1 Regional efforts in controlling TB: progress and challenges for future Pierpaolo de Colombani...

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Regional efforts in controlling TB: progress and challenges for future

Pierpaolo de Colombani

Medical Officer

WHO-EURO, DHP/CDS/TUB

2nd National conference on the national response to TB epidemic: 10 main TB challenges and ways to

combat them

Kyiv, 13-14 November 2007

http://www.i-volume.com/stoptb/details.asp?id=590

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Topics:

Overview of TB epidemiology

Progress towards the TB targets

Challenges for TB control in EEUR

Opportunities for TB control in EEUR

Regional efforts in controlling TB: progress and challenges for future

http://www.i-volume.com/stoptb/details.asp?id=590

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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)

8.8 million new TB cases(>80% in Asia and sub-Saharan Africa)

Estimated TB burden; world, 2005

27 000 XDR-TB cases

TB incidence stable or in decline in all six WHO regions

4

No estimate

0–999

10 000–99 999

100 000–999 999

1 000 000 or more

1000–9999

Estimated number of new TB cases (all forms)

Estimated number of TB cases; world, 2005

Africa29%

Western Pacific22%

South East Asia34%

The Americas4%

Eastern Mediterranean

6%Europe

5%

WHO. Global tuberculosis control: surveillance, planning, financing; WHO report 2007. Geneva: WHO (WHO/HTM/TB/2007.376)

5

Estimated incidence of TB; EUR, 2005

TB cases (all) per 100,000 pop.< 1010-2425-7475-124125-198


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

6

Trend in notification of TB; EUR, 1980-2005

79

41

12

0

10

20

30

40

50

60

70

80

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

Cas

es n

oti

fied

per

100

000

po

p.

East Europe (18 countries)

Europe (53 countries)

European Union (with subsequent EU enlargements)

7

170 000

TB burden and priority for action; EUR, 2005

18 high-priority countries for TB control

in East EUR (EEUR)

1. Armenia

2. Azerbaijan

3. Belarus

4. Bulgaria

5. Estonia

6. Georgia

7. Kazakhstan

8. Kyrgyzstan

9. Latvia

10. Lithuania

11. Moldova

12. Romania

13. Russian Fed.

14. Tajikistan

15. Turkey

16. Turkmenistan

17. Ukraine

18. Uzbekistan

Number of new estimated TB cases indicated by the size of the bubble

46 000


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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

By 2015 (Stop TB Partnership targets)Prevalence and mortality associated with TB reduced of 50%

By 2015 (Millennium Development Goals)Goal 6: combat HIV/AIDS, malaria and other diseasesTarget 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 TBIndicator 24: detection and cure of TB cases under DOTS

The global targets for TB controlIm

pac

tO

utc

om

e

http://www.stoptb.org/

9

55

84

5565

131

14

59

118

14

27

42

27

0

20

40

60

80

100

120

140

EUR East EUR Other EUR

1990 2004 2005 Target

6 8 6816

27

15

23 4 30

20

40

60

80

100

120


1990 2004 2005 Target

TB prevalence rate per 100 000 population TB death rate per 100 000 population

57 55 54 55 50 5048 48 4956 62

6983

92 92106 110 110 112 108 108 112

15 1538

20

0

20

40

60

80

100

120

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Target


TB incidence rate per 100 000 population

Progress on MDG 6 (1 of 2)

10

AMR (4%)

EUR (5%)

SEAR (34%)

WPR (22%)

AFR (29%)

EMR (6%)

60

65

70

75

80

85

90

95

100

0 10 20 30 40 50 60 70 80 90 1002005 Case Detection (%)

2004

Tre

atm

ent S

ucce

ss (%

)


Progress on MDG 6 (2 of 2)

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Challenges and opportunities for TB control; EEUR

Challenges Opportunities

Access of DOTS Drug resistance HIV epidemic Health infrastructure Prisons Awareness of TB

Berlin Declaration on TB

(22 October 2007) Stop TB Strategy Plan to Stop TB in 18 high-priority

countries of the European Region Global resources Health system reforms Stop TB Partnership

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Population living in areas with DOTS; EUR, 2005

17%

33% 36%42%

47%

60%

2000 2001 2002 2003 2004 2005

Population living with DOTS (%)no Stop TB Strategy< 1010 - 4950 - 99100

Note: 100% population coverage by the Stop TB Strategy in 2007 in Russian Federation and Ukraine.

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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

Zignol M, Hosseini MS, Wright A et al. Global incidence of multidrug-resistant tuberculosis. JID 2006, 194:479-485.

