Symposium 13 - APRC 2024

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Symposium 13：Programmatic Management of Drug-resistant TB: Progress and Challenges

Drug-resistant tuberculosis (TB) is difficult to manage. A substantial proportion of rifampicin-resistant TB have not been detected. Among those who have been detected, some were lost to followed up or died before treatment. Among those who have been enrolled on treatment, a substantial proportion of patients interrupted treatment, in part because the duration of treatment was lengthy and the drugs used were toxic. The expanded use of rapid molecular test has helped detected rifampicin-resistant TB and resistance to second line drugs. The use of short regimens of rifampicin-resistant TB may have great potential to improve outcome of treatment of rifampicin-resistant TB. However, innovative and effective model of care will be crucial for strengthening programmatic management of drug-resistant TB. Mitigating the risk of acquired resistance to new and repurposed drugs has becoming a new challenge. Solution to address catastrophic costs incurred due to rifampicin-resistant TB is urgently needed.

Date: Sunday, April 28, 2024 | Time: 08:30-10:00 (GMT+8)

Moderator: Dr. Jen-Jyh Lee (Taiwan) | Dr. Hoang Thi Thanh Thuy (Vietnam)

Time (GMT+8)	Topic	Speaker	Country / Region
08:30-09:00	Progress and challenges of programmatic management of drug-resistant TB in Indonesia	Dr. Erlina Burhan	Indonesia
09:00-09:30	Application of short regimens of rifampicin-resistant TB in Viet Nam: challenges and opportunity	Dr. Hoang Thi Thanh Thuy	Vietnam
09:30-10:00	Operation and challenges of Taiwan multidrug-resistant TB Consortium: the way forward	Dr. Chou-Jui Lin	Taiwan

Progress and challenges of programmatic management of drug-resistant TB in Indonesia

Abstract:
Indonesia is one of the countries with the highest burden of Drug-Resistant Tuberculosis (DR TB) in the world. Stakeholders in Indonesia have implemented interventions to address this gap, including policy interventions, social support, medical approaches, technological advancements, and environmental interventions. Indonesia has implemented all WHO TB treatment guidelines, ranging from 18- to 20-month treatment regimens to the latest 6-month BPaLM and BPaL guidelines. These shorter and availability of the regiment might be helpful for patients. But that is not the only problem. There are still wide gaps in diagnosis and management of DR TB. Previous data have reported, Indonesia as one of the 10 countries accounted for 70% of the global gap between the estimated number of people who developed MDR/RR TB and the number of people enrolled on treatment for MDR/RR TB in 2022. This poses a major challenge to achieve goal target of ending the global TB epidemic by 2030. We need better understanding to identify the programmatic gaps of DR TB which defining from access to testing, confirmation of diagnosis, treatment initiation, and treatment completion. Since the end of the COVID-19 pandemic declared, the progress of TB services has significantly improved. Addressing patient’s access, Indonesia is increasing the number of healthcare facilities equipped with DR TB diagnostic tools and emphasizing contact investigations. In terms of diagnosis, the procurement of advanced diagnostic services has aided such as GeneXpert testing, followed by LPA. However, current policies in Indonesia are still striving to strengthen resistance TB examination services. Indonesia is also engaging in research on artificial intelligence to enhance the speed and accuracy of TB diagnosis. Regarding DR TB treatment and prevention, Indonesia actively performs treatment guidelines from the WHO. Additionally, Indonesia has begun actively participating in the development and research of new TB drugs, including TB vaccination.

Dr. Erlina Burhan

Pulmonologist | Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia – Persahabatan Hospital
Indonesia

Professional Experience:

For over two decades, Dr. Erlina Burhan, MSc, PhD, has been a dedicated pulmonologist specializing in lung infections, with a primary focus on tuberculosis (TB). She is renowned for her expertise and practices at Persahabatan National Respiratory Referral Hospital, the leading center for TB care in Indonesia. Dr. Burhan has played a pivotal role in initiating and advancing the country’s drug-resistant TB program, including the early introduction of short treatment regimens. Over the past ten years, she has been instrumental in promoting the public-private partnership model for delivering TB services in Indonesia. Additionally, she holds prominent positions on advisory boards of multiple non-governmental organizations dedicated to TB care and serves as the Chair of the professional coalition for TB in the country.

Dr. Burhan’s expertise also extends to academia, where she imparts her knowledge as a lecturer at the Faculty of Medicine of Universitas Indonesia. Her remarkable contributions include significant roles in more than 20 clinical and observational trials conducted in Indonesia. Beyond her clinical and academic pursuits, she is actively engaged in public education efforts aimed at TB elimination and combating the societal stigma associated with the disease. Dr. Burhan effectively utilizes social media platforms to amplify her mission.

