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PPT Gargioni "The Global Burden of Tuberculosis: Epidemiology and operational challenges"

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PPT Gargioni "The Global Burden of Tuberculosis: Epidemiology and operational challenges", Symposium on TB, 14 October, II Session, Monza, Italy.

PPT Gargioni "The Global Burden of Tuberculosis: Epidemiology and operational challenges", Symposium on TB, 14 October, II Session, Monza, Italy.

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  • Regarding the big challenge of TB/HIV, on the left are the case notifications of selected African countries. These curves show that, when HIV began to spread in the mid-1980s, TB started increasing fast, reaching many times the original rate. One can easily imagine the impact on already weak services and realise why TB is the number one killer of PLHIV. On the right, the pie tells you where the HIV-associated TB cases are: 85% in Africa and 15% in other continents. We do have interventions that are effective to prevent the burden of TB on HIV and that of HIV on TB. We need the GF to promote their use in a bolder way than today.
  • This slide that contains all essential numbers WHO estimates that worldwide in 2007 over 9 million TB cases occurred (and of those, 4 million infectious, sputum-smear (+)). 1.65 million people died of TB, which means 4500 every day. WHO estimates, based on surveys conducted in over 110 settings in the last decade, that nearly half a million cases are multi-drug resistant, and 130,000 of them lethal WHO estimates that XDR-TB cases, which are resistant to all most potent first-line and second-line, reserve drugs, were about 50,000, the majority of which are lethal. Finally, well over 700,000 cases of the 9 million are linked with HIV/AIDS. This is slightly less than 10%. In Africa, this % is much higher, up to50%. In the rest of the world, however, the vast majority of TB cases are not due to HIV.
  • This slide that contains all essential numbers WHO estimates that worldwide in 2007 over 9 million TB cases occurred (and of those, 4 million infectious, sputum-smear (+)). 1.65 million people died of TB, which means 4500 every day. WHO estimates, based on surveys conducted in over 110 settings in the last decade, that nearly half a million cases are multi-drug resistant, and 130,000 of them lethal WHO estimates that XDR-TB cases, which are resistant to all most potent first-line and second-line, reserve drugs, were about 50,000, the majority of which are lethal. Finally, well over 700,000 cases of the 9 million are linked with HIV/AIDS. This is slightly less than 10%. In Africa, this % is much higher, up to50%. In the rest of the world, however, the vast majority of TB cases are not due to HIV.
  • However, Even at maximum DOTS coverage, case detection seems to remain below the 70% target level in most settings (Dye et al 2002) So we need innovative approaches to case detection. The DEWG is a mechanism to do whatever it needs to be done We need to ensure we make good use of it. The 2nd ad hoc Committee produced some recommendations for action, the DEWG is a tool to facilitate/implement some of them.
  • In this Lancet article we argued that TB control must be based on action in 4 areas if we have to make incidence decline more quickly and target elimination. The first is obviously the core business of TB control programmes. The focus must be on early and increased case detection to cut transmission. This is why TB/HIV interventions that can prevent TB or detect it early are so crucial. Secondly, a TB control programme cannot operate in isolation. Free services and access to all are crucial. Especially relevant here will be robust laboratory networks. With more TB suspects being identified, there will be a greater need to ensure access to sensitive diagnostic tests, and ultimately quality drugs, a regulated private care, etc. The third area belongs to the development agenda and is beyond the reach of the health sector. History in the industrialized world tells us that when development happens and is sustainable, the social and economic factors maintaining TB in a community are progressively mitigated. The fourth area is research. We need new tools and their rapid transfer to endemic countries. Mathematical models have shown that a point-of-care diagnostic, a shorter regimen for treatment and prophylaxis, and, ultimately, a potent pre- and post-exposure vaccine will be crucial for elimination.
  • Partnering initiatives at country level could offer an inclusive platform to all stakeholders working on TB prevention, care and control in the country. Organizations from different sectors of society (public, civil society, private/business sector) could decide to come together in a voluntary alliance to develop and implement a shared national TB plan to achieve the objectives of TB prevention, care and control. In coordination with the NTP, a partnering initiative would support the national TB plan by harnessing the contributions of all partners . Being an inclusive platform, organizations working under various service delivery areas (from DOTS expansion and enhancement to MDRTB and TB/HIV) could sit around the same table and discuss how to better address the national TB plan taking into account the services/competences/resources they could provide in different geographic areas. The nature of partnering initiatives would necessarily be country-specific , expressing typical cultural and organizational diversity. Depending on the local situation, countries might decide to build upon already existing forms of collaboration/coordination, such as the Interagency Coordination Committee, and start a partnering initiative.
