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Opportunities Shift in Perspective for Infectious Disease Control (Porter et al 1999 Health Policy and Planning 14: 322-328) From: • Disease specificity and verticality To: • Integrated/ Horizontal linkages • Standardised interventions • Flexibility/context sensitivity • Short term orientation • Longer term objectives/sustainability • Emphasis on product/targets • Emphasis on process Shift in Perspective for Infectious Disease Control (Porter et al 1999 Health Policy and Planning 14: 322-328) From: • Limited to health sector To: • Linking multiple sectors • Focus on individual ‘risk’ • Understanding social vulnerability: risk in the context of everyday life • Operating without reference to global processes • Taking globalization as referent and context • Working on behalf of populations • Working in partnership with communities Tuberculosis Control as an example Historical decline of TB, 1840-1960 Standardised notification rate 400 Phase 1 Koch’s discovery 200 0 Antibiotic era Segregation of poor consumptives in enlarged and improved workhouses infirmaries 300 100 Phase 4 Phase 3 Phase 2 Systematic segregation of consumptives, rich and poor, In hospitals and sanatoria Initial effect of segregation of poor consumptives in work house 1840 1860 1880 1900 1920 1940 Year Source: data derived from various sources including T. McKewon. The modern rise of population, London: Edward Arnold 1976. 1960 TB & Poverty overlap Source: World Economic Forum, 2005 Risk factors for TB Risk factor Relative risk for active TB disease (range) Weighted prevalence, total population Population Attributable Fraction (Range) HIV infection 8.3 (6.1-10.8) 1.1% 7.3% (5.2-9.6) Malnutrition 4.0 (2.0-6.0) 17.2% 34.1% (14.7-46.3) Diabetes 3.0 (1.5-7.8) 3.4% 6.3% (1.6-18.6) Alcohol 2.9 (1.9-4.6) 3.2% 5.7% (2.8-10.3) Active smoking 2.6 (1.6-4.3) 18.2% 22.7% (9.9-37.4) Indoor pollution 1.5 (1.2-3.2) 71.1% 26.2% (12.4-61.0) From Lonnroth K et Al. Global epidemiology of tuberculosis. Seminars in Respiratory and Critical Care Medicine, 3 March 2008 WHO-recommended Global Strategy to Stop TB and reach the targets for 2015 1. Pursuing quality DOTS expansion and enhancement • • • • • Political commitment Case detection through bacteriology Standardised treatment, with supervision and patient support Effective drug supply system Monitoring system and impact evaluation 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 Stop TB Department Global TB Control Targets: the theory • 2015: 50% reduction in TB prevalence and deaths • 2050: elimination (<1 case per million population) • 5-10% declining incidence per year: – 70% detection rate – 85% successful treatment Global TB Control Targets: the reality Case detection rate • 61% globally in 2006 • 46% in Africa • 52% in European/Eastern Mediterranean regions • 2/3 of missing cases are in China, India, Africa Treatment success rate • 84.6% globally • 70% in Eastern Europe • 76% in Africa