Determinanti di salute globalestoptb.it/wp-content/uploads/2019/04/8_Raviglione.pdf2019/04/08 ·...

StopTB Italia © 2012-2014 StopTB Italia Onlus / Tel: +39 [2] 64445886 / 64443321 Fax: +39 [2] 64445826 / CF: 97372750154 Indirizzo: viale Zara 81 , 20159 Milano, Italia - www.stoptb.it

Determinanti di salute globale(e le implicazioni per «End TB»)

Mario Raviglione

Università di MilanoUniversità di Ginevra

Mario C. Raviglione

Global Health Centre

Courtesy of Prof. K. Lönn roth

Health is a contributor and a beneficiary of development

Mario C. Raviglione


Most SDGs are relevant for health

• TB burden

• Comun denominatore

• Fattori di rischio e determinanti socio-economici

• Soluzioni nell’era dello sviluppo umano sostenibile


Mario C. Raviglione


• TB burden




Mario C. Raviglione



Estimated number of cases

Estimated number of deaths

1.6 million*• 1 million in males• 0.6 million in women• 0.23 in children

10 million (133 per 100,000)

• 6.4 million males• 3.6 million females• 1 million children

558,000

All forms of TB

Multidrug-resistant TBMDR/RR-TB

HIV-associated TB 0.9 million (9%) 300,000

Source: WHO Global Report, 2018

The Global Burden of TB, latest estimates 2017

230,000

* Including deaths attributed to HIV/TB

Latently infected 1.7 billion

Mario C. Raviglione


7

TB is in every countryHighest incidence rates in Africa and parts of Asia

SE AsiaAfricaW PacificEast MedAmericasEurope

N = 10 million

44% South-East Asia18% Western Pacific

25% Africa8% Eastern Mediterranean 3% Americas , 3% Europe

Source: WHO Global Report, 2018

Mario C. Raviglione


Top 10 Causes of Deaths Globally, 2016 (N= 56.9M)Top 10 Causes of Deaths Globally, 2016 (N= 56.9M)

Mario C. Raviglione


Causes of death by different income level, 2016 Causes of death by different income level, 2016

Mario C. Raviglione


Estimates of TB disease burden 2000–2017

Peak of the epidemic

10m

0.9 m

6.4m

1.3m

0.3m

Mario C. Raviglione


47% decline between 1990 and 2015Falling 1.4% per year (2000-2015). 18% drop between 2000 and 2015

• TB burden





Mario C. Raviglione


x

How to interrupt the cycle of transmission?

Mario C. Raviglione

Global Health

1.Preventing exposure

in the environment

3. Preventing disease: LTBI treatment (+BCG)

4. Preventing spreading:

early diagnosis and treatment

x xMario C. Raviglione


2. Preventing

LTBI: Vaccine?

Risk Factors

Risk Factors

Risk Factors

Risk Factors

ExposureLatent

(sub-clinical)Infection

InfectiousTuberculosis

Non-infectiousTuberculosis

Death

Natural history of tuberculosis: the basis

1.7 billion 10 M / yr

1.6 M / yr

Largely exogenous•Particles/volume x exposure time•Production of infectious droplets•Clearance of air

Largely endogenous• Performance of cell-mediated immunity• Medical conditions: HIV/AIDS, diabetes, malnutrition, use of steroids

or TNF-a inhibitors, tobacco-related lung disease, alcohol abuse, etc.

Poverty, poor living conditions, malnutrition, inequities

Mario C. Raviglione

Global Health

Linked to access: Failed or late diagnosis, inadequate treatment, type of TB, co-morbidities

Mario C. Raviglione

Global Health

Mario C. Raviglione


What is the common denominator?

