global tuberculosis control today: expectations from …global tuberculosis control today:...
TRANSCRIPT
Global tuberculosis control today: expectations from the PPM Subgroup
Mario C. Raviglione, M.D.Director, Stop TB DepartmentWHO, Geneva, Switzerland
6th Meeting of the Subgroup on Public-Private Mix for TB Care and ControlIstanbul, Turkey16 February 2010
Estimated number of cases
Estimated number of deaths
1.3 million*
(range, 1.1–1.7 million)
9.37 million
(range, 8.9–9.9 million)
0.5 million
All forms of TB
Multidrug-resistant TB (MDR-TB)
HIV-associated TB 1.4 million (15%)(range, 1.3–1.6 million)
0.52 million
(range, 0.45–0.62 million)
The global burden of TB in 2008
*excluding deaths among HIV+ people
>150,000
Estimated TB Incidence rates, 2008
Africa
31%
West Pacific 20%
SE Asia 34%
Europe 5%
East Mediterranean 7%
Americas 3%
Impact of HIV on TB in Africa
Notified cases per 100,000 pop. 1980-2008
Percentage of global estimated HIV-positive TB cases
EMR
Cameroon
Thailand
Brazil
Democratic Republic of the Congo
China
Myanmar
EUR
Côte d'Ivoire
Malawi
United Republic of Tanzania
AMR
Zambia
WPR
Ethiopia
Mozambique
Kenya
Uganda
Zimbabwe
Nigeria
India
SEA
South Africa
AFR
1% 5% 10% 20% 50% 90%
0
100
200
300
400
500
600
700
1980 1984 1988 1992 1996 2000 2004 2008
Botswana
Côte d'Ivoire
DR Congo
Gabon
Guinea
Kenya
Malawi
Mozambique
South Africa
UR Tanzania
Zimbabwe
4/5 of all estimated TB/HIV cases are in Africa
MDR-TB % among new cases,1994-2007
0.00 - 0.99
1.00 - 2.99
3.00 - 5.99
6.00 – 10.00
>10.00
No data
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 2009. All rights reserved
* Sub-national coverage in India, China, Russia, Indonesia.
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 2009. All rights reserved
Countries with at least one confirmed XDR-TB case, as of December 2009
Argentina Burkina Faso Georgia Kenya Nepal Qatar Swaziland Viet Nam
Armenia Canada Germany Latvia Netherlands Republic of Korea Sweden
Australia China India Lesotho Norway Republic of Moldova Thailand
Azerbaijan Colombia Iran (Islamic Republic of) Lithuania Oman Romania Ukraine
Bangladesh Czech Republic Ireland Mexico Peru Russian Federation United Arab Emirates
Belgium Ecuador Israel Mozambique Philippines Slovenia United Kingdom
Botswana Estonia Italy Myanmar Poland South Africa United States of America
Brazil France Japan Namibia Portugal Spain Uzbekistan
TB Control Global Targets
2015: 50% reduction in TB prevalence and deaths by 2015
2050: elimination (<1 case per million population)
2015: Goal 6: Combat HIV/AIDS, malaria and other diseases
Target 8: to have halted by 2015 and begun to reverse the incidence…
Indicator 23: incidence, prevalence and deaths associated with TB
Indicator 24: proportion of TB cases detected and cured under DOTS
The global response: Stop TB Strategy & Global Plan
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
Treatment success target reached globally: 87% in 2007-8
Su
ccessfu
l tr
ea
tmen
t ra
te (
%)
in
DO
TS
co
ho
rts
85
77
79
77
79
81
80
82
82
82
83
84 85
87
40
50
60
70
80
90
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
But not in the Americas, Africa and Europe
92 88 82 7967
88
0
20
40
60
80
100
W P
acifi
cSE A
sia
EMR
Am
eric
asA
fric
aEuro
pe
5.7 million notified
cases
X.X million sm+
notified cases
30405060
70
8090
30
40
50
60
70
80
90
30
4050
6070
80
90
Africa-high HIV Africa-low HIV Eastern Europe
Red line: Global Plan milestones and 2015 target for CDR
Black dots: actual CDR
South-East AsiaLatin AmericaEastern Mediterranean
GLOBALWestern Pacific
Case detection stagnating globally, gap with Global Plan widening
CDR stable at ~70% since 2005
2002 2008 2015
61% in 2008vs. Global Plan
milestone of 71%
201520082002201520082002
Gap especially large in Africa
Case d
ete
cti
on
rate
(%
)
1990 1995 2000 2005
Rate
per
10
0,0
00 p
op
ula
tion
150
145
140
135
130
125
120
Incidence rates falling globally after peak in 2004
Peak in 2004
World as a whole on track to achieve MDG target 6.c
Number of cases in millions
0
2
4
6
8
10
1990 1993 1996 1999 2002 2005 2008
What are the challenges in 2010?
1. DOTS quality not uniform; only 61% of all estimated cases reported; diagnosis probably late in most settings
2. TB/HIV, especially in Africa; MDR-TB, especially in former USSR and China; XDR-TB everywhere we look for it
3. Weak health systems and services compromising TB care; lack of bold policies on free access to care, drug quality and restriction, labs, human resources, infection control, etc.
4. Not all care providers, non-state and even governmental, working at high standard; weak public-private links
5. Communities often un-aware, un-involved, not mobilised
6. Research not yet delivering innovative tools, transfer of technology slow, and operational research neglected
Public-Private Mix for TB care and control: Milestones
2001: Informal global consultation; Lancet publication
2002: Inclusion of PPM in the Expanded DOTS Strategy
2003: Evidence-base on working models from diverse settings
2004: PPM for TB: What makes it work?.. Cross-country analysis
2005: Cost-effectiveness shown; "public-private" to "all providers"
2006: PPM/ISTC essential components of the Stop TB Strategy
2007: PPM guidance/ISTC/NSA tool implemented in diverse settings
2008: PPM activities in 58 out of 93 Global Fund grants
2009: Appeal for PPM scale up in "Beijing CfA" and WHA 2009
0
20
40
60
80
100
120
140
160
99q1
99q3
00q1
00q3
01q1
01q3
02q1
02q3
03q1
03q3
04q1
04q3
05q1
05q3
Quarter
Annualis
ed r
ate
of
ss+
cases d
iagnosed p
er
100,0
00
NGO
Private
Corporate
Medical college
Other Government
Health Department
•Public and private medical colleges (yellow) diagnose a huge number of cases, but many of them are from outside the city and need to be refereed for treatment elsewhere.
•The increase in diagnosed cases represents increased notification after medical colleges and other providers started to report to NTP in a standardised way
Case recovery into the NTP by different care providers, Bangalore, 1999-2005
Increasing case notifications is good,But…it is not yet early case detection
Trend of Global Fund support for PPM activities – progress is evident
Public-Private Mix for TB care and control: Unfinished agenda
• More projects than programmes?
• Large proportion of care providers still to be engaged?
• Capacity strengthening within the non-state sector?
• Unabated misuse of anti-TB medicines?
• Measurement of contribution weak?
• Regulatory approaches and their effectiveness?
• Limited uptake/input by MDR-TB, TB/HIV, GLI, ACSM?
• Promoting systems approach?: every health unit lists and showsevery health unit lists and shows
how all care providers in its area contribute to TB/MDRhow all care providers in its area contribute to TB/MDR--TB/TBTB/TB--HIV controlHIV control
with enhanced equity in access to carewith enhanced equity in access to care……..
Many thanksto all
Acknowledgements: M. Uplekar, K. Lönnroth, S.S. Lal