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Updates on situation of drug-resistant tuberculosis in Papua New Guinea, with special emphasis on Daru Island

This document is a copy of the statement issued by WHO Representative Office in Papua New Guinea. The document can be accessed at:
http://www.wpro.who.int/papuanewguinea/areas/tb_leprosy/daru_update/en/#.Vv6JBB78mPA.email
April 2016

Background

Tuberculosis (TB) remains a major public health threat in Papua New Guinea. TB kills more people in Papua New Guinea than any other infectious disease. The problem is further compounded by high levels of drug resistant TB particularly in hot-spot areas1, namely Daru of South Fly District in the Western Province2,3, the National Capital District and the Gulf province4.

Recognising the serious problem with drug resistant TB in Papua New Guinea, the Government of Papua New Guinea in coordination with all partners established an emergency response team (ERT) in August 2014. The ERT assists in raising high-level advocacy, resource mobilization, planning and monitoring of implementation of the national response to drug-resistant TB. Subsequently, an accelerated response plan was developed in January 2015 and the government and partners have been further increasing their efforts to address the issue. As part of continued support for the country’s effort, the Western Pacific Regional Green Light Committee (rGLC) conducted its annual mission to Papua New Guinea in May 2015 and made a series of recommendations. The rGLC is a group of international TB experts to support public health response to address drug-resistant TB across the Western Pacific Region. Although the next rGLC mission is planned later this year, significant progress has already been observed.

The purpose of this document is to provide an update on the progress made since May 2015 and WHO’s position to further support country’s efforts.

Progress since the rGLC mission to Papua New Guinea in May 2015

With substantial efforts of the central and local governments, local health workers and engaged communities, supported by international and local partners, significant progress has been observed, particularly improvements in diagnosis, treatment and care for patients with drug-resistant TB in Daru.

  • Increasing funding: The Government of Papua New Guinea has committed funding to implement the accelerated response plan to address MDR-TB and released 8 million Kina (equivalent to US$ 2.6 million) in January 2016. The Australian Government continues to provide significant financial support
  • Improving patient support while on treatment: To ensure all patients successfully complete their treatment, community-based treatment teams, the Daru Accelerated Response for Tuberculosis (DART), have been established. Patients can receive treatment close to home and also nutritional support through a daily lunch for every visit.
  • Organizing care around individual patient needs: Weekly individual care planning meetings have been instituted in Daru General Hospital with a focus on delivering patient-centred care.
  • Improving access to essential medicines to treat drug-resistant TB: The government procures all second-line TB medicines and medicines to treat side effects. These are available to patients with drug-resistant TB free of charge.
  • Expanding access to a new medicine: Building on the experience in the compassionate use of bedaquiline since 2013, the National TB programme introduced a procedure for access to bedaquiline for patients required the drug. Currently, six patients (five in Daru and one in Port Moresby) are treated with a regimen containing bedaquiline. Expanded access to novel TB drugs can be critical for curing patients when an effective treatment regimen cannot be designed with existing medicines.
  • More patients successfully treated: Since June 2015, only 3% of patients discontinued treatment within six months after initiating MDR-TB treatment, compared to more than 60% of patients were lost to follow up previously. This indicates improvement in patient education and support as well as better clinical care including management of adverse side effects.
  • More patients diagnosed with TB and MDR-TB at an earlier stage of the disease: Diagnosis of patients with drug-resistant TB is significantly improving due to expanded use of a rapid diagnostic technology (Xpert MTB/RIF), active contact tracing and international collaboration with offshore laboratories. In 2015, 120 patients were diagnosed with drug-resistant TB (43% increase from 2014) and all of these patients were enrolled for treatment.
  • Improving in-country diagnostic capacity: The National TB Reference Laboratory in the Central Public Health Laboratory, Port Moresby developed its capacity to conduct culture and drug susceptibility testing, which was previously only possible by offshore reference laboratories.
  • Preventing transmission: Infection prevention and control have been strengthened through administrative, mechanical and personal protective measures. The hospital management developed its infection control plan, introduced a cough triage centre, assigned an infection control focal person and regularly monitors use of protective equipment by health care staff in the MDR-TB ward.
  • Updating policies to further strengthen the services: To build on these improvements, the Department of Health 's National TB Program has released its updated approaches to further strengthen the TB services in Daru in the following four areas (National TB Programme Directives issued on 18 March 2016):
    1. Patients can start treatment for MDR-TB on an outpatient basis without requiring hospitalization according to the conditions and preference of patients
    2. Trained community health workers can supervise and support treatment of patients with MDR-TB care in the community
    3. A new diagnostic technology, Xpert MTB/RIF, can be used to diagnose all people who are presumed to have active TB
    4. The use of a new drug, bedaquiline, is expanded.

