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Tuberculosis Control

Tuberculosis Control. Dr. Yeşim YASİN Fall-2013. Outline. What is Tuberculosis (TB)? Burden of TB, TB/HIV, MDR-TB Strategy , targets , progress Prevention and Control Programmes of TB Challenges towards elimination.

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Tuberculosis Control

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  1. Tuberculosis Control Dr. Yeşim YASİN Fall-2013

  2. Outline • What is Tuberculosis (TB)? • Burdenof TB, TB/HIV, MDR-TB • Strategy, targets, progress • Preventionand Control Programmes of TB • Challengestowardselimination

  3. What is TB? • One of the oldest diseases known in the history. • It is a preventable and a curable disease if detected and treated early.

  4. Prevelance of infection • About one-third of the world‘s population is infectedwith TB bacilli • people have been infected by TB bacteria but are not (yet) ill with disease and cannot transmit the disease.

  5. After a healthy person with a healthy immune system breaths in TB bacteria, he or she will have 10% lifetime chance of developing TB. • Immune-compromised personshave a much higher risk of falling ill.

  6. active TB (disease) delays in seeking care/diagnosis/treatment results in transmission of the bacteria to others

  7. People ill with TB (activecase) can infect up to 10-15 people through close contact over the course of a year • Without proper treatment up to two thirds of people ill with TB will die.

  8. Natural history of TB

  9. The most common source of Tuberculosis infection is the human case whose sputum is positive for the tubercle bacilli, and who has either received no treatment for it or not got treated fully. Such sources can discharge the bacilli in their sputum for years Transmitted by droplet nuclei • TB bacilli have a thick waxy coat,theyare slow growing and they can survive in the body for many years in a dormant or inactive state whereby people are infected but show no signs of TB disease.

  10. Host factors People who are co-infected with HIV and TB are 21 to 34 times more likely to become sick with TB • After20 years of age, TB tends to affect moremales due to higher exposure to infection and higher prevalence ofrisk factors. • Host susceptibility is universal, but the risk of infection is directlyand mainly related to the degree of exposure.

  11. Socialfactors

  12. Incidence of someselectedinfectiousdiseasesbyyears(per 100000 population), Turkey Healthstatisticyearbook 2010

  13. 2011 Data-Turkey • Incidence: 24/100K (WHO estimate) • Patients in total: 15.679 (21/100K) registered • Patients in total in Istanbul:4.898 (36/100K) registered • New cases in Istanbul: 4.457AFB+ patients: 1.794 (registered)

  14. TB mortality risk factors • Site (higher in positive smear) • Type of disease (association to…) • Timeliness of diagnosis and treatment • Appropriate diagnosis • Mistake in reading X-rays • Mistake in interpreting signs and symptoms • Timely/Delayed diagnosis • Timely/Delayed treatment • Quality of treatment

  15. Whyworryabout TB?

  16. Somefacts • TB is the second (only to HIV/AIDS) greatest killer worldwide due to a single infectious agent. • 8.7 million new cases in 2011; 13% is co-infected with HIV • 22 high-burden countries account for 80% of the world’s TB cases. • 1.4 millionpeopledied: 430.000 were HIV+ • Almost 60.000 people worldwide lives with MDR-TB • The largest number of new TB cases occurred in Asia, accounting for 60% of new cases globally • Funding is inadequate

  17. Estimated number of cases Estimated number of deaths 1.4 million (1.3-1.6 million) 430,000 (400,000-460,000) Unknown, but probably>150,000 • 8.7 million (8.3-9.0 million) • 1.1 million (13%) (1.0-1.2 million) • Up to 0.5 million All forms of TB HIV associated TB MDR-TB

  18. Incidence rates, 2011

  19. TB cases, deaths, 1990-2011 Incidence Mortality All cases Peak > 9 million in early 2000s, 8.7 million in 2011 Total mortality peaked early 2000s at >1.8 million 1.4 million in 2011 millions HIV+ cases HIV+ mortality

  20. TB/HIV Coinfection 80% of all TB/HIV cases are in Africa TB leading cause of death in PLHIV: ¼ of PLHIV worldwide die due to TB. PLHIV infected with TB: 20-40 times more likely to develop active TB. Untreated, TB in PLHIV leads to death in weeks

  21. Distribution of MDR-TBamong new TB cases, 1994-2011

  22. Number of MDR-TB cases, 2011 Russian Federation 44,000 (14% of global MDR burden) Ukraine 9,000 Based on survey data Pakistan 10,000 (3% of global MDR burden) China 61,000 (20% of global MDR burden) India 66,000 (21% of global MDR burden) South Africa 8,100 Based on survey data

  23. To date, 84 countries that reported XDR-TB About 9% of MDR-TB cases are XDR

  24. 1. Pursue high-quality DOTS expansion • 2. Address TB-HIV, MDR-TB, and needs of the poor and vulnerable • 3. Contribute to health system strengthening • 4. Engage all care providers • 5. Empower people with TB and communities • 6. Enable and promote research Goal 6: to have halted by 2015 and begun to reverse the incidence… 2015: 50% reduction in TB prevalence and deaths compared to 1990 2050: elimination (<1 case per million population)

