Dr. Anne Fanning -- Stopping TB: Will we meet the 2015 targets and ELIMINATE by 2050?

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Stopping TB will we meet the 2015 targets, and
ELIMINATE by 2050?

• Edmonton
• March 23, 2012

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Outline of what it will take

• 2011 global TB trends, goals
• Will we meet 2015 goals
• New strategies to address impediments
• And then what about 2050
• Local challenges

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TB rates/100,000, in Canada compared with sample
countries (2010)
Note South Africa at 981/100,000 removed
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Latest global TB estimates and notification
2010- following consultation in 78 countries
revision of estimates were reduced
Estimated number of cases
Cases reported DOTS
All forms of TB Greatest number of cases in
Asia greatest rates per capita in Africa
6.2 million (80 per 100,000)
8.8 million (128 per 100,000)

New Smear positive
2.6 million
4.1 million?
Women
3.5m
HIV-associated TB
1.1m (13)
486,000
290,000 (50,000 XDR)
53,000, (only 46,000 Rx)
Multidrug-resistant TB (MDR-TB)
1.4 million (.35 mHIV, .15 mMDR, .03mXDR, .32 m
women
Deaths
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Estimated TB incidence rate, 2010
Estimated new TB cases (all forms) per 100 000
population
No estimate
024
2549
5099
100299
300 or more
The boundaries and names shown and the
designations used on this map do not imply the
expression of any opinion whatsoever on the part
of the World Health Organization concerning the
legal status of any country, territory, city or
area or of its authorities, or concerning the
delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate
border lines for which there may not yet be full
agreement. ? WHO 2006. All rights reserved
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National TB control Programs in resource poor
settings (The DOTS Strategy)
modeled by Styblo, Tanzania 1970s

• Essential elements
• Find sputum smear cases--- Lab network
• Case definition and Standard treatment---manual
• uninterrupted supply of high quality drugs
• Directly observed therapy DOT
• recording and reporting, outcome evaluation
• government commitment

Assuming Human Resources and infrastructure
World Bank assessed as the most cost-effective
health strategy (1990)
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DOTS Expansion 1990-2001
Total number of countries
200
155
DOTS launched
147
150
126
122
Number of countries
New Framework
104
98
100
73
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19
15
10
0
2001
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Year
Global Tuberculosis Control. WHO Report 2003.
WHO/CDS/TB/2003.316
World Health Organization
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Global action on TB

• 1990 World Bank evaluation of National TB
  Programs as cost effective
• Rising rates, Falling funding
• 1993 WHO declared TB a Global emergency
• 1994 DOTS marketing strategy
• 1998 London Ad hoc proposed a
• Partnership

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the STOP TB Partnership2000
Now about 800 organizational members,
Global Partners Forum
Global TB Fund Global TB Drug Facility
Coordinating Board Partnership Secretariat
WHO Technical Advisory Group
W O R K I N G G R O
U P S
TB Vaccine Development Coalition
Global Alliance for TB Drug RD
LAB Strengthening
TB Diagnostics Initiative
Global DOTS Expansion
DOTS-Plus MDR-TB
TB/HIV
Advocacy, Communications and Social mobilization
working group
Financing Task Force
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Treatment of TB 2009 guidelines first
evidence-based lthttp//whqlibdoc.who.int/publicati
ons/2010/9789241547833_eng.pdfgt

• New case, (lt1mo past treatment)
• New Pulmonary 1 of 2 smear (culture NB where
  HIVgt1) or MD diagnosed Sm neg
• New EP culture and pathology recommended
• 2HRZE/4HRE
• Daily is optimal ( esp HIV)or Daily 2mo 3/week
  (DOT), or 3/week throughout except HIV

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Re-Treatment of TB 2009 (guidelines first
evidence-based) lthttp//whqlibdoc.who.int/publicat
ions/2010/9789241547833_eng.pdf

• Retreatment case (all must have culture and DST
  before start of Rx)
• Relapsed following cure or complete treatment
• Defaulted gt2month of treatment -----
• if low MDR old cat II2HRZES/1HRZE/5HRE.
• Failed Still at 5 months refer for MDR
  treatment
• If retreatment in high MDR country, start empiric
  MDR regimen (4 drugs)
• If failure at 5 months culture DST and empiric
  MDR

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Empiric MDR treatment

• Culture and DTS obtain before start
• Rapid wait
• Long- start empiric
• Choices by group, in priority order
• Oral 1st line PZA, rifabutin, emb
• Injectables ami,kana, cap,strep
• FQslevo,moxi,oflox
• Oral static PAS, cycloserine,Ethion,Terizidone,pr
  o
• Other clofaz,linezolid,amx/clv,thiocet,imipenim/c
  ilastin, high H, Clari
• Rules 4 drugs, none which failed before, based
  on country experience, duration18mo after culture
  conversion
• When results of DST tailor

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Millennium Development Goals

• By 2015, compared with 1990 (MDG goal 6 reduce
  the burden of HIV Malaria and other tropical
  diseases)
• Reverse the rise peak in 2002 at 141/100,000
  (decline 1.3/y)
• Cut prevalence in half (1990-300 2010, 178
  target 150)
• Cut mortality (case fatality) in half, 1990- 30,
  2010, 15/100,000. Target 12 will likely be met
  in all regions
• By 2050 eliminate TB as a Public Health problem

