Tuberculosis Control in the Asia Pacific Region Achievements, Deficiencies & Future Directions Dr Ral Antic Chair, Scientific Committee IUATLD-APR Australia
The 1 st Asian Pacific Regional Conference 2007, IUATLD - APR ‘OVERCOMING AN OLD SCOURGE WITH A NEW FACE’
The 1 st Asian Pacific Regional Conference 2007, IUATLD - APR ‘OVERCOMING AN OLD SCOURGE WITH A NEW FACE’ We could have (& have) been discussing, in this context • Tuberculosis • COPD • Asthma • Sleep Disorders ……. & others
Achievements in the last decade What is different in the handling of these various disorders is • The extent of the global and regional strategic planning for TB • The structured multi-faceted public health approach as we have discussed • That we are driving the ‘change agenda’ working back from defined targets and outcomes
Achievements and Deficiencies in TB Global, Regional & Country • What are we trying to achieve? • Are our Directions and Targets right and achievable • Do we have the ‘capacity’ to achieve the Vision, Goals and Targets we have set?
Achievements in TB in the last decade • The provision of effective Global, Regional and Country Leadership • A sustained focus on development and updating of a Global and Regional Strategic Direction • Its implementation in a strategic fashion • Improvement in case detection and treatment • Infrastructure building • Better Surveillance and Quality monitoring
Achievements and Deficiencies Global, Regional & Country • In the last decade, we have appropriately changed direction • But with the current tools, change is understandably slow. • And this leaves us to wonder whether we are doing a good job.
Achievements and Deficiencies Global, Regional & Country • What is the burden of ill-health from TB ?
The Global TB Epidemic ‘Global TB Control’ , WHO Report 2007 • TB is still a major cause of death worldwide, but the global epidemic is on the threshold of decline • TB prevalence and death rates have probably been falling globally for several years • But the total number of new TB cases is still rising slowly, as the population grows and the case-load continues to grow in the African, Eastern Mediterranean and SEA Regions
Estimated Burden from TB and Trends Western Pacific Region • Estimated 4 million cases of TB in WPR – 2 million new cases • Seven high burden countries account for >95% – Cambodia, China, Lao PDR, Mongolia, PNG, Philippines & Vietnam
Stop TB Partnership Targets By 2005: At least 70% of people with sputum smearpositive TB will be diagnosed (i. e. under the DOTS strategy), and at least 85% cured By 2015: The global burden of TB (per capita prevalence and death rates) will be reduced by 50% relative to 1990 levels By 2050: The global incidence of active TB will be less than 1 case per million population/year
WP Regional Goals & Targets Regional Committee WPR, 2000 Goal: • Reduce TB prevalence and mortality by 50% in 2010 compared with 2000 Intermediate Targets (towards this goal): 1. Detect 70% of estimated active cases 2. Treat successfully 85% of these cases 3. 100% DOTS coverage
What we have achieved in WPR achieved these intermediate targets in 2005. Also – 26 countries globally have achieved targets - including China, the Philippines, Vietnam – Targets were missed narrowly Globally: • case detection - 60% • treatment success - 84% – Treatment success in the SEA Region > 85%
MDR-TB and XDR-TB ‘The Global MDR-TB and XDR-TB Response Plan 2007 -2008’ WHO Report 2007 • > 400 000 new cases of MDR-TB every year • due to under investment in basic TB control, poor management of anti-TB drugs and transmission of drugresistant strains. • MDR-TB is much more difficult and costly to treat than drug susceptible TB • recent work has shown that it is feasible and costeffective to treat even in settings of limited resources.
MDR-TB and XDR-TB ‘The Global MDR-TB and XDR-TB Response Plan 2007 -2008’ WHO Report 2007 • Emerging XDR-TB • The economic, social and health security of countries and communities with a high prevalence of TB threatened by it • It is virtually untreatable TB among the breadwinners, parents and economically productive age groups.
