Open Forum 4: Key issues in TB Drug Development, August 18, 2010, Addis Ababa, Ethiopia TB epidemic and progress towards the Millennium Development Goals Haileyesus Getahun Stop TB Department, WHO Geneva, Switzerland
Outline of presentation Global TB epidemiology Global TB targets for 2015 Progress towards global TB targets Moving beyond 2015 Conclusion
The global burden of TB in 2008 All forms of TB Estimated number of cases 9.4 million (range, 8.9 9.9 million) Estimated number of deaths 1.3 million* (range, 1.1 1.7 million) HIV-associated TB 1.4 million (15%) (range, 1.3 1.6 million) 0.52 million (range, 0.45 0.62 million) Multidrug-resistant TB (MDR-TB) 0.5 million ~ 0.15million *excluding deaths among HIV+ people
Highest incidence rates in Africa Linked to high rates of HIV infection: 78% of estimated HIV+ TB cases in Africa
Estimated HIV prevalence in new TB cases, 2008
Most TB cases are still in Asia Europe 4% EMR 7% Americas 3% South- East Asia 34% Africa 30% 55% cases in Asia Western Pacific 21%
Global TB targets set for 2015 1.Millennium Development Goals Halt and reverse incidence of TB (MDG 6, Target 6.c) 2. Stop TB Partnership targets Halve 1990 prevalence and mortality rates (per 100 000 population) Prevalence target: <148/100,000 (164 in 2008) Mortality target: <14/100,000 (20 in 2008)
Additional targets in the Global Plan 1.Detect 84% of smear-positive cases, and successfully treat 87% of them, by 2015 2. TB/HIV (2010) 85% TB patients tested for HIV by 2010 320,000 HIV+ TB patients received ART by 2010 3.X/MDR-TB (2015) 80% (~400,000) cases diagnosed and treated 4.Financing US$5 9 billion per year for TB control, 2010 2015
Progress towards global TB targets Nine TB epidemiological regions Africa (High HIV and Low HIV) Europe (Central and Eastern) Established market economies (the rich countries) Eastern Mediterranean South East Asia Western Pacific Incidence, prevalence and mortality targets Traffic light analogy (red, yellow and green)
Incidence rates falling globally Africa-high HIV Africa-low HIV Central Europe Rate per 100,000 population Eastern Europe EME* E. Mediterranean Latin America South-East Asia W. Pacific Incidence falling in all sub-regions except African countries with low HIV prevalence *EME = Established Market Economies
Progress to the prevalence target Rate per 100,000 population 700 600 500 400 300 200 250 200 150 100 160 140 120 100 80 60 40 Africa-high HIV 1990 1995 2000 2005 400 350 300 250 200 40 35 30 25 20 15 10 500 400 300 200 Africa-low HIV 1990 1995 2000 2005 120 100 80 60 40 20 400 350 300 250 200 150 100 400 350 300 250 200 150 100 Central Europe Eastern Europe EME* E. Mediterranean Latin America South-East Asia W. Pacific 1990 1995 2000 2005 Five regions reached target already SE Asia and E. Mediterranean may be able to achieve target African countries far from target, such that target unlikely to be reached globally Black line marks target level at 50% of 1990 prevalence rate *EME = Established Market Economies
Rate per 100,000 population 100 80 60 40 20 40 35 30 25 20 15 20 15 10 5 Progress to mortality target Africa-high HIV Africa-low HIV Central Europe 1990 1995 2000 2005 55 50 45 40 35 30 25 20 Eastern Europe EME* E. Mediterranean 2.5 2.0 1.5 1.0 Latin America South-East Asia W. Pacific 60 50 40 30 20 1990 1995 2000 2005 14 12 10 8 6 4 2 100 80 60 40 20 70 60 50 40 30 20 1990 1995 2000 2005 Black line marks target level at 50% of 1990 mortality rate Four regions appear to have reached target of halving 1990 mortality rate already (green) SE Asia, E. Mediterranean and E. Europe may be able to achieve target African countries far from target, such that target unlikely to be reached globally *EME = Established Market Economies
What about other targets? Treatment success rate TB/HIV and MDR targets Funding targets
Treatment success target reached globally Successful treatment rate (%) in DOTS cohorts 90 80 70 60 50 40 77 79 77 79 81 80 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 82 82 82 83 85 84 85 87 But not in the Americas, Africa and Europe 2006 2007
Global plan TB/HIV and MDR targets: 2008 Global plan target 2.3 million TB patients tested for HIV 300,000 started on ART 16 million PLHIV screened for TB 110,000 X/MDR cases treated Actual coverage 1, 374,000 HIV tested (60% of the planned) 109,000 on ART (36% of the planned) 1,385,000 screened (8.7% of the planned) 30,000 cases notified (27% of the planned)
Funding has increased 5 4.1 4 US$ billions 3 2 2.7 Unknown Global Fund Grants (excl. GF) Loans 1 Government (health system) Government (NTP budget) 0 2006 2007 2008 2009 2010 Data based on ~ 100 countries each year with ~ 94% estimated global cases technical assistance and R & D not included
But falls short of Global Plan targets, except in E. Europe 4 3.8 3 Other US$ billions 2.7 2 1.3 1 1.7 TB/HIV MDR-TB DOTS 0 GP AF GP AF GP AF GP AF GP AF 2006 2007 2008 2009 2010 Data based on ~ 100 countries All regions each except year Eastern with ~ Europe 94% estimated global cases In E Europe available funds (AF) exceeds Global plan (GP) targets
Beyond the global TB targets OF 2015 TB elimination by 2050 (Incidence of active TB < 1 per million)
Treating latent TB is crucial 4 Month rg. 2 Month rg. 10 days rg. (Incidence per million) Proc Natl Acad Sci U S A. 2009 Aug 18;106(33):13980-5.
Conclusion Targets are in general on track in several regions but unlikely achievable globally. Incidence target has been achieved globally except in Africa with low HIV Mortality and prevalence targets are unlikely to be achieved in Africa Latent TB treatment with robust and new drug could be crucial for TB elimination