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Global TB control: Current status with particular attention to TB among women and children Katherine Floyd Stop TB Department World Health Organization 42 nd Union World Conference on Lung Health Stop TB Symposium Lille, 26 October 2011
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  • Global TB control: Current status with particular attention

    to TB among women and children

    Katherine Floyd

    Stop TB Department

    World Health Organization

    42nd Union World Conference on Lung Health

    Stop TB Symposium

    Lille, 26 October 2011

  • Overview

    Launched 11 October

    1. The burden of disease caused by TB

    and progress towards 2015 targets

    2. Progress in implementing and

    financing TB care and control Comparisons with targets in Stop TB

    Partnership's Global Plan 20112015

    3. TB in women and children What global notification and survey data

    tell us

  • 1. Burden of disease and

    progress towards 2015

    targets

  • Progress in applying the Task Force framework for assessment

    of TB surveillance data, as of July 2011

    Major progress in measuring and

    estimating disease burden

    96 country consultations in 2 years

    17 African countries plus India and China in past year

    April 2009 June 2010

    December 2010 July 2011

  • Countries for which direct measurements of TB mortality are available, 2010Direct measurements of mortality national vital registration (90 countries) + mortality surveys (India)

    91 countries, 46% estimated global TB deaths,

    Up from 89 countries with 8% global TB deaths in 2010

    China and India for the first time in 2011

  • Cambodia PhilippinesThailandEritreaIndonesiaMalaysia Bangladesh Myanmar Cambodia Ghana Kenya

    Viet Nam

    Viet Nam China Nigeria South Africa Indonesia

    The Gambia

    Lao PDR

    Ethiopia

    Uganda

    Rwanda Mozambique

    Zambia

    Malawi

    NepalTanzania

    Philippines

    Bangladesh

    Thailand

    0

    2

    4

    6

    8

    2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013-

    15

    Nu

    mb

    er

    of

    surv

    eys

    Asia Africa Non Global Focus country

    21 Global Focus countries

    selected by Task Force

    Pakistan

    MyanmarIntensive efforts at

    global and national

    level to design,

    finance, implement,

    analyse, report since

    early 2008

    Asia -

    GFC

    Africa -

    GFC Other

    Prevalence surveys major global momentum

    Global focus countries (GFC)

    selected by WHO Global Task

    Force on TB Impact Measurement

  • TB cases and deaths, 19902010 absolute numbers

    Incidence Mortality

    HIV-negative

    mortality

    1990 2000 2010 2000 1990 2010

    Mil

    lio

    ns

    Peak at 1.8 in 2003

    1.4 in 2010

    1.5

    1.0

    0.5

    0 0

    2

    4

    6

    8

    Peak at 9.0 in 2005

    8.8 in 2010

    10 2.0

    1.01.2 million (1214%)

    TB cases among people

    living with HIV in 2010

  • Most TB cases in Asia and Africa

    South-East Asia 40%

    Western Pacific 19%

    Africa 26%

    E. Mediterranean 7%

    Europe 5%

    Americas 5%

    37% in India + China

    26% in India

  • Most TB deaths in Asia and Africa

    Western Pacific 12%

    SE Asia 47%

    Americas 2%

    Europe 6%

    E. Mediterranean 9%

    Africa 24%

    35% in India + China

    30% in India

  • Incidence, prevalence and

    mortality rates: global estimates

    Peak in 2002

    Target Target

    Prevalence Mortality

    150

    100

    50

    0

    Rate

    per

    100,0

    00 p

    op

    ula

    tio

    n

    250

    200

    150

    100

    50

    0

    Incidence

    25

    20

    15

    10

    5

    0

    1990 2010 1990 2015 1990 2015

    40% decline since 1990 Falling 1.3% per year

  • Dramatic reductions in TB cases

    and deaths in China, 19902010

    Incidence and

    notifications Prevalence Mortality

    1990 1990 1990 2010 2010 2010

    Halved in 20 years Cut almost 80%

    Incidence

    falling

    3.4%/year

  • 2. Progress in implementing and financing TB care and control

  • 7.6

    8.8

    3.7

    5.8 Global notifications

    (black)

    in context of

    estimated incidence

    (green) T

    B c

    as

    es

    (m

    illi

    on

    s)

    1990 2000 2010

    CDR 65% (6368%)

  • Case notifications by region, 19902010 Incidence in green

    2010 CDR: 5664% 2010 CDR: 7585% 2010 CDR: 5671%

    2010 CDR: 6776% 2010 CDR: 5765% 2010 CDR: 7386%

    Notifications in black

    Africa Americas E. Mediterranean

    Europe SE Asia W. Pacific

  • Treatment success 87% globally

    Global, new sm+ WHO Regions, new sm+

    but Europe lagging behind

    93

    88

    81

    76

    67

    87

    85

    84

    86 86

    83

    80

    76

    78

    80

    82

    84

    86

    88

    2003

    2004

    2005

    2006

    2007

    2008

    2009

    Tre

    atm

    en

    t su

    ccess r

    ate

    (%

    )