MDR-TB and XDR-TB ‘The Global MDR-TB and XDR-TB Response Plan 2007 -2008’ WHO Report 2007 • Strengthening the coverage and quality of basic TB control is the first and most important measure to prevent MDR-TB and is the fundamental platform for deploying management of drug resistant TB • Treat 1. 6 rather than 0. 8 million in 2008 with MDR-TB and save 134000 lives • More costly >US$ 2. 1 B extra
Case Detection in WPR • From < 40% to >70% overall in 5 years • Achieved by: – – – Developing a strategic approach, The Global Plan to Stop TB Strengthening political commitment Accelerating DOTS expansion in public facilities Higher case detection success in many countries TB care more available and accessible Improving collaboration of health care providers – Increase in financing and other resources
TB Performance Indicators in the Western Pacific Region, 2004 “Strategic Plan to Stop TB in the Western Pacific 2006 – 2010” Prevalance Rate (/105) Case detection SS+ (%) Treatment Success (%) Mortality Rate (/105) Australia 6 56 95 1 Cambodia 709 61 93 94 China 221 65 94 17 Hong Kong 77 72 78 6 Japan 39 62 76 4 Lao PDR 318 55 79 25 Malaysia 133 69 72 16 Mongolia 209 80 87 24 11 59 36 1 Papua New Guinea 448 31 58 42 Philippines 463 73 88 48 Republic of Korea 125 59 82 10 41 67 77 4 232 89 92 22 New Zealand Singapore Vietnam TB Performance Indicators in the South East Asia Region, 2004 “National Tuberculosis Control Programs South East Asia Region” Prevalance Rate (/105) Case detection SS+ (%) Treatment Success (%) Mortality Rate (/105) Indonesia 262 66 90 41 Thailand 218 73 74 20
Some future barriers to TB Control • Poverty, Housing, Social disruption • The under-diagnosis of TB • Perceived complexity of the public health systems we are promoting • Natural progression of resistance in drugs • The benefits and risks of having joint project eg malaria, smoking cessation, HIV-TB
Towards the Goals and Targets Although the TB burden may be falling globally, the decline is not fast enough to meet the impact targets “Strategic Plan to Stop TB in the Western Pacific 2006 – 2010 ”
Estimated Trends Western Pacific Region • A decline of 15% in prevalence & 12% in mortality between 2000 -2004 – Annual average of 4% and 3% respectively
Will achieving WHO targets reduce the notification rate? The barriers – Spread of HIV – Accumulation of MDR-TB cases – Insufficient access to high quality TB care for the poor and vulnerable populations and in private sector – Lack of national guidelines & training materials – Lack of human resources and their development AND/OR – the rising numbers and urbanisation of the population – Estimated targets and actual incidence need discussion
3 main areas of concern • The current level of 70% detection will not be sufficient • MDR-TB and TB-HIV co-infection will slow the annual decline • Conventional DOTS service delivery does not guarantee equitable access to TB Services
The current position A new ‘Strategic Plan to Stop TB in the Western Pacific 2006 -2010’ has been developed to achieve the new targets.
The new Strategic Plan for WPR 2006 -2010 • To achieve the 50% reduction in prevalence & death rates, an 8% annual decline is needed • The current annual decline is 3 -4% • There thus needs to be a change in approach • This is the basis of the strengthened effort defined in the new Strategic Plan
TB (all case) notification and death rates per 100, 000 in South Australia 1900 and 2006 Notification Rate/100, 000 160 140 Death Rate 120 Notification Rate 100 80 3% decline The National TB Campaign 60 40 20 improved socioeconomic conditions 4% 10% 8% 14% 0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 Year
The National TB Campaign Australia, 1948 -1975 • National Leadership (NTP) • Commitment from – National & State Govt • Funding • Legislative muscle – mandatory participation – The Health Professions – The community, because of • community concern • promotion of TB the disease and of the TB Campaign • Financial incentives for patients with active disease to adhere to treatment • A new Strategic Direction & sound systems, infrastructure – Adequate funding – Effective system of care • active disease and infection case finding, new drugs, centralised treatment – – Adequate laboratory services DOT? Free drug supplies Appropriate monitoring systems, for individual care and Program • No public/private mix, MDR-TB, HIV issues, but migration+
TB (all case) notification rate per 100, 000 South Australia - 1945 to 2006 The National TB Campaign 20 18 50 16 14 40 12 30 10 Target rate of decline 10% per year 8 20 6 Excess cases 4 10 2 0 0 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year Death Rate Target decline rate 2000 2005 Decline in Death Rate/ 100, 000 Notification Rate / 100, 000 60
TB notification rate by age, Australian-Born South Australians between 1987 - 2006 9 Notification Rate/100, 000 8 7 6 5 4 3 2 1 1987 -1991 1992 -1996 1997 -2001 2002 -2006 0 0<14 15<24 25<34 Age 35<44 45<54 55<64 > 65
Framework of the Strategic Plan to Stop TB in the Western Pacific 2006 - 2010 VISION GOAL Elimination of TB as a public health problem To reduce prevalence and mortality from all forms of TB by one half by 2010 relative to 2000, contributing to the achievement of the Millennium Development Goals