Poverty

TB linked to HIV infection, malnutrition, alcohol, drug and tobacco use, diabetes

Migrants, refugees, prisoners, ethnic minorities face risks, discrimination & barriers to care

Half a million women and 250,000 children died of TB in 2016

TB spreads in poor, crowded & poorly ventilated settings

Who carries the burden of tuberculosis?Mostly, the most vulnerable, the poorest…

Mario C. Raviglione

Global Health

Mario C. Raviglione


The lower the GDP per capitathe higher TB incidence

Relationship Gross Domestic Product/capita and TB incidenceRealtionship Gross National Income/capita and TB incidence

Mario C. Raviglione

Global Health

Mario C. Raviglione


The lower the GNI* per capitathe higher TB incidence

*GNI = GDP + income of foreign residents

Economic growth & equity; improved living conditions and nutrition;

universal health coverage with high quality TB diagnosis and treatment

Source: Gapminder 2012

Mario C. Raviglione

Global Health

Mario C. Raviglione


GDP/capita and TB incidence by continent

Nat Rev Microbiol 2012; 10: 407–16.

-10%/year

TB incidence declined up to 10%/year after WWII in Europe

Sustained socio-economic development Universal health coverage & social protection accessible to all Screening of high-risk groups (but limited impact) Infection control practices

TB mortality

TB incidence

Mario C. Raviglione


The Netherlands England & Wales

6160

Undoing: TB and the collapse of the Soviet Union and the socialist block

0

1

2

3

4

5

0

20

40

60

80

100

120

140

1980 1985 1990 1995 2000 2005 2010 2015

New

cas

es ('

000s

) per

yea

r - H

unga

ry

New

cas

es ('

000s

) per

yea

r - R

ussi

a

Years

RussiaHungary

Courtesy of Dr Chris Dye

Courtesy of Prof. K. LönnrothMario C. Raviglione


-more crowding?

-higher prevalence of HIV, smoking, malnutrition, alcoholism, social marginalization etc?

-poor access to health services, diagnostic delays, prolonged infectiousness in poor communities?

TB incidence rates & socio-economic level, New York, 1973(SE level estimated on the basis of education, occupation and income)

Hinman AR et al, Am J Epidem 103:490, 1976

"The possibility of eradicating TB in a country is essentially a function of its economic level" (G. Canetti, 1962)

Mario C. Raviglione

Global Health

Mario C. Raviglione


An ecologic analysis of determinants of TB incidence trends Variable S

ub-

Sa

hara

n A

fric

a

Cen

tral

& E

ast

ern

E

uro

pe

Hig

h in

com

e

Ea

ster

n

Me

dite

rran

ean

Latin

Am

eric

a &

C

arib

bea

n

So

uth-

Eas

t Asi

a &

W

est

ern

Pac

ific

Wor

ld

Human Development Index 0.60 0.20

Corruption 0.52

GDP per capita 0.61 0.34

Change GDP 0.21

Income < $1

Income < $2 0.43

Income inequality

Population under 15 yr

Urban population

Foreign born TB 0.47

Diabetes 0.47

Undernutrition 0.36 0.31

Men smokers

Women smokers 0.45

HIV prevalence 0.41

HIV prevalence in TB patients 0.26

Water 0.41

Sanitation 0.40 0.43 0.26

Solid fuel 0.30

Health expenditure per capita 0.66Government health expenditure per capita 0.63

Health expenditure as % GDP 0.23 0.53

Health workers 0.33

Change under 5 mortality 0.36

Under 5 mortality 0.39 0.35 0.29 0.25

TB expenditure per capita 0.49

TB expenditure per patient

Detection all new TB

Detection new smear+ TB 0.32

Treatment success

New TB successfully treated

Smear+ TB successfully treated

32 measures of development, economy, population, behavioural & biological risk, health services, and TB control assessed for ecological association with incidence trends during 1997-2006 for 134 countries in 6 regions

World-wide: Human Development Index*, Child mortality, and Access to Sanitation were associated with faster incidence decline

*Calculated on the basis of life expectancy, literacy rate, and GDP/capita

Mario C. Raviglione

Global HealthMario C. Raviglione


(Dye C, Lönnroth K, Jaramillo E, Williams BG, Raviglione M. Bull WHO 2009; 87:683)Yellow:(+) trendBlue: (-) trend

• TB burden





Mario C. Raviglione


Relative risk for active TB disease

Weighted prevalence (22 HBCs)

Population Attributable Fraction

in Adults

HIV infection 20.6/26.7* 0.5% 10%Malnutrition 3.2** 16.5% 27%Diabetes 3.1 3.4% 6%Alcohol use (>40g / d)

2.9 7.9% 13%

Active smoking 2.6 18.2% 23%Indoor Air Pollution

1.5 71.1% 26%

Sources: Lönnroth K, Raviglione M. Global Epidemiology of Tuberculosis: Prospects for Control. Semin Respir Crit Care Med 2008; 29: 481-491. *Updated data in GTR 2009. RR=26.7 used for countries with HIV <1%. **Updated data from Lönnroth et al. A consistent log-linear relationship between tuberculosis incidence and body-mass index.

