Dr Ral Antic Chair, Scientific Committee IUATLD-APR Australia Tuberculosis Control in the Asia...

Dr Ral AnticChair, Scientific Committee IUATLD-APR

Australia

Tuberculosis Control in the Asia Pacific Region

Achievements, Deficiencies & Future Directions

The 1st Asian Pacific Regional Conference 2007, IUATLD -

APR

‘OVERCOMING AN OLD SCOURGE WITH A NEW FACE’

The 1st Asian Pacific Regional Conference 2007, IUATLD - APR

‘OVERCOMING AN OLD SCOURGE WITH A NEW FACE’

We could have (& have) been discussing, in this context

• Tuberculosis• COPD• Asthma• Sleep Disorders ……. & others

Achievements in the last decade

What is different in the handling of these various disorders is

• The extent of the global and regional strategic planning for TB

• The structured multi-faceted public health approach as

we have discussed

• That we are driving the ‘change agenda’ working back from defined targets and outcomes

Achievements and Deficiencies

in TBGlobal, Regional & Country

• What are we trying to achieve?• Are our Directions and Targets right and

achievable• Do we have the ‘capacity’ to achieve the

Vision, Goals and Targets we have set?

Achievements in TB in the last decade

• The provision of effective Global, Regional and Country Leadership

• A sustained focus on development and updating of a Global and Regional Strategic Direction

• Its implementation in a strategic fashion • Improvement in case detection and

treatment• Infrastructure building• Better Surveillance and Quality monitoring


Global, Regional & Country

• In the last decade, we have appropriately changed direction

• But with the current tools, change is understandably slow.

• And this leaves us to wonder whether we are doing a good job.


Global, Regional & Country

• What is the burden of ill-health from TB ?

The Global TB Epidemic ‘Global TB Control’ , WHO Report 2007

• TB is still a major cause of death worldwide, but the global epidemic is on the threshold of decline

• TB prevalence and death rates have probably been falling globally for several years

• But the total number of new TB cases is still rising slowly, as the population grows and the case-load continues to grow in the African, Eastern Mediterranean and SEA Regions

Estimated Burden from TB and Trends Western Pacific Region

• Estimated 4 million cases of TB in WPR– 2 million new cases

• Seven high burden countries account for >95% – Cambodia, China, Lao PDR, Mongolia, PNG,

Philippines & Vietnam

Stop TB Partnership Targets

By 2005: At least 70% of people with sputum smear-positive TB will be diagnosed (i.e. under the DOTS strategy), and at least 85% cured

By 2015: The global burden of TB (per capita prevalence and death rates) will be reduced by 50% relative to 1990 levels

By 2050: The global incidence of active TB will be less than 1 case per million population/year

WP Regional Goals & TargetsRegional Committee WPR, 2000

Goal: • Reduce TB prevalence and mortality by

50% in 2010 compared with 2000

Intermediate Targets (towards this goal):

1. Detect 70% of estimated active cases2. Treat successfully 85% of these cases3. 100% DOTS coverage

What we have achieved in WPR

WPR achieved these intermediate targets in 2005.

Also– 26 countries globally have achieved targets -

including China, the Philippines, Vietnam– Targets were missed narrowly Globally:

• case detection - 60%• treatment success - 84%

– Treatment success in the SEA Region > 85%

MDR-TB and XDR-TB ‘The Global MDR-TB and XDR-TB Response Plan 2007-2008’

WHO Report 2007

• > 400 000 new cases of MDR-TB every year • due to under investment in basic TB control, poor

management of anti-TB drugs and transmission of drug-resistant strains.

• MDR-TB is much more difficult and costly to treat than drug susceptible TB

• recent work has shown that it is feasible and cost-

effective to treat even in settings of limited resources.


WHO Report 2007

• Emerging XDR-TB

• The economic, social and health security of countries and communities with a high prevalence of TB threatened by it

• It is virtually untreatable TB among the bread-winners, parents and economically productive age groups.


