tb: forgotten but not gone

7/30/2019 TB: Forgotten but not gone

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Forgotten But Not Gone

J2J Lung Health Media Training

Lee B. Reichman, M.D., M.P.H.

Kuala Lumpur, Malaysia

November 12, 2012


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TB Historical Permutation

17th - 18th centuries TB took 1 in 5 adult lives

1850 - 1950 one billion people died of TB

Next decade 2010-2020

300 million new infections 90 million new cases

30 million deaths

More people died from TB last year than

any year in history


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Estimated MDR-TB incidence rates, 2009(new and previously treated)

MDR-TB

casesemerging

annually,

100,000

population

African countries with estimated

MDR-TB incidence rates 15 MDR-

TB cases per 100,000 population

Botswana: 27 / 100,000

Mozambique: 16 / 100,000

Namibia: 17 / 100,000

Rwanda: 16 / 100,000South Africa: 26 / 100,000

Swaziland: 23 / 100,000

Zimbabwe: 19 / 100,000India: 8 / 100,000

Selected countries of the

former Soviet Union:Estonia: 7 / 100,000

Kazakhstan: 57 / 100,000

Russia: 27 / 100,000

Tajikistan: 59 / 100,000

China: 7 / 100,000


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1991 World Health Assembly recognized thegrowing importance of TB as a public healthproblem

A new framework for TB control was developed

A global strategy called DOTS was introduced(originally stood for Directly Observed Treatment,Short Course)


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DOTS: 1991-2005 Political commitment

Case detection using sputum microscopy among personsseeking care for prolonged cough

Standardized short-course chemotherapy under propercase-management conditions including DOT

Regular drug supply

Standardized recording and reporting system that allowsassessment of individual patients as well as overall programperformance


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Co-infection between TB and HIV

Multidrug-resistant TB (MDR-TB)

Resistance to isoniazid and rifampin the 2 most

powerful anti-TB drugs

Extensively-drug resistant TB (XDR-TB)

MDR-TB plus resistance to any fluoroquinolone and atleast 1 second-line injectable (AMI, KAN, CAP)

Totally Drug Resistant TB (TDR-TB)

Resistant to all anti-TB drugs?


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The Global Burden of TB/HIV 1/3 of 33 million people

living with HIV/AIDSco-infected with TB(>10 million people)

Without treatment, 90%will die within months

HIV and TB form a lethal combination, each speedingthe other's progress

TB is the leading cause of death among HIV-positive people (up to 50% of all patientsworldwide)


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Co-Existence of HIV & TB infection

TB Infection

HIVInfection


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Estimated HIV Prevalence inNew TB Cases, 2010


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MDRTB/XDRTB - The Big Problem!

500,000 new MDR-TB cases estimatedannually

XDR-TB in 68 countries


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Use of One DrugKnowingly or Unknowingly

Sensitive bacilli killed

Resistant bacilli multiply unimpeded

Resistant bacilli become dominant

Efficacy of Fluroquinolones in TB and nonTB infection suggests increases in cross

species resistance will increase as hasalready been shown


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Inadequacies in Physician Practices

Major Recurring Practice Delays in diagnosis and errors in treatment

Resulting In

Increased risk and likelihood of disease transmission

More advanced and complicated disease

Lengthened hospital stays

Increased medical costs

Development of MDR-TB and XDR-TB Development of TDR-TB?


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International Standards for TB Care


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National (and local) tuberculosis control programs

Influential professional societies

Professional (medical and nursing) schools

NGOs

Patient and community organizations

Technical agencies

Funding agencies


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International Standard for TB Care


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International Standard for TB CareDiagnosis

All persons with otherwise unexplained cough lasting for 2-3 weeks or

more should be evaluated for tuberculosis



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International Standard for TB CareDiagnosis

Microbiological evaluation (smear culture) is essential for all patients(including children, extra-pulmonary, and persons with radiographicabnormalities)



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International Standard for TB CareTreatment

The provider is responsible for prescribing an adequateregimen and ensuring adherence



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International Standard for TB CareTreatment

A patient-centered, individualized approach to treatment should bedeveloped for all patients.

A central element is direct observation by a treatment supporter.

C ?


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Where Are The Missing Cases?

