Download Progress and Challenges Toward the Goal of Global TB Elimination

Towards the ultimate goal of global TB
elimination - progress and challenges
UNION NAR 25 Feb 2016
Knut Lönnroth
Global TB Programme
WHO
Outline
1. The new global TB targets
2. Progress so far - did we reach the MDG targets?
3. The new End TB strategy – what's new?
4. Some of the challenges – and solutions
5. Towards elimination - framework for lowincidence countries
Vision, goal, targets, milestones
Vision:
A world free of TB
Zero TB deaths,
Zero TB disease, and Zero
TB suffering
Goal:
End the Global TB
epidemic: incidence
<10/100,000
End TB strategy – "Projected" acceleration of TB incidence decline
Current global trend: -1.5%/year
Optimize use of current & new
tools emerging from pipeline,
pursue UHC and social
protection, social determinants
-10%/year by 2025
-5%/year
Introduce new tools: a vaccine, new
drugs and shorter regimens for
treatment of active TB and latent
infection, a point-of-care test
-17%/year
And then – towards elimination
<100 cases (all forms)
per million
Low incidence
<1 case (all forms)
per million
<10 cases (all forms)
Elimination
per million
Pre-elimination By 2050, or later?
By 2035?
Progress so far
MDG6 TB target achieved
Rate per 100,000 population
REVERSED
Incidence
Falling 1.5% per
year (2000-2014).
18% drop since 2000
1990
2000
2014
But not according to plan:
Projection in previous Global Plan (2006-2015)
2015
2035
"The planned interventions at
the level of scale-up reached in
2015 will result in an average
rate of decline in global TB
incidence of 5–6% per year."
Source: Maher D, et al. Planning to improve global health: the next decade of tuberculosis
control. Bulletin of the WHO 2007;85:341-347.
Did we reach the MDG-related targets?
Global tends
"Ending TB" level
Americas
"Ending TB" level
43 million lives saved
BETWEEN 2000 AND 2014
TB = 43m
HIV = 7.8m
Malaria = 7m
But still; 1.5 million TB deaths in 2014
TB ranks alongside HIV
as a leading cause of death
2012, WHO Global Health Observatory
2014, WHO and UNAIDS
TB
HIV/AIDS
TB
In grey: TB/HIV deaths
HIV/AIDS
Millions
The End TB Strategy
Implementing the End TB Strategy
THE ESSENTIALS aims to guide actions
at national level to adapt, launch and
implement the World Health
Organization’s End TB Strategy.
It calls for major transformations in the
way we all work to better support
those affected and to end the
epidemic.
Launch: March 2016:
www.who.int/TB
The End TB Strategy:
3 pillars and 4 principles
Measuring progress
TOP-TEN PRIORITY INDICATORS (NOT RANKED) FOR MONITORING IMPLEMENTATION
OF THE END TB STRATEGY AT GLOBAL AND NATIONAL LEVELS, WITH RECOMMENDED
TARGET LEVELS THAT APPLY TO ALL COUNTRIES
Indicator
Recommended
target level*
≥90%
1
TB treatment coverage
2
TB treatment success rate
3
Percentage of TB-affected households that experience catastrophic costs due to TB
4
Percentage of newly notified TB patients tested using WHO-recommended rapid tests
≥90%
5
LTBI treatment coverage (relevant risk groups)
≥90%
6
Contact investigation coverage
≥90%
7
DST coverage for TB patients
100%
8
Treatment coverage, new TB drugs
≥90%
9
Documentation of HIV status among TB patients
100%
10 Case fatality ratio (CFR)
≥90%
0%
≤5%
What's new?
1.
Adaptation needed
 Attention to risk groups and vulnerable groups - know your epidemic
2.
Earlier detection and more accurate diagnosis
 Contact investigation re-emphasized, including LTBI management
 Systematic screening in selected high-risk groups (with attention to over-diagnosis)
 Universal DST
3.
More patient-centered care
 Tailored patient support (especially for vulnerable groups)
 Manage co-morbidities
4.
UHC and SDG agenda




