tuberculosis control dr. yeşim yasİn fall-2013. outline what is tuberculosis (tb)? burden of tb,...

Tuberculosis Control

Dr. Yeşim YASİN Fall-2013

Outline

• What is Tuberculosis (TB)?

• Burden of TB, TB/HIV, MDR-TB

• Strategy, targets, progress

• Prevention and Control Programmes of TB

• Challenges towards elimination

2

What is TB?

• One of the oldest diseases known in the

history.

• It is a preventable and a curable disease if

detected and treated early.

3

4

Prevelance of infection

• About one-third of the world‘s population is

infected with TB bacilli

people have been infected by TB bacteria

but are not (yet) ill with disease and cannot

transmit the disease.

5

• After a healthy person with a healthy

immune system breaths in TB bacteria, he

or she will have 10% lifetime chance of

developing TB.

• Immune-compromised persons have a

much higher risk of falling ill. 6

active TB (disease)

delays in seeking care/diagnosis/treatment

results in transmission of the

bacteria to others7

People ill with TB (active case)

can infect up to 10-15 people

through close contact over the

course of a year

• Without proper treatment

up to two thirds of people

ill with TB will die. 8

Natural history of TB

Factors

Agent factors

Host factors

Social factors

9

Agent Factors

AgentSource of infection communicability

TB bacilli have a thick waxy coat,they are slow growing and they can survive in the

body for many years in a dormant or inactive state whereby people are infected but

show no signs of TB disease.

The most common source of Tuberculosis infection is

the human case whose sputum is positive for the tubercle bacilli, and who

has either received no treatment for it or not got treated fully. Such sources can discharge the bacilli in

their sputum for years

Transmitted by droplet nuclei

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Host factors

Host Factors

All age groups

Males>Females Nutrition İmmunity

Host susceptibility is universal, but the risk of infection is directly and mainly related to the degree of exposure.

After 20 years of age, TB tends to affect more males due to higher exposure to infection and higher prevalence of risk factors.

People who are co-infected with HIV and TB are 21 to 34 times more likely to become sick with TB

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Social factors

Social Factors

Population explosion

Over-crowded

living con.

Under- nutrition

Lack of education

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Incidence of some selected infectious diseases by years

(per 100000 population), Turkey

Health statistic year book 2010

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2011 Data-Turkey• Incidence: 24/100K (WHO estimate)• Patients in total: 15.679 (21/100K) registered• Patients in total in Istanbul: 4.898 (36/100K) registered• New cases in Istanbul: 4.457 AFB+ patients: 1.794

(registered)

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TB mortality risk factors

• Site (higher in positive smear)• Type of disease (association to…)• Timeliness of diagnosis and treatment• Appropriate diagnosis• Mistake in reading X-rays• Mistake in interpreting signs and symptoms

• Timely/Delayed diagnosis• Timely/Delayed treatment• Quality of treatment

Why worry about TB?

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Some facts• TB is the second (only to HIV/AIDS) greatest killer worldwide due to a

single infectious agent.

• 8.7 million new cases in 2011; 13% is co-infected with HIV

• 22 high-burden countries account for 80% of the world’s TB cases.

• 1.4 million people died: 430.000 were HIV+

• Almost 60.000 people worldwide lives with MDR-TB

• The largest number of new TB cases occurred in Asia, accounting for

60% of new cases globally

• Funding is inadequate

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Estimated number of cases

• 8.7 million (8.3-9.0 million)• 1.1 million (13%) (1.0-1.2 million)• Up to 0.5 million

Estimated number of deaths

• 1.4 million (1.3-1.6 million)• 430,000 (400,000-460,000)• Unknown, but

probably>150,000

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All forms of TB

HIV associated TB

MDR-TB

Incidence rates, 2011

19

TB cases, deaths, 1990-2011

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Incidence Mortality

All cases

HIV+ cases

Peak > 9 million in early 2000s, 8.7 million in 2011

Total mortality peaked early 2000s at >1.8 million 1.4 million in 2011

HIV+ mortality

millions

TB/HIV Coinfection80% of all TB/HIV cases are in Africa TB leading cause of death in PLHIV: ¼ of PLHIV worldwide die due to TB. PLHIV infected with TB: 20-40 times more likely to develop active TB. Untreated, TB in PLHIV leads to death in weeks 21