Population attributable fraction:Selected Risk Factors & Determinants

Mario C. Raviglione


1

1 1

P RRPAF

P RR

Population attributable fraction - Regional variations

Mario C. Raviglione


0

5

10

15

20

25

30

35

40

ARF HighHIV

AFR LowHIV

CEUR EEUR EME EMR LAC SEAR WPR

Pop

ulat

ion

attr

ibut

able

fra

ctio

n (%

)

HIV

Undernourishment

Smoking

Diabetes

Alcohol abuse

Mario C. Raviglione


Courtesy of Prof. K. Lönnroth

Risk factors and determinants in detail

Mario C. Raviglione



India

Bangl

Vietnam

Ghana

Ind+DOTS

Risk factors and determinants in detail HIV, Under-nutrition and Diabetes

(Havlir et al 2008)

Odone A, Houben R, White RG, Lönnroth K. Lancet Diabetes and Endocrinology 2014; 2: 754–64

• TB burden





Mario C. Raviglione


A new era with new ambitions and a paradigm shift

UN Sustainable Development Goals: 2016 – 203017 goals and 169 targets

“Ensure healthy lives and promote well-being for all at all ages”

Mario C. Raviglione

Global Health

Mario C. Raviglione


3.3 End the epidemics of AIDS, tuberculosis, malaria

&neglected tropical diseases and combat

hepatitis, water-borne and other communicable diseases

3.2 Reducechild and

neonatal mortality

3.1 ReduceMaternalmortality

3.5 Strengthen Prevention and

treatment of substance abuse (narcotics, alcohol)

3.6 ReduceMortality

due to road traffic injuries

3.4 Reducemortality due to NCD and improve mental health

3.8 Achieve universal

health coverage

3.9 Reduce deaths and illness

due to pollution and contamination

3.7 Universalaccess to sexual and

reproductive health-care services

3.a Strengthen implementation FCTC (tobacco)

3.b Access to affordable essential medicines and

technologies

3.c Increased health financing and health

workforce in developing countries

3.d Enhance capacity for early warning, risk reduction and

management of national and global health risks

SDG 3 and its 13 targets by 2030

3.3 End the epidemics of AIDS, tuberculosis, malaria

&neglected tropical diseases and combat

hepatitis, water-borne and other communicable diseases

Mario C. Raviglione

Global Health

Mario C. Raviglione


SDG TARGET 3.3 – BY 2030END THE TB EPIDEMIC

The opportunity of the SDG era to reach the end TB targets

Mario C. Raviglione

Global Health

Mario C. Raviglione


67th World Health Assembly, Geneva, May 2014

Mario C. Raviglione

Global Health

Mario C. Raviglione


The End TB Strategy 2016-2030/5: Vision, Targets and Pillars

Vision: A world free of TB Zero TB deaths, Zero TB disease, and Zero TB suffering

Goal: End the Global TB epidemic

Mario C. Raviglione

Global Health

Mario C. Raviglione


EXPOSURESUFFERING

AND DEATHSACTIVE DISEASELATENT INFECTION

Environment

CROWDING, POOR VENTILATION

SILICA, INDOOR AIR POLLUTION

POOR LIVING AND WORKING CONDITIONS

CONDUCIVE ENVIRONMENT FOR TRANSMISSION

GOAL 3: UHC TB

SERVICESBetter TB diagnosis, treatment, care

AT-RISK BEHAVIOUR& HEALTH CONDITIONS

GOAL 3: HIV, NCD,

RISK FACTORS

HIV/AIDS

NCDs: diabetes, smoking, alcohol…

GOAL 1: SOCIAL PROTECTION WHEN

ILL

Why a multisectoral approach to end TB?

