DEWG progress report 2009

DEWG meetingGENEVA

13-14 October 2009

Léopold BLANC TBS/STB/WHO

Secretary of the DEWG

Global TB estimates and notification - 2007

Estimated number of

cases

Cases reported

DOTS

5.6 million5.6 million(80 per (80 per 100,000)100,000)

9.27 million9.27 million(139 per (139 per 100,000)100,000)

2.6 million(63%)

4.1 million

All forms of TB Greatest number of cases in Asia; greatest rates per capita in Africa

Multidrug-resistant TB (MDR-TB)

New Smear positive

511,000

30,000

HIV-associated TB 1.4 (15%) 300,000

% of MDR among new and re-treatment TB cases, 2007

No estimate

< 3%

3 – 5 %3 – 5 %

6 – 19%

>= 20 %

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2009. All rights reserved

Countries that had reported at least oneXDR-TB case by end April 2009

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2009. All rights reserved

Argentina Canada Georgia Japan Myanmar Philippines Russian Federation UkraineArmenia China Germany Kenya Namibia Poland Slovenia United Arab EmiratesAustralia Colombia India Latvia Nepal Portugal South Africa United KingdomAzerbaijan Czech Republic Iran (Islamic Republic of) Lesotho Netherlands Qatar Spain United States of AmericaBangladesh Ecuador Ireland Lithuania Norway Republic of Korea Swaziland UzbekistanBotswana Estonia Israel Mexico Oman Republic of Moldova Sweden Viet NamBrazil France Italy Mozambique Peru Romania Thailand

No reported activity

< 15%

15% to 50%

More than 50%

More than 75%

Proportion of TB patients tested for HIV

Key

Countries testing Tuberculosis Patients for HIV 2007

135 countries reporting 16% of all TB cases tested.

TB/HIV intervention scale-up, Africa*

Intervention, 2007 Actual Global Plan

% tested 56% 56%

% HIV+ TB on CPT 75% 90%

HIV+ TB on ART (000s) 64 157

-

0.1

0.2

0.3

0.4

0.5

2005 2006 2007

Mil

lio

ns

TB patients tested for HIV

-

40

80

120

160

200

2005 2006 2007

Th

ou

san

ds

HIV+ TB patients on CPT

*Africa has 85% HIV+ TB cases globally

-10203040506070

2005 2006 2007

Th

ou

sa

nd

s

HIV+ TB patients on ART

DOTS Progresses DOTS Progresses the link with implementationthe link with implementation

0

10

20

30

40

50

60

70

80

1990 1995 2000 2005 2010 2015

Year

Cas

e de

tect

ion

rate

, all

form

s of

TB

(%

)

average rate of progress, 1995-2000

DOTS begins

(b)

Cairoprep

impl

scale up

accel

2004 ?

DEWG 2004

Treatment success on target (>85%), case detection stalling after years of expansion

Europe: 70%, Africa: 75%, Americas: 75%

Treatment success (%) among sputum smear+ cases

77 79 77 7981 80 82 82 82 83 84 85 84.5

0

10

20

30

40

50

60

70

80

90

100

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Africa: 47%; Europe 51%; East. Med: 60%

Estimated case detection (%) of sputum smear + cases

63% in 2007

0

20

40

60

80

1990 1995 2000 2005 2010

Whole Country

DOTSTarget 85%

• TB/HIV: TB systematic screening of HIV positive persons implemented only in few places

• MDR-TB management limited to small projects except in few countries

• Involvement of non public health care providers in TB control still limited (scaling-up PPM in only few countries)

• Human resources crisis in Africa in particular

• Community involvement still timid in many countries. Patients groups just starting

• Patient charter available in very limited number of countries

The stop TB strategy not broadly implemented

Way forward to attain MDGs

• Need to accelerate efforts in TB control by:1. aiming at more than 85% cure (with new drugs?)

2. aiming to 100% case detection (universal access)

3. shorten diagnostic delay (cut transmission, reduce suffering): need indicator of delay in diagnostic

• A proposed framework to identify required actions to improve case detection and reduce delays

DEWG progress report 2009

10 outputs defined in the DEWG plan of action

1. Reinforcing support to countries2. Monitoring Global plan implementation (WHO TB control report

and Stop TB partnership report)3. Funding TB control in countries 4. Health system strengthening5. Human resource strengthening6. Involvement of communities and patients7. TB and poverty8. Control of childhood TB9. PPM10.Introduction to New Approaches and new Tools (INAT)

What is ?