WHO Report 2007

• Strengthening the coverage and quality of basic TB control is the first and most important measure to prevent MDR-TB and is the fundamental platform for deploying management of drug resistant TB

• Treat 1.6 rather than 0.8 million in 2008 with MDR-TB and save 134000 lives

• More costly >US$ 2.1B extra

Case Detection in WPR

• From < 40% to >70% overall in 5 years• Achieved by:

– Developing a strategic approach, The Global Plan to Stop TB

– Strengthening political commitment– Accelerating DOTS expansion in public facilities– Higher case detection success in many countries – TB care more available and accessible – Improving collaboration of health care providers

– Increase in financing and other resources

TB Performance Indicators in the Western Pacific Region, 2004

“Strategic Plan to Stop TB in the Western Pacific 2006 – 2010”

Prevalance Rate (/105)

Case detection SS+ (%)

Treatment Success (%)

Mortality Rate (/105)

Australia 6 56 95 1

Cambodia 709 61 93 94

China 221 65 94 17

Hong Kong 77 72 78 6

Japan 39 62 76 4

Lao PDR 318 55 79 25

Malaysia 133 69 72 16

Mongolia 209 80 87 24

New Zealand 11 59 36 1

Papua New Guinea 448 31 58 42

Philippines 463 73 88 48

Republic of Korea 125 59 82 10

Singapore 41 67 77 4

Vietnam 232 89 92 22

TB Performance Indicators in the South East Asia Region, 2004

“National Tuberculosis Control Programs South East Asia Region”





Indonesia 262 66 90 41

Thailand 218 73 74 20

Some future barriers to TB Control

• Poverty, Housing, Social disruption• The under-diagnosis of TB • Perceived complexity of the public health

systems we are promoting• Natural progression of resistance in drugs• The benefits and risks of having joint

project eg malaria, smoking cessation, HIV-TB

Towards the Goals and Targets

Although the TB burden may be falling globally, the decline is not fast enough to meet the impact targets

“Strategic Plan to Stop TB in the Western Pacific 2006 –

2010”

Estimated Trends Western Pacific Region

• A decline of 15% in prevalence & 12% in mortality between 2000-2004– Annual average of 4% and 3% respectively

Will achieving WHO targets reduce the notification rate?

The barriers – Spread of HIV– Accumulation of MDR-TB cases – Insufficient access to high quality TB care for the poor

and vulnerable populations and in private sector– Lack of national guidelines & training materials– Lack of human resources and their development

AND/OR– the rising numbers and urbanisation of the population– Estimated targets and actual incidence need discussion

3 main areas of concern

• The current level of 70% detection will not be sufficient

• MDR-TB and TB-HIV co-infection will slow the annual decline

• Conventional DOTS service delivery does not guarantee equitable access to TB Services

The current position

A new ‘Strategic Plan to Stop TB in the Western Pacific 2006-2010’ has been developed to achieve the new targets.

The new Strategic Plan for WPR 2006-2010

• To achieve the 50% reduction in prevalence & death rates, an 8% annual decline is needed

• The current annual decline is 3-4%• There thus needs to be a change in

approach• This is the basis of the strengthened effort

defined in the new Strategic Plan

TB (all case) notification and death rates per 100,000 in South Australia

1900 and 2006

0

20

40

60

80

100

120

140

160

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

Year

No

tifi

cati

on

Rat

e/10

0,00

0 Death Rate

Notification Rate

The National TB

Campaign

improved

socioeconomic

conditions

14%

10%

8%

3% decline

4%

The National TB Campaign Australia, 1948-1975

• National Leadership (NTP)• Commitment from

– National & State Govt• Funding• Legislative muscle –

mandatory participation

– The Health Professions– The community,

because of• community concern • promotion of TB the

disease and of the TB Campaign

• Financial incentives for patients with active disease to adhere to treatment

• A new Strategic Direction & sound systems, infrastructure– Adequate funding – Effective system of care

