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End TB strategy target setting Philippe Glaziou Manila, December 2014.

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Presentation on theme: "End TB strategy target setting Philippe Glaziou Manila, December 2014."— Presentation transcript:

1 End TB strategy target setting Philippe Glaziou Manila, December 2014

2 Outline Rationale for global projections post-2015 TB burden assessment Country targets –Short-term (3-5 years) –Long-term (≥10 years)

3 Decline in TB burden in England and Wales TB mortality TB incidence -3%/year

4 CFR in England and Wales Global CFR : 1.5 million deaths / 9 million incident Chemotherapy introduced Global CFR in 2013

5 Slow decline in global incidence, faster decline in mortality Incidence Mortality (including HIV) Falling 2% per year (2007-2013) Falling 4.7% per year (2007-2013)

6 Why is global TB incidence declining so slowly?

7 Average lifetime risk of disease 5- 15% * World 7 billion Infected ≈2.3 billion Disease ≈9 million/yr * Am J Epidemiol Vol. 152, No. 3, 2000

8 Tools required for mitigating infection Mass Screening and Treatment may stop transmission but not TB reactivation Mass Prophylactic Treatment –IPT prevents 70% of reactivation in HIV-neg Safety on a mass scale? (4-7/100,000 fatal hepatitis) Millard PS et al. West J Med. 1996 Jun;164(6):486-91. Mass Post-Exposure Vaccination

9 Business as usual Global TB incidence rate -2%/year

10 Optimize use of current tools, universal access, social protection Business as usual -10%/year -5%/year -2%/year

11 R&D pipelines No point of care test yet 2 new drugs, little epi impact anticipated 15 vaccines in development New vaccine not likely until 2024 (AERAS)

12 Beyond 2025 Potential impact of vaccine – Introduced in 2025 – 60% post-exposure efficacy – 95% coverage reached after 10 years – Assess year by which epidemic of TB could be "ended" ~2 7+ billion TB disease

13 Technological breakthrough by 2025 addresses the pool of infection Business as usual Optimize current tools Post-exposure vaccine ± safe PT "End the global TB epidemic" -10%/yr -2%/yr -5%/yr -17%/yr

14 Goal: End the global TB epidemic 2025 and 2035 TB targets TB incidence TB deaths Rate per 100,000 population Millions 10 per 100,000 -75% vs. 2015 -95% vs. 2015

15 Estimating TB incidence National incidence surveys impractical Best documented through state-of-the art TB surveillance. Estimates are uncertain due to –Under-reporting –Under-diagnosis Estimation from tuberculin surveys not satisfactory Prevalence surveys

16 Capture-recapture in Iraq 1980 detected, under-reporting = 16% 473 additional cases estimated (394–565)

17 How else can we estimate incidence? -From results of prevalence surveys

18 mortality cure Untreated Treated Method 1 – deterministic model

19 Method 1 UTPrevalence (per 1000) Duration (year) Incidence (per 1000/yr) Myanmar 2009 300796.1 (5-7.5)1.8 (1.1-1.6)3.3 (2-4.8) Thailand 2012 136602.5 (1.9-3.5)1.1 (0.5-1.6)2.3 (1-3.5) Indonesia 2013 4071226.6 (5.2 – 8.1)1.6 (1 – 2.2)4.1 (2.4 – 5.8) π ~ U (0, 0.1)

20 Method 2 Reverse WHO method to estimate prevalence from incidence based on standard assumptions about disease duration (4 case categories) –Notified HIV- ~ U (0.2 - 2) year –Not notified HIV- ~ U (1 - 4) year –Notified HIV+ ~ U (0.01 – 1) year –Not notified HIV+ ~ U (0.01 – 0.2) year

21 Incidence in Indonesia (2013), ensemble model Method 2 (duration) Method 1 (dynamic) Ensemble 402 (276 - 552) per 100,000/year

22 Data on TB deaths (HIV-) from vital registration

23 Sources of data Best sources of data on TB burden are –TB notifications when data meet quality criteria and under-reporting low and documented –TB mortality from Vital Registration with COD –Prevalence from national prevalence surveys Impact assessment methods tailored to the existing data 2015: meeting the WHO task force on TB impact measurement to review methods to evaluate the 2015 targets achievement

24 Short-term targetting (3-5 years) Monitor progress towards set target Use a directly measured indicator –Not incidence, not CDR, because in most cases it will not be possible to state whether the country is on track –Mortality if Vital Registrations or sample VR –Prevalence if repeat survey within the programme cycle –Case notifications –Treatment success

25 Adaptation at country level Short-term targets (2016-2020) –Based on a thorough epi analysis, standards and benchmarks for surveillance –Assessment of planned actions Long-term targets (2025, 2035) –Project incidence and CFR over time –Target for catastrophic cost achieved if universal access is achieved

26 In conclusion Ambitious post-2015 global targets Country adoption of targets: –Evaluate surveillance system –Projections Short-term, programme planning based on measurable indicators Long-term, based on indicators that will become measurable –Acceleration of the decline in incidence –Improvements over the case fatality ratio (% of incident cases who die from TB)  faster decline of TB mortality

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