• Established in 2007 by the DEWG, hosted by WHO/HQ

• Objectives:– facilitate access to high-quality technical assistance – encourage TA planning at all levels, especially national level – improve TA efficiency by ensuring that needs are met while

minimizing redundant TA – promote capacity-building at all levels in terms of TA planning and

training of consultants according to international standards

• Tool: TBTEAM web site (http://www.stoptb.org/wg/tbteam/ta/)• Partners: ATS, BMG Foundation, CDC, DAHW/GLRA, Damien Foundation,

FHI, GDF, GIP ESTHER, GLC, The GF, HSI, ICN, John Snow, Inc., KNCV, MSH, PIH, PATH, PSI, Project Hope, RIT/JATA, Samm Health International, TBCAP, The Union, UNDP, USAID, World Bank, World Vision International, PEPFAR, GLI.

1. Reinforcing support to countries

How has progressed?

1. Reinforcing support to countries

2007 2008 2009

(Jan – Oct)

Missions entered

281 456 1102

Requests successfully addressed

11/12 (92%) 57/66 (86%) 48/55 (87%)

Focal points using web tool

7 14 30

Experts in roster performing missions

? 1/3 1/3

2. Monitoring & Evaluation Main achievements 2009

Task force on impact measurement:

1. Strengthening routine surveillance• Regional workshops for 21 EUR, 9 SEA and 14 LA countries.• Country missions to reassess the estimates of TB in 3 HBC

2. Implementation of prevalence surveys for TB disease• 22 Global Focus countries (16 HBC) for prevalence surveys• Vietnam and the Philippines completed survey and analysis• 3 training workshops on development of survey protocol for 7 HBC• Bangladesh completed the field operations• 6 protocols for surveys were reviewed• Myanmar started survey field operations

3. Review of Methods used to produce epidemiological estimatesof the epidemiological burden of TB, TB/HIV and MDR-TB.

Data reported (online*) in 2009

Region Data reported

Notifications/treatment outcomes

Strategy Financing

Africa (n=46) 46 46 45 41

Americas (n=36) 35 35 35 31

Europe (n=53) 41 41 39 31

EMR (n=22) 22 22 22 22

SE Asia (n=11) 11 11 11 10

W Pacific (n=36) 30 30 29 24

Total (204) 185 185 181 159

HBCs 21 21 21 16

*See: http://www.stoptb.org/tme/

Follow-up queries based on systematic review of data distributed to NTP managers of 22 HBCs, to allow discussion this week

Data reported (online*) in 2009

2. Monitoring & Evaluation Main achievements 2009

1. Follow-up on Berlin Declaration: the 18 priority countries in Europe have prepared or are preparing plan to strengthen TB control and target M/XDR-TB …

2. Follow-up meeting on the declaration of TB emergency in Africa (Maputo 2005): review in WHO Regional committee Kigali 3 September 2009 with high commitment from ministers

3. Programme reviews organized in 8 countries in 2009

3. Funding TB controlMain achievements 2009

1. GF round 9:

500M for 2 years. 53 countries applied30 approved (60%)

51 51

60

38 4037 39

50

62

0

200

400

600

800

1000

1200

1400

1600

1800

1 (16) 2 (28) 3 (20) 4 (19) 5 (24) 6 (35) 7 (21) 8 (29) 9 (32)

Round

US

$ m

illi

on

s

0

10

20

30

40

50

60

70

Ap

pro

val

rate

(%

)

Grant amount Phase 1 (2-year funding) Total budget approved (5-year funding)Approval rate

4. Health System Strengthening Main achievements 2009

1. HSS framework used in GF proposal preparation and in programme reviews

2. PAL implemented in 12 countries (expansion phase) and more than 40 countries are at different stages of implementation or preparation of PAL implementation.

