Tuberculosis (TB) has affected humans for millennia and has been one of the greatest plagues in history, killing over 100 million people in the last century alone. Significant advances in understanding and treating TB have been made over the past 200 years, including the discovery of the bacteria that causes TB by Robert Koch in 1882, the development of antibiotics and drug regimens in the 1940s-1950s, and the World Health Organization's Directly Observed Treatment, Short-course strategy in the 1990s which helped lower global TB rates. However, TB remains a major global health problem and the WHO aims to continue efforts to further reduce the worldwide burden of the disease.

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3. Dr. Ashraf El Adawy
Consultant Chest Physician
TB TEAM EXPERT - WHO

4. TUBERCULOSIS...
●The greatest killer of all time...
●The captain of all the men of death...
●Over the last century, TB has killed more than 100 million people.

5. TB was a death sentence for many

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One in four died of the disease in 1800, and by the late 1890's it was still one in seven.
Until the early twentieth century it was the greatest killer of all.

8. Among the communicable disease, TB is the second leading cause of death world wide after HIV/ AIDS (cleveland clinic 2008)
TB is one of the top 3 killer diseases world-wide along with HIV & malaria.

9.  “If the importance of a disease for mankind is measured by the number of fatalities it causes, then tuberculosis must be considered much more important than those most feared infectious diseases”
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Robert Koch, March 24, 1882

10. Many names……0ne disease
●Consumption
●Phthisis
●Pott's disease
●White Plague are all terms used to refer to TB throughout history.

11. Earlier TB has been called by numerous names
1.Consumption (because of the severe weight loss and the way the infection appeared to “consume” the patient),
2.Phthisis pulmonaris
3.White death (or white plague) because of the extreme pallor seen among those infected.
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12. TB has affected humans for millennia
Tuberculosis has been known to mankind since ancient times.
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14. The depictions of a gibbus in statuettes of Ancient Egyptian and pre-Columbian origin represents clear evidence of spinal TB.

15. It describes a pulmonary consumption associated with the cervical lymph nodes. It recommended that it be treated with the surgical lancing of the cyst and the application of a ground mixture of acacia seyal, peas, fruits, animal blood, insect blood, honey and salt.
The Ebers Papyrus, also known as Papyrus Ebers, is an Egyptian medical papyrus dating to circa 1550 BC. Among the oldest and most important medical papyri of ancient Egypt, it was purchased at Luxor, (Thebes) in the winter of 1873–74 by Georg Ebers. It is currently kept at the library of the University of Leipzig, in Germany
The Ebers Papyrus

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17. Akhenaten and his wife Nefertiti both died from tuberculosis
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18. 460 BC
Hippocrates identifies phtisis (greek word meaning "consumption") as the most widespread disease of the times and notes that is almost always fatal.

19. Aristotle (384–322 BC), believed phthisis to be contagious even though general opinion at the time tended to the alternative theory that the disease was hereditary.

20. Ebn Sina
The Famous Arab Scientist (980-1037)
in his book “Al-Kanoun”
describedtuberculosis (Al-Sol) in details.

21. Although it was a prevalent killer, humans did not begin to notice and study this disease until Ibn Sina wrote “The Cannon of Medicine” in the 1020s
Ibn Sina, was the first to note that pulmonary TB was a communicable disease thereby requiring a method of quarantine to limit its spread.
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22. Tuberculosis in the Middle ages
Evidence of tuberculosis of the cervical lymph nodes or lymph nodes of the neck termed scrofula is found in the Middle ages.
 It was termed as the “king’s evil” and was widely believed that the kings of England and France could cure scrofula simply by touching those affected
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23. Royal Touch
Henry IV of France touching numerous sickly individuals during the ceremony of the "royal touch"

24. Mycobacterium tuberculosis (MTB) was the cause of the "White Plague" of the 17th and 18th centuries in Europe.
 During this period nearly 25 percent of all adult deaths were caused by MTB
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25. The White Death: A History of Tuberculosis
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26. The scientific advances
One of the most important physicians was René Laennec, (1781-1826). who died from the disease at the age of 45, after contracting tuberculosis while studying contagious patients and infected bodies. Laennec invented the stethoscope in 1816
Rene Laennec
(1781-1826)

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28. In 1834
In 1834, Johann Lukas Schönlein of Würzburg (1793–1864) coined the term ‘tuberculosis’ to describe affliction with tubercles.

29. Brehmer was diagnosed with tuberculosis and told to find a healthier climate.
He went to the Himalayas, continued his studies, and found himself cured.
 In 1854 he returned to Germany to study medicine, ultimately writing a dissertation titled "Tuberculosis is a Curable Disease".[
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1854 Hermann Brehmer

30. 1854 Hermann Brehmer
German Botanist
Dissertation (TB is a curable disease)
Established first sanatorium in Germany
Beginning of sanatorium era

31. TB R/ in the pre-antibiotica era.
Before the discovery of effective anti-tuberculosis drugs, (R/) of TB was mainly Conservative, directed at relief of symptoms, with attention to lifestyle
Patients followed a regimen of bed rest, open air, and sunshine

32. 1859
Hermann Brehmer . Establishes the first sanatorium at Goerbersdorf in Silesia.

