the burden of tb in 2006 1.7 million deaths in 2004 – 98% of these in developing world 250,000...
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The burden of TB in 2006
1.7 million deaths in 2004 – 98% of these in developing world250,000 deaths due
to TB/HIV
MDR-TB present in 102 of 109 countries and settings surveyed in 1994-2002
8.9 million new cases in 2004 – 80% in 22 high-burden countries
0 - 9991000 - 999910 000 – 99 999100 000 - 999 999
No estimate1 000 000 or more
Estimated number of new cases (all forms)
ASIA55%
AFRICA29%
AMERICAS 4%
EAST. MEDIT. 7%EUROPE 5%
Asia has the highest number of cases and TB has resurged in Europe...
Global incidence is rising at 1% due to increases In Africa and E. Europe
0
100
200
300
400
1990 1995 2000 2005
Est
imat
ed T
B i
nci
den
ce/1
00K
/yr Africa - high HIV
Africa - low HIV
WorldE Europe
World exc Afr EEur
WHO European Region WHO European Region
25 EU countries
53 countries
18 high priority countries for TB
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.
14. Tajikistan
15. Turkey
16. Turkmenistan
17. Ukraine
18. Uzbekistan
TB case notification rate in EUR, 1980-04TB case notification rate in EUR, 1980-04
295,240East+ EUR(18 countries)
354,954All EUR
(53 countries)
54,231European Union
(25 countries)
Annual TB cases per 100,000 pop.
Year0
10
20
30
40
50
60
70
80
90
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04
373,497
TB incidence in EUR TB incidence in EUR
13/100 000 - first fifteen members of the EU
27/100 000 - ten new members of the EU (enlargement in 2004)
53/100 000 - four countries accessing the EU
98/100 000 - countries bordering EU
50/100 000 - overall TB incidence in EUR
Mean annual change in TB notification rates, 2000-2004
No data / <60 cases/yr
-11% to -3%
-2% to +1%
+2% to +6%
>+6%
% change
EuroTB
Proportion of TB cases of foreign origin, Europe, 2004
No data
0-4
5-19
20-39
40+
% cases of foreign origin
Andorra
Malta
Monaco
San Marino
EuroTB
Global TB control targets
2005: World Health Assembly:- To detect at least 70% of infectious TB cases- To treat successfully at least 85% of detected cases
2015: 50% reduction in TB prevalence and deaths by 2015
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: prevalence and deaths associated with TB
Indicator 24: proportion of TB cases detected
and cured under DOTS
DOTS in EURDOTS in EUR
population (%)no DOTS< 1010-90> 90
1995 - 6 countries; 2004 - 43 countries, 47% population
Plan to Stop TB in EEUR: achievementsPlan to Stop TB in EEUR: achievements
TUR
UZB
AZE EST
GEO
KAZ
KGZ
MDA
ROM
RUS
TJK
TKM
ARM
LVA LTUBLR
UKR
55
60
65
70
75
80
85
90
95
100
0 10 20 30 40 50 60 70 80 90 1002004 case detection (%)
2003
tre
atm
ent
succ
ess
(%)
TARGET STOP TB strategy:
• DOTS
• MDR-TB, TB/HIV,
prisons
• Health system
• All providers
• ACSM, people,
patients
• Research
Note: DOTS achievements in new smear-positive pulmonary TB cases
Proportion of pulmonary cases with positive sputum smear, East*, 1999-2004
* including countries where pulmonary classification was applied for three or more consecutive years
15%
30%
45%
60%
1999 2000 2001 2002 2003 2004
% of pulmonary cases
Moldova, Rep
Kyrgyzstan
Armenia
Georgia
Kazakhstan
Turkmenistan
Azerbaijan
Treatment outcomes, new definite pulmonary cases*, 2003
* Culture positive in EU & West and Centre; smear positive in Macedonia FYR and East. Countries with nationwide representative data; excluding 4 countries with < 10 cases (EU & West)
§ Mean percentage (country range in brackets)
EU & West§
20 countries
Balkans§
4 countries
East§
6 countries
Success 76% (54-88%) 83% (82-91%) 71% (55-84%)
Death 7% (0-13%) 4% (2-4%) 5% (2-9%)
Failure 1% (0-11%) 4% (0-5%) 10% (3-14%)
Still on treatment 3% (0-14%) 0.6% (0.0-0.7%) 0.1% (0.0-1.1%)
Other (Default, Transferred,
Unknown)
13% (0-25%) 8% (4-15%) 14% (5-36%)
EuroTB
Outcomes among new, definite pulmonary TB cases, EU & other regions, 2003*
* Mean for 19 EU countries (EuroTB); data from other regions refer to DOTS cohorts (WHO Global Tuberculosis Control: Surveillance, Planning, Financing. 2006)
Despite low mortality rates, the proportion of TB patients notified in the EU who die while on treatment is substantial, even when compared to other regions in the world. This is one limitation keeping many EU countries from achieving the WHO target of 85% success among previously untreated pulmonary TB cases.
