progress and challenges toward the goal of global tb ... · towards elimination - framework for...
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Towards the ultimate goal of global TB elimination - progress and challenges
UNION NAR 25 Feb 2016 Knut Lönnroth
Global TB Programme WHO
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Outline
1. The new global TB targets
2. Progress so far - did we reach the MDG targets?
3. The new End TB strategy – what's new?
4. Some of the challenges – and solutions
5. Towards elimination - framework for low-incidence countries
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Vision: A world free of TB Zero TB deaths, Zero TB disease, and Zero TB suffering
Goal: End the Global TB epidemic: incidence <10/100,000
Vision, goal, targets, milestones
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End TB strategy – "Projected" acceleration of TB incidence decline
Optimize use of current & new tools emerging from pipeline,
pursue UHC and social protection, social determinants
-10%/year by 2025
-17%/year
Current global trend: -1.5%/year
Introduce new tools: a vaccine, new drugs and shorter regimens for
treatment of active TB and latent infection, a point-of-care test
-5%/year
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And then – towards elimination
<100 cases (all forms)
per million
Low incidence
<10 cases (all forms)
per million
Pre-elimination
By 2035?
<1 case (all forms)
per million
Elimination
By 2050, or later?
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Progress so far
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MDG6 TB target achieved
REVERSED R
ate
pe
r 1
00
,00
0 p
op
ula
tio
n
Incidence
1990 2000 2014
Falling 1.5% per
year (2000-2014).
18% drop since 2000
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But not according to plan: Projection in previous Global Plan (2006-2015)
Source: Maher D, et al. Planning to improve global health: the next decade of tuberculosis control. Bulletin of the WHO 2007;85:341-347.
"The planned interventions at the level of scale-up reached in 2015 will result in an average rate of decline in global TB incidence of 5–6% per year."
2015 2035
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Did we reach the MDG-related targets?
"Ending TB" level
"Ending TB" level
Global tends
Americas
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Malaria = 7m
HIV = 7.8m
TB = 43m
43 million lives saved BETWEEN 2000 AND 2014
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But still; 1.5 million TB deaths in 2014
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2012, WHO Global Health Observatory
In grey: TB/HIV deaths
Millions
2014, WHO and UNAIDS
TB
HIV/AIDS
TB
HIV/AIDS
TB ranks alongside HIV as a leading cause of death
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The End TB Strategy
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Implementing the End TB Strategy
THE ESSENTIALS aims to guide actions
at national level to adapt, launch and
implement the World Health
Organization’s End TB Strategy.
It calls for major transformations in the
way we all work to better support
those affected and to end the
epidemic.
Launch: March 2016:
www.who.int/TB
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The End TB Strategy:
3 pillars and 4 principles
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Measuring progress TOP-TEN PRIORITY INDICATORS (NOT RANKED) FOR MONITORING IMPLEMENTATION
OF THE END TB STRATEGY AT GLOBAL AND NATIONAL LEVELS, WITH RECOMMENDED
TARGET LEVELS THAT APPLY TO ALL COUNTRIES
Indicator Recomm-
ended target level*
1 TB treatment coverage ≥90%
2 TB treatment success rate ≥90%
3 Percentage of TB-affected households that experience catastrophic costs due to TB 0%
4 Percentage of newly notified TB patients tested using WHO-recommended rapid tests ≥90%
5 LTBI treatment coverage (relevant risk groups) ≥90%
6 Contact investigation coverage ≥90%
7 DST coverage for TB patients 100%
8 Treatment coverage, new TB drugs ≥90%
9 Documentation of HIV status among TB patients 100%
10 Case fatality ratio (CFR) ≤5%
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What's new? 1. Adaptation needed
Attention to risk groups and vulnerable groups - know your epidemic
2. Earlier detection and more accurate diagnosis
Contact investigation re-emphasized, including LTBI management Systematic screening in selected high-risk groups (with attention to over-diagnosis) Universal DST
3. More patient-centered care
Tailored patient support (especially for vulnerable groups) Manage co-morbidities
4. UHC and SDG agenda
Identify and address access barriers and health care quality deficiencies Regulatory approaches (notification, medicines, vital registration, etc) Social protection – a means as well as an outcome Prevention through addressing risk factors and social determinants
5. Research – no new tools, no ending TB
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Global Action Framework
on TB research
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Some challenges
…and solutions
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Reaching the "missed" cases early is crucial (~3.6 million not diagnosed or reported)
Share of total missed cases
10 countries account for 75%
(2.7 million) of the estimated
“missed” cases globally
Indonesia + India:
1.2 million “missed” people
Estimated incidence Global notifications
9.6 million estimated
6 million notified
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Case detection
Private sector notification in Inida
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Required actions to improve early detection
Improve access – special focus on vulnerable groups
Universal health coverage – general access barriers
Improve awareness
Improve diagnostics
Engage all care providers – full notification
Contact investigation (with LTBI management of children <5), systematic screening of PLHIV and other selected risk groups
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Ref: G
lob
al TB
Co
ntro
l Rep
ort 2
01
5
Percentage of new TB cases with MDR-TB
Highest % in the former USSR countries
India, China, Russia, Pakistan and Ukraine
have 62% of all MDR-TB cases
MDR-TB: 3% of new TB cases globally
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End TB Strategy: Universal DST Universal health coverage including access to drugs, high quality patient friendly care, social protection
Special focus on vulnerable and hard-to-reach groups
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MDR TB treatment outcomes
Patient support (education, social, financial, comorbidities, DOT, etc)
Delivery models (decentralisation, patient friendly)
New medicines and regimens - research
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Ref: G
lob
al TB
Co
ntro
l Rep
ort 2
01
5
74% of TB/HIV cases
in Africa
12% of TB cases globally attributable to HIV:
Other risk factors dominate in other regions
Estimated HIV prevalence in new TB cases, 2014
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Population attributable fraction – some risk factors for progression to disease
Relative risk for
active TB disease
Weighted
prevalence
(adults 22 HBCs)
Population
Attributable
Fraction (adults)
HIV infection 20.6/26.7 0.8% 16%
Malnutrition 3.2 16.7% 27%
Diabetes 3.1 5.4% 10%
Alcohol use
(>40g / d) 2.9 8.1% 13%
Active smoking 2.0 26% 21%
Indoor Air
Pollution 1.4 71.2% 22%
1
1 1
P RRPAF
P RR
Sources: Lönnroth K, Castro K, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, Raviglione M. Tuberculosis control 2010 – 2050: cure, care and social
change. Lancet 2010 DOI:10.1016/s0140-6736(10)60483-7.
