Transcript Slide 1

Tuberculosis Control in the
Asia Pacific Region
Achievements, Deficiencies &
Future Directions
Dr Ral Antic
Chair, Scientific Committee IUATLD-APR
Australia
The 1st Asian Pacific Regional
Conference 2007, IUATLD - APR
‘OVERCOMING AN OLD SCOURGE WITH A
NEW FACE’
The 1st Asian Pacific Regional
Conference 2007, IUATLD - APR
‘OVERCOMING AN OLD SCOURGE WITH A
NEW FACE’
We could have (& have) been discussing, in this
context
• Tuberculosis
• COPD
• Asthma
• Sleep Disorders ……. & others
Achievements in the last decade
What is different in the handling of these various disorders
is
• The extent of the global and regional strategic planning for TB
• The structured multi-faceted public health approach as we have
discussed
• That we are driving the ‘change agenda’ working back from
defined targets and outcomes
Achievements and Deficiencies
in TB
Global, Regional & Country
• What are we trying to achieve?
• Are our Directions and Targets right and
achievable
• Do we have the ‘capacity’ to achieve the Vision,
Goals and Targets we have set?
Achievements in TB in the last decade
• The provision of effective Global, Regional and
Country Leadership
• A sustained focus on development and updating
of a Global and Regional Strategic Direction
• Its implementation in a strategic fashion
• Improvement in case detection and treatment
• Infrastructure building
• Better Surveillance and Quality monitoring
Achievements and Deficiencies
Global, Regional & Country
• In the last decade, we have appropriately changed
direction
• But with the current tools, change is understandably
slow.
• And this leaves us to wonder whether we are doing a
good job.
Achievements and Deficiencies
Global, Regional & Country
• What is the burden of ill-health from TB ?
The Global TB Epidemic
‘Global TB Control’ , WHO Report 2007
• TB is still a major cause of death worldwide, but the
global epidemic is on the threshold of decline
• TB prevalence and death rates have probably been
falling globally for several years
• But the total number of new TB cases is still rising
slowly, as the population grows and the case-load
continues to grow in the African, Eastern Mediterranean
and SEA Regions
Estimated Burden from TB and Trends
Western Pacific Region
• Estimated 4 million cases of TB in WPR
– 2 million new cases
• Seven high burden countries account for >95%
– Cambodia, China, Lao PDR, Mongolia, PNG,
Philippines & Vietnam
Stop TB Partnership Targets
By 2005: At least 70% of people with sputum smearpositive TB will be diagnosed (i.e. under the DOTS
strategy), and at least 85% cured
By 2015: The global burden of TB (per capita prevalence
and death rates) will be reduced by 50% relative to 1990
levels
By 2050: The global incidence of active TB will be less
than 1 case per million population/year
WP Regional Goals & Targets
Regional Committee WPR, 2000
Goal:
•
Reduce TB prevalence and mortality by 50% in
2010 compared with 2000
Intermediate Targets (towards this goal):
1. Detect 70% of estimated active cases
2. Treat successfully 85% of these cases
3. 100% DOTS coverage
What we have achieved in WPR
WPR achieved these intermediate targets in 2005.
Also
– 26 countries globally have achieved targets including China, the Philippines, Vietnam
– Targets were missed narrowly Globally:
• case detection
- 60%
• treatment success - 84%
– Treatment success in the SEA Region > 85%
MDR-TB and XDR-TB
‘The Global MDR-TB and XDR-TB Response Plan 2007-2008’ WHO
Report 2007
• > 400 000 new cases of MDR-TB every year
• due to under investment in basic TB control, poor
management of anti-TB drugs and transmission of drugresistant strains.
• MDR-TB is much more difficult and costly to treat than
drug susceptible TB
• recent work has shown that it is feasible and costeffective to treat even in settings of limited resources.
MDR-TB and XDR-TB
‘The Global MDR-TB and XDR-TB Response Plan 2007-2008’
WHO Report 2007
• Emerging XDR-TB
• The economic, social and health security of
countries and communities with a high
prevalence of TB threatened by it
• It is virtually untreatable TB among the breadwinners, parents and economically productive
age groups.
