Tuberculosis (TB) is a deadly infectious disease affecting one-third of the world's population, with approximately 9.6 million cases and 1.5 million deaths reported in 2014. High-risk groups include economically disadvantaged individuals, immunocompromised persons, and those with inadequate access to healthcare. The WHO and UN have established strategies to drastically reduce TB incidence and mortality rates by 2030, emphasizing the need for ethical considerations in care and resource allocation.

1. TUBERCULOSIS (TB)
Lead: Dr Sharanya Rajan
Dr Shelly Coe
Amy Fornah
Anoosha Anoosha
Lourena Ferreira Mendes
Louise Hart
Marya Salhab 1
Public Health
Project

2. 1 - Introduction
● Tuberculosis (TB) is one of the world’s deadliest disease.
● One third of the world’s population is infected with TB.
● In 2014, 9.6 million people felt sick with TB worldwide and
there were 1.5 million TB deaths worldwide.
Source- (CDC,2014)
2

3. 2 - Identify public health problem
● Tuberculosis (TB), is an infectious disease caused by the bacillus Mycobacterium
tuberculosis complex: Mycobacterium tuberculosis, africanum, and bovis.
● Pulmonary TB or Extrapulmonary TB
● INFECTION — Inhalation of aerosol droplets containing M. tuberculosis with
subsequent deposition in the lungs.
● 5-15% of those infected with M. tuberculosis will develop TB in their lifetime
(HORSBURGH, 2016)
3

4. 3 - Scope/Extent of problem
● Tuberculosis has killed roughly 1 billion people in the past two centuries (Dheda, 2016);
● Estimated 10.4 million new (incidence) TB cases worldwide (WHO,2016);
● 0.47:0.67 female-to-male ratio of TB cases globally (WHO, 2015);
● Mortality fell by 22% between 2000-2015, however TB remains in the top 10 causes of
death worldwide (WHO,2016);
● In 2015, 480 000 new cases of multidrug-resistant (MDR-TB) tuberculosis were estimated
to have occurred worldwide (WHO,2016);
● US$ 6.6 billion spent on TB care and prevention on LMIC in 2016 (WHO,2016). 4

5. Ratio of female to male TB cases notified globally is 0.47:0.67 (WHO., 2015)
In 2015, of the 10.4 million new (incident) TB cases worldwide, 5.9 million (56%) were among men, 3.5 million
(34%) among women and 1.0 million (10%) among children. People living with HIV accounted for 1.2 million (11%)
of all new TB cases.
Table: Worldwide results of smear positive test in men and
women in 2004 (WHO, 2015)
5

6. 4 - Who is affected
Added slides- From slide 6 to 11
6

7. Who Is Affected By Tuberculosis ?
- High Risk Groups
1. Low Socioeconomic Population
2. Gender and Ethnicity
3. Immunocompromised Individuals
4. Children
5. Prisoners and Immigrants
6. Old History of Tuberculosis or Past History of
Inadequately treated Tuberculosis
7. Increased exposure to T.B infected individuals 7

8. Source- (WHO,2016)
8

9. Where are the people affected by TB located ?
-TB Endemic Regions/Areas
9

10. 2015 TB INCIDENCE RATES
10
(WHO, 2016)

11. (WHO, 2016) 11

12. 5 - Socio-economic determinants
● The population distribution of TB reflects the distribution of
these social determinants;
● Food insecurity and malnutrition;
● Poor housing and environmental conditions;
● Financial, geographic, and cultural barriers to health care
access;
● Financial impact;
12(Reid, S., 2012; Murray, E.,2013)

13. Socio-economic determinants
● Unemployment;
● TB is more prevalent in younger age-group between the ages of 18-47 years;
● Stigma;
● Improved socioeconomic conditions have been accompanied by a decline in the
tuberculosis burden;
● Investments in low and middle-income countries fall almost US$ 2 billion short
of the US$ 8.3 billion needed in 2016; this annual gap will widen in 2020
13
(WHO, 2016; Lawn,S, 2011)