VULNERABLE GROUPSincl. children, women,

migrants, prisoners, etc.

MAL-NUTRITION

FOOD INSECURITY

STIGMA/DISCRIMINATION, MARGINALIZATION

IMPAIRED HOST DEFENCE/SUSCEPTIBILITY

Formidable challenges remain… and they cannot be solved solely within the health sector

WITHIN NTPs and HEALTH SECTOR

Addressing the “missed” cases, MDR-TB as a crisis, joint TB/HIV response

Universal health coverage

HIV, tobacco, alcohol, diabetes

Increasing financing to close gaps

Intensifying research

WHAT ABOUT BEYOND NTP & HEALTH ?

Poverty and lack of social protection

Malnutrition

Poor living or working conditions: slums, air pollution, mining, prisons

Discrimination, stigma, war, migration

Inequities and inequalities

Mario C. Raviglione

Global Health

Mario C. Raviglione


Composition of TB related costs and solutions

Source: Tanimura T, Jaramillo E, Weil D, Raviglione M, Lönnroth K. Financial burden for tuberculosis patients in low- and middle-income countries – a systematic review. ERJ 2014

Mario C. Raviglione

Global Health

Mario C. Raviglione


UNIVERSAL HEALTH COVERAGE

SOCIAL PROTECTION

Costs for TB patients as percentage of annual income

Higher cost among:•People with multi-drug resistant TB•People from low socioeconomic groups

Source: Tanimura T, Jaramillo E, Weil D, Raviglione M, Lönnroth K. Financial burden for tuberculosis patients in low- and middle-income countries – a systematic review. ERJ 2014

Mario C. Raviglione



TB patient cost survey implementation in 30 high-burden countries

Mario C. Raviglione

Global Health

Mario C. Raviglione


Recent (2016/2017) TB patient cost surveysPreliminary findings

Results: More than 2/3 of TB-affected households experience catastrophic costs (>20% of annual household income) in Myanmar, Vietnam and East Timor

Higher among the poorest

Close to 100% for people with multi-drug resistant TB

Methods: Garcia I, Siroka A, Weil D, Floyd K, Lönnroth K. Tuberculosis Patient Cost Surveys: A Handbook. WHO/HTM/TB/2017.24. Geneva: World health Organization, 2017

Mario C. Raviglione



Proportion with catastrophic total costs due to TB (preliminary results from selected national surveys)

Total costs, including income loss and non-medical expenditures

Income loss dominates in many settings

Income loss due to disease, disability or health seeking is not considered in the UHC framework!

Mario C. Raviglione



Universal Health Coverage “cube”:

Providing more services, reaching more people, and offering more financial protection

Mario C. Raviglione

Global Health

Mario C. Raviglione


Adding a "social protection floor"

Mario C. Raviglione



Crude correlation between social protection spending and TB prevalence

Mario C. Raviglione



What proportion of GDP is spent on social protection?

26/03/19Knut Lönnroth 43Mario C. Raviglione



Mario C. Raviglione


Ending extreme poverty and expanding social protection coverage will reduce tuberculosis incidence by 84%

Conclusioni

Mario C. Raviglione


• L’incidenza della TBC è piu’ alta quando c’è la povertà, il comune denominatore dei determinanti e fattori di rischio

• I fattori di rischio e i determinanti socio-economici della salute e della TBC sono ormai ben noti e vi sono mezzi per alleviarne l’impatto

• Nell’era dello sviluppo umano sostenibile (SDG), le opportunità per affrontare la TBC includono strategie chiare di riduzione della povertà attraverso UHC e protezione sociale ad evitare il circolo vizioso “povertà-TB-povertà”

StopTB Italia © 2012-2014 StopTB Italia Onlus / Tel: +39 [2] 64445886 / 64443321 Fax: +39 [2] 64445826 / CF: 97372750154 Indirizzo: viale Zara 81 , 20159 Milano, Italia - www.stoptb.it

Molte grazie a tutti

Determinanti di salute globalestoptb.it/wp-content/uploads/2019/04/8_Raviglione.pdf2019/04/08 ·...

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