Tuberculosis 2013: basics, burden, impact, challenges, innovations Photo: Riccardo Venturi GLOBAL TB PROGRAMME Dr Mario Raviglione Director, Global TB Programme, World Health Organization, Geneva, Switzerland Geneva Journalism & Health Mentoring Initiative Geneva, 20 May 2013
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Tuberculosis 2013: basics, burden, impact, challenges, innovations Photo: Riccardo Venturi GLOBAL TB PROGRAMME Dr Mario Raviglione Director, Global TB.
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Impact of interventions, and progress in TB care and control
Vision beyond 2015
Innovations necessary towards elimination
GLOBAL TB PROGRAMME
• Tuberculosis (TB) is one of the oldest diseases of humans• TB is a major cause of death worldwide, it competes with
HIV/AIDS as the greatest killer globally due to a single infectious agent
• TB is also one of the top killers of women worldwide, half a million women died from TB in 2011
• TB is caused by the bacterium Mycobacterium tuberculosis• TB usually affects the lungs, although other organs are
involved in 15-30% of cases • If properly treated, TB caused by drug-susceptible strains is
curable in virtually all cases • If untreated, TB may be fatal within 5 years in 2/3 of cases • One third of world has latent TB infection
Tuberculosis: basics
GLOBAL TB PROGRAMME
Mycobacterium tuberculosis complex: M. tuberculosis, M. bovis, M. microti, M. africanum,M. pinnipedii, M. caprae ( and M. canettii)
Robert Koch discovered the cause of TB 24 March 1882
GLOBAL TB PROGRAMME
How is TB transmitted? ..Via aerosolised particles from infectious patients
TB linked to HIV infection, malnutrition, alcohol, drug and tobacco use, diabetes
Half a million women and over 65,000 children die of TB each year; 10 million “TB” orphans
Migrants, prisoners, minorities, refugees face risks, discrimination & barriers to care
Poor, crowded & poorly ventilated settings
Who carries the burden of tuberculosis?…mostly, the most vulnerable
GLOBAL TB PROGRAMME
Estimated number of cases
Estimated number of deaths
1.4 million*(1.3–1.6 million)
8.7 million(8.3–9.0 million)
Up to 0.5 million
All forms of TB
Multidrug-resistant TB
HIV-associated TB 1.1 million (13%) (1.0–1.2 million)
430,000(400,000–460,000)
Source: WHO Global Tuberculosis Report 2012 * Including deaths attributed to HIV/TB
The Global Burden of TB -2011
Unknown, but probably > 150,000
GLOBAL TB PROGRAMME
Incidence rates, 2011
Highest rates in Africa, linked to high rates of HIV infection~80% of HIV+ TB cases in Africa
Per 100 000 population≥300
150–29950–149
0–2425–49
GLOBAL TB PROGRAMME
TB/HIV co-infection: 80% of burden 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
80% of all TB/HIV cases are in Africa
GLOBAL TB PROGRAMME
Drug resistant TB: Major challenge
o Multi-drug resistant TB (MDR-TB)
• Second-line drugs, toxic, costly, lengthy
o Extensively drug resistant TB (XDR-TB)
• Almost incurable, fatal
o Drug resistant TB results from inadequate TB care and irrational use of drugs
o New York epidemic in early 90’s – Cost of response: US$ 1 billion
GLOBAL TB PROGRAMME
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines
for which there may not yet be full agreement. WHO 2012. All rights reserved
Estimated number of MDR-TB Cases, 2011>60% of all cases are in 6 countries
Russian Federation 44,000
(14% of global MDR burden)
India66,000
(21% of global MDR burden)
China61,000
(20% of global MDR burden)
Philippines11,000
(4% of global MDR burden)
Pakistan10,000
(3% of global MDR burden)
South Africa8,100
Based on old survey data
GLOBAL TB PROGRAMME
Spotlight on XDR-TB
Case of Atlanta lawyer with presumed XDR-TB caused international concern
GLOBAL TB PROGRAMME
To date, 84 countries have reported at least one XDR-TB case
About 9% of MDR-TB cases are XDR
GLOBAL TB PROGRAMME
The case of Mumbai and the “TDR-TB outbreak”
Udwadia ZF, Amale RA, Ajbani KK, Rodrigues C. Totally drug-resistant tuberculosis in India. Clin Infect Dis. 2012 Feb 15;54(4):579–81.
The global response: Targets, Global Plan, and Stop TB Strategy
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
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)
Pursue DOTS Address TB/HIV and
MDR-TB
Strengthen systems
THE WHO STOP TB STRATEGY
Engage all care providers
Empower communities
Promote research
GLOBAL TB PROGRAMME
Incidence
Mortality
Global Progress
51 million patients cured, 1995-2011
20 million lives saved since 1995
2015 MDG and other international targets on track
BUT, TB incidence declining far too slowly, 1/3 of cases not in the system, MDR-TB un-tackled etc.