14. Justification of
Importance
Marya Salhab
Shelly Coe
14

15. Curable Disease, Global Epidemic
● Leading cause of infectious death worldwide, especially in developing
countries.
● 2nd most common cause death of adults worldwide.
Economic Burden
● Huge financial costs for the people with TB, their families, and communities
● Drain on society’s resources due to treatment costs, patient costs, and
productivity losses
● The Global burden of TB is approximately $12 billion annually
Marya Salhab
Shelly Coe
JUSTIFICATION OF IMPORTANCE
15

16. WHO Priority
● Eradication of TB is included in the UN’s Millennium Development Goals
(MDGs) 2000-2015.
● The Sustainable Development Goals (SDGs) for 2030 superseded the MDGs in
2015, with SDG 3.3 focused on ending the epidemic of TB.
● WHO’s Stop TB Strategy, now the End TB Strategy for 2016-2035, calls for:
○ 90% reduction in TB deaths by 2030
○ 80% reduction in TB incidence by 2030
○ No TB-affected households to face catastrophic costs by 2020
○ The rate of decline in TB incidence to accelerate from 1.5% to 4 – 5% annually by 2020
Marya Salhab
Shelly Coe
JUSTIFICATION OF IMPORTANCE
16

17. TB disproportionately affects poor and vulnerable populations, ethical principles of
social justice and equity must be considered in the care of patients and control of
the disease to ensure balance of individual rights and liberties. (WHO, 2011)
Many of the moral and ethical issues raised by infectious diseases are related to
the diseases’ powerful ability to “engender fear in individuals and panic in
populations.” This fear can become a principal force in clinical and public health
decision-making, leading to ethical issues concerning just distribution of resources
and human rights. (Smith et al, 2004)
MORAL AND ETHICAL CONSIDERATIONS
Marya Salhab
Shelly Coe
17

18. ● Governments have a responsibility to provide free TB Care
● Patients need to be fully informed and counselled about their treatment
● Health care providers have an obligation to support patients to complete
therapy
● Health care workers have obligations to provide care, but also a right to
adequate protection
● Involuntary isolation should never be a routine component of TB programmes
● Research on TB is necessary and should be conducted in an ethical manner
● The Current one-size fits all treatment interventions (DOTS)
ISSUES
Marya Salhab
Shelly Coe
(WHO, 2014)18

19. Updated guidance from WHO emphasized a deeper
focus on ethical issues related to:
● Pediatric TB
● TB treatment in prisons
● TB and migration
● Suboptimal treatment of MDR and XDR TB
Promote the use of non-stigmatizing language
In 2015, the Stop TB Partnership launched United to End
TB: Every Word Counts which addressed the role of
language in TB stigma.
● First language guide for TB partners and stakeholders
● Supports the Global End TB Strategy 2016-2035
Stigma Contagion, defect, disability
Marya Salhab
Shelly Coe (Frick, 2015)
19

20. Interventions
20

21. 21

22. TYPES OF INTERVENTIONS
TB interventions could include focussing on:
- Preventing infection
- Halting progression from infection to active disease
- Treating active disease
- Addressing underlying systematic TB factors
Two examples of TB interventions
- Vaccination programmes
- DOTS strategy
22

23. TB Vaccinations
23

24. DOTS
24

25. TB Vaccinations: Advantages
● Helps reduce infection rates
● Also reduces risk for those infected from developing active disease
● High protective efficacy against serious forms of disease in children
● Estimated averts one case of meningeal TB in the first 5 years of life per
3435 vaccinated children and one case of miliary TB for every 9314
vaccinations
● Cost effectiveness of intervention - costs $40-170 per DALYS gained
25

26. TB Vaccinations: Limitations and Challenges
● Efficacy
● Restricted use
● Health system requirements
● Logistical challenges
● Community concerns
● Effect on skin tests
26

27. DOTS: Advantages
● Efficacy
● Improved completion rates
● Cost-effectiveness
● Flexibility
● Face to Face support
Source: WHO 2004 in Focus
27

