1. Health Organization The Challenges Facing Tuberculosis Control Blantyre Hospital, Malawi: TB Division, 3 patients per bed

2. The Burden of Tuberculosis, 2009  9.27 million new cases in 2007, 80% in 22 high-burden countries  1.75 million deaths in 2007 and 98% of these in the developing world  0.45 million deaths due to TB/HIV  0.5 million Multi-drug resistant TB (MDRTB) in 2007

3. Estimated TB Incidence Rates 25 - 49 50 - 99 100 - 300 0 - 9 10 - 24 300 or more No Estimate Rate per 100 000

4. 0 50 100 150 200 250 300 350 400 199019921994199619982000200220042006 Cases per 100,000 population Africa South-East Asia WORLD Western Pacific Eastern Mediterranean Europe Americas Cases in millions 0 2 4 6 8 10 19901994199820022006 Incidence rates stable or falling slowly 9.15

5. Incidence Rate trend of pulmonary TB in Saudi Arabia (per 100000) 1999 – 2008

6. Global TB Control Targets 2015: 50% reduction in TB prevalence and deaths by 2015 2050 : elimination (<1 case per million population) 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

7. The DOTS Strategy (1994) Government commitment to TB control Case detection primarily by smear microscopy mostly on self-reporting symptomatic patients Standardised short-course chemotherapy under proper case management conditions, including DOT System of regular drug supply Efficient monitoring system for programme supervision and evaluation

8. DOTS and overall SS+ case detection a flattening curve Global Plan: 65% in 2006 78% by 2010 77 69 67 52 46 0 20 40 60 80 100 W Pacific Americas SE Asia EMR Europe Africa 2.5 million detected and notified out of 4.1 million estimated

9. The gaps in basic TB control! Not all TB cases are detected Not all TB cases are detected early enough Not all TB cases are treated Not all TB cases are treated well enough

10. 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…. What are the key challenges to increasing case detection?

11. The Challenges Facing TB Control Delay in detection of pulmonary TB -difficult access to HC services - Lack of awareness about TB - Fear Delay in reporting TB Cases

12. The Challenges Facing TB Control Deficiencies in protecting contacts - Variations in contact investigation - Difficulties in finding contacts Inappropriate or inadequate therapy Failure to complete therapy (defaults)

13. The Challenges Facing TB Control Imported TB - Immigrants from high burden countries - More delay in TB detection - Impact of social factors Pool of latent TB - Risk of reactivation is 10% in a lifetime - In normal individuals: risk is 0.1% per year - Risk is more with impaired immunity

14. Impact of HIV on TB World Health Organization  Direct:  Reactivation of TB infection acquired before HIV infection (from 10% lifetime to 3-13%/year)  Rapid progression of TB infection acquired after HIV infection  Indirect:  Transmission to the population not infected with HIV

15. MDR-TB: Global Rates Resistance to both INH & Rifampicin Increasing rate 2002 : 272,900 (1.1%) 2007 : 510,500 (4.9%) Estimated 43% of global MDR-TB cases have had prior treatment China, India and Russian Federation accounts for 62% of the MDR burden

16. Transmission of TB Almost always by airborn route Indoors: TB bacilli remain suspended in air for hours At diagnosis ; 30 – 40% of contacts have +ve PPD Infection is dependent on duration of exposure Infection more likely in close contacts of SS+ patients Infectiousness rapidly decreases shortly after starting multiple drug therapy

17. Facing the challenges Early detection and treatment of TB cases: - Easy access to health care - Increase awareness of TB among HC workers - Availability of diagnostic facilities - Availability of effective chemotherapy - Ensuring adherence to standard practice

18. Facing the challenges Reduce incidence of TB among high risk groups: - Contacts of TB patients - Immigrants from high burden countries - Prisoners - Immunocompromised Address MDR TB and HIV Surveillance and monitoring of outcome Engaging all health care providers Promoting research

19. Is TB elimination possible? Slow incidence rate decline Need Substantial advances in diagnosis and therapy: - Better diagnostic tests for TB and latent TB - More effective drugs for treatment - Better vaccines for prevention

21. Impact of drug resistance on TB cure rates with standard 4-drug therapy Espinal, JAMA 2000; 283:2537

22. Global Strategy to Stop TB 2006-2015 1.Pursuing quality DOTS expansion and enhancement Government commitment with long-term planning and adequate resources to reach targets Case detection through bacteriology and strengthening of laboratory network Standardised treatment, under proper case management conditions including DOT and patient support Effective and regular drug supply system Monitoring system for supervision and evaluation, including impact measurement Additional components 2Addressing TB/HIV and MDR-TB 3. Contributing to health system strengthening 4. Engaging all care providers 5. Empowering patients and communities 6. Enabling and promoting research World Health Organization