Key Findings and Recommendations External review to TB

Key Findings and Recommendations External review to TB Prevention, Control and Care in the Republic of Kazakhstan Astana, 16 May 2013 Dr Masoud Dara Programme Manager, TB and M/XDR-TB WHO Regional Office for Europe

Outline of presentation • Summary epidemiological situation in the Region and Kazakhstan • Overview of finding and recommendations of the extensive programme review 2012 • Next steps

No reason to be complacent about TB in the WHO European Region • Total of over 500 000 estimated TB patients in the Region © Carl Cordonnier • 380 000 new TB cases estimated to occur in a year • 44 000 deaths, mostly in the east © Ivan Chernichckin

TB burden unequally distributed among countries

Millennium Development Goal 6: Europe not on track to halve TB mortality by 2015 TB incidence TB mortality target TB prevalence Decline of TB incidence and prevalence likely to be achieved target

M/XDR-TB in the European Region

Consolidated Action Plan to Prevent and Combat MDR-TB (MAP) • Prompt diagnosis including newly endorsed molecular diagnostic techniques • Equitable access to adequate treatment • Health system approach to MDR-TB prevention and control • Emphasis on involvement of civil society organizations • Identifying and addressing social determinants • Working in partnership, twinning of cities/programmes • Robust monitoring framework, accountability and follow-up • Including neglected aspects (e. g. palliative care, surgery)

Overview of the Action Plan Goal • To contain the spread of drug-resistant TB by achieving universal access to prevention, diagnosis and treatment of M/XDR-TB in all Member States of the WHO European Region by 2015 Targets • To decrease by 20 percentage points the proportion of MDRTB among previously treated patients by end 2015 • To diagnose at least 85% of estimated MDR-TB patients by 2015 • To treat successfully at least 75% of notified MDR-TB patients by 2015

Incidence (green), notification (black) in 100, 000 population

Summary epidemiological situation • Notification 2011: 26211 (162 in 100 k). New 14396 (including SS+3289), 11815 retreatment (45% of all TB cases) • MDR-TB among new cases 30% • MDR-TB among previously treated cases 51. 3% • 1. 6% HIV prevalence among incident TB cases

Programme review in a nutshell • Previous extensive review in 2007 • 16 international experts from 11 countries including USAID, CDC and KNCV HQ • 10 -16 May 2012 • Akmolinsky Oblast, Almaty, Almatinsky Oblast and South Kazakhstan Oblast • Desk review, interviews, observation and verification • Based on six health system building blocks

Key findings • Excellent progress in all aspects of TB prevention, control and care – Through care – MDR-TB diagnosis and treatment – Infection control – Surveillance – Monitoring and supervision • TB and M/XDR-TB still a big public health challenge • Contact investigation has a low yield

Childhood TB - recommendations • Update childhood TB treatment and prophylactic treatment guidelines in accordance with latest WHO guidelines (2011) • Train TB pediatricians on new treatment guidelines • Improve diagnostic specimen collection for bacteriological confirmation of diagnosis in children • Revise criteria for hospitalization and placing children in sanatoriums

OR - recommendations • Prepare plan for building research capacity for the NTP and Oblast staff and organize trainings/coaching on OR • Increase use of routinely collected data for OR • Based on the result of programme review set research priorities (WHO and partners will provide assistance)

Prison sector - recommendations • • • Improve timely start of treatment for TB and DR-TB (start treatment when diagnosed) Increase access to rapid molecular diagnosis of DR-TB, at least to R Provide universal coverage with DST at least to FLD for all S+/C+ patients Provide access to Cat IV treatment to all patients registered with DR-TB, including XDR-TB Strengthen the IC in TB penitentiaries: Administrative separation by smear/culture and DST status Environmental measures: installation of adequate quantity of UVGIs Individual protection cough etiquette and masks for patients and respirators for personnel Address the problem of understaffing and motivation of personnel Strengthen the through-care system.

TB/HIV • Diagnosis of TB not in HIV/AIDS centres • Low case detection of TB among PLWH • Insufficient clinical management of TB/HIV patients • Late start of ART in co-infected individuals

TB/HIV recommendations – ART to all patients with active TB as soon as TB treatment is tolerated – IPT to PLHIV with LTB, monitor outcomes – Improve TB/HIV data coordination and use for managerial decisions

Findings TB laboratory diagnosis • The rate of sputum and culture confirmation is low (30% smear positivity among new cases in 2010) • Well-developed laboratory network including sample referral and laboratory infrastructure, good materials and resources, high level of performance discipline • Biosafety concerns in some facilities with regard to engineering, equipment and GLP • Methods for rapid detection of TB and anti-TB drug resistance prediction are not (yet) in place

Recommendations laboratory • Finalize and implement National Laboratory Strategic Plan for the development of laboratory services • Develop and implement a comprehensive QMS in all laboratories and develop a quality manual • Optimize biosafety and develop a biosafety manual • Implement rapid methods for the detection of (MDR) TB for all MDR-TB suspects and HIV+ patients • Optimize TB laboratory diagnosis by organizing TA and training on primary isolation and culture of TB • Develop and implement a computerized LIMS

Migration- Recommendations • To examine the recently published Minimum Package of Cross border TB Control and Care • To pilot cross border TB control and care between selected countries of CAR (WHO ready to assist) • To provide measures on infection control for the patients moving from one country to another

Governance -recommendations • In addition to supervisory visits, use teleconference calls for regular support to the Regions • Use data for improving programme performance at Oblast level • Consider establishing Kazakhstan National Stop TB partnership

TB Surveillance, Monitoring & Evaluation Main recommendations: • Further develop and strengthen the electronic TB recording and reporting system by: – a) establishing a National TB Register for Prevention and Treatment as a unified source of data/information for the NTP and the SES – b) integrating TB laboratory services and prison TB care services into electronic recording and reporting • Conduct a country-wide review of the current practice and efficiency of population screenings for TB. • Initiate monitoring of drug side effects within the surveillance system. Develop SOPs for their management. • Develop SOPs for data quality, data storage and data safety.

TB - health system issues: Key recommendations • Design and introduce patient centered approaches which will help proper strategic planning and inform decision on changes in financing, care delivery, staffing, information system, etc. • Conduct comprehensive analysis of TB hospitals’ performance using proper methodology for activities, expenditure, and outcomes • Promote outpatient TB case management (e. g. MDR-TB case management), • Start asap with a limited-scale demonstration project in few territories • Develop clear criteria for hospitalization and discharge (based on clinical but not on ‘epidemiological’ or social factors) • Scale up rapid diagnostics for TB and MDR-TB (e. g. Xpert), change diagnostic algorithm and adjust service delivery accordingly (including stopping cultures at rayon level) • Adjust payment mechanisms for TB case management for a higher impact

Recommendations – Anti-TB drugs • Mo. H/SK Pharmacia/NTP: Promote process of WHO prequalification by including it as a requirement in tender documentation for state procurement • Local Manufacturers: start the process of WHO prequalification • Mo. H/NTP: facilitate process of registration of pediatric formulations • Mo. H/NTP: Monitor side effects of the 1 st and 2 nd line anti-TB drugs • Mo. H/NTP: Plan operational research on risk factors and rates of 1 st and 2 nd line side effects among TB patients and on management of those side effects

Next steps • Developing Concept Note • High Level policy Dialogue • Continuous dialogue and sustainable technical assistance • Cross border TB control and care • Robust monitoring to document the progress

Joint launch of the MAP

Thank you for your attention Email: Tuberculosis@euro. who. int