Framework of the Strategic Plan to Stop TB in the Western Pacific 2006 - 2010 1. To sustain and optimize the quality of DOTS and go beyond the ‘ 70/85’ targets OBJECTIVES Case detection rate (beyond 70%) Cure rate (beyond 85%) 2. To ensure equitable access to high quality TB care for all people with TB Proportion of Facilities (include private or general hospitals) providing or referring to DOTS (at least 90%) 3. To adapt DOTS to respond to MDR TB and TB-HIV co infection Proportion of identified MDR-TB cases by DST provided with 2 nd line treatment (at least 90%) Proportion of identified HIV positive TB, eligible for ART, that are provided with ART (at least 90%) CORE TARGETS Beyond 70% CDR At least 90% DOTS-Plus Treatment coverage of MDR-TB At least 90% ART coverage of HIV positive TB At least 90% PPMD coverage
Framework of the Strategic Plan to Stop TB in the Western Pacific 2006 - 2010 Country capacity quality of diagnosis for TB assured (i. e. smear microscopy, culture, chest X-ray) At least 90% laboratory units with satisfactory performance Uninterrupted supply of quality-assured anti-TB EXPECTED drugs at all DOTS units RESULTS 100% of treatment units with uninterrupted supply of drugs in a given year Enhanced case management for all registered TB cases, including smear negative TB All HBC have developed guidelines for diagnosis & treatment of smear negative TB e. g. children Improved TB case management in non. NTP TB facilities At least 85% cure rate of TB cases managed by non. NTP facilities Adoption of the International Standards of TB Care & the Patients Charter for TB Care All countries have introduced the above standards Increased utilization of TB services by poor & vulnerable populations At least 10% of cases notified under pro-poor TB initiatives Country-driven advocacy, communications & social mobilisation strategies developed & implemented All HBC are implementing ACSM strategies for TB control on a national scale Assessment of MDR-TB in targeted countries All targeted countries Have assessed their MDR-TB situation through drug resistance surveillance DOTS-Plus initiated/scaled up in targeted countries At least 6 have initiated/scaled up DOTS-Plus. At least 10%0 f failure cases tested by DST TB-HIV framework for collaboration developed & implemented All targeted countries are implementing TB-HIV surveillance Access of TB patients to HIV Services At least 70% of TB patients tested for HIV in Category 1 and 2 countries/areas. At least 70% of newly diagnosed patients with HIV tested for TB
Components of the Strategic Plan & Implementation approaches 1. Pursue high quality DOTS expansion & enhancement a. Political commitment with increased & sustained financing b. Case detection through quality assured bacteriology c. Standardised treatment with supervision & patient support d. An effective drug supply & management system e. Monitoring & evaluation system & impact measurement
Components of the Strategic Plan & Implementation approaches 2. Address TB-HIV, MDR-TB & other challenges a. Implement collaborative TB-HIV activities b. Prevent & control MDR-TB c. Address prisoners, refugees & other high-risk groups 3. Contribute to health system strengthening a. Actively participate in efforts to improve policy, human resources, financing, management service delivery & information systems b. Share innovations, including the Practical Approach to Lung Health (PAL) c. Adapt innovations from other fields
Components of the Strategic Plan & Implementation approaches 4. Engage all care providers a. Public-Public & Public-Private Mix approaches b. International Standards for TB Care (ISTC) 5. Empower people with TB & communities a. Advocacy, communications & social mobilisation b. Community participation in TB care c. Patients Charter for TB Care 6. Enable & promote research a. Program- based operational research b. Research to develop new drugs, vaccines & diagnostics
Framework of the Strategic Plan to Stop TB in the Western Pacific 2006 - 2010 ACTIVITIES CROSSCUTTING ISSUES Activities directed at producing expected results are to be implemented at inter-country, regional and country levels: - Inter-country and regional activities are in the WHO plans of action - Country level activities are in the National TB Control Plans 2006 -2010 1. Ensured availability of essential staff required for TB control 90% of key positions required for TB control filled by trained staff 2. Sufficient financing for TB control ensured All HBC develop annual funding plan for NTP that incorporates all financial inputs and funding gaps 3. Evidence-based policy and implementation strategy development through operations research (e. g. PAL, information system, child TB, and new diagnostic modalities)
Estimated TB incidence rate, 2005 Estimated new TB cases (all forms) per 100 000 population No estimate 0 -24 25 -49 50 -99 100 -299 300 or more 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 2006. All rights reserved
What have we learned from the presentations? • The current burden of disease remains large • There are important Regional and Country successes • Some targets are being achieved but • The targets and so strategic plans are needing to be revised to achieve the primary Goal • There are significant barriers • Do we have systems in place to achieve these targets and overcome the barriers?