GLOBAL TB PROGRAMME
Innovating with GeneXpert
WHO endorsement December 2010
Nearly 83 countries using it in March 2013
GLOBAL TB PROGRAMME
WHO GLOBALTB PROGRAMME
The WHO Global TB Programme aims to advance universal access to
TB prevention, care and control, guide the global response to
threats, and promote innovation.
A World FREE of TBVISION:
MISSION:
GLOBAL TB PROGRAMME
What we do: our core functions
Provide global leadership on TB; Develop policies, strategies and standards for TB prevention, care and control; Coordinate technical support to Member States, catalyze change, and build
sustainable capacity; Monitor the global TB situation, and measure progress in TB care, control, and
financing; Shape the TB research agenda and stimulate the generation, translation and
dissemination of valuable knowledge; Facilitate and engage in partnerships for TB action.
ZERO TB DEATHS
VISION
A WORLD FREE OF TB
The TB Elimination Strategy
ZERO TB CASES
ZERO TB SUFFERING
TOWARDS
Universal high-
quality TB care and
prevention
Bold policies and supportive
systems
Intensified research
and innovation
Proposed Pillars and Principles of the Post-2015 TB Strategy
Targets for 2025/2030
Target 1
75%/80% reduction in
deaths due to TB (compared with
2015)
Target 2
40%/60% reduction in TB incidence rate
(compared with 2015)
Target 3
No catastrophic expenditures for families
affected by TB
GLOBAL TB PROGRAMME
CHALLENGES TO “ELIMINATION"?
1. Funding not secure; catastrophic expenditure for the poor
2. Only 2/3 of estimated cases reported or detected (late)
3. TB/HIV major impact in Africa
4. MDR-TB, with high burden in former USSR and China
5. Un-engaged non-state practitioners and communities, and the private sector
6. Weak health policies, systems and services
7. Social and economic determinants maintain TB
8. Research awakening: old diagnostics, drugs and vaccines
GLOBAL TB PROGRAMME
ROADBLOCK 1: Lack of commitment
"…
…"
GLOBAL TB PROGRAMME
ROADBLOCK 2: FundingU
S$ b
illio
ns
Funding gap vs Global Plan ~ US$2–3 billion per yearFunding gaps reported by countries US$0.7 billion in 2013
GLOBAL TB PROGRAMME
Sputum smear microscopyDiscovered 1882
DIAGNOSTIC
1st-line TB drugs Discovered 1943-1970
TREATMENTVACCINE
BCGDeveloped 1920s
ROADBLOCK 3: Today, most used tools for TB control are old and not conducive to elimination
GLOBAL TB PROGRAMME
ROADBLOCK 3: Bedaquiline – First drug in forty years
• Only data from Phase IIb trials available , further efficacy and safety data will be needed from rigorously conducted Phase III trials
• On December 28, 2012, the U.S. Food and Drug Administration approved bedaquiline
• Caution on use • WHO advises that a single drug deemed to
be effective should never be added alone to a regimen to which a patient is not responding to
• WHO has initiated a review process aimed at developing rapid interim guidance on the potential use of bedaquiline for the treatment of MDR-TB.
• Interim guidance from WHO in coming month
GLOBAL TB PROGRAMME
1. For elimination one would need potent short treatments, mass 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. TB Vaccine development: we need a global coalition of all engaged agencies so that efforts are harmonised and coordinated. This is not a job for one agency only!
4. Increased financial resources for research: keep working together to provide the right messages to investors
ROADBLOCK 3: Research key for elimination
GLOBAL TB PROGRAMME
What is in the pipelines for new diagnostics, drugs and vaccines in 2013?
Diagnostics:₋ 7 new diagnostics or diagnostic
methods endorsed by WHO since 2007;₋ 6 in development; ₋ yet no PoC test envisaged
Drugs:- 1 new drug 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
GLOBAL TB PROGRAMME
Roadblock 4: Unregulated private sector
• Private sector is first point of care in many settings
• Diverse network of formal and informal providers ranging from hospitals, corporate sector to the traditional healers and quacks
• 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
• Untapped potential• Private sector engagement crucial in
closing the gap on case detection
GLOBAL TB PROGRAMME
Roadblock 5: Taking on the Pharmaceutical Industry
• Lobbying, promotion, economic incentives and infiltration
• Quality differentiation based on level of regulation
• Counterfeit medicines• Drug resistance• BUT, we need them on our side!