Post on 08-Apr-2018
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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TB BASICS
Refresher What is tuberculosis?
The Lung Health Program
International Journalists as GlobalHealth Advocates
TB BASICS
Refresher What is tuberculosis?
The Lung Health Program
International Journalists as GlobalHealth Advocates
Lee Reichman, MD, MPHCancun, Mexico
December 1-7, 2009
Lee Reichman, MD, MPHCancun, Mexico
December 1-7, 2009
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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TB Historical PermutationTB Historical Permutation
17th - 18th centuries TB took 1 in 5 adultlives
1850 - 1950 one billion people died of TB
Current decade 2000-2010
300 million new infections
90 million new cases
30 million deaths
More people died from TB last year thanany year in history
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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TB Could Be EliminatedBecause We Understand It
TB Could Be EliminatedBecause We Understand It
We know its:
Cause Transmission
Treatment
Prevention
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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TB Isnt EliminatedTB Isnt Eliminated
Because:
Nobody seems to care
This wouldnt be toleratedfor any other disease
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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Deaths Due To:Deaths Due To:
TB (annually) 1,770,000
SARS 813
Avian Influenza 6,250
Anthrax 5
Mad Cow Disease 1 (Cow)
Smallpox 0
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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What is Tuberculosis?What is Tuberculosis?
Infectious disease caused by a germ calledMycobacterium tuberculosis
It is spread through the air
Usually affects the lungs although it canaffect any organ
Is spread when someone who is sick withTB disease of the lungs coughs or sneezes,releasing germs and a person nearbybreathes in these infected droplets
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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What happens when you
breathe in TB germs? A person infectedwith the TB bacteria is
not necessarily sick
TB infection: The natural defense system cankeep the bacteria under control and person isnot sick
TB disease (active TB) : Immune system
cannot keep the bacteria under control andthey multiply rapidly, making the person sick
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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Most effective way to stop
transmission
Most effective way to stop
transmission Isolate patients with suspected or confirmed
TB disease immediately
Start treatmentwith anti-TB medicine
As long as TB patient is onappropriate TB medicines and takes
medications as directed, the potentialto infect other people will declinerapidly.
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Development of TB diseaseDevelopment of TB disease
HIV-negative: about 10% of people infected with TBwill develop TB disease within their lifetime
Anyone can get TB!
However, there are some groups at greater risk fordeveloping TB disease:
People with HIV infection
Those infected in the last 2 years
Babies and young children
People who inject illegal drugs or abuse alcohol People sick with other diseases that weaken the immunesystem
Elderly people
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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Diagnosis of TB DiseaseDiagnosis of TB Disease
A person suspected of having TB diseasemay have these symptoms:
Fever, cough (3 weeks), chest pain, nightsweats, weight loss, fatigue, coughing up
blood, decreased appetite
Diagnosis:
Patient history and clinical exam
Laboratory tests Chest x-rays
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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Treatment of TB DiseaseTreatment of TB Disease
TB is curable!
TB treatment strategy (DOTS)
Standardized, short-course
Proper patient management
Treatment
6 months
4 antibiotic-drugs for 2 months
2 antibiotic-drugs for 4 months
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TB/HIVTB/HIV
TB/HIV is a lethalcombination, each speedingthe others progress
Risk of progression of TBdisease much greater inHIV-infected persons
About 10% chance everyyear
TB is leading cause of deathin those with HIV
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Co-Existence of HIV & TB infectionCo-Existence of HIV & TB infection
Risk of Active TB
10% per year10% per lifetime
.0017% per year
TB
InfectionHIV
Infection
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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HIV Drives the TB Epidemic:HIV Drives the TB Epidemic:
TB Trends in Africa 1980TB Trends in Africa 1980--20062006
0
100
200
00
400
00
600
00
1980 198 1990 199 2000 200
N
tificati
nratea
f
rm
s
Zim a e Ken a a a iTan an ia te d 'Iv ire th Africa
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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Drug Resistant TBDrug Resistant TB
Man-made phenomenon
Causes:
Inadequate or incomplete
treatment Interruption in the supply
of essential drugs
Poor quality drugs
Treatment of MDR-TB Very long 18-24 months
Toxic 2nd line drugs
Expensive
Persons at increased risk
With history of TB
treatment Received inadequate
treatment for >2 weeks
Contacts of known drug-resistant patients
Born or living in areaswith high prevalence ofdrug-resistant TB
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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Pathogenesis ofDrug Resistance 1
IP
R
INH
RIF
P A
INH II
I
I
I
I
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Pathogenesis ofDrug Resistance 2
INHRIF
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
IP
I
IR
IR
IR
IR
IR
IR IR
IR
IRIR
IRIRP
IR
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Unsexy TuberculosisUnsexy Tuberculosis
Concern and attention re: XDR-TB is appropriate, but skips themore important message
XDR-TB, MDR-TB, and drug-sensitive tuberculosis are all thesame disease
The only difference is that MDR-TB is drug-sensitive tuberculosis
modified by inappropriate treatment or drug taking, and XDR-TBis MDR-TB thus modified
We need to recognize that there are more than 9,000,000 newactive drug-sensitive cases of tuberculosis globally that could befeeding drug resistance
It might be a less sexy concept, but they all must be appropriately
treated with current strategies (as well as new diagnostics,drugs, vaccines, and proper infection control measures) to avoidpreventable MDR-TB and XDR-TB, which are always lurking
Preventing active, drug-sensitive tuberculosis, or treating itproperly, should be everybodys priority; it is the only way toprevent MDR-TB and XDR-TB
- Reichman, LB: The Lancet, 2009
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TB Remains a Global KillerTB Remains a Global Killer
Why does TB still infect one-third ofthe worlds population and remain aglobal health threat despite the fact
that highly cost-effective drugs areavailable to eradicate it?
