tb epidemic and progress towards the millennium

Haileyesus GetahunStop TB Department, WHO

Geneva, Switzerland

TB epidemic and progress towards the Millennium Development Goals

Open Forum 4: Key issues in TB Drug Development, August 18, 2010, Addis Ababa, Ethiopia

Outline of presentation

• Global TB epidemiology

• Global TB targets for 2015

• Progress towards global TB targets

• Moving beyond 2015

• Conclusion

Estimated number of

cases

Estimated number of

deaths

1.3 million*(range, 1.1–1.7 million)

9.4 million(range, 8.9–9.9 million)

0.5 million

All forms of TB

Multidrug-resistant TB (MDR-TB)

HIV-associated TB 1.4 million (15%)(range, 1.3–1.6 million)

0.52 million(range, 0.45–0.62 million)

The global burden of TB in 2008

*excluding deaths among HIV+ people

~ 0.15million

Highest incidence rates in Africa

Linked to high rates of HIV infection:78% of estimated HIV+ TB cases in Africa

Estimated HIV prevalence in new TB cases, 2008

Most TB cases are still in Asia

South-East Asia

34%

Africa30%

Western Pacific

21%

EMR7%

Europe4%

Americas3%

55% cases in Asia

1.Millennium Development Goals Halt and reverse incidence of TB(MDG 6, Target 6.c)

2. Stop TB Partnership targets

Halve 1990 prevalence and mortality rates (per 100 000 population)

Prevalence target: <148/100,000 (164 in 2008)

Mortality target: <14/100,000 (20 in 2008)

Global TB targets set for 2015

1.Detect 84% of smear-positive cases, and successfully treat 87% of them, by 2015

2. TB/HIV (2010) 85% TB patients tested for HIV by 2010 320,000 HIV+ TB patients received ART by 2010

3.X/MDR-TB (2015) 80% (~400,000) cases diagnosed and treated

4.Financing US$5–9 billion per year for TB control, 2010–2015

Additional targets in the Global Plan

Nine TB epidemiological regions Africa (High HIV and Low HIV) Europe (Central and Eastern) Established market economies (the rich countries) Eastern Mediterranean South East Asia Western Pacific

Incidence, prevalence and mortality targets Traffic light analogy (red, yellow and green)

Progress towards global TB targets

Incidence rates falling globally

Incidence falling in all sub-regions

except African

countries with low HIV prevalence

*EME = Established Market Economies

Rat

e pe

r 100

,000

pop

ulat

ion

Central EuropeAfrica-low HIVAfrica-high HIV

Eastern Europe EME* E. Mediterranean

W. PacificSouth-East AsiaLatin America

200300400500600700

100

150

200

250

406080

100120140160

1990 1995 2000 2005

200

250

300

350

400

10152025303540

200

300

400

500

1990 1995 2000 2005

20406080

100120

100150200250300350400

100150200250300350400

1990 1995 2000 2005

Africa-high HIV

Rat

e pe

r 100

,000

pop

ulat

ion

Progress to the prevalence targetCentral EuropeAfrica-low HIV

Eastern Europe EME* E. Mediterranean

W. PacificSouth-East AsiaLatin America

*EME = Established Market Economies

Five regions reached target already

SE Asia and E. Mediterranean may be able to achieve target

African countries far from target, such that target unlikely to be reached globally

Black line marks target level at 50% of 1990 prevalence rate

20

40

60

80

100

15

20

25

30

35

40

5

10

15

20

1990 1995 2000 2005

2025303540455055

1.0

1.5

2.0

2.5

20

30

40

50

60

1990 1995 2000 2005

2

4

6

8

10

12

14

20

40

60

80

100

20

30

40

50

60

70

1990 1995 2000 2005

Progress to mortality targetAfrica-high HIV Africa-low HIV Central Europe

Eastern Europe EME* E. Mediterranean

Latin America South-East Asia W. Pacific

Rat

e pe

r 100

,000

pop

ulat

ion

Four regions appear to have reached target of halving 1990 mortality rate already (green)

SE Asia, E. Mediterranean and E. Europe may be able to achieve target

African countries far from target, such that target unlikely to be reached globally

*EME = Established Market EconomiesBlack line marks target level at 50% of 1990 mortality rate

What about other targets?

Treatment success rateTB/HIV and MDR targetsFunding targets

Treatment success target reached globallySu

cces

sful

trea

tmen

t rat

e (%

) in

DO

TS c

ohor

ts

85

77

79

77

79

81

80

82

82

82

83

84 85

87

40

50

60

70

80

90

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

But not in the Americas, Africa and Europe

Global plan TB/HIV and MDR targets: 2008

Global plan target

• 2.3 million TB patients tested for HIV

• 300,000 started on ART

• 16 million PLHIV screened for TB

• 110,000 X/MDR cases treated

Actual coverage

• 1, 374,000 HIV tested (60% of the planned)

• 109,000 on ART (36% of the planned)

• 1,385,000 screened(8.7% of the planned)

• 30,000 cases notified(27% of the planned)

Funding has increased

technical assistance and R & D not includedData based on ~ 100 countries each year with ~ 94% estimated global cases

0

1

2

3

4

5

2006 2007 2008 2009 2010

US$

bill

ions

Unknown

Global Fund

Grants (excl. GF)

Loans

Government (health system)

Government (NTP budget)

2.7

4.1

But falls short of Global Plan targets, except in E. Europe

All regions except Eastern EuropeData based on ~ 100 countries each year with ~ 94% estimated global cases

In E Europe available funds (AF) exceeds Global plan (GP) targets

0

1

2

3

4

GP AF GP AF GP AF GP AF GP AF

2006 2007 2008 2009 2010

Other

TB/HIV

MDR-TB

DOTSUS$

bill

ions

3.8

1.72.7

1.3

Beyond the global TB targets OF 2015

TB elimination by 2050

(Incidence of active TB < 1 per million)

Treating latent TB is crucial

2 Month rg.4 Month rg.

10 days rg.

Proc Natl Acad Sci U S A. 2009 Aug 18;106(33):13980-5.(Incidence per million)

Conclusion

• Targets are in general on track in several regions but unlikely achievable globally.

• Incidence target has been achieved globally except in Africa with low HIV

• Mortality and prevalence targets are unlikely to be achieved in Africa

• Latent TB treatment with robust and new drug could be crucial for TB elimination