Transcript TB - WHCA

Photo: Riccardo Venturi
Tuberculosis 2013:
basics, burden, impact, challenges,
innovations
Dr Mario Raviglione
Director, Global TB Programme,
World Health Organization, Geneva, Switzerland
GLOBAL TB
PROGRAMME
Geneva Journalism & Health
Mentoring Initiative
Geneva, 20 May 2013
Overview
 Basics
 Burden of TB, TB/HIV, MDR-TB
 Impact of interventions, and
progress in TB care and control
 Vision beyond 2015
 Innovations necessary towards
elimination
GLOBAL TB
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Tuberculosis: basics
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Tuberculosis (TB) is one of the oldest diseases of humans
TB is a major cause of death worldwide, it competes with
HIV/AIDS as the greatest killer globally due to a single
infectious agent
TB is also one of the top killers of women worldwide, half a
million women died from TB in 2011
TB is caused by the bacterium Mycobacterium tuberculosis
TB usually affects the lungs, although other organs are
involved in 15-30% of cases
If properly treated, TB caused by drug-susceptible strains is
curable in virtually all cases
If untreated, TB may be fatal within 5 years in 2/3 of cases
One third of world has latent TB infection
GLOBAL TB
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Robert Koch discovered the cause of TB
24 March 1882
Mycobacterium tuberculosis complex:
M. tuberculosis, M. bovis, M. microti, M. africanum,
M. pinnipedii, M. caprae ( and M. canettii)
GLOBAL TB
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How is TB transmitted? ..Via aerosolised
particles from infectious patients
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Who carries the burden of tuberculosis?
…mostly, the most vulnerable
Poor, crowded & poorly ventilated
settings
Half a million women and
over 65,000 children die of
TB each year; 10 million
“TB” orphans
Migrants, prisoners, minorities,
refugees face risks, discrimination
& barriers to care
TB linked to HIV infection, malnutrition,
alcohol, drug and tobacco use, diabetes
The Global Burden of TB -2011
Estimated number
of cases
All forms of TB
8.7 million
(8.3–9.0 million)
HIV-associated TB
Multidrug-resistant TB
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1.4 million*
(1.3–1.6 million)
1.1 million (13%)
430,000
(1.0–1.2 million)
(400,000–460,000)
Up to 0.5 million
Unknown, but
probably > 150,000
Source: WHO Global Tuberculosis Report 2012
GLOBAL TB
Estimated number
of deaths
* Including deaths attributed to HIV/TB
Incidence rates, 2011
0–24
25–49
50–149
150–299
≥300
Per 100 000 population
Highest rates in Africa, linked to high rates of HIV infection
GLOBAL TB
~80% of
HIV+ TB cases in Africa
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TB/HIV co-infection: 80% of burden in Africa
 TB leading cause of death in PLHIV
 ¼ of PLHIV worldwide die due to TB.
 PLHIV infected with TB 20-40 times
more likely to develop active TB.
 Untreated, TB in PLHIV leads to death
in weeks
 80% of all TB/HIV cases are in Africa
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Drug resistant TB: Major challenge
o Multi-drug resistant TB (MDR-TB)
• Second-line drugs, toxic, costly, lengthy
o Extensively drug resistant TB (XDR-TB)
• Almost incurable, fatal
o Drug resistant TB results from inadequate TB care and irrational use of drugs
o New York epidemic in early 90’s – Cost of response: US$ 1 billion
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Estimated number of MDR-TB Cases, 2011
>60% of all cases are in 6 countries
Russian Federation
44,000
(14% of global MDR burden)
China
61,000
(20% of global MDR
burden)
South Africa
8,100
Based on old
survey data
Pakistan
10,000
(3% of global MDR
burden)
India
66,000
Philippines
11,000
(21% of global MDR
burden)
(4% of global
MDR burden)
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 2012. All rights reserved
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Spotlight on XDR-TB
Case of Atlanta lawyer with presumed XDR-TB caused international concern
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To date, 84 countries have reported
at least one XDR-TB case
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About 9% of MDR-TB cases are XDR
The case of Mumbai and the
“TDR-TB outbreak”
Udwadia ZF, Amale RA, Ajbani KK, Rodrigues C. Totally drug-resistant
tuberculosis in India. Clin Infect Dis. 2012 Feb 15;54(4):579–81.
GLOBAL TB
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The global response:
Targets, Global Plan, and Stop TB Strategy
Goal 6: to have halted
by 2015 and begun
to reverse the
incidence…
2015: 50% reduction in TB
prevalence and deaths
compared to 1990
2050: elimination (<1 case
per million population)
1.
Pursue high-quality DOTS
expansion
2.
Address TB-HIV, MDR-TB, and
needs of the poor and
vulnerable
3.
Contribute to health system
strengthening
4.
Engage all care providers
5.
Empower people with TB and
communities
6.
Enable and promote research
THE WHO STOP TB STRATEGY
Pursue DOTS
Address TB/HIV
and MDR-TB
Engage all
care providers
Empower
communities
Strengthen
systems
Promote research
Global Progress
Incidence
 51 million patients
cured, 1995-2011
 20 million lives saved
since 1995
Mortality
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 2015 MDG and other
international targets
on track
 BUT, TB incidence
declining far too
slowly, 1/3 of cases
not in the system,
MDR-TB un-tackled
etc.
