International Union Against Tuberculosis and Lung Disease

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• International Union Against Tuberculosis and Lung
  Disease

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WHO Report 2005 Global Tuberculosis Control

• Update estimates of incidence in 2003
• 8.8 million new cases of TB (140/100,000),
• 3.9 million smear-positive (62/100,000)
• 674,000 HIV infected (11/100,000)
• Update estimates of prevalence in 2003
• 15.4 million new cases of TB (245/100,000),
• 6.9 million smear-positive (109/100,000)

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WHO Report 2005 Global Tuberculosis Control

• Tuberculosis death 1.7 million (28/100,000)
• The global incidence rate of TB (per capita) was
  growing at approximately 1.0 per year, mainly in
  African countries with high HIV prevalence

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WHO Report 2005 Global Tuberculosis Control

• A total of 182 countries were implementing DOTS
  strategy in 2003
• 77 of the worlds population covered by DOTS.
• DOTS programmes notified
• 3.7 million new TB cases,
• 1.8 million were smear-positive, represent 45 of
  the estimated incidence.
• Treatment success under DOTS for the 2002 cohort
  was 82 on average.

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Progress in Global Tuberculosis Control

• 1980s IUATLD model Programme
• 1991 WHA resolution
• To detect at least 70 of all new infectious
  cases and to cure at least 85 of those detected
• 1993 WHO declare a Global Emergency
• 1994 Framework of Tuberculosis Control
• 1998 STOP TB partnership

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Principles of IUATLD Collaborative Tuberculosis
Programme

• Political commitment on the part of government
• A secure supply of drugs and materials
• A network of microscopy centers with quality
  control
• Proper recording and reporting of cases

Bull Int Union Tuberc 9166195
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To obtain the levels of cure necessary to achieve
an epidemiologic impact, it is necessary to
employ Short-Course Chemotherapy

• Additional conditions required
• adequate supervision of drug taking during the
  initial intensive phase,
• proper training and supervision of NTP staff,
• step-wise introduction of short-course
  chemotherapy?

Bull Int Union Tuberc 9166195
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Progress in Global Tuberculosis Control

• 1980s IUATLD model Programme
• 1991 WHA resolution
• To detect at least 70 of all new infectious
  cases and to cure at least 85 of those detected
• 1993 WHO declare a Global Emergency
• 1994 Framework of Tuberculosis Control
• 1998 STOP TB partnership

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Progress in Global Tuberculosis Control

• 2000 Amsterdam Declaration to Stop TB
• 2000 G8 Okinawa meeting ,
• to reduce TB deaths and prevalence of the disease
  by 50 by 2010
• 2000 UN Millennium Development Goals,
• Goal 6 Target 8 to have halted by 2015, and begun
  to reverse, the incidence of priority
  communicable disease, including TB
• 2001 Global Fund to fight AIDS, TB
• and Malaria (GFATM)

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THE PURPOSE OF THE GLOBAL PLAN

• Eliminate tuberculosis (TB) as a public health
  problem. That and nothing less is the goal of the
  Global Partnership to Stop TB.
• We, the members of the Partnership, know it will
  not happen overnight with a disease that has cast
  a centuries-long shadow still, that is our
  aimand we can achieve it.

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The challenge of eradication lessons from past
eradication campaigns

• Political commitment
• Program leadership
• A technically sound and feasible plan
• Surveillance as a strategy
• Quality control process indicators which is
  specific, measurable, adaptable and adjusted to
  need, reasonable, and time limited
• Research

Int J Tuberc Lung Dis 19982 (suppl 1)S4-S8
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A strategic plan for the elimination of
tuberculosis in the United States

• A national goal of TB elimination (an incidence
  of less than one case per million population) by
  the year 2010
• An interim target of an incidence of 3.5 per
  100,000 by the year 2000

MMWR 198938269-72
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Progressing Toward Tuberculosis Elimination In
Low-Incidence Areas of the United States

• From 1992 through 2000, the incidence of TB
  decreased by 45
• In 2000, 22 (44) states had tuberculosis
  incidence rates less than or equal to 3.5
  cases/100,000 population
• During 2003, a total of 14,871 tuberculosis (TB)
  cases (5.1 cases per 100,000 population) were
  reported MMWR
  200453209-213