  • What we have observed is that following a partnering process helps when building and strengthening a national partnership. The partnering process is based on three components: partnership exploration, building and maintenance – which are basically related to take the decision about working together, putting together the means/tools to work together, working. I will mention examples of how countries have used this process – examples are taken from exchange I have with focal points, presentations in meetings, questionnaires, etc.
  • If the initial partners (institutions, such NTP or WHO Country Office, or other actors from the civil society and private/business sector) decide it is worth to create a partnering initiative, they could take on a partnering process . This is a dynamic process based on three continuously evolving components: partnership exploration, building and maintenance. The partnership exploration component includes: building a common vision, identifying and starting a dialogue with all relevant partners, mapping resources (not only financial, but also human and technical). The partnership building component includes: jointly preparing an operational plan, agreeing on a partnering agreement, designing a governance structure, setting up the basic secretariat and launching the initiative publicly. The partnership maintenance component relates to the implementation of the activities for which the partnership has been established, including monitoring and evaluation.

PPT Gargioni "The Global Burden of Tuberculosis: Epidemiology and operational challenges" PPT Gargioni "The Global Burden of Tuberculosis: Epidemiology and operational challenges" Presentation Transcript

  • The Global Burden of Tuberculosis: Epidemiology and operational challenges Giuliano Gargioni, M.D. Team Leader, Stop TB Partnership World Health Organization, Geneva, Switzerland Tubercolosi: una malattia complessa Villa Reale Monza, Italy, 14 October 2011 Photo: Riccardo Venturi Photo: Dominic Chavez
  • Overview of this presentation
    • Burden of TB, TB/HIV, MDR-TB
    • Progress towards international targets
    • Challenges in 2011
    • Actions needed
    • The role of National Stop TB Partnerships
  • Overview of this presentation
    • Burden of TB, TB/HIV, MDR-TB
    • Progress towards international targets
    • Challenges in 2011
    • Actions needed
    • The role of National Stop TB Partnerships
  • Estimated number of cases Estimated number of deaths 1.7 million (range: 1.5–2.0 million) 9.4 million (range: 8.9–9.9 million) 440,000 (range: 390,000–510,000) All forms of TB Multidrug-resistant TB (MDR-TB) HIV-associated TB 1.1 million (12%) (range: 1.0–1.2 million) 380,000 (range: 320,000–450,000) The Global Burden of TB -2009 about 150,000 0–24 25–49 50–99 100–299 300 and higher No estimate available
  • TB Incidence Rates - 2009
    • Highest burden in Asia (55% of 9.4 million cases)
    • Highest rates in Africa, due to high HIV infection rate
    • ~80% of HIV+ TB cases are in Africa
    Per 100 000 population 0–24 25–49 50–99 100–299 >300 No estimate Africa 30% West Pacific 20% SE Asia 35% Europe 4% East Mediterranean 7% Americas 3%
  • Impact of HIV on TB in Africa Notified cases per 100,000 pop. 1980-2008
    • 79% of all TB/HIV cases world-wide are in Africa
    • 50% of all TB/HIV cases world-wide in 9 African countries
    • 23% of the estimated 2 million HIV deaths due to TB
  • % MDR-TB among new TB cases, 1994-2009 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 2010. All rights reserved
  • 13 top settings with highest % of MDR-TB among new cases, 2001-2010 35.3 Minsk, Belarus (2010) Preliminary results
  • Time trends in TB and MDR-TB: reverting, controlling, and alarming… Botswana Tomsk Oblast, Russia Estonia
  • Countries that had reported at least one XDR-TB case by end March 2011 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 2011. All rights reserved
  • Overview of this presentation
    • Burden of TB, TB/HIV, MDR-TB
    • Progress towards international targets
    • Challenges in 2011
    • Actions needed
    • The role of National Stop TB Partnerships
  • The global response: Stop TB Strategy & Global Plan To save lives, prevent suffering, protect the vulnerable, & promote human rights
    • Pursue high-quality DOTS expansion
    • Address TB-HIV, MDR-TB, and needs of the poor and vulnerable
    • Contribute to health system strengthening
