1. La tubercolosi nel terzo millennio
Lucio Casali
Firenze, 21 novembre 2015 1

2. The Global Burden of TB - 2013
Estimated number of cases
Estimated number of deaths
1.5 million*
in children
in women
9 million
126 per 100,000
550,000 in children
3.3 m in women
480,000
All forms of TB
Multidrug-resistant TB
HIV-associated TB
1.1 million (13%)
360,000
210,000
Source: WHO Global TB Report * Including deaths attributed to HIV/TB

3. TB cases and deaths in slow decline, 1990-2013
Total mortality peaked in 2002 at 1.7 million
1.5 million in 2013
Incidence peaked at 9.5 million in 2004
9 million in 2013
All TB deaths

4. Accelerating response to TB/HIV means cutting suffering, transmission and mortality
Estimated HIV prevalence in new TB cases, 2013
78% of TB/HIV cases in Africa
Ref: Global TB Control Report 2014
Other co-morbidities emerging in other regions
Workshop for 18 high-priority countries of the WHO European Region on recording and reporting of drug resistant tuberculosis

5. Addressing MDR-TB as a crisis The “orphan” disease
Percentage of new TB cases with MDR-TB
Ref: Global TB Control Report 2014
Highest % in the former USSR countries
India, China, Russia, Pakistan and Ukraine
have 60% of all MDR-TB cases
Workshop for 18 high-priority countries of the WHO European Region on recording and reporting of drug resistant tuberculosis

6. …mostly, the most vulnerable
Who carries the burden of tuberculosis?
…mostly, the most vulnerable
TB spreads in poor, crowded & poorly ventilated settings
510,000 women and 80,000 children die of TB each year; 10 million “TB” orphans
Migrants, prisoners, minorities, refugees face risks, discrimination & barriers to care
TB linked to HIV infection, malnutrition, alcohol, drug and tobacco use, diabetes

8. Poverty-disease trap as applied to TB
Health in all policies, UHC, public health
TB diagnosis and treatment
Wealth and wealth distribution
Undernutrition
Poor housing
Risk factors for infectious diseases and NCDs
Poor health care access TB
Poverty
Social and financial support
Worse health and stigma – loss of income
Catastrophic health expenditure:
10-50% of annual income lost!

9. Patient
Total
Health C.S.

10. Conclusion
This review suggests that there is an unacceptable time delay before the diagnosis of pulmonary tuberculosis is made.
There is a need to revise the current case finding
strategies.

11. Global progress on impact - 2013
37 million lives saved since 2000
Reduction in TB mortality rate 45% since 1990
Incidence falling slowly (1.5%/yr):
2015 MDG on track
4.8 million lives saved since 2005 through TB/HIV collaborative activities
86% cure rate
61 million patients cured,

12. Challenges: Priorities for action 2015
Reaching the “missed” cases
(3 million not in the system)
Address MDR-TB as crisis
Accelerate response to TB/HIV
Increase financing to close
resource gaps
Intensify research and ensure rapid uptake of innovations

13. Share of total missed cases India: 1 million cases “missed”
Reaching the "missed" cases early means cutting transmission (nearly 3 million not diagnosed or reported)
Share of total missed cases
9 million estimated
6 million notified
10 countries account for 74% (2.4 million) of the estimated “missed” cases globally
India: 1 million cases “missed”
Estimated incidence
Global notifications
Ref: Global TB Control Report 2013

14. Vision, goal, targets, milestones
Vision: A world free of TB
Zero TB deaths, Zero TB disease, and Zero TB suffering
Goal: End the Global TB epidemic (<10 cases per 100,000 population)
INDICATORS
MILESTONES
TARGETS
2020
2025
SDG 2030
End TB 2035
Reduction in number of TB deaths compared with 2015 (%)
35%
75%
90%
95%
Reduction in TB incidence rate compared with 2015 (%)
20% (<85/ )
50% (<55/ )
80% (<20/ )
90% (<10/ )
TB-affected families facing catastrophic costs due to TB (%)
Zero

15. The End TB Strategy: 3 pillars and 4 Principles
Bold policies and supportive systems
Integrated, patient-centered TB care and prevention
Intensified research and innovation
Government stewardship and accountability, with monitoring and evaluation
Building a strong coalition with civil society and communities
Protecting and promoting human rights, ethics and equity
Adaptation of the strategy and targets at country level, with global collaboration

