Principle of Tuberculosis Control. CHIANG Chen-Yuan MD, MPH, DrPhilos

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1 Principle of Tuberculosis Control CHIANG Chen-Yuan MD, MPH, DrPhilos

2 Estimated global tuberculosis burden 2015 an estimated 10.4 million incident cases of TB (range, 8.7 million 12.2 million) 142 cases per population 11%) among people living with HIV (range, ) incident cases of RR/MDR-TB worldwide Global TB Report 2016

3 Global TB Report 2016 Estimated TB incidence rates, 2015

4

5 per population Notification rates per 100,000 population of new TB cases, by age groups, 2012, Mongolia Total Age (years)

6 Tuberculosis: infection and disease Exposure to source of infection Latent Infection with Mycobacterium tuberculosis Active tuberculosis disease 6

7 The Global Burden of Latent Tuberculosis Infection In 2014, the global burden of LTBI was 23.0% (95% uncertainty interval: 20.4%±26.4%), amounting to approximately 1.7 billion people. WHO South-East Asia, Western-Pacific, and Africa regions had the highest prevalence and accounted for around 80% of those with LTBI. PLoS Med 13(10): e doi: /journal.pmed

8 The Global Burden of Latent Tuberculosis Infection PLoS Med 13(10): e doi: /journal.pmed

9 Between Host Transmission Latent TB Susceptible Latent TB, resistant Susceptible TB Resistant TB 9

10 Incidence and relative risk of active tuberculosis for selected risk factors Relative risk Leung CC, et al. Eur Respir J 2011; 37:

11 Between Host Transmission Intensified case finding and effective treatment Infection control Latent TB Susceptible Latent TB, resistant Susceptible TB Resistant TB Risk factor management Treatment of latent TB infection Vaccination? 11

12 Proportion of patients Fate of tuberculosis patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% No treatment Taiwan 1962 Dead Bacteriology positive Bacteriology negative Grzybowski S, Enarson DA. Bull Int Union Tuberc Lung Dis 1978;53:

13 Proportion of patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Fate of tuberculosis patients No treatment Taiwan 1962 IUATLD model programmes Dead Bacteriology positive Bacteriology negative Bull Int Union Tuberc Lung Dis 1978;53:7. Bull Int Union Tuberc 1991;66:195 13

14 Principles of IUAT Collaborative Tuberculosis Programme Political commitment on the part of government A secure supply of drugs and materials A network of microscopy centers Proper recording and reporting of cases adequate supervision of drug taking proper training and supervision of NTP staff step-wise introduction of short-course chemotherapy Bull Int Union Tuberc 1991;66:195

15 Directly Observed Treatment, Short-course (DOTS) Strategy 1. Government commitment to sustained TB control 2. Case detection by sputum smear microscopy 3. Standardized treatment regimen 4. An uninterrupted supply of essential anti-tb drugs 5. A standardized recording and reporting system

16 Targets of tuberculosis control The outcome targets set by the World Health Assembly in 1991 to detect at least 70% of new smear-positive cases in DOTS programmes to successfully treat at least 85% of detected cases.

17 Trend of Tuberculosis Case Notification Rates, , Viet Nam WHO Tuberculosis Control in the Western Pacific Region Report

18 National survey of tuberculosis prevalence in Vietnam In 2006, the estimated prevalence of smear-positive tuberculosis: 89 per population The observed prevalence of sputum smear-positive pulmonary TB was 145 per in persons aged 15 years (95%CI ), which was 1.6 times as high as previously estimated. Hoa NB, et al. Bull World Health Organ 2010;88:

19 Longer delays in tuberculosis diagnosis among women in Vietnam Men Weeks (95% CI) Women Weeks (95% CI) Patient delay 7.6 ( ) 7.9 ( ) Doctor delay 3.8 ( ) 5.4 ( ) Total delay 11.4 ( ) 13.3 ( ) Long NH, et al. Int J Tuberc Lung Dis 1999;3:388-93

20 Incidence of TB Estimating TB incidence from estimates of the proportion of cases detected Estimating TB incidence from data on case notifications and expert opinion for high-income countries Estimating TB incidence from empirical measurements of disease prevalence WHO Global TB Repot 2014

21 Methods used to estimate TB incidence Number of country 2014/2015 % of global incident cases 2014/2015 Case notification data combined with expert opinion about case detection gaps Results from national TB prevalence surveys Notifications in high-income countries adjusted by a standard factor to account for under-reporting and under-diagnosis Results from inventory/capture-recapture studies 120/74 51%/22% 19/20 46%/62% 73/118 3%/15.5% 5/5 0.5%/0.5% Global TB Report 2015/2016

22 Floyd K, et al. 2016

23 TB prevalence (smear-positive) to TB case notification (new smear-positive) ratio Global Tuberculosis Report 2016

24 Floyd K, et al. 2016

25 History: Diagnosis of tuberculosis Co-morbidity (HIV, Diabetes Mellitus, Cancer, etc.) Tuberculosis treatment Contact of tuberculosis patients Symptoms and signs Sputum smear: identifies the most powerful sources of infection, relatively low sensitivity with paucibacillary specimens Sputum culture Chest radiograph Nucleic Acid Amplification, Xpert MTB/RIF test The key to the diagnosis of TB is a high index of suspicion

26 Map of the intervention area for Xpert MTB/RIF testing in Eastern Nepal. Int J Tuberc Lung Dis 2015;19(5):

27

28 Five priority actions required to accelerate progress towards 2015 targets Reach the missed cases Address MDR-TB as a public health crisis Accelerate the response to TB/HIV. Increase financing to close all resource gaps Ensure rapid uptake of innovations 28

29

30 The Sustainable Development Goals

31 Global TB Report 2016 The END TB Strategy

32

33 Global TB Report 2016

34 Global TB Report 2016

35 Global TB Report 2016

36 Smoking and tuberculosis disease Lin HH, et al. PloS Med 2007;4(1): e20:doi: /journal.pmed Bates M N, Arch Intern Med 2007;167:335-42

37 Exposure to Second-Hand Smoke and the Risk of Tuberculosis in Children and Adults Patra J, et al. (2015) PLoS Med 12(6): e doi: /journal.pmed

38

39 Projected TB incidence Projected TB mortality Projected TB prevalence

40 In summary Reduce the incidence of tuberculosis infection 1. Intensified case finding (reduce patient delay and health system delay) and effective treatment, including MDR-TB 2. Infection control Reduce the risk of developing tuberculosis disease 1. risk factors management and addressing social determinants 2. treatment of latent tuberculosis infection

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