MMWR 200251(RR-5)1-17
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Unique Challenges to Good Tuberculosis Control in
Low-Incidence States

• Loss of Expertise
• Scarcity of Special Facilities for Prolonged
  Health Care
• Laboratory Costs and Decreased Proficiency
• Travel in Rural Areas
• Loss of Funds and Personnel Dedicated to
  Tuberculosis Control

MMWR 200251(RR-5)1-17
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Tuberculosis elimination in the countries of
Europe and other industrialized countries

• The basic strategy that appears effective are
• Direct government responsibility for diagnosis,
  treatment and prevention of tuberculosis
• Properly designed disease surveillance and a
  programme monitoring system
• Specialized tuberculosis personnel at regional
  and provincial level, responsible for close
  monitoring of the diagnostic skills and patient
  prioritization in general health institution.

Eur respis J 199141288-95
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DefinitionDefined by Tuberculosis Incidence

• High risk group 100 per 100,000
• Low incidence country
• less than 10 per 100,000 (All form)
• Elimination phase
• less than 1 per 100,000 (All form)
• Elimination achieved
• 0.1 per 100,000 (smear positive)

Eur respis J 199141288-95
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European framework for tuberculosis control and
elimination in countries with a low incidence

• A general approach to tuberculosis which ensures
  rapid detection and treatment of all the cases
  and prevention of unnecessary deaths
• An overall control strategy aimed at reducing the
  incidence of tuberculosis infection (risk-group
  management and prevention of transmission of
  infection in institutional settings)
• A tuberculosis elimination strategy aimed at
  reducing the prevalence of tuberculosis infection
  (outbreak management and provision of preventive
  therapy for specified groups and individuals).

Eur Respir J 2002 19 765775
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THE OBJECTIVES OF THE GLOBAL PLAN

• To expand our current strategyDOTSso that all
  people with TB have access to effective diagnosis
  and treatment.
• To adapt this strategy to meet the emerging
  challenges of HIV and TB drug resistance.
• To improve existing tools by developing new
  diagnostics, new drugs, and a new vaccine.
• To strengthen the Global Partnership to Stop TB
  so that proven TB-control strategies are
  effectively applied.

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Stop TB Partnership Working Group

• DOTS expansion
• HIV/TB
• MDR-TB
• TB diagnostics
• Global Alliance for TB Drug Development
• TB Vaccine

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Tuberculosis - Africa, High HIV
400
350
300
250
Standardized case
notificaiton rate
200
150
100
50
0
1980
1985
1990
1995
2000
WHO 2003
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Principles of Global drug resistance surveillance

• the sample was representative of all TB cases in
  the setting under evaluation
• new patients were clearly distinguished from
  those with previous treatment and
• optimal laboratory performance was assured and
  maintained through links with a supranational
  reference laboratory (SRL).

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Sampling strategies for monitoring of drug
resistance

• countrywide, continuous surveillance of the
  population
• surveys with sampling of all diagnostic centres
  during a specified period
• surveys with randomly selected clusters of
  patients
• surveys with cluster sampling proportional to the
  number of cases notified by the diagnostic centre.

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External Quality Assurance

• Proficiency testing
• exchange of a panel of 20 (or more) pretested
  isolates between the SRL and the NRL. Results of
  this round determine, in part, whether the NRL is
  able to conduct DST for the survey or whether
  additional training is necessary.
• Quality control of survey results
• For QA of survey results, the NRL sends a
  percentage of both resistant and susceptible
  isolates to the SRL for checking. The percentage
  of isolates sent for checking is determined
  before the beginning of the survey.