  25. Global progress on impact •  51 million patients cured, 1995-2011 •  20 million lives saved since 1995 •  2015 MDG target on track: global TB incidence rate peaked in early 2000s •  BUT, TB incidence declining too slowly, 1.4 million people still dying, MDR-TB response slow, gaps in financing

  26. Prevention and Control of TB

  27. A B

  28. Risk and Prevention-1 Risk and Prevention-1 1- Cough out TB particles - strength of cough (adults>>>children) 2- Live bacteria - smear + or culture + 3- Cavity

  29. Risk and Prevention-2 Risk and Prevention-2 • Person A • Medication (DOT) • Isolation • <4 years • At night • Surgical mask • Person B • Space • Natural ventilation/fan • Air purifying respirator (N95) • Ultra Violet Germicidal Irradiation (UVGI) • High Efficiency Particulate Air (HEPA) Filter • Negative pressure

  30. TB CONTROL TB Control • Detection and treatment of cases • Treatment of latent infection • Vaccination

  31. The three priority strategies for TB prevention and control programs are: • Identifying and treating individuals who have active TB. • Finding and screening individuals who have had contact with TB patients to determine whether they are infected or have active TB, and providing appropriate treatment. • Screening populations at high risk for TB infection to detect infected persons and provide therapy to prevent progression to active TB.

  32. Tuberculosis prevention and control programs • 1994 “Directly Observed Treatment, Short Course” (DOTS)strategy • each country to detect smear-positive TBcases • offer standardized DOT , • with the objective of curing over85% of TB patients.

  33. DOTS DOTS • Governmental commitment to TB Control • Reliable and continious supply of high-quality Anti-TB drugs • Microbiologic confirmation of TB diagnosis • Supervision (DOT) of standardized short course Anti-TB theraphy-at least during the initial phase • System for registration and follow-up

  34. What can DOTS do What can DOTS do? • Increase treatment completion and cure rates • Reduce the emergence of drug resistant TB • Improve cost-effectivenss of TB Control • Reduce TB incidence in conjunction with other interventions.

  35. Challenges Challenges • HIV epidemic • MDR-TB, XDR-TB • Health system weakness and political will • Poor infrastructure and lack of support • Private practitioners • Prisons

  36. DOTS in Turkey DOTs in Turkey • Since 2003 Ministry of Health performed pilot studies for DOTs (Directly Observed Theraphy Short-course). • In 2006 TuberculosisControlProgrammewasintegratedtoprimaryhealthcaresystemandDOTs is expanded in Turkey.

  37. DOT DOT • DOT can leadtoreductions in relapseandacquireddrugresistance

  38. Tuberculosis Prevention and Control Program in Turkey • Mainstrategiesinclude: • BCG vaccination • Casefinding • Effectivechemotheraphy • Healtheducation • Chemoprophylaxis • Monitoringandevaluationsystem

  39. BCG vaccination BCG only at birth (orfirstcontact with healthservices) • This is the current recommendation of the EPI (Expanded Program on Immunization) and the Global Tuberculosis Programme and is the policy in our country. • BCG protects against serious childhood forms of Tuberculosis, such as TB meningitis and miliary TB. • Itmay not protectto a highdegreeagainstadultpulmonaryforms of thedisease.

  40. Casefinding • The aim is to reduce the transmission of TB by screening high risk populations (eg. those at an increased risk of exposure to TB infection, most notably contacts of infectious cases) and to detect and treat active disease earlier than would otherwise occur.

  41. Chemoprophylaxis • Chemoprophylaxis • Primaryprevention • Decreaseincidence rate of TB • ByusingIsoniazid (INH)

  42. Tuberculosis 1 • Tuberculosis control and elimination 2010–50: cure, care, and social development Knut Lönnroth, Kenneth G Castro, Jeremiah MuhwaChakaya, Lakhbir Singh Chauhan, Katherine Floyd, Philippe Glaziou, Mario C Raviglione

  43. Challenges to “elimination” • Commitment by governments and stakeholders fluctuating • Funding not secure; catastrophic costs for the poor un-resolved • Only 2/3 of estimated cases reported or detected • TB/HIV major impact in Africa • MDR-TB, with high burden in former USSR , China etc • Un-engaged non-state practitioners • Social and economic determinants maintaining TB • Research in need of intensification and investments

  44. 1- Lack of commitment

  45. 2- Funding Funding gap vs Global Plan ~ US$2–3 billion per year Funding gaps reported by countries US$0.7 billion in 2013 US billions dollars 2013 2014 2015

  46. 3- The case detection/notification gap • Global notifications Estimated incidence • 3: The case detection/notification gap Nearly 3 million TB cases either not notified or not detected 8.7 7.8 TB cases (millions) 5.8 3.7 1990 2000 2010

  47. GeneXpert 85 countries using it by mid-2013

  48. 4- Responding to the TB/HIV epidemic The WHO policy on collaborative TB/HIV activities

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