Appendix A
Agenda

With the development of antibiotics in the twentieth century, tuberculosis gradually lost its central position as a global health concern—it was considered a disease of the past or one that was only associated with the extreme poverty of the developing world. However, this view of tuberculosis is out of date.

Tuberculosis is today one of the leading causes of death in the world—4,500 people die daily from the disease. Although many cases of TB can be cured by available antibiotics, multidrug-resistant TB (MDR TB) is a major and growing threat worldwide. Strains of TB resistant to even the second-line therapies (XDR TB) are documented in over 50 countries, including the United States, and we are seeing the emergence of strains that are fully resistant to treatment. And while the epidemic of TB is still primarily centered in the developing world, the reach of MDR extends to every continent, including both rich and poor countries. The global battle against TB, once thought won, is today very real.

The Institute of Medicine (IOM) Forum on Drug Discovery, Development, and Translation is conducting a series of workshops in the United States and in high-burden countries—including South Africa, Russia, China, and India. The first workshop, held in November 2008, included experts from around the world, and was framed by a commissioned paper developed by Partners in Health that provided new data on the nature and spread of MDR TB. In addition, in February 2009, the Forum held a public briefing on MDR TB for Congressional staff in Washington, DC. Details of both meetings, including the agendas and speaker presentations, are available on the Forum’s website (www.iom.edu/drug).



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Appendix A Agenda With the development of antibiotics in the twentieth century, tuberculosis gradually lost its central position as a global health concern—it was consid- ered a disease of the past or one that was only associated with the extreme poverty of the developing world. However, this view of tuberculosis is out of date. Tuberculosis is today one of the leading causes of death in the world— 4,500 people die daily from the disease. Although many cases of TB can be cured by available antibiotics, multidrug-resistant TB (MDR TB) is a major and growing threat worldwide. Strains of TB resistant to even the second-line therapies (XDR TB) are documented in over 50 countries, including the United States, and we are seeing the emergence of strains that are fully resistant to treatment. And while the epidemic of TB is still primarily centered in the developing world, the reach of MDR extends to every continent, including both rich and poor countries. The global battle against TB, once thought won, is today very real. The Institute of Medicine (IOM) Forum on Drug Discovery, Develop- ment, and Translation is conducting a series of workshops in the United States and in high-burden countries—including South Africa, Russia, China, and India. The first workshop, held in November 2008, included experts from around the world, and was framed by a commissioned paper developed by Partners in Health that provided new data on the nature and spread of MDR TB. In addition, in February 2009, the Forum held a public briefing on MDR TB for Congressional staff in Washington, DC. Details of both meetings, including the agendas and speaker presentations, are avail- able on the Forum’s website (www.iom.edu/drug). 95

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96 DRUG-RESISTANT TUBERCULOSIS IN SOUTHERN AFRICA IOM is partnering with the Academy of Science of South Africa (ASSAf) to convene a 2-day workshop on MDR TB. The workshop will bring together disease experts, community leaders, policy makers, and patient advocates to examine the state of MDR TB in the South Africa region, to learn from the experiences of the South African public health community in its fight against MDR TB, and to draw lessons regarding best practices and novel approaches that can be applied both within and beyond the region. Proceedings of the workshop will be published and disseminated globally. The South Africa meeting will focus on various aspects of MDR TB: 1. Epidemiology. The latest information on the spread of MDR/XDR TB in Africa and globally, including the nature of the coinfection with HIV, will be presented and discussed. 2. Diagnostics and Preventive Therapies. The challenges associated with rapid diagnosis of TB and resistance testing in resource- constrained environments will be explored, as well as opportunities for expansion of laboratory capacity and point-of-care diagnosis. 3. Treatment. The limitations of current treatment, including the capacity of current health systems to address the needs of TB patients, the limited numbers of patients receiving appropriate treatment, and challenges in treating migrant workers, will be examined. 4. Transmission and Infection Control. The meeting will explore our growing understanding of the modes of transmission of MDR TB, and the strategies needed to address them. 5. Pediatric TB. The devastating spread of MDR TB among children and the unique challenges they pose for prevention and treatment will be explored. 6. Policy. The workshop will analyze the effects of MDR TB beyond patients in order to highlight areas for improved policy and next steps.

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97 APPENDIX A The Emerging Threat of Multidrug-Resistant Tuberculosis: Global and Local Challenges and Solutions Pretoria, South Africa Day 1 March 3, 2010 Registration 8h30-9h00 Breakfast and coffee will be served at this time. Welcome and Opening Remarks 9h00-9h30 Roseanne Diab, ASSAf Lerole David Mametja, Ministry of Health, South Africa Perceptions vs. Realities: Summary of 2008 MDR TB 9h30-9h45 Workshop in Washington, DC Gail Cassell, Eli Lilly and Company Session 1: A Realistic Assessment of the Spread of MDR/ 9h45-11h45 XDR TB in Sub-Saharan Africa with an Emphasis on South Africa Moderator: Gerald Friedland, Yale School of Medicine Capacity for Health Care Across Southern Africa and MDR/XDR TB Tomas Zimba, Maputo Central Hospital, Mozambique Evolution of XDR TB in KwaZulu-Natal Willem Sturm, Nelson Mandela School of Medicine, University of KwaZulu-Natal Prevalence of Drug Resistance at the Initiation of Second-Line Drugs and Existence of Totally Drug- Resistant TB Martie van der Walt, Medical Research Council of South Africa

