1. Tuberculosis Control
Dr. Yeşim YASİN
Fall-2013

2. Outline What is Tuberculosis (TB)? Burden of TB, TB/HIV, MDR-TB
Strategy, targets, progress
Prevention and Control Programmes of TB
Challenges towards elimination

3. What is TB? One of the oldest diseases known in the history.
It is a preventable and a curable disease if detected and treated early.

5. Prevelance of infection
About one-third of the world‘s population is infected with TB bacilli
people have been infected by TB bacteria but are not (yet) ill with disease and cannot transmit the disease.

6. After a healthy person with a healthy immune system breaths in TB bacteria, he or she will have 10% lifetime chance of developing TB.
Immune-compromised persons have a much higher risk of falling ill.

7. results in transmission of the bacteria to others
active TB (disease)
delays in seeking care/diagnosis/treatment
results in transmission of the bacteria to others

8. People ill with TB (active case) can infect up to people through close contact over the course of a year
Without proper treatment up to two thirds of people ill with TB will die.

9. Natural history of TB Factors Agent factors Host factors
Social factors

10. Agent Factors Source of infection communicability Agent
The most common source of Tuberculosis infection is the human case whose sputum is positive for the tubercle bacilli, and who has either received no treatment for it or not got treated fully. Such sources can discharge the bacilli in their sputum for years
Agent Factors
Agent
Source of infection
communicability
Transmitted by droplet nuclei
TB bacilli have a thick waxy coat,they are slow growing and they can survive in the body for many years in a dormant or inactive state whereby people are infected but show no signs of TB disease.

11. Host factors
After 20 years of age, TB tends to affect more males due to higher exposure to infection and higher prevalence of risk factors.
People who are co-infected with HIV and TB are 21 to 34 times more likely to become sick with TB
Host Factors
All age groups
Males>Females
Nutrition
İmmunity
Host susceptibility is universal, but the risk of infection is directly and mainly related to the degree of exposure.

12. Over-crowded living con.
Social factors
Social Factors
Population explosion
Over-crowded living con.
Under- nutrition
Lack of education

13. Incidence of some selected infectious diseases by years (per 100000 population), Turkey
Tb incidence was calculated by the WHO, tb incidence will be provided once it is published in the global tb report 2011 of the WHO.
Health statistic year book 2010

14. 2011 Data-Turkey Incidence: 24/100K (WHO estimate)
Patients in total: (21/100K) registered
Patients in total in Istanbul: (36/100K) registered
New cases in Istanbul: AFB+ patients: (registered)

15. TB mortality risk factors
Site (higher in positive smear)
Type of disease (association to…)
Timeliness of diagnosis and treatment
Appropriate diagnosis
Mistake in reading X-rays
Mistake in interpreting signs and symptoms
Timely/Delayed diagnosis
Timely/Delayed treatment
Quality of treatment

16. Why worry about TB?

17. Some facts
TB is the second (only to HIV/AIDS) greatest killer worldwide due to a single infectious agent.
8.7 million new cases in 2011; 13% is co-infected with HIV
22 high-burden countries account for 80% of the world’s TB cases.
1.4 million people died: were HIV+
Almost people worldwide lives with MDR-TB
The largest number of new TB cases occurred in Asia, accounting for 60% of new cases globally
Funding is inadequate
Over 95% of TB deaths occur in low- and middle-income countries.
TB is among the top three causes of death for women aged 15 to 44.

18. Estimated number of cases Estimated number of deaths
8.7 million
( million)
1.1 million (13%)
( million)
Up to 0.5 million
1.4 million
( million)
430,000
(400, ,000)
Unknown, but probably>150,000
All forms of TB
HIV associated TB
MDR-TB

19. Incidence rates, 2011

20. TB cases, deaths, 1990-2011 Incidence Mortality All cases
Peak > 9 million in early 2000s, 8.7 million in 2011
Total mortality peaked early 2000s at >1.8 million
1.4 million in 2011
millions
HIV+ cases
HIV+ mortality

21. TB/HIV Coinfection 80% of all TB/HIV cases are in Africa
TB leading cause of death in PLHIV: ¼ of PLHIV worldwide die due to TB.
PLHIV infected with TB: times more likely to develop active TB.
Untreated, TB in PLHIV leads to death in weeks