• active disease and infection case finding, new drugs, centralised treatment

– Adequate laboratory services– DOT?– Free drug supplies– Appropriate monitoring

systems, for individual care and Program

• No public/private mix, MDR-TB, HIV issues, but migration+

TB (all case) notification rate per 100,000

South Australia - 1945 to 2006 The National TB Campaign

0

10

20

30

40

50

60

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

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n R

ate

/ 1

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,00

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2

4

6

8

10

12

14

16

18

20

Death Rate Target decline rate

De

cli

ne

in

De

ath

Ra

te/

10

0,0

00

Excess cases

Target rate of decline 10% per year

TB notification rate by age, Australian-Born South Australians between 1987 -

2006

0<14 15<24 25<34 35<44 45<54 55<64 > 65

1987-19911992-1996

1997-2001

2002-2006

0

1

2

3

4

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6

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8

9

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Age

Elimination of TB as a public health problem

Elimination of TB as a public health problemVISIONVISION

To reduce prevalence and mortality from all forms of TB by one half by 2010 relative to 2000,

contributing to the achievement of the Millennium Development Goals

To reduce prevalence and mortality from all forms of TB by one half by 2010 relative to 2000,

contributing to the achievement of the Millennium Development Goals

GOALGOAL

Framework of the Strategic Plan to Stop TB in the Western Pacific 2006 -

2010

1.To sustainand optimizethe quality ofDOTS and gobeyond the

‘70/85’ targetsCase detection rate

(beyond 70%)Cure rate

(beyond 85%)

2. To ensureequitableaccess to

highquality TBcare for allpeople with

TBProportion of

Facilities (includeprivate or general

hospitals) providing

or referring to DOTS

(at least 90%)

3. To adaptDOTS to

respond to MDR

TB and TB-HIVco infectionProportion of

identified MDR-TBcases by DST

provided with 2nd line

treatment (at least 90%)Proportion ofidentified HIV

positive TB, eligiblefor ART, that are

provided with ART(at least 90%)

OBJECTIVESOBJECTIVES

CORE TARGETS

Beyond 70% CDR

At least 90%DOTS-Plus Treatment

coverage of MDR-TB

At least 90% ART coverage

of HIV positive TBAt least 90%

PPMD coverage


2010


2010 Country capacity quality of diagnosis for TB assured (i.e. smear microscopy, culture, chest X-

ray)At least 90%

laboratory units with satisfactory performance Uninterrupted supply

of quality-assured anti-TB drugs at all

DOTS units100% of treatment units

with uninterrupted supply

of drugs in a given yearEnhanced casemanagement for all

registered TB cases,

including smearnegative TBAll HBC have

developedguidelines for

diagnosis& treatment of smear

negative TB e.g. children

Increased utilization of TB

services by poor &vulnerable populations

At least 10% of cases notifiedunder pro-poor TB initiatives

Improved TB casemanagement in non-

NTP TB facilitiesAt least 85% cure rate ofTB cases managed by non-

NTP facilities

Adoption of theInternational Standards

ofTB Care & the Patients

Charter for TB CareAll countries have introduced

the above standards

Country-driven advocacy,

communications & social

mobilisation strategiesdeveloped & implemented

All HBC are implementingACSM strategies for TB

controlon a national scale

DOTS-Plus initiated/scaled up

in targeted countriesAt least 6 have initiated/scaled

upDOTS-Plus. At least 10%0f failure

cases tested by DSTTB-HIV framework forcollaboration developed &

implementedAll targeted countries are

implementing TB-HIV surveillance

Access of TB patients to HIV

Services At least 70% of TB patients

testedfor HIV in Category 1 and 2

countries/areas. At least 70% of

newly diagnosed patients with HIV

tested for TB

EXPECTED

RESULTS

Assessment of MDR-TBin targeted countries

All targeted countriesHave assessed their MDR-TB

situation through drug resistance

surveillance

Components of the Strategic Plan & Implementation approaches

1. Pursue high quality DOTS expansion & enhancementa. Political commitment with increased &

sustained financing b. Case detection through quality assured

bacteriologyc. Standardised treatment with supervision &

patient supportd. An effective drug supply & management systeme. Monitoring & evaluation system & impact

measurement


2. Address TB-HIV, MDR-TB & other challengesa. Implement collaborative TB-HIV activitiesb. Prevent & control MDR-TBc. Address prisoners, refugees & other high-risk groups