What else can/should we need to do? • What more should we (jointly) do – as the Union, the APR IUATLD, WHO, APSR & the many other organizations and as individuals? • What is the real view of our Communities and Governments about TB - what is the image of TB? • What can this and our future Conferences and its participants contribute to furthering the objectives of the Region? • What are the special skills and the special ‘Capital’ that the attendees and their organisations bring?
The Future Direction • • • The vision ‘The elimination of TB’ is right The objectives are right. It needs global and local leadership It needs the proper application of our knowledge The resolve must be strengthened All cases have to be found and treated New drugs must be found More resources are needed TB can be eliminated.
It can be and it has to be done
My Thanks To: The The The Congress President Secretariat Chair of the Organizing Committee Chair of the Organizing Scientific Committee Speakers and …. to all of you who have attended and participated
Tuberculosis Control in the Asia Pacific Region Achievements, Deficiencies & Future Directions Dr Ral Antic Chair, Scientific Committee IUATLD-APR Australia
What is the role of APR IUATLD? • • Workforce Training Advocacy Service provision
What is the APR IUATLD • The Asian Pacific Region of the UNION • In 2006, the Eastern Region IUATLD was divided into 2 new Regions, the South East Asian and Asian Pacific • The aim was to reduce the size of the Regions to help facilitate their TB work • There are 16 APR constituent member countries and other organisations and individuals
The different & complementary roles • • Global and regional organisations Organisations within each country Governments Government and non-Government Organisations – Different countries – Within countries
Functional relationships • Organisations responsible for different diseases with overlapping risk factors and populations – e. g. malaria, TB, AIDS
The challenges and barriers 1 • The Private Sector – NTP does not cover private sectors. Detailed information on case-finding activities & treatment outcomes are not known yet. The pilot project of Private-public mix (PPM) just started this year on a small scale with collaboration from some of university hospitals – NTP has a plan to make guidelines for PPM – The issues and challenges relate to improving the quality of reporting and treatment activities within the private sector • How to increase the level of access of illegal foreign workers to medical facilities • Case Finding and associated delays • How to strengthen the capabilities of health workers in conducting contact investigation of TB outbreaks
The barriers 1 • Laboratories • Challenge is to integrate commercial laboratories into the laboratory network of NTP and to expand quality assurance system • Coordination & collaboration between TB, HIV, Malaria programs • High burden and mortality of HIV among TB patients and TB among HIV-infected persons, and the high mortality rate of TB/HIV patients, successful TB/HIV collaboration is essential. • The political commitment has been critical for initiating the collaboration between programs • The support from technical and financial partners has facilitated the implementation of the collaborative activities
The barriers 2 • This largely entails the sustenance of quality D. O. T. S. implementation and undertaking this in the context of health sector reforms and globalization. DOTS and DOTS beyond is our way forward. (Phil) • The challenges including: ( chin) – – – – – Migrants, MDR-TB, TB/HIV Quality of DOTS implementation to be improved Mechanism to ensure sustainability Inadequate human resource Adequacy of infrastructure Adequate funding of Programs Surveillance Health promotion Strengthen human resource development Lack of resources to tackle new challenges
Future Directions The global community needs to continue to take responsibility and make world-wide TB control a high priority
Strategic Plan to Stop TB in the Western Pacific 2006 -2010 • A Road Map – Ensure quality of TB Services – Respond to challenge of rising MDRTB, TB-HIV co-infection – Increasing case detection rate – To get public and private health sector involved in TB control – Increasing funding and regional and country level
