Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
MOVING TOWARDS TB ELIMINATION:
EXPERIENCE AND LESSON LEARNED
THROUGH ERS ENGAGEMENT IN
EUROPE
G. B. Migliori
WHO Collabora...
Faculty disclosure
NO COI !!!
Introduction
AIMS: to describe
• The evolution of the strategies to prevent and manage TB
• The evolution of the concept o...
Introduction
AIMS: to describe
• The evolution of the strategies to prevent and manage TB
• The evolution of the concept o...
Sotgiu et al, NEJM 2013
6
INTERVENTIONS TO PREVENT AND MANAGE TB
First sanatorium
Germany, 1857 First Dispensary,
Scotland, 1897
Koch, Mtb,
1882
D...
7
DOTS
• Government commitment
• Case detection by SS microscopy among self-
reporting symptomatic patients
• Standardised...
STOP TB STRATEGY (WHO)
1. Pursue high-quality DOTS expansion and enhancement
• Political commitment with increased and sus...
Introduction
AIMS: to describe
• The evolution of the strategies to prevent and manage TB
• The evolution of the concept o...
Core additional interventions to pursue
elimination
• 1) Ensuring early detection of TB patients and their
treatment until...
Core additional interventions to pursue
elimination
• 1) Ensuring early detection of TB patients and their
treatment until...
Elimination programmatic
pre-requirements (1)
• Government and private-sector commitment towards
elimination
• National sc...
Elimination programmatic
pre-requirements (2)
• Case detection through case-finding among
symptomatic individuals presenti...
Introduction
AIMS: to describe
• The evolution of the strategies to prevent and manage TB
• The evolution of the concept o...
WORLD HEALTH ASSEMBLY APPROVES POST-2015
GLOBAL TB STRATEGY AND TARGETS –
WHA TB RESOLUTION
ZERO
TB DEATHS
A WORLD FREE OF TB
Vision
ZERO
TB CASES
ZERO
TB SUFFERINGGLOBALTB
PROGRAMME
Goal and Targets
Target 1
95% reduction in
TB deaths (compared
with 2015)
Target 2
<10/100 000
TB incidence rate
2035
GOAL...
TARGETS
• 35% reduction in
TB deaths
• <85/100 000 TB
incidence rate
• No affected
families with
catastrophic
costs due to...
High-
quality,
integrated
TB care
and
prevention
Bold
policies and
supportive
systems
Intensified
research
and
innovation
...
POST-2015 TB STRATEGY: PILLAR 1
Treatment of all people with
TB including drug-resistant
TB, with patient-centered
support...
Integrated, patient-
centered TB Care and
Prevention
Early diagnosis of TB including
universal drug-susceptibility
testing...
Full implementation of Global Plan: 2015 MDG
target reached but TB not eliminated by 2050
Current rate of
decline -2%/yr
W...
-3.4%/yr
-5%/yr
Incidence Prevalence
-3%/yr
-7%/yr
China
Cambodia
Sustained socio-
economic development
Stop TB Strategy w...
Full implementation of Global Plan: 2015 MDG
target reached but TB not eliminated by 2050
Current rate of
decline -2%/yr
W...
Nat Rev Microbiol 2012; 10: 407–16.
-10%/year Sustained socio-economic
development
Universal health coverage &
social prot...
Full implementation of Global Plan: 2015 MDG
target reached but TB not eliminated by 2050
Current rate of
decline -2%/yr
W...
Eskimos in Alaska, NW Canada and Greenland:
15% per year incidence decline
Highly focused & high
intensity interventions
S...
Can TB control among Eskimos be generalised to
the world?
Full implementation of Global Plan: 2015 MDG
target reached but TB not eliminated by 2050
Current rate of
decline -2%/yr
W...
DEFINITIONS
• Low-incidence countries: TB notification rate of <10 cases (all
forms) per 100,000 population and year. Prev...