    • Engage all care providers
    • Empower people with TB and communities
    • Enable and promote research
  • 2015: Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6c : to have halted by 2015 and begun to reverse the incidence… *Indicator 6.9: incidence, prevalence and mortality associated with TB *Indicator 6.10: proportion of TB cases detected and cured under DOTS 2015: 50% reduction in TB prevalence and deaths by 2015 2050: elimination (<1 case per million population) The Global TB Control Targets
  • Achievements thus far
    • 41 million patients cured, 1995-2009
    • 6 million deaths averted compared to 1995 care standards
    • Mortality reduced by 35% since 1990 and 2015 50% mortality target on track globally
    • Cure rates >85%, care for TB/HIV improving
    • 2015 MDG target on track: global TB incidence peaked in 2004
    • But…. TB incidence declining too slowly, case detection stagnating, and MDR-TB care only now starting scale-up
  • Prevalence and mortality: global estimates shaded area = uncertainty band 2015 Mortality 1990 35 25 15 0 target Prevalence 1990 300 200 100 0 2015 target
  • Incidence rates falling globally after peak in 2004, but only at <1%/year Peak in 2004 Incidence (all forms, incl. PLHIV) TB Notifications Incidence TB in PLHIV shaded area = uncertainty band Notification gap
  • Overview of this presentation
    • Burden of TB, TB/HIV, MDR-TB
    • Progress towards international targets
    • Challenges in 2011
    • Actions needed
    • The role of National Stop TB Partnerships
  • The main challenges in 2011
    • Funding not secure
    • Only 63% of all estimated cases reported
    • TB/HIV major impact in Africa
    • MDR-TB, with high burden in former USSR and China
    • Weak health policies, systems and services
    • Un-engaged non-state practitioners
    • Un-aware, un-involved communities
    • R&D and transfer of tools/technology: Xpert MTB-RIF, and soon new drugs
  • Funding required, Global Plan Plan component US$ billions, 2011–15 % total IMPLEMENTATION 36.9 79% DOTS 22.6 48% MDR-TB 7.1 15% TB/HIV 2.8 6% Lab strengthening 4.0 8% Technical assistance 0.4 1% R&D 9.8 21% TOTAL 46.7 100%
  • Treatment success 86% globally Global WHO Regions Progress in most regions, but Europe lagging behind W. Pacific SE Asia EMR Africa 93 88 80 Americas 77 66 Europe
  • HIV testing for TB patients expanding Africa World More needed to reach 100% targets in Global Plan Several countries show very high testing rates are achievable Rwanda: 97% Kenya: 88% Tanzania: 88% Malawi: 86% Mozambique: 84% Percentage of TB patients
  • CPT and ART for HIV+ TB patients More needed to reach 100% targets in Global Plan But several countries show higher rates of enrolment are possible CPT 86%–97% in 2009 Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda ART close to 50% in 2009 Rwanda, Malawi CPT ART Percentage of HIV+ TB patients
    • A . Establish NTP-NACP collaborative mechanisms
      • Coordinating bodies
      • Surveillance of HIV prevalence among TB cases
      • TB/HIV planning
      • Monitor and evaluate collaborative TB/HIV activities
    • B . Decrease burden of TB among PLHIV (the &quot; 3 Is &quot;)
      • Intensified TB case finding
      • INH preventive therapy
      • Infection control in health care and congregate settings
    • C . Decrease burden of HIV among TB patients
      • HIV testing and counselling
      • HIV prevention methods
      • Co-trimoxazole preventive therapy
      • HIV/AIDS care and support
      • ARVs
    Policy on collaborative TB/HIV activities WHO recommendations
  • Increasing notifications via PPM (public-private mix) Source: 2010 WHO global TB control report, Table 7, page 16 NATIONAL PARTS OF COUNTRY
  • Proportion of TB patients tested for MDR-TB remains low New Global plan target for 2015 = 20% Previously treated Global plan target for 2015 = 100%
    • Action plans in 26 countries
    • In 23, funding increased from $ 0.1b in 2009 to 0.5b in 2011 (need is $ 0.9b)
    • Most countries still rely on external resources
    • 16 countries have a culture lab per 5m people and a DST lab per 10m people
    • 11 countries are introducing GenXpert
    • 10% only of 250,000 estimated cases on treatment
    • 13 countries reported cure rates ( 25-82% for 2007 cohort)
    • 19 countries did not report stock-out of 2 nd -line drugs
    • 14 countries have national plans for infection control
