Transcript Multi and extensively drug-resistant TB: which is the

Regional efforts in controlling TB: progress and
challenges for future
2nd National conference on the
national response to TB epidemic:
10 main TB challenges and ways to
combat them
Kyiv, 13-14 November 2007
Pierpaolo de Colombani
Medical Officer
WHO-EURO, DHP/CDS/TUB
1
Regional efforts in controlling TB: progress and
challenges for future
Topics:
 Overview of TB epidemiology
 Progress towards the TB targets
 Challenges for TB control in EEUR
 Opportunities for TB control in EEUR
2
Estimated TB burden; world, 2005
8.8 million new TB cases
(>80% in Asia and sub-Saharan Africa)
TB incidence stable
or in decline in all
six WHO regions
1.6 million TB deaths
(195 000 due to TB/HIV)
424 000 MDR-TB cases
(MDR-TB in 102 of 109
countries surveyed in
1994-2002)
27 000 XDR-TB cases
3
Estimated number of TB cases; world, 2005
Estimated number of new TB
cases (all forms)
No estimate
Western Pacific
22%
0–999
The Americas
4%
1000–9999
10 000–99 999
Africa
29%
South East
Asia
34%
Eastern
1 000 000 or more
Mediterranean
Europe
6%
5%
WHO. Global tuberculosis control: surveillance, planning, financing; WHO report 2007. Geneva: 4
100 000–999 999
WHO (WHO/HTM/TB/2007.376)
Estimated incidence of TB; EUR, 2005
50 / 100 000
average in the region
5 - 198 / 100 000 range Norway - Tajikistan
445,000
number of new TB cases
66,000
number of deaths due to TB
TB cases (all) per 100,000 pop.
< 10
10-24
25-74
75-124
125-198
WHO. Global tuberculosis control: surveillance, planning, financing; WHO report 2007. Geneva: 5
WHO (WHO/HTM/TB/2007.376)
Trend in notification of TB; EUR, 1980-2005
80
79
East Europe (18 countries)
Europe (53 countries)
Cases notified per 100 000 pop.
70
European Union (with subsequent EU enlargements)
60
50
41
40
30
20
12
10
0
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05
Year
6
TB burden and priority for action; EUR, 2005
Number of new estimated TB cases
indicated by the size of the bubble
18 high-priority countries for TB control
in East EUR (EEUR)
170 000
46 000
1. Armenia
10. Lithuania
2. Azerbaijan
11. Moldova
3. Belarus
12. Romania
4. Bulgaria
13. Russian Fed.
5. Estonia
14. Tajikistan
6. Georgia
15. Turkey
7. Kazakhstan
16. Turkmenistan
8. Kyrgyzstan
17. Ukraine
9. Latvia
18. Uzbekistan
WHO. Global tuberculosis control: surveillance, planning, financing; WHO report 2007. Geneva:
7
WHO (WHO/HTM/TB/2007.376)
Impact
The global targets for TB control
By 2015 (Millennium Development Goals)
Goal 6:
combat HIV/AIDS, malaria and other diseases
Target 8:
to halt and begin to reverse the incidence of malaria and
other major diseases (such as TB)
Indicator 23: prevalence and mortality associated with TB
Indicator 24: detection and cure of TB cases under DOTS
Outcome
By 2015 (Stop TB Partnership targets)
Prevalence and mortality associated with TB reduced of 50%
By 2005 (World Health Assembly targets)
- Detection of at least 70% of infectious TB cases
- Cure (successful treatment) of at least 85% of detected cases
8
Progress on MDG 6 (1 of 2)
TB incidence rate per 100 000 population
106 110 110 112 108 108 112
120
100
80
60
92
83
48
48
40
38
20
20
56
49
92
69
62
57
55
55
54
50
50
15
15
2004
2005

0
1990
1991
1992
1993
1994
1995
1996
1997
EUR
1998
2000
East EUR
TB prevalence rate per 100 000 population
2001
2002
2003
Target
Other EUR
TB death rate per 100 000 population
120
131
140
1999
118
120
100
100
84
80
60
65
55
80
59
60
55
42
40
40
27
27
14 14
20
16 15
20
6
0
8
7
3
8
4
0
EUR
1990
East EUR
2004
2005
Other EUR
Target
EUR
1990
East EUR
2004
2005
6
2
2
3
9
Other EUR
Target
Progress on MDG 6 (2 of 2)
100
2004 Treatment Success (%)
95
90
WPR (22%)
85
EMR (6%)
80
SEAR (34%)
AMR (4%)
75
EUR (5%)
70
AFR (29%)
65
60
0
10
20
30
40
50
60
2005 Case Detection (%)
70
80
90
WHO. Global tuberculosis control: surveillance, planning, financing; WHO report 2007. Geneva:
10
WHO (WHO/HTM/TB/2007.376)
100
Challenges and opportunities for TB control; EEUR
Challenges
Opportunities
 Access of DOTS
 Berlin Declaration on TB
 Drug resistance
(22 October 2007)
 HIV epidemic
 Stop TB Strategy
 Health infrastructure
 Plan to Stop TB in 18 high-priority
 Prisons
 Awareness of TB
countries of the European Region
 Global resources
 Health system reforms
 Stop TB Partnership
11
Population living in areas with DOTS; EUR, 2005
60%
33%
36%
2001
2002
42%
47%
17%
2000
2003
2004
2005
Population living with DOTS (%)
no Stop TB Strategy
< 10
10 - 49
50 - 99
100
Note: 100% population coverage by the Stop TB Strategy in 2007 in Russian Federation and Ukraine. 12
Top 14 sites MDR-TB (all cases); world, 2004
All cases (%)
23.4
Kazakhstan
20.1
Estonia
19.5
Georgia
18.9
Moldova
18.8
Azerbaijan
18.5
Uzbekistan
16.8
Russian Fed.
