Regional efforts in controlling TB: progress and challenges for future 2nd National conference on the national response to TB epidemic: 10 main TB challenges and ways to combat them Kyiv, 13-14 November 2007 Pierpaolo de Colombani Medical Officer WHO-EURO, DHP/CDS/TUB

Regional efforts in controlling TB: progress and challenges for future Topics: Overview of TB epidemiology Progress towards the TB targets Challenges for TB control in EEUR Opportunities for TB control in EEUR

Estimated TB burden; world, 2005 8.8 million new TB cases (>80% in Asia and sub-Saharan Africa) 1.6 million TB deaths (195 000 due to TB/HIV) TB incidence stable or in decline in all six WHO regions 424 000 MDR-TB cases (MDR-TB in 102 of 109 countries surveyed in 1994-2002) 27 000 XDR-TB cases

Estimated number of TB cases; world, 2005 Estimated number of new TB cases (all forms) No estimate 0–999 1000–9999 10 000–99 999 100 000–999 999 1 000 000 or more WHO. Global tuberculosis control: surveillance, planning, financing; WHO report 2007. Geneva: WHO (WHO/HTM/TB/2007.376)

Estimated incidence of TB; EUR, 2005 50 / 100 000 average in the region 5 - 198 / 100 000 range Norway - Tajikistan 445,000 number of new TB cases 66,000 number of deaths due to TB TB cases (all) per 100,000 pop. < 10 10-24 25-74 75-124 125-198 WHO. Global tuberculosis control: surveillance, planning, financing; WHO report 2007. Geneva: WHO (WHO/HTM/TB/2007.376)

Trend in notification of TB; EUR, 1980-2005 The notification rate of TB cases to WHO during the years 1980-2005 can provide a first overall picture of TB in the European Region: In 2005, the average TB notification rate for all WHO European Region was 41 new TB cases per 100 000 population, with a trend during the years basically reflecting the epidemiology in eastern Europe and in the Russian Federation. In eastern Europe, the TB notification rate has reached 79 per 100 000 population, with a levelling-off during the last years. The socioeconomic crisis and the deterioration of medical infrastructure in the countries of the Former Soviet Union during the 1990s contributed to the dramatic increase in TB notification rates, with increasing levels of MDR-TB and HIV-related TB (TB/HIV). In the European Union, the TB notification rate has had a decreasing trend since the early 80's, with some fluctuations seen after the admission of new member countries.

18 high-priority countries for TB control in East EUR (EEUR) TB burden and priority for action; EUR, 2005 Number of new estimated TB cases indicated by the size of the bubble 18 high-priority countries for TB control in East EUR (EEUR) 1. Armenia 2. Azerbaijan 3. Belarus 4. Bulgaria 5. Estonia 6. Georgia 7. Kazakhstan 8. Kyrgyzstan 9. Latvia 10. Lithuania 11. Moldova 12. Romania 13. Russian Fed. Tajikistan Turkey 16. Turkmenistan 17. Ukraine 18. Uzbekistan 170 000 46 000 According to the latest estimates, there were 445 000 new TB cases and almost 66 000 deaths associated with TB in the WHO European Region, in 2005. Seventy-five percent of the new cases of disease were in eastern Europe, with a distribution shown in this map according to the size of the red bubble. In Russian Federation only, it is estimated that 170 000 new TB cases occur in a year. In our context, for eastern Europe we refer to the TB epidemiological sub-region composed by 18 countries of high-priority for TB control in the WHO European region: Armenia, Azerbaijan, Belarus, Bulgaria, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Republic of Moldova, Romania, Russian Federation, Tajikistan, Turkey, Turkmenistan, Ukraine and Uzbekistan (in orange colour in the map). In these 18 countries, the National TB control programmes continue to perform poorly due to factors such as lack of political will; socioeconomic deterioration; poorly developed health systems with poorly trained and motivated staff; insufficient integration of TB services; emergence of drug resistant TB; increasing levels of HIV infection; large penitentiary system with poor TB and other services; incomplete engagement of all health care providers and poor involvement of civil society. WHO. Global tuberculosis control: surveillance, planning, financing; WHO report 2007. Geneva: WHO (WHO/HTM/TB/2007.376)