TARGETS
<100 cases per million
Current TB burden-2012
in low-incidence countries
<10 cases per million
Pre-elimination: 20...
Economic development: better nutrition & housing
Universal health coverage & social protection
TB care widely accessible t...
What is in the pipelines for new diagnostics,
drugs and vaccines in 2013?
Diagnostics:
₋7 new diagnostics or diagnostic me...
Introduction
AIMS: to describe
• The evolution of the strategies to prevent and manage TB
• The evolution of the concept o...
7 Core areas:
1. TB control commitment, TB
awareness, and capacity of
health systems
2. Surveillance
3. Laboratory service...
ACKNOWLEDGMENTS
COUNTRY RESPONDENTS
ALBANIA Hasan Hafizi
BELGIUM Maryse Wanlin, Wouter Arrazola de Onate, Guido Groenen
CR...
EUROPE HOW FAR TO REACH ELIMINATION?
EU LOW / MIDDLE TB INCIDENCE COUNTRIES ITALY
10 (33%) No TB Elimination plan NO
7 (23...
INCIDENCE DECLINE: TECHNOLOGICAL BREAKTHROUGH BY 2025
ADDRESSING THE POOL OF LATENT INFECTION
Business as usual
Optimize c...
Introduction
AIMS: to describe
• The evolution of the strategies to prevent and manage TB
• The evolution of the concept o...
TB Elimination: from Wolfheze to Rome
THANK Rome 4-5 July 2014
Wolfheze, May 1990
WHO/ERS SUMMIT ON TB
Rome July 4th-5th 2014
Elimination of TB in low incidence countries
• New WHO/ERS Framework launched ...
Generalised (with social gradient)
Important community transmission
Many incident cases from recent transmission
Relativel...
ACTION FRAMEWORK
8 PRIORITY ACTIONS FOR ELIMINATION IN LOW-INCIDENCE COUNTRIES
Invest in
research
and new tools
Optimize t...
OBSERVED VS. REQUIRED ANNUAL RATE OF
CHANGE TO REACH TB ELIMINATION BY 2035
IN LOW-INCIDENCE COUNTRIES.
OBSERVED VS. REQUIRED ANNUAL RATE OF
CHANGE TO REACH TB ELIMINATION BY 2050
IN LOW-INCIDENCE COUNTRIES.
PROJECTED INCIDENCE RATES IN LOW-
INCIDENCE COUNTRIES IN 2035 CONSIDERING
A DECLINE OF 90% BETWEEN 2015 AND 2035.
-5
5
15
25
35
45
55
65
75
85
95
105
115
125
135
145
155
1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2...
Introduction
AIMS: to describe
• The evolution of the strategies to prevent and manage TB
• The evolution of the concept o...
L’UNDICENNE È IN ISOLAMENTO ALLA CLINICA DE MARCHI
Casi di Tbc a Milano, iniziata la terapia
sul ragazzino con forma multi...
Index case
FAMILY
Male, 12 years
Laryngeal + PTB
Long diagnostic delay
Direct Sputun examination +++
Resistant to SHREZ+FQ...
TREATING M/XDR-TB IS DIFFICULT
www.tbconsilium.org
ERS/WHO Consilium for M/XDR-TB
Objectives:
To allow a European clinician, free
cost, to load patient’s data and
receive in...
The web platform www.tbconsilium.org
• Now in ENG. RUS, SPA, PORT (FREN)
• Hosted in Switzerland (-> Swiss regulation)
• 4...
www.tbconsilium.org
Conclusions
• 1. While TB Elimination was considered an advocacy tool for
>20 years, there is epidimiological plausibility...
ERS Conference, Munich, September 2014:
the launch
THANK
YOU !
