The Global Burden of Tuberculosis:  Epidemiology and operational challenges Giuliano Gargioni, M.D. Team Leader, Stop TB P...
Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international target...
Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international target...
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 mill...
TB Incidence Rates - 2009 <ul><li>Highest burden in Asia (55% of 9.4 million cases) </li></ul><ul><li>Highest rates in Afr...
Impact of HIV on TB in  Africa Notified cases per 100,000 pop. 1980-2008 <ul><li>79% of all TB/HIV cases world-wide are in...
% MDR-TB among new TB cases, 1994-2009 The boundaries and names shown and the designations used on this map do not imply t...
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...
Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international target...
The global response:  Stop TB Strategy & Global Plan To save lives, prevent suffering, protect the vulnerable, & promote h...
2015: Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6c : to have halted by 2015 and begun to reverse the inci...
Achievements thus far <ul><li>41 million patients cured, 1995-2009 </li></ul><ul><li>6 million deaths averted compared to ...
Prevalence and mortality: global estimates shaded area = uncertainty band 2015 Mortality 1990 35 25 15 0 target Prevalence...
Incidence rates falling globally after peak in 2004, but only at <1%/year Peak in 2004 Incidence (all forms, incl. PLHIV) ...
Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international target...
The main challenges in 2011 <ul><li>Funding not secure </li></ul><ul><li>Only 63% of all estimated cases reported </li></u...
Funding required, Global Plan Plan component US$ billions, 2011–15 % total IMPLEMENTATION 36.9 79% DOTS 22.6 48% MDR-TB 7....
Treatment success 86% globally Global WHO Regions Progress in most regions, but Europe lagging behind W. Pacific SE Asia E...
HIV testing for TB patients expanding Africa World More needed to reach 100% targets in Global Plan Several countries show...
CPT and ART for HIV+ TB patients More needed to reach 100% targets in Global Plan But several countries show higher rates ...
<ul><li>A .  Establish NTP-NACP collaborative mechanisms </li></ul><ul><ul><li>Coordinating bodies </li></ul></ul><ul><ul>...
Increasing notifications via PPM  (public-private mix) Source: 2010 WHO global TB control report, Table 7, page 16 NATIONA...
Proportion of TB patients tested for MDR-TB remains low New Global plan target for 2015 = 20% Previously treated Global pl...
<ul><li>Action  plans  in 26 countries </li></ul><ul><li>In 23,  funding increased  from $ 0.1b in 2009 to 0.5b in 2011 (n...
Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international target...
Innovative Actions Needed in 4 Areas  <ul><ul><li>Early & increased case detection: new tools </li></ul></ul><ul><ul><li>S...
<ul><li>The world is  on track  to achieve the target of incidence reduction and the 50% mortality decrease in 2015 </li><...
Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international target...
Transforming the fight against TB: who is going to do it? <ul><li>TB as a disease      medical approach </li></ul><ul><li...
Why a national partnership to stop TB? <ul><li>Usually national Stop TB partnerships focus on: </li></ul><ul><li>Effective...
Key features of national partnerships <ul><li>Inclusive platform for  all partners  interested and working for TB preventi...
Partnerships in HBCs Afghanistan Bangladesh Brazil Cambodia China DR Congo Ethiopia India Indonesia Kenya Mozambique Myanm...
Partnering process (more than a &quot;launching&quot;) EXPLORATORY WORKSHOP C O R E G R O U P FORMAL LAUNCH
Partnering process <ul><li>Exploration </li></ul><ul><li>building a common vision </li></ul><ul><li>identifying and starti...
Many thanks to all
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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.