18. Le nuove metodiche diagnostiche
La più recente novità nella diagnosi di laboratorio è il GeneXpert

19. Le nuove metodiche diagnostiche

20. Xpert MTB/RIF: performance
Hot-spot gene rpoB
Campioni clinici
Identificazione casi di TBC
Specificità %
Sensibilità %, BAAR-pos.
75-84%, BAAR-neg.
Identificazione casi resistenti alla rifampicina
Specificità 97-99%
Sensibilità 91-97%
Casi di co-infezione TBC-HIV
Sensibilità 86% (HIV-neg: 92%)
Boehme CC et al Lancet 377(9776):
Theron G et al Am J Respir Crit Care Med 184:

21. Political commitment needs to be backed by financing
IMPLEMENTATION
$2 billion
Funding gap
RESEARCH
$677 M
$1.32 billion
Funding gap
$8 billion funding required for TB prevention, diagnosis and treatment
$2 billion funding required for research and development
TAG TB R&D report 2013
Workshop for 18 high-priority countries of the WHO European Region on recording and reporting of drug resistant tuberculosis

22. Funding gaps, US$ billions by region
Rest of
the World
Biggest gaps in Africa: 59% of total gap,
19%
Gap in Asia could be bigger if domestic funding (in India, Indonesia, Philippines etc.) does not grow at projected level
Africa
Asia
22%
59%
Smaller gaps in Rest of World but critical to fill for MDR response and quality TB care, esp. in Europe
Rest of World
Africa
Asia
This slides shows the funding needs and gaps by Regions. Again there are 3 points to highlight here:
CLIC: The first is that Africa accounts for the biggest share of the total gap - 59%;
CLIC: The second is that Asia accounts for 22% of the gap, although, as I pointed out on the previous slide, this gap will be bigger if the domestic funding projections used for the demand forecast do not materialize in practice. For instance, we assume that some governments in large countries in Asia will keep their commitment to progressively move towards full financing from domestic sources. If this does not happen, the gap will be large, even in growing economies.
The third point is that the gaps look relatively small in other parts of the world such as Eastern Europe, but I need to emphasize that it is critical to fill these gaps to respond to the MDR-TB epidemic and to ensure provision of high quality TB care, within reformed and better systems, that prevents MDR-TB from arising.

23. Impact if funding gap closed: lives saved
Millions
Millions
Lives saved (TB)
Lives saved (MDR-TB)
0.2 million
Status Quo
Status Quo
This slide shows the impact in terms of lives saved if there is full funding for the period compared with a status quo scenario, meaning a flat line.
With full funding, an extra 1.2 million lives will be saved.
In addition, if we stick with the status quo, there will be a failure in our global response to MDR-TB and a failure to adopt innovations, especially rapid diagnostic tests for TB and MDR-TB that we are strongly promoting.
Can we really afford that??
Status quo implies:
1.2 million lives lost
Failure in MDR response
Failure to adopt rapid diagnostic tests

27. ACTIONS NEEDED ON ALL FRONTS FROM PREVENTION TO CURE
Five priority actions to address the global MDR-TB crisis
ACTIONS NEEDED ON ALL FRONTS FROM PREVENTION TO CURE

29. Projected acceleration of TB incidence decline to target levels
Current global trend: -1.5%/year
Average -10%/year
by 2025
Optimize use of current & new tools emerging from pipeline, pursue UHC and social protection
The 10% per year fall in incidence that is needed by 2025 has been previously achieved only within the wider context of UHC and broader social and economic development. UHC means providing all people with access to needed services of sufficient quality to be effective, without their use imposing financial hardship. Progress in the countries with the highest burden today, such as China, India, Indonesia, Nigeria and South Africa will strongly influence whether targets can be achieved or not. To lower cases to 10 per 100,0000 population by 2035 ("end the global TB epidemic") and achieve a 95% reduction in TB deaths by 2035 will need a technological breakthrough by 2025 that will allow an unprecedented acceleration in the rate at which TB incidence falls between 2025 and This will only happen with substantial investment in R&D in the years up to 2025, so that new tools such as a post-exposure vaccine or a short, efficacious and safe treatment for latent infection that could substantially lower the risk of developing TB among the approximately 2 billion people that are already infected, are developed.
Introduce new tools: a vaccine, a new easier prophylaxis & treatment regimen, a PoC test
-5%/year
Average
-17%/year