Towards TB elimination - Giovanni Battista Migliori
Towards TB elimination - Giovanni Battista Migliori
Towards TB elimination - Giovanni Battista Migliori
Upcoming SlideShare
Loading in …5
×

Towards TB elimination - Giovanni Battista Migliori

890 views

Published on

Professor G. B. Migliori - WHO Collaborating Centre for TB and Lung Disease, Fondazione S. Maugeri, Care and Research Institute Tradate, Italy
Find out more on http://goo.gl/8GUwwL

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Towards TB elimination - Giovanni Battista Migliori

  1. 1. MOVING TOWARDS TB ELIMINATION: EXPERIENCE AND LESSON LEARNED THROUGH ERS ENGAGEMENT IN EUROPE G. B. Migliori WHO Collaborating Centre for TB and Lung Disease, Fondazione S. Maugeri, Care and Research Institute Tradate, Italy
  2. 2. Faculty disclosure NO COI !!!
  3. 3. Introduction AIMS: to describe • The evolution of the strategies to prevent and manage TB • The evolution of the concept of TB elimination • The new WHO Post-2015 Strategy and the concept of pre-elimination • The outcomes of a European ERS, WHO and ECDC survey evaluating European preparedness to reach elimination • The strategies to prevent and manage TB within the new TB Elimination framework for low TB incidence countries • An example of epidemic of XDR-TB in a major city, which summarizes the different issues discussed above.
  4. 4. Introduction AIMS: to describe • The evolution of the strategies to prevent and manage TB • The evolution of the concept of TB elimination • The new WHO Post-2015 Strategy and the concept of pre-elimination • The outcomes of a European ERS, WHO and ECDC survey evaluating European preparedness to reach elimination • The strategies to prevent and manage TB within the new TB Elimination framework for low TB incidence countries • An example of epidemic of XDR-TB in a major city, which summarizes the different issues discussed above.
  5. 5. Sotgiu et al, NEJM 2013
  6. 6. 6 INTERVENTIONS TO PREVENT AND MANAGE TB First sanatorium Germany, 1857 First Dispensary, Scotland, 1897 Koch, Mtb, 1882 Drugs, 1945-1962 MMR,1950-1980 Fox:Ambulatory treatment, 1968 Styblo model, 1978 DOTS, 1991 sanatoria Outbreak Management, Risk Group Management screening BCG vaccination drug therapy Socio-economic improvement Pneumotorax, Italy, 1907
  7. 7. 7 DOTS • Government commitment • Case detection by SS microscopy among self- reporting symptomatic patients • Standardised short-course chemotherapy for at least all confirmed smear positive cases, DOT during the intensive phase for all new SS+ cases, continuation phase of RMP-containing regimens and the whole re-treatment regimen. • A regular, uninterrupted supply of all essential anti- TB drugs • A standardised R&R system allowing assessment of case-finding and treatment results and of NTP performances Int J Tuberc Lung Dis 2001; 5(3):213-215
  8. 8. STOP TB STRATEGY (WHO) 1. Pursue high-quality DOTS expansion and enhancement • Political commitment with increased and sustained financing • Case detection through quality-assured bacteriology • Standardised treatment, with supervision and patient support • An effective drug supply and management system • Monitoring & evaluation system, and impact measurement 2 Address TB/HIV, MDR-TB and other challenges 3. Contribute to health system strengthening 4. Engage all care providers 5. Empower people with TB and communities 6. Enable and promote research
  9. 9. Introduction AIMS: to describe • The evolution of the strategies to prevent and manage TB • The evolution of the concept of TB elimination • The new WHO Post-2015 Strategy and the concept of pre-elimination • The outcomes of a European ERS, WHO and ECDC survey evaluating European preparedness to reach elimination • The strategies to prevent and manage TB within the new TB Elimination framework for low TB incidence countries • An example of epidemic of XDR-TB in a major city, which summarizes the different issues discussed above.