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Quality assurance programme for drug
susceptibility testing of M. Tuberculosis in the
WHO/IUATLD Supranational Laboratory Network (SRL)

• Five rounds of proficiency testing, 1994-1998
• a high degree of agreement of the testing of
  isoniazid and rifampin
• Discordant results for streptomycin and
  ethambutol
• The sensitivity of testing of ethambutol
  increased from 60 in round 1 to 98 in round 5
• Regular proficiency testing can significantly
  improve the quality of drug susceptibility
  testing

Laszlo A, Int J Tuberc Lung Dis
19971231-8. Laszlo A, Int J Tuberc Lung Dis
20026748-56.
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Any resistance among new cases
The overall drug resistance ranged from 0
(Andorra, Iceland, Malta) to 57.1 (Kazakhstan),
with a median of 10.2 (95 CI 8.811.6).
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MDR among new cases
Prevalence of MDR ranged from 0 (Andorra,
Cambodia, Iceland, Luxembourg, Malta, New
Zealand, Oman, Scotland, Slovenia, and
Switzerland) to 14.2 (Kazakhstan and Israel).
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Outcome of Pulmonary MDR-TB

• Of the 299 patients, 153(51.2) were cured,
  31(10.4) failed, 28(9.4) died, and 87(29.1)
  defaulted.
• Of the 61 patients in group 1, 35(57.4) were
  cured, 7(11.5) died, and 19(31.2) defaulted.
• Of the 113 in group 2, 44(38.9) were cured,
  19(16.8) failed, 16(14.2) died, and 34(30.1)
  defaulted.
• Of the 125 patients in group 3, 74(59.2) were
  cured, 12(9.6) failed, 5(4) died, and 34(27.2)
  defaulted

Chiang C-Y, submitted
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Outcome of pulmonary MDR-TB patients who received
at least one second line drugs
Number ()
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Outcome of pulmonary MDR-TB patients who received
at least one second line drugs
Number ()
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Relapse of MDR-TB after cure

• Among 153 patients who were cured, 10 (6.5)
  patients relapsed
• First line drugs 14.3 (4.2 per 1,000
  person-months ),
• Second line drugs without ofloxacin 6.8 (1.7
  per 1,000 person-months) ,
• Second line drugs with ofloxacin 2.7 (0.7 per
  1,000 person-months ).
• Patients in group 3 were significantly less
  likely to relapse than those in group 1 (HR 0.16,
  95CI 0.03-0.81).

Chiang C-Y. Submitted
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Quality AssuranceA system to continuously
improve the reliability and efficiency of practice

• Quality control (QC) A systematic internal
  monitoring of working practices, technical
  procedures, equipment, and materials, including
  quality of stains.
• External quality assessment (EQA) A process to
  assess laboratory performance.
• Quality improvement (QI) A process of data
  collection, data analysis and problem solving to
  permanently remove obstacles to success. It
  involves continued monitoring, identifying
  defects, followed by remedial action. QI often
  relies on effective on-site evaluation visits.

External quality assessment for AFB smear
microscopy. Washington, DC, 2002
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External Quality Assessment (EQA)

• On-site Evaluation
• Panel Testing
• Blinded Rechecking

External quality assessment for AFB smear
microscopy. Washington, DC, 2002
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Blinded Rechecking

• Sampling 10 of negatives and 100 of positives
  is no longer recommended.
• Positive and negative slides are no longer stored
  separately.
• Rechecking is always blinded
• Discrepancies should be resolved by a second
  controller.
• Performance is assessed based on the number and
  type of errors exceeding a predetermined
  threshold, rather than calculating a percentage
  of errors.

External quality assessment for AFB smear
microscopy. Washington, DC, 2002
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Result of slides rechecking
Concordant slides N
Number of slides rechecked
Major errors
Minor errors
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Global Elimination of TuberculosisThe
challenges to achieving elimination

• The large pool in infection in the community
• The long incubation period
• The inadequacy of the tools and strategies
  currently available
• Poverty
• Inadequate and declining health services
• HIV infection
• Sustaining commitment to the fight against
  tuberculosis over the long term

Int J Tuberc Lung Dis 20037(12)s328-s332
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The Second Global Plan to Stop TB (2006-2015)

• Global TB control targets
• 2005 (World Health Assembly)
• Process target
• to detect 70 of smear-positive cases
• to treat successfully 85 of all such cases
• 2015 (Millennium Development Goals)
• Impact target
• to halve TB prevalence and deaths