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Risk factor and risk group approach: 1. Document TB distribution, risk factors, and drivers of the epidemic
2. Minimize access barriers
3. Screening in selected high risk groups
4. Patient centred and tailored care
5. Deal with comorbidities
6. Provide social and financial support
7. Prevent by reducing population-level exposure to risk factors and
underlying social drivers
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Poverty-disease trap
Poverty TB
• Undernutrition • Poor housing • HIV • NCDs and NCD risk factors (diabetes,
smoking, alcohol, etc) • Poor health care access
• High direct and indirect health care costs • Loss of employment and income • On average 50% of annual income lost!
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End TB Achieve SDGs TB control is a beneficiary of and a contributor to global development
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SDGs: Health is a beneficiary and contributor
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Critical funding gaps
$1.4 billion
funding gap
$8 billion funding required in 2015 for
TB prevention, diagnosis and treatment
$1.32 billion
funding gap
TAG TB R&D report 2014
RESEARCH –
at least US$ 2 billion per year needed
$677
availabl
e in 2013
IMPLEMENTATION – US$8 billion needed in 2015
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Trends in international donor funding for HIV, malaria and TB, 2005-2013
$1.4 billion funding gap
$1.32 billion funding gap
0
1
2
3
4
5
6
7
8
9
2005 2006 2007 2008 2009 2010 2011 2012 2013
US$
bill
ion
s
HIV/AIDS Malaria TB
Source: Creditor reporting system. Paris: Organisation of Economic Co-operation and Development
Note: HIV funding is recorded as “STD control including HIV/AIDS”.
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Investing in the TB response is top value-for-money
Development - The economics of optimism , Jan 24th 2015 - The debate heats up about what goals the world should set itself for 2030
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Global plan 2016-2020 - Estimated Financial needs
Up from 8 billion/y in 2015 to ~12 billion/y
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Adaptation for low-incidence countries
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33 low-incidence countries and territories* (notification rate <10/100,000, 2012 data)
*Population >300,000
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ACTION FRAMEWORK 8 priority actions for elimination in low-incidence countries
Invest in research
and new tools
Optimize
prevention and care of drug-resistant TB
Address special needs of migrants; cross-
border issues
Address most vulnerable and hard-
to-reach groups
Support global TB prevention, care
and control
Ensure continued surveillance and
programme monitoring &
evaluation
Undertake
screening for active TB and latent TB infection
in high-risk groups and provide appropriate
treatment
Ensure political commitment, funding and stewardship for
planning and essential services
of high quality
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8. Support global TB prevention, care, and control
Contribute and mobilise financial resources
Promote global TB advocacy and visibility
Support bi-lateral and multi-lateral
collaboration and technical assistance.
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FRAMEWORK available at: http://www.who.int/tb/publications/elimination_framework/en/
Lönnroth K, Migliori GB, Raviglione MR, et al. Towards tuberculosis elimination: An action
framework for low-incidence countries. Eur Respir J 2015 2015; 45: 928–952
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So, what was new again?
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Vision: A world free of TB Zero TB deaths, Zero TB disease, and Zero TB suffering
Goal: End the Global TB epidemic: incidence <10/100,000
Reaching very ambitious targets
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With evolved strategy elements 1. Adaptation needed (one size fits one)
Attention to risk groups and vulnerable groups - know your epidemic
2. Earlier detection and more accurate diagnosis
Systematic screening in selected high-risk groups (with attention to over-diagnosis) Contact investigation re-emphasized, including LTBI management Universal DST
3. More patient-centered care
Tailored patient support (especially for vulnerable groups) Manage co-morbidities
4. UHC and SDG agenda
Identify and address access barriers and health care quality deficiencies Regulatory approaches (notification, medicines, vital registration, etc) Social protection – a means as well as an outcome Prevention through addressing risk factors and social determinants
5. Research – no new tools, no ending TB