Dr Paul Nunn, Coordinator, TB Operations and Coordination, World Health Organization UNITAID Technical Briefing 65th World Health Assembly, 21st May 2012

1. UNITAID Technical Briefing
65th World Health Assembly, 21st May 2012
Tuberculosis Access Issues
The Key Challenges in MDR-TB
Paul Nunn
Stop TB Dept., WHO
UNITAID Technical Briefing, 65th World Health Assembly, 21st May 2012

2. Definitions
• MDR (multi-drug resistance) = Resistance to
at least INH and RIF
• XDR (eXtensively drug resistant) = MDR plus
resistance to fluoroquinolones, and one of the
second-line injectable drugs (amikacin,
kanamycin, or capreomycin)
UNITAID Technical Briefing, 65th World Health Assembly, 21st May 2012

3. Distribution of proportion of MDR among new TB cases,
1994-2010
0-<3
3-<6
6-<12
12-<18
>18
No data available
Subnational data only
UNITAID Technical Briefing, 65th World Health Assembly, 21st May 2012

4. Distribution of proportion of MDR among previously
treated TB cases, 1994-2010
0-<6
6-<12
12-<30
30-<50
>50
No data available
Subnational data only 3.6% of all TB, but rising in many countries
UNITAID Technical Briefing, 65th World Health Assembly, 21st May 2012

5. UNITAID Technical Briefing, 65th World Health Assembly, 21st May 2012

6. Challenge 1 – Very few patients are
treated MDR-TB treatment levels
compared to estimated
burden in 2010
No treatment reported. Some
440,000 treatment probably obtained, quality
estimated 387 unknown
cases
Countries report treatment, standard
unknown
40
13 Treated in WHO/ Green Light
Committee programmes
UNITAID Technical Briefing, 65th World Health Assembly, 21st May 2012

7. Challenge 2 - A "Catch 22"
• A course of SLDs is prohibitively
expensive
• Because the market for SLDs is tiny
$20 for a course of first line treatment
$4000 for a course of 2nd line treatment
UNITAID Technical Briefing, 65th World Health Assembly, 21st May 2012

8. Challenge 3 – Finance insufficient
• Global Plan 2011-2015
– $1.3 billion per year rising to $4.4 billion
• In many high MDR-TB burden countries cost of
treatment exceeds annual GDP per caput
• Donor funding for 2011 $0.14 billion
UNITAID Technical Briefing, 65th World Health Assembly, 21st May 2012

9. Challenge 4 – Weak systems for
management and regulation
• Access to MDR-TB care is limited in the public
sector
• Care is often sought from untrained providers
who do not follow international standards
• Second-line drugs not internationally quality
assured and purchase unregulated in many
countries (exceptions – Brazil and South Africa)
• Weak infection control practices in care facilities
• Shortages of trained staff
• Infectious patients remain in community
UNITAID Technical Briefing, 65th World Health Assembly, 21st May 2012

10. Challenge 5 – Access to diagnosis
• Laboratories capable of drug susceptibility
testing are few
• Classical methods of diagnosis take 3 months
or more
• New, rapid molecular tests expensive and
rolling out, but slowly
UNITAID Technical Briefing, 65th World Health Assembly, 21st May 2012

11. There are , so
solutions
to all these
challenges
UNITAID Technical Briefing, 65th World Health Assembly, 21st May 2012