Region Success Death Failure Other
European Union 76% 7.2% 1.1% 16.2%
Africa 72% 7.0% 1.4% 19.8%
The Americas 82% 4.9% 1.2% 12.4%
Eastern Mediterranean 82% 2.9% 1.4% 14.1%
South-East Asia 85% 4.5% 2.1% 8.1%
Western Pacific 91% 2.3% 1.1% 5.1%
East – West divide
EuroTB
East West
Notification data Aggregated Individual
Culture confirmation None to low High
Main trend in notification rate Incremental Declining
Epidemic type Diffuse Concentrated
Imported TB Low (<1%) High (29%)
Drug resistance High Low
HIV in TB cases < 1% 0-16%
Outcomes ↑ failures ↑ deaths
Vision: A WORLD FREE OF TB
Goal: To dramatically reduce the global burden of TB by 2015 in line with the MDGs and the Stop TB Partnership targets
Objectives:• Achieve universal access to high-quality diagnosis and patient-centred
treatment• Reduce the human suffering and socio-economic burden associated with TB• Protect poor and vulnerable populations from TB, TB/HIV and multidrug-
resistant TB• Support development of new tools and enable their timely and effective use
Why the new Stop TB Strategy ? Vision, Goals, Objectives
Plan to Stop TB in EEUR: Planned milestonesPlan to Stop TB in EEUR: Planned milestones
MilestonesYear
2007 2008 2009 2010
Population covered by DOTS services (%) 60 75 90 100
TB cases accessing quality-assured culture and drug
susceptibility testing (%)
40 60 80 90
Population covered by adequate MDR-TB
management services. (%)
25 40 55 70
Countries implementing collaborative TB/HIV
activities (%)
20 35 65 100
Countries with TB care in prisons of equivalent
standards than outside (%)
25 40 55 70
Countries where TB care is integrated at primary
health care level (%)
25 40 55 70
Countries where communities are involved to ensure
quality TB care (%)
25 40 55 70
What are the main challenges ?
1. DOTS not yet fully expanded and of high quality everywhere2. TB/HIV, especially in Africa, and MDR-TB, especially in former USSR
and China3. Weak health systems and services impeding proper TB control and
care4. Not all practitioners engaged5. Communities un-aware and un-involved6. Research not producing yet new tools and outside of the interest of
TB "controllers"
Western and Central EuropeWestern and Central Europe
0
20
40
60
80
100All hetero Hetero males Hetero females MSM IDU
Today, mainly sexual transmission in Western and Central Europe Exceptions: significant IDU epidemics in ESP, POR, ITA, SWI, POL 25-65% of all cases are among MSM Up to 75% of all heterosexual cases are among immigrants from high prevalence countries and women are >50% of all
heterosexual cases Vulnerable Groups: MSM & immigrants, specially immigrant women
Eastern EuropeEastern Europe
0
20
40
60
80
100
Russian F. Ukraine Belarus Moldova Lithuania Latvia Estonia Kazakhstan Uzbekistan Kyrgyzstan Tajikistan
IDU among those with known transmission route
Mainly IDU related transmission in Eastern Europe 68-85% of all cases are male Up to 30% of infected females are IDU and 50% are partners of IDU 30-50% of all HIV infections are among those under 25 years Vulnerable Groups: IDU, sex workers, prisoners, ethnic minorities, migrants
84%
2%
<20%
20-40%
40-60%
60-80%
50%
6%
6.1%
13%
10%
>80%
81%
25.5%
11%
8.2%
90%
57%
83%
29%
64%
74%
60%
16%
4%
19.4%
7%
15%
16%
<1%
24%
87%
60%
68%
14.5%
71%
5%
6%
IDU as % of all HIV/AIDS casesIDU as % of all HIV/AIDS casesNOTE: % of AIDS cases in countries not reporting HIV Sources: EuroHIV; national reports;NOTE: % of AIDS cases in countries not reporting HIV Sources: EuroHIV; national reports;
0%
11%
17%
20%
5%
82%
2%
51%
3%
14%
16%
1.8%
16%
32%
29%
16%
34%
82%
80%
86%
71%
76%
85%
<20%
20-40%
40-60%
60-80%
83%
61%
76%
78%
