Advocacy, Communication, and Social Mobilization to Fight XDR TB

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Advocacy, Communication, and Social Mobilization
to Fight XDR TB

• Wanda Walton, PhD, MEd
• Communications, Education, and Behavioral Studies
  Branch
• Division of Tuberculosis Elimination

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ACSM to Address Key Challenges to TB Control at
Country Level

• Improving case detection and treatment adherence
• Combating stigma and discrimination
• Empowering people affected by TB
• Mobilizing political commitment and resources for
  TB

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Framework for ACSM to Address Key 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 about XDR
  TB, informing and creating awareness
• Advocacy to place XDR TB control high on the
  political agenda, foster political will, increase
  financial and other resources, e.g., human
  resources
• Social mobilization to bring together allies to
  raise awareness and demand for program needs,
  assist in delivery of resources and services,
  create sustainable change

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XDR TB Extensive (or Extreme) Drug Resistant TB

• XDR TB extensive (or extreme) drug resistant TB
• MDR TB - defined as TB resistant to at least the
  2 most potent anti-TB drugs, isoniazid and
  rifampicin (first-line drugs)
• XDR TB - defined as MDR TB that is also
  resistant to 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
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First-line drugs and treatment of
drug-susceptible TB
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Second-Line Drugs and Treatment of
Multidrug-Resistant TB
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Resistance by definition
Resistance possible or likely
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Extensive Drug Resistance Among MDR TB Isolates
Submitted to 14 Supranational Reference Labs, by
Region 20002004
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XDR TBAwareness and Emergency Response

• Oral and poster presentations at IUATLD
  conference, November 2005
• CDC report on Emergence of Mycobacterium
  tuberculosis with Extensive Resistance to
  Second-Line Drugs --- Worldwide, 2000--2004,
  March 24, 2006
• 16th International AIDS Conference presentation,
  August 2006
• Global alert issued by WHO on emerging threat of
  highly lethal strains of drug resistant TB (XDR
  TB) on September 5, 2006
• Emergency experts meeting (MRC, WHO, CDC) in
  Johannesburg, 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-Natal Province (KZN), South
Africa

• Reports of high mortality from TB in ARV
  treatment program in 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
  institutions throughout KNZ

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Expert Consultation on Drug Resistant 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
  South Africa (RSA) Department of Health
• Key stakeholders with experience in
  drug-resistant TB response 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 TB
  programs to strengthen treatment adherence and
  achieve high rates of treatment completion for
  all TB patients
• Develop national emergency response plan for
  MDR/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 TB
  laboratory capacity
• Urgently implement broad infection control
  practices in health care facilities with special
  emphasis on those facilities providing care for
  PLWHA

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7-Point Plan Long Term Response

• Establish capacity for clinical public health
  managers to effectively respond to MDR/XDR TB
• Promote universal access to ARVs for all TB
  patients through collaboration with HIV/AIDS
  treatment and care programs
• Support an increase in research for anti-TB drug
  development and rapid diagnostic test development
  for 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, are human
beings with human rights. We must treat all
people with TB with respect, preserve their
dignity, and save their lives. There is no role
for stigma and discrimination in managing TB.

• Professor Gavin Churchyard
• Director, Aurum Institute for Health Research

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TB Disease
Latent TB Infection
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XDR TB
MDR TB
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XDR TB Messages First global report of highly
drug resistant TB, which shows widespread
presence of virtually untreatable TB

• Survey of global network of supranational TB
  reference laboratories, located on 6 continents
• 2 of the isolates (347 out of nearly 18,000)
  were identified w/ extensive drug resistance
• XDR TB was ID-ed in all regions, but was most
  frequent in the countries of the former Soviet
  Union and in Asia
• While global trend data is limited, available
  data may indicate some increases in XDR TB
• In U.S., found 4 of MDR TB cases were highly
  drug resistant
• In Latvia, MDR TB, 19 of MDR TB cases were
  highly drug resistant

