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9.4 million
(range: 8.99.9 million)
1.7 million
(range: 1.52.0 million)
380,000
(range: 320,000450,000)
440,000
(range: 390,000510,000)
about 150,000
024 024 2549 2549 5099 5099 100299 100299 300 and higher >300 No estimate available No estimate
SE Asia 35%
600
500
400
300
200
100
0-<3 3-<6 6-<12 12-<18 >=18 No data available Subnational data only
Australia, Democratic Republic of the Congo, Fiji, Guam, New Caledonia, Solomon Islands and Qatar reported data on combined new and previously treated cases.
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 2010. All rights reserved
Preliminary results
35.3
28.3 27.3 23.8 22.3 20.0 19.4 19.3 19.2 16.5 16.1 16.0 15.4 14.8 0 5 10 15 20 25 30
____ TB
____ MDR-TB
10
10
-2.4% per year
2007
2009
Estonia
1000
100
10
Botswana
19.4% per year 1 1996 1998 2000 2002 2004 2006 2008
Countries that had reported at least one XDR-TB case by end March 2011
Argentina Armenia Australia Austria Azerbaijan Bangladesh Belgium Botswana Brazil Burkina Faso
Bhutan Cambodia Canada Chile China Colombia Czech Republic Ecuador Egypt Estonia
France Georgia Germany Greece India Indonesia Iran (Islamic Rep. of) Ireland Israel Italy
Japan Kazakhstan Kenya Kyrgyzstan Latvia Lesotho Lithuania Mexico Mozambique Myanmar
Namibia Nepal Netherlands Norway Pakistan Peru Philippines Poland Portugal Qatar
Republic of Korea Republic of Moldova Romania Russian Federation Slovenia South Africa Spain Swaziland Sweden Tajikistan
Thailand Togo Tunisia Ukraine United Arab Emirates United Kingdom United States of America Uzbekistan Viet Nam
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 2011. All rights reserved
2.
3.
4.
5. 6.
2015: Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6c: to have halted by 2015 and begun to reverse the incidence
*Indicator 6.9: incidence, prevalence and mortality associated with TB *Indicator 6.10: proportion of TB cases detected and cured under DOTS
2015: 50% reduction in TB prevalence and deaths by 2015 2050: elimination (<1 case per million population)
Mortality
200
25
15 100
target
0 1990 2015 1990
target
2015
Incidence rates falling globally after peak in 2004, but only at <1%/year
Incidence (all forms, incl. PLHIV)
Notification gap
Peak in 2004
TB Notifications
Incidence TB in PLHIV
% total
10000 9000
IMPLEMENTATION
79%
8000 7000 6000 5000 4000 3000 2000 1000 0 2010 2011 2012 2013 2014 2015 Funding needed Funding available
TOTAL
46.7
100%
WHO Regions
95
86 86
93 W. Pacific 88 SE Asia EMR 80 Africa Americas
90 85 80 75 70
85 85 83 80 80
84
77 66 Europe
2008
60
53
50 40 30
22 20 38
45
Africa
26 22
20
9 12 11 3
World
10
4
100
CPT
80
83 70 75
60
ART
40
37
20
Coordinating bodies Surveillance of HIV prevalence among TB cases TB/HIV planning Monitor and evaluate collaborative TB/HIV activities
Intensified TB case finding INH preventive therapy Infection control in health care and congregate settings
IV testing and counselling HIV prevention methods Co-trimoxazole preventive therapy IV/AIDS care and support ARVs
36
36 29 25
35 30 25 20 15 10 5 0 19 17 15 14 13 28 21
Cambodia
Indonesia
National NATIONAL
gap
Philippines
Myanmar
Ghana
China
India
Iran
Tanzania
Pakistan
Mexico
Increasing case notifications is good, Butit is not yet early case detection
Annualised rate of ss+ cases diagnosed per 100,000
Case recovery into the NTP by different care providers, Bangalore, 1999-2005
NGO 100 80 60 40 20 0
99q1 99q3 00q1 00q3 01q1 01q3 02q1
Quarter