Distribution of MDR-TB among new TB cases, 1994-2011

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Number of MDR-TB cases, 2011

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Russian Federation 44,000 (14% of global MDR burden)

China61,000 (20% of global MDR burden)

India66,000 (21% of global MDR burden) South Africa

8,100 Based on survey data

Pakistan 10,000 (3% of global MDR burden)

Ukraine 9,000 Based on survey data

To date, 84 countries that reported XDR-TB

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About 9% of MDR-TB cases are XDR

• 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 25

Goal 6: to have halted by 2015 and begun to reverse the incidence…

2015: 50% reduction in TB prevalence and deaths compared to 1990

2050: elimination (<1 case per million population)

Global progress on impact

• 51 million patients cured, 1995-2011

• 20 million lives saved since 1995

• 2015 MDG target on track: global TB incidence rate peaked in early 2000s

• BUT, TB incidence declining too slowly, 1.4 million people still dying, MDR-TB response slow, gaps in financing

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Prevention and Control of TB

29A B

Risk and Prevention-1

1- Cough out TB particles - strength of cough (adults>>>children)

2- Live bacteria- smear + or culture +

3- Cavity30

Risk and Prevention-1

Risk and Prevention-2• Person A• Medication (DOT)• Isolation• <4 years• At night

• Surgical mask

• Person B• Space• Natural ventilation/fan• Air purifying respirator (N95)• Ultra Violet Germicidal Irradiation (UVGI)• High Efficiency Particulate Air (HEPA) Filter• Negative pressure

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Risk and Prevention-2

TB CONTROL

•Detection and treatment of cases•Treatment of latent infection•Vaccination

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TB Control

The three priority strategies for TB

prevention and control programs are:

• Identifying and treating individuals who have active TB.

• Finding and screening individuals who have had contact with

TB patients to determine whether they are infected or have

active TB, and providing appropriate treatment.

• Screening populations at high risk for TB infection to detect

infected persons and provide therapy to prevent progression

to active TB.33

Tuberculosis prevention and control

programs

• 1994 “Directly Observed Treatment, Short Course”

(DOTS) strategy

• each country to detect smear-positive TB cases

• offer standardized DOT ,

• with the objective of curing over 85% of TB patients.

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DOTS

• Governmental commitment to TB Control• Reliable and continious supply of high-

quality Anti-TB drugs•Microbiologic confirmation of TB diagnosis• Supervision (DOT) of standardized short

course Anti-TB theraphy-at least during the initial phase• System for registration and follow-up

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DOTS

What can DOTS do

• Increase treatment completion and cure rates• Reduce the emergence of drug resistant

TB• Improve cost-effectivenss of TB Control• Reduce TB incidence in conjunction with

other interventions.36

What can DOTS do?

Challenges

• HIV epidemic•MDR-TB, XDR-TB• Health system weakness and political will• Poor infrastructure and lack of support• Private practitioners• Prisons

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Challenges

DOTS in Turkey

• Since 2003 Ministry of Health performed

pilot studies for DOTs (Directly Observed

Theraphy Short-course).

• In 2006 Tuberculosis Control Programme

was integrated to primary health care

system and DOTs is expanded in Turkey.38

DOTs in Turkey

DOT

• DOT can lead to reductions in

relapse and acquired drug

resistance

39

DOT

Tuberculosis Prevention and Control

Program in Turkey

• Main strategies include:

• BCG vaccination

• Case finding

• Effective chemotheraphy

• Health education

• Chemoprophylaxis

• Monitoring and evaluation system 40

BCG vaccination

BCG only at birth (or first contact with health services)

• This is the current recommendation of the EPI

(Expanded Program on Immunization) and the Global

Tuberculosis Programme and is the policy in our country.

• BCG protects against serious childhood forms of

Tuberculosis, such as TB meningitis and miliary TB.