  10. 10. Core additional interventions to pursue elimination • 1) Ensuring early detection of TB patients and their treatment until cure and preventing avoidable death from TB • 2) Reducing the incidence of infection by risk group management and prevention of transmission of infection in institutional settings • 3) Reducing the prevalence of tuberculosis infection through outbreak management and provision of preventive therapy for specified groups and individuals
  11. 11. Core additional interventions to pursue elimination • 1) Ensuring early detection of TB patients and their treatment until cure and preventing avoidable death from TB (C); • 2) Reducing the incidence of infection by risk group management and prevention of transmission of infection in institutional settings (C,E) • 3) Reducing the prevalence of tuberculosis infection through outbreak management and provision of preventive therapy for specified groups and individuals (E)
  12. 12. Elimination programmatic pre-requirements (1) • Government and private-sector commitment towards elimination • National schemes for TB control and elimination • National TB policy • National TB network • Legal framework • Human resources development and health education • Research • International and European collaboration
  13. 13. Elimination programmatic pre-requirements (2) • Case detection through case-finding among symptomatic individuals presenting to health services and • Active case-finding in special groups • Standard approach to treatment of disease and TB infection • Accessibility to TB diagnostic and treatment services • Surveillance and treatment outcome monitoring for TB diseases and TB infection
  14. 14. Introduction AIMS: to describe • The evolution of the strategies to prevent and manage TB • The evolution of the concept of TB elimination • The new WHO Post-2015 Strategy and the concept of pre-elimination • The outcomes of a European ERS, WHO and ECDC survey evaluating European preparedness to reach elimination • The strategies to prevent and manage TB within the new TB Elimination framework for low TB incidence countries • An example of epidemic of XDR-TB in a major city, which summarizes the different issues discussed above.
  15. 15. WORLD HEALTH ASSEMBLY APPROVES POST-2015 GLOBAL TB STRATEGY AND TARGETS – WHA TB RESOLUTION
  16. 16. ZERO TB DEATHS A WORLD FREE OF TB Vision ZERO TB CASES ZERO TB SUFFERINGGLOBALTB PROGRAMME
  17. 17. Goal and Targets Target 1 95% reduction in TB deaths (compared with 2015) Target 2 <10/100 000 TB incidence rate 2035 GOAL: End the Global TB Epidemic GLOBAL TB PROGRAMME
  18. 18. TARGETS • 35% reduction in TB deaths • <85/100 000 TB incidence rate • No affected families with catastrophic costs due to TB TARGETS • 75% reduction in TB deaths • <55/100 000 TB incidence rate • No affected families with catastrophic costs due to TB TARGETS • 90% reduction in TB deaths • <20/100 000 TB incidence rate • No affected families with catastrophic costs due to TB GOAL • 95% reduction in TB deaths • <10/100 000 TB incidence rate • No affected families with catastrophic costs due to TB 20352020 20302025 Getting there: Milestones
  19. 19. High- quality, integrated TB care and prevention Bold policies and supportive systems Intensified research and innovation Post-2015 TB Strategy Proposed Pillars and Principles
  20. 20. POST-2015 TB STRATEGY: PILLAR 1 Treatment of all people with TB including drug-resistant TB, with patient-centered support 3 Preventive treatment of people at high-risk and vaccination for TB 4 Early diagnosis of TB including universal drug susceptibility testing; systematic screening of contacts and high-risk groups 1 2 Collaborative TB/HIV activities and management of co-morbidities High- quality, integrated TB care and prevention GLOBAL TB PROGRAMME
