The burden of TB in 2006 1.7 million deaths in 2004 – 98% of these in developing world 250,000 deaths due to TB/HIV MDR-TB present in 102 of 109 countries.

The burden of TB in 2006

1.7 million deaths in 2004 – 98% of these in developing world250,000 deaths due

to TB/HIV

MDR-TB present in 102 of 109 countries and settings surveyed in 1994-2002

8.9 million new cases in 2004 – 80% in 22 high-burden countries

0 - 9991000 - 999910 000 – 99 999100 000 - 999 999

No estimate1 000 000 or more

Estimated number of new cases (all forms)

ASIA55%

AFRICA29%

AMERICAS 4%

EAST. MEDIT. 7%EUROPE 5%

Asia has the highest number of cases and TB has resurged in Europe...

Global incidence is rising at 1% due to increases In Africa and E. Europe

0

100

200

300

400

1990 1995 2000 2005

Est

imat

ed T

B i

nci

den

ce/1

00K

/yr Africa - high HIV

Africa - low HIV

WorldE Europe

World exc Afr EEur

WHO European Region WHO European Region

25 EU countries

53 countries

18 high priority countries for TB

1. Armenia

2. Azerbaijan

3. Belarus

4. Bulgaria

5. Estonia

6. Georgia

7. Kazakhstan

8. Kyrgyzstan

9. Latvia

10. Lithuania

11. Moldova

12. Romania

13. Russian Fed.

14. Tajikistan

15. Turkey

16. Turkmenistan

17. Ukraine

18. Uzbekistan

TB case notification rate in EUR, 1980-04TB case notification rate in EUR, 1980-04

295,240East+ EUR(18 countries)

354,954All EUR

(53 countries)

54,231European Union

(25 countries)

Annual TB cases per 100,000 pop.

Year0

10

20

30

40

50

60

70

80

90

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04

373,497

TB incidence in EUR TB incidence in EUR

13/100 000 - first fifteen members of the EU

27/100 000 - ten new members of the EU (enlargement in 2004)

53/100 000 - four countries accessing the EU

98/100 000 - countries bordering EU

50/100 000 - overall TB incidence in EUR

Mean annual change in TB notification rates, 2000-2004

No data / <60 cases/yr

-11% to -3%

-2% to +1%

+2% to +6%

>+6%

% change

EuroTB

Proportion of TB cases of foreign origin, Europe, 2004

No data

0-4

5-19

20-39

40+

% cases of foreign origin

Andorra

Malta

Monaco

San Marino

EuroTB

Global TB control targets

2005: World Health Assembly:- To detect at least 70% of infectious TB cases- To treat successfully at least 85% of detected cases

2015: 50% reduction in TB prevalence and deaths by 2015

2015: Goal 6: Combat HIV/AIDS, malaria and other diseases Target 8: to have halted by 2015 and begun to reverse the incidence… Indicator 23: prevalence and deaths associated with TB

Indicator 24: proportion of TB cases detected

and cured under DOTS

DOTS in EURDOTS in EUR

population (%)no DOTS< 1010-90> 90

1995 - 6 countries; 2004 - 43 countries, 47% population

Plan to Stop TB in EEUR: achievementsPlan to Stop TB in EEUR: achievements

TUR

UZB

AZE EST

GEO

KAZ

KGZ

MDA

ROM

RUS

TJK

TKM

ARM

LVA LTUBLR

UKR

55

60

65

70

75

80

85

90

95

100

0 10 20 30 40 50 60 70 80 90 1002004 case detection (%)

2003

tre

atm

ent

succ

ess

(%)

TARGET STOP TB strategy:

• DOTS

• MDR-TB, TB/HIV,

prisons

• Health system

• All providers

• ACSM, people,

patients

• Research

Note: DOTS achievements in new smear-positive pulmonary TB cases

Proportion of pulmonary cases with positive sputum smear, East*, 1999-2004

* including countries where pulmonary classification was applied for three or more consecutive years

15%

30%

45%

60%

1999 2000 2001 2002 2003 2004

% of pulmonary cases

Moldova, Rep

Kyrgyzstan

Armenia

Georgia

Kazakhstan

Turkmenistan

Azerbaijan

Treatment outcomes, new definite pulmonary cases*, 2003

* Culture positive in EU & West and Centre; smear positive in Macedonia FYR and East. Countries with nationwide representative data; excluding 4 countries with < 10 cases (EU & West)

§ Mean percentage (country range in brackets)

EU & West§

20 countries

Balkans§

4 countries

East§

6 countries

Success 76% (54-88%) 83% (82-91%) 71% (55-84%)

Death 7% (0-13%) 4% (2-4%) 5% (2-9%)

Failure 1% (0-11%) 4% (0-5%) 10% (3-14%)

