Global TB control: Current status with particular attention to TB among women and children Katherine Floyd Stop TB Department World Health Organization 42 nd Union World Conference on Lung Health Stop TB Symposium Lille, 26 October 2011
Overview 1. The burden of disease caused by TB and progress towards 2015 targets 2. Progress in implementing and financing TB care and control Comparisons with targets in Stop TB Partnership's Global Plan 2011 2015 Launched 11 October 3. TB in women and children What global notification and survey data tell us
1. Burden of disease and progress towards 2015 targets
Major progress in measuring and Progress in applying the Task Force framework for assessment estimating disease burden of TB surveillance data, of July 2011 April 2009 June 2010 December 2010 July 2011 96 country consultations in 2 years 17 African countries plus India and China in past year
Direct measurements of mortality es national for which vital direct registration measurements (90 countries) of TB mortality + mortality are available, surveys (India) 2010 91 countries, 46% estimated global TB deaths, Up from 89 countries with 8% global TB deaths in 2010 China and India for the first time in 2011
Number of surveys Prevalence surveys major global momentum 8 6 4 Intensive efforts at global and national level to design, finance, implement, analyse, report since early 2008 Global focus countries (GFC) selected by WHO Global Task Force on TB Impact Measurement 21 Global Focus countries selected by Task Force Pakistan Thailand Lao PDR Tanzania Malawi Uganda Myanmar Bangladesh Viet Nam Philippines Nepal 2 0 Ethiopia Rwanda The Gambia Mozambique Viet Nam China Nigeria South Africa Indonesia Cambodia Malaysia Indonesia Eritrea Thailand Philippines Bangladesh Myanmar Cambodia Ghana Kenya Zambia 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013-15 Asia Asia - Africa - Non Other Global Focus country GFC GFC
Millions TB cases and deaths, 1990 2010 absolute numbers 10 Incidence 2.0 Mortality 8 1.5 6 4 Peak at 9.0 in 2005 8.8 in 2010 1.0 HIV-negative mortality 2 1.0 1.2 million (12 14%) TB cases among people living with HIV in 2010 0.5 Peak at 1.8 in 2003 1.4 in 2010 0 0 1990 2000 2010 1990 2000 2010
Most TB cases in Asia and Africa E. Mediterranean 7% Europe 5% Americas 5% South-East Asia 40% Africa 26% 37% in India + China 26% in India Western Pacific 19%
Most TB deaths in Asia and Africa E. Mediterranean 9% Europe 6% Americas 2% Africa 24% SE Asia 47% 35% in India + China 30% in India Western Pacific 12%
Rate per 100,000 population Incidence, prevalence and mortality rates: global estimates Incidence Prevalence Mortality 150 250 25 100 Peak in 2002 200 20 150 15 50 0 Falling 1.3% per year 100 50 0 Target 10 5 0 Target 40% decline since 1990 1990 2010 1990 2015 1990 2015
Dramatic reductions in TB cases and deaths in China, 1990 2010 Incidence and notifications Prevalence Mortality Incidence falling 3.4%/year Halved in 20 years Cut almost 80% 1990 2010 1990 2010 1990 2010
2. Progress in implementing and financing TB care and control
TB cases (millions) 7.6 8.8 Global notifications (black) in context of estimated incidence (green) 3.7 5.8 CDR 65% (63 68%) 1990 2000 2010
Case notifications by region, 1990 2010 Incidence in green Notifications in black Africa Americas E. Mediterranean 2010 CDR: 56 64% 2010 CDR: 75 85% 2010 CDR: 56 71% Europe SE Asia W. Pacific 2010 CDR: 67 76% 2010 CDR: 57 65% 2010 CDR: 73 86%
Treatment success rate (%) Treatment success 87% globally but Europe lagging behind Global, new sm+ WHO Regions, new sm+ 88 86 84 83 85 84 86 86 87 95 90 85 W. Pacific 93 SE Asia 89 EMR 88 82 80 80 Africa 81 80 75 Americas 76 78 70 Europe 67 76 65 2003 2004 2005 2006 2007 2008 2009 2003 2004 2005 2006 2007 2008 2009
Number of patients (thousands) Notifications of MDR-TB increasing BUT only ~ 1 in 6 (16%) of estimated cases of MDR-TB among reported TB patients diagnosed and treated in 2010 60 Notified cases of MDR-TB Global Plan target ~270,000 in 2015 300 MDR-TB cases treated and estimated numbers not treated for MDR-TB, among notified TB patients, 2010 290,000 50 53,000 250 Not on treatment 40 200 Treated 30 150 20 100 10 19,000 50 0 2005 2006 2007 2008 2009 2010 0 SE Asia W. Pacific Europe Africa EMR Americas World
% of patients % of patients Proportion of TB patients tested for MDR-TB remains low 40% 35% 30% 25% 20% 30% New cases Global plan target for 2015 = 20% 60% 50% 40% 30% 51% Previously treated Global plan target for 2015 = 100% 15% 20% 19% 10% 5% 0% Europe 5% 1% 0.4% 0.2% 0.1% Americas SE Asia W Pacific EMR Africa WORLD 2% 10% 0% Europe Americas EMR 6% Africa 3% 2% 6% 0.3% W Pacific SE Asia WORLD