MDR-TB and XDR-TB
‘The Global MDR-TB and XDR-TB Response Plan 2007-2008’
WHO Report 2007
• Strengthening the coverage and quality of basic TB
control is the first and most important measure to
prevent MDR-TB and is the fundamental platform for
deploying management of drug resistant TB
• Treat 1.6 rather than 0.8 million in 2008 with MDR-TB
and save 134000 lives
• More costly >US$ 2.1B extra
Case Detection in WPR
• From < 40% to >70% overall in 5 years
• Achieved by:
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–
–
–
–
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Developing a strategic approach, The Global Plan to Stop TB
Strengthening political commitment
Accelerating DOTS expansion in public facilities
Higher case detection success in many countries
TB care more available and accessible
Improving collaboration of health care providers
– Increase in financing and other resources
TB Performance Indicators in the Western Pacific Region, 2004
“Strategic Plan to Stop TB in the Western Pacific 2006 – 2010”
Prevalance Rate
(/105)
Case detection
SS+ (%)
Treatment Success
(%)
Mortality Rate
(/105)
Australia
6
56
95
1
Cambodia
709
61
93
94
China
221
65
94
17
Hong Kong
77
72
78
6
Japan
39
62
76
4
Lao PDR
318
55
79
25
Malaysia
133
69
72
16
Mongolia
209
80
87
24
11
59
36
1
Papua New Guinea
448
31
58
42
Philippines
463
73
88
48
Republic of Korea
125
59
82
10
41
67
77
4
232
89
92
22
New Zealand
Singapore
Vietnam
TB Performance Indicators in the South East Asia Region, 2004
“National Tuberculosis Control Programs South East Asia Region”
Prevalance Rate
(/105)
Case detection
SS+ (%)
Treatment Success
(%)
Mortality Rate
(/105)
Indonesia
262
66
90
41
Thailand
218
73
74
20
Some future barriers to TB Control
• Poverty, Housing, Social disruption
• The under-diagnosis of TB
• Perceived complexity of the public health
systems we are promoting
• Natural progression of resistance in drugs
• The benefits and risks of having joint project eg
malaria, smoking cessation, HIV-TB
Towards the Goals and Targets
Although the TB burden may be falling
globally, the decline is not fast enough to
meet the impact targets
“Strategic Plan to Stop TB in the Western Pacific 2006 – 2010”
Estimated Trends Western Pacific
Region
• A decline of 15% in prevalence & 12% in
mortality between 2000-2004
– Annual average of 4% and 3% respectively
Will achieving WHO targets reduce the
notification rate?
The barriers
– Spread of HIV
– Accumulation of MDR-TB cases
– Insufficient access to high quality TB care for the poor and
vulnerable populations and in private sector
– Lack of national guidelines & training materials
– Lack of human resources and their development
AND/OR
– the rising numbers and urbanisation of the population
– Estimated targets and actual incidence need discussion
3 main areas of concern
• The current level of 70% detection will not be
sufficient
• MDR-TB and TB-HIV co-infection will slow the
annual decline
• Conventional DOTS service delivery does not
guarantee equitable access to TB Services
The current position
A new ‘Strategic Plan to Stop TB in the
Western Pacific 2006-2010’ has been
developed to achieve the new targets.
The new Strategic Plan for WPR
2006-2010
• To achieve the 50% reduction in prevalence &
death rates, an 8% annual decline is needed
• The current annual decline is 3-4%
• There thus needs to be a change in approach
• This is the basis of the strengthened effort
defined in the new Strategic Plan
TB (all case) notification and death rates per
100,000 in South Australia
1900 and 2006
Notification Rate/100,000
160
140
Death Rate
120
Notification Rate
100
80
3% decline
The National TB
Campaign
60
40
20
improved
socioeconomic
conditions 4%
10%
8%
14%
0
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
Year
The National TB Campaign
Australia, 1948-1975
• National Leadership (NTP)
• Commitment from
– National & State Govt
• Funding
• Legislative muscle –
mandatory participation
– The Health Professions
– The community, because of
• community concern
• promotion of TB the disease
and of the TB Campaign
• Financial incentives for
patients with active disease to
adhere to treatment
• A new Strategic Direction &
sound systems, infrastructure
– Adequate funding
– Effective system of care
• active disease and infection
case finding, new drugs,
centralised treatment
–
–
–
–
Adequate laboratory services
DOT?
