511,000 (57% new cases) ~50,000 ~30,000

Transcription

1 Latest global TB estimates (Updated Mar 2009) All forms of TB Greatest number of cases in Asia; greatest rates per capita in Africa Multidrug-resistant TB (MDR-TB) Estimated number of cases 9.27 million (139 per 100,000) 511,000 (57% new cases) Estimated number of deaths 1.77 million (27 per 100,000) ~150,000 Extensively drugresistant TB (XDR-TB) ~50,000 ~30,000 HIV-associated TB 1.37 million 15% of TB cases 456,000 26% TB deaths 23% HIV deaths

2 Estimated Annual MDR TB Incidence* N ~ 500,000 *WHO, 2009 More than cases From to cases From to cases From 100 to 999 cases Less than 100 cases

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4 Global Coverage on Anti-Tuberculosis Drug Resistance Surveillance No data Subnational and/or old data (before 2003) Nationwide and recent data (after 2003) Ongoing survey

5 Countries ever reporting cases of MDR XDR

6 Estimated MDR-TB No estimate ,200 1,201 3,600 3,601 15,914 Over 75,000 MDR-TB cases estimated to have emerged in AFR in % of whom would be sputum smear positive

7 Trends in drug resistant TB in previously untreated patients 4 % MDR among new TB cases R 2 = Year

8 MDR-TB KZN 2006 Patients diagnosed and treated at KGV Patients diagnosed Patents seen and not diagnosed?????????????? Patients not seen and not diagnosed????????????????????????

9 Results (x) Availability of facilities for culture & DST* 3 Culture & DST available No culture & DST available 3 18 * The number of facilities is indicated for countries having more than one as at October 2009 Source: WHO/AFRO

10 True Global and Sub Saharan Africa Extent of MDR & XDR TB??? Knowledge of true extent of MDR & XDR TB epidemic hampered by a lack of lab capacity and health system infrastructure

11 MDR XDR TB in Sub Saharan Africa Volatile, growing True extent not known but likely grossly underestimated by current available data Its concentration reflects availability of diagnostics MDR/XDR TB Vision of the future - -

12 Next steps -Laboratory surveillance for MDR-TB and XDR-TB should be strengthened and expanded across all countries of the Region. -New opportunities with the EXPAND TB Project (Côte d Ivoire, DR Congo, Ethiopia, Lesotho, Cameroon, Kenya, Senegal, Swaziland, Uganda, UR Tanzania, Zambia) -New surveys ongoing in several countries (Benin, Botswana, Lesotho, Madagascar, Mozambique, Namibia, Nigeria, Swaziland, Togo, Zambia)

13 What is the Size of the Problem? Estimates of Drug-resistant TB burden The Global Project has used surveillance data to estimate the proportion of MDR-TB among new and previously treated cases for each country (including those with no previous surveys) to enable policy-makers, politicians, and programme managers to gauge the size, location, and severity of the MDR-TB problem, and compare it to susceptible TB and other health problems. Based on these estimates, there were 511,000 MDR-TB cases in 2007 (4 9% of the 10 4 million total TB episodes in 2007). Of these, 289,000 were among new TB cases (3 1% of new cases), and 221,000 were among individuals previously treated (19% of previously treated cases). India and China together carry approximately 50% of the global burden, followed by the Russian Federation (7%) and South Africa (3%). However, the accuracy of such estimates is not only constrained by the limitations of the surveillance data listed above, but is also compounded by the assumptions inherent in the process of estimation. More and better surveillance data are needed to improve the robustness of these estimates. Finally, although it is well known that MDR and XDR-TB are associated with greater mortality than drug-susceptible TB, no national level data regarding mortality from MDR or XDR-TB are available from high TB prevalence countries.

