Towards the ultimate goal of global TB elimination - progress and challenges

UNION NAR 25 Feb 2016 Knut Lönnroth

Global TB Programme WHO

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

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

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

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?

Progress so far

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

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

Did we reach the MDG-related targets?

"Ending TB" level

"Ending TB" level

Global tends

Americas

Malaria = 7m

HIV = 7.8m

TB = 43m

43 million lives saved BETWEEN 2000 AND 2014

But still; 1.5 million TB deaths in 2014

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

The End TB Strategy

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

The End TB Strategy:

3 pillars and 4 principles

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%

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

Global Action Framework

on TB research

Some challenges

…and solutions

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

Case detection

Private sector notification in Inida

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

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

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

MDR TB treatment outcomes

Patient support (education, social, financial, comorbidities, DOT, etc)

Delivery models (decentralisation, patient friendly)

New medicines and regimens - research

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

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.

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

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!

End TB Achieve SDGs TB control is a beneficiary of and a contributor to global development

SDGs: Health is a beneficiary and contributor

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

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”.

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

Global plan 2016-2020 - Estimated Financial needs

Up from 8 billion/y in 2015 to ~12 billion/y

Adaptation for low-incidence countries

33 low-incidence countries and territories* (notification rate <10/100,000, 2012 data)

*Population >300,000

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

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.

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

So, what was new again?

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

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