    Response to M/XDR-TB in 27 HBCs: 2011 Progress Report
  • Overview of this presentation
    • Burden of TB, TB/HIV, MDR-TB
    • Progress towards international targets
    • Challenges in 2011
    • Actions needed
    • The role of National Stop TB Partnerships
  • Innovative Actions Needed in 4 Areas
      • Early & increased case detection: new tools
      • Scale-up TB/HIV and MDR-TB interventions
      • M&E and impact measurement
      • Engage all care providers
      • Active screening among at-risk populations
    Socio-economic factors: living conditions, food insecurity, awareness, risk behaviour, access to care MDR-TB, Multi drug resistant TB M&E, Monitoring and evaluation Innovative action needed in 4 spheres TB care and control Development agenda Research sensu lato Health systems and policies Free services, labs, quality drugs, regulated private care, better M&E
      • New tools
      • Operational research
      • Transfer of technology
    • The world is on track to achieve the target of incidence reduction and the 50% mortality decrease in 2015
    • Universal access to quality TB care requires strengthening of lab services, further progress in implementation of PPM and TB/HIV interventions, massive scale-up of care for MDR-TB
    • Bold health policies , new tools rapidly transferred to endemic countries, and alleviation of socio-economic barriers are necessary to achieve acceleration of decline and elimination
    Situation in 2011
  • Overview of this presentation
    • Burden of TB, TB/HIV, MDR-TB
    • Progress towards international targets
    • Challenges in 2011
    • Actions needed
    • The role of National Stop TB Partnerships
  • Transforming the fight against TB: who is going to do it?
    • TB as a disease  medical approach
    • TB as public health problem (policy and practice based on essential elements of disease control)  DOTS strategy
    • TB as a socially relevant health problem
        • All of the above and:
        • Social determinants
        • Inter-sectoral approach
        • Social awareness and support
    • Stop TB Strategy
  • Why a national partnership to stop TB?
    • Usually national Stop TB partnerships focus on:
    • Effective advocacy and communication:
      • Upstream: secure political support, resource mobilization
      • Downstream: involve partners that are influential of people's behaviour/practice.
    • Catalyse/boost implementation through the involvement of other partners and sectors (civil society and business/private sector).
  • Key features of national partnerships
    • Inclusive platform for all partners interested and working for TB prevention, care, control
    • Different sectors: state (NTP) and non-state (civil society organizations and private/business sector)
    • Mapping of partners' contributions
    • Shared plan based on national TB plan with roles and responsibilities for each partner
    • Resource mobilization plan jointly developed (including in-kind resources, local donors, external donors)
    PUBLIC CIVIL SOCIETY PRIVATE INTERNAT.
  • Partnerships in HBCs Afghanistan Bangladesh Brazil Cambodia China DR Congo Ethiopia India Indonesia Kenya Mozambique Myanmar Nigeria Pakistan Philippines Russian Federation South Africa Thailand Uganda UR Tanzania Vietnam Zimbabwe AFRO Francophone Forum Ghana Kenya Nigeria Swaziland Uganda AMRO Brazil Canada Dominican Rep. Mexico Peru’ USA EMRO Regional Partnership Afghanistan Djibouti Egypt Jordan Iran Kuwait Morocco Pakistan Sudan Syria EURO Italy UK (Results) WPRO Japan Republic of Korea Philippines Vietnam SEARO Bangladesh India Indonesia Nepal Thailand National Stop TB Partnering initiatives Partnerships in WHO regions and High Burden Countries
  • Partnering process (more than a &quot;launching&quot;) EXPLORATORY WORKSHOP C O R E G R O U P FORMAL LAUNCH
  • Partnering process
    • Exploration
    • building a common vision
    • identifying and starting a dialogue with all relevant partners
    • mapping resources (not only financial, but also human and technical)
    • Building
    • jointly preparing an operational plan
    • agreeing on a partnering agreement
    • designing a governance structure
    • setting up the basic secretariat
    • launching the initiative publicly
    • Maintenance
    • implementation of the activities by partners, including monitoring and evaluation
  • Many thanks to all