  21. 21. Integrated, patient- centered TB Care and Prevention Early diagnosis of TB including universal drug-susceptibility testing ; systematic screening of contacts and high-risk groups Treatment of all people with TB including drug -resistant TB; and patient support Collaborative TB/HIV activities and management of co- morbidities Preventive treatment for persons at high-risk; and vaccination against tuberculosis Bold policies and supportive systems Political commitment with adequate resources for TB care and prevention Engagement of communities , civil society organizations, and all public and private care providers Universal health coverage policy; and regulatory framework for case notification, vital registration, quality and rational use of medicines, and infection control Social protection, poverty alleviation, and actions on other determinants of TB Intensified Research and Innovation Discovery, development and rapid uptake of new tools, interventions and strategies Research to optimize implementation and impact, and promote innovations Targets: 95% reduction in deaths and 90% reduction in incidence (< 10 cases / 100,000 population) by 2035 Post-2015 Global TB Strategy: Pillars
  22. 22. Full implementation of Global Plan: 2015 MDG target reached but TB not eliminated by 2050 Current rate of decline -2%/yr W Europe after WWII - 10%/yr China, Cambodia -4%/yr Elimination target:<1 / million / yr -20%/yr China, Cambodia -4%/yr
  23. 23. -3.4%/yr -5%/yr Incidence Prevalence -3%/yr -7%/yr China Cambodia Sustained socio- economic development Stop TB Strategy with adequate resources TB care subsidized and decentralised BCG vaccination in infants Decline in TB burden in China and Cambodia Recipe:
  24. 24. Full implementation of Global Plan: 2015 MDG target reached but TB not eliminated by 2050 Current rate of decline -2%/yr W Europe after WWII -10%/yr China, Cambodia -4%/yr Elimination target:<1 / million / yr -20%/yr W Europe after WWII -10%/yr
  25. 25. Nat Rev Microbiol 2012; 10: 407–16. -10%/year Sustained socio-economic development Universal health coverage & social protection TB care widely accessible BCG vaccination in children Screening of high-risk groups (but limited impact) Infection control practices (?) TB incidence declined 10%/year after WWII in Europe (the Netherlands) Recipe:
  26. 26. Full implementation of Global Plan: 2015 MDG target reached but TB not eliminated by 2050 Current rate of decline -2%/yr W Europe after WWII - 10%/yr China, Cambodia -4%/yr Elimination target:<1 / million / yr -20%/yr Eskimos > 10 ; < 20
  27. 27. Eskimos in Alaska, NW Canada and Greenland: 15% per year incidence decline Highly focused & high intensity interventions Screening and massive TLTBI TB care decentralised BCG vaccination Improved health access & social protection Economic development (?) Recipe: -17%/year (1955-74) -8.7%/year (1972-74) Grzybowski S, Styblo K, Dorken E. Tuberculosis in Eskimos. Tubercle 1976; (suppl.) 57: 1-58
  28. 28. Can TB control among Eskimos be generalised to the world?
  29. 29. Full implementation of Global Plan: 2015 MDG target reached but TB not eliminated by 2050 Current rate of decline -2%/yr W Europe after WWII - 10%/yr China, Cambodia -4%/yr Elimination target:<1 / million / yr -20%/yr Elimination target:<1 /million/yr -20%/yr
  30. 30. DEFINITIONS • Low-incidence countries: TB notification rate of <10 cases (all forms) per 100,000 population and year. Previous alternative thresholds: <20/100,000, or <16/100,000. • Pre-elimination: <10 notified TB cases (all forms) per million population per year. This is the same as proposed by Clancy et al in 1991. • TB elimination: <1 notified TB case (all forms) per million population and year. • Alternative definitions: European region, <1 sputum-smear positive case per million; ECDC has proposed all forms of TB. US CDC defines elimination in the USA as < 1 case of TB, all forms, per million population.
  31. 31. TARGETS <100 cases per million Current TB burden-2012 in low-incidence countries <10 cases per million Pre-elimination: 2035 in low-incidence countries <1 case per million Elimination: 2050
  32. 32. Economic development: better nutrition & housing Universal health coverage & social protection TB care widely accessible to all and of high-standards Focused, high-intensity interventions, including BCG in children Screening of high-risk groups and mass TLTBI Infection control practices However… while incidence decline can accelerate, “elimination” is another story, as it requires major reduction of: In turn, this requires…new tools and increased financing (i) transmission rate, and (ii) reactivation of latent infection among the already infected What is needed to accelerate incidence decline and target "elimination"?