Prisons Correctional institutions Social sponsored centers Development of a TB like Unit Cooperation and coordination of NTP, NTP/HIV, Ministry of Health, Ministry of Labor, War Invalids and Social Welfare and Ministry of Public Security • Sustain political interest, training guidelines, advocacy and incentives, monitoring and supervision • • •
Financing TB Control Although the funds available for TB control have increased enormously since 2002 ($2. 0 billion US in 2007). Interventions on the scale required by the Global Plan to Stop TB would cost an extra $1. 1 billion US in 2007 • • The Global Plan is more costly than country budgets primarily because it anticipates greater TB/HIV requirements: – management, advocacy, communication & social mobilisation, especially in the African and South-East Asia regions Greater expenditure was associated with improved case-finding in Bangladesh, China, Congo, India, Indonesia, Kenya, Myanmar & Nigeria There was no systematic relationship between incremental expenditure and improved case detection across all HBCs The relationship between spending and case-finding needs to be investigated and understood country by country.
DOTS and the Stop TB Strategy • Most government health services now recognise that TB control must go beyond DOTS, but the broader Stop TB • Strategy is not yet fully operational in most countries
Future Directions • Countries and regions are more likely to reach these targets if they can increase budgets and step up activities in line with the Global Plan. • Procedures for collecting financial and epidemiological data, and other information about programme performance, must be systematically improved. • Surveillance and monitoring, and well-designed surveys, are a prerequisite for the accurate evaluation of progress in TB control.
The STOP TB STRATEGY The Objectives • To achieve universal access to high quality diagnosis and patient centered treatment • To reduce the suffering and socioeconomic burden associated with TB • To protect poor and vulnerable populations from TB, TBHIV and MDR-TB • To support development of new tools and enable their timely and effective use
HIV-TB IN THE WESTERN PACIFIC REGION PROGRESS OF TB/HIV COINFECTION CONTROL IN CHINA DR. PHILIPPE GLAZIOU Y. J. LAI*, S. W. JIANG*, W. B. YU**, L. ZHOU*, *National Center for TB Control and Prevention, China CDC, China **Tuberculosis Office of China Global Fund Program To address high case fatality rates, it is necessary to rapidly step-up the implementation of; • provider-initiated HIV testing • systematic detection of TB in HIV-infected individuals including diagnosis of the smear negative forms of TB • infection control in AIDS care settings • adequate treatment and support of dually infected individuals, including anti-retroviral therapy during the course of TB treatment
LATENT TB INFECTION IN HIV: TO TREAT OR NOT TO TREAT ? NITIPATANA CHIERAKUL • Early benefit but long term protection is uncertain
AGING OF TB EPIDEMIC, CASE OF JAPAN DR. TAKASHI YOSHIYAMA • As community wide burden is reduced, the high prevalence in the aged becomes more noticeable • The previously infected population is living longer • In countries where transmission of infection has been low, the numbers in the aged population is falling. • The case fatality rate of older tuberculosis cases is high and WHO target of 85% treatment success is difficult to achieve
TRADITIONAL AND NOVEL DIAGNOSTIC TESTS FOR TB INFECTION TORU MORI • TST opened the way to the modern epidemiology of TB decades ago. • The diagnosis TB infection is important both in high and low-prevalence settings for epidemiological surveillance and research, indication for treatment of latent TB infection, an adjunct for diagnosis of active TB, etc. • The new technology, Interferon-gamma release assay (IGRA), has been tested extensively, and it seems that it is practically as sensitive as TST and far exceeds its specificity. Other aspects of its performance, including influence of immunocompromizing factors, effects of treatment (both in active disease and latent TB infection), and cost-effectiveness have gradually been clarified.
