1. 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, November 2007
Pierpaolo de Colombani
Medical Officer
WHO-EURO, DHP/CDS/TUB

2. 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

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

4. 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 –
or more
WHO. Global tuberculosis control: surveillance, planning, financing; WHO report Geneva: WHO (WHO/HTM/TB/ )

5. Estimated incidence of TB; EUR, 2005
50 / average in the region
/ 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
WHO. Global tuberculosis control: surveillance, planning, financing; WHO report Geneva: WHO (WHO/HTM/TB/ )

6. Trend in notification of TB; EUR, 1980-2005
The notification rate of TB cases to WHO during the years 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.

7. 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
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 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 Geneva: WHO (WHO/HTM/TB/ )

8. 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

9. Progress on MDG 6 (1 of 2)  TB incidence rate per 100 000 population
TB prevalence rate per population
TB death rate per 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 ( ), 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 , 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.

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

11. 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 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.

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

13. 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:

14. 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: (access 9 Oct 2007)

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

16. New HIV cases notified by EUR area, 1995-04

17. 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

18. 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.

19. Top 20 countries with highest prison population rate; world, 1998-05
6 countries from EUR
Walmsley R. World Prison Population List, 6th Ed.; London King’s College, International Centre for prison Studies (

20. 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

21. 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

22. 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

23. The Stop TB Strategy: The Patients’ Charter for TB Care14

24. 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 % of their annual expenditure per capita for health (which is only US$ 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
Gap 8 (i.e US$ per person by governments)

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

26. 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

27. 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

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

29. Stop TB Partnership for Europe