The epidemiology of tuberculosis

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1 The epidemiology of tuberculosis Tuberculosis Workshop Shanghai, May 28 Philippe Glaziou World Health Organization

2 Outline Epidemiology refresher Estimates of tuberculosis disease burden Notifications Progress in tuberculosis control Tuberculosis drug resistance TB-HIV will be presented separately

3 A model for TB epidemiology births uninfected primary TB latent TB primary TB infected: latent exogenous + endogenous TB deaths failure infectious TB relapse natural cure + drug cure treatment non-infectious TB relapse failure TB deaths failed recovered failed

4 TB incidence and prevalence rates incidence rate new TB cases = population!1 prevalence rate = existing TB cases population!1

5 Incidence, prevalence and disease duration Incidence (year 3) = 12 cases Prevalence in March of year 3 = 24 cases

6 Incidence, prevalence and disease duration Incidence (year 3) = 12 Prevalence in March of year 3 = 6

7 Important TB indicators Notification rate per 1, (all forms of TB, smear positive TB) Case detection rate = notifications / incidence Cure rate = % of smear positive cases finishing treatment and confirmed smear negative at the end of treatment TB case fatality rate = % deaths during TB treatment TB mortality rate = TB deaths / population

8 Estimating incidence, prevalence 1. incidence TB = 2. incidence TB = 3. incidence TB 4. incidence TB = and mortality notifications proportion detected prevalence duration = incidence infection! Styblo ratio deaths proportion cases dying (case fatality rate) Incidence, prevalence, deaths derived by rearranging 4 equations

9 Stop TB Strategy

10 Millennium Development Goals Implementation (DOTS) Indicator 24 (target year 25) Case detection 7% (> 6 m diagnosed) Treatment success 85% (> 5 m cured DOTS) Impact Indicator 23 (target year 215 cf 199) Prevalence 5% of 3/1K Deaths 5% of 3/1K (< 1m deaths) Stop TB Department

11 Outline Epidemiology refresher Estimates of tuberculosis disease burden Notifications Progress in tuberculosis control Tuberculosis drug resistance

12 Estimated numbers of new cases, 26 Estimated number of new TB cases (all forms) No estimate 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 26. All rights reserved

13 Estimated TB incidence rate, 26 Estimated new TB cases (all forms) per 1 population No estimate 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 26. All rights reserved

14 Trends in estimated TB incidence rates (all forms, purple lines), and the annual change in incidence rates (red lines), for nine subregions and the world, Incidence rate (per 1 /year) High-income countries Change in incidence rate (% per year) Incidence rate (per 1 /year) Central Europe Change in incidence rate (% per year) Incidence rate (per 1 /year) Latin America Change in incidence rate (% per year) Incidence rate (per 1 /year) Incidence rate (per 1 /year) Eastern Mediterranean Eastern Europe Change in incidence rate (% per year) Change in incidence rate (% per year) Incidence rate (per 1 /year) Incidence rate (per 1 /year) South- East Asia Africa - low HIV Change in incidence rate (% per year) Change in incidence rate (% per year) Incidence rate (per 1 /year) Incidence rate (per 1 /year) Western Pacific Africa - high HIV Change in incidence rate (% per year) Change in incidence rate (% per year)

15 Frequency distribution of estimated changes in the TB incidence rate for 134 countries in 6 subregions, SEARWPR LAC EMR High income C&EEUR AFR

16 Correlates of the average annual change in TB incidence rate (vertical axes, %/yr), , in different subregions of the world (a) Latin America R 2 = Percent adults infected with HIV (b) High-income countries 4 r 2 = Percent of TB cases foreign born (c) Central and Eastern Europe r 2 =.66 4 (d) Eastern Mediterranean r 2 = Health expenditure per capita ($PPP) Health expenditure as percentage of GDP (e) Sub-Saharan Africa (f) Central and Eastern Europe r 2 = r 2 =

17 Estimated global prevalence, mortality and incidence rates, Prevalence Mortality Incidence

18 Estimated TB prevalence (a) and death rates (b), by WHO region, for the MDG baseline year 199 and for 26, compared with the MDG target for 215 and with prevalence and death rates projected for 215 based on current trends (a) TB prevalence rate per 1 population (b) TB death rate per 1 population AFR AMR EMR EUR SEAR WPR World AFR AMR EMR EUR SEAR WPR World (current trends) MDG target (current trends) MDG target

19 Outline Epidemiology refresher Estimates of tuberculosis disease burden Notifications Progress in tuberculosis control Tuberculosis drug resistance

20 Tuberculosis notification rates, 26 Notified TB cases (new and relapse) per 1 population No report 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 26. All rights reserved

21 Progress towards the 7% case detection target (a) Case detection rate, smear-positive cases (%) WHO target 7% DOTS begins Year average rate of progress (a) Open circles mark the number of new smear-positive cases notified under DOTS , expressed as a percentage of estimated new cases in each year. The solid line through these points indicates the average annual increment from 1995 to 2 of about 134 new cases, compared to the average increment from 2 to 26 of about 242 cases. Closed circles show the total number of smear-positive cases notified (DOTS and non-dots) as a percentage of estimated cases.