    65

    70

    75

    80

    85

    90

    95

    2003

    2004

    2005

    2006

    2007

    2008

    2009

    Europe

    Americas

    Africa

    EMR

    SE Asia 89

    W. Pacific

  • Notifications of MDR-TB increasing BUT only ~ 1 in 6 (16%) of estimated cases of MDR-TB

    among reported TB patients diagnosed and treated in 2010

    Notified cases of MDR-TB

    0

    10

    20

    30

    40

    50

    60

    2005 2006 2007 2008 2009 2010

    Nu

    mb

    er

    of

    pa

    tie

    nts

    (th

    ou

    sa

    nd

    s)

    19,000

    53,000

    Global Plan target ~270,000 in 2015

    0

    50

    100

    150

    200

    250

    300

    SE A

    sia

    W. P

    acifi

    c

    Euro

    pe

    Afric

    a

    EMR

    Am

    eric

    as

    Wor

    ld

    Not on treatment

    Treated

    MDR-TB cases treated and

    estimated numbers not treated

    for MDR-TB, among notified TB

    patients, 2010 290,000

  • Proportion of TB patients tested

    for MDR-TB remains low

    51%

    19%

    6%3% 2%

    6%

    0.3%

    0%

    10%

    20%

    30%

    40%

    50%

    60%

    Euro

    pe

    Am

    eric

    as

    EMR

    Afric

    a

    W P

    acifi

    c

    SE A

    sia

    WORLD

    % o

    f p

    ati

    en

    ts

    Global plan target

    for 2015 = 100%

    Previously treated

    30%

    5%

    1% 0.2%2%

    0.4% 0.1%0%

    5%

    10%

    15%

    20%

    25%

    30%

    35%

    40%

    Euro

    pe

    Am

    eric

    as

    SE A

    sia

    W P

    acifi

    c

    EMR

    Afric

    a

    WORLD

    % o

    f p

    ati

    en

    ts

    New cases

    Global plan target

    for 2015 = 20%

  • HIV testing for TB patients expanding

    Although more needed to reach 100% targets in Global Plan

    Several countries

    with very high

    testing rates in 2010

    Rwanda: 98%

    Kenya: 91%

    Tanzania: 90%

    Malawi: 88%

    Mozambique: 88% P

    erc

    en

    tag

    e o

    f T

    B p

    ati

    en

    ts

    44

    411

    22

    56

    47

    38

    59

    3

    8 12

    2022

    28

    34

    0

    10

    20

    30

    40

    50

    60

    70

    2003

    2004

    2005

    2006

    2007

    2008

    2009

    2010

    World

    Africa

  • CPT and ART for HIV-positive TB

    patients More needed to reach 100% targets in Global Plan

    Higher rates possible

    Perc

    en

    tag

    e o

    f H

    IV+

    TB

    pati

    en

    ts

    7577

    7166

    7777

    46

    37

    3230

    45

    35

    0

    10

    20

    30

    40

    50

    60

    70

    80

    90

    100

    2005

    2006

    2007

    2008

    2009

    2010

    CPT

    ART

    CPT >90% in 2010 Burkina Faso, Burundi, India, Kenya,

    Lesotho, Malawi, Mali, Mozambique,

    Myanmar, Namibia, Rwanda,

    Swaziland, Tanzania, Uganda

    ART > 80% in 2010 Brazil, Myanmar, Russia

    ART > 50% in 2010 India, Thailand, S. Africa

  • Funding for TB control increasing 97 countries, 92% global notifications

    0

    1

    2

    3

    4

    5

    2006 2007 2008 2009 2010 2011 2012

    US

    $ b

    illio

    ns (

    co

    nsta

    nt

    2011 p

    rices)

    Grants, excl. GF

    Global Fund

    Government

    Total

    4.4

    3.5

    2006 2007 2008 2009 2010 2011 2012

  • BRICS mostly domestic funding,

    other HBCs ~50% is donor funding

    BRICS

    96% domestic financing

    Other 17 high-burden

    countries

    49% donor financing

    Domestic

    Domestic

    Grants

    Grants US

    $ m

    illi

    on

    s

    US

    $ m

    illi

    on

    s

  • Underfunding persists

    0

    0.5

    1

    1.5

    2

    2.5

    3

    2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

    US

    $ b

    illio

    ns

    Funding gaps reported

    by countries

    Funding gaps vs.

    Global Plan

    Funding gaps vs Global

    Plan, excl. MDR-TB

    2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

    0

    0.5

    1

    1.5

    2

    2.5

    3

  • Scaling up treatment of MDR-TB

    to reach Global Plan targets funding required by country group

    Total

    BRICS

    Other middle-income

    Low-income

  • 3. TB in women and children what do global surveillance data and surveys tell us?