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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 to
  treat, 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
  additional effective drugs, the majority of TB
  cases occur in places unlikely to have access
• Limited drugs mean that patients with XDR TB are
  virtually untreatable according to international
  TB treatment guidelines in most countries

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XDR TB Messages Worsening drug resistance around
the world poses a serious threat to our ability
to treat control TB (2)

• Patients with drug-resistant TB have worse
  treatment outcomes (death or treatment failure)
• Compared to patients with MDR TB, those with XDR
  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 HIV
  infection died, despite adequate response to ARVs

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XDR TB Messages Critically 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 treatment
  through DOTS programs
• Strengthen lab capacity for diagnosis of MDR TB
  and second-line drug susceptibility testing
• Use of quality-assured TB drugs
• Expand surveillance to determine trends and
  better evaluate XDR TB
• Must have adequately functioning TB programs to
  address 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,
  lower cost second line drugs while ensuring their
  proper use to prevent 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 susceptibility testing, 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

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XDR TB Messages CDC is partnering to raise
awareness and enhance strategies for TB
prevention worldwide (2)

• New messages
• Participation in expert consultation with WHO and
  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
  division of TB elimination, said emergence of a
  super-resistant strain is a potent reminder that
  tuberculosis remains a formidable threat. "It
  is widely distributed geographically, including
  in the United States, and renders patients
  virtually untreatable," Castro said.
• Dr. Marcos Espinal, executive secretary of WHO's
  TB elimination program, called XDR TB a veritable
  death sentence. "If people are failing first- and
  second-line drugs and we don't have in the
  pipeline a new drug for immediate use, that's a
  crisis," he said.

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Media Response to XDR TB in South Africa
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XDR-TB WHO expresses concern
WHO background briefing note issued prior to
XDR-TB Expert Consultation meeting in South Africa
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XDR-TB Coverage from international
broadcasters
 
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XDR-TB Coverage in major weekly journals
Newsweek Sept. 13, 2006 WHO recently issued a
warning that deadly new strains of tuberculosis
appear to be spreading around the globe HIV
sufferers are particularly vulnerable because of
their weakened immune systems. TB, already the
worlds fourth most fatal infectious disease,
could wreak havoc with AIDS treatment programs
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XDR-TB Coverage in major weekly journals
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XDR-TB African press coverage
New TB strain in SA 'No time to wait' 07
September 2006 The extreme drug-resistant
tuberculosis (XDR-TB) in KwaZulu-Natal must be
dealt with urgently, international health experts
said in Johannesburg on Thursday."There is no
time to wait before we embark on decisive
action," said the World Health Organisation's Dr
Ernesto Jaramillo, explaining that an epidemic
could have a deadly impact.
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XDR-TB International press coverage
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XDR-TB International headlines
Deadly TB strain spreading across globe
Africa "Extreme" TB Bug Prompts Calls for Rapid
Action
Experts call for urgent steps to battle virulent
TB strain
South Africa Action plan developed to combat
drug resistant TB
WHO urges South Africa to curb TB killer super-bug
Global alert over deadly new TB strains
TB strain with extreme resistance to drugs
creates nightmare scenario
TB experts will grapple with deadly new strains
WHO
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XDR-TB 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 South African province of
KwaZulu-Natal were found to have a form of the
disease resistant to enough existing drugs that
it is virtually incurable. All but 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
  to ensure no delays in the global response to XDR
  TB
• 3. Case definitions Ensure consistency in
  surveillance and case management
• 4. Monitoring and evaluation Determine
  geographical and temporal spread of XDR TB

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Stop TB XDR Response (2)

• 5. Communications Provide a proactive flow of
  information to all stakeholders, including member
  states and the global media
• 6. Case management Define the optimal way of
  rapidly identifying suspect XDR cases and
  ensuring appropriate treatment determine
  appropriate infection 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 Raviglione