  33. 33. What is in the pipelines for new diagnostics, drugs and vaccines in 2013? Diagnostics: ₋7 new diagnostics or diagnostic methods endorsed by WHO since 2007; ₋6 in development; ₋yet no PoC test envisaged Drugs: -2 new drugs approved in 2012 & 2013 for MDR-TB : little impact on epidemiology; -a regimen and other 2-3 drugs likely to be introduced in the next 4-7 years Vaccines: ₋11 vaccines in advanced phases of ₋development; ₋1 reported in 2012 with no detectable efficacy
  34. 34. Introduction AIMS: to describe • The evolution of the strategies to prevent and manage TB • The evolution of the concept of TB elimination • The new WHO Post-2015 Strategy and the concept of pre-elimination • The outcomes of a European ERS, WHO and ECDC survey evaluating European preparedness to reach elimination • The strategies to prevent and manage TB within the new TB Elimination framework for low TB incidence countries • An example of epidemic of XDR-TB in a major city, which summarizes the different issues discussed above.
  35. 35. 7 Core areas: 1. TB control commitment, TB awareness, and capacity of health systems 2. Surveillance 3. Laboratory services 4. Prompt, quality TB care for all 5. M/XDR-TB and TB/HIV co- infection 6. New tools 7. Partnership and collaboration
  36. 36. ACKNOWLEDGMENTS COUNTRY RESPONDENTS ALBANIA Hasan Hafizi BELGIUM Maryse Wanlin, Wouter Arrazola de Onate, Guido Groenen CROATIA Vera Katalinić Janković, Alexander Simunovic CZECH REPUBLIC Jiri Wallenfels DENMARK Peter Henrik Andersen ESTONIA Piret Viiklepp, Manfred Danilovits, Tiina Kummik FINLAND Petri Ruutu FRANCE Thierry. M. Comolet GERMANY Walter Haas GREECE Mina Gaga HUNGARY Zsofia Pusztai IRELAND Joan O Donnell ISRAEL Daniel Chemtob ITALY Enrico Girardi KOSOVO-UNIMIK Rukije Mehmeti LATVIA Vija Riekstina MALTA Analita Pace Asciak NORWAY Trude M Arnesen POLAND Ewa Augustynowicz-Kopeć PORTUGAL Raquel Duarte, Ana Maria Correia R. OF MACEDONIA Stefan Talevski ROMANIA Gilda Popescu, Domnica Chiotan SERBIA Gordana Radosavljevic Asic SLOVAKIA Ivan Solovic SLOVENIA Marijan Ivanuša SPAIN Elena Rodríguez Valín SWEDEN Jerker Jonsson SWITZERLAND Peter Helbling, Jean Pierre Zellweger THE NETHERLANDS Gerard de Vries, Connie Erkens UK Laura Anderson,Ian Laurenson
  37. 37. EUROPE HOW FAR TO REACH ELIMINATION? EU LOW / MIDDLE TB INCIDENCE COUNTRIES ITALY 10 (33%) No TB Elimination plan NO 7 (23%) No TB elimination guideline NO 15 (50%) No HRD plan NO 10 (33%) No TB Reference centres YES 16 (53%) No TB budget NO 11 (37%) No supervision NO 25 (87%) No modelling NO 5 (17%) No NRL performing all F/SLD DST YES 4 (13%) No free access for all TB cases YES 20 (67%) No all F/SLD NO 10 (33%) Drugs stock-outs NO 10 (33%) No TB/HIV collab. activities NO 13 (43%) Hospital-based MDR-TB care YES 21 (70%) No strategy to introduce new tools NO 21 (70%) No international collaboration for TB control/elimination NO 10 (33%) No TB Consilium NO
  38. 38. INCIDENCE DECLINE: TECHNOLOGICAL BREAKTHROUGH BY 2025 ADDRESSING THE POOL OF LATENT INFECTION Business as usual Optimize current tools, ensure UHC and SP New tools: vaccine, prophylaxis Average -10%/year -5%/year -2%/year Average - 17%/year GLOBAL TB PROGRAMME
  39. 39. Introduction AIMS: to describe • The evolution of the strategies to prevent and manage TB • The evolution of the concept of TB elimination • The new WHO Post-2015 Strategy and the concept of pre-elimination • The outcomes of a European ERS, WHO and ECDC survey evaluating European preparedness to reach elimination • The strategies to prevent and manage TB within the new TB Elimination framework for low TB incidence countries • An example of epidemic of XDR-TB in a major city, which summarizes the different issues discussed above.