33. Typical set-up of the TB patients spontaneously
recovered from TB (left: male ward; right: female
ward) in the fresh mountain air at the Swiss Alpine
Clinic (Heiligenschwendi, 1900)

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37. Cases were treated at home, in sanatoria and / or in hospitals. Results of R/ were poor, only 25% of subjects with open TB had sputum conversion after 2- 6 months of sanatorium R/..
50% of all new smear positive cases died within 5 years, the other 50% survived with varying degrees of morbidity.
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TB R/ in the pre-antibiotica era.

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Many referred to the disease as the “Romantic disease.“ Pulmonary TB was romanticized in the arts and music of the 19th century

39. Dumas's La Dame aux camélias
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40. Hugo's Les Misérables
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41. In 1882: Discovery of the causative agent
On March 24, 1882, Dr. Robert Koch ,a German scientist announced the discovery of Mycobacterium tuberculosis, the bacteria that cause TB.

42. Robert Koch was awarded the Nobel Prize in medicine in 1905.
In 1982, a century after Dr. Koch’s announcement, the first world TB day was sponsored by the WHO &IUATLD
World TB Day is held on March 24 each year in commemoration of Koch’s discovery
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44. 1895: X Ray
Wilhelm Konrad von Roentgen
Discovered the radiation that bears his name. With this discovery, it was now possible to follow and accurately review the progress and severity of a patient's disease.

45. 1890 Robert Koch . Introduces tuberculin.

46. By Calmette and Guérin, 1906-1921
Invention of BCG Vaccine

47. No New TB Vaccine in > 90 Years
BCG developed in 1921

48. 1944 onwards Start of the Chemotherapy era

49. 1944
Waksman, Schatz and Bugie . Discovered streptomycin, the first effective antibiotic against tuberculosis.
Streptomycin purified from Streptomyces griseus was first administered to a human on November 20, 1944.

50. NOBEL PRIZE MEDICINE 1952 / SELMAN WAKSMAN
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51. History of anti-TB drugs
1944 STREPTOMYCIN
1949 P A S
1952 ISONIAZID
1954 PYRIZINAMIDE
1955 CYCLOSERINE
1962 ETHAMBUTOL
1963 RIFAMPICIN

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Breakthrough in the Fight Against TB
Drugs that could kill TB bacteria were discoveredin 1940s and 1950s
Streptomycin (SM) discovered in 1943
Isoniazid (INH) and p-aminosalicylic acid (PAS) discovered between 1943 and 1952

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54. Sir John Crofton Leading figure in respiratory medicine and the treatment of tuberculosis
1960
Dr John Crofton, a TB expert, proposed that a combination of drugs — Streptomycin, PAS and Isoniazid — made TB completely curable and declared "all out war" to conquer the disease.
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55. 1950 -1980
Progressive decline in TB incidence in the industrialized countries
1980s – 1990s
The AIDS epidemic has serious repercussions on TB epidemiology, increasing the incidence of TB both in industrialized countries and in developing countries.
Multi drug resistance poses increasing problems with regard to the efficacy of the therapy in use

56. Module 2 – Epidemiology of
Tuberculosis
10,000
12,000
14,000
16,000
18,000
20,000
22,000
24,000
26,000
28,000
1982 1986 1990 1994 1998 2002 2008
20% increase
No. of Cases
Reported TB Cases, U.S., 1982-2008
Year
U.S. TB Resurgence
1986 - 1992
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57. Module 1 – Transmission and Pathogenesis of Tuberculosis
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TB Resurgence
Increase in TB in mid 1980s
Contributing factors:
1.Inadequate funding for TB control programs
2.HIV epidemic
3.Increased immigration from countries where TB is common
4.Spread in homeless shelters and correctional facilities
5.Increase and spread of multidrug-resistant TB
March 16, 1992 Newsweek Magazine Cover

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59. The Global Emergency
In 1993, The World Health Organization declares TB a global emergency, estimating that one third of the world's population (2 billion people) is latently infected with TB and 8-9 million cases of active TB occur each year.
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60. The Directly Observed Treatment Short-course (DOTS) Strategy was developed as a response to the global emergency
Directly Observed Therapy Short Course (DOTS) strategy recommended by WHO and introduced to endemic countries.
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61. oDOTS is the internationally recommended strategy to control TB developed in 1995(WHO global strategy) .
oDOTS has been described by the World Bank as “one of the most cost-effective of all health interventions.”
oDOTS has been implemented in 184 countries.