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98 DRUG-RESISTANT TUBERCULOSIS IN SOUTHERN AFRICA Putting Resistance in Perspective: The Korean Experience and Polymorphisms Associated with Resistance and Cross Resistance Clifton Barry, National Institutes of Health Discussion with Audience 11h30-11h45 LUNCH 11h45-12h45 Keynote Address 12h45-13h45 Moderator: Janet Tobias, Ikana Media Epidemiology and Management of MDR TB in Children Simon Schaaf, Department of Paediatrics and Child Health, Stellenbosch University Discussion with Audience 13h30-13h45 Session 2: Coinfection with HIV/AIDS: Clinical 13h45-15h15 Outcomes and Consequences Moderator: Richard Chaisson, Center for Tuberculosis Research, Johns Hopkins University Tugela Ferry Experience in a Community Hospital Neel Gandhi, Tugela Ferry Care and Research Collaboration (TF CARES) Albert Einstein College of Medicine Outcomes from TB Referral Hospitals, KwaZulu-Natal Nesri Padayatchi, University of KwaZulu-Natal Outcomes from the Eastern Cape Charlotte Kvasnovsky, Medical Research Council Mortality and Causes of Death in South Africa Maletela Tuoane-Nkhasi, Statistics South Africa Discussion with Audience 15h00-15h15 BREAK 15h15-15h30

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99 APPENDIX A Session 3: Alternative Strategies 15h30-17h00 Moderator: Robin Wood, University of Cape Town Community-Based Care Kristina Wallengren, Medical Research Council ART for the Prevention and Treatment of MDR TB Stephen Lawn, University of Cape Town Intensified TB Case Finding Among HIV-Infected Patients Sabine Verkuijl, International Center for AIDS Care and Treatment Programs (ICAP-SA), Mailman School of Public Health, Columbia University South-to-South Assistance to Initiate MDR TB Care in Ethiopia (Note: via phone) Anne Goldfeld, Harvard University Discussion with Audience 16h45-17h00 ADJOURN 17h00 Group Dinner for Speakers 18h00 Day 2 March 4, 2010 Session 4: Transmission and Strategies for Infection 8h00-10h00 Control Moderator: Neel Gandhi, Tugela Ferry Care and Research Collaboration (TF CARES) Proof of Principle: Transmission of MDR TB in the AIR Facilities Matsie Mphahlele, Medical Research Council

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100 DRUG-RESISTANT TUBERCULOSIS IN SOUTHERN AFRICA Epidemic in Tugela Ferry: Transmission and Impact of Infection Control Gerald Friedland, Yale School of Medicine (in place of Anthony Moll, Church of Scotland Hospital) Household Contacts Claudio Marra, Church of Scotland Hospital Careworkers Karen Shean, University of Cape Town Migrant Workers in Lesotho Maketekete Thotolo, Adventist Development and Relief Agency An Evaluation of Infection Control Infrastructure and Health Worker KAP in MDR/XDR TB Care Settings Jason E. Farley, Johns Hopkins University Discussion with Audience 9h45-10h00 BREAK 10h00-10h30 Session 5: Application of Molecular Biology to Shape 10h30-12h15 Policy Moderator: Elaine Gallin, Doris Duke Charitable Foundation Drug-Resistant Genotypes: Implication for Point-of-Care Detection of Resistance in Different Geographies Paul van Helden, Stellenbosch University Genetic Analysis of Drug-Resistant Strains in South Africa Robin Warren, Stellenbosch University Bench to Bush in Biomarker Studies in Africa: Implications for MDR TB Treatment and Drug Development Shreemanta Parida, Max Planck Institute for Infection Biology, Berlin, Germany

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101 APPENDIX A Discussion with Audience 12h00-12h15 LUNCH 12h15-13h00 Session 6: How Close Are We? 13h00-14h15 Moderator: Martie van der Walt, Medical Research Council of South Africa Current Status of Diagnostics Globally for the Detection of Drug Resistance with Emphasis on Point of Care William Jacobs, Einstein School of Medicine Challenges in Laboratory Capacity in Diagnosing Drug- Resistant TB in South Africa Gerrit Coetzee, National Health Laboratory Services, South Africa Information Solutions to Enhance Laboratory Capacity in Evaluation of New Diagnostics and Therapies Dale Nordenberg, Novasano Health and Science Discussion with Audience 14h00-14h15 Session 7: Research Gaps, Priorities, and Opportunities— 14h15-15h15 Report from NIH Workshop Valerie Mizrahi, National Health Laboratory Service Barbara Laughon, National Institutes of Health Discussion with Audience 15h00-15h15 BREAK 15h15-15h30 Session 8: Convergence of Science and Policy to Create a 15h30-16h45 Blueprint for Action Moderator: Queta Bond, Burroughs Wellcome Fund (retired) Where Are We and Where Do We Go from Here? Salim Abdool Karim, University of KwaZulu-Natal

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102 DRUG-RESISTANT TUBERCULOSIS IN SOUTHERN AFRICA Panelist Response: Gail Cassell, Eli Lilly and Company Norbert Ndjeka, Department of Health, South Africa Sidney Parsons, Council for Scientific and Industrial Research Discussion with Audience 16h30-16h45 ADJOURN 17h00