Global TB control

Progress and challenges

Reaching all TB patients

Quality TB care for all

DOTS Expansion Working Group

Paris 15 October 2008
Léopold BLANC WHO/STB/TBS
Estimated TB incidence rate, 2006

West Pacific 21%

Africa
Estimated new TB cases
(all forms) per 100 000 31%
population
No estimate Americas 4%
0–24
SE Asia 34%
25–49 East Mediterranean 6%
50–99
100–299
Europe 5%
300 or more
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Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
 WHO 2006. All rights reserved
Global TB Control Targets

2015: Goal 6: Combat HIV/AIDS, malaria and other diseases

Target 8: to have halted by 2015 and begun to reverse the
incidence…
Indicator 23: incidence, prevalence and deaths associated with TB
Indicator 24: 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)
Latest global TB estimates - 2006

Estimated Cases
number of reported
cases DOTS

All forms of TB 9.15 million 5.27 million

Greatest number of cases in Asia;
greatest rates per capita in Africa
(139 per 100,000) (80 per 100,000)

New Smear positive 4.1 million 2.5 million

(61%)
Multidrug-resistant
TB (MDR-TB) 489,000 23,353

HIV-associated TB 709,000 (8%) ??

DOTS and overall SS+ case detection
a flattening curve

80 2.5 million
all notified detected and
DOTS notified out
60 of 4.1 million
estimated

Global Plan:
40 100
77 69 65% in 2006
80 67
60 52 52 46 78% by 2010
40
20
20 0

0
1990 1995 2000 2005 2010
Treatment success target reached in
2005 (globally, DOTS programmes)

86 85
84
83
82 82 82
82 81
80
Percentage

2.34 million
79 79
78 77 77
244,662

74

70
1999
1997
1998

2000
2001
2002
2003
1994
1995
1996

2004
2005
Europe: 71%, Africa: 76%, Americas: 78%
TB prevalence and mortality

350
Prevalence Mortality
35
Cases per 100,000 population

300

Deaths per 100,000 population

30
250
25

200 20

150 15
Target = 148 Target = 14
100 10
Total deaths from TB
50 5
in 2006 = 1.65 million
0 0
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

Falling… but need to fall faster to reach targets

Incidence rates stable or falling slowly
Cases in millions
10
8
400 9.15
6
4
350 2
Africa
0
Cases per 100,000 population

300
South-East Asia
250
WORLD
200
Western Pacific
150
Eastern
100 Mediterranean
Europe
50
Americas
0
The STOP TB Strategy

1. Pursue high-quality DOTS expansion and enhancement

• Political commitment with increased and sustained financing
• Early case detection through quality assured bacteriology
• Standardised treatment, with supervision and patient support
• An effective drug supply and management system
• Monitoring & evaluation system, and impact measurement

2. Address TB-HIV, MDR-TB and other challenges

 TB/HIV collaborative activities
 Prevention and control of multidrug-resistant TB
 Addressing TB contacts, prisoners, refugees, and other highly vulnerable groups and special situations

3. Contribute to health system strengthening

 Active participation in efforts to improve system-wide policy, human resources, financing, management, service
delivery, and information systems
 Sharing of innovations that strengthen systems, including the Practical Approach to Lung Health (PAL) and infection
control in congregate settings
 Adaptation of innovations from other fields

4. Engage all care providers

 Public-public, and public-private mix (PPM) approaches, including NGOs, FBOs and professional societies
 International Standards for TB Care

5. Empower people with TB, and communities

 Advocacy, communication and social mobilization
 Community participation in TB Care
 Patients' Charter for Tuberculosis Care

6. Enable and promote research

 Programme-based operational research and introduction of new tools into practice
 Research to develop new diagnostics, drugs and vaccines
 The Stop TB strategy in a framework
Political commitment with
2. TB-HIV, TB contacts,
increased and sustained
prisoners, refugees,
financing
vulnerable groups,
special situations