22. Distribution of MDR-TB among new TB cases, 1994-2011

23. Number of MDR-TB cases, 2011 Russian Federation 44,000
(14% of global MDR burden)
Ukraine 9,000
Based on survey data
Pakistan 10,000
(3% of global MDR burden)
China
61,000
(20% of global MDR burden)
India
66,000
(21% of global MDR burden)
South Africa 8,100
Based on survey data

24. To date, 84 countries that reported XDR-TB
About 9% of MDR-TB cases are XDR

25. 1. Pursue high-quality DOTS expansion
2. Address TB-HIV, MDR-TB, and needs of the poor and vulnerable
3. Contribute to health system strengthening
4. Engage all care providers
5. Empower people with TB and communities
6. Enable and promote research
Goal 6: to have halted by 2015 and begun to reverse the incidence…
2015: 50% reduction in TB prevalence and deaths compared to 1990
2050: elimination (<1 case per million population)

26. Global progress on impact
 51 million patients cured,
 20 million lives saved since 1995
 2015 MDG target on track: global TB incidence rate peaked in early 2000s
 BUT, TB incidence declining too slowly, 1.4 million people still dying, MDR-TB response slow, gaps in financing

28. Prevention and Control of TB

29. A B

30. Risk and Prevention-1 Risk and Prevention-1 1- Cough out TB particles
- strength of cough
(adults>>>children)
2- Live bacteria
- smear + or culture +
3- Cavity

31. Risk and Prevention-2 Risk and Prevention-2 Person A Medication (DOT)
Isolation
<4 years
At night
Surgical mask
Person B
Space
Natural ventilation/fan
Air purifying respirator (N95)
Ultra Violet Germicidal Irradiation (UVGI)
High Efficiency Particulate Air (HEPA) Filter
Negative pressure

32. TB CONTROL TB Control Detection and treatment of cases
Treatment of latent infection
Vaccination

33. The three priority strategies for TB prevention and control programs are:
Identifying and treating individuals who have active TB.
Finding and screening individuals who have had contact with TB patients to determine whether they are infected or have active TB, and providing appropriate treatment.
Screening populations at high risk for TB infection to detect infected persons and provide therapy to prevent progression to active TB.

34. Tuberculosis prevention and control programs
1994 “Directly Observed Treatment, Short Course” (DOTS) strategy
each country to detect smear-positive TB cases
offer standardized DOT ,
with the objective of curing over 85% of TB patients.

35. DOTS DOTS Governmental commitment to TB Control
Reliable and continious supply of high-quality Anti-TB drugs
Microbiologic confirmation of TB diagnosis
Supervision (DOT) of standardized short course Anti-TB theraphy-at least during the initial phase
System for registration and follow-up

36. What can DOTS do What can DOTS do?
Increase treatment completion and cure rates
Reduce the emergence of drug resistant TB
Improve cost-effectivenss of TB Control
Reduce TB incidence in conjunction with other interventions.

37. Challenges Challenges HIV epidemic MDR-TB, XDR-TB
Health system weakness and political will
Poor infrastructure and lack of support
Private practitioners
Prisons

38. DOTS in Turkey DOTs in Turkey
Since 2003 Ministry of Health performed pilot studies for DOTs (Directly Observed Theraphy Short-course).
In 2006 Tuberculosis Control Programme was integrated to primary health care system and DOTs is expanded in Turkey.
DOTs is the medication of the tuberculosis patients directly by the health personnel or a competent person until the full treatment is concluded.

39. DOT
DOT
DOT can lead to reductions in relapse and acquired drug resistance

40. Tuberculosis Prevention and Control Program in Turkey
Main strategies include:
BCG vaccination
Case finding
Effective chemotheraphy
Health education
Chemoprophylaxis
Monitoring and evaluation system
In order to reverse the increasing trend in TB, effective control and prevention is required in all countries.
DOT strategy is the main national strategy in TB

41. BCG vaccination
BCG only at birth (or first contact with health services)
This is the current recommendation of the EPI (Expanded Program on Immunization) and the Global Tuberculosis Programme and is the policy in our country.
BCG protects against serious childhood forms of Tuberculosis, such as TB meningitis and miliary TB.
It may not protect to a high degree against adult pulmonary forms of the disease.

42. Case finding
The aim is to reduce the transmission of TB by screening high risk populations (eg. those at an increased risk of exposure to TB infection, most notably contacts of infectious cases) and to detect and treat active disease earlier than would otherwise occur.