16.4
Lithuania
13.6
Ukraine
11.5
Latvia
10.9
Tajikistan
10.6
Kyrgyzstan
10.4
Belarus
08.9
China
Estimated ~ 70,000 MDR-TB cases in EUR
13
Zignol M, Hosseini MS, Wright A et al. Global incidence of multidrug-resistant tuberculosis. JID 2006, 194:479-485.
Countries with confirmed XDR-TB; world, October 2007
Argentina
Latvia
Armenia
Lithuania
Azerbaijan
Mexico
Australia
Mozambique
Bangladesh
Netherlands
Brazil
Norway
Canada
Peru
Chile
Poland
China
Portugal
Czech Rep.
Rep. of Korea
Ecuador
Romania
Estonia
Russian Fed.
France
Slovenia
Georgia
South Africa
Germany
Spain
Ireland
Sweden
Iran
Vietnam
Israel
UK
Italy
USA
Japan
Estimated ~ 10,000 XDR-TB cases in EUR
14
Source: http://www.who.int/tb/xdr/en/index.html (access 9 Oct 2007)
Unsuccessful TB treatment outcome; WHO region, 2004
DOTS
Non - DOTS
AFR
AFR
AMR
AMR
EMR
EMR
EUR
EUR
SEAR
SEAR
WPR
WPR
0
10
Died
Failed
Defaulted
20
Transfered
30
Not evaluated
0
10
Died
Failed
20
Defaulted
30
Transfered
40
Not evaluated
WHO. Global tuberculosis control: surveillance, planning, financing; WHO report 2007. Geneva:
15
WHO (WHO/HTM/TB/2007.376)
New HIV cases notified by EUR area, 1995-04
100,000
80,000
60,000
40,000
20,000
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
100,000
100,000
80,000
80,000
60,000
60,000
40,000
40,000
20,000
20,000
0
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
16 2003 2004
1995 1996 1997 1998 1999 2000 2001 2002
HIV prevalence among new adult TB cases; EUR, 2005
• HIV prevalence in TB cases with 4.6% regional average
• Lack of good, reliable and country-wide information
HIV prevalence in TB cases (%)
no information
<1
1-5
5-10
>10
• Limited collaboration between HIV and TB programmes
• Different patterns and type of co-infection in W and E
• Lack of community and activists involvement
17
Inadequate health systems leading to inequitable
access to health services; EUR, 2003
Out-of-pocket (OOPS) spending increasing with decreasing of public
spending on health, used as proxy of inadequate health care services
80%
TJK
GEO
AZE
OOPS as % total health spending
70%
ARM
60%
KGZ
ALB
UZB
50%
CYP
LVA
KAZ
BIH
GRC
BGR
MDA
40%
ROU
TKM
30%
RUS
UKR
POL
EST
20%
10%
ISR
CHE
PRT
HUN
ESP
LTU
BEL
SCG
ITA
BLRAUT TUR FIN
MLT
HRV
DNK
MKD
SWE
IRL
SVK
GBR
FRA
SVN
CZE
NLD
LUX
R2 =
ISL
NOR
DEU
0.80
0%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
Public spending on health as %GDP
Source: WHO/EURO, Kutzin J.
7.0%
8.0%
18
9.0%
6 countries from EUR
750
700
650
600
550
500
450
400
350
300
Detainees per 100,000 population
Top 20 countries with highest prison population rate;
world, 1998-05
8)
99
(1 3)
NT 00
(2 3)
s
le o
til ic 200
An to R n ( 2)
er sta 00
Pu kh n (2
za ta 02)
Ka yzs (20 04)
rg s (20
Ky ma ca
ha fri 6) 3)
Ba h A 99 00
ut s (1 s (2
So ive evi
d
al &N )
M itts 003
4)
.K (2
St ine 3) 200
ra 200 K (
Uk e ( l U )
liz Is 99
Be an (19
ym e
0)
Ca am )
00
3
(2 )
rin 00
Su (2 tan 03
ba nis (20
Cu me US
rk l.
Tu Is )
in 03 3)
rg 0
Vi (2 00
2
u
la a ( )
)
Pa ud 003 05
rm (2 (20
Be rus ed.