  • Disaggregation of TB notifications by sex, 2010

    Disaggregation for all forms

    Disaggregation for at least S+

    No disaggregation

    Notifications disaggregated by sex: available data, 2010

    All cases

    Sm+ cases only

    No disaggregated data ~28% not disaggregated overall

    ~50% sm-/EP notifications not

    disaggregated by sex

  • Notifications among women, countries reporting cases disaggregated by sex, 2010

    ~38% cases notified

    globally are among

    women

    35%

    42%

    0%

    10%

    20%

    30%

    40%

    50%

    sm+ sm-/EP

    Perc

    en

    tag

    e o

    f to

    tal

    30

    47

    33

    49

    4134

    0%

    10%

    20%

    30%

    40%

    50%

    60%

    EMR

    Afric

    a

    SE A

    sia

    Am

    eric

    as

    Euro

    pe

    W P

    acifi

    c

    Perc

    en

    tag

    e o

    f to

    tal

    sm+

    sm-/EP

    Variation by region

    higher percentage of

    cases among women in

    Africa and EMR

  • Cases among women

    in prevalence surveys in Asia

    0%

    5%

    10%

    15%

    20%

    25%

    30%

    35%

    40%

    45%

    Chi

    na (1

    990)

    Kor

    ea (1

    990)

    Kor

    ea (1

    995)

    Phi

    lippi

    nes

    (199

    7)

    Cam

    bodi

    a (2

    002)

    Phi

    lippi

    nes

    (200

    7)

    Vie

    t Nam

    (200

    7)

    Mya

    nmar

    (200

    9)

    Chi

    na (2

    010)

    % o

    f p

    rev

    ale

    nt

    ca

    se

    s a

    mo

    ng

    wo

    me

    n

    sm+ smear or culture positive

  • Surveys also suggest cases among

    women are more likely to be notified

    0

    0.1

    0.2

    0.3

    0.4

    0.5

    0.6

    0.7

    Kor

    ea (19

    95)

    Cam

    bod

    ia (2

    002)

    Indon

    esia

    (200

    4)

    Phi

    lippi

    nes

    (200

    7)

    Vie

    t Nam

    (200

    7)

    Mya

    nmar

    (200

    9)

    Chi

    na (2

    010)

    No

    tifi

    cati

    on

    rate

    /pre

    vale

    nce r

    ate

    Men Women

  • Disaggregation of TB notifications by age, 2010

    Disaggregation for all forms

    Disaggregation for at least S+

    No disaggregation

    All cases

    Sm+ cases only

    No disaggregated data

    ~60% notified cases among children can

    be identified from routine reporting

    ~45% sm-/EP

    notifications not age

    disaggregated

    ~85% notified cases

    among children are

    sm-/EP cases

    Notifications disaggregated by age: available data, 2010

  • Notifications among children, countries reporting age-disaggregated data, 2010

    BUT: high levels of

    under-reporting of cases

    thought to exist e.g. due

    to lack of linkages

    between NTPs and

    paediatricians

    2%

    10%

    0%

    2%

    4%

    6%

    8%

    10%

    12%

    sm+ sm-/EP

    Perc

    en

    tag

    e o

    f all c

    ases

    Estimated at least 6% of

    global notifications are

    among children

    17

    1

    3

    0.51.7

    0%

    5%

    10%

    15%

    20%

    Afric

    a

    SE

    Asi

    a

    EM

    R

    Am

    eric

    as

    Eur

    ope

    W P

    acifi

    c

    Perc

    en

    tag

    e o

    f all

    cases

    Sm-/EP

    Sm+

  • Estimates of TB burden among

    women and children

    Estimated 3.2 million (range 3.03.5 million) new

    cases among women in 2010

    Estimated ~10% of cases are among children

    Estimated ~320,000 deaths among HIV-negative

    women in 2010 and ~0.5 million deaths among

    women including HIV-associated TB

  • 1. Reporting of notification data disaggregated

    by age and sex from all countries Case or patient-based electronic recording and

    reporting

    2. Prevalence surveys in Africa

    3. Studies to quantify "under-reporting" of

    cases among children and actions to reduce

    under-reporting (and over-diagnosis)

    Next steps for better assessment

    of TB among women and children

  • www.who.int/

    tb/data

  • Acknowledgements

    >400 people

    Core Report Team

    Annabel Baddeley, Monica Dias, Dennis

    Falzon, Christopher Fitzpatrick,

    Katherine Floyd, Christopher Gilpin,

    Philippe Glaziou, Tom Hiatt,

    Andrea Pantoja, Delphine Sculier,

    Babis Sismanidis, Hazim Timimi, Wayne

    van Gemert, Mukund Uplekar,

    + Ikushi Onozaki and Wataru Kashino

    USAID

    WHO Regional Offices

    Amal Bassili, Andrei Dadu, Daniel Kibuga,

    Khurshid Hyder, Rafael Lopez-Olarte,

    Wilfred Nkhoma, Nobu Nishikiori,

    Anglica Salomao

    who contributed to reporting, validation

    and review of data in 2011