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
PDF file of National Strategic Plan for Elimination of TB ( 2017-2025).
World Tb them for 24 march 2017 is continuation of "unite to end TB(2016)....that is "leave no one Behind"
Presentation delivered by Dr Masoud Dara, Programme Manager a.i., Tuberculosis and multidrug-resistant tuberculosis, Division of Communicable Diseases, Health Security and Environment at the 65th session of the WHO Regional Committee for Europe (Vilnius, Lithuania, 14–17 September 2015)
PDF file of National Strategic Plan for Elimination of TB ( 2017-2025).
World Tb them for 24 march 2017 is continuation of "unite to end TB(2016)....that is "leave no one Behind"
Presentation delivered by Dr Masoud Dara, Programme Manager a.i., Tuberculosis and multidrug-resistant tuberculosis, Division of Communicable Diseases, Health Security and Environment at the 65th session of the WHO Regional Committee for Europe (Vilnius, Lithuania, 14–17 September 2015)
Designing vaccines for specific populations and germs - Slides by Professor E...WAidid
The presentation given by Professor Susanna Esposito at ECCMID 2019. A view on vaccines recommendations, combined vaccinations and impact of vaccination practices in the eradication of major infectious diseases.
To learn more, please visit www.waidid.org
Influenza vaccination and prevention of antimicrobial resistance - Slides by ...WAidid
The lecture presented by Professor Susanna Esposito at AMR 2019 on influenza vaccination and abuse of available antimicrobials.
To learn more, please visit www.waidid.org.
POINT-of-IMPACT testing. A European perspective - Bert NiestersWAidid
At SoGat meeting 2019 Bert Niesters - Professor in Molecular Diagnostic in Clinical Virology, Medical Molecular Microbiologist at University Medical Center Groningen, Department of Medical Microbiology, Division of Clinical Viroloy, The Netherlands - has talked about the developing trends in molecular diagnostics and the impact on the Laboratory.
To learn more, please visit www.waidid.org!
Measles and its prevention - Slideset by professor EdwardsWAidid
In this study Professor Kathryn M. Edwards (Sarah H. Sell and Cornelius Vanderbilt Professor - Division of Pediatric Infectious Diseases - Vanderbilt University Medical Center) provides an update on measles and its prevention.
To learn more, please visit www.waidid.org!
Is the use of antibiotics necessary in the treatment of diarrhoea?WAidid
Slide set presented by professors Per Ashorn (Finland) and Miguel O'Ryan (Chile) at the International Pediatric Association Congress in Panamá City, on March 18th.
To learn more, please visit www.waidid.org!
Are we running out of antibiotics? - Slideset by Professor EspositoWAidid
How does antibiotic resistance happen?
This work, edited by the professor Susanna Esposito, tries to answer this question underlining the importance of prescribing the right drug with the right dose and duration, to avoid any kind of abuse that may cause or increase antibiotic resistance.
To learn more please visit www.waidid.org
Mandatory vaccinations: the italian experience - Slideset by Professor EspositoWAidid
Every year 2.5 million lives are saved by vaccines. In this slideset Professor Susanna Esposito gives an overview on the vaccine coverage in Italy, including the latest laws on mandatory and recommended vaccines.
To learn more please visit www.waidid.org
Efficacy differences between PCV10 and PCV13 - Slideset by Professors Esposit...WAidid
This slideset edited by Professors Esposito, Palmu, De Wals and Sanders for the Second WAidid Congress present some studies that compare in different countries (including Finland, Sweden, Quebec and the Netherlands) efficacy differences between PCV10 and PCV13.
To learn more please visit www.waidid.org
Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...WAidid
«The first cause of recurrent infections in children is... childhood itself.» (J. Gary Wheeler)
Is it possibe to treat and prevent recurrent respiratory infections (RTIs) in pediatric age? Some studies have shown that immunostimulants/immunomodulators can reduce and prevent RTIs in children.
To learn more please visit www.waidid.org
The importance of pertussis booster vaccine doses throughout life - Slideset ...WAidid
Pertussis is still a worldwide problem: every year there are almost 20-50 million cases and 300.000 deaths.
The incidence is increasing especially between adults and adolescents, with consequences on infants. For this reason, the increasing of a vaccination strategy for adolescent and adult is needed...
To learn more, please visit www.waidid.org.
Vaccination in immunosuppressed adults - Slideset by professor Katie FlanaganWAidid
Immune compromised persons are generally at increased risk of morbidity and mortality from many vaccine preventable diseases, but since many vaccines, especially the live ones, are contraindicated in many immunocompromising situations, the degree of patients' impairment should be assessed each time in order to determine the best vaccination strategy...
