The Global Project on AntiTB Drug Resistance Surveillance

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The Global Project on Anti-TB Drug Resistance
Surveillance

• TME Epidemiology Training Course Caucasus

Tbilisi, Georgia 3-6 May 2005
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The WHO/IUATLD Global Project on
Anti-Tuberculosis Drug Resistance Surveillance
Principles -Sample accurately represents
population under study -Quality assured
laboratory results -Differentiation between
new and previously treated cases

• Guidelines for surveillance of drug resistance in
  tuberculosis
• Supranational Laboratory Network
• 20 laboratories, coordinating center
• PT and QA
• 1997, 1st report 35 settings, 2000, 2nd report
  58 settings, 2004, 3rd report 77 settings
• Objectives
• Estimate the magnitude of drug resistance
  globally
• Determine trends
• Evaluate the progress of TB programmes
• Strengthen laboratory networks
• Data to inform policy decisions DOTS-Plus,
  Laboratory strengthening subgroup, regimen
  evaluation

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New contributions from the 3rd global report

• ? In the 3rd report, 77 Geographic settings,
  representing 20
• of new sputum smear positive cases globally
  (almost 70,000
• TB cases tested). 39 settings had never
  previously been
• reported.
• ? 17 settings in high burden countries. Of
  these, 14 had
• never previously been reported.
• At least two data points from 46 settings
  however, it is
• still early to interpret trends from the
  majority of these
• settings with any certainty.
• 10 settings with a high prevalence of MDR among
  new cases were identified, 5 had never
  previously been reported, 6 are located in the
  former Soviet Union.
• Directed focus on settings with suspected high
  prevalence MDR, and high burden of tuberculosis.

• Areas
• COVERAGE
• HIGH BURDEN
• TRENDS
• HOTSPOTS
• SURVEILLANCE

SURVIELLANCE
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Any resistance among new cases by WHO region
1999-2002
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MDR among new cases by WHO region 1999-2002
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Prevalence of MDR by treatment status, ranked by
new cases
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Trends in MDR among new cases in selected
countries
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Medians of resistance among previously treated
cases by WHO region 1999-2002
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Proportion of retreatment cases among
smear-positive cases 2003
For Russia, all cases are included not only
smear-positive
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High TB burden countries
India 2003
419,668 notified new ss 120,989 notified
retreatment cases Retreatment 22.4 of
ss (up to 41 in some states)
Few surveys done, 3.4 among new in
Tamil Nadu
South Africa 2002
98,799 notified new ss 17,869 notified
retreatment cases Retreatment 18 of ss
(16.3-35.8) 1.8 MDR among new, 6.7 Rtmt 4000
confirmed MDR cases on treatment
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Kazakhstan 2002
9,706 notified new ss 2,900 notified retreatment
cases Retreatment 23 of ss (survey indicates
47) 14.2 among new and 56.4 among
retreatment 71.8 resistant to all drugs
tested Est 11,025 MDR cases
Kyrgyzstan 2003
1487 notified new ss 852 notified retreatment
cases Retreatment 36.4 of ss Only 26 of
retreated cases cured No survey 24.3 MDR among
new 56.1 MDR among Rtmt (non-nat'l-CRH)
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China 2003
267,414 notified new ss 68,881 notified
retreatment cases Retreatment 25.7 of ss (20
DOTS vs. 30 non-DOTS) 6/ 31 provinces
surveyed MDR among new range (2.1 10.4) MDR
among rtmt range (17.5 36.6)

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Pre-requisites for Drug Resistance Surveillance

• Political commitment
• Means that government actively supports
  evaluation of drug resistance in the country.
  This includes assuring sufficient laboratory and
  programme staff to carry out the survey and
  allowing transport of specimens to SRL for QA.
• National survey team
• A national survey team is essential to coordinate
  and conduct a drug resistance survey. This team
  should include a principle investigator for
  overall coordination, a laboratory specialist and
  an epidemiologist/statistician. This team is
  primarily responsible for drafting the protocol,
  gaining national consensus on the protocol,
  preparing the survey by conducting necessary
  training and trial runs, implementing and
  supervising the survey, conducting quality
  assurance and finally analyzing the data.
• Functioning laboratory network
• To conduct a drug resistance survey microscopy
  must be functioning well enough to detect smear
  positive cases, on which the sample is based.
  Usually a national reference laboratory is
  responsible for culture and DST during the course
  of the survey. The head of a Supranational
  laboratory visits the NRL before the start to
  ensure biosafety precautions are in place.
  Following, a panel of coded strains are sent for
  proficiency testing. During the course of the
  survey all resistant strains and a percentage of
  susceptible strains are rechecked by the SRL. If
  a NRL is not yet in place the SRL may agree to
  test the specimens directly.

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