28. DOTS: Limitations and Challenges
● Resourcing
● Patient inconvenience
● Stigma
● Non-compliance
● Suitability for context
● Suitability for complex cases
● Not tackling root causes
28

29. Conclusion
29

30. “Countries are failing to diagnose and
treat millions of people with TB.
Governments need to get their heads out
of the sand and realize that TB is not a
disease consigned to the 1800s; we see
and treat TB in our clinics every day, and
it's a deadly threat to all of us.”
The governments are mainly failing
because of shortage of funding.
- WHO TB control leader
30

31. References
Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health.
Geneva, Switzerland: WHO, 2008. http://whqlibdoc.who.int/publications/2008/9789241563703_ eng.pdf Accessed October 20, 2016
FRICK, M.W., 2015. Ethical Considerations in TB. San Antonio, TX: Heartland National TB Center.
HORSBURGH, R.C., Sep 29, 2016, 2016-last update, Epidemiology of tuberculosis [Homepage of UpToDate], [Online]. Available:
www.uptodate.com.
Lönnroth K, Jaramillo E, Williams B, Dye C, Raviglione M. Tuberculosis: the role of risk factors and social determinants. In: Blas E, Sivasankara
Kurup A, eds. Equity, social determinants and public health programmes. Geneva, Switzerland: WHO, 2010: pp 219–241.
SMITH, C.B., BATTIN, M.P., JACOBSON, J.A., FRANCIS, L.P., BOTKIN, J.R., ASPLUND, E.P., DOMEK, G.J. and HAWKINS, B., 2004. Are there
Characteristics of Infectious Diseases that Raise Special Ethical Issues? Developing World Bioethics, 4(1), pp. 1-16.
STOP TB PARTNERSHIP, November 4, 2015, 2015-last update, TB language guide: ‘United to End TB: Every Word Counts’ [Homepage
of TB Online, Global Tuberculosis Community Advisory Board], [Online]. Available: http://www.tbonline.info/posts/2015/11/4/tb-language-
guide-united-end-tb-every-word-counts/ Accessed [11/06, 2016].
31

32. References
WHO, 2016-last update, Trade, foreign policy, diplomacy and health: Tuberculosis control [Homepage of WHO], [Online]. Available:
http://www.who.int/trade/distance_learning/gpgh/gpgh3/en/index7.html Accessed [11/11, 2016].
WHO, 2016-last update, Tuberculosis (TB): Addressing the needs of vulnerable populations [Homepage of WHO], [Online]. Available:
http://www.who.int/tb/areas-of-work/population-groups/en/ Accessed [11/06, 2016].
WHO, 2016-last update, Tuberculosis (TB): Childhood TB [Homepage of WHO], [Online]. Available: http://www.who.int/tb/areas-of-
work/children/en/ Accessed [11/06, 2016].
WHO, March 22, 2016, 2016-last update, WHO calls on countries and partners to "Unite to End Tuberculosis" [Homepage of WHO],
[Online]. Available: http://who.int/mediacentre/news/statements/2016/tb-day/en/ [11/06, 2016].
WHO, 2014. ETHICAL ISSUES IN TUBERCULOSIS PREVENTION, CARE AND CONTROL. WHO’s Department of Knowledge, Ethics, and Research
(KER) and the Global TB Programme (GTB).
WHO, 2011. ETHICAL ISSUES IN TUBERCULOSIS PREVENTION, CARE AND CONTROL. WHO.
WHO, 2010. Guidance on ethics of tuberculosis prevention, care and control. Switzerland: WHO.
32