Innovating with GeneXpert
WHO endorsement December 2010
GLOBAL TB
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Nearly 83 countries using it
in March 2013
WHO GLOBAL
TB PROGRAMME
VISION:
A World FREE of TB
MISSION:
The WHO Global TB Programme
aims to advance universal access to
TB prevention, care and control,
guide the global response to
threats, and promote innovation.
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What we do: our core functions
 Provide global leadership on TB;
 Develop policies, strategies and standards for TB prevention, care and control;
 Coordinate technical support to Member States, catalyze change, and build
sustainable capacity;
 Monitor the global TB situation, and measure progress in TB care, control, and
financing;
 Shape the TB research agenda and stimulate the generation, translation and
dissemination of valuable knowledge;
 Facilitate and engage in partnerships for TB action.
GLOBAL TB
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The TB Elimination Strategy
VISION
A WORLD FREE OF TB
TOWARDS
ZERO
ZERO
TB DEATHS TB CASES
ZERO
TB SUFFERING
Proposed Pillars and Principles of the
Post-2015 TB Strategy
Universal
highquality TB
care and
prevention
Bold
policies and
supportive
systems
Intensified
research
and
innovation
Targets for 2025/2030
Target 1
75%/80%
reduction in
deaths due to TB
(compared with
2015)
Target 2
Target 3
40%/60%
reduction in TB
incidence rate
(compared with
2015)
No
catastrophic
expenditures
for families
affected by TB
CHALLENGES TO “ELIMINATION"?
1.
Funding not secure; catastrophic expenditure for the poor
2.
Only 2/3 of estimated cases reported or detected (late)
3.
TB/HIV major impact in Africa
4.
MDR-TB, with high burden in former USSR and China
5.
Un-engaged non-state practitioners and communities, and the private
sector
6.
Weak health policies, systems and services
7.
Social and economic determinants maintain TB
8.
Research awakening: old diagnostics, drugs and vaccines
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ROADBLOCK 1: Lack of commitment
"…
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ROADBLOCK 2: Funding
US$ billions
Funding gap vs Global Plan ~ US$2–3 billion per year
Funding gaps reported by countries US$0.7 billion in 2013
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ROADBLOCK 3: Today, most used tools for TB control
are old and not conducive to elimination
DIAGNOSTIC
Sputum smear microscopy
Discovered 1882
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VACCINE
TREATMENT
BCG
Developed 1920s
1st-line TB drugs
Discovered 1943-1970
ROADBLOCK 3: Bedaquiline – First drug in forty years
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Only data from Phase IIb trials available ,
further efficacy and safety data will be
needed from rigorously conducted Phase
III trials
On December 28, 2012, the U.S. Food and
Drug Administration approved bedaquiline
Caution on use
WHO advises that a single drug deemed to
be effective should never be added alone
to a regimen to which a patient is not
responding to
WHO has initiated a review process aimed
at developing rapid interim guidance on
the potential use of bedaquiline for the
treatment of MDR-TB.
Interim guidance from WHO in coming
month
GLOBAL TB
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ROADBLOCK 3: Research key for elimination
1. For elimination one would need potent short treatments, mass TLTBI and potent
pre- and post-exposure vaccines. None is available today
2. Basic research is fundamental to gain further knowledge and R&D pipelines must be
expanded , nurtured and well-financed.
3. TB Vaccine development: we need a global coalition of all engaged agencies so that
efforts are harmonised and coordinated. This is not a job for one agency only!
4. Increased financial resources for research: keep working together to provide the
right messages to investors
GLOBAL TB
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What is in the pipelines for new diagnostics,
drugs and vaccines in 2013?
Diagnostics:
₋ 7 new diagnostics or diagnostic
methods endorsed by WHO since 2007;
₋ 6 in development;
₋ yet no PoC test envisaged
Drugs:
- 1 new drug approved in late 2012, but
probably little impact on epidemiology;
- 1 expected to be approved in 2013;
- a regimen and other 2-3 drugs likely to be
introduced in the next 4-7 years
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Vaccines:
₋ 11 vaccines in advanced phases of
₋ development;
₋ 1 just reported with no detectable efficacy
Roadblock 4: Unregulated private sector
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Private sector is first point of care in
many settings
Diverse network of formal and
informal providers ranging from
hospitals, corporate sector to the
traditional healers and quacks
Contribution to finding people with
TB between 10%-40% in countries
Collaboration exists but still not
enough in many settings. Efforts
need to be made on both ends
Untapped potential
Private sector engagement crucial in
closing the gap on case detection
Roadblock 5: Taking on the Pharmaceutical Industry
• Lobbying, promotion, economic
incentives and infiltration
• Quality differentiation based on
level of regulation
• Counterfeit medicines
• Drug resistance
• BUT, we need them on our side!
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TB crosses borders
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?
Question
for you 
How would you
increase
the profile of TB?