5. Human resources Main achievements 2009

1. Planning the development of human resources for health for implementation of the Stop TB Strategy - A handbook (WHO7HTM/TB/2008.407)

2. Revised set of training modules for Management of TB at Health Facility level (revision to reflect the Stop TB strategy. Includes a module on infection control)

3. New page on HRD on the WHO Stop TB Department's website

4. A total of 94 countries, including 14 HBCs have conducted a recent HRD needs assessment

5. 90 countries, including 14 HBCs reported having a comprehensive plan for HRD related to TB control

5. Human resources activities Main orientation 2010-2011

HRD issues figures prominently in the Beijing call for action in the WHA resolution and in the Stop TB partners forum

The 62 WHA URGES all Member States: to achieve universal access to diagnosis and treatment of M/XDR-TB……. by means of….

(d) making available sufficiently trained and motivated staff in order to enable diagnosis, treatment and care of tuberculosis including multidrug-resistant and extensively drug-resistant tuberculosis, as an integral part of efforts to address the overall health workforce crisis;

Stop TB Partnership Partners Forum, in Rio de Janeiro March 2009, Joint WG meeting (TB/HIV, MDR-TB, GLI, DEWG) recommend:

Establish a taskforce to address the cross cutting issue of human resources across the working groups. TB must be part of the

broader global health workforce movement.

6. ACSM SubgroupMain achievements 2009

• Documentation of ACSM Best Practices (pre-launch in Cancun).

• Document on how to work with media for correct reporting of key TB messages to a wide audience.

• Worked with WHO/TME team to revise ACSM indicators in TB control questionnaire.

• Set criteria for TBTEAM experts roster for ACSM TA providers to ensure quality and consistent TA of entire Component 5.

6. ACSM Subgroup Main orientation 2010-2011

• Provide guidance on M&E for ACSM and community involvement (Rio Recommendation).

• Build further evidence, to support strategic planning, design, implementation and evaluation of ACSM interventions.

• Consolidate ACSM in TB prevention and care in countries (Strategic plan, focal persons, partnering approach).

• Advocate ACSM as cross-cutting issue affecting all components of Stop TB Strategy by showing evidence and partnering approaches.

7. TB & Poverty SubgroupMain achievements 2009

Advocacy

– Debate on ‘Free Diagnosis’ in Rio Forum

– Systematic review underway on interventions addressing socio-economic conditions which can potentially be replicated in TB control

Research

– Patient cost measurement tool piloted

– Mainstreamed measurement of equity impact through NDWG Blueprint and TREAT TB

Support

– Global Indigenous STOP TB Strategy agreed, presented at UNFPII

– Trained programme managers in 24 Chinese provinces on equity and gender (population coverage c. 1 billion)

7. TB & Poverty Subgroup: Activities to improve case detection and TB care

• Rio recommendations on availability of free diagnosis for TB suspects

• Piloted mechanisms to increase equity in access to TB diagnosis in China through elimination of patient up-front payment

• Supported health systems trial in Malawi and Sudan to increase access to TB and HIV services through close-to-community providers

7. TB & Poverty Subgroup:Main orientation 2010-2011

• Subgroup OVI’s: By 2010 all countries will:– Have capacity to monitor extent to which TB control reaches

the poor & vulnerable

– Have key strategies for improving access to TB control for the poor & vulnerable

• Selected directions for 2010-2011– Promotion of concepts and practical implementation of free

diagnosis

– Papers forthcoming on equity and PPM

– Recruitment of indigenous TB focal person

– Assessment of equity in access to MDR services in at least one country

8. Childhood TB subgroupMain achievements 2009

• Attendance at programme reviews (India, Bulgaria, Romania) and technical assistance in training and national guidelines development (Pakistan, Philippines, Papua New Guinea)

• International Training Workshops:– Cape Town, September 2009

– Bangalore/Delhi and Nepal – October 2009

• Post-Graduate course at Union's Europe region conference, Dubrovnik, May 2009

• Post-Graduate course and 3 symposia at the 40th Union's World Conference on Lung Health, December 2009, Cancun, Mexico

8. Childhood TB subgroup Main achievements 2009

• Work towards updating of the Childhood TB Guidance (document published in 2006);

– Five systematic literature reviews completed; one more ongoing

– Interim instructions on the use of the existing fixed-dose formulations with new dosing of Isoniazid, Rifampicin and Pyrazinamide

• Development of the "Guidance for National TB and HIV Programmes on the Management of Tuberculosis in HIV-infected Children:

• Input provided into the update of the Guidelines on INH Preventive Chemotherapy in HIV-infected children (work led by WHO HIV department)

• Participation in the update of the Global Plan to Stop TB, specifically addressing research needs for the use of new tools;

