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The Challenges Facing Tuberculosis Control Blantyre Hospital, Malawi: TB Division, 3 patients per bed Health Organization The Burden of Tuberculosis, 2009 9.27 million new cases in 2007, 80% in 22 high-burden countries 1.75 million deaths in 2007 and 98% of these in the developing world 0.45 million deaths due to TB/HIV 0.5 million Multi-drug resistant TB (MDRTB) in 2007 Estimated TB Incidence Rates Rate per 100 000 0-9 10 - 24 25 - 49 50 - 99 100 - 300 300 or more No Estimate Incidence rates stable or falling slowly 400 Cases per 100,000 population 350 300 250 10 8 6 4 2 0 Cases in millions 9.15 Africa South-East Asia WORLD 200 Western Pacific 150 100 Eastern Mediterranean Europe 50 Americas 0 Incidence Rate trend of pulmonary TB in Saudi Arabia (per 100000) 1999 – 2008 Global TB Control Targets 2015: Goal 6: Combat HIV/AIDS, malaria and other diseases Target 8: Indicator 23: Indicator 24: to have halted by 2015 and begun to reverse the incidence… incidence, prevalence and deaths associated with TB proportion of TB cases detected and cured under DOTS 2015: 50% reduction in TB prevalence and deaths by 2015 2050: elimination (<1 case per million population) The DOTS Strategy (1994) • Government commitment to TB control • Case detection primarily by smear microscopy mostly on self-reporting symptomatic patients • Standardised short-course chemotherapy under proper case management conditions, including DOT • System of regular drug supply • Efficient monitoring system for programme supervision and evaluation DOTS and overall SS+ case detection a flattening curve 80 2.5 million detected and notified out of 4.1 million estimated all notified DOTS 60 40 100 80 60 40 20 0 20 77 69 67 52 52 46 Global Plan: 65% in 2006 78% by 2010 0 1990 1995 2000 2005 2010 The gaps in basic TB control! • Not all TB cases are detected • Not all TB cases are detected early enough • Not all TB cases are treated • Not all TB cases are treated well enough What are the key challenges to increasing case detection? • About 40% (3 – 5.6 M) of estimated cases are not notified (and not diagnosed?) • Are the cases not notified or not identified? Identified but not notified: in health sector but not in DOTS providers Not notified because not identified : informal care providers, home, etc…. The Challenges Facing TB Control • Delay in detection of pulmonary TB -difficult access to HC services - Lack of awareness about TB - Fear • Delay in reporting TB Cases The Challenges Facing TB Control • Deficiencies in protecting contacts - Variations in contact investigation - Difficulties in finding contacts • Inappropriate or inadequate therapy • Failure to complete therapy (defaults) The Challenges Facing TB Control • Imported TB - Immigrants from high burden countries - More delay in TB detection - Impact of social factors • Pool of latent TB - Risk of reactivation is 10% in a lifetime - In normal individuals: risk is 0.1% per year - Risk is more with impaired immunity Impact of HIV on TB Direct: Reactivation of TB infection acquired before HIV infection (from 10% lifetime to 3-13%/year) Rapid progression of TB infection acquired after HIV infection Indirect: Transmission to the population not infected with HIV World Health Organization MDR-TB: Global Rates • Resistance to both INH & Rifampicin • Increasing rate 2002 : 272,900 (1.1%) 2007 : 510,500 (4.9%) • Estimated 43% of global MDR-TB cases have had prior treatment • China, India and Russian Federation accounts for 62% of the MDR burden Transmission of TB • • • • • • Almost always by airborn route Indoors: TB bacilli remain suspended in air for hours At diagnosis ; 30 – 40% of contacts have +ve PPD Infection is dependent on duration of exposure Infection more likely in close contacts of SS+ patients Infectiousness rapidly decreases shortly after starting multiple drug therapy Facing the challenges • Early detection and treatment of TB cases: - Easy access to health care - Increase awareness of TB among HC workers - Availability of diagnostic facilities - Availability of effective chemotherapy - Ensuring adherence to standard practice Facing the challenges • Reduce incidence of TB among high risk groups: - Contacts of TB patients - Immigrants from high burden countries - Prisoners - Immunocompromised • Address MDR TB and HIV • Surveillance and monitoring of outcome • Engaging all health care providers • Promoting research Is TB elimination possible? • Slow incidence rate decline • Need Substantial advances in diagnosis and therapy: - Better diagnostic tests for TB and latent TB - More effective drugs for treatment - Better vaccines for prevention Impact of drug resistance on TB cure rates with standard 4-drug therapy % Success New Case Retreated Pan-susceptible Any resistance, not MDR INH resistance, not MDR RIF resistance, not MDR MDR Espinal, JAMA 2000; 283:2537 85 81 82 73 52 67 56 54 53 29 Global Strategy to Stop TB 2006-2015 1. Pursuing quality DOTS expansion and enhancement • • • • • Government commitment with long-term planning and adequate resources to reach targets Case detection through bacteriology and strengthening of laboratory network Standardised treatment, under proper case management conditions including DOT and patient support Effective and regular drug supply system Monitoring system for supervision and evaluation, including impact measurement Additional components 2 Addressing TB/HIV and MDR-TB 3. Contributing to health system strengthening 4. Engaging all care providers 5. Empowering patients and communities 6. Enabling and promoting research World Health Organization