33. REFERENCES
Amo-Adjei, J., Kumi-Kyereme, A., Fosuah-Amo, H. and Awusabo-Asare, K. (2014) 'The politics of tuberculosis and HIV service integration
in Ghana.', Social Science and Medicine, 117 .
Arnold, A. (2016) 'XDR-TB transmission in London: Case management and contact tracing investigation assisted by early whole
genome sequencing', The Journal of infection, 73 (3), .
Bell, C., Duncan, G., Eang, R. and Saini, B. (2015) '
Stakeholder Perceptions of a Pharmacy-Initiated Tuberculosis Referral Program in Cambodia, 2005-2012', Asia-Pacific Journal of Public
Health, 27 (2), .
Berzkalns, A., Bates, J., Ye, W., Mukasa, L., France, A., Patil, N. and Yang, Z. (2014) 'The road to tuberculosis (Mycobacterium tuberculosis)
elimination in Arkansas; a re-examination of risk groups', Public Library of Science, 9 .
Brimnes, N. (1982) 'BCG vaccination and WHO's global strategy for tuberculosis control 1948–1983', Social science & medicine, 67
(5), pp.863.
Chiang, C., Van Weezenbeek, C. and Mori, T. (2013) 'Challenges to the global control of tuberculosis', Respirology, 18 (4), .
D'Ambrosio, L., Centis, R., Sotgiu, G., Pontali, E., Spanevello, A. and Migliori, G. (2015) 'New anti-tuberculosis drugs and regimens: 2015
update', ERS Monograph, .
Dheda, K. (2016) 'Tuberculosis', The Lancet, 387 (10024), pp.1211.
Elmi, O., Hasan, H., Abdullah, S., Mat Jeab, M., Bin Alwi, Z. and Naing, N. (2015) '
Multidrug-resistant tuberculosis and risk factors associated with its development: a retrospective study', Journal Of Infection In Developing
Countries, 9 (10), .
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34. REFERENCES
Frieden, T. (2002) 'Can tuberculosis be controlled?', International Journal of Epidemiology, 31 (5), pp.894.
Holloway, K., Staub, K., Ruhli, F. and Henneberg, M. (2014) 'Lessons from history of socioeconomic improvements: a new approach to treating
multi-drug-resistant tuberculosis', Journal of biosocial science, 46 (5), .
Interrante, J., Haddad, M., Kim, L. and Gandhi, N. (2015) 'Exogenous Reinfection as a Cause of Late Recurrent Tuberculosis in the United
States', Annals Of The American Thoracic Society, 12 (11), .
Lawn, S. and Zumla, A. (2011) 'Tuberculosis', The Lancet, 378 .
Lobato, M., Sun, S., Moonan, P., Weis, S., Saiman, L., Reichard, A. and Feja, K. (2008) 'Underuse of Effective Measures to Prevent and
Manage Pediatric Tuberculosis in the United States', Archives of Pediatrics & Adolescent Medicine, 162 (5), .
Mears, J., Abubakar, I., Crisp, D., Maguire, H. and Innes, J. (2014) 'Prospective evaluation of a complex public health intervention: lessons
from an initial and follow-up cross-sectional survey of the tuberculosis strain typing service in England', BMC public health, 14 .
Murray, E., Bond, V., Marais, B., Godfrey-Faussett, P., Ayles, H. and Beyers, N. (2013) '
High levels of vulnerability and anticipated stigma reduce the impetus for tuberculosis diagnosis in Cape Town, South Africa',
Health Policy and Planning, 28 (4), pp.410.
Olfatifar, M., Karami, M., Hosseini, S. and Parvin, M. (2016) 'Clustering of pulmonary tuberculosis in Hamadan province, west of Iran: A
population based cross sectional study (2005-2013)', Journal of Research in Health Sciences, 16 (3), .
Onozuka, D. and Hagihara, A. (2015) '
The association of extreme temperatures and the incidence of tuberculosis in Japan', International Journal of Biometeorology, 59 (8), .
Reid, S., Topp, S. and Turnbull, E. (2012) '
Tuberculosis and HIV Control in Sub-Saharan African Prisons: "Thinking Outside the Prison Cell"', The Journal of Infectious Diseases, 205 (2),
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Simon, G. (2016) 'Impacts of neglected tropical disease on incidence and progression of HIV/AIDS, tuberculosis', International Journal of
Infectious Diseases, 42 .
White, C. and Veronica, L. (2002) 'Management of tuberculosis in a British inner‐city population', Journal of public health medicine, 24
(1), .
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35. REFERENCES
White, P. and Abubakar, I. (2016) 'Improving control of tuberculosis in low-burden countries: Insights from mathematical modeling', Frontiers
in Microbiology, 394 .
Yasin, Y. (2015) 'Infection of the Invisible: Impressions of a Tuberculosis Intervention Program for Migrants in Istanbul', Journal of
immigrant and minority health, 17 (5), .
Dye C, Lönnroth K, Jaramillo E, et al. Trends in tuberculosis incidence and their determinants in 134 countries. Bull World Health
Organ 2009; 87:683. 27.
Lienhardt C. From exposure to disease: the role of environmental factors in susceptibility to and development of tuberculosis.
Epidemiol Rev 2001; 23:288
35