• Creation of the Childhood TB sub-group of the New Diagnostics Working Group (to be launched in December 2009)

8. Childhood TB subgroup Main orientation 2010-2011

• Finalize Childhood TB Guidance's revision• TA to countries in developing training material

and guidelines• Participation in programme reviews• Post-graduate courses and symposia at the

Union's conferences (global and regional)• Research agenda – trials in use of new

diagnostics and new drugs in children

9. PPM SubgroupMain achievements 2009

• ISTC dissemination: 11 National Professional Associations awarded grants to prepare ISTC implementation plans (ATS)

• Linking hospitals: Document summarizing guiding principles prepared (KNCV)

• Engaging all care providers for TB/HIV collaborative activities: Pilot projects implemented in two countries (Union/FHI)

• Documentation of work-place TB and TB/HIV programmes in five countries (WHO)

• Documentation on engaging social security organization in TB control in two countries (MSH/WHO)

9. PPM SubgroupMain achievements 2009

• Documentation for guidance on measuring PPM contribution to TB control (WHO/MSH/Union)

• Organized "First consultation on engaging business sector in TB control" (WHO)

• Documentation on supply and use of anti-TB medicines in four countries (WHO)

• Support and documentation of PPM scale up in India and China (WHO)

• Preliminary analysis of PPM components of Global Fund grants (WHO/GF)

• Documentation of PPM for MDR-TB management in two countries, and preparation of background paper for Beijing meeting

• PPM Newsletter

9. PPM Subgroup Main orientation 2010-2011

• Development of a PPM tool-box on evidence-based strategies to engage different types of public and private care providers in TB care and control

• Organization of the sixth global meeting of the PPM Subgroup

• Engaging large hospitals to improve TB case detection and care

• In-depth analysis of support for PPM in Global Fund grants to understand and address gaps and weaknesses

• Support and assist documentation of PPM scale-up in countries

• Regulatory approaches to ensure standardized TB care by non-programme providers

– restricting access to anti-TB medicines

– setting up certification and accreditation systems

10. Introducing New Approaches and ToolsMain achievements 2009

Retooling Task Force Dissemination of New Laboratory Diagnostic Tools for TB Control (Dec 2008)

Participations in Thematic Track "From Research to Retooling" In STOP TB Partner Forum in Rio

The Partnership Coordinating Board (March 2009)

Dissolution of the Retooling Task Force

Creation of a sub-group on Introducing New Approaches and Tools under the DEWG: The 1st core group meeting: 12 Oct, 2009

10. Introducing New Approaches and Tools Improving case detection and TB care

• Facilitate country planning to prepare for coming new approaches and technologies to improve case detection through documents and tools developed by the Retooling TF

• Promote operational researches or pilot programmes to develop algorithm and approaches to improve case detection

10. Introducing New Approaches and Tools Main orientation 2010-2011

To be defined soon: • Provide platform to interface the working groups of

different areas• Solicit information from NTPs and implementing

partners on the challenges being faced • Prioritize and coordinate a concerted responses to the

operational challenges indentified• Prioritize operational and evaluation research

TBCAP supported activities APA4 (1 Oct2008 - 30 Sept 2009)

Tool /project Lead TBCTAPartner

Description

Expanded use of planning and budgeting tool

WHO 2 workshops: one for 16 francophone African countries and the second one for GLC consultants

Dissemination of X-ray tool JATA training workshops in use of the tool in Asia and Africa

Tool to estimate patients' costs KNCV Information gathered from Ghana, Vietnam and Dominican Republic

Manual for TB specific DQA Tool WHO/KNCV /Union

Tool and guidelines - field testing in 4 countries

QUOTE TB Light - patient center approach

KNCV Tested in Nigeria and Brazil. Tool will be completed by end of October 2009.

Training workshops on TB Infection control, PAL, Lab culture/ DST

WHO andThe Union

Capacity building for several priority countries

Institutional capacity building PMU Support to training centres in Nigeria and Indonesia

Conclusion Conclusion Back to the early years of the DEWG

Year 2001 : preparation

Year 2002 : implementation

Year 2003 : scaling up

Year 2004 : accelerating actions

Year 2005 : broadening the scope of interventions

…………………………………..

Year 2010: achieving higher and earlier case detection, maintain high cure