & Int. Herald Tribune

EXTREME TUBERCULOSIS

SEPTEMBER 14, 2006

TB is outrunning us. In the last few months, 53 patients in the SouthAfrican province of KwaZulu-Natal were found to have a form of thedisease resistant to enough existing drugs that it is virtually incurable. Allbut one of those patients have died

Stinginess created this problem. Generosity is needed to fix it.

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Stop TB XDR Response

1. Coordination Develop an appropriate,coordinated global response to XDR TB

2. Resource mobilization Raise sufficient funds toensure no delays in the global response to XDR

TB3. Case definitions Ensure consistency insurveillance and case management

4. Monitoring and evaluation Determinegeographical and temporal spread of XDR TB

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Stop TB XDR Response (2)

5. Communications Provide a proactive flow ofinformation to all stakeholders, including memberstates and the global media

6. Case management Define the optimal way of

rapidly identifying suspect XDR cases and ensuringappropriate treatment; determine appropriateinfection control measures in health facilities

7. Country support Ensure a timely and sufficient

response to requests from countries for assistance

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This time, I bet you that if the press is

prompted and well prepared, journalists will

come like flies around a cake and other

objects...Mario Raviglion