36. Not Harvard formatted
•Case study of Hoa, Nguyen Binh et al. "National Survey Of Tuberculosis Prevalence In Viet Nam". Bulletin of the World Health Organization
88.4 (2010): 273-280. Web.
•Dye C. Global epidemiology of tuberculosis. Lancet. 2006;367:938–40.[PubMed]
•9. Diwan VK, Thorson A. Sex, gender, and tuberculosis. Lancet. 1999;353:1000–1. [PubMed]
•REF: World Health Organization. Use of high burden country lists for TB by WHO in the post-2015 era: Summary. Available at:
http://www.who.int/tb/publications/global_report/high_tb_burdencountrylists2016-2020summary.pdf?ua=1 (Accessed on September 13,
2016).
•Global Tuberculosis Report 2014. Geneva, World Health Organization, 2014. Copyright © 2014 World Health Organization. Available at:
http://apps.who.int/iris/bitstream/10665/137094/1/9789241564809_eng.pdf?ua=1. (Accessed on January 12, 2015).
• Zaman, K. "Tuberculosis: A Global Health Problem". J Health Popul Nutr 28.2 (2010): n. pag. Web
36

37. Slides to be deleted
37

38. Tuberculosis
GLOBAL EPIDEMIC
38

39. Tuberculosis (TB), is an infectious disease caused by the bacillus Mycobacterium
tuberculosis complex: Mycobacterium tuberculosis, africanum, and bovis.
Typically affects the lungs (Pulmonary TB), but can affect other sites (Extrapulmonary TB)
INFECTION — Inhalation of aerosol droplets containing M. tuberculosis with subsequent
deposition in the lungs leads to one of four possible outcomes:
●Immediate clearance of the organism
●Primary disease: immediate onset of active disease
●Latent infection
●Reactivation disease: onset of active disease many years following a period of latent
infection
5-15% of those infected with M. tuberculosis will develop TB in their lifetime, though
higher if infected with HIV.
39

40. Disease
2nd most common cause
of death in adults
worldwide
40

41. Current treatment recommendations
New cases drug-susceptible TB: 6 month regimen of four first-line drugs:
● Isoniazid, refampicin, ethambutol and pyrazinamide
Treatment for muliti-drug resistant (MDR-TB) and refampicin-resistant (RR-TB) is 9-12
months.
BCG vaccine used to prevent severe forms in children.
41

42. Epidemiology
Scope and Extent of
Burden of Disease
42

43. SCOPE
● Tuberculosis has killed roughly 1 billion people in the past two centuries
● estimated 10.4 million new (incident) TB cases worldwide
● Mortality fell by 22% between 2000-2015, TB remains in the top ten
causes of death worldwide
● In 2015, 580 000 new cases of multidrug-resistant (MDR-TB) tuberculosis were
estimated to have occurred worldwide
● Total number of people infected from TB:
43