Still on treatment 3% (0-14%) 0.6% (0.0-0.7%) 0.1% (0.0-1.1%)

Other (Default, Transferred,

Unknown)

13% (0-25%) 8% (4-15%) 14% (5-36%)

EuroTB

Outcomes among new, definite pulmonary TB cases, EU & other regions, 2003*

* Mean for 19 EU countries (EuroTB); data from other regions refer to DOTS cohorts (WHO Global Tuberculosis Control: Surveillance, Planning, Financing. 2006)

Despite low mortality rates, the proportion of TB patients notified in the EU who die while on treatment is substantial, even when compared to other regions in the world. This is one limitation keeping many EU countries from achieving the WHO target of 85% success among previously untreated pulmonary TB cases.

Region Success Death Failure Other

European Union 76% 7.2% 1.1% 16.2%

Africa 72% 7.0% 1.4% 19.8%

The Americas 82% 4.9% 1.2% 12.4%

Eastern Mediterranean 82% 2.9% 1.4% 14.1%

South-East Asia 85% 4.5% 2.1% 8.1%

Western Pacific 91% 2.3% 1.1% 5.1%

East – West divide

EuroTB

East West

Notification data Aggregated Individual

Culture confirmation None to low High

Main trend in notification rate Incremental Declining

Epidemic type Diffuse Concentrated

Imported TB Low (<1%) High (29%)

Drug resistance High Low

HIV in TB cases < 1% 0-16%

Outcomes ↑ failures ↑ deaths

Vision: A WORLD FREE OF TB

Goal: To dramatically reduce the global burden of TB by 2015 in line with the MDGs and the Stop TB Partnership targets

Objectives:• Achieve universal access to high-quality diagnosis and patient-centred

treatment• Reduce the human suffering and socio-economic burden associated with TB• Protect poor and vulnerable populations from TB, TB/HIV and multidrug-

resistant TB• Support development of new tools and enable their timely and effective use

Why the new Stop TB Strategy ? Vision, Goals, Objectives

Plan to Stop TB in EEUR: Planned milestonesPlan to Stop TB in EEUR: Planned milestones

MilestonesYear

2007 2008 2009 2010

Population covered by DOTS services (%) 60 75 90 100

TB cases accessing quality-assured culture and drug

susceptibility testing (%)

40 60 80 90

Population covered by adequate MDR-TB

management services. (%)

25 40 55 70

Countries implementing collaborative TB/HIV

activities (%)

20 35 65 100

Countries with TB care in prisons of equivalent

standards than outside (%)

25 40 55 70

Countries where TB care is integrated at primary

health care level (%)

25 40 55 70

Countries where communities are involved to ensure

quality TB care (%)

25 40 55 70

What are the main challenges ?

1. DOTS not yet fully expanded and of high quality everywhere2. TB/HIV, especially in Africa, and MDR-TB, especially in former USSR

and China3. Weak health systems and services impeding proper TB control and

care4. Not all practitioners engaged5. Communities un-aware and un-involved6. Research not producing yet new tools and outside of the interest of

TB "controllers"

Western and Central EuropeWestern and Central Europe

0

20

40

60

80

100All hetero Hetero males Hetero females MSM IDU

Today, mainly sexual transmission in Western and Central Europe Exceptions: significant IDU epidemics in ESP, POR, ITA, SWI, POL 25-65% of all cases are among MSM Up to 75% of all heterosexual cases are among immigrants from high prevalence countries and women are >50% of all

heterosexual cases Vulnerable Groups: MSM & immigrants, specially immigrant women

Eastern EuropeEastern Europe

0

20

40

60

80

100

Russian F. Ukraine Belarus Moldova Lithuania Latvia Estonia Kazakhstan Uzbekistan Kyrgyzstan Tajikistan

IDU among those with known transmission route

Mainly IDU related transmission in Eastern Europe 68-85% of all cases are male Up to 30% of infected females are IDU and 50% are partners of IDU 30-50% of all HIV infections are among those under 25 years Vulnerable Groups: IDU, sex workers, prisoners, ethnic minorities, migrants

84%

2%

<20%

20-40%

40-60%

60-80%

50%

6%

6.1%

13%

10%

>80%

81%

25.5%

11%

8.2%

90%

57%

83%

29%

64%

74%

60%

16%

4%

19.4%

7%

15%

16%

<1%

24%

87%

60%

68%

14.5%

71%

5%

6%

IDU as % of all HIV/AIDS casesIDU as % of all HIV/AIDS casesNOTE: % of AIDS cases in countries not reporting HIV Sources: EuroHIV; national reports;NOTE: % of AIDS cases in countries not reporting HIV Sources: EuroHIV; national reports;

