Global tuberculosis control today: expectations from the PPM Subgroup

Mario C. Raviglione, M.D.Director, Stop TB DepartmentWHO, Geneva, Switzerland

6th Meeting of the Subgroup on Public-Private Mix for TB Care and ControlIstanbul, Turkey16 February 2010

Estimated number of cases

Estimated number of deaths

1.3 million*

(range, 1.1–1.7 million)

9.37 million

(range, 8.9–9.9 million)

0.5 million

All forms of TB

Multidrug-resistant TB (MDR-TB)

HIV-associated TB 1.4 million (15%)(range, 1.3–1.6 million)

0.52 million

(range, 0.45–0.62 million)

The global burden of TB in 2008

*excluding deaths among HIV+ people

>150,000

Estimated TB Incidence rates, 2008

Africa

31%

West Pacific 20%

SE Asia 34%

Europe 5%

East Mediterranean 7%

Americas 3%

Impact of HIV on TB in Africa

Notified cases per 100,000 pop. 1980-2008

Percentage of global estimated HIV-positive TB cases

EMR

Cameroon

Thailand

Brazil

Democratic Republic of the Congo

China

Myanmar

EUR

Côte d'Ivoire

Malawi

United Republic of Tanzania

AMR

Zambia

WPR

Ethiopia

Mozambique

Kenya

Uganda

Zimbabwe

Nigeria

India

SEA

South Africa

AFR

1% 5% 10% 20% 50% 90%

0

100

200

300

400

500

600

700

1980 1984 1988 1992 1996 2000 2004 2008

Botswana

Côte d'Ivoire

DR Congo

Gabon

Guinea

Kenya

Malawi

Mozambique

South Africa

UR Tanzania

Zimbabwe

4/5 of all estimated TB/HIV cases are in Africa

MDR-TB % among new cases,1994-2007

0.00 - 0.99

1.00 - 2.99

3.00 - 5.99

6.00 – 10.00

>10.00

No data

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 2009. All rights reserved

* Sub-national coverage in India, China, Russia, Indonesia.

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 2009. All rights reserved

Countries with at least one confirmed XDR-TB case, as of December 2009

Argentina Burkina Faso Georgia Kenya Nepal Qatar Swaziland Viet Nam

Armenia Canada Germany Latvia Netherlands Republic of Korea Sweden

Australia China India Lesotho Norway Republic of Moldova Thailand

Azerbaijan Colombia Iran (Islamic Republic of) Lithuania Oman Romania Ukraine

Bangladesh Czech Republic Ireland Mexico Peru Russian Federation United Arab Emirates

Belgium Ecuador Israel Mozambique Philippines Slovenia United Kingdom

Botswana Estonia Italy Myanmar Poland South Africa United States of America

Brazil France Japan Namibia Portugal Spain Uzbekistan

TB Control Global Targets

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

2050: elimination (<1 case per million population)

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: incidence, prevalence and deaths associated with TB

Indicator 24: proportion of TB cases detected and cured under DOTS

The global response: Stop TB Strategy & Global Plan

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

Treatment success target reached globally: 87% in 2007-8

Su

ccessfu

l tr

ea

tmen

t ra

te (

%)

in

DO

TS

co

ho

rts

85

77

79

77

79

81

80

82

82

82

83

84 85

87

40

50

60

70

80

90

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

But not in the Americas, Africa and Europe

92 88 82 7967

88

0

20

40

60

80

100

W P

acifi

cSE A

sia

EMR

Am

eric

asA

fric

aEuro

pe

5.7 million notified

cases

X.X million sm+

notified cases

30405060

70

8090

30

40

50

60

70

80

90

30

4050

6070

80

90

Africa-high HIV Africa-low HIV Eastern Europe

Red line: Global Plan milestones and 2015 target for CDR

Black dots: actual CDR

South-East AsiaLatin AmericaEastern Mediterranean

GLOBALWestern Pacific

Case detection stagnating globally, gap with Global Plan widening

CDR stable at ~70% since 2005

2002 2008 2015

61% in 2008vs. Global Plan

milestone of 71%

201520082002201520082002

Gap especially large in Africa

Case d

ete

cti

on

rate

(%

)

1990 1995 2000 2005

Rate

per

10

0,0

00 p

op

ula

tion

150

145

140

135

130

125

120

Incidence rates falling globally after peak in 2004

Peak in 2004

World as a whole on track to achieve MDG target 6.c

Number of cases in millions

0

2

4

6

8

10

1990 1993 1996 1999 2002 2005 2008

What are the challenges in 2010?

1. DOTS quality not uniform; only 61% of all estimated cases reported; diagnosis probably late in most settings

2. TB/HIV, especially in Africa; MDR-TB, especially in former USSR and China; XDR-TB everywhere we look for it

3. Weak health systems and services compromising TB care; lack of bold policies on free access to care, drug quality and restriction, labs, human resources, infection control, etc.

4. Not all care providers, non-state and even governmental, working at high standard; weak public-private links

5. Communities often un-aware, un-involved, not mobilised

6. Research not yet delivering innovative tools, transfer of technology slow, and operational research neglected

Public-Private Mix for TB care and control: Milestones

2001: Informal global consultation; Lancet publication

2002: Inclusion of PPM in the Expanded DOTS Strategy

2003: Evidence-base on working models from diverse settings

2004: PPM for TB: What makes it work?.. Cross-country analysis

2005: Cost-effectiveness shown; "public-private" to "all providers"

2006: PPM/ISTC essential components of the Stop TB Strategy

2007: PPM guidance/ISTC/NSA tool implemented in diverse settings

2008: PPM activities in 58 out of 93 Global Fund grants

2009: Appeal for PPM scale up in "Beijing CfA" and WHA 2009

0

20

40

60

80

100

120

140

160

99q1

99q3

00q1

00q3

01q1

01q3

02q1

02q3

03q1

03q3

04q1

04q3

05q1

05q3

Quarter

Annualis

ed r

ate

of

ss+

cases d

iagnosed p

er

100,0

00

NGO

Private

Corporate

Medical college

Other Government

Health Department

•Public and private medical colleges (yellow) diagnose a huge number of cases, but many of them are from outside the city and need to be refereed for treatment elsewhere.

•The increase in diagnosed cases represents increased notification after medical colleges and other providers started to report to NTP in a standardised way

Case recovery into the NTP by different care providers, Bangalore, 1999-2005

Increasing case notifications is good,But…it is not yet early case detection

Trend of Global Fund support for PPM activities – progress is evident

Public-Private Mix for TB care and control: Unfinished agenda

• More projects than programmes?

• Large proportion of care providers still to be engaged?

• Capacity strengthening within the non-state sector?

• Unabated misuse of anti-TB medicines?

• Measurement of contribution weak?

• Regulatory approaches and their effectiveness?

• Limited uptake/input by MDR-TB, TB/HIV, GLI, ACSM?

• Promoting systems approach?: every health unit lists and showsevery health unit lists and shows

how all care providers in its area contribute to TB/MDRhow all care providers in its area contribute to TB/MDR--TB/TBTB/TB--HIV controlHIV control

with enhanced equity in access to carewith enhanced equity in access to care……..

Many thanksto all

Acknowledgements: M. Uplekar, K. Lönnroth, S.S. Lal