  40. 40. TB Elimination: from Wolfheze to Rome THANK Rome 4-5 July 2014 Wolfheze, May 1990
  41. 41. WHO/ERS SUMMIT ON TB Rome July 4th-5th 2014 Elimination of TB in low incidence countries • New WHO/ERS Framework launched on Sunday (Room AZ-4 h. 12.45) • Summary report published in the ERJ • Unprecedent media coverage:187 cuttings, in 11 countries, > 500,000 page views every months
  42. 42. Generalised (with social gradient) Important community transmission Many incident cases from recent transmission Relatively high burden among young people Dominant public health problem Poorly resourced health systems Low incidence High incidence Epidemiological characteristics Highly concentrated to risk groups Close to elimination in large parts of the population Low transmission Outbreaks in special groups LTBI relatively more important Migration impact Stronger health system but less TB visibility
  43. 43. ACTION FRAMEWORK 8 PRIORITY ACTIONS FOR ELIMINATION IN LOW-INCIDENCE COUNTRIES Invest in research and new tools Optimize the prevention and care of drug-resistant TB Address special needs of migrants and cross-border issues Address the most vulnerable and hard- to-reach groups Support global TB prevention, care and control Ensure continued surveillance, programme monitoring & evaluation , and case-based data management Undertake screening for active TB and latent TB infection in TB contacts and selected high-risk groups, and provide appropriate treatment Ensure political commitment, funding and stewardship for planning and essential services of high quality
  44. 44. OBSERVED VS. REQUIRED ANNUAL RATE OF CHANGE TO REACH TB ELIMINATION BY 2035 IN LOW-INCIDENCE COUNTRIES.
  45. 45. OBSERVED VS. REQUIRED ANNUAL RATE OF CHANGE TO REACH TB ELIMINATION BY 2050 IN LOW-INCIDENCE COUNTRIES.
  46. 46. PROJECTED INCIDENCE RATES IN LOW- INCIDENCE COUNTRIES IN 2035 CONSIDERING A DECLINE OF 90% BETWEEN 2015 AND 2035.
  47. 47. -5 5 15 25 35 45 55 65 75 85 95 105 115 125 135 145 155 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 All SS+ cases SS+ Cypriots SS+ Foreign Born All TB per 1,000,000 pop 1 Case per million TB Elimination is possible: the case of Cyprus (ERJ 2014)
  48. 48. Introduction AIMS: to describe • The evolution of the strategies to prevent and manage TB • The evolution of the concept of TB elimination • The new WHO Post-2015 Strategy and the concept of pre-elimination • The outcomes of a European ERS, WHO and ECDC survey evaluating European preparedness to reach elimination • The strategies to prevent and manage TB within the new TB Elimination framework for low TB incidence countries • An example of epidemic of XDR-TB in a major city, which summarizes the different issues discussed above.
