1. 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

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

3. 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

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

5. Political commitment Sustained political commitment

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

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

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

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

10. 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

11. 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

12. 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

13. 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

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

15. 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

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

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

18. TB by sex and site of disese, 2002 Men197970% Women86530% Pulmonary235183% Extrapulmonary49317% Þ Blöndal

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

20. Euro TB Pulmonary TB by sputum smear/culture. Lithuania, 2002. Sputum smear positive120251% Smear negative1149 Culture positive154454% Culture negative1300 Þ Blöndal

21. 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 1st line drugs –2nd 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

22. 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

23. Supervisors appointed. Regular meetings.

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

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

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

29. Success Default Source: Central Registry

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

31. Source: Central TB Registry

32. DOTS-Plus 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

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

34. Prevalence of resistance, Lt 2002 Never treatedPrevious treatment INH24%61% Rifampicin9%51% INH+R9%51% Etambutol7%36% Strepto20%55% Int J Tuberc Lung Dis 9(2):170-174, 2005 Implications for tx

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

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

40. 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

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

42. 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

45. Edita Davidaviciene and Dalia Gaidamoniene nurturing the NTB flower