Free drug supplies
Appropriate monitoring
systems, for individual care
and Program
• No public/private mix, MDR-TB,
HIV issues, but migration+
TB (all case) notification rate per 100,000
South Australia - 1945 to 2006
The National TB Campaign
20
18
50
16
14
40
12
30
10
Target rate of decline 10% per year
8
20
6
Excess cases
4
10
2
0
0
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
Year
Death Rate
Target decline rate
2000
2005
Decline in Death Rate/ 100,000
Notification Rate / 100,000
60
TB notification rate by age, Australian-Born
South Australians between 1987 - 2006
9
Notification Rate/100,000
8
7
6
5
4
3
2
1
1987-1991
1992-1996
1997-2001
2002-2006
0
0<14
15<24
25<34
Age
35<44
45<54
55<64
> 65
Framework of the Strategic Plan to Stop TB
in the Western Pacific 2006 - 2010
VISION
GOAL
Elimination of TB as a public health problem
To reduce prevalence and mortality from all forms of TB by
one half by 2010 relative to 2000, contributing to the
achievement of the Millennium Development Goals
Framework of the Strategic Plan to Stop TB
in the Western Pacific 2006 - 2010
1.To sustain
and optimize
the quality of
DOTS and go
beyond the
‘70/85’ targets
OBJECTIVES
Case detection rate
(beyond 70%)
Cure rate
(beyond 85%)
2. To ensure
equitable
access to high
quality TB
care for all
people with TB
Proportion of
Facilities (include
private or general
hospitals) providing
or referring to DOTS
(at least 90%)
3. To adapt
DOTS to
respond to MDR
TB and TB-HIV
co infection
Proportion of
identified MDR-TB
cases by DST
provided with 2nd line
treatment
(at least 90%)
Proportion of
identified HIV
positive TB, eligible
for ART, that are
provided with ART
(at least 90%)
CORE
TARGETS
Beyond 70% CDR
At least 90%
DOTS-Plus
Treatment
coverage of
MDR-TB
At least 90%
ART coverage of
HIV positive TB
At least 90%
PPMD coverage
Framework of the Strategic Plan to Stop TB
in the Western Pacific 2006 - 2010
Country capacity
quality of diagnosis
for TB assured (i.e.
smear microscopy,
culture, chest X-ray)
At least 90% laboratory
units with satisfactory
performance
Uninterrupted supply of
quality-assured anti-TB
EXPECTED drugs at all DOTS units
RESULTS
100% of treatment units
with uninterrupted supply
of drugs in a given year
Enhanced case
management for all
registered TB cases,
including smear
negative TB
All HBC have developed
guidelines for diagnosis
& treatment of smear
negative TB e.g. children
Improved TB case
management in nonNTP TB facilities
At least 85% cure rate of
TB cases managed by nonNTP facilities
Assessment of MDR-TB
in targeted countries
All targeted countries
Have assessed their MDR-TB
situation through drug resistance
surveillance
DOTS-Plus initiated/scaled up
Adoption of the
in targeted countries
International Standards of
At least 6 have initiated/scaled up
TB Care & the Patients
DOTS-Plus. At least 10%0f failure
Charter for TB Care
All countries have introduced
the above standards
Increased utilization of TB
services by poor &
vulnerable populations
At least 10% of cases notified
under pro-poor TB initiatives
Country-driven advocacy,
communications & social
mobilisation strategies
developed & implemented
All HBC are implementing
ACSM strategies for TB control
on a national scale
cases tested by DST
TB-HIV framework for
collaboration developed &
implemented
All targeted countries are
implementing TB-HIV surveillance
Access of TB patients to HIV
Services
At least 70% of TB patients tested
for HIV in Category 1 and 2
countries/areas. At least 70% of
newly diagnosed patients with HIV
tested for TB
Components of the Strategic Plan &
Implementation approaches
1. Pursue high quality DOTS expansion &
enhancement
a. Political commitment with increased & sustained
financing
b. Case detection through quality assured bacteriology
c. Standardised treatment with supervision & patient