3. Contribute to health system strengtheninga. Actively participate in efforts to improve policy, human

resources, financing, management service delivery & information systems

b. Share innovations, including the Practical Approach to Lung Health (PAL)

c. Adapt innovations from other fields


4. Engage all care providersa. Public-Public & Public-Private Mix approaches b. International Standards for TB Care (ISTC)

5. Empower people with TB & communitiesa. Advocacy, communications & social mobilisationb. Community participation in TB carec. Patients Charter for TB Care

6. Enable & promote researcha. Program- based operational researchb. Research to develop new drugs, vaccines &

diagnostics

ACTIVITIES

Activities directed at producing expected results are to be implemented at inter-country, regional and country levels:

- Inter-country and regional activities are in the WHO plans of action

- Country level activities are in the National TB Control Plans 2006-2010


2010

1. Ensured availability of essential staff required for TB control90% of key positions required for TB control filled by trained staff2. Sufficient financing for TB control ensuredAll HBC develop annual funding plan for NTP that incorporates all financial inputs

and funding gaps3. Evidence-based policy and implementation strategy development through operations research (e.g. PAL, information system, child TB, and new diagnostic modalities)

CROSS-CUTTING ISSUES

Estimated TB incidence rate, 2005

No estimate

0-24

50-99

100-299

300 or more

25-49

Estimated new TB cases (all forms) per 100 000 population

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

What have we learned from the presentations?

• The current burden of disease remains large

• There are important Regional and Country successes

• Some targets are being achieved but • The targets and so strategic plans are needing to be revised to

achieve the primary Goal

• There are significant barriers

• Do we have systems in place to achieve these targets and overcome the barriers?

What else can/should we need to do?

• What more should we (jointly) do – as the Union, the APR IUATLD, WHO, APSR & the many other organizations and as individuals?

• What is the real view of our Communities and Governments about TB - what is the image of TB?

• What can this and our future Conferences and its participants contribute to furthering the objectives of the Region?

• What are the special skills and the special ‘Capital’ that the attendees and their organisations bring?

The Future Direction

• The vision ‘The elimination of TB’ is right• The objectives are right.• It needs global and local leadership• It needs the proper application of our knowledge• The resolve must be strengthened• All cases have to be found and treated• New drugs must be found• More resources are needed• TB can be eliminated.

It can be and

it has to be done

My Thanks

To:The Congress PresidentThe SecretariatThe Chair of the Organizing Committee The Chair of the Organizing Scientific

CommitteeThe Speakers

and …. to all of you who have attended and participated

Dr Ral AnticChair, Scientific Committee IUATLD-APR

Australia

Tuberculosis Control in the Asia Pacific Region

Achievements, Deficiencies & Future Directions

What is the role of APR IUATLD?

• Workforce• Training• Advocacy• Service provision

What is the APR IUATLD

• The Asian Pacific Region of the UNION• In 2006, the Eastern Region IUATLD was

divided into 2 new Regions, the South East Asian and Asian Pacific

• The aim was to reduce the size of the Regions to help facilitate their TB work

• There are 16 APR constituent member countries and other organisations and individuals

The different & complementary roles

• Global and regional organisations• Organisations within each country• Governments• Government and non-Government

Organisations– Different countries– Within countries

Functional relationships

• Organisations responsible for different diseases with overlapping risk factors and populations– e.g. malaria, TB, AIDS

The challenges and barriers 1• The Private Sector

– NTP does not cover private sectors. Detailed information on case-finding activities & treatment outcomes are not known yet. The pilot project of Private-public mix (PPM) just started this year on a small scale with collaboration from some of university hospitals

– NTP has a plan to make guidelines for PPM – The issues and challenges relate to improving the

quality of reporting and treatment activities within the private sector

• How to increase the level of access of illegal foreign workers to medical facilities

• Case Finding and associated delays• How to strengthen the capabilities of health workers

in conducting contact investigation of TB outbreaks

The barriers 1

• Laboratories• Challenge is to integrate commercial laboratories into

the laboratory network of NTP and to expand quality assurance system

• Coordination & collaboration between TB, HIV, Malaria programs

• High burden and mortality of HIV among TB patients and TB among HIV-infected persons, and the high mortality rate of TB/HIV patients, successful TB/HIV collaboration is essential.