The global targets for TB control By 2015 (Millennium Development Goals) Goal 6: combat HIV/AIDS, malaria and other diseases Target 8: to halt and begin to reverse the incidence of malaria and other major diseases (such as TB) Indicator 23: prevalence and mortality associated with TB Indicator 24: detection and cure of TB cases under DOTS Impact By 2015 (Stop TB Partnership targets) Prevalence and mortality associated with TB reduced of 50% By 2005 (World Health Assembly targets) - Detection of at least 70% of infectious TB cases - Cure (successful treatment) of at least 85% of detected cases Outcome

Progress on MDG 6 (1 of 2)  TB incidence rate per 100 000 population TB prevalence rate per 100 000 population TB death rate per 100 000 population The TB control targets for the European Region, and for the 18 countries of eastern Europe, are set by the WHO World Health Assembly under the Millennium Development Goal (MDG) n° 6, Target 8: “to have halted and begun to reverse incidence by 2015”. Under this MDG, there are also the additional targets of halving the TB prevalence and death rates, compared with the 1990 year levels, by 2015. 1st graph: based on the trends estimated for the previous years (1990-2005), the incidence of TB in the European Region could be decreased in future, if not already happening. 2nd and 3rd graphs: more challenging are the targets of halving TB prevalence and especially TB death rate in eastern Europe: difficult because these rates were already quite low in 1990 is considering their dramatic increase during the following years. The Global Plan to Stop TB 2006-2015, issued by the Stop TB Partnership last year (2006), suggests that these targets will be reached later than 2015 in eastern Europe and in Africa due to the challenges posed by MDR-TB and HIV-related TB respectively. “Special” efforts are required from all of us to overcome these “special” challenges in our Region.

Progress on MDG 6 (2 of 2) WHO. Global tuberculosis control: surveillance, planning, financing; WHO report 2007. Geneva: WHO (WHO/HTM/TB/2007.376)

Challenges and opportunities for TB control; EEUR Access of DOTS Drug resistance HIV epidemic Health infrastructure Prisons Awareness of TB Berlin Declaration on TB (22 October 2007) Stop TB Strategy Plan to Stop TB in 18 high-priority countries of the European Region Global resources Health system reforms Stop TB Partnership Main challenges for TB control in eastern Europe: low access to international standards TB services (only 46% DOTS population coverage in 2005); high levels of multidrug resistant TB (the top 13 countries with highest multidrug resistant TB incidence in the world are in eastern Europe); growing HIV epidemic which is expected to significantly increase the number of TB cases in the future years; still large pool of prisoners at special risk of TB and HIV; the low awareness and high stigma on TB among people and policy makers. There are also important opportunities to take advantage of: the commitment of all WHO European Region Member States, already expressed in the 52nd Regional Committee (2002) and the follow-up letter of the Regional Director in 2005; the availability of a revised strategy to control TB, The Stop TB Strategy; the international consensus over the Global Plan to Stop TB 2006-2015 and the availability soon of our Regional Plan to Stop TB in eastern Europe; the commendable efforts by most of the countries to modernize their health care systems; the international coordination given by the Stop TB Partnership globally and in Europe; the increasing availability of global resources, including the Global Fund.

Population living in areas with DOTS; EUR, 2005 Population living with DOTS (%) no Stop TB Strategy < 10 10 - 49 50 - 99 100 Note: 100% population coverage by the Stop TB Strategy in 2007 in Russian Federation and Ukraine.