5.
Identify and address access barriers and health care quality deficiencies
Regulatory approaches (notification, medicines, vital registration, etc)
Social protection – a means as well as an outcome
Prevention through addressing risk factors and social determinants
Research – no new tools, no ending TB
Global Action Framework
on TB research
Some challenges
…and solutions
Reaching the "missed" cases early is crucial
(~3.6 million not diagnosed or reported)
9.6 million estimated
Share of total missed cases
6 million notified
10 countries account for 75%
(2.7 million) of the estimated
“missed” cases globally
Estimated incidence
Global notifications
Indonesia + India:
1.2 million “missed” people
Case detection
Private sector
notification in
Inida
Required actions to improve early detection
 Improve access – special focus on vulnerable groups
 Universal health coverage – general access barriers
 Improve awareness
 Improve diagnostics
 Engage all care providers – full notification
 Contact investigation (with LTBI management of children <5),
systematic screening of PLHIV and other selected risk groups
MDR-TB: 3% of new TB cases globally
Ref: Global TB Control Report 2015
Percentage of new TB cases with MDR-TB
Highest % in the former USSR countries
India, China, Russia, Pakistan and Ukraine
have 62% of all MDR-TB cases
End TB Strategy:
Universal DST
Universal health coverage
including access to drugs, high
quality patient friendly care,
social protection
Special focus on vulnerable
and hard-to-reach groups
MDR TB treatment outcomes
 Patient support (education, social, financial, comorbidities, DOT, etc)
 Delivery models (decentralisation, patient friendly)
 New medicines and regimens - research
Estimated HIV prevalence in new TB cases, 2014
74% of TB/HIV cases
in Africa
Ref: Global TB Control Report 2015
12% of TB cases globally attributable to HIV:
Other risk factors dominate in other regions
Population attributable fraction –
some risk factors for progression to disease
PAF 
P   RR  1
P   RR  1  1
Relative risk for
active TB disease
Weighted
prevalence
(adults 22 HBCs)
Population
Attributable
Fraction (adults)
HIV infection
20.6/26.7
0.8%
Malnutrition
3.2
16.7%
Diabetes
3.1
5.4%
16%
27%
10%
Alcohol use
(>40g / d)
2.9
8.1%
13%
Active smoking
2.0
26%
Indoor Air
Pollution
1.4
71.2%
21%
22%
Sources: Lönnroth K, Castro K, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, Raviglione M. Tuberculosis control 2010 – 2050: cure, care and social
change. Lancet 2010 DOI:10.1016/s0140-6736(10)60483-7.
Risk factor and risk group approach:
1.
Document TB distribution, risk factors, and drivers of the epidemic
2.
Minimize access barriers
3.
Screening in selected high risk groups
4.
Patient centred and tailored care
5.
Deal with comorbidities
6.
Provide social and financial support
7.
Prevent by reducing population-level exposure to risk factors and
underlying social drivers
Poverty-disease trap
•
•
•
•
Poverty
Undernutrition
Poor housing
HIV
NCDs and NCD risk factors (diabetes,
smoking, alcohol, etc)
• Poor health care access
• High direct and indirect health care costs
• Loss of employment and income
• On average 50% of annual income lost!
TB
End TB
Achieve SDGs
TB control is a beneficiary of and a contributor to global development
SDGs: Health is a beneficiary and contributor
Critical funding gaps
IMPLEMENTATION –
US$8 billion needed in 2015
$1.4 billion
funding gap
RESEARCH –
at least US$ 2 billion per year needed
$677
availabl
e in 2013
$1.32 billion
funding gap
$8 billion funding required in 2015 for
TB prevention, diagnosis and treatment
TAG TB R&D report 2014
Trends in international donor funding for
HIV, malaria and TB, 2005-2013
9
8
US$ billions
7
6
5
$1.4 billion
funding gap
4
3
2
$1.32 billion
funding gap
1
0
2005
2006
2007
2008
HIV/AIDS
2009
Malaria
2010
2011
TB
Source: Creditor reporting system. Paris: Organisation of Economic Co-operation and Development
Note: HIV funding is recorded as “STD control including HIV/AIDS”.
2012
2013
Investing in the TB response is top value-for-money
Development - The economics of optimism , Jan 24th 2015 - The debate heats up about what goals the world should set itself for 2030
Global plan 2016-2020 Estimated Financial needs
Up from 8 billion/y in 2015 to ~12 billion/y
Adaptation for low-incidence countries
33 low-incidence countries and territories*
(notification rate <10/100,000, 2012 data)
*Population >300,000
ACTION FRAMEWORK
8 priority actions for elimination in low-incidence countries
Ensure political
commitment, funding
and stewardship for
planning and essential
services
of high quality
Address most
vulnerable and hardto-reach groups
Undertake
screening for active
TB and latent TB infection
in high-risk groups and
provide appropriate
treatment
Support global
TB prevention, care
and control
Invest in
research
and new tools
Address special needs
of migrants; crossborder issues
Ensure continued
surveillance and
programme
monitoring &
evaluation
Optimize
prevention and care of
drug-resistant TB
8. Support global TB prevention, care,
and control
Contribute and mobilise financial resources
Promote global TB advocacy and visibility
Support bi-lateral and multi-lateral
collaboration and technical assistance.
FRAMEWORK available at:
http://www.who.int/tb/publications/elimination_framework/en/
Lönnroth K, Migliori GB, Raviglione MR, et al. Towards tuberculosis elimination: An action
framework for low-incidence countries.
Eur Respir J 2015 2015; 45: 928–952
So, what was new again?
Reaching very ambitious targets
Vision:
A world free of TB
Zero TB deaths,
Zero TB disease, and Zero
TB suffering
Goal:
End the Global TB
epidemic: incidence
<10/100,000
With evolved strategy elements
1.
Adaptation needed (one size fits one)
 Attention to risk groups and vulnerable groups - know your epidemic
2.
Earlier detection and more accurate diagnosis
 Systematic screening in selected high-risk groups (with attention to over-diagnosis)
 Contact investigation re-emphasized, including LTBI management
 Universal DST
3.
More patient-centered care
 Tailored patient support (especially for vulnerable groups)
 Manage co-morbidities
4.
UHC and SDG agenda




5.
Identify and address access barriers and health care quality deficiencies
Regulatory approaches (notification, medicines, vital registration, etc)
Social protection – a means as well as an outcome
Prevention through addressing risk factors and social determinants
Research – no new tools, no ending TB