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

  1. 1. 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
  2. 2. Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international targets </li></ul><ul><li>Challenges in 2011 </li></ul><ul><li>Actions needed </li></ul><ul><li>The role of National Stop TB Partnerships </li></ul>
  3. 3. Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international targets </li></ul><ul><li>Challenges in 2011 </li></ul><ul><li>Actions needed </li></ul><ul><li>The role of National Stop TB Partnerships </li></ul>
  4. 4. 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
  5. 5. TB Incidence Rates - 2009 <ul><li>Highest burden in Asia (55% of 9.4 million cases) </li></ul><ul><li>Highest rates in Africa, due to high HIV infection rate </li></ul><ul><li>~80% of HIV+ TB cases are in Africa </li></ul>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%
  6. 6. Impact of HIV on TB in Africa Notified cases per 100,000 pop. 1980-2008 <ul><li>79% of all TB/HIV cases world-wide are in Africa </li></ul><ul><li>50% of all TB/HIV cases world-wide in 9 African countries </li></ul><ul><li>23% of the estimated 2 million HIV deaths due to TB </li></ul>
  7. 7. % 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
  8. 8. 13 top settings with highest % of MDR-TB among new cases, 2001-2010 35.3 Minsk, Belarus (2010) Preliminary results
  9. 9. Time trends in TB and MDR-TB: reverting, controlling, and alarming… Botswana Tomsk Oblast, Russia Estonia
  10. 10. 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
  11. 11. Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international targets </li></ul><ul><li>Challenges in 2011 </li></ul><ul><li>Actions needed </li></ul><ul><li>The role of National Stop TB Partnerships </li></ul>
  12. 12. The global response: Stop TB Strategy & Global Plan To save lives, prevent suffering, protect the vulnerable, & promote human rights <ul><li>Pursue high-quality DOTS expansion </li></ul><ul><li>Address TB-HIV, MDR-TB, and needs of the poor and vulnerable </li></ul><ul><li>Contribute to health system strengthening </li></ul><ul><li>Engage all care providers </li></ul><ul><li>Empower people with TB and communities </li></ul><ul><li>Enable and promote research </li></ul>
  13. 13. 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
  14. 14. Achievements thus far <ul><li>41 million patients cured, 1995-2009 </li></ul><ul><li>6 million deaths averted compared to 1995 care standards </li></ul><ul><li>Mortality reduced by 35% since 1990 and 2015 50% mortality target on track globally </li></ul><ul><li>Cure rates >85%, care for TB/HIV improving </li></ul><ul><li>2015 MDG target on track: global TB incidence peaked in 2004 </li></ul><ul><li>But…. TB incidence declining too slowly, case detection stagnating, and MDR-TB care only now starting scale-up </li></ul>
  15. 15. 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
  16. 16. 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
  17. 17. Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international targets </li></ul><ul><li>Challenges in 2011 </li></ul><ul><li>Actions needed </li></ul><ul><li>The role of National Stop TB Partnerships </li></ul>
  18. 18. The main challenges in 2011 <ul><li>Funding not secure </li></ul><ul><li>Only 63% of all estimated cases reported </li></ul><ul><li>TB/HIV major impact in Africa </li></ul><ul><li>MDR-TB, with high burden in former USSR and China </li></ul><ul><li>Weak health policies, systems and services </li></ul><ul><li>Un-engaged non-state practitioners </li></ul><ul><li>Un-aware, un-involved communities </li></ul><ul><li>R&D and transfer of tools/technology: Xpert MTB-RIF, and soon new drugs </li></ul>
  19. 19. 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%
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. <ul><li>A . Establish NTP-NACP collaborative mechanisms </li></ul><ul><ul><li>Coordinating bodies </li></ul></ul><ul><ul><li>Surveillance of HIV prevalence among TB cases </li></ul></ul><ul><ul><li>TB/HIV planning </li></ul></ul><ul><ul><li>Monitor and evaluate collaborative TB/HIV activities </li></ul></ul><ul><li>B . Decrease burden of TB among PLHIV (the &quot; 3 Is &quot;) </li></ul><ul><ul><li>Intensified TB case finding </li></ul></ul><ul><ul><li>INH preventive therapy </li></ul></ul><ul><ul><li>Infection control in health care and congregate settings </li></ul></ul><ul><li>C . Decrease burden of HIV among TB patients </li></ul><ul><ul><li>HIV testing and counselling </li></ul></ul><ul><ul><li>HIV prevention methods </li></ul></ul><ul><ul><li>Co-trimoxazole preventive therapy </li></ul></ul><ul><ul><li>HIV/AIDS care and support </li></ul></ul><ul><ul><li>ARVs </li></ul></ul>Policy on collaborative TB/HIV activities WHO recommendations