  49. 49. L’UNDICENNE È IN ISOLAMENTO ALLA CLINICA DE MARCHI Casi di Tbc a Milano, iniziata la terapia sul ragazzino con forma multiresistente Esposito (Sitip): casi pediatrici del genere mai riscontrati negli ultimi 30 anni. Terapia sperimentale con 5 farmaci Preoccupano i casi di tubercolosi a Milano. Sette quelli resi noti negli ultimi giorni: tre bambini di una scuola media, due di una scuola elementare della zona nord-est (asintomatici) e due studenti stranieri della facoltà di Scienze politiche dell’Università Statale. A far scattare l’allarme è stato un bambino italiano di 11 anni che frequenta la scuola media. «È arrivato da noi per un problema apparentemente di otorinolaringoiatra, ma le sue condizioni generali e il quadro respiratorio ci hanno insospettito. Subito abbiamo pensato alla tubercolosi e la diagnosi è stata confermata» spiega Susanna Esposito, direttore della Clinica Pediatrica I dell’Ospedale Maggiore Policlinico di Milano e presidente della Società Italiana di Infettivologia Pediatrica (SITIP). Il bambino, ricoverato nella clinica De Marchi, «è affetto da un ceppo multiresistente, chiamato XDR, caratterizzato da una resistenza allargata a un vasto numero di farmaci - chiarisce Esposito -. Si tratta di un ceppo molto raro e difficile da trattare che abitualmente non colpisce soggetti in età pediatrica, né quelli perfettamente immunocompetenti o senza patologie di base Corriere della Sera 31/10/2011
  50. 50. Index case FAMILY Male, 12 years Laryngeal + PTB Long diagnostic delay Direct Sputun examination +++ Resistant to SHREZ+FQ+Inj+Eto Haarlem strain Mother, TST+, QF+ PTB, immigrant, histopathology+, CXR improved Cat 1 21 classmates tested: 1 monolateral pleurisy (immigrant) 10 TST+, QF+ (7 native, 3 immigrant) 2 dental hygienists tested: 2TST+, QF+ 56 playmates tested: 3 TST+, QF- (BCG vaccinated) 24 students tested in parallel class performing common activities: 1 TST+, QF+ 1TST+, QF- 57 students tested in other classes: 1TST+, QF+ 13 TST+, QF- TB disease TST+, QF+ TST+, QF - 18 school staff tested: 4TST+, QF+ 5TST+, QF- Sister 6 yrs, PTB Brother 10 yrs, PTB Father, TST-, QF- 19 school canteen staff tested: 3 TST+, QF - 37 educators tested: 1 TST+, QF- Summer camp circle 27 tested: All TST-, QF- Sport related circle Catechism related circle 50 tested: 1 TST+, QF+ 4 TST+, QF- Other contacts
  51. 51. TREATING M/XDR-TB IS DIFFICULT www.tbconsilium.org
  52. 52. ERS/WHO Consilium for M/XDR-TB Objectives: To allow a European clinician, free cost, to load patient’s data and receive in 1 working day suggestions by 2 experts on how to manage a difficult-to treat TB case To support follow-up of TB patients travelling within Europe Web-based regional platform Specialized team able to cover several perspectives:(clinical for both adults and children, surgical, radiological, public health, psychological, nursing, etc. Managed by ERS, in collaboration with WHO Europe (formal agreement) and ECDC
  53. 53. The web platform www.tbconsilium.org • Now in ENG. RUS, SPA, PORT (FREN) • Hosted in Switzerland (-> Swiss regulation) • 4 processes supported + 2 in preparation: o “Consilium” (get experts advice on cases in24-36 hrs) o Trans border cases (send a case to a National TB Project Representative) o M&E of guidelines implementation o Expert opinion for compassionate use o Patient’s track o LTBI management • Next steps: « Drug-O-Gram » plug in
  54. 54. www.tbconsilium.org
  55. 55. Conclusions • 1. While TB Elimination was considered an advocacy tool for >20 years, there is epidimiological plausibility • 2. The majority of low TB incidence counries is on track to reach pre-elimination by 2035 (2050) and scale-up elimination thereafter • 3. Among the conditions to reach TB elimination: - new vaccine, new point-of-care/rapid test, new effective short regimens to treat TB and LTBI - Sound health policies beyond NTP
  56. 56. ERS Conference, Munich, September 2014: the launch
  57. 57. THANK YOU !

×