WHO position on the progress and the updated approaches

  • WHO supports the new approaches of the National TB Programme on MDR-TB treatment on an outpatient basis as well as community-based care and support that is close to patient homes.
  • WHO supports the use of Xpert MTB/RIF as the initial diagnostic test for TB diagnosis as per global WHO policy guidance5.
  • WHO advises that the use of new drugs should be further extended to ensure that all patients who are eligible for treatment are provided with adequate treatment regimens that include new drugs when necessary. Specifically, WHO recommends that:
    1. the use of bedaquiline should be extended to include all MDR-TB patients for whom a conventional regimen cannot be designed, as per current interim WHO policy guidance; and
    2. delamanid should be included according to current interim WHO policy guidance.
  • WHO supports continued monitoring of TB service delivery to ensure that adherence to treatment (with patient support) is maintained, treatment response and drug safety are continuously measured and promptly addressed, and barriers to scale-up of treatment are removed quickly.
  • WHO supports the acceleration of proactive approaches for case detection and prevention such as preventive therapy6 and infection control at household and community levels.
  • WHO recommends extending these additional policies to the whole country in a stepwise manner and as soon as possible.
  • WHO welcomes the progress to date, and is committed to providing continued support to Papua New Guinea and stakeholders for TB control and to maintain the emergency response to MDR-TB in hot spot areas including Daru.

The fourth Core Group (CG) meeting of the Global Drug-resistant TB Initiative (GDI)

The fourth Core Group (CG) meeting of the Global Drug-resistant TB Initiative (GDI) was held on 1 December 2015 in Capetown, South Africa. All members (bar 1) of the CG, attended the meeting, along with observers from the Global Laboratory Initiative (GLI), Global TB Drugs Facility (GDF), Global Fund (GF), USAID, and Leaders of the GDI Task Force on "Access to new DR-TB drugs.

The objectives of the meeting were:

  • To follow up on recommendations made and action points agreed upon during 3rd GDI CG meeting in May 2015, and subsequent monthly teleconferences;
  • To provide an update on progress in scale up of MDR-TB services and care, and updates on new policies;
  • To provide an update on the Joint GDI and GLI Partners Forum, April 2015;
  • To provide an update on the progress of the respective GDI Task Forces and from the Infection Control (IC) sub-group; and
  • To discuss the GDI CG membership, the GDI "Costed Framework Plan, 2016-2017" and the GDI workplan for 2016.

The participants were briefed about the activities of the GDI Secretariat since the third CG meeting held in May 2015. An update was provided to the CG on "progress in scale-up MDR-TB services and care, and on new policies". This was followed by a "Joint update from the GDI and the GLI" at which the members of the GLI Core Group were present for the update and subsequent discussions. The respective GDI Task Forces and the TB Infection Control sub-group presented the progress and the activities in their respective areas to the GDI CG. A final session then discussed the "GDI CG membership, the GDI Costed Framework Plan 2016-17, GDI funding and workplan for 2016".

All meeting documents can be found at the " Meetings" tab."

The third Core Group (CG) meeting of the Global Drug-resistant TB Initiative (GDI)

The third Core Group (CG) meeting of the Global Drug-resistant TB Initiative (GDI) was held on 1 May 2015 in Geneva, Switzerland. All members of the CG, attended the meeting, along with observers from the Global Laboratory Initiative (GLI), Global TB Drugs Facility (GDF), Global Fund (GF), Infection Prevention and Control (IC) sub-group and the USAID.