• It may not protect to a high degree against adult

pulmonary forms of the disease.41

Case finding

• The aim is to reduce the transmission of TB by

screening high risk populations (eg. those at

an increased risk of exposure to TB infection,

most notably contacts of infectious cases) and

to detect and treat active disease earlier than

would otherwise occur. 42

Chemoprophylaxis

• Primary prevention

• Decrease incidence rate of TB

• By using Isoniazid (INH)

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Chemoprophylaxis

Tuberculosis 1• Tuberculosis control and elimination

2010–50: cure, care, and social development

Knut Lönnroth, Kenneth G Castro, Jeremiah Muhwa Chakaya, Lakhbir Singh Chauhan, Katherine Floyd, Philippe Glaziou, Mario C Raviglione

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Challenges to “elimination”

1. Commitment by governments and stakeholders fluctuating

2. Funding not secure; catastrophic costs for the poor un-resolved

3. Only 2/3 of estimated cases reported or detected 4. TB/HIV major impact in Africa 5. MDR-TB, with high burden in former USSR , China etc 6. Un-engaged non-state practitioners 7. Social and economic determinants maintaining TB 8. Research in need of intensification and investments

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1- Lack of commitment

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2- Funding

47

US

billi

ons

dolla

rs

Funding gap vs Global Plan ~ US$2–3 billion per year Funding gaps reported by countries US$0.7 billion in 2013

2013 2014 2015

3- The case detection/notification gap

• Global notifications Estimated incidence

• 3: The case detection/notification gap Nearly 3 million TB cases either not notified or not detected 481990 2000 2010

TB c

ases

(mill

ions

)3.7

7.88.7

5.8

GeneXpert

4985 countries using it by mid-2013

4- Responding to the TB/HIV epidemic

The WHO policy on collaborative TB/HIV activities

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4- Responding to TB/HIV epi. through collaborative efforts

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5- Responding to MDR-TB

The New England Journal of Medicine

MDR Tuberculosis — Critical Steps for Prevention and Control

Eva Nathanson, M.Sc., Paul Nunn, F.R.C.P., Mukund Uplekar, M.D., Katherine Floyd, Ph.D., Ernesto Jaramillo, M.D., Ph.D., Knut Lönnroth, M.D., Ph.D., Diana Weil, M.Sc., and Mario Raviglione, M.D.

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Review Article

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WHA resolution 2009 (22 May) includes all essential policies

6- Unregulated private sector• Private sector is first point of care

in many settings. India: 70% of people with cough go first to private practitioners

• Diverse network of formal and informal providers ranging from hospitals and corporate sector to the traditional healers and quacks

• Private sector engagement crucial in closing the gap on case detection

• Contribution to finding people with TB between 10%-40% in countries

• Collaboration exists but still not enough in many settings. Efforts need to be made on both ends

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7- Alleviation of risk factors & soc-economic determinants

RR for active TB Weighted prevalence (22 HBCs)

Population attributable fraction

HIV infection 20.6/26.7 1.1% 19%

Malnutrition 3.2 16.5% 27%

Diabetes 3.1 3.4% 6%

Alcohol use (>40 g/day)

2.9 7.9% 13%

Active smoking 2.6 18.2% 23%

Indoor air pollution 1.5 71.1% 26%55

8- Intensive investments in R&D to develop new tools

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Diagnostic Vaccine Treatment

Sputum smear microscopy BCG 1st-line TB drugs Discovered 1882 Developed 1920s Discovered 1943-1970

8- New tool pipelines in 2013

Diagnostics: • 7 new diagnostics or diagnostic methods endorsed by WHO since

2007; • 6 in development; • yet no Point of Care (PoC) test envisaged

Drugs: • 1 new drug (Bedaquiline) approved in late 2012, but probably little

impact on epidemiology; • 1 expected to be approved in 2013; • a regimen and other 2-3 drugs likely to be introduced in the next 4-7

years Vaccines:

• 11 vaccines in advanced phases of development; • 1 just reported with no detectable efficacy

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8. Research as the key for elimination• 1.For elimination one would need rapid diagnostics at point of

care, potent short treatments, mass treatment of latent TB infection (TLTBI), and potent pre- and post-exposure vaccines. None is available today

• 2.Basic research is fundamental to gain further knowledge and R&D pipelines must be expanded, nurtured and well-financed

• 3.Increased financial resources for research: the need for research is estimated at 2 billion US$ per year; today, about 650 million US$ are invested.

• 4.Develop coalitions to maximize outcomes and ensure a continuum of research efforts so that basic science and R&D pipelines are informed by needs, and operational research allows rapid adaptation and introduction in high-burden settings

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THANK YOU!

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