TB: Forgotten But Not Gone

Forgotten But Not Gone
J2J Lung Health Media Training
Lee B. Reichman, M.D., M.P.H. Kuala Lumpur, Malaysia
November 12, 2012
TB Historical Permutation
17th - 18th centuries TB took 1 in 5 adult lives
1850 - 1950 one billion people died of TB

Next decade 2010-2020
300 million new infections 90 million new cases 30 million deaths
More people died from TB last year than any year in history
Estimated TB Incidence Rates, 2010
Estimated MDR-TB incidence rates, 2009 (new and previously treated)

Selected countries of the former Soviet Union: Estonia: 7 / 100,000 Kazakhstan: 57 / 100,000 Russia: 27 / 100,000 Tajikistan: 59 / 100,000
MDR-TB cases emerging annually, per 100,000 population
African countries with estimated MDR-TB incidence rates 15 MDRTB cases per 100,000 population Botswana: 27 / 100,000 Mozambique: 16 / 100,000 Namibia: 17 / 100,000 Rwanda: 16 / 100,000 South Africa: 26 / 100,000 Swaziland: 23 / 100,000 Zimbabwe: 19 / 100,000
China: 7 / 100,000
India: 8 / 100,000
Global TB Control: Background

1991 World Health Assembly recognized the growing importance of TB as a public health problem
A new framework for TB control was developed A global strategy called DOTS was introduced (originally stood for Directly Observed Treatment, Short Course)
International TB Control Strategy

DOTS: 1991-2005
Political commitment Case detection using sputum microscopy among persons seeking care for prolonged cough Standardized short-course chemotherapy under proper case-management conditions including DOT Regular drug supply Standardized recording and reporting system that allows assessment of individual patients as well as overall program performance
International TB Control Strategy

Stop TB Strategy: 2006 - current
1. Pursue high-quality DOTS expansion and enhancement 2. Address TB/HIV, MDR-TB and other challenges 3. Contribute to health system strengthening 4. Engage all care providers 5. Empower people with TB, and communities 6. Enable and promote research
Emergence of worst-case TB scenarios

Co-infection between TB and HIV Multidrug-resistant TB (MDR-TB)
Resistance to isoniazid and rifampin the 2 most powerful anti-TB drugs
Extensively-drug resistant TB (XDR-TB)

MDR-TB plus resistance to any fluoroquinolone and at least 1 second-line injectable (AMI, KAN, CAP)
Totally Drug Resistant TB (TDR-TB)

Resistant to all anti-TB drugs
The Global Burden of TB/HIV

1/3 of 33 million people living with HIV/AIDS co-infected with TB (>10 million people) Without treatment, 90% will die within months
HIV and TB form a lethal combination, each speeding the other's progress
TB is the leading cause of death among HIVpositive people (up to 50% of all patients worldwide)
Co-Existence of HIV & TB infection
TB Infection
HIV Infection
10% per lifetime 10% per year .0017% per year
Risk of Active TB
Estimated HIV Prevalence in New TB Cases, 2010
MDRTB/XDRTB - The Big Problem!

500,000 new MDR-TB cases estimated annually XDR-TB in 68 countries <5% of estimated MDR-TB cases detected in 2006 10% of MDR-TB cases projected to be treated in 2008 and 3% only under GLC standards About 85% of the global MDR-TB burden in 27 countries
Sources: Global TB Report, 2008 and IV Global DRS Report, 2008
Use of One Drug Knowingly or Unknowingly

Sensitive bacilli killed
Resistant bacilli multiply unimpeded

Resistant bacilli become dominant Efficacy of Fluroquinolones in TB and non TB infection suggests increases in cross species resistance will increase as has already been shown
Available Data on Anti-TB Drug Resistance, 2010
Estimated Absolute Number of MDR-TB Cases, 2009
Countries that had reported at least one XDR-TB case by end 2010
Unsexy Tuberculosis
Concern and attention re: XDR-TB is appropriate, but skips the more important message XDR-TB, MDR-TB, and drug-sensitive tuberculosis are all the same disease The only difference is that MDR-TB is drug-sensitive tuberculosis modified by inappropriate treatment or drug taking, and XDR-TB is MDR-TB thus modified We need to recognize that there are more than 9,000,000 new active drugsensitive cases of tuberculosis globally that could be feeding drug resistance It might be a less sexy concept, but they all must be appropriately treated with current strategies (as well as new diagnostics, drugs, vaccines, and proper infection control measures) to avoid preventable MDR-TB and XDRTB, which are always lurking Preventing active, drug-sensitive tuberculosis, or treating it properly, should be everybodys priority; it is the only way to prevent MDR-TB and XDR-TB
Reichman, LB The Lancet, 2009
Inadequacies in Physician Practices