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Reversed the rise in 2002 at 141, falling 1.3/y
now 128
Prevalence 178, target for 2015 , 140 will not be
reached
Mortality falling and target of 12 will be
reached, Now at 15
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Incidence rates stable or falling slowly
9.27





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impediments

• Still limited access
• HIV co-infection
• Drug resistance
• Failing health infrastructure (Lab challenges,
  human resources)
• Community commitment
• POVERTY and the social determinants of health
• Donor fatigue

.the plan for 2011-2015, 6 elements
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DOTS expansion- to find more cases under DOTS
(61 in 06)

• Greater access to care (Task Forces)
• Public Private Partnerships (incr detection40)
• Better treatment for children, Dx, Rx and
  prevention
• Better lab capacity (DST, Gene Xpert)
• Health system strengthening (introducing
  electronic reporting)
• Uninterrupted drug supply-GDF
• TB and poverty

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2a)HIV TB interventions

• Collaboration at all levels diagnosis, clinical
  care, epidemiologic information
• Triple I for HIV patients
• 1. Intensified TB testing in HIV,
• 2. INH prophylaxis, and
• 3. Infection control
• VCT for TB patients treat HIV CPT ARV
• HIV prevention, treatment and care
• Community support, reduce stigma

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HIV TB targets
HIV TB 2010 target
TB patients tested for HIV 34 100
HIV TB patients treated with CPT 77 100
HIV TB patients treated for HIV 46 100
living with HIV Screened for TB 56 100
people living with HIV attending HIV Services enrolled in IPTprevention 12 100
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2b) Improve management of MDR TB (resistance to
HR)

• Lab access lt 5 of TB cases are cultured and
  Direct sensitivity testing (DST)
• Estimated prevalence 290,000 MDR, only 53,000
  reported and about 45,000 under good DOTS
  approved program

Goal to treat 800,000 in DOTS programs
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MDR challenges

• Goal 1 microscopy centre /100,000 8/22 HBC dont
  have
• Goal 1 culture lab/ 5 M
• Goal 1 DST lab/ 10 M- 16/36 MDR co dont have
• Gene Xpert cost 17,000/unit, 17/case 26 of 145
  countries eligible have
• Second line drug access, cost, distribution,
  training and supervision challenges

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Gene Xpert C Evans PLOS July 11, 20118e1001064

• Cefeid /FIND/ NIH Gene Xpert MTB/RIF, a
  cartridge-based, automated diagnostic test .
• Purifies, identifies, amplifies M tuberculosis
  (MTB), resistance to rifampicin (RIF), in lt2 hr
• 2010/12 WHO endorsed NAA system for MTB and rif
  resistance identification in low income endemic
  countries.
• Advantage, point of care dx without expertise
• Concerns- closed systems may avoid DNA
  contamination
• Smear negative detects 50 of liquid culture
• Cost / machine , 20/ cartridge

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MDR Targets
Drug resistant TB 2010 target
previously treated tested for DST 6 100
of culture pos tested for DST 1.8 20
Countries of HB or high MDR with gt1 lab DST per 5 million 20 36
confirmed MDR enrolled on treatment 46,000 270,000
Treatment success among MDR 57 75
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3. Contribute to Health System strengthening

• Challenges
• Human resources ( Brain drain )
• Physical facilities
• Lab facilities- see above
• management
• Training
• Logistics to assure no stock-outs of diagnostics
  and therapeutics
• Political will and funding

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4. Engage all care providers

• Beyond the public system
• Private now 20-40 of notifications
• (pharmacies)
• Traditional
• Faith based
• Military
• Prisons

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Need for Public private mix (PPM)

• NTPs need to connect to
• hospitals academic institutions, prisons,
  military
• Volunteer sector NGOs, community based orgs,
  faith based.
• For profit practitioners, traditional healers,
  pharmacists
• Role of NTP steward, set standards, train,
  supervise

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PPM successes

• Improve practice by education with International
  Standards of TB Care
• Increase case detection and reduce diagnostic
  delay 20-40
• Improve access
• Reduce cost to patient with free drugs, and
  access closer to home
• Improves epidemiologic surveillance completeness
• Improves management of overall system

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5. Empower people and communities with TB

• Long neglected is the link of poverty and TB ,
  both as a cause and an effect
• Rates began to decline before drugs as the
  industrial revolution improved living conditions.

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Decline of TB rates before drugs
In the first half of the 20th century when no TB
drugs, rates of TB infection and mortality
declined an average of 5 per year in Western
Europe
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The Mycobacterium is necessary but not sufficient
for Tuberculosis Poverty is the driver
Its the housing, stupid
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6. Build Research

• Advocate for new drugs, diagnostics and vaccine
• Build capacity for operations research

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Funding facts

• 2012 anticipated TB funding
• 4.4 billion domestic funding (86)
• 12 from Global Fund,
• 2 from other agencies.
• BRICS (Brazil, Russia, India, China, South
  Africa) invested 2.1 Billion, 95domestic
• Other High Burden countries only 0.6 Billion
• Major challenge is to scale up MDR, and if BRICS
  can fully finance, donors can go to other HBC

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TB Funding of 4.4 billion leaves a gap of 1
billion and depends 86 on domestic spending
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Trends in development assistanceTed Schrecker, U
Ottawa
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World TB day 2012
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In my lifetime

• So hurry up!

