Global tuberculosis control today: expectations from the PPM Subgroup

Transcription

1 Global tuberculosis control today: expectations from the PPM Subgroup Mario C. Raviglione, M.D. Director, Stop TB Department WHO, Geneva, Switzerland 6 th Meeting of the Subgroup on Public-Private Mix for TB Care and Control Istanbul, Turkey 16 February 2010

2 The global burden of TB in 2008 Estimated number of cases Estimated number of deaths All forms of TB 9.37 million (range, million) 1.3 million* (range, million) HIV-associated TB 1.4 million (15%) (range, million) 0.52 million (range, million) Multidrug-resistant TB (MDR-TB) 0.5 million >150,000 *excluding deaths among HIV+ people

3 Estimated TB Incidence rates, 2008 West Pacific 20% SE Asia 34% Africa 31% Americas 3% East Mediterranean 7% Europe 5%

4 Impact of HIV on TB in Africa 4/5 of all estimated TB/HIV cases are in Africa AFR South Africa SEA India Nigeria Zimbabwe Uganda Kenya Mozambique Ethiopia WPR Zambia AMR United Republic of Tanzania Malawi Côte d'ivoire EUR Myanmar China Democratic Republic of the Congo Brazil Thailand Cameroon EMR 1% 5% 10% 20% 50% 90% Percentage of global estimated HIV-positive TB cases Notified cases per 100,000 pop Botswana 600 Côte d'ivoire DR Congo Gabon 500 Guinea Kenya Malawi 400 Mozambique South Africa UR Tanzania 300 Zimbabwe

5 MDR-TB % among new cases, * Sub-national coverage in India, China, Russia, Indonesia >10.00 No data The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO All rights reserved

6 Countries with at least one confirmed XDR-TB case, as of December 2009 Argentina Burkina Faso Georgia Kenya Nepal Qatar Swaziland Viet Nam Armenia Canada Germany Latvia Netherlands Republic of Korea Sweden Australia China India Lesotho Norway Republic of Moldova Thailand Azerbaijan Colombia Iran (Islamic Republic of) Lithuania Oman Romania Ukraine Bangladesh Czech Republic Ireland Mexico Peru Russian Federation United Arab Emirates Belgium Ecuador Israel Mozambique Philippines Slovenia United Kingdom Botswana Estonia Italy Myanmar Poland South Africa United States of America Brazil France Japan Namibia Portugal Spain Uzbekistan The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO All rights reserved

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

8 The global response: Stop TB Strategy & Global Plan 1. Pursue high-quality DOTS expansion 2. Address TB-HIV, MDR-TB, and needs of the poor and vulnerable 3. Contribute to health system strengthening 4. Engage all care providers 5. Empower people with TB and communities 6. Enable and promote research

9 Treatment success target reached globally: 87% in But not in the Americas, Africa and Europe W Pacific SE Asia 2006 EMR Americas 2007 Africa Europe Successful treatment rate (%) in DOTS cohorts

10 Case detection stagnating globally, gap with Global Plan widening Africa-high HIV Africa-low HIV Eastern Europe Case detection rate (%) Eastern Mediterranean 2002 Western Pacific CDR stable at ~70% since Gap especially large in Africa Latin America GLOBAL 61% in 2008 vs. Global Plan milestone of 71% South-East Asia million notified Red line: Global Plan cases milestones and 2015 X.X million sm+ target for CDR notified cases Black dots: actual CDR

11 Incidence rates falling globally after peak in Number of cases in millions Peak in Rate per 100,000 population World as a whole on track to achieve MDG target 6.c

12 What are the challenges in 2010? 1. DOTS quality not uniform; only 61% of all estimated cases reported; diagnosis probably late in most settings 2. TB/HIV, especially in Africa; MDR-TB, especially in former USSR and China; XDR-TB everywhere we look for it 3. Weak health systems and services compromising TB care; lack of bold policies on free access to care, drug quality and restriction, labs, human resources, infection control, etc. 4. Not all care providers, non-state and even governmental, working at high standard; weak public-private links 5. Communities often un-aware, un-involved, not mobilised 6. Research not yet delivering innovative tools, transfer of technology slow, and operational research neglected

13 Public-Private Mix for TB care and control: Milestones 2001: Informal global consultation; Lancet publication 2002: Inclusion of PPM in the Expanded DOTS Strategy 2003: Evidence-base on working models from diverse settings 2004: PPM for TB: What makes it work?.. Cross-country analysis 2005: Cost-effectiveness shown; "public-private" to "all providers" 2006: PPM/ISTC essential components of the Stop TB Strategy 2007: PPM guidance/istc/nsa tool implemented in diverse settings 2008: PPM activities in 58 out of 93 Global Fund grants 2009: Appeal for PPM scale up in "Beijing CfA" and WHA 2009

14 Increasing case notifications is good, But it is not yet early case detection Annualised rate of ss+ cases diagnosed per 100, q1 Case recovery into the NTP by different care providers, Bangalore, q3 00q1 00q3 01q1 01q3 02q1 02q3 Quarter 03q1 03q3 04q1 04q3 05q1 05q3 NGO Private Corporate Medical college Other Government Health Department Public and private medical colleges (yellow) diagnose a huge number of cases, but many of them are from outside the city and need to be refereed for treatment elsewhere. The increase in diagnosed cases represents increased notification after medical colleges and other providers started to report to NTP in a standardised way

15 Trend of Global Fund support for PPM activities progress is evident

16 Public-Private Mix for TB care and control: Unfinished agenda More projects than programmes? Large proportion of care providers still to be engaged? Capacity strengthening within the non-state sector? Unabated misuse of anti-tb medicines? Measurement of contribution weak? Regulatory approaches and their effectiveness? Limited uptake/input by MDR-TB, TB/HIV, GLI, ACSM? Promoting systems approach?: every health unit lists and shows how all care providers in its area contribute to TB/MDR-TB/TB TB/TB-HIV control with enhanced equity in access to care.

17 Many thanks to all Acknowledgements: M. Uplekar, K. Lönnroth, S.S. Lal