They are not detected due to poor laboratory capacity


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At home, if services are not accessible


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In other un-connected public systems (prisons)


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In the private sector


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Patient Involvement in Medical Care

Patients and their families have become increasinglyinvolvedand influentialin all aspects of medical care

In the mid-eighties, as the first anti-viral drugs for treatingAIDS were being developed, activists demanded to

participate in the design of clinical trials directed by theNational Institutes of Health and pharmaceutical companies

Laypeople now routinely sit on committees on the N.I.H. andon hospitals institutional review boards, which assess theethicality and scientific merit of clinical trials

The Patients Charter for


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Tuberculosis Care


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Patients Rights


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Patient s Rights

You have the right to:

Care;

Dignity;

Information;

Choice;Confidence;

Justice;

Organization;

Security

Source: Patients Charter for TB Care, 2006

Patients Responsibilities


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Patient s Responsibilities

You have the responsibility to:

Share information;

Follow treatment;

Contribute to Community Health;

Show Solidarity

Source: Patients Charter for TB Care, 2006


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TB at a Crossroad of Global TB Control

US domestic decline of TB since prior to development ofdrugs

US resurgence of TB during the 1980s and 1990s, largelydue to neglect

Massive and effective response

TB on the radar screen domestically

TB on the radar screen internationally


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BUT TB Remains a Global Killer

Why does TB still infect one-third of theworlds population and remain a globalhealth threat despite the fact that highlycost-effective drugs are available toeradicate it?

Ch ll i TB C t l


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Challenges in TB Control

Insufficient financial and human resources

Inadequate healthcare infrastructure

Weak laboratory capacity and lack of new rapid diagnostictools

Lack of new drugs that would cure TB in a shorter time

Lack of effective vaccine that would prevent TB

Poor use of infection control in healthcare settings

HIV and MDR/XDR threats

Minimal social mobilization for TB control and minimalpopulation awareness stigma


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As we cure increasing numbers, theremaining cases are those most difficult to

treat, with impossible social problems,and/or severe, virtually untreatable but still

transmissible, drug resistance

THE FEW REMAINING CASES


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THE FEW REMAINING CASES

This talk has concentrated on the difficult remaining T

cases

With DOTS and case management along with funding,interest and involvement in developing new tools andstrategies for combating TB we have taken care of the

easy ones and

Expertise decreases

Funding decreases

Innovative Initiatives are de-emphasized or evenforgotten

Tuberculosis Control and Elimination


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2010-50: Cure, Care, and Social Development - 1

Rapid expansion of the standardized approach to tuberculosisdiagnosis and treatment that is recommended by WHO allowedmore than 51 million people to be cured between 1995 and 2011and 20 million lives have been saved

Tuberculosis remains a severe global public health threat

Although the overall target related to the Millenium DevelopmenGoals of halting and beginning to reverse the epidemic mighthave already been reached, the more important long-termelimination target set for 2050 will not be met with presentstrategies and instruments

-Lonnroth, Castro, Chakaya, et al, Lancet, 2010Updated 2012



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Several key challenges persist: Many vulnerable people do not have access to affordable

services of sufficient quality

Technologies for diagnosis, treatment, and prevention are oldand inadequate

Multi-drug resistant tuberculosis is a serious threat in manysettings

HIV/AIDS continues to fuel the tuberculosis epidemic,especially in Africa

Other risk factors and underlying social determinants help to

maintain tuberculosis




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Acceleration of the decline towards elimination of this

disease will need invigorated actions in four broad areas Continued scale-up of early diagnosis and proper treatment fo

all forms of tuberculosis

Development and enforcement of bold health-system policies

Establishment of links with the broader development agenda Promotion and intensification of research towards innovations


Annik Rouillion


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Defaulters and Motivation

to default is the natural reaction of normal,sensible people: The person who continues t

swallow drugs or have injections with

complete regularity in the absence ofencouragement and help from others is the

abnormal one.

- Bull IUAT1972; 47:68-75

Why do we need to care about


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Why do we need to care aboutTB in the rest of the world?

Lessons from Andrew Speaker


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Lessons from Andrew Speaker

TB has not gone away, it remains with us, highly prevalent and

transmissible Anybody can get tuberculosis, not only poor people, minorities, or the

foreign-born

TB anywhere is TB everywhere

All resistant TB, MDR and XDR TB is preventable by proper TBdiagnosis and treatment

Good public health is a silent secret, but when there is a small glitch, becomes major news

We desperately need new tools for TB diagnosis and treatment

You dont want to sit on an airplane for 8 hours next to an untreatedcoughing person with anykind of TB, be it drug sensitive, MDR or XD


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18004TBDOCS (482-3627)

www.umdnj.edu/globaltb

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tb: forgotten but not gone

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