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The inuit story
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TB in the north 1950, Alaska, Canada, Greenland-
Stefan Grzybowski, Tubercle, 1976 Sup

• First recorded rates of TB in Eskimo
• 1955 Greenland, 2320/100,000
• 1955 Alaska, 1540/100,000
• 1960-63 NWT Canada,1095/100,000
• ARI
• Greenland 18
• Alaska 25
• Interventions
• All case find and cure
• Greenland BCG
• NWT BCG And Proph
• Alaska Ambulatory treatmetn IHN

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Inuit treatment and outcomes of the 1950s and
present
Region Rate /100,000 1955-60 ARI Intervention rate/100,000 2010 (other)
Alaska 1540 25 Ambulatory treatment IHN AIAN 33(8)
NWT 1095 ? Treat BCG Proph Nunavut 304
Greenland 2320 18 Treat BCG 112 (in 2009)
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The Greenland story
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Need for Program targets and indicators

• Complete treatment in 12 months
• Contacts Found, tested, proph, complete
• Lab turnaround time
• Treatment start in 7 days, 4 drugs in 100
• Culture conversion in 60 days
• Data reporting
• Universal genotyping
• Universal HIV testing
• Immigrant refugee screen
• HR plan
• Evaluation Plan
• Training plan

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Summary

• Global TB incidence peaked in 2002, and is
  slowly falling in all regions even Sub-saharan
  Africa
• Challenge to sustain control in a flagging
  economy, address MDR capacity, reach
  marginalized populations, eg Canadian Aboriginal
• Impediments access to care and social
  determinants of poverty, education, need to be
  addressed
• Donor fatigue, as GFATM misses round 11 is there
  an ethical responsibility?
• Response a personal commitment to STOP TB

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References

• Treatment of tuberculosis Guidelines 2009
  http//whqlibdoc.who.int/publications/2010/9789241
  547833_eng.pdf
• Global TB control lthttp//whqlibdoc.who.int/public
  ations/2011/9789241564380_eng.pdfgt
• Implementing the STOP TB strategy
  http//whqlibdoc.who.int/publications/2008/9789241
  546676_eng.pdf
• WHO childhood TB http//whqlibdoc.who.int/hq/2006/
  WHO_HTM_TB_2006.371_eng.pdf
• Global Plan to STOP TB 2006-2015
  http//whqlibdoc.who.int/publications/2006/9241594
  87X_eng.pdf
• International Standards of TB care
  http//www.who.int/tb/publications/2006/istc_repor
  t.pdf
• 2009Management of Tuberculosis training for
  health facility staff
• lthttp//www.who.int/tb/publications/2010/who_htm_t
  b_2009_423/en/index.htmlgt
• gt

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References

• RichM,CegielskiP, Jaramillo E,Lambrechts.
  Guidelines for the programmatic management of
  drug-resistant tuberculosis, WHO 2006
• Multidrug and extensively drug resistant
  TB(M/XDR-TB) surveillance and response. WHO 2010
• Guidelines for Treatment of TB lt
  http//whqlibdoc.who.int/publications/2010/9789241
  547833_eng.pdfgt
• Toward universal access to MDR XDR TB by 2015 lt
  http//www.who.int/tb/publications/2011/mdr_report
  _2011/en/index.htmlgt
• Guidelines for programmatic management of MDR TB
  2011lt http//www.who.int/tb/challenges/mdr/program
  matic_guidelines_for_mdrtb/en/index.html gt
• Guidelines for iintensified case finding and INH
  prophyoaxis in Resource constrained settings
• lt http//whqlibdoc.who.int/publications/2011/97892
  41500708_eng.pdf gt

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Process to promote PPM

1. Situation analysis
2. Steering committee
3. Guildelines
4. Implement
5. Supervise
6. evaluate

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What factors influence TB rates

• For a long time the sole measures were the
  elements of program, the presence of a plana
  manual, an adequate supply of drugs, a quality
  assured laboratory, a recording and reporting
  system, and training of health workers. These
  elements were known as DOTS

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DOTS is essential , but not sufficient for
ELIMINATION
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Summary

• 2 billion infected
• Annual cases 8-9 milliononly 6.2m reported, 80
  in low income countries Annual deaths 1.1
  million
• And yet TB is---
• Totally curable, easily preventable, at low cost
  13-25
• Proven management strategy (2-300/case)
• Challenges
• HIV co-infection estimate gt1.million need to find
  and treat
• Increasing MRD, few cultures and DST labs
• Need to support health services infrastructure
  and communities
• Need for new diagnostics, drugs and vaccine to be
  affordable and accessible
• Funding about 5 Billion annually plus MDR Scale
  up