support
d. An effective drug supply & management system
e. Monitoring & evaluation system & impact
measurement
Components of the Strategic Plan &
Implementation approaches
2. Address TB-HIV, MDR-TB & other challenges
a. Implement collaborative TB-HIV activities
b. Prevent & control MDR-TB
c. Address prisoners, refugees & other high-risk groups
3. Contribute to health system strengthening
a. Actively participate in efforts to improve policy, human
resources, financing, management service delivery &
information systems
b. Share innovations, including the Practical Approach to Lung
Health (PAL)
c. Adapt innovations from other fields
Components of the Strategic Plan &
Implementation approaches
4. Engage all care providers
a. Public-Public & Public-Private Mix approaches
b. International Standards for TB Care (ISTC)
5. Empower people with TB & communities
a. Advocacy, communications & social mobilisation
b. Community participation in TB care
c. Patients Charter for TB Care
6. Enable & promote research
a. Program- based operational research
b. Research to develop new drugs, vaccines & diagnostics
Framework of the Strategic Plan to Stop TB
in the Western Pacific 2006 - 2010
ACTIVITIES
CROSSCUTTING
ISSUES
Activities directed at producing expected results are to be implemented
at inter-country, regional and country levels:
- Inter-country and regional activities are in the WHO plans of action
- Country level activities are in the National TB Control Plans 2006-2010
1. Ensured availability of essential staff required for TB control
90% of key positions required for TB control filled by trained staff
2. Sufficient financing for TB control ensured
All HBC develop annual funding plan for NTP that incorporates all financial inputs
and funding gaps
3. Evidence-based policy and implementation strategy development
through operations research (e.g. PAL, information system, child TB, and
new diagnostic modalities)
Estimated TB incidence rate, 2005
Estimated new TB
cases
(all forms) per 100 000
population
No estimate
0-24
25-49
50-99
100-299
300 or more
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
 WHO 2006. All rights reserved
What have we learned from the
presentations?
•
The current burden of disease remains large
•
There are important Regional and Country successes
•
Some targets are being achieved but
•
The targets and so strategic plans are needing to be revised to achieve the
primary Goal
•
There are significant barriers
•
Do we have systems in place to achieve these targets and overcome the
barriers?
What else can/should we need to do?
• What more should we (jointly) do – as the Union, the APR IUATLD,
WHO, APSR & the many other organizations and as individuals?
• What is the real view of our Communities and Governments about
TB - what is the image of TB?
• What can this and our future Conferences and its participants
contribute to furthering the objectives of the Region?
• What are the special skills and the special ‘Capital’ that the
attendees and their organisations bring?
The Future Direction
•
•
•
•
•
•
•
•
•
The vision ‘The elimination of TB’ is right
The objectives are right.
It needs global and local leadership
It needs the proper application of our knowledge
The resolve must be strengthened
All cases have to be found and treated
New drugs must be found
More resources are needed
TB can be eliminated.
It can be
and
it has to be done
My Thanks
To:
The
The
The
The
The
Congress President
Secretariat
Chair of the Organizing Committee
Chair of the Organizing Scientific Committee
Speakers
and …. to all of you who have attended and
participated
Tuberculosis Control in the
Asia Pacific Region
Achievements, Deficiencies &
Future Directions
Dr Ral Antic
Chair, Scientific Committee IUATLD-APR
Australia
What is the role of APR IUATLD?