  24. 24. Increasing notifications via PPM (public-private mix) Source: 2010 WHO global TB control report, Table 7, page 16 NATIONAL PARTS OF COUNTRY
  25. 25. 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%
  26. 26. <ul><li>Action plans in 26 countries </li></ul><ul><li>In 23, funding increased from $ 0.1b in 2009 to 0.5b in 2011 (need is $ 0.9b) </li></ul><ul><li>Most countries still rely on external resources </li></ul><ul><li>16 countries have a culture lab per 5m people and a DST lab per 10m people </li></ul><ul><li>11 countries are introducing GenXpert </li></ul><ul><li>10% only of 250,000 estimated cases on treatment </li></ul><ul><li>13 countries reported cure rates ( 25-82% for 2007 cohort) </li></ul><ul><li>19 countries did not report stock-out of 2 nd -line drugs </li></ul><ul><li>14 countries have national plans for infection control </li></ul>Response to M/XDR-TB in 27 HBCs: 2011 Progress Report
  27. 27. Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international targets </li></ul><ul><li>Challenges in 2011 </li></ul><ul><li>Actions needed </li></ul><ul><li>The role of National Stop TB Partnerships </li></ul>
  28. 28. Innovative Actions Needed in 4 Areas <ul><ul><li>Early & increased case detection: new tools </li></ul></ul><ul><ul><li>Scale-up TB/HIV and MDR-TB interventions </li></ul></ul><ul><ul><li>M&E and impact measurement </li></ul></ul><ul><ul><li>Engage all care providers </li></ul></ul><ul><ul><li>Active screening among at-risk populations </li></ul></ul>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 <ul><ul><li>New tools </li></ul></ul><ul><ul><li>Operational research </li></ul></ul><ul><ul><li>Transfer of technology </li></ul></ul>
  29. 29. <ul><li>The world is on track to achieve the target of incidence reduction and the 50% mortality decrease in 2015 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>Situation in 2011
  30. 30. Overview of this presentation <ul><li>Burden of TB, TB/HIV, MDR-TB </li></ul><ul><li>Progress towards international targets </li></ul><ul><li>Challenges in 2011 </li></ul><ul><li>Actions needed </li></ul><ul><li>The role of National Stop TB Partnerships </li></ul>
  31. 31. Transforming the fight against TB: who is going to do it? <ul><li>TB as a disease  medical approach </li></ul><ul><li>TB as public health problem (policy and practice based on essential elements of disease control)  DOTS strategy </li></ul><ul><li>TB as a socially relevant health problem </li></ul><ul><ul><ul><li>All of the above and: </li></ul></ul></ul><ul><ul><ul><li>Social determinants </li></ul></ul></ul><ul><ul><ul><li>Inter-sectoral approach </li></ul></ul></ul><ul><ul><ul><li>Social awareness and support </li></ul></ul></ul><ul><li>Stop TB Strategy </li></ul>
  32. 32. Why a national partnership to stop TB? <ul><li>Usually national Stop TB partnerships focus on: </li></ul><ul><li>Effective advocacy and communication: </li></ul><ul><ul><li>Upstream: secure political support, resource mobilization </li></ul></ul><ul><ul><li>Downstream: involve partners that are influential of people's behaviour/practice. </li></ul></ul><ul><li>Catalyse/boost implementation through the involvement of other partners and sectors (civil society and business/private sector). </li></ul>
  33. 33. Key features of national partnerships <ul><li>Inclusive platform for all partners interested and working for TB prevention, care, control </li></ul><ul><li>Different sectors: state (NTP) and non-state (civil society organizations and private/business sector) </li></ul><ul><li>Mapping of partners' contributions </li></ul><ul><li>Shared plan based on national TB plan with roles and responsibilities for each partner </li></ul><ul><li>Resource mobilization plan jointly developed (including in-kind resources, local donors, external donors) </li></ul>PUBLIC CIVIL SOCIETY PRIVATE INTERNAT.
  34. 34. 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
  35. 35. Partnering process (more than a &quot;launching&quot;) EXPLORATORY WORKSHOP C O R E G R O U P FORMAL LAUNCH
  36. 36. Partnering process <ul><li>Exploration </li></ul><ul><li>building a common vision </li></ul><ul><li>identifying and starting a dialogue with all relevant partners </li></ul><ul><li>mapping resources (not only financial, but also human and technical) </li></ul><ul><li>Building </li></ul><ul><li>jointly preparing an operational plan </li></ul><ul><li>agreeing on a partnering agreement </li></ul><ul><li>designing a governance structure </li></ul><ul><li>setting up the basic secretariat </li></ul><ul><li>launching the initiative publicly </li></ul><ul><li>Maintenance </li></ul><ul><li>implementation of the activities by partners, including monitoring and evaluation </li></ul>
  37. 37. Many thanks to all

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