14 MDR cases among new and retreatment % of MDR among new and retreatmenttb cases, cases, < 3% 3 5 % 6 19% >= 20 % No estimate 511,000 incident cases MDR-TB in ,000 among all new cases (3.1%), 221,000 among previously treated cases (19%). 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 All rights reserved

15 MDR TB among new cases * Sub-national coverage in India, China, Russia, Indonesia. < 3% 3-6 % > 6 % 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 All rights reserved

16 Methods Data source: Global Project on anti-tb drug resistance surveillance and WHO's global TB data collection. 46 countries of WHO/AFR For multi-drug resistant TB: distinction made between countries reporting results of nationwide, representative drug susceptibility testing (DST) surveys since 2000 and those with other data. For extensively-drug resistant TB: include cases detected at routine diagnostic testing (4 countries), in nationwide DST surveys (2 countries), and in surveys of second-line drug (SLD) susceptibility in a convenience sample of MDR-TB cases (2 countries). Source of shapefile:

17 Proportions of MDR-TB Among New TB Cases No data < 3% 3%-6% >6.0% * Sub-national coverage in India, Russia, Indonesia.

18 Proportions of MDR-TB Among New TB Cases No data < 3% 3%-6% >6.0% * Sub-national coverage in India, Russia, Indonesia.

19 Proportions of MDR-TB Among Previously Treated TB Cases No data <15% 15%-30% 30%-50% >50% * Sub-national coverage in India, Russia, Indonesia.

20 Proportions of MDR-TB Among Previously Treated TB Cases No data <15% 15%-30% 30%-50% >50% * Sub-national coverage in India, Russia, Indonesia.

21 Global Coverage on Anti-Tuberculosis Drug Resistance Surveillance No data Subnational and/or old data (before 2003) Nationwide and recent data (after 2003) Ongoing survey

22 Proportions of MDR-TB Among New TB Cases No data < 3% 3%-6% >6.0% * Sub-national coverage in India, Russia, Indonesia.

23 Proportions of MDR-TB Among Previously Treated TB Cases No data <15% 15%-30% 30%-50% >50% * Sub-national coverage in India, Russia, Indonesia.

24 Only 5 countries with HIV status Little trend data Poor infrastructure limited information Faster and more info if use molecular techniques, but now only INH and RIF

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26 Countries reporting XDR-TB MDR & XDR reports, Country* MDR XDR MDR XDR MDR XDR Botswana Burkina Faso Kenya 1 1 Mozambique Namibia South Africa 7, , Swaziland * Lesotho not included

27 Hippo Wallowing in Shallows of Chobe River

28 An update on drug-resistant tuberculosis in Africa Falzon D 1, Zignol M 1, Nkhoma W 2, van Gemert W 1, Wright A 1, Jaramillo E 1 1 STOP TB Dept (TB/HIV and Drug Resistance), WHO, Geneva, Switzerland 2 WHO Regional Office for Africa, Harare, Zimbabwe 40 th Union World Conference on Lung Health, Cancun, MEXICO Union / CDC Late-breaker Session on TB Monday, 7 December (Room Gran Cancun 4)

29 Objective An update on reports of drug-resistant tuberculosis from countries of the African Region of the World Health Organisation (WHO/AFRO) until November 2009

30 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

31 Green Light Committee Established by WHO through efforts of Stop TB Partnership Working Group on MDR TB in 2000 Need for establishing a pooled procurement mechanism for high quality second-line drugs Increasing availability of 2 nd -line drugs increasing resistance to 2 nd -line drugs Need for preserving effectiveness of 2 nd -line drugs, prevent worse drug resistance Need for scientific evidence on management of MDR TB 60%-90% price reductions negotiated with drug manufacturers

32 Increasing Access to MDR TB Treatment projects and 26,000 patients provided with 2 nd -line drugs over 6 years Number of MDR TB Treatment Projects

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35 Proportion of estimated MDR-TB cases treated in AFRO countries in ,000 Estimated MDR total Estimated MDR SS+ 45,000 9,000 Outside GLC Reported MDR cases GLC : 4% Recruitment of MDR-TB patients on GLC-approved projects Country Total Burkina Faso DR Congo Guinea Kenya Lesotho Rwanda Total ,015

36 Countries reporting data from representative DR surveys No data reported Non - countrywide data (before 2000) Countrywide data (before 2000) Countrywide data ( )