To learn more, please visit www.waidid.org.
Potential advantages of booster containing PCV regimen - Professor Shabir MadhiWAidid
This slideset, realized by Professor Shabir Madhi on the occasion of the 11th ISPPD held in Melbourne last April, evaluates the potential advantages of booster containing PCV dosing schedule.
To learn more, visit www.waidid.org!
Lymphogranuloma venereum - Professor Ivan HungWAidid
In the following slides, professor Ivan Hung (WAidid board member) report a case of Lymphogranuloma Venereum and a short review of its possible source of infection, in order not to understimate the risk of infections, mainly in promiscuous behavioural context.
To learn more, visit www.waidid.org.
Bacterial and bacterial-like sepsis in children - Susanna Esposito WAidid
How to detect and prevent bacterial and bacterial-like sepsis in children and adolescents? Professor Susanna Esposito presents in this slideset data on epidemiology, etiology and mortality rates of pediatrical sepsis, and then discusses the possible treatment and the more efficient way of preventing the burden of pediatric sepsis.
To learn more, visit www.waidid.org.
Guidelines on the management of cystic fibrosis in the adult - Professor Fran...WAidid
Forecasts for 2025 in 16 European countries indicate that the number of cystic fibrosis patients will increase by 50% and the number of CF adults will increase by 75%. The transition from a child service to an adult service is crucial, that's why - suggests Professor Blasi (Milan, Italy) in his slideset - there's a strong need to supply a continuing medical education to healthcare workers dealing with CF and to rethink more adequate structures.
To learn more, please visit www.waidid.org!
Katie Flanagan - Malaria vaccines current status and challengesWAidid
Vaccines are considered the most cost-effective means of control, prevention, elimination, eradication of infectious diseases: for this reason, a malaria vaccine would greatly assist in the drive to eradicate malaria from the world. Professor Flanagan presents in this slideset the current status and challenges of developing malaria vaccines.
To learn more, visit www.waidid.org!
New perspectives in the treatment of multidrug-resistant tuberculosis - Profe...WAidid
The slideset offers an overview of MDR-TB: the epidemiology, the efficacy of the available treatments, and the new perspectives in the management of the pathology.
The slideset underlines, moreover, the existence of a free cost online instrument developed by ERS together with WHO to help clinician from all Europe to manage difficult-to-treat TB cases: TB Consilium.
Indicators of acute otitis media severity - Prof. Tal MaromWAidid
The slideset of professor Marom investigates the possibility and ways to establish the severity of AOM and focuses on the differences between pneumococcal vs non-pneumococcal AOM.
FInd more on www.waidid.org
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Towards TB elimination - Giovanni Battista Migliori
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
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. 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.
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
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. 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. 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.
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
• 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
12. 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)
13. 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
14. 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
15.
16. 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.
17. WORLD HEALTH ASSEMBLY APPROVES POST-2015
GLOBAL TB STRATEGY AND TARGETS –
WHA TB RESOLUTION
18. ZERO
TB DEATHS
A WORLD FREE OF TB
Vision
ZERO
TB CASES
ZERO
TB SUFFERINGGLOBALTB
PROGRAMME
19. 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
20. 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
22. 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
23. 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
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
China, Cambodia
-4%/yr
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
W Europe after WWII
-10%/yr
27. 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:
28. 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
29. 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
30. Can TB control among Eskimos be generalised to
the world?
31. 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
32. 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.
33. 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
34. 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"?
35. 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
36. 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.
37. 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
38. 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
39. 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
40. 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
41. 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.
42. TB Elimination: from Wolfheze to Rome
THANK Rome 4-5 July 2014
Wolfheze, May 1990
43. 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
44. 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
45. 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
46. OBSERVED VS. REQUIRED ANNUAL RATE OF
CHANGE TO REACH TB ELIMINATION BY 2035
IN LOW-INCIDENCE COUNTRIES.
47. OBSERVED VS. REQUIRED ANNUAL RATE OF
CHANGE TO REACH TB ELIMINATION BY 2050
IN LOW-INCIDENCE COUNTRIES.
48. PROJECTED INCIDENCE RATES IN LOW-
INCIDENCE COUNTRIES IN 2035 CONSIDERING
A DECLINE OF 90% BETWEEN 2015 AND 2035.
49. -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)
50. 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.
51. 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
52. 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
54. 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
55. 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
58. 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