1. High quality DOTS (ISTC)

Susceptible or resistant (MDR-XDR)
adult or children
5. Empower • Case detection through quality 3. Contribute to HSS
people with TB, assured bacteriology
communities HR , Financing, PAL,
• Effective (std) treatment, with Laboratory, IC etc…
ACSM, CTBC, supervision and patient support
Patient charter
• Effective drug supply and
management system
• Monitoring & evaluation system,
impact measurement
4. Engage all
6. Enable and promote research care providers
New diagnostics, drugs, vaccines (PPM)
Re-tooling, OR
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….
Contribution of case recovery into the NTP by
different care providers, Yogyakarta, 2000-2004

Courtesy: Dr Jan Voskens, KNCV, Indonesia

Contribution of case recovery into the NTP by
different care providers, Mumbai, 1999-2003

70

60
40% increase by PPM
Annualised rate NSP / 100,000

providers
50

TB hosp DOT
40
NGOs
Med colleges DOT
30 Mumbai PP
Mumbai RNTCP
20

10

0
1Q1999

2Q1999

3Q1999

4Q1999

1Q2000

2Q2000

3Q2000

4Q2000

1Q2001

2Q2001

3Q2001

4Q2001

1Q2002

2Q2002

3Q2002

4Q2002

1Q2003

2Q2003

3Q2003

4Q2003
Quarter

Source: RNTCP, Mumbai, India

Contribution of case recovery into the NTP by
different care providers, Bangalore, 1999-2005

160
Annualised rate of ss+ cases diagnosed per 100,000

140

120
NGO
100 Private
Corporate
80
Medical college
60 Other Government
Health Department
40

20

0
99q1

99q3

00q1

00q3

01q1

01q3

02q1

02q3

03q1

03q3

04q1

04q3

05q1

05q3
Quarter

•Public and private medical colleges (yellow) diagnose a huge number of cases, but many of them are from outside the city
and need to be refereed for treatment elsewhere.
•The increase in diagnosed cases represents increased notification after medical colleges and other providers started to
report to NTP in a standardised way
The stop TB strategy not
broadly implemented

• TB/HIV: systematic provision of HIV test not yet widely

implemented in areas with high HIV prevalence
• MDR-TB management limited to small projects except in
few countries
• Involvement of non public health care providers in TB
control still limited (scaling-up PPM in only few countries)
• Human resources crisis in Africa in particular
• Community involvement still timid in many countries.
Patients groups just starting
• Patient charter available in very limited number of
countries
Key issues

• Case notification not increasing in many settings

• >= 85% success rate obtained in many DOTS countries

• Need to accelerate efforts in TB control by:

– continue increasing treatment success
– aiming at reaching all TB patients
– shorten diagnostic delay (cut transmission, reduce suffering): no
indicator of delay in diagnostic

• A proposed framework to identify required actions to

improve case detection and reduce delays
Conceptual framework for improved and
early case notification/detection
TB and Poverty DOTS / MDR/HIV
PPM
HSS/HR
Expansion
ACSM Minimize
Effective TB screening in Paediat. TB
Health access
health services, on broader
Community education barriers
indication
PAL
engagement
Symptoms Patient Health care Improve Lab
recognised delay utilisation diagnostic Srtength
quality, new
tools

Short-cut
Active TB Active case finding Diagnosis Improve
referral
Contact Clinical risk Risk and
investig groups populations notification
Infected -Children -HIV -Prisons Notification systems
-Other risk -Previous TB -Urban slums
groups -Malnourished -Poor areas
-All household -Smokers -Migrants New diagnostic tools
TB determinants -Workplace -Diabetics -Workplace
-Wider -Drug abusers -Elderly Infection control
TB/HIV
 Proposing a framework for
priority setting

1. Intensify effective case identification on broader indications and ensure current policy is
followed throughout health system

2. Target cases already diagnosed but not notified under DOTS

– Expansion / intensification of DOTS, MDR-TB management, PPM, TB/HIV
– Improve referral and notification systems, regulation and enforcement

3. Improve diagnostic capacity and quality (in whole health system)

– Effective use of existing tools for diagnosing drug-susceptible and drug-resistant TB
– Implement new tools

4. Reinforce current strategy for active case finding and broaden it

– Broaden contact investigation
– Broaden indication for screening of additional clinical risk groups beside HIV
– Screening in risk populations in particular HIV infected persons
– Reinforce household contact investigatio

5. Improve health education and social mobilization to improve knowledge and rational
health seeking