Estimated ~ 70,000 MDR-TB cases in EUR

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Countries with confirmed XDR-TB; world, October 2007

Source: http://www.who.int/tb/xdr/en/index.html (access 9 Oct 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

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Unsuccessful TB treatment outcome; WHO region, 2004

0 10 20 30

WPR

SEAR

EUR

EMR

AMR

AFR

Died Failed Defaulted Transfered Not evaluated

DOTS Non - DOTS

0 10 20 30 40

WPR

SEAR

EUR

EMR

AMR

AFR

Died Failed Defaulted Transfered Not evaluated


16

0

20,000

40,000

60,000

80,000

100,000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

0

20,000

40,000

60,000

80,000

100,000

1995 1996 1997 1998 1999 2000 2001 2002 2003 20040

20,000

40,000

60,000

80,000

100,000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

New HIV cases notified by EUR area, 1995-04

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HIV prevalence among new adult TB cases; EUR, 2005

HIV prevalence in TB cases (%)no information<11-55-10>10

• HIV prevalence in TB cases with 4.6% regional average

• Lack of good, reliable and country-wide information

• Limited collaboration between HIV and TB programmes

• Different patterns and type of co-infection in W and E

• Lack of community and activists involvement

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Inadequate health systems leading to inequitable access to health services; EUR, 2003

AZE

TJK

GEO

ARM

KAZ

KGZ

UZB

TKM

ALB

LVA

RUSUKR

ROU

MDABGR

EST

POL

BIH

BLRLTU

GRC

AUT

SVK

TUR

ESP

FIN

MKD

HUN

ISR

NLDLUX

BELITA

HRV

SVN

PRTCHE

CZEGBR

SCGMLTDNK

FRA

SWENOR

DEU

ISL

CYP

IRL

R2 = 0.80

0%

10%

20%

30%

40%

50%

60%

70%

80%

0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0%

Public spending on health as %GDP

OO

PS

as

% t

ota

l h

eal

th s

pen

din

g

Source: WHO/EURO, Kutzin J.

Out-of-pocket (OOPS) spending increasing with decreasing of public spending on health, used as proxy of inadequate health care services

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300350400450500550600650700750

Deta

inee

s pe

r 100

,000

pop

ulat

ion

Walmsley R. World Prison Population List, 6th Ed.; 2005. London King’s College, International Centre for prison Studies (http://www.kcl.ac.uk/depsta/rel/icps/world-prison-population-list-2005.pdf)

Top 20 countries with highest prison population rate; world, 1998-05

6 countries from EUR

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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

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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

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The Stop TB Strategy: International Standards for TB Care

Diagnosis Standard 1: TB suspicion if 2-3 weeks productive coughStandard 2: always 2-3 sputum samples for microscopyStandard 3: appropriate specimen if extrapulm. TB suspectStandard 4: sputum microscopy in suggestive chest x-rayStandard 5: SS- with microscopy, x-ray, antibiotics; cultureStandard 6: SS- children with x-ray, history, skin test; culture

Treatment Standard 7: doctor caring of patient’s adherence to treatmentStandard 8: standardized regimens, doses, FDCStandard 9: arrangements (incl. DOT) tailored to each patientStandard 10: follow-up with sputum microscopy (2nd,5th,end)Standard 11: written complete medical record maintainedStandard 12: HIV counselling and testing (routine or ad hoc)Standard 13: access to antiretroviral treatmentStandard 14: assess risk of drug resist., if yes DST for H,R,EStandard 15: 4-drug regiment for 18 months if drug resistance

Public health responsibility

Standard 16: all contacts screened for latent/active TBStandard 17: reporting of TB detection and treatment outcome

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The Stop TB Strategy: The Patients’ Charter for TB Care

Securityjob security, food

supplements

Organizationjoin/establish organizations, participate as stakeholder

Justicemake a complain, appeal to higher

authority

Confidencerespect of privacy, religion, culture, confidentiality

Choicesecond medical opinion, refuse

interventions, take part of research

Informationavailability/cost of services, medical

procedures, copy of medical records,

counselling

Dignitywithout stigma or

prejudice or discrimination, moral support

THE RIGHTS OF THE TB PATIENT

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0

10

20

30

40

50

60

70

80

90

100

2007 2008 2009 2010 2015

Pe

rce

nta

ge

(%

)

Areas served by DOTS

TB cases detected

TB cases cured

TB drug resistance tested

MDR-TB cases treated

TB cases with HIV test offered

TB at primary care level

Plan to Stop TB in 18 high-priority countries of the WHO European Region, 2007-2015

US$ billionNeeded 14.8Available 6.7Gap 8 (i.e. 1- 3.1 US$ per person by governments)

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12 $20 $ 17 $

111 $

15 $

112 $

50

33 33

4450

91

2002(round 1)

2002(round 2)

2003(round 3)

2004(round 4)

2005(round 5)

2006(round 6)

Total budget (lifetime)approved (US$ m)

Approval rate (%)

Global Fund funds increasing for TB control; EUR, 2002-06

US$ million

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Stop TB

DOTS (political commitment,

quality bacteriology, guaranteed treatment, ensured drug supply,

monitoring and evaluation)

Engage all providers

Research

Empower patients and communities

Health system strengthening

TB/HIV, MDR-TB, etc.

Health system

Leadership and governance

Financing

Medical products and commodities

Service delivery

Health systems: merging interests with Stop TB

Health work force

Information

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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

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2004/03

2002/01

2005/04

2003/02

55

60

65

70

75

80

85

90

95

100

0 10 20 30 40 50 60 70 80 90 100TB case detection (%)

TB tr

eatm

ent s

ucce

ss (%

)

TARGET

Note: progress in new sputum smear-positive cases under DOTS

Health systems: reform leading to improved TB control

Kyrgyzstan:

Manas Taalimi Reform,

phase II (2001-2006)

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Stop TB Partnership for Europe

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