5Prevelance of infection About one-third of the world‘s population is infected with TB bacillipeople have been infected by TB bacteria but are not (yet) ill with disease and cannot transmit the disease.
6After 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.
7results in transmission of the bacteria to others active TB (disease)delays in seeking care/diagnosis/treatmentresults in transmission of the bacteria to others
8People ill with TB (active case) can infect up to people through close contact over the course of a yearWithout proper treatment up to two thirds of people ill with TB will die.
9Natural history of TB Factors Agent factors Host factors Social factors
10Agent 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 yearsAgent FactorsAgentSource of infectioncommunicabilityTransmitted by droplet nucleiTB 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.
11Host factorsAfter 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 TBHost FactorsAll age groupsMales>FemalesNutritionİmmunityHost susceptibility is universal, but the risk of infection is directly and mainly related to the degree of exposure.
12Over-crowded living con. Social factorsSocial FactorsPopulation explosionOver-crowded living con.Under- nutritionLack of education
13Incidence 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
142011 Data-Turkey Incidence: 24/100K (WHO estimate) Patients in total: (21/100K) registeredPatients in total in Istanbul: (36/100K) registeredNew cases in Istanbul: AFB+ patients: (registered)
15TB mortality risk factors Site (higher in positive smear)Type of disease (association to…)Timeliness of diagnosis and treatmentAppropriate diagnosisMistake in reading X-raysMistake in interpreting signs and symptomsTimely/Delayed diagnosisTimely/Delayed treatmentQuality of treatment
17Some factsTB 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 HIV22 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-TBThe largest number of new TB cases occurred in Asia, accounting for 60% of new cases globallyFunding is inadequateOver 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.
18Estimated number of cases Estimated number of deaths 8.7 million( million)1.1 million (13%)( million)Up to 0.5 million1.4 million( million)430,000(400, ,000)Unknown, but probably>150,000All forms of TBHIV associatedTBMDR-TB
20TB cases, deaths, 1990-2011 Incidence Mortality All cases Peak > 9 million in early 2000s, 8.7 million in 2011Total mortality peaked early 2000s at >1.8 million1.4 million in 2011millionsHIV+ casesHIV+ mortality
21TB/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
22Distribution of MDR-TB among new TB cases, 1994-2011
23Number of MDR-TB cases, 2011 Russian Federation 44,000 (14% of global MDR burden)Ukraine 9,000Based on survey dataPakistan 10,000(3% of global MDR burden)China61,000(20% of global MDR burden)India66,000(21% of global MDR burden)South Africa 8,100Based on survey data
24To date, 84 countries that reported XDR-TB About 9% of MDR-TB cases are XDR
251. Pursue high-quality DOTS expansion 2. Address TB-HIV, MDR-TB, and needs of the poor and vulnerable3. Contribute to health system strengthening4. Engage all care providers5. Empower people with TB and communities6. Enable and promote researchGoal 6: to have halted by 2015 and begun to reverse the incidence…2015: 50% reduction in TB prevalence and deaths compared to 19902050: elimination (<1 case per million population)
26Global 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
30Risk 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
31Risk and Prevention-2 Risk and Prevention-2 Person A Medication (DOT) Isolation<4 yearsAt nightSurgical maskPerson BSpaceNatural ventilation/fanAir purifying respirator (N95)Ultra Violet Germicidal Irradiation (UVGI)High Efficiency Particulate Air (HEPA) FilterNegative pressure
32TB CONTROL TB Control Detection and treatment of cases Treatment of latent infectionVaccination
33The 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.
34Tuberculosis prevention and control programs 1994 “Directly Observed Treatment, Short Course” (DOTS) strategyeach country to detect smear-positive TB casesoffer standardized DOT ,with the objective of curing over 85% of TB patients.
35DOTS DOTS Governmental commitment to TB Control Reliable and continious supply of high-quality Anti-TB drugsMicrobiologic confirmation of TB diagnosisSupervision (DOT) of standardized short course Anti-TB theraphy-at least during the initial phaseSystem for registration and follow-up
36What can DOTS do What can DOTS do? Increase treatment completion and cure ratesReduce the emergence of drug resistant TBImprove cost-effectivenss of TB ControlReduce TB incidence in conjunction with other interventions.
37Challenges Challenges HIV epidemic MDR-TB, XDR-TB Health system weakness and political willPoor infrastructure and lack of supportPrivate practitionersPrisons
38DOTS 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.
39DOTDOTDOT can lead to reductions in relapse and acquired drug resistance
40Tuberculosis Prevention and Control Program in Turkey Main strategies include:BCG vaccinationCase findingEffective chemotheraphyHealth educationChemoprophylaxisMonitoring and evaluation systemIn 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
41BCG vaccinationBCG 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.
42Case findingThe 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.
43Chemoprophylaxis Chemoprophylaxis Primary prevention Decrease incidence rate of TBBy using Isoniazid (INH)
44Tuberculosis 1Tuberculosis control and elimination 2010–50: cure, care, and social developmentKnut Lönnroth, Kenneth G Castro, Jeremiah Muhwa Chakaya, Lakhbir Singh Chauhan, Katherine Floyd, Philippe Glaziou, Mario C Raviglione
45Challenges to “elimination” Commitment by governments and stakeholders fluctuatingFunding not secure; catastrophic costs for the poor un-resolvedOnly 2/3 of estimated cases reported or detectedTB/HIV major impact in AfricaMDR-TB, with high burden in former USSR , China etcUn-engaged non-state practitionersSocial and economic determinants maintaining TBResearch in need of intensification and investments
472- Funding Funding gap vs Global Plan ~ US$2–3 billion per year Funding gaps reported by countries US$0.7 billion in 2013US billions dollars
483- The case detection/notification gap Global notifications Estimated incidence3: The case detection/notification gap Nearly 3 million TB cases either not notified or not detected8.77.8TB cases (millions)5.83.7
49GeneXpert 85 countries using it by mid-2013 Innovating with GeneXpert essential, but not sufficient to solve the case detection gap85 countries using it by mid-2013
504- Responding to the TB/HIV epidemic The WHO policy on collaborative TB/HIV activities
514- Responding to TB/HIV epi. through collaborative efforts
52The New England Journal of Medicine 5- Responding to MDR-TBThe New England Journal of MedicineMDR Tuberculosis — Critical Steps for Prevention and ControlEva 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
53WHA resolution 2009 (22 May) includes all essential policies
546- Unregulated private sector Private sector is first point of care in many settings. India: 70% of people with cough go first to private practitionersDiverse network of formal and informal providers ranging from hospitals and corporate sector to the traditional healers and quacksPrivate sector engagement crucial in closing the gap on case detectionContribution to finding people with TB between 10%-40% in countriesCollaboration exists but still not enough in many settings. Efforts need to be made on both ends
557- Alleviation of risk factors & soc-economic determinants RR for active TBWeighted prevalence (22 HBCs)Population attributable fractionHIV infection20.6/26.71.1%19%Malnutrition3.216.5%27%Diabetes3.13.4%6%Alcohol use (>40 g/day)2.97.9%13%Active smoking2.618.2%23%Indoor air pollution1.571.1%26%
568- Intensive investments in R&D to develop new tools Diagnostic Vaccine TreatmentSputum smear microscopy BCG st-line TB drugsDiscovered Developed 1920s Discovered
578- 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 envisagedDrugs: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 yearsVaccines:11 vaccines in advanced phases of development;1 just reported with no detectable efficacy
588. 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 today2.Basic research is fundamental to gain further knowledge and R&D pipelines must be expanded, nurtured and well-financed3.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