44. Ratio of female to male TB cases notified globally is 0.47:0.67 (WHO., 2015)
In 2015, of the 10.4 million new (incident) TB cases worldwide, 5.9 million (56%) were among men, 3.5 million
(34%) among women and 1.0 million (10%) among children. People living with HIV accounted for 1.2 million (11%)
of all new TB cases.
Table: Worldwide results of smear positive test in men and
women in 2004 (WHO, 2015)
44

45. The future for TB
● The WHO and other health organisations have been working together to eradicate TB. The MDGs (2000–2015)
have now been superseded by the Sustainable Development Goals (SDGs), which have an end date of 2030.
● The Sustainable Development Goals (SDGs) for 2030 were adopted by the United Nations, all member states, in
2015.
● Similarly, WHO’s Stop TB Strategy has been replaced by the End TB Strategy, which covers the period 2016–
2035, and calls for a 90% reduction in TB deaths, and an 80% reduction in the TB incidence rate by 2030,
compared with 2015.
● One of the targets is to end the global TB epidemic. SDG 3 Ensure healthy lives and promote well-being for all at
all ages (3.3 By 2030,end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and
combat hepatitis, water-borne diseases and other communicable diseases.)
● The rate of decline in TB incidence remained at only 1.5% from 2014 to 2015. This needs to accelerate to a 4–
5% annual decline by 2020 to reach the first milestones of the End TB Strategy.
● 2020 milestones of the End TB Strategy are a 35% reduction in the absolute number of TB deaths and a 20%
reduction in the TB incidence rate, compared with levels in 2015; and that no TB-affected households face
catastrophic costs. (WHO, 2016)
45

46. SOCIO-ECONIMIC
● improved socioeconomic conditions have been accompanied by a decline in the tuberculosis burden in industrialized
countries over the past century
● Food insecurity and malnutrition, poor housing and environmental conditions, and financial, geographic, and cultural
barriers to health care access , including difficulties in transport to health facilities . In turn, the population distribution
of TB reflects the distribution of these social determinants, which influence the 4 stages of TB pathogenesis:
exposure to infection, progression to disease, late or inappropriate diagnosis and treatment, and poor treatment
adherence and success.
46

47. SOCIO ECONOMIC
GAP in reported cases and incident cases. In 2015, 6.1 million new TB cases were notified to national authorities
and reported to WHO. However, globally there was a 4.3 million gap between incident and notified cases, with
India, Indonesia and Nigeria accounting for almost half of this gap.
GAP in MDR-TB detection and treatment. Of the 580K eligible for treatment, only 125K (20%) were enrolled.
Investments in low and middle-income countries fall almost US$ 2 billion short of the US$ 8.3 billion needed in
2016. This annual gap will widen to US$ 6 billion in 2020 if current funding levels do not increase.
Overall health financing needs improvement, since government expenditures on health are less than the WHO
benchmark of 6% of the GDP in 150 countries, and OOP (out of pocket) expenditures exceeded 45% in 46
countries including 11 of the high TB burden countries.
Research underfunded.
47

48. Interventions
48

49. DOT (direct observation of therapy) Strategy
49

50. 3 important interventions under the umbrella of DOT
strategy:
Direct observation of therapy (DOT)
Effective drug supply (including BCG vaccines, ANTI-TB drugs
and drugs for MDR-TB.
Rapid Molecular testing (for accurate diagnosis)
50

51. Tuberculosis: scope/extent
● Modelling studies suggest that tuberculosis elimination is probably only achievable by 2050 if therapeutic and
diagnostic interventions (early case detection and high cure rates) are combined with preventive strategies
(vaccines and treatment of the latent tuberculosis reservoir in 2 billion people in high-burden and low-burden
settings)
● Tuberculosis remains a disease of poverty, associated with
overcrowding and undernutrition;
● HIV is the most potent of risk factors for TB; Heavy alcohol
consumption, smoking, diabetes and imunosupressive drugs have long
been associated with high risk of TB;
● LMIC relies heavily on sputum smear microscopy and chest radiology;
unsatisfactory and unavailable at patients’ first point of contact with
the health system;
51