•
•
•
•
Workforce
Training
Advocacy
Service provision
What is the APR IUATLD
• The Asian Pacific Region of the UNION
• In 2006, the Eastern Region IUATLD was divided
into 2 new Regions, the South East Asian and
Asian Pacific
• The aim was to reduce the size of the Regions to
help facilitate their TB work
• There are 16 APR constituent member countries
and other organisations and individuals
The different & complementary
roles
•
•
•
•
Global and regional organisations
Organisations within each country
Governments
Government and non-Government Organisations
– Different countries
– Within countries
Functional relationships
• Organisations responsible for different diseases
with overlapping risk factors and populations
– e.g. malaria, TB, AIDS
The challenges and barriers 1
• The Private Sector
– NTP does not cover private sectors. Detailed information on
case-finding activities & treatment outcomes are not known
yet. The pilot project of Private-public mix (PPM) just started
this year on a small scale with collaboration from some of
university hospitals
– NTP has a plan to make guidelines for PPM
– The issues and challenges relate to improving the quality of
reporting and treatment activities within the private sector
• How to increase the level of access of illegal foreign
workers to medical facilities
• Case Finding and associated delays
• How to strengthen the capabilities of health workers in
conducting contact investigation of TB outbreaks
The barriers 1
• Laboratories
• Challenge is to integrate commercial laboratories into the
laboratory network of NTP and to expand quality assurance
system
• Coordination & collaboration between TB, HIV, Malaria
programs
• High burden and mortality of HIV among TB patients and TB
among HIV-infected persons, and the high mortality rate of
TB/HIV patients, successful TB/HIV collaboration is essential.
• The political commitment has been critical for initiating the
collaboration between programs
• The support from technical and financial partners has
facilitated the implementation of the collaborative activities
The barriers 2
• This largely entails the sustenance of quality D.O.T.S.
implementation and undertaking this in the context of health sector
reforms and globalization. DOTS and DOTS beyond is our way
forward. (Phil)
• The challenges including: ( chin)
–
–
–
–
–
–
–
–
–
–
Migrants, MDR-TB, TB/HIV
Quality of DOTS implementation to be improved
Mechanism to ensure sustainability
Inadequate human resource
Adequacy of infrastructure
Adequate funding of Programs
Surveillance
Health promotion
Strengthen human resource development
Lack of resources to tackle new challenges
Future Directions
The global community needs to continue to take
responsibility and make world-wide TB control a
high priority
Strategic Plan to Stop TB in the
Western Pacific 2006-2010
• A Road Map
– Ensure quality of TB Services
– Respond to challenge of rising MDRTB, TB-HIV
co-infection
– Increasing case detection rate
– To get public and private health sector involved in TB
control
– Increasing funding and regional and country level
Prisons
Correctional institutions
Social sponsored centers
Development of a TB like Unit
Cooperation and coordination of NTP, NTP/HIV,
Ministry of Health, Ministry of Labor, War Invalids
and Social Welfare and Ministry of Public Security
• Sustain political interest, training guidelines, advocacy
and incentives, monitoring and supervision
•
•
•
•
•
Financing TB Control
Although the funds available for TB control have increased enormously
since 2002 ($2.0 billion US in 2007). Interventions on the scale
required by the Global Plan to Stop TB would cost an extra $1.1 billion
US in 2007
•
•
•
•
The Global Plan is more costly than country budgets primarily because it
anticipates greater TB/HIV requirements:
– management, advocacy, communication & social mobilisation, especially
in the African and South-East Asia regions
Greater expenditure was associated with improved case-finding in
Bangladesh, China, Congo, India, Indonesia, Kenya, Myanmar & Nigeria
There was no systematic relationship between incremental expenditure and
improved case detection across all HBCs
The relationship between spending and case-finding needs to be
investigated and understood country by country.
DOTS and the Stop TB Strategy
• Most government health services now recognise
that TB control must go beyond DOTS, but the
broader Stop TB
• Strategy is not yet fully operational in most
countries
Future Directions
• Countries and regions are more likely to reach these
targets if they can increase budgets and step up
activities in line with the Global Plan.