Top 14 sites MDR-TB (all cases); world, 2004 23.4 Kazakhstan 20.1 Estonia 19.5 Georgia 18.9 Moldova 18.8 Azerbaijan 18.5 Uzbekistan 16.8 Russian Fed. 16.4 Lithuania 13.6 Ukraine 11.5 Latvia 10.9 Tajikistan 10.6 Kyrgyzstan 10.4 Belarus 08.9 China Estimated ~ 70,000 MDR-TB cases in EUR Zignol M, Hosseini MS, Wright A et al. Global incidence of multidrug-resistant tuberculosis. JID 2006, 194:479-485.

Countries with confirmed XDR-TB; world, October 2007 Argentina Latvia Armenia Lithuania Azerbaijan Mexico Australia Mozambique Bangladesh Netherlands Brazil Norway Canada Peru Chile Poland China Portugal Czech Rep. Rep. of Korea Ecuador Romania Estonia Russian Fed. France Slovenia Georgia South Africa Germany Spain Ireland Sweden Iran Vietnam Israel UK Italy USA Japan Estimated ~ 10,000 XDR-TB cases in EUR Source: http://www.who.int/tb/xdr/en/index.html (access 9 Oct 2007)

Unsuccessful TB treatment outcome; WHO region, 2004 DOTS Non - DOTS WHO. Global tuberculosis control: surveillance, planning, financing; WHO report 2007. Geneva: WHO (WHO/HTM/TB/2007.376)

New HIV cases notified by EUR area, 1995-04

HIV prevalence among new adult TB cases; EUR, 2005 HIV prevalence in TB cases (%) no information <1 1-5 5-10 >10 HIV prevalence in TB cases with 4.6% regional average Lack of good, reliable and country-wide information Limited collaboration between HIV and TB programmes Different patterns and type of co-infection in W and E Lack of community and activists involvement

Inadequate health systems leading to inequitable access to health services; EUR, 2003 Out-of-pocket (OOPS) spending increasing with decreasing of public spending on health, used as proxy of inadequate health care services Gov’t health spending as a %GDP explains 80% of the variation in the share of OOPS. So while Tajikistan and Norway may share the objective of protecting their populations against financial risk, what they can actually attain in terms of this objective are quite different. Also why it is important to have good data. The latest update of the HFA database has some very different numbers on public and private health spending for many of the countries – we think that prior to this, we were under-stating the problem of financial protection facing many countries in the region. Source: WHO/EURO, Kutzin J.

Top 20 countries with highest prison population rate; world, 1998-05 6 countries from EUR Walmsley R. World Prison Population List, 6th Ed.; 2005. London King’s College, International Centre for prison Studies (http://www.kcl.ac.uk/depsta/rel/icps/world-prison-population-list-2005.pdf)

The Berlin Declaration on tuberculosis Berlin, 22 October 2007 49 country delegations Commitment to: - strengthen TB control - adopt the Stop TB Strategy - ensure sustainable financing

The Stop TB Strategy Pursue high-quality DOTS expansion and enhancement (political commitment, quality bacteriology, guaranteed treatment, ensured drug supply, monitoring and evaluation) Address TB-HIV, MDR-TB and other challenges (prisoners, other risk groups) Contribute to health system strengthening Engage all care providers (public-private, international standards) Empower patients and communities (ACSM, community participation, patients’ charter) Enable and promote research The internationally recommended Stop TB Strategy is the result of the continuous evolution and adaptation of the DOTS strategy to tackle the major barriers to TB control in different country situations. It has six components: 1) Pursue high-quality DOTS expansion and enhancement, under which the 5 components of DOTS (good diagnosis, good and continuous treatment, good recording and reporting, enough resources) ensure international standards of TB care. 2) Address TB/HIV, MDR-TB and other challenges (e.g. prisoners and other disadvantaged people) so relevant to the European Region 3) Contribute to health system strengthening under which national TB programmes should contribute to strengthening all 6 building blocks of health system and should receive its support 4) Engage all care providers including public sector, private sector, academia, nongovernmental organizations (NGO) 5) Empower people with TB, and communities through advocacy-communication-social mobilization activities and promotion of the right in receiving proper care (TB Patient’s Charter) 6) Enable and promote research