Major Recurring Practice
Delays in diagnosis and errors in treatment
Resulting In
Increased risk and likelihood of disease transmission
More advanced and complicated disease

Lengthened hospital stays Increased medical costs
Development of MDR-TB and XDR-TB

Development of TDR-TB?
World TB Day 2006 - Dr Lee launches the International Standards for TB Care & the Patients' Charter for TB Care
International Standards for TB Care
ISTC: Key Partners in Implementation

National (and local) tuberculosis control programs Influential professional societies Professional (medical and nursing) schools NGOs Patient and community organizations Technical agencies Funding agencies
International Standard for TB Care: Diagnosis

All persons with otherwise unexplained cough lasting for 2-3 weeks or more should be evaluated for tuberculosis
International Standard for TB Care: Diagnosis

Microbiological evaluation (smear culture) is essential for all patients (including children, extra-pulmonary, and persons with radiographic abnormalities)
International Standard for TB Care: Treatment

The provider is responsible for prescribing an adequate regimen and ensuring adherence
International Standard for TB Care: Treatment

A patient-centered, individualized approach to treatment should be developed for all patients. A central element is direct observation by a treatment supporter.
Where Are The Missing Cases?

They are not detected due to poor laboratory capacity

At home, if services are not accessible

In other un-connected public systems (prisons)

In the private sector
Patient Involvement in Medical Care

Patients and their families have become increasingly involvedand influentialin all aspects of medical care
In the mid-eighties, as the first anti-viral drugs for treating AIDS were being developed, activists demanded to participate in the design of clinical trials directed by the National Institutes of Health and pharmaceutical companies Laypeople now routinely sit on committees on the N.I.H. and on hospitals institutional review boards, which assess the ethicality and scientific merit of clinical trials
The Patients Charter for Tuberculosis Care
The Patients Charter for Tuberculosis Care

Companion document to International Standards
Initiated and developed by patients from around the world

Outlines rights and responsibilities of people with tuberculosis Affirms that empowerment is catalyst for effective collaboration of the patient with health providers and authorities
Patients Rights
You have the right to:
Care;
Dignity; Information;
Choice;
Confidence; Justice; Organization; Security
Source: Patients Charter for TB Care, 2006
Patients Responsibilities
You have the responsibility to:
Share information; Follow treatment; Contribute to Community Health; Show Solidarity
Source: Patients Charter for TB Care, 2006
TB at a Crossroad of Global TB Control

US domestic decline of TB since prior to development of drugs
US resurgence of TB during the 1980s and 1990s, largely due to neglect Massive and effective response TB on the radar screen domestically TB on the radar screen internationally
BUT TB Remains a Global Killer Why does TB still infect one-third of the worlds population and remain a global health threat despite the fact that highly cost-effective drugs are available to eradicate it?
Challenges in TB Control
Insufficient financial and human resources
Inadequate healthcare infrastructure

Weak laboratory capacity and lack of new rapid diagnostic tools
Lack of new drugs that would cure TB in a shorter time

Lack of effective vaccine that would prevent TB Poor use of infection control in healthcare settings HIV and MDR/XDR threats Minimal social mobilization for TB control and minimal population awareness stigma
As we cure increasing numbers, the remaining cases are those most difficult to treat, with impossible social problems, and/or severe, virtually untreatable but still transmissible, drug resistance
THE FEW REMAINING CASES