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
02q3
03q1
03q3
04q1
04q3
05q1
05q3
New
% of patients
Previously treated
80%
% of patients
29% 11% 2% 2% 1% 0%
16% 9% 7% 6% 7% 2%
7%
10% 0%
er ic as SE A si a W Pa ci fic
ic a
ro pe
LD
si a A W
A fr
O R
m er
Eu r
Eu
ac ifi
EM
fri ca
EM
A m
.P
SE
RL D
ic a
op e
16 countries have a culture lab per 5m people and a DST lab per 10m people 11 countries are introducing GenXpert 10% of 250,000 estimated cases on treatment 13 countries reported cure rates (25-82% for 2007 cohort) 19 countries did not report stock-out of 2nd-line drugs 14 countries have national plans for infection control
Full implementation of Global Plan: 2015 MDG target reached but TB not eliminated by 2050
10000
Current rate of decline
Incidence/million/yr
1000
TB incidence 10x lower than today, but >100x higher than elimination target in 2050
100
10
1 2000
2010
2020 Year
2030
2040
2050
Development agenda
Socio-economic factors: living conditions, food insecurity, awareness, risk behaviour, access to care
P RR 1
HIV infection
20.6/26.7*
1.1%
Malnutrition
Diabetes Alcohol use (>40g / d) Active smoking Indoor Air Pollution
3.2**
3.1 2.9 2.6 1.5
16.5%
3.4% 7.9% 18.2% 71.1%
Sources: Lnnroth K, Raviglione M. Global Epidemiology of Tuberculosis: Prospects for Control. Semin Respir Crit Care Med 2008; 29: 481-491. *Updated data in GTR 2009. RR=26.7 used for countries with HIV <1%. **Updated data from Lnnroth et al. A consistent log-linear relationship between tuberculosis incidence and body-mass index.
Vaccine Nearly 90 years old Unreliable protection against pulmonary TB No apparent impact on the TB epidemic Buta dozen candidates in clinical trial
Regimen 1 = 4-month, no effect on DR Regimen 2 = 2-month, 90% effective in M/XDR Regimen 3 = 10-day, 90% effective in M/XDR
1. Xpert MTB/RIF should be used as the initial diagnostic test in individuals suspected of having MDR-TB or HIV-associated TB (strong recommendation) 2. Xpert MTB/RIF may be used as a follow-on test to microscopy where MDR and/or HIV is of lesser concern, especially in smear-negative specimens (conditional recommendation, major resource implications) Phased implementation & evaluation 2011
Scale up 2012
35
Current Therapy
4 drugs; 6 month therapy (2RHZE + 4RH) At least 4 drugs (including injectable); 18 months; poorly tolerated Drug-drug interactions (DDI) with ARVs 6-9 months H
Unmet Needs
Shorter, simpler therapy
Drug-Resistant M(X)DR-TB
TB/HIV co-Infection Latent TB Infection
For all indications and treatment, issues in delivery and access Need shorter and simpler therapies against both DS and DR-TB
Adapted from TB Alliance
Discovery
Preclinical Development
Clinical Development
Lead Optimization Nitroimidazoles Mycobacterial Gyrase Inhibitors Riminophenazines Diarylquinoline Translocase-1 Inhibitor MGyrX1 inhibitor InhA Inhibitor GyrB inhibitor LeuRS Inhibitor
Phase I AZD5847
Phase II TMC-207 OPC-67683 PA-824 SQ-109 PNU -100480 LL3858 Rifapentine Linezolid
Phase III
Conclusions
1. The world is on track to achieve the (un-ambitious) target of incidence reduction and the 50% mortality decrease in 2015 2. Universal access to quality TB care requires strengthening of lab services, further progress in implementation of PPM and TB/HIV interventions, massive scale-up of care for MDR-TB 3. Bold health policies, new tools rapidly transferred to endemic countries, and alleviation of socioeconomic barriers are necessary to achieve acceleration of decline and elimination