STOP TB Canada

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STOPPING TB

• Yes we can
• March 26, 2010
• Edmonton

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Outline of what it will take

• Understanding the global TB goals and impediments
  
• Why DOTS has stalled new strategies
• Understanding Canadian goals and impediments
• What we can do
• And why

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Latest global TB estimates and notification - 2008
Estimated number of cases
Cases reported DOTS
5.6 million (80 per 100,000)
9.4 million (139 per 100,000)
All forms of TB Greatest number of cases in
Asia greatest rates per capita in Africa

2.6 million (63)
4.1 million
New Smear positive
Multidrug-resistant TB (MDR-TB)
150,000
511,000 (50,000 XDR)
HIV-associated TB
1.4 (15)
486,000
Deaths
1.8 million (.52 mHIV, .15 mMDR, .03mXDR)
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Estimated TB incidence rate, 2008
Estimated new TB cases (all forms) per 100 000
population
No estimate
024
2549
5099
100299
300 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 2006. All rights reserved
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The DOTS StrategyTB management in Resource poor
settingsNational TB control Program
modeled by Styblo, Tanzania 1970s

• Essential elements
• Find symptomatics microbiology Lab network
• Case definition and Standard treatment---manual
• Uninterrupted supply of high quality drugs
• Directly observed therapy DOT
• recording and reporting, outcome evaluation
• government commitment

Assuming Human Resources and infrastructure
World Bank assessed as the most cost-effective
health strategy (1990)
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Targets

• By 2005 (WHA set in 1991) By
  2007
• Find 70------60.................................
  63
• Cure 85-----84..................................
  87
• By 2015, compared with 1990 (MDG goal 6)
• Reverse the rise peak in 2004, 142/100,000
  (decline lt1/y)
• Cut prevalence in half (1990-300 2008 200)
• Cut mortality (case fatality) in half, 1990- 30,
  2008 19
• not happening quickly enough
• By 2050 eliminate TB as a Public Health problem

Cost est 60 billion 11 billion for new tools
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Incidence rates stable or falling slowly
9.27





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impediments

• HIV co-infection
• Failing health infrastructure (Lab challenges,
  human resources)
• Drug resistance
• Community commitment
• Donor fatigue
• POVERTY and the social determinants of health

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The Stop TB strategy in a framework
Political commitment with increased and sustained
financing
2. TB-HIV, TB contacts, prisoners, refugees,
vulnerable groups, special situations
High quality DOTS (ISTC) Susceptible or resistant (MDR-XDR) adult or children High quality DOTS (ISTC) Susceptible or resistant (MDR-XDR) adult or children High quality DOTS (ISTC) Susceptible or resistant (MDR-XDR) adult or children
Case detection through quality assured bacteriology Effective (std) treatment, with supervision and patient support Effective drug supply and management system Monitoring evaluation system, impact measurement
5. Empower people with TB, communities ACSM,
CTBC, Patient charter
3. Contribute to HSS HR , Financing, PAL,
Laboratory, IC etc
4. Engage all care providers (PPM)
6. Enable and promote research New diagnostics,
drugs, vaccines Re-tooling, OR
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TB rates/100,000, in Canada compared with sample
countries (1999)
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Controlling TB

• Find and cure the cases (DOTS)
• Find the contacts infected and at risk of
  reactivation and give prophylaxis
• Maintain surveillance among those at risk.

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Tuberculosis in Canadacontribution by Foreign
born and Aboriginal 1980-07
2007 1547 cases 4.7/106 FB 14.1 Aboriginal
25.7 Other,CB 0.7
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Tuberculosis incidence rate by origin Canada
1992 - 2006
Foreign Born__ Aboriginal___ Canadian born
other______
Canadian born Aboriginal
Foreign-born
Rate per 100,000 population
Canadian born non-Aboriginal
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Canadian Tuberculosis Incidence Rates by
Province/Territory, 2006
lt 5.0 (national rate) 5.1-9 10-29 gt 30
TB Prevention and Control Provisional rates per
100,000 population 2007.11
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Rates of TB in Indigenous peoples of Australia
New Zealand US and Canada
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Mean rate of change of TB rates in 5 countries
1996-2007
country Indigenous overall
Canada 2.67 -4.1
Australia 19 -1.1
New Zealand 1.9 .45
US -6.1 -5.7
Greenland 13.9 Denmark -0.7
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Disaggregated data from the Latin region del
Granado)
Country TB in Indigenous TB in General Population
Chili 170 25
Brazil 118 41
Columbia 76 51
Uraguay 55 41
Paraguay 392 40
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The Greenland story
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RR, prevalence, attributable fraction due to
selected causes
Risk Factor Relative risk of TB reactivation Prevalence in the high burden countries Attributable fraction in the population
HIV infection 8.3 (6.1 -10.8) 1.1 7.3 (5.2-9.6)
Malnutrition 4.0 (2.0-6.0) 17.2 34.1 (14.7-46.3)
Diabetes 3.0 (1.5-7.8) 3.4 6.3(1.6-18.6)
Alcoholism 2.9 (1.9-4.6) 3.2 5.7(2.8-10.3)
Smoking 2.6 (1.6-4.3) 18.2 22.7(9.9-37.4)
Household pollution 1.5 (1.2-3.2) 71.1 26.2(12.4-61)
Lonnroth, K., et al., Drivers of tuberculosis
epidemics The role of risk factors and social
determinants, Social Science Medicine (2009),
doi10.1016/j.socscimed.2009.03.041. Article in
press
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DOTS is essential , but not sufficient for
ELIMINATION
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What factors influence TB rates