• Procedures for collecting financial and epidemiological
data, and other information about programme
performance, must be systematically improved.
• Surveillance and monitoring, and well-designed surveys,
are a prerequisite for the accurate evaluation of progress
in TB control.
The STOP TB STRATEGY
The Objectives
• To achieve universal access to high quality diagnosis and
patient centered treatment
• To reduce the suffering and socioeconomic burden
associated with TB
• To protect poor and vulnerable populations from TB, TBHIV and MDR-TB
• To support development of new tools and enable their
timely and effective use
HIV-TB IN THE WESTERN PACIFIC REGION
PROGRESS OF TB/HIV COINFECTION CONTROL IN CHINA
DR. PHILIPPE GLAZIOU
Y.J.LAI*, S.W.JIANG*,W.B. YU**, L.ZHOU*,
*National Center for TB Control and Prevention, China CDC, China
**Tuberculosis Office of China Global Fund Program
To address high case fatality rates, it is necessary
to rapidly step-up the implementation of;
• provider-initiated HIV testing
• systematic detection of TB in HIV-infected individuals
including diagnosis of the smear negative forms of TB
• infection control in AIDS care settings
• adequate treatment and support of dually infected
individuals, including anti-retroviral therapy during the
course of TB treatment
LATENT TB INFECTION IN HIV: TO TREAT OR NOT TO TREAT ?
NITIPATANA CHIERAKUL
• Early benefit but long term protection is
uncertain
AGING OF TB EPIDEMIC, CASE OF JAPAN
DR. TAKASHI YOSHIYAMA
• As community wide burden is reduced, the high
prevalence in the aged becomes more noticeable
• The previously infected population is living longer
• In countries where transmission of infection has been
low, the numbers in the aged population is falling.
• The case fatality rate of older tuberculosis cases is high
and WHO target of 85% treatment success is difficult to
achieve
TRADITIONAL AND NOVEL DIAGNOSTIC
TESTS FOR TB INFECTION
TORU MORI
• TST opened the way to the modern epidemiology of TB
decades ago.
• The diagnosis TB infection is important both in high and
low-prevalence settings for epidemiological surveillance
and research, indication for treatment of latent TB
infection, an adjunct for diagnosis of active TB, etc.
• The new technology, Interferon-gamma release assay
(IGRA), has been tested extensively, and it seems that it
is practically as sensitive as TST and far exceeds its
specificity. Other aspects of its performance, including
influence of immunocompromizing factors, effects of
treatment (both in active disease and latent TB infection),
and cost-effectiveness have gradually been clarified.
MDR-TB: DISEASE IN THE WPR
DR. PHILIPPE GLAZIOUDRUG
SUSCEPTIBILITY TESTS FOR FIRST & SECOND LINE DRUGS IN DIAGNOSIS OF MDR &
XDR TUBERCULOSIS
DR CAMILLA RODRIGUES, MD
NEW DRUGS AND DRUG REGIMENS IN THE TREATMENT OF CHRONIC AND MDR-TB
W.W. Yew
• Posing a threat to TB Control in several countries in WPR
• Special programs may be required to reduce its
increasing prevalence
– Improved interventions under DOTS
– Programmatic management MDR-TB
– urgent need to strengthen capacity for prompt and accurate
laboratory based diagnosis of tuberculosis and detection of drug
resistance
– strengthening of DOTS and DOTS-Plus programmes, infection
control, and information sharing to enable local and global
control
– Development of new drugs is a mandatory focus of activity too.
THE SINGAPORE TB ELIMINATION PROGRAMME (STEP)
DR CYNTHIA CHEE
• Reduction in prevalence via STEP program
TB-HIV TREATMENT IN A PRISON SETTING
DR. BENEDICT SIM LIM HENG
TUBERCULOSIS (TB)- HUMAN IMMUNODEFICIENCY VIRUS (HIV) SCREENING
PROGRAMME IN CLOSED SETTINGS
B. VENUGOPALAN (MPH)
Disease Control Unit, Selangor State Health Department, Ministry of Health, Malaysia.