F
la
Be ian )
ss 03
Ru (20
A
US
Walmsley R. World Prison Population List, 6th Ed.; 2005. London King’s College, International Centre
19 for
prison Studies (http://www.kcl.ac.uk/depsta/rel/icps/world-prison-population-list-2005.pdf)
The Berlin Declaration on tuberculosis
 Berlin, 22 October 2007
 49 country delegations
 Commitment to:
- strengthen TB control
- adopt the Stop TB Strategy
- ensure sustainable financing
20
The Stop TB Strategy
1)
Pursue high-quality DOTS expansion
and enhancement (political commitment,
quality bacteriology, guaranteed treatment,
ensured drug supply, monitoring and evaluation)
2)
Address TB-HIV, MDR-TB and other
challenges (prisoners, other risk groups)
3)
Contribute to health system
strengthening
4)
Engage all care providers (public-private,
international standards)
5)
Empower patients and communities
(ACSM, community participation, patients’
charter)
6)
Enable and promote research
21
The Stop TB Strategy: International Standards for TB Care
Diagnosis
Standard 1: TB suspicion if 2-3 weeks productive cough
Standard 2: always 2-3 sputum samples for microscopy
Standard 3: appropriate specimen if extrapulm. TB suspect
Standard 4: sputum microscopy in suggestive chest x-ray
Standard 5: SS- with microscopy, x-ray, antibiotics; culture
Standard 6: SS- children with x-ray, history, skin test; culture
Treatment
Standard 7: doctor caring of patient’s adherence to treatment
Standard 8: standardized regimens, doses, FDC
Standard 9: arrangements (incl. DOT) tailored to each patient
Standard 10: follow-up with sputum microscopy (2nd,5th,end)
Standard 11: written complete medical record maintained
Standard 12: HIV counselling and testing (routine or ad hoc)
Standard 13: access to antiretroviral treatment
Standard 14: assess risk of drug resist., if yes DST for H,R,E
Standard 15: 4-drug regiment for 18 months if drug resistance
Public health
responsibility
Standard 16: all contacts screened for latent/active TB
Standard 17: reporting of TB detection and treatment22outcome
The Stop TB Strategy: The Patients’ Charter for TB Care
Security
job security, food
supplements
Dignity
without stigma or
prejudice or
discrimination,
moral support
Information
availability/cost of
services, medical
procedures, copy of
medical records,
counselling
THE RIGHTS
OF THE TB
PATIENT
Organization
join/establish
organizations,
participate as
stakeholder
Justice
make a complain,
appeal to higher
authority
Choice
second medical
opinion, refuse
interventions, take
part of research
Confidence
respect of privacy,
religion, culture,
confidentiality
23
Plan to Stop TB in 18 high-priority countries of the
WHO European Region, 2007-2015
100
90
Percentage (%)
80
Areas served by DOTS
70
60
TB cases detected
50
TB cases cured
40
TB drug resistance tested
30
MDR-TB cases treated
20
TB cases with HIV test offered
10
TB at primary care level
0
2007
2008
2009
2010
2015
US$ billion
Needed
14.8
Available
6.7
24
Gap
8 (i.e. 1- 3.1 US$ per person by governments)
Global Fund funds increasing for TB control; EUR, 2002-06
US$ million
112 $
111 $
91
Total budget (lifetime)
approved (US$ m)
50
50
44
33
20 $
12 $
2002
(round 1)
2002
(round 2)
Approval rate (%)
33
17 $
2003
(round 3)
15 $
2004
(round 4)
2005
(round 5)
2006
(round 6)
25
Health systems: merging interests with Stop TB
Stop TB
Health system
DOTS
(political commitment,
quality bacteriology,
guaranteed treatment,
ensured drug supply,
monitoring and evaluation)
Leadership and governance
TB/HIV, MDR-TB, etc.
Health work force
Financing
Health system strengthening
Engage all providers
Medical products and
commodities
Empower patients and
communities
Information
Research
Service delivery
26
Health systems: opportunities for TB delivery at PHC level
 Suspect TB and react quickly
 Collect 3 sputum samples from each suspect
 Smear samples and/or send samples to
designed laboratory for microscopy
 Refer TB suspects for early TB diagnosis
 Provide directly observed treatment (DOT)
 Coordinate support to TB patients
 Trace treatment defaulters
 Refer patients with adverse drug reactions
 Keep TB records and reporting
 Monitor populations at special risk of TB
 Educate patients, families, community
 Check TB contacts (symptoms, skin testing)
 Provide BCG vaccination
27
Health systems: reform leading to improved TB control
100
Kyrgyzstan:
TB treatment success (%)
95
TARGET
Manas Taalimi Reform,
90
phase II (2001-2006)
85
80
2005/04
2004/03
75
70
2002/01
2003/02
65
60
55
0
10
20
30
40
50
60
70
80
90
100
TB case detection (%)
Note: progress in new sputum smear-positive cases under DOTS
28
Stop TB Partnership for Europe
29