• For a long time the sole factors measured were
  the elements of program, the presence of a plana
  manual, an adequate supply of drugs, a quality
  assured laboratory, a recording and reporting
  system, and training of health workers DOTS

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Decline of TB rates before drugs
In the first half of the 20th century when no TB
drugs, rates of TB infection and mortality
declined an average of 5 per year in Western
Europe
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Conceptual framework of determinants of TB
Lonnroth, K., et al., Drivers of tuberculosis
epidemics The role of risk factors and social
determinants, Social Science Medicine (2009),
doi10.1016/j.socscimed.2009.03.041. Article in
press
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Determinants of TB trendsOxlade et al

• 1990-2005 assessed the association of paramenters
• 165 countries collection of Health indicators
  Life Expectancy, lt MR, Measles vaccination
  cover, HIV incidence
• TB incidence and MDR prevalence, and treatment
  success under DOTS
• Economic indicators GDP and GINI index
• Each one year increase in life expectancy was
  associated with a 7.8/105 decline in TB incidence
• A 1/1000 decrease in child MR was associated with
  a 1/105 decrease in TB incidence
• Only in low HIV prevalence countries was TB
  treatment success rate associated with a 1/105
  decrease in incidence
• Many countries with declining general health
  indicators had increasing TB rates

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Determinants of TB trends Dye, Lonnroth,
Jaramillo, Williams, Raviglione

• Assumption that the fall in TB rates is
  attributable to DOTS
• Method
• Comparative analysis 1997-2006
• Annual rate of change of TB incidence and 32
  independent variables describing the countrys
  economy, population behavioral and biologic risk
  factors for TB, health services and intensity of
  TB control
• Results
• 134 countries where the rate of change about 10
• Average rate of change was -1.9
• Faster in high income countries -3.9
• ssAf average up 1.8
• Conclusion
• Incidence declined more quickly in countries with
  high HDI And lower child mortality
• TB rate fall was linked in the Latin region with
  detection rate of smear positive cases

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Social determinants
Aboriginal ( non aboriginal Canada US AUS NZ Greenland
HS grad gap 37(65) 28 71(80) 9 23(49) 26 62(76) 14 96
U grad gap 5.8(18.1) 12.3 12(24) 12 3(25) 22 8(13) 5 na
Crowding Person/ room .6(.4)
Income (USD) gap 16,572 (25,615) 9043 28,919 (37,057) 9138 394(665)/ week 271 14,000 ( 18,500) 4500 20,000
Median age 29.6 (36) 29(35) 21(36) 23(36) 39.8
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Indigenous health indicator gap
Aboriginal(non-abriginal) Canada US AUS NZ Greenland(Denmark)
Life expectancy in years m/f gap 6977/ (7782) 8/5.5 7379/ (7581) 5/3 6773 (7782) Adjusted 109 6671 (7681 9/9 75.580.2
Infant ltone year MR/1000 6.4/5.2 1.2 8.7/6.8 1.9 7.3 3.1 na
HIV of new infections gap 20 2/105 40 greater prevalence 6.8/105
Suicide/105 gap 24(11) 13/105 6.5/105 6.2/105 105/105
TB/105 Factor 25.8(4) 6.5X 5.4(4) 1.4X 6.9(5) 1.4X 8.5(7) 1.2x 60(7) 8.5x
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The Mycobacterium is necessary but not sufficient
for Tuberculosis Poverty is the driver
Its the housing stupid
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Missing elements the social determinants of
health

• Access to care
• Income
• Education
• Housing

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New DOTS strategies

• DOTS Expansion, with more political commitment,
  better lab support with cultures, better
  management, records and evaluation
• Address HIV MDR
• Health system strengthening, human resources,
• Engage all practitioners, private, military,
  faithbased
• Empower people with TB and communities
• Promote research

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• Public health is purchasable. Within a few
  natural and important limitations any community
  can determine its own health.
• Hermann M. Biggs(29 Sep 1859 -28 Jun 1923)New
  York City's Public Health Officer and public
  health pioneer