The Stop TB Strategy: International Standards for TB Care Diagnosis Standard 1: TB suspicion if 2-3 weeks productive cough Standard 2: always 2-3 sputum samples for microscopy Standard 3: appropriate specimen if extrapulm. TB suspect Standard 4: sputum microscopy in suggestive chest x-ray Standard 5: SS- with microscopy, x-ray, antibiotics; culture Standard 6: SS- children with x-ray, history, skin test; culture Treatment Standard 7: doctor caring of patient’s adherence to treatment Standard 8: standardized regimens, doses, FDC Standard 9: arrangements (incl. DOT) tailored to each patient Standard 10: follow-up with sputum microscopy (2nd,5th,end) Standard 11: written complete medical record maintained Standard 12: HIV counselling and testing (routine or ad hoc) Standard 13: access to antiretroviral treatment Standard 14: assess risk of drug resist., if yes DST for H,R,E Standard 15: 4-drug regiment for 18 months if drug resistance Public health responsibility Standard 16: all contacts screened for latent/active TB Standard 17: reporting of TB detection and treatment outcome 14

The Stop TB Strategy: The Patients’ Charter for TB Care 14

Plan to Stop TB in 18 high-priority countries of the WHO European Region, 2007-2015 The effective implementation of the Stop TB Strategy in eastern Europe is outlined in the “Plan to Stop TB in the 18 high-priority countries of the WHO European Region”, which was discussed with all countries and main TB partners in the region this year and will be finalized soon. The plan is built on the achievement of very challenging milestones, mostly by the year 2010: expand DOTS population coverage to 100%; increase case detection to 73%; cure drug susceptible TB cases according to DOTS to 85%; expand laboratory capacity for anti-TB drug-susceptibility testing to 92% (and to 100% by 2015); properly treat multidrug resistant TB cases to 100%; ensure HIV counselling and testing in TB patients to 85%; and ensure TB care at primary health care level to 70% (and to 95% by 2015). Out of the US$ 14.8 billion needed to implement the Regional Plan, only 45% are estimated will be available. However, governments are requested to increase their allocation of 0.1-0.3% of their annual expenditure per capita for health (which is only US$ 1-3.1 per person) to fill in the financial gap. This effort seems feasible, providing a wide agreement and commitment. The costs of technical assistance might not be covered through the same mechanism. US$ billion Needed 14.8 Available 6.7 Gap 8 (i.e. 1- 3.1 US$ per person by governments)

Global Fund funds increasing for TB control; EUR, 2002-06 US$ million

Health systems: merging interests with Stop TB DOTS (political commitment, quality bacteriology, guaranteed treatment, ensured drug supply, monitoring and evaluation) Leadership and governance Financing TB/HIV, MDR-TB, etc. Health work force Health system strengthening Medical products and commodities Engage all providers The Stop TB Strategy should not be seen as promoting independent services from the general health system of a country but as a strategy that outlines cost-effective interventions of public health impact that should be sustained by the collaboration with the general health system. The main challenge, especially in eastern Europe, is to strengthen the several linkages that national TB programmes implementing the Stop TB Strategy components have and should have with each of the six health system building blocks. Empower patients and communities Information Research Service delivery

Health systems: opportunities for TB delivery at PHC level Suspect TB and react quickly Collect 3 sputum samples from each suspect Smear samples and/or send samples to designed laboratory for microscopy Refer TB suspects for early TB diagnosis Provide directly observed treatment (DOT) Coordinate support to TB patients Trace treatment defaulters Refer patients with adverse drug reactions Keep TB records and reporting Monitor populations at special risk of TB Educate patients, families, community Check TB contacts (symptoms, skin testing) Provide BCG vaccination

Health systems: reform leading to improved TB control TARGET Kyrgyzstan: Manas Taalimi Reform, phase II (2001-2006) Note: progress in new sputum smear-positive cases under DOTS

Stop TB Partnership for Europe