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 2011–2015
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, 1990–2010 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
1.0–1.2 million (12–14%)
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, 1990–2010
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% (63–68%)
Case notifications by region, 1990–2010 Incidence in green
2010 CDR: 56–64% 2010 CDR: 75–85% 2010 CDR: 56–71%
2010 CDR: 67–76% 2010 CDR: 57–65% 2010 CDR: 73–86%
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
Europe
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%
Europe
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%
Europe
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
Europe
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%
Chin
a (1
990)
Kore
a (1
990)
Kore
a (1
995)
Phili
ppin
es (1
997)
Cam
bodia (2
002)
Phili
ppin
es (2
007)
Vie
t Nam
(200
7)
Mya
nmar
(2009
)
Chin
a (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
Kore
a (1
995)
Cam
bodia
(200
2)
Indones
ia (2
004)
Phili
ppines
(200
7)
Vie
t Nam
(200
7)
Mya
nmar
(2009
)
Chin
a (2010
)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 A
sia
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 3.0–3.5 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,
Angélica Salomao
who contributed to reporting, validation
and review of data in 2011
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