Looking into the mirror of tuberculosis Supervisors meeting

Looking into the mirror of tuberculosis Supervisors’ meeting Vilnius, Lithuania, May 20, 2005 Slightly modified before meeting in the Directory of Health in Iceland Thorsteinn Blöndal MD, Med Dr

Content • • Introduction Backstage history TB epidemiology in Lithuania Thoughts about the future Þ Blöndal

Introduction • After a long time of uninterest in TB, WHO & IUATLD succeeded in bringing TB back to the global health agenda • The new parole was DOTS • DOTS (directly observed treatment, short course) Þ Blöndal

Directly observed treatment, short course = DOTS A strategy of comprehensive TB control comprising five essential elements: 1. 2. 3. 4. 5. Political commitment Quality assured smear microscopy Standardized chemotherapy Uninterrupted drug supply Recording and reporting system Þ Blöndal

Political commitment Sustained political commitment

Quality assured smear microscopy Access to quality assured TB microscopy for case detection among persons presenting with symptoms of TB WHO 2003

Standardized chemotherapy to all cases under proper case management conditions including direct observation of treatment (DOT) WHO 2003

Uninterrupted drug supply Uninterrupted supply of quality-assured drugs with reliable drug procurement and distribution systems WHO 2003

Recording and reporting system enabling outcome assessment of each patient and assessment of the overall program performance WHO 2003

Backstage Political initiative among Nordic governments resulted in: • Nordic Baltic TB Project 2000 -2002 • ‘Task Force’ 2002 -2004. Expansion of DOTS for prevention and control of TB in Lithuania Þ Blöndal

Backstage history • Annexed by the USSR in 1940 • Became the first of the Soviet republics to declare its independence March 11, 1990 • Surges in TB followed as well as in psychiatric illness, particularly affective disorders and depression • Treatment interruptions in TB were common, a situation that promoted the development of drug resistance Þ Blöndal

Post-communist transition and health in Europe • In 2000 there was a 12 year difference in life expectancy between the former Sovient Union countries and W-Europe • Health gains in the west have been driven mainly by reductions in cariovascular disease (diet, treatment for hypertension) • High alcohol consumption, injury, violence • Communicable disease, among other TB BMJ 2004; 329, 1355 -1356

Finances • Through Lithuanian state budget • The total budget from Nordic Baltic for the project in the Baltics in 1999 -2000 was 1, 7 million USD • Lithuania received 400. 000 Euros during the TF period 2002 -2004 Þ Blöndal

Tuberculosis notification rates, Europe, 1997 TB notification rate/100 000 < 10 10 to 19 20 to 49 50 and over not available Euro. TB

Overview • In 1998 the Lithuanian government expressed committment to implementation of DOTS and the National Prevention and Control Strategy was approved • In 1998 -2000 three pilots • In 2000 -2003 DOTS expansion • 2004 – DOTS maintainance

Non-MDR TB, new and relapses. Lithuania. Source: Central registry. There is a clear downgoing trend after 1998.

Non-MDR tuberculosis. Lithuania. Source: Central registry.

TB by sex and site of disese, 2002 • Men • Women 1979 865 70% 30% • Pulmonary 2351 • Extrapulmonary 493 83% 17% Þ Blöndal

Non-MDR Tuberculosis. Lithuania. Source: Central registry.

Pulmonary TB by sputum smear/culture. Lithuania, 2002. • Sputum smear positive 1202 • Smear negative 1149 51% • Culture positive • Culture negative 54% 1544 1300 Euro TB Þ Blöndal

Achievements during 1997 to 2005 • Sustained political commitment: Yes • Quality assured smear microscopy: – No of microscopy labs from 200 to 14; – culture labs from 17 to 5, – 5 labs doing sensitivity tests to 1 st line drugs – 2 nd line drugs from 1 to 2. – Courses. • Standard chemo under proper conditions: – DOT coverage from 0 1997 to 95% 2004. Courses for nurses & doctors. Þ Blöndal

Achievements from 1998 • Uninterrupted supply of drugs: – Almost. Last time was 1998. No policy for management of drug resistant TB. DOTS plus beginning in 2006 • Reporting/recording as outcome assessment: – Upgrading of hardware, software, furniture at the premises of Central registry – Training courses Þ Blöndal

Supervisors appointed. Regular meetings.

New pulmonary tuberculosis. Mode of detection. Source: Central registry.

Comparison of reported case finding. Lithuania 1996 – 2004. Registry.

Treatment outcome % new pulmonary Sm+ and/or C + (MDR excluded) Lithuanian TB register

Success Default Source: Central Registry

Tx outcome 2003. Pulmonary, new vs relapses. MDR excluded % Lithuanian TB register

Source: Central TB Registry

DOTS-Plus is a case-management strategy designed to manage MDR-TB using 2 nd line drugs within the DOTS strategy in low- and middle-income countries DOTS-Plus means DOTS first Þ Blöndal

Anti-TB drug resistance by entry category, Europe, 2001 isoniazid 55 rifampicin multidrug resistant ethambutol streptomycin West (15 countries) Centre (6 countries) East (3 Baltic countries) % of resistance (mean) 50 45 40 35 30 25 20 15 10 5 0 New (n=8 458) Retreated (n=1 039) New (n=6 290) Retreated (n=1 067) New (n=2 258) Retreated (n=872) Euro. TB

Prevalence of resistance, Lt 2002 Never treated • • • INH Rifampicin INH+R Etambutol Strepto 24% 9% 9% 7% 20% Previous treatment 61% 51% 36% 55% Implications for tx Int J Tuberc Lung Dis 9(2): 170 -174, 2005

Resistance pattern, 2002, Lt % Int J Tuberc Lung Dis 9(2): 170 -174, 2005

Treatment outcome 2001. MDR vs other new pulmonary cases % Lithuanian TB register

Thoughts • Public health differs from clinical medicine in being particularly sensitive to the financial income of the state (among other factors) • The conncection of TB and poverty is well established. With economical development and higher GNP TB in Lithuania will probably go away Þ Blöndal

Percentual change from previous year’s GDP and TB in Lithuania. New cases and relapses. Data source: Central registry and www. std. lt

More thoughts • TB prevalence depends on a vast number of factors. Now in 2005 there is a clear improving trend in the overall TB situation in Lithuania • The MDR threat however is appalling • DOTS must remain strong • DOTS-plus must start as soon as possible Þ Blöndal

Edita Davidaviciene and Dalia Gaidamoniene nurturing the NTB flower