MDR-TB: DISEASE IN THE WPR DR. PHILIPPE GLAZIOUDRUG SUSCEPTIBILITY TESTS FOR FIRST & SECOND LINE DRUGS IN DIAGNOSIS OF MDR & XDR TUBERCULOSIS DR CAMILLA RODRIGUES, MD NEW DRUGS AND DRUG REGIMENS IN THE TREATMENT OF CHRONIC AND MDR-TB W. W. Yew • Posing a threat to TB Control in several countries in WPR • Special programs may be required to reduce its increasing prevalence – Improved interventions under DOTS – Programmatic management MDR-TB – urgent need to strengthen capacity for prompt and accurate laboratory based diagnosis of tuberculosis and detection of drug resistance – strengthening of DOTS and DOTS-Plus programmes, infection control, and information sharing to enable local and global control – Development of new drugs is a mandatory focus of activity too.
THE SINGAPORE TB ELIMINATION PROGRAMME (STEP) DR CYNTHIA CHEE • Reduction in prevalence via STEP program
TB-HIV TREATMENT IN A PRISON SETTING DR. BENEDICT SIM LIM HENG TUBERCULOSIS (TB)- HUMAN IMMUNODEFICIENCY VIRUS (HIV) SCREENING PROGRAMME IN CLOSED SETTINGS B. VENUGOPALAN (MPH) Disease Control Unit, Selangor State Health Department, Ministry of Health, Malaysia. • Many barriers to TB control, institutional, high burden of TB/HIV on entry, staff morale, drug availability and delivery etc • In 1993, WHO presented their guidelines on HIV infection and AIDS in prisons and the 1 st guiding principle in that article quoted was that “All prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community without discrimination, in particular with respect to their legal status or nationality. ” • Changes in policy, attitudes and resources needed
What are we trying to achieve? • Millennium Development Goals • Stop TB Partnership targets
Pre-Conference Workshop 1 National TB Control Program Summary & Remarks Dr Ral Antic Chair Scientific Committee IUATLD-APR Australia
TB Control in WPR-current state 1. We have heard reports from a mix of High, Intermediate and Low burden countries 2. Significant improvements in reported results 3. WHO targets are reported to be overall being met 4. Yet ongoing burden of disease is often reported as high and trend of morbidity and mortality is ‘stagnant’ • • Ageing population and access to illegal migrants HIV-TB co-infection MDR-TB levels rising in some countries The performance of the private sector and general hospitals is variable Concern re care in the poor and vulnerable populations Health sector infrastructure variable especially in districts Funding and health workforce, although improved remains an issue
TB Performance Indicators in the Western Pacific Region, 2004 “Strategic Plan to Stop TB in the Western Pacific 2006 – 2010” Prevalance Rate (/105) Case detection SS+ (%) Treatment Success (%) Mortality Rate (/105) Australia 6 56 95 1 Cambodia 709 61 93 94 China 221 65 94 17 Hong Kong 77 72 78 6 Japan 39 62 76 4 Lao PDR 318 55 79 25 Malaysia 133 69 72 16 Mongolia 209 80 87 24 11 59 36 1 Papua New Guinea 448 31 58 42 Philippines 463 73 88 48 Republic of Korea 125 59 82 10 41 67 77 4 232 89 92 22 New Zealand Singapore Vietnam TB Performance Indicators in the South East Asia Region, 2004 “National Tuberculosis Control Programs South East Asia Region” Prevalance Rate (/105) Case detection SS+ (%) Treatment Success (%) Mortality Rate (/105) Indonesia 262 66 90 41 Thailand 218 73 74 20
Estimated WPR Burden from TB and Trends • Estimated 4 million cases of TB in WPR – 2 million new cases • Seven high burden countries account for >95% – Cambodia, China, Lao PDR, Mongolia, PNG, Philippines & Vietnam • A decline of 15% in prevalence & 12% in mortality between 2000 -2004 – Annual average of 4% and 3% respectively
ACHIEVEMENTS • • • In Leadership terms In Strategic Planning Implementation Strategy Activities Infrastructure building Surveillance and Quality monitoring
Incentives Direct • To the health care providers • To the person with TB • To the community Indirect?