This talk has concentrated on the difficult remaining TB cases With DOTS and case management along with funding, interest and involvement in developing new tools and strategies for combating TB we have taken care of the easy ones and Expertise decreases
Funding decreases
Innovative Initiatives are de-emphasized or even forgotten
Tuberculosis Control and Elimination 2010-50: Cure, Care, and Social Development - 1
Rapid expansion of the standardized approach to tuberculosis diagnosis and treatment that is recommended by WHO allowed more than 51 million people to be cured between 1995 and 2011, and 20 million lives have been saved
Tuberculosis remains a severe global public health threat Although the overall target related to the Millenium Development Goals of halting and beginning to reverse the epidemic might have already been reached, the more important long-term elimination target set for 2050 will not be met with present strategies and instruments
-Lonnroth, Castro, Chakaya, et al, Lancet, 2010 Updated 2012
Several key challenges persist:
Many vulnerable people do not have access to affordable services of sufficient quality Technologies for diagnosis, treatment, and prevention are old and inadequate Multi-drug resistant tuberculosis is a serious threat in many settings HIV/AIDS continues to fuel the tuberculosis epidemic, especially in Africa Other risk factors and underlying social determinants help to maintain tuberculosis
Acceleration of the decline towards elimination of this disease will need invigorated actions in four broad areas
Continued scale-up of early diagnosis and proper treatment for all forms of tuberculosis Development and enforcement of bold health-system policies Establishment of links with the broader development agenda Promotion and intensification of research towards innovations
Defaulters and Motivation

to default is the natural reaction of normal, sensible people: The person who continues to swallow drugs or have injections with complete regularity in the absence of encouragement and help from others is the abnormal one.
Annik Rouillion
- Bull IUAT 1972; 47:68-75
Why do we need to care about TB in the rest of the world?
Lessons from Andrew Speaker

TB has not gone away, it remains with us, highly prevalent and transmissible
Anybody can get tuberculosis, not only poor people, minorities, or the foreign-born
TB anywhere is TB everywhere
All resistant TB, MDR and XDR TB is preventable by proper TB diagnosis and treatment
Good public health is a silent secret, but when there is a small glitch, it becomes major news
We desperately need new tools for TB diagnosis and treatment

You dont want to sit on an airplane for 8 hours next to an untreated coughing person with any kind of TB, be it drug sensitive, MDR or XDR
INFORMATION LINE
18004TBDOCS (482-3627) www.umdnj.edu/globaltb

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Forgotten But Not Gone

J2J Lung Health Media Training

Lee B. Reichman, M.D., M.P.H. Kuala Lumpur, Malaysia

November 12, 2012

1850 - 1950 one billion people died of TB

Estimated TB Incidence Rates, 2010

Estimated MDR-TB incidence rates, 2009 (new and previously treated)

MDR-TB cases emerging annually, per 100,000 population

Global TB Control: Background

International TB Control Strategy

International TB Control Strategy

Emergence of worst-case TB scenarios

Extensively-drug resistant TB (XDR-TB)

Totally Drug Resistant TB (TDR-TB)

The Global Burden of TB/HIV

Co-Existence of HIV & TB infection

Estimated HIV Prevalence in New TB Cases, 2010

MDRTB/XDRTB - The Big Problem!

Sources: Global TB Report, 2008 and IV Global DRS Report, 2008

Use of One Drug Knowingly or Unknowingly

Resistant bacilli multiply unimpeded

Available Data on Anti-TB Drug Resistance, 2010

Estimated Absolute Number of MDR-TB Cases, 2009

Inadequacies in Physician Practices

More advanced and complicated disease

Development of MDR-TB and XDR-TB

International Standards for TB Care

ISTC: Key Partners in Implementation

International Standard for TB Care: Diagnosis

International Standard for TB Care: Diagnosis

International Standard for TB Care: Treatment

International Standard for TB Care: Treatment

Where Are The Missing Cases?

Where Are The Missing Cases?

Where Are The Missing Cases?

Where Are The Missing Cases?

Patient Involvement in Medical Care

The Patients Charter for Tuberculosis Care

The Patients Charter for Tuberculosis Care

Initiated and developed by patients from around the world

Source: Patients Charter for TB Care, 2006

TB at a Crossroad of Global TB Control

Inadequate healthcare infrastructure

Lack of new drugs that would cure TB in a shorter time

THE FEW REMAINING CASES

-Lonnroth, Castro, Chakaya, et al, Lancet, 2010 Updated 2012

-Lonnroth, Castro, Chakaya, et al, Lancet, 2010 Updated 2012

Defaulters and Motivation

- Bull IUAT 1972; 47:68-75

Why do we need to care about TB in the rest of the world?

Lessons from Andrew Speaker

We desperately need new tools for TB diagnosis and treatment

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