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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The Global Burden of TuberculosisNO NEW DRUGS / NO NEW TOOLSThe Global Burden of TuberculosisNO NEW DRUGS / NO NEW TOOLS
Last new drug class specifically for TB -Rifampin (1968 Europe, 197 US)
Most widely used diagnostic test -Tuberculin (1890)
Ineffective most widely used vaccine -
BCG (1919)
Wouldnt one think that largest killer of anysingle infection deserves better, newer tools?
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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Approved & Major ExperimentalARV Drugs (1987-2008)
Approved & Major ExperimentalARV Drugs (1987-2008)
ARV Class Approved ExperimentalUnder
Investigation
ExperimentalInterrupted
NRTI 8 12 8
NNRTI 9 6
PI 10 5
Entry Inhibitors 2 17 10
IntegraseInhibitors
1 5 2
MaturationInhibitors
0 3 0
Gene Therapy 0 0
TOTAL 25 55 30
Vitoria MAA, October 2008
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NEW TOOLSNEW TOOLS
There are now 3 major global efforts to alleviatethis problem
Foundation for Innovative New Drugs (FIND)
AERAS Global Vaccine Foundation
Global Alliance for TB Drug Development
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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About AerasAbout Aeras
International non-profit organization with 1 current partners,among them:
Crucell NV (Netherlands), Statens Serum Institut (Denmark),GSK (Belgium), Max Planck Institute (Germany), UCLA (USA),University of Cape Town (S. Africa), St. Johns Medical College(India)
Aeras forms joint development teams with partners todevelop promising TB vaccine candidates currently thereare 3 leading candidate regimens
Primary funding provided by the Bill & Melinda GatesFoundation with additional funding from CDC, NIH, andDanida
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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The Problem:The Problem:Current TB therapy, though efficacious, is inadequate to control theglobal TB epidemic - too long and too complex
Global Alliance for Tuberculosis
Drug Development
Growing Epidemic
5% increase in annual incidence in Africa
1% increase in annual incidence globally
Current status9 million new cases annually
2 million deaths annuallyReference: Global tuberculosis control: surveillance, planning, financing. WHO
Report 2005.
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The TB AllianceThe TB Alliance
Founded in 2000 (Cape Town Declaration)
Independent Non-Profit Organization
International Public-Private Partnership
Based in New York with offices in Brussels andCape Town
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The TB AllianceThe TB Alliance
Mission
Develop new, better drugs for TB
Ensure affordability, access and
adoption (AAA)
Coordinate and catalyze TB drugdevelopment activities worldwide
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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The SolutionThe Solution
New
drugs combined intoshorter, simpler regimens
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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1. Active disease
2. MDR-TB
3. TB/HIV co-infection
. Latent infection (LTBI)
TB Alliance PrioritiesBased on impact and feasibility
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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Challenges in TB ControlChallenges in TB Control
Insufficient financial and human resources
Inadequate healthcare infrastructure
Weak laboratory capacity and lack of new rapid
diagnostic tools
Lack of new drugs that would cure TB in a shorter time
Lack of effective vaccine that would prevent TB
Poor use of infection control in healthcare settings
Minimal social mobilization for TB control and minimalpopulation awareness stigma
HIV and MDR/XDR threats
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Why do we need to care aboutTB in the rest of the world?
Why do we need to care aboutTB in the rest of the world?
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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Lessons from Andrew SpeakerLessons from Andrew Speaker
TB has not gone away, it remains with us, highly prevalent andtransmissible
Anybody can get tuberculosis, not only poor people,minorities, or the foreign-born
TB anywhere is TB everywhere
All resistant TB, MDR and XDR TB is preventable by proper TBdiagnosis and treatment
Good public health is a silent secret, but when there is a small
glitch, it becomes major news
We desperately need new tools for TB diagnosis and treatment
You dont want to sit on an airplane for 8 hours next to anuntreated coughing person with anykind of TB, be it drugsensitive, MDR or XDR
8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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8/7/2019 Refresher: What is tuberculosis? (Lee B. Reichman, M.D., M.P.H.)
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18004TBDOCS (482-3627)
www.umdnj.edu/globaltb
INFORMATION LINE