22 Smear-positive case detection rate by DOTS programmes, by WHO region, AFR AMR EMR EUR SEAR WPR Global

23 Outline Epidemiology refresher Estimates of tuberculosis disease burden Notifications Progress in tuberculosis control Tuberculosis drug resistance

24 Number of countries implementing DOTS (out of a total of 212 countries), Number of countries

25 DOTS coverage by WHO region, AFR AMR EMR EUR SEAR WPR The shaded portion of each bar shows the DOTS coverage as a percent of the population. The numbers in each bar show the population (in millions) within (dark portion) or outside (light portion) DOTS areas"

26 Treatment outcomes for HIV-positive and HIVnegative TB patients, 25 cohort The numbers under the bars are the numbers of patients included in the cohort Not evaluated Transferred Defaulted Failed Died Com pleted Cured 2 HIV+ Smear-positive (6113) HIV- (14857) Smear-negative HIV+ (81) and HIV- extrapulmonary (132984) HIV+ (2577) Re-treatment HIV- (34863) (data from 47 countries) (data from 42 countries) (data from 25 countries)

27 Outcomes for those patients not successfully treated, by WHO region, 25 cohort DOTS Non - DOTS AFR AFR AMR AMR EMR EMR EUR EUR SEAR WPR SEAR WPR Died Failed Defaulted Transfered Not evaluated

28 1 DOTS progress in high-burden countries, China Cambodia Bangladesh Indonesia Viet Nam Afghanistan Philippines Target zone Treatment success (%) Nigeria Pakistan DR India Congo Ethiopia UR Tanzania Kenya Mozambique Brazil Thailand Uganda South Africa Russian Federation Myanmar DOTS case detection rate (new smear-positive, %)

29 Engagement of different types of providers in referral of TB suspects, high-burden countries, 26 Public general hospitals Medical college hospitals Military health-care facilities Prison health-care facilities NGO/mission clinics and hospitals Health facilities governed by health-insurance agencies Corporate health-care services Private hospitals Private practitioners Number of countries

30 Engagement of different types of providers in free-of-charge TB treatment with recommended drugs, high-burden countries, 26 Public general hospitals Medical college hospitals Military health-care facilities Prison health-care facilities NGO/mission clinics and hospitals Health facilities governed by health-insurance agencies Corporate health-care services Private hospitals Private practitioners Number of countries

31 Outline Epidemiology refresher Estimates of tuberculosis disease burden Notifications Progress in tuberculosis control Tuberculosis drug resistance

32 5 in Western Pacific 11 Europe 5 Americas 2 in South East Asia Coordinating Centre SRL Under evaluation 2 in African region 1 Eastern Mediterranean

33 MDR-TB among all TB cases * Sub-national averages applied to China, Russia, Indonesia. < 6% 6-2 % 2-4% >4% 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 26. All rights reserved

34 MDR estimates among new TB cases by country MDR (%) WPR SEA EUR EMR AMR AFR Vertical segments represent 95% confidence intervals of country estimates; The horizontal lines show the global estimate with confidence bounds (dashed lines).

35 MDR (%) MDR among retreatment TB cases by country WPR SEA EUR EMR AMR AFR Vertical segments represent 95% confidence intervals of country estimates; The horizontal lines show the global estimate with confidence bounds (dashed lines).

36 MDR-TB among all TB cases P = TB notification rate Any INH resistance among all TB cases Hong Kong SAR p=

37 Estonia p=.6213 p= Latvia p= Lithuania p= notification rate % MDR among new

38 % MDR-TB among new cases TB notification rate % Any INH resistance among new cases Peru

39 % MDR-TB among new cases p= TB notification rate % Any INH resistance among new cases Korea p=

40 % XDR-TB among MDR * Sub-national averages applied to Russia!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! < 3% or less than 2 cases in a survey 3-1% > 1% Report of at least one case 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 26. All rights reserved

41 Notified cases of MDR-TB (24 26) and projected patients to be treated (27 28) 5 non-glc GLC Global plan target for number of MDR-TB patients to be enrolled on treatment: 26: 14 thousand 27: 52 thousand 28: 98 thousand (11, 25%) 25 (16, 48%) 26 (18, 78%) 27 (112, 8%) 28 (116, 86%)

42 MDR-TB treatment outcomes in seven countries, 23 cohort Germany (94) Lithuania (31) Brazil (316) Estonia (16) Latvia (165) Romania (585) Peru (158) Cured Completed Died Failed Defaulted Transferred Not evaluated

43 Global burden of MDR-TB 26 estimates of MDR-TB 489,139 incident cases 95% CI [455, 615,] 4.8% 95% CI [4.6% 6%] of all TB cases notified in 26

44 In conclusion, there were in million new TB cases 1.7 million deaths from TB 14 million prevalent TB cases.5 million new MDR-TB cases Slow progress in case detection Decline in TB disease burden Challenge of HIV-TB and MDR-TB

45

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