0%

11%

17%

20%

5%

82%

2%

51%

3%

14%

16%

1.8%

16%

32%

29%

16%

34%

82%

80%

86%

71%

76%

85%

<20%

20-40%

40-60%

60-80%

83%

61%

76%

78%

72%

>80%

73%

25.5%

80%

70%

77%

78%

89%

80%

80%

73%

77%

16%

69%

75%

97%

90%

63%

81%

75%

80%

71%

75%

71%

80%

78%

Males as % of all HIV/AIDS casesMales as % of all HIV/AIDS casesNOTE: % of AIDS cases in countries not reporting HIV Sources: EuroHIV; national reports;NOTE: % of AIDS cases in countries not reporting HIV Sources: EuroHIV; national reports;

62%

78%

71%

66%

63%

68%

79%

80%

61%

80%

85%

74%

82%72%

83%

64%

NA

84%

81%

72%

RUSRUS

ARMARM

KAZKAZ

KYZKYZUZBUZB

TKMTKM TJKTJK

GEOGEOAZEAZE

ESTEST

LATLAT

LITLIT BELBEL

UKRUKR

BULBUL

ROMROMMOLMOL

ALBALB

no HAART (<1%) good coverage (>70%)

poor access ( 1-10%) partial coverage (10-70%)

BIH, FYM, YUG

TURTUR

Access to HAART, 03/2003

RUSRUS**

ARM*ARM*

KAZ*KAZ*

UZB*UZB*

TKMTKM TJK*TJK*

AZE*AZE*

BELBEL

UKRUKR**

no HAART very poor coverage ( 1-10%) * in the process of scaling up ART

poor coverage (10-50%) moderate coverage (50-75%) disputed coverage estimates or insufficient data available

good coverage (over 75%)

Access to HAART, 01/2006

HIV infection among TB cases, 1998-2004*

* Excluding countries with less than 2 datapoints in the last 3 years or less than 50 TB notifications annually

The proportion of TB cases with HIV infection has increased in Estonia and Latvia, but is still highest in Portugal and Spain. In other countries of the Balkans and East providing data, levels have remained below 1%.

0

2

4

6

8

10

12

14

16

18

1998 1999 2000 2001 2002 2003 2004

% TB casesPortugal

Spain

Belgium

Estonia

Netherlands

Israel

Latvia

Denmark

Slovenia

Romania

Uzbekistan

Lithuania

Albania

Azerbaijan

Armenia

Czech Rep.

Reported to WHO (2005)52,800 TB patients HIV tested

5,800 tested positive14 started the ART

Estimated HIV prevalence 2005Estimated HIV prevalence 2005

Country HIV prev. (%) Country HIV prev. (%)

Pop.

(2003)

TB

(2005)

Pop.

(2003)

TB

(2005)

Ukraine 1.4 8.3 Armenia 0.1 0.8

Russian Federation 1.1 6.8 Uzbekistan 0.1 0.6

Estonia 1.1 6.6 Kyrgyzstan 0.1 0.5

Latvia 0.6 3.9 Lithuania 0.1 0.4

Belarus 0.5 2.9 Azerbaijan <0.1 0.1

Moldova 0.2 1.4 Tajikistan <0.1 0.0

Georgia 0.1 1.3 Turkmenistan <0.1 0.0

Kazakhstan 0.2 1.2 Europe 4.7

Source: UNAIDS (2004); WHO Global TB Report (2006)

% HIV prevalence estimated in general population and TB patients (adults)

European Framework for TB/HIVEuropean Framework for TB/HIVInterim policy on collaborative TB/HIV activitiesInterim policy on collaborative TB/HIV activities

a. Establish the mechanism for collaborationa. Set up a coordinating body for TB/HIV b. Conduct surveillance of HIV prevalence among TB patientsc. Joint TB/HIV planningd. Conduct monitoring and evaluation

• Decrease the burden of TB in people living with HIV/AIDS• Intensified TB case finding• Introduce INH preventive therapy• Ensure TB infection control in health care and congregate settings

• Decrease the burden of HIV in TB patients• Provide HIV testing and counselling• Introduce HIV prevention methods• Introduce co-trimoxazole preventive therapy• Ensure HIV/AIDS care and support• ART

Cat 1: national adult HIV prevalence >1% or HIV prevalence in TB pts >5%: all activities recommended in the Interim policy to be considered for implementation

Cat 2: national adult HIV prevalence below 1% and administrative areas with adult HIV prevalence >1% - combination of Cat 1 and Cat.3

Cat 3: national adult HIV prevalence below 1% and no administrative areas with adult HIV prevalence >1%: Conduct surveillance of HIV prevalence among TB

patients Decrease the burden of TB in people living with

HIV/AIDS with focus on groups at high risk for TB and HIV – IDUs, MSM, sex workers, those living in congregate settings)