• Many barriers to TB control, institutional, high burden of
TB/HIV on entry, staff morale, drug availability and
delivery etc
• In 1993, WHO presented their guidelines on HIV
infection and AIDS in prisons and the 1st guiding
principle in that article quoted was that “All prisoners
have the right to receive health care, including
preventive measures, equivalent to that available in the
community without discrimination, in particular with
respect to their legal status or nationality.”
• Changes in policy, attitudes and resources needed
What are we trying to achieve?
• Millennium Development Goals
• Stop TB Partnership targets
Pre-Conference Workshop 1
National TB Control Program
Summary & Remarks
Dr Ral Antic
Chair Scientific Committee IUATLD-APR
Australia
TB Control in WPR-current state
1. We have heard reports from a mix of High,
Intermediate and Low burden countries
2. Significant improvements in reported results
3. WHO targets are reported to be overall being met
4. Yet ongoing burden of disease is often reported as high
and trend of morbidity and mortality is ‘stagnant’
•
•
•
•
•
•
•
Ageing population and access to illegal migrants
HIV-TB co-infection
MDR-TB levels rising in some countries
The performance of the private sector and general hospitals
is variable
Concern re care in the poor and vulnerable populations
Health sector infrastructure variable especially in districts
Funding and health workforce, although improved remains
an issue
TB Performance Indicators in the Western Pacific Region, 2004
“Strategic Plan to Stop TB in the Western Pacific 2006 – 2010”
Prevalance Rate
(/105)
Case detection
SS+ (%)
Treatment Success
(%)
Mortality Rate
(/105)
Australia
6
56
95
1
Cambodia
709
61
93
94
China
221
65
94
17
Hong Kong
77
72
78
6
Japan
39
62
76
4
Lao PDR
318
55
79
25
Malaysia
133
69
72
16
Mongolia
209
80
87
24
11
59
36
1
Papua New Guinea
448
31
58
42
Philippines
463
73
88
48
Republic of Korea
125
59
82
10
41
67
77
4
232
89
92
22
New Zealand
Singapore
Vietnam
TB Performance Indicators in the South East Asia Region, 2004
“National Tuberculosis Control Programs South East Asia Region”
Prevalance Rate
(/105)
Case detection
SS+ (%)
Treatment Success
(%)
Mortality Rate
(/105)
Indonesia
262
66
90
41
Thailand
218
73
74
20
Estimated WPR Burden from TB and
Trends
• Estimated 4 million cases of TB in WPR
– 2 million new cases
• Seven high burden countries account for >95%
– Cambodia, China, Lao PDR, Mongolia, PNG,
Philippines & Vietnam
• A decline of 15% in prevalence & 12% in
mortality between 2000-2004
– Annual average of 4% and 3% respectively
ACHIEVEMENTS
•
•
•
•
•
•
In Leadership terms
In Strategic Planning
Implementation Strategy
Activities
Infrastructure building
Surveillance and Quality monitoring
Incentives
Direct
• To the health care providers
• To the person with TB
• To the community
Indirect?
WP Regional Goals & Targets
Regional Committee WPR, 2000
Goal:
•
Reduce TB prevalence and mortality by 50% in
2010 compared with 2000
Intermediate Targets (towards this goal):
1. Detect 70% of estimated active cases
2. Treat successfully 85% of these cases
3. 100% DOTS coverage
Case Detection in WPR
• From < 40% to >70% overall in 5 years
• Achieved by:
–
–
–
–
–
–
Developing a strategic approach, The Global Plan to Stop TB
Strengthening political commitment
Accelerating DOTS expansion in public facilities
Higher case detection success in many countries
TB care more available and accessible
Improving collaboration of health providers
– Increase in financing and other resources
Treatment Success
• Overall the percentage of registered new TB
patients completing anti TB treatment > 85%
for last 10 years
• 5 of the 7 high burden of TB countries are
achieving this target
Estimated numbers of new cases, 2005
Estimated number
of new TB cases
(all forms)
No estimate
0-999
1000-9999
10 000-99 999
100 000- 999 999
1 000 000 or more
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
 WHO 2006. All rights reserved
Will achieving WHO targets reduce the
notification rate?