37 Percentage of MDR-TB among new patients No data reported 0% 0.90% 0.91% 1.90% 1.91% 3.90% * Latest available data from before 2000 * * * Partial geographic coverage

38 Trends in drug resistant TB in previously untreated patients Botswana Sierra Leone South Africa* MDR-TB Any resistance * Mpumalanga Province

39 ???? Very few DR patients are detected. Diagnostic DST of previously untreated TB cases is very rare and many of the retreated cases tested were in South Africa. When excluding this country, only 4% of estimated smear positive MDR-TB cases occurring in 2007 were being reported by the other countries reporting. There is a paucity of information about the relationship between HIV and MDR-TB. Very few countries have reliable data on drug resistance. By 2008, only 11 of 46 countries (Algeria, Botswana, Côte d'ivoire, Ethiopia, Gambia, Madagascar, Rwanda, Senegal, South Africa, UR Tanzania, Zambia) had reported DR data from a well-designed countrywide survey performed in 2000 or later. A number of large countries including Nigeria and Angola have no data while others like Kenya and Mozambique have not reported study results. As a result there is overreliance on statistical modelling for estimates of MDR in the whole of the AFRO region and this also impinges upon the accuracy of the global estimate. Very few countries report relatively few XDR-TB cases. Up to now only 6 countries, all located in the southern part of the Region, have reported one case or more of XDR. About 97% of cases have been reported by South Africa, which is known to host migrant labourers from nearby countries which up to now either reported zero cases (Malawi, Zimbabwe) or single patients (eg, Lesotho, Mozambique). Very little information about treatment outcomes for DR TB patients. Only the DRC is reporting a sizeable cohort (>100) of cases, in which one fifth were reported to default. Few countries have applied to GLC to treat DR patients. Only 18 countries (out of 46 countries) have ever applied for concessionally-priced drugs and technical support, and 11 of these only since Treatment has only started in 7 countries and one half of the 2,400 treatments approved to date were in one country (DRC) while in other high-mdr-tb burden countries there are either no GLC projects (Nigeria, South Africa) or treatment for under 50 cases (Ethiopia). The scale-up anticipated is overall modest and, for certain countries, not realistic.

40 Additional slides

41 5 in Western Pacific 13 in Europe 6 in Americas 2 in SE Asia Coordinating Centre SRL 2 in Africa 1 in Eastern Mediterranean

42 Summary- Transmission Understanding TB transmission informs interventions Need for greater understanding of latency Exploit molecular and geospacial tracking techniques Support community based studies Household Community Health Care Setting Where were your last 100 cases of TB acquired? Reactivation Adapted from Peter Godfrey- Faussett, Capetown, 2009

43 The Fourth I: Antiretroviral therapy Antiretroviral therapy is one of the most effective interventions against TB The reduced risk of TB in HIV infected patients receiving ART is one of the strongest arguments supporting early ART initiation

44 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

45 Green Light Committee Established by WHO through efforts of Stop TB Partnership Working Group on MDR TB in 2000 Need for establishing a pooled procurement mechanism for high quality second-line drugs Increasing availability of 2 nd -line drugs increasing resistance to 2 nd -line drugs Need for preserving effectiveness of 2 nd -line drugs, prevent worse drug resistance Need for scientific evidence on management of MDR TB 60%-90% price reductions negotiated with drug manufacturers

46 Increasing Access to MDR TB Treatment projects and 26,000 patients provided with 2 nd -line drugs over 6 years Number of MDR TB Treatment Projects

47 GLC countries Burkina Faso Cameroon DR Congo Ethiopia Guinea Kenya Lesotho Liberia Mali Mozambique Nigeria Rwanda Senegal Swaziland Tanzania Uganda Zambia Zimbabwe

48 What is NOT so good about the SRLN? Concentration of SRLs in Europe Only two SRLs in Africa Not enough SRLs linked to francophone countries Overlap between SRLs supporting different countries Technical assistance not well co-ordinated Some countries are not linked to an SRL 2 nd Meeting of the Global Laboratory Initiative, Les Pensières, Veyrier-du-Lac, France October 2009