The objectives of the meeting were:

  • To follow up on recommendations from the GDI/GLI forum, including the issue of the "call to action on the introduction of new anti-TB drugs"
  • To follow up on recommendations and action points agreed upon during 2nd GDI CG meeting and subsequent monthly teleconferences
  • To provide an update on the progress of the GDI Task Forces, and the Infection Control (IC) sub-group
  • To review the strategic priorities of GDI and plan subsequent activities for the next year; and
  • To discuss the GDI "costed framework" and the work plan

The participants were briefed about the activities of the GDI Secretariat since the second CG meeting held in October 2014.

Following discussions between the GDI CG members and interested participants from the Joint GDI/GLI Partners Forum, there was general consensus that no-one wanted any "new" structures outside of considering a new Task Force. Hence GDI CG agreed that the creation of a GDI Task Force to address this issue was the best solution.

A joint session of the GDI and GLI CGs discussed the issue of growing gaps between the number of MDR-TB cases detected and the numbers started on treatment. GDI and GLI chairs also reviewed the recommendations from the previous joint meeting, as well as relevant issues raised during the Joint GDI/GLI partners forum.

All meeting documents can be found at the ‘Meetings’ tab.

Professor Charles Daley, MD, elected as Chair of the Core Group of Global Drug-resistant TB Initiative (GDI)

Professor Charles Daley, MD, was elected as the Chair of Core Group of the Global Drug-resistant TB Initiative (GDI) by the Core Group members. Dr Daley has served till recently as the Chair of the global Green Light Committee (gGLC) and brings with him strong clinical and educational background, field experience, leadership, and the ability to bring people together for global scale up of the programmatic management of drug-resistant TB (PMDT).

Dr Daley has worked with drug resistant tuberculosis patients for 20 years. He developed and implemented a national tuberculosis advice line that helped TB programs across the United States manage complicated forms of tuberculosis, including drug-resistant tuberculosis (DR-TB). He participated in the development of the WHO 2008 Emergency Update of the Guidelines for the Programmatic Management of Drug-resistant Tuberculosis as well as the 2011 updates to the PMDT guidelines. Over the past few years, he has provided monitoring and technical assistance support to several high TB/ MDR-TB burden countries including China, the Philippines, Peru, and Kyrgyzstan. He has facilitated several international PMDT trainings aimed at building capacity for scale-up of PMDT. He has also conducted research in countries such as Tanzania, Uganda, Brazil, and Colombia.

Core Group members of the Global Drug-resistant TB Initiative


Background

Drug-resistant tuberculosis (DR-TB), particularly multi-drug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB) represent significant threats to global TB control efforts and a major public health concern in several countries. Levels of MDR-TB remain worryingly high in some parts of the world, notably countries in Eastern Europe and Central Asia. In several of these countries, up to 32% of new cases and more than 50% of previously treated cases have MDR-TB.

The World Health Organization (WHO) estimates that worldwide 450,000 people developed multi-drug resistant TB (MDR-TB) and at least 170,000 deaths were caused by MDR-TB in 2012. Globally, the overall detection of cases of MDR-TB increased from 29,000 in 2008 to about 94,000 in 2012. However, only around 77,000 eligible patients were actually put on MDR-TB treatment. Despite progress, the number of MDR-TB cases initiated on proper treatment in 2012 represented only 17% of the estimated cases of MDR-TB. Achieving universal access to treatment as envisaged in resolution WHA62.15 requires a bold and concerted drive on many fronts of TB care.

The Global Drug-resistant TB Initiative (GDI) has been recently constituted as a Working Group for drug- resistant TB related issues (DR-TB) replacing the previous MDR-TB Working Group and the global Green Light Committee (gGLC). The main focus of the GDI will be accelerating the global response to DR-TB through a partnership approach with involvement of all key stakeholders.