72%
>80%
73%
25.5%
80%
70%
77%
78%
89%
80%
80%
73%
77%
16%
69%
75%
97%
90%
63%
81%
75%
80%
71%
75%
71%
80%
78%
Males as % of all HIV/AIDS casesMales as % of all HIV/AIDS casesNOTE: % of AIDS cases in countries not reporting HIV Sources: EuroHIV; national reports;NOTE: % of AIDS cases in countries not reporting HIV Sources: EuroHIV; national reports;
62%
78%
71%
66%
63%
68%
79%
80%
61%
80%
85%
74%
82%72%
83%
64%
NA
84%
81%
72%
RUSRUS
ARMARM
KAZKAZ
KYZKYZUZBUZB
TKMTKM TJKTJK
GEOGEOAZEAZE
ESTEST
LATLAT
LITLIT BELBEL
UKRUKR
BULBUL
ROMROMMOLMOL
ALBALB
no HAART (<1%) good coverage (>70%)
poor access ( 1-10%) partial coverage (10-70%)
BIH, FYM, YUG
TURTUR
Access to HAART, 03/2003
RUSRUS**
ARM*ARM*
KAZ*KAZ*
UZB*UZB*
TKMTKM TJK*TJK*
AZE*AZE*
BELBEL
UKRUKR**
no HAART very poor coverage ( 1-10%) * in the process of scaling up ART
poor coverage (10-50%) moderate coverage (50-75%) disputed coverage estimates or insufficient data available
good coverage (over 75%)
Access to HAART, 01/2006
HIV infection among TB cases, 1998-2004*
* Excluding countries with less than 2 datapoints in the last 3 years or less than 50 TB notifications annually
The proportion of TB cases with HIV infection has increased in Estonia and Latvia, but is still highest in Portugal and Spain. In other countries of the Balkans and East providing data, levels have remained below 1%.
0
2
4
6
8
10
12
14
16
18
1998 1999 2000 2001 2002 2003 2004
% TB casesPortugal
Spain
Belgium
Estonia
Netherlands
Israel
Latvia
Denmark
Slovenia
Romania
Uzbekistan
Lithuania
Albania
Azerbaijan
Armenia
Czech Rep.
Reported to WHO (2005)52,800 TB patients HIV tested
5,800 tested positive14 started the ART
Estimated HIV prevalence 2005Estimated HIV prevalence 2005
Country HIV prev. (%) Country HIV prev. (%)
Pop.
(2003)
TB
(2005)
Pop.
(2003)
TB
(2005)
Ukraine 1.4 8.3 Armenia 0.1 0.8
Russian Federation 1.1 6.8 Uzbekistan 0.1 0.6
Estonia 1.1 6.6 Kyrgyzstan 0.1 0.5
Latvia 0.6 3.9 Lithuania 0.1 0.4
Belarus 0.5 2.9 Azerbaijan <0.1 0.1
Moldova 0.2 1.4 Tajikistan <0.1 0.0
Georgia 0.1 1.3 Turkmenistan <0.1 0.0
Kazakhstan 0.2 1.2 Europe 4.7
Source: UNAIDS (2004); WHO Global TB Report (2006)
% HIV prevalence estimated in general population and TB patients (adults)
European Framework for TB/HIVEuropean Framework for TB/HIVInterim policy on collaborative TB/HIV activitiesInterim policy on collaborative TB/HIV activities
a. Establish the mechanism for collaborationa. Set up a coordinating body for TB/HIV b. Conduct surveillance of HIV prevalence among TB patientsc. Joint TB/HIV planningd. Conduct monitoring and evaluation
• Decrease the burden of TB in people living with HIV/AIDS• Intensified TB case finding• Introduce INH preventive therapy• Ensure TB infection control in health care and congregate settings
• Decrease the burden of HIV in TB patients• Provide HIV testing and counselling• Introduce HIV prevention methods• Introduce co-trimoxazole preventive therapy• Ensure HIV/AIDS care and support• ART
Cat 1: national adult HIV prevalence >1% or HIV prevalence in TB pts >5%: all activities recommended in the Interim policy to be considered for implementation
Cat 2: national adult HIV prevalence below 1% and administrative areas with adult HIV prevalence >1% - combination of Cat 1 and Cat.3
Cat 3: national adult HIV prevalence below 1% and no administrative areas with adult HIV prevalence >1%: Conduct surveillance of HIV prevalence among TB
patients Decrease the burden of TB in people living with
HIV/AIDS with focus on groups at high risk for TB and HIV – IDUs, MSM, sex workers, those living in congregate settings)
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