Percentage of TB patients HIV testing for TB patients expanding Although more needed to reach 100% targets in Global Plan 70 60 50 40 30 20 22 8 12 38 20 47 22 56 28 59 34 Africa World Several countries with very high testing rates in 2010 Rwanda: 98% Kenya: 91% Tanzania: 90% Malawi: 88% Mozambique: 88% 10 0 4 4 3 11 2003 2004 2005 2006 2007 2008 2009 2010
Percentage of HIV+ TB patients CPT and ART for HIV-positive TB patients More needed to reach 100% targets in Global Plan 100 Higher rates possible 90 80 70 60 50 40 30 20 77 35 77 45 66 30 71 32 75 37 77 46 CPT ART CPT >90% in 2010 Burkina Faso, Burundi, India, Kenya, Lesotho, Malawi, Mali, Mozambique, Myanmar, Namibia, Rwanda, Swaziland, Tanzania, Uganda ART > 80% in 2010 Brazil, Myanmar, Russia 10 0 ART > 50% in 2010 India, Thailand, S. Africa 2005 2006 2007 2008 2009 2010
US$ billions (constant 2011 prices) Funding for TB control increasing 97 countries, 92% global notifications 5 4 3.5 4.4 Total Government 3 2 1 0 2006 2006200720072008 20082009 20092010 20102011 20112012 2012 Global Fund Grants, excl. GF
US$ millions US$ millions BRICS mostly domestic funding, other HBCs ~50% is donor funding Domestic BRICS 96% domestic financing Grants Domestic Grants Other 17 high-burden countries 49% donor financing
US$ billions Underfunding persists 3 2.5 Funding gaps vs. Global Plan 2 1.5 Funding gaps vs Global Plan, excl. MDR-TB 1 0.5 Funding gaps reported by countries 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Scaling up treatment of MDR-TB to reach Global Plan targets funding required by country group Total BRICS Other middle-income Low-income
3. TB in women and children what do global surveillance data and surveys tell us?
Notifications disaggregated by sex: available data, 2010 Disaggregation of TB notifications by sex, 2010 ~50% sm-/ep notifications not disaggregated by sex ~28% not disaggregated overall All cases Sm+ cases only No disaggregated data
Percentage of total Percentage of total Notifications among women, countries reporting cases disaggregated by sex, 2010 50% 40% 30% 20% 10% 35% 42% ~38% cases notified globally are among women 0% sm+ sm-/ep 60% 50% 40% 30% 20% 10% 0% 47 49 33 41 30 34 sm+ sm-/ep Variation by region higher percentage of cases among women in Africa and EMR EMR Africa SE Asia Americas Europe W Pacific
% of prevalent cases among women Cases among women in prevalence surveys in Asia 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% China (1990) Korea (1990) sm+ smear or culture positive Korea (1995) Philippines (1997) Cambodia (2002) Philippines (2007) Viet Nam (2007) Myanmar (2009) China (2010)
Notification rate/prevalence rate Surveys also suggest cases among women are more likely to be notified 0.7 Men Women 0.6 0.5 0.4 0.3 0.2 0.1 0 Korea (1995) Cambodia (2002) Indonesia (2004) Philippines (2007) Viet Nam (2007) Myanmar (2009) China (2010)
Notifications disaggregated by age: available data, 2010 Disaggregation of TB notifications by age, 2010 ~45% sm-/ep notifications not age disaggregated ~85% notified cases among children are sm-/ep cases ~60% notified cases among children can be identified from routine reporting Disaggregation for all forms All cases Sm+ cases only No disaggregated data
Percentage of all cases Percentage of all cases Notifications among children, countries reporting age-disaggregated data, 2010 12% 10% 8% 6% 10% Estimated at least 6% of global notifications are among children 4% 2% 2% 0% 20% 15% 10% 17 sm+ sm-/ep Sm-/EP Sm+ BUT: high levels of under-reporting of cases thought to exist e.g. due to lack of linkages between NTPs and paediatricians 5% 0% 3 1.7 1 0.5 Africa SE Asia EMR Americas Europe W Pacific
Estimates of TB burden among women and children Estimated 3.2 million (range 3.0 3.5 million) new cases among women in 2010 Estimated ~10% of cases are among children Estimated ~320,000 deaths among HIV-negative women in 2010 and ~0.5 million deaths among women including HIV-associated TB
Next steps for better assessment of TB among women and children 1. Reporting of notification data disaggregated by age and sex from all countries Case or patient-based electronic recording and reporting 2. Prevalence surveys in Africa 3. Studies to quantify "under-reporting" of cases among children and actions to reduce under-reporting (and over-diagnosis)
www.who.int/ tb/data
Acknowledgements Core Report Team Annabel Baddeley, Monica Dias, Dennis Falzon, Christopher Fitzpatrick, Katherine Floyd, Christopher Gilpin, Philippe Glaziou, Tom Hiatt, Andrea Pantoja, Delphine Sculier, Babis Sismanidis, Hazim Timimi, Wayne van Gemert, Mukund Uplekar, + Ikushi Onozaki and Wataru Kashino WHO Regional Offices Amal Bassili, Andrei Dadu, Daniel Kibuga, Khurshid Hyder, Rafael Lopez-Olarte, Wilfred Nkhoma, Nobu Nishikiori, Angélica Salomao USAID >400 people who contributed to reporting, validation and review of data in 2011