The barriers
– Spread of HIV
– Accumulation of MDR-TB cases
– Insufficient access to high quality TB care for the poor and
vulnerable populations
– Sub-optimal TB management practices in growing private sector
– Lack of National guidelines & training materials
– Lack of human resources and their development
AND/OR
– the rising population numbers
– Incorrect targets for the desired outcome
Future Directions
• The current level of detection of 70% will not be sufficient
–
–
–
–
Enhancing active case finding approaches
Enhancing lab capacity
New diagnostic tools
Sustaining established mechanisms - e.g. monitoring and supervision of
DOTS implementation
• MDR-TB and TB-HIV co-infection will slow the annual decline
• Conventional DOTS service delivery does not guarantee equitable
access to TB Services
– In some countries, the same standards of care received through NTP
service delivery are not met by general hospitals, private providers, and
for the homeless, drug users, migrants & prisoners
What have we learned from these
presentations?
• The current burden of disease remains large
• There are important Regional and Country
successes
• Some targets are being achieved but
• The targets have needed to be revised to achieve
the objects
• There are significant barriers
• Do we have systems in place to achieve these
targets?
Pre-Conference Workshop 1
National TB Control Program
Concluding remarks for the Workshop
Dr Ral Antic
Chair Scientific Committee IUATLD-APR
Australia
Barriers to success
• Rising MDR-TB
• Rising TB & HIV Co-infection
• Access to poor & vulnerable populations
– Prisons,homeless
• Aging population
• Suboptimal health infrastructure
– Lack of health workers
– Suboptimal laboratory facilities
‘Programmatic’ factors
1.
2.
3.
4.
Accessibility of treatment services
Awareness of TB in the community
Uninterrupted supply of effective TB drugs
Treatment adherence through DOTS
Will achieving WHO targets reduce the
notification rate?
The barriers
– Spread of HIV
– Accumulation of MDR-TB cases
– Insufficient access to high quality TB care for the poor
and vulnerable populations and private sector
– Lack of National guidelines & training materials
– Lack of human resources and their development
AND/OR
– the rising population numbers
– Incorrect targets for the desired outcome
The 3 main areas to be addressed
• The current level of 70% detection will not be
sufficient
• MDR-TB and TB-HIV co-infection will slow the
annual decline
• Conventional DOTS service delivery does not
guarantee equitable access to TB Services
The new Strategic Plan for WPR
2006-2010
• To achieve the 50% reduction in prevalence &
death, an 8% annual decline is needed
• The current annual decline is 3%
• There thus needs to be a change in approach
• This is the basis of the strengthened effort
defined in the new Strategic Plan
Reasons for significant improvements
in TB Control
• The rapid expansion of DOTS after WHO
declared a global TB crisis in 1993
• Higher case detection and treatment success in
many countries
• The Stop TB Partnership, est in 2000,
• The Global Plans to Stop TB
• The significant increase in resources for TB
• TB care more available and accessible
Will achieving WHO targets improve
notification rate?
The barriers
• Spread of HIV
• Accumulation of MDR-TB cases
• Insufficient access to high quality TB care for the
poor and vulnerable populations
• Sub-optimal TB management practices in
growing private sector
• Lack of National guidelines & training materials
• Lack of human resources and their development
Tuberculosis notification rates, 2005
Notified TB cases
(new and relapse)
per 100 000
population
No report
0-24
25-49
50-99
100 or more
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
 WHO 2006. All rights reserved
TB Notification rate by population group for
South Australia, 2006
Notification Rate/100,000
35
30
25
20
15
10
5
0
Overseas Born
0<14
15<24
Australian Born
25<34
Age
35<44
45<54
Indigenous
55<64
>65