52. Tuberculosis: scope/extent
● The only licensed vaccine, BCG, was first given to a human infant in 1921; it has
done little to contain the current tuberculosis pandemic;
● the incidence of TB has been shown to be inversely related to per capita gross
domestic product;
● Health system strengthening is indispensable for successful TB programmes and all
health-care providers must be engaged;
● Human errors in prescribing inadequate regimens, inconsistent dosing and poor
quality of drugs, resulting in the emergence of drug resistance and treatment failure
52

53. Tuberculosis: scope/extent
● Low confidence in patient confidentiality and anticipated HIV-related stigma act
as direct deterrents to TB diagnosis and treatment;
● TB control policy relies on passive case finding (PCF)—the voluntary
presentation of individuals to local health services;
● Treatment of MDR-TB infections is much more complicated and complex, less
effective, leads to high toxicity, and is very costly compared with the treatment
of patients infected with susceptible TB strains ;
53

54. scope/extent
● ?urbanization and an increase in the incidences of tuberculosis.
● Directly observed treatment of TB rapidly reduces mortality; death rates in
DOTS programmes throughout the world are generally less than 5%
● community-based public health interventions targeting vulnerable
populations when dealing with an infectious disease like TB.
54

55. TB PROGRAMS FINANCING
● US$ 6.6 billion was available for TB care and prevention in low and middle-income countries in
2016, of which 84% was from domestic sources;
● national TB programmes (NTPs) in low-income countries continue to rely on international donors
for almost 90% of their financing; using national social protection platforms is a priority
● TB research and development remains severely underfunded
● Considerable inequalities among countries in access to TB diagnosis and treatment that need to
be addressed
● The BRICS countries (Brazil, the Russian Federation, India, China and South Africa), which
collectively account for about 50% of the world’s TB cases, rely mostly or exclusively (the
exception is India) on domestic funding.
● Four diagnostic tests were reviewed and recommended by WHO: the loop-mediated isothermal
ampli- fication test for TB (known as TB-LAMP), two line probe assays (LPAs) for the detection
of resistance to the firstline anti-TB drugs isoniazid and rifampicin, and an LPA for the detection
of resistance to second-line anti-TB drugs.
55

56. Mortality and incidence rates
•World Health Assembly resolution recognized TB
as a major global health problem in 1991.
•Treatment developed by the WHO in the mid-1990:
the five-element Directly Observed Therapy, Short-
course (DOTS) strategy: 8 Million deaths averted.
•Global decline.
Four dimensions of
tuberculosis (TB)
elimination in low-
incidence countries.
56

57. 57

58. Designated as a prior area by the WHO
● Spreads through air so hard to stop
● Affects lungs but can also spread to other areas such as brain
● Symptoms depend on where in the body the TB bacteria is growing: difficult to diagnose
● Difficult treatment
● People with immunodeficiency (HIV, drug resistance…) more likely to not survive treatments.
● TB is still an important cause of death in poor countries (ex: Africa).
● TB needs to be treated carefully because there is a risk of relapse.
Zaman, K. "Tuberculosis: A Global Health Problem". J Health Popul Nutr 28.2 (2010): n. pag. Web.
58

59. The curable disease that continues to kill
•Leading cause of morbidity and mortality in developing
countries: 86% of all cases in Africa and Asia.
•Declining trend was observed in most developed countries, this
was not evident in many developing countries.
•In developing countries, about 7% of all deaths are attributed
to TB which is the most common cause of death from a single
source of infection among adults. It is the first infectious disease
declared by the World Health Organization (WHO) as a global
health emergency.
•10.4 million new TB cases worldwide in 2015.
•60% of these cases in: India, Africa, Nigeria, Pakistan.
•1.8 million people died in 2015
•Global tb death fallen by 22% since 2000.
•However, TB is still in top 10 causes of death globally in 2015.
(WHO)
“Countries are failing to diagnose and
treat millions of people with TB.
Governments need to get their heads out
of the sand and realize that TB is not a
disease consigned to the 1800s; we see
and treat TB in our clinics every day, and
it's a deadly threat to all of us.”
The governments are mainly failing
because of shortage of funding.
- WHO TB control leader
59