WP Regional Goals & Targets Regional Committee WPR, 2000 Goal: • Reduce TB prevalence and mortality by 50% in 2010 compared with 2000 Intermediate Targets (towards this goal): 1. Detect 70% of estimated active cases 2. Treat successfully 85% of these cases 3. 100% DOTS coverage
Case Detection in WPR • From < 40% to >70% overall in 5 years • Achieved by: – – – Developing a strategic approach, The Global Plan to Stop TB Strengthening political commitment Accelerating DOTS expansion in public facilities Higher case detection success in many countries TB care more available and accessible Improving collaboration of health providers – Increase in financing and other resources
Treatment Success • Overall the percentage of registered new TB patients completing anti TB treatment > 85% for last 10 years • 5 of the 7 high burden of TB countries are achieving this target
Estimated numbers of new cases, 2005 Estimated number of new TB cases (all forms) No estimate 0 -999 1000 -9999 10 000 -99 999 100 000 - 999 1 000 or more 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 2006. All rights reserved
Will achieving WHO targets reduce the notification rate? The barriers – Spread of HIV – Accumulation of MDR-TB cases – Insufficient access to high quality TB care for the poor and vulnerable populations – Sub-optimal TB management practices in growing private sector – Lack of National guidelines & training materials – Lack of human resources and their development AND/OR – the rising population numbers – Incorrect targets for the desired outcome
Future Directions • The current level of detection of 70% will not be sufficient – – Enhancing active case finding approaches Enhancing lab capacity New diagnostic tools Sustaining established mechanisms - e. g. monitoring and supervision of DOTS implementation • MDR-TB and TB-HIV co-infection will slow the annual decline • Conventional DOTS service delivery does not guarantee equitable access to TB Services – In some countries, the same standards of care received through NTP service delivery are not met by general hospitals, private providers, and for the homeless, drug users, migrants & prisoners
What have we learned from these presentations? • The current burden of disease remains large • There are important Regional and Country successes • Some targets are being achieved but • The targets have needed to be revised to achieve the objects • There are significant barriers • Do we have systems in place to achieve these targets?
Pre-Conference Workshop 1 National TB Control Program Concluding remarks for the Workshop Dr Ral Antic Chair Scientific Committee IUATLD-APR Australia
Barriers to success • Rising MDR-TB • Rising TB & HIV Co-infection • Access to poor & vulnerable populations – Prisons, homeless • Aging population • Suboptimal health infrastructure – Lack of health workers – Suboptimal laboratory facilities
‘Programmatic’ factors 1. 2. 3. 4. Accessibility of treatment services Awareness of TB in the community Uninterrupted supply of effective TB drugs Treatment adherence through DOTS
Will achieving WHO targets reduce the notification rate? The barriers – Spread of HIV – Accumulation of MDR-TB cases – Insufficient access to high quality TB care for the poor and vulnerable populations and private sector – Lack of National guidelines & training materials – Lack of human resources and their development AND/OR – the rising population numbers – Incorrect targets for the desired outcome
The 3 main areas to be addressed • The current level of 70% detection will not be sufficient • MDR-TB and TB-HIV co-infection will slow the annual decline • Conventional DOTS service delivery does not guarantee equitable access to TB Services
The new Strategic Plan for WPR 2006 -2010 • To achieve the 50% reduction in prevalence & death, an 8% annual decline is needed • The current annual decline is 3% • There thus needs to be a change in approach • This is the basis of the strengthened effort defined in the new Strategic Plan
Reasons for significant improvements in TB Control • The rapid expansion of DOTS after WHO declared a global TB crisis in 1993 • Higher case detection and treatment success in many countries • The Stop TB Partnership, est in 2000, • The Global Plans to Stop TB • The significant increase in resources for TB • TB care more available and accessible
Will achieving WHO targets improve notification rate? The barriers • Spread of HIV • Accumulation of MDR-TB cases • Insufficient access to high quality TB care for the poor and vulnerable populations • Sub-optimal TB management practices in growing private sector • Lack of National guidelines & training materials • Lack of human resources and their development
Tuberculosis notification rates, 2005 Notified TB cases (new and relapse) per 100 000 population No report 0 -24 25 -49 50 -99 100 or more 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 2006. All rights reserved
TB Notification rate by population group for South Australia, 2006 Notification Rate/100, 000 35 30 25 20 15 10 5 0 Overseas Born 0<14 15<24 Australian Born 25<34 Age 35<44 45<54 Indigenous 55<64 >65
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