• The political commitment has been critical for initiating the collaboration between programs

• The support from technical and financial partners has facilitated the implementation of the collaborative activities

The barriers 2

• This largely entails the sustenance of quality D.O.T.S. implementation and undertaking this in the context of health sector reforms and globalization. DOTS and DOTS beyond is our way forward. (Phil)

• The challenges including: ( chin)– Migrants, MDR-TB, TB/HIV– Quality of DOTS implementation to be improved– Mechanism to ensure sustainability– Inadequate human resource– Adequacy of infrastructure– Adequate funding of Programs– Surveillance– Health promotion– Strengthen human resource development– Lack of resources to tackle new challenges

Future Directions

The global community needs to continue to take responsibility and make world-wide

TB control a high priority

Strategic Plan to Stop TB in the Western Pacific 2006-2010

• A Road Map– Ensure quality of TB Services– Respond to challenge of rising MDRTB, TB-HIV

co-infection– Increasing case detection rate– To get public and private health sector

involved in TB control– Increasing funding and regional and country

level

• Prisons• Correctional institutions• Social sponsored centers• Development of a TB like Unit• Cooperation and coordination of NTP,

NTP/HIV, Ministry of Health, Ministry of Labor, War Invalids and Social Welfare and Ministry of Public Security

• Sustain political interest, training guidelines, advocacy and incentives, monitoring and supervision

Financing TB ControlAlthough the funds available for TB control have increased

enormouslysince 2002 ($2.0 billion US in 2007). Interventions on the scalerequired by the Global Plan to Stop TB would cost an extra

$1.1 billionUS in 2007

• The Global Plan is more costly than country budgets primarily because it anticipates greater TB/HIV requirements:– management, advocacy, communication & social mobilisation,

especially in the African and South-East Asia regions• Greater expenditure was associated with improved case-finding in

Bangladesh, China, Congo, India, Indonesia, Kenya, Myanmar & Nigeria

• There was no systematic relationship between incremental expenditure and improved case detection across all HBCs

• The relationship between spending and case-finding needs to be investigated and understood country by country.

DOTS and the Stop TB Strategy

• Most government health services now recognise that TB control must go beyond DOTS, but the broader Stop TB

• Strategy is not yet fully operational in most countries

Future Directions• Countries and regions are more likely to reach

these targets if they can increase budgets and step up activities in line with the Global Plan.

• Procedures for collecting financial and epidemiological data, and other information about programme performance, must be systematically improved.

• Surveillance and monitoring, and well-designed surveys, are a prerequisite for the accurate evaluation of progress in TB control.

The STOP TB STRATEGY

The Objectives• To achieve universal access to high quality

diagnosis and patient centered treatment

• To reduce the suffering and socioeconomic burden associated with TB

• To protect poor and vulnerable populations from TB, TB-HIV and MDR-TB

• To support development of new tools and enable their timely and effective use

HIV-TB IN THE WESTERN PACIFIC REGION PROGRESS OF TB/HIV COINFECTION CONTROL IN CHINA

DR. PHILIPPE GLAZIOUY.J.LAI*, S.W.JIANG*,W.B. YU**, L.ZHOU*,

*National Center for TB Control and Prevention, China CDC, China**Tuberculosis Office of China Global Fund Program

To address high case fatality rates, it is necessary

to rapidly step-up the implementation of;• provider-initiated HIV testing • systematic detection of TB in HIV-infected

individuals including diagnosis of the smear negative forms of TB

• infection control in AIDS care settings • adequate treatment and support of dually

infected individuals, including anti-retroviral therapy during the course of TB treatment

LATENT TB INFECTION IN HIV: TO TREAT OR NOT TO TREAT ?

NITIPATANA CHIERAKUL

• Early benefit but long term protection is uncertain

AGING OF TB EPIDEMIC, CASE OF JAPANDR. TAKASHI YOSHIYAMA

• As community wide burden is reduced, the high prevalence in the aged becomes more noticeable

• The previously infected population is living longer• In countries where transmission of infection has

been low, the numbers in the aged population is falling.