60. Fig: Estimated new tuberculosis cases (all forms) per 100,000 population per year. (WHO Global tuberculosis Report., 2014)
Global Tuberculosis Report 2014. Geneva, World Health Organization, 2014. Copyright © 2014 World Health Organization. Available at:
http://apps.who.int/iris/bitstream/10665/137094/1/9789241564809_eng.pdf?ua=1. (Accessed on January 12, 2015).
60

61. ● 95 percent of TB cases occur in developing countries.
● 1 in 14 new TB cases occur in individuals who are
infected with HIV (6% of all TB cases); 78 percent of
these cases occur in Africa.
● 480,000 cases of multidrug-resistant (MDR)-TB also
occur annually.
● Socioeconomic development and access and quality of
health services appear to be important TB control
measure.
● Risk factors for TB: host immunity (eg: immunologic
defects that lead to increased susceptibility to infection),
environmental exposure to infection (eg: risk of
exposure to a case of infectious TB)
Fig: Countries with high burden of tuberculosis (WHO., 2015)
REF: World Health Organization. Use of high burden country lists for TB by WHO in the post-2015 era: Summary. Available at:
http://www.who.int/tb/publications/global_report/high_tb_burdencountrylists2016-2020summary.pdf?ua=1 (Accessed on September 13, 2016).
61

62. TB in men, women and age groups.
Case study of Hoa, Nguyen Binh et al. "National Survey Of
Tuberculosis Prevalence In Viet Nam". Bulletin of the World Health
Organization 88.4 (2010): 273-280. Web
Table: Worldwide results of smear positive test in men and
Ratio of female to male TB cases notified globally is 0.47:0.67
(WHO., 2015)
62

63. Political Commitment
● Provision of adequate resources (financial, human and infrastructure)
● Political authorities participation in advocacy of TB laws and policies
promulgations and social protection interventions.
63

64. National notification and vital registration systems (with standard coding of causes of death) of high coverage and
quality are needed in all countries.
BCG vaccination should be provided as part of national childhood immunization programs according to a country’s TB
epidemiology. Funding to accelerate the production of new Vaccines for prevention in adults needed!
Rapid molecular tests should be funded for diagnosis in all countries, since more accurate than the standard sputum
smears, and more rapid culture.
64

65. Case Detection
● Active case findings
● Training pharmacists and traditional healers
● Training, deployment and supervision of 2 sputum fixers
65

66. Standardized Treatment
● First and second line of anti-TB drugs
● Supervised treatment (direct observation of therapy)
● Improving access to treatment
● Preventive therapy in people with HIV infection
● Preventive therapy of people in contact with TB patients
66

67. Effective Drug Supply
● Proper distribution of drugs among patients
● Free of charge
● BCG Immunization
67

68. Tuberculosis: scope/extent
● Widespread emergence of extensively drug-resistant (XDR) TB and
resistance beyond XDR tuberculosis;
● Global diagnostic capacity is low, and the case detection rate is
suboptimum (64% in 2013); Underdiagnoses is another issue. Access to TB
preventive treatment needs to be expanded.
● Increasing age, more extensive disease, and HIV co-infection are
associated with increased mortality;
● Preventive therapy for people at high risk is an important component of
the strategies to eliminate TB outlined by WHO in their post-2015 strategy.
● Communitybased, low-cost, sensitive, user-friendly, high-throughput, and
same-day point-of-care screening test for TB is clearly needed;
68

69. CONCLUSION
“Countries are failing to diagnose and treat millions of
people with TB. Governments need to get their heads
out of the sand and realize that TB is not a disease
consigned to the 1800s; we see and treat TB in our
clinics every day, and it's a deadly threat to all of us.”
The governments are mainly failing because of
shortage of funding.
- WHO TB control leader
69

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