62. Implementation of DOTS, 2006
184 countries (out of 212)
> 90%pop
low incidence, non-DOTS
10 - 90% pop
No report
non-DOTS
Implementation of DOTS

63. TB Control: The 5 components of DOTS
TB Register
Political commitment
Diagnosis by microscopy
Adequate supply of SCC drugs
Directly observed treatment
Accountability

64. World Health Assembly 1991
" The objectives of TB control as adopted by the (WHA)are to attain a global target of cure of 85% sputum-positive patients under treatment and detection of 70% of cases by the year 2000"

65. “The growing tuberculosis epidemic is no longer an emergency only for those who care about health, but for those who care about justice”
(World Health Organization. TB - A global emergency. Geneva WHO 1994)

67. Global control of TB is a leading public health priority

68. The Global Targets
We have clear and measurable targets to fight TB:
Detection and cure through DOTS.
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85
0
10
20
30
40
50
60
70
80
90
100
DETECTION TREATMENT SUCCESS
DETECTION AND CURE TARGETS FOR 2005 in %
DETECTION TREATMENT SUCCESS
•Targets set for 2000; later postponed to 2005.

69. Status Of DOTS Implementation
70
32
85 80
0
20
40
60
80
100
Detection Target Detent ion Achieved Treatment success
Target
Treatment Success
Achieved
ACHIEVED vs. TARGET
Limits to case detection under DOTS
Detecting new cases is the main PROBLEM


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70. 0
10
20
30
40
50
60
70
80
90
100
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
•Case detection rate or cure rate (%)
Target cure 85%
Target detection 70%
Case detection rate 2004: 53% Cure rate 2003: 83%

72. The final push to 70% case detection?
0
10
20
30
40
50
60
70
80
1990 1995 2000 2005 2010 2015
Year
Case detection DOTS, smear+
cases (%)
average rate of
progress 1995-2000
accelerated progress
to 2005 target
WHO target 70%
As DOTS coverage & cure rates are high, finding TB cases
is now the priority area for TB control

73. A major obstacle in the fight to STOP TB is the rate of case detection.
WE MUST ACCELERATE TB DETECTION RATES!
DOTS is not the final solution to the TB crisis.

74. From DOTS to the Stop TB Strategy
Building on Achievements for Future Planning
Stop TB Partnership Symposium at the 37th UNION World Conference on TB and Lung Disease
31st October 2006, Paris

75. Stop TB Strategy to reach the 2015 MDGs
• Vision: A WORLD FREE OF TB • Goal:To dramatically reduce the global burden of TB by 2015 in line with the MDGs and the Stop TB Partnership targets

76. Global TB control targets
2005: World Health Assembly:
- To detect at least 70% of infectious TB cases
- To treat successfully at least 85% of detected cases
2015: 50% reduction in TB prevalence and death rates by 2015 2050 world free of TB
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: prevalence and deaths associated with TB
Indicator 24: proportion of TB cases detected
and cured under DOTS

79. The Practical Approach to Lung health (PAL) is a syndromic approach to the management of patients who attend primary health care services for respiratory symptoms
Patients over the age of 5 years attending primary health care (PHC) settings seek health care for respiratory symptoms.

80. The PAL strategy
Rationale
25-33% of patients go to PHC for respiratory diseases
Primary care is weak and TB suspects are not identified
Respiratory care should be standardized, co-ordinated, and cost-effective, as in DOTS and IMCI
Solution
Standardized syndromic guidelines for diagnosis and treatment
Coordinated referral mechanisms between levels

81. PAL strategy
Standardization of health care procedures
Coordination between health care levels
 Focus on priority respiratory diseases > 5 yrs:
+ TB
+ ARI (pneumonia)
+ CRDs (asthma, COPD)

82. PAL helps detecting TB cases, among patients with respiratory symptoms within PHC settings and improves the quality of TB diagnoses through the appropriate management of patients with respiratory symptoms.
PAL contributes to improving the quality of health care
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83. TB

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85. The TB mortality rate has decreased 41% since 1990.
No country has ever eliminated this disease.
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86. The World Health Organisation estimates that 20 million lives have been saved from TB in the past two decades as a result of global efforts to fight TB. This is good news, but there is still much to be done. Every day, 24,000 people fall ill with TB, and 3,836 people die - despite the fact that TB is curable.
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88. WHO Global TB Report, 2012
8.7 million new cases of TB in 2011 1.4 million deaths in 2011 0.5 million MDR-TB cases TB is the biggest infectious killer among people infected with HIV TB is one of the top killers of women worldwide, half a million women died from TB in 2011.

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91. Czech Rep.
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 WHO 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 2005. All rights reserved
Ecuador
Georgia
Argentina
Bangladesh
Germany
Rep of Korea
Armenia
Russian Fed.
South Africa
Portugal
Latvia
Mexico
Peru
USA
Brazil
UK
Sweden
Thailand
Chile
Based on information provided to WHO Stop TB Department - June 2008
Spain
China, Hong Kong SAR
France
Japan
Norway
Canada
Italy
Netherlands
Estonia
Lithuania
Ireland
Romania
Israel
Azerbaijan
Poland
Slovenia
India
Australia
Mozambique
Vietnam
Countries with XDR-TB confirmed cases as of June 2008
Ukraine
Moldova
Philippines
Botswana
Nepal
Islamic Rep. of Iran
Lesotho
Swaziland
Namibia