43. Chemoprophylaxis Chemoprophylaxis Primary prevention
Decrease incidence rate of TB
By using Isoniazid (INH)

44. Tuberculosis 1
Tuberculosis control and elimination 2010–50: cure, care, and social development
Knut Lönnroth, Kenneth G Castro, Jeremiah Muhwa Chakaya, Lakhbir Singh Chauhan, Katherine Floyd, Philippe Glaziou, Mario C Raviglione

45. Challenges to “elimination”
Commitment by governments and stakeholders fluctuating
Funding not secure; catastrophic costs for the poor un-resolved
Only 2/3 of estimated cases reported or detected
TB/HIV major impact in Africa
MDR-TB, with high burden in former USSR , China etc
Un-engaged non-state practitioners
Social and economic determinants maintaining TB
Research in need of intensification and investments

46. 1- Lack of commitment

47. 2- Funding Funding gap vs Global Plan ~ US$2–3 billion per year
Funding gaps reported by countries US$0.7 billion in 2013
US billions dollars

48. 3- The case detection/notification gap
Global notifications Estimated incidence
3: The case detection/notification gap Nearly 3 million TB cases either not notified or not detected
8.7
7.8
TB cases (millions)
5.8
3.7

49. GeneXpert 85 countries using it by mid-2013
Innovating with GeneXpert essential, but not sufficient to solve the case detection gap
85 countries using it by mid-2013

50. 4- Responding to the TB/HIV epidemic
The WHO policy on collaborative TB/HIV activities

51. 4- Responding to TB/HIV epi. through collaborative efforts

52. The New England Journal of Medicine
5- Responding to MDR-TB
The New England Journal of Medicine
MDR Tuberculosis — Critical Steps for Prevention and Control
Eva Nathanson, M.Sc., Paul Nunn, F.R.C.P., Mukund Uplekar, M.D., Katherine Floyd, Ph.D., Ernesto Jaramillo, M.D., Ph.D., Knut Lönnroth, M.D., Ph.D., Diana Weil, M.Sc., and Mario Raviglione, M.D.
Review Article

53. WHA resolution 2009 (22 May) includes all essential policies

54. 6- Unregulated private sector
Private sector is first point of care in many settings. India: 70% of people with cough go first to private practitioners
Diverse network of formal and informal providers ranging from hospitals and corporate sector to the traditional healers and quacks
Private sector engagement crucial in closing the gap on case detection
Contribution to finding people with TB between 10%-40% in countries
Collaboration exists but still not enough in many settings. Efforts need to be made on both ends

55. 7- Alleviation of risk factors & soc-economic determinants
RR for active TB
Weighted prevalence (22 HBCs)
Population attributable fraction
HIV infection
20.6/26.7
1.1%
19%
Malnutrition
3.2
16.5%
27%
Diabetes
3.1
3.4% 6%
Alcohol use (>40 g/day)
2.9
7.9%
13%
Active smoking
2.6
18.2%
23%
Indoor air pollution
1.5
71.1%
26%

56. 8- Intensive investments in R&D to develop new tools
Diagnostic Vaccine Treatment
Sputum smear microscopy BCG st-line TB drugs
Discovered Developed 1920s Discovered

57. 8- New tool pipelines in 2013 Diagnostics:
7 new diagnostics or diagnostic methods endorsed by WHO since 2007;
6 in development;
yet no Point of Care (PoC) test envisaged
Drugs:
1 new drug (Bedaquiline) approved in late 2012, but probably little impact on epidemiology;
1 expected to be approved in 2013;
a regimen and other 2-3 drugs likely to be introduced in the next 4-7 years
Vaccines:
11 vaccines in advanced phases of development;
1 just reported with no detectable efficacy

58. 8. Research as the key for elimination
1.For elimination one would need rapid diagnostics at point of care, potent short treatments, mass treatment of latent TB infection (TLTBI), and potent pre- and post-exposure vaccines. None is available today
2.Basic research is fundamental to gain further knowledge and R&D pipelines must be expanded, nurtured and well-financed
3.Increased financial resources for research: the need for research is estimated at 2 billion US$ per year; today, about 650 million US$ are invested.
4.Develop coalitions to maximize outcomes and ensure a continuum of research efforts so that basic science and R&D pipelines are informed by needs, and operational research allows rapid adaptation and introduction in high-burden settings

59. THANK YOU!