Application of short regimens of rifampicin-resistant TB in Viet Nam: challenges and opportunity

Abstract:
Since 2016, short regimens for rifampicin-resistant tuberculosis (TB) have been applied in Vietnam according to WHO recommendations. Its positive results compared with longer regimens encourage increased implementation of these regimens nationwide. Most recently, the BPaL regimen also demonstrates encouraging outcomes. There was a consensus among clinicians that BPaL regimen is more tolerable for patients as it comprises only three medicines; patients also reported preferring the BPaL regimen. The adverse events may be severe, but can be controlled.

Although the primary outcomes of short regimens are recognized to be better than those of long regimens, the recurrence rate of short regimens has not been fully evaluated. Furthermore, there are differences in the treatment success rates of short regimens when performed under research conditions (above 80%) compared to the results when it was implemented under program conditions (below 75%) in Vietnam. The reason may be related to laboratory capacity, human resources, care models and quality of medical services at the study sites, which are considered better than other sites in the country.

Therefore, to expand the implementation of these regimens nationwide, solutions are needed to address these problems in many treatment facilities, which suggest an opportunity to improve Programmatic Management of Drug resistant TB (PMDT) in Vietnam by strengthening laboratories capacity, developing human resource, decentralization of diagnostic and treatment management capacity, and application of advance technology for patient adherence and adverse event monitoring.

Dr. Hoang Thi Thanh Thuy

Focal Person of Programmatic Management of Drug Resistant TB (PMDT) | National TB Control Programme of Vietnam
Vietnam

Professional Experience:

Dr. Hoang Thi Thanh Thuy has been served as focal person for PMDT/NTP in Vietnam, a trainer for courses on the management of DR-TB in Vietnam, researcher for some clinical trials as well as being a Vice chair of the National clinical advisory Committee on Drug resistant TB in Vietnam.

Dr. Thuy is currently a member of the Green Light Committee of the Western Pacific Region, a member of the Core Group/Global Drug-Resistant TB Initiative, a Technical Advisor on MDR-TB issues for the Global Fund Project for TB in Vietnam.

Operation and challenges of Taiwan multidrug-resistant TB Consortium: the way forward

Abstract:
Taiwan multidrug-resistant TB Consortium (TMTC) was established in 2007 with the goal to avert high failure and loss-to-follow-up rate among MDRTB patients treated in late 1990s in Taiwan. With full funding support from the Centers of Disease Control (CDC) in Taiwan, TMTC was able to provide free MDRTB treatment, adverse events management, financial incentives and directly observed therapy –– all in a patient-centered approach organized by designated hospitals. This reformed care model soon led to significant improvement of treatment outcome of MDRTB patients, who were mainly treated with injectable-based long regimen. Besides clinical patient management, TMTC also had quarterly meetings and annual evaluation with the CDC, which in turn help to consolidate the policies and maintain consistent care qualities. However, MDRTB patients in Taiwan were generally older and with comorbidities compared with those in high burden countries.

To ensure patient safety, TMTC initiated a two-year project of active drug-safety monitoring (aDSM) in 2017 as the program started to adopt new and/or repurposed drugs and novel regimens. This aDSM activity greatly expanded TMTC’s capacity for adverse events detection and management, and further paved the way for introducing different short regimens as the landscape of MDRTB treatment changes rapidly. As this programmatic success has translated into epidemiological impact, the number of MDRTB patients continues to decline since 2007.

It is therefore pivotal for TMTC to maintain excellent programmatic performance as the patients got fewer in the last mile to end TB.

Dr. Chou-Jui Lin

Attending Physician | Taoyuan General Hospital, Ministry Of Health And Welfare
Taiwan

Professional Experience:

Dr. Rebecca Chou-Jui Lin has been devoted in clinical care for drug-resistant tuberculosis patients and leading one of the Taiwan MDRTB consortium pilot hospitals in Taiwan since 2007. She also participated in providing technical assistance and international training courses regarding drug-resistant tuberculosis over the years.

Dr. Jen-Jyh Lee

Consultant | Hualien Tzu Chi Hospital
Taiwan

Professional Experience:

Current Position
Consultant, Buddhist Tzu Chi General Hospital (January 2021 to present)
Assistant Professor, Tzu Chi University, Hualien, Taiwan (August 2011 to present)

Working Experience
April 2004 to March 2010 President, Taiwan Society of Tuberculosis
May 2010 to May 2018 President, National Tuberculosis Association, Taipei, Taiwan
Commander of Eastern Taiwan, Infections Disease Control Network (May 2003 to December 2020)
Section chief, TB Lab Section, Buddhist Tzu Chi General Hospital (July 2007 to December 2020)
Section chief, Infection Prevention And Control, Buddhist Tzu Chi General Hospital (July 2017 to December 2020)

Symposium 13：Programmatic Management of Drug-resistant TB: Progress and Challenges

APRC 2024 Secretariat

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