• The case fatality rate of older tuberculosis cases is high and WHO target of 85% treatment success is difficult to achieve

TRADITIONAL AND NOVEL DIAGNOSTIC TESTS FOR TB INFECTION

TORU MORI

• TST opened the way to the modern epidemiology of TB decades ago.

• The diagnosis TB infection is important both in high and low-prevalence settings for epidemiological surveillance and research, indication for treatment of latent TB infection, an adjunct for diagnosis of active TB, etc.

• The new technology, Interferon-gamma release assay (IGRA), has been tested extensively, and it seems that it is practically as sensitive as TST and far exceeds its specificity. Other aspects of its performance, including influence of immunocompromizing factors, effects of treatment (both in active disease and latent TB infection), and cost-effectiveness have gradually been clarified.

MDR-TB: DISEASE IN THE WPRDR. PHILIPPE GLAZIOUDRUG

SUSCEPTIBILITY TESTS FOR FIRST & SECOND LINE DRUGS IN DIAGNOSIS OF MDR & XDR TUBERCULOSIS

DR CAMILLA RODRIGUES, MD NEW DRUGS AND DRUG REGIMENS IN THE TREATMENT OF CHRONIC AND MDR-TB

W.W. Yew

• Posing a threat to TB Control in several countries in WPR

• Special programs may be required to reduce its increasing prevalence– Improved interventions under DOTS– Programmatic management MDR-TB– urgent need to strengthen capacity for prompt and accurate

laboratory based diagnosis of tuberculosis and detection of drug resistance

– strengthening of DOTS and DOTS-Plus programmes, infection control, and information sharing to enable local and global control

– Development of new drugs is a mandatory focus of activity too.

THE SINGAPORE TB ELIMINATION PROGRAMME (STEP)DR CYNTHIA CHEE

• Reduction in prevalence via STEP program

TB-HIV TREATMENT IN A PRISON SETTINGDR. BENEDICT SIM LIM HENG

TUBERCULOSIS (TB)- HUMAN IMMUNODEFICIENCY VIRUS (HIV) SCREENING PROGRAMME IN CLOSED SETTINGS

B. VENUGOPALAN (MPH)Disease Control Unit, Selangor State Health Department, Ministry of Health,

Malaysia.

• Many barriers to TB control, institutional, high burden of TB/HIV on entry, staff morale, drug availability and delivery etc

• In 1993, WHO presented their guidelines on HIV infection and AIDS in prisons and the 1st guiding principle in that article quoted was that “All prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community without discrimination, in particular with respect to their legal status or nationality.”

• Changes in policy, attitudes and resources needed

What are we trying to achieve?

• Millennium Development Goals• Stop TB Partnership targets

Dr Ral AnticChair Scientific Committee IUATLD-APR

Australia

Pre-Conference Workshop 1

National TB Control Program

Summary & Remarks

TB Control in WPR-current state

1. We have heard reports from a mix of High, Intermediate and Low burden countries

2. Significant improvements in reported results3. WHO targets are reported to be overall being met4. Yet ongoing burden of disease is often reported as

high and trend of morbidity and mortality is ‘stagnant’

• Ageing population and access to illegal migrants• HIV-TB co-infection• MDR-TB levels rising in some countries• The performance of the private sector and general

hospitals is variable• Concern re care in the poor and vulnerable populations• Health sector infrastructure variable especially in

districts• Funding and health workforce, although improved

remains an issue

TB Performance Indicators in the Western Pacific Region, 2004

“Strategic Plan to Stop TB in the Western Pacific 2006 – 2010”





Australia 6 56 95 1

Cambodia 709 61 93 94

China 221 65 94 17

Hong Kong 77 72 78 6

Japan 39 62 76 4

Lao PDR 318 55 79 25

Malaysia 133 69 72 16

Mongolia 209 80 87 24

New Zealand 11 59 36 1

Papua New Guinea 448 31 58 42

Philippines 463 73 88 48

Republic of Korea 125 59 82 10

Singapore 41 67 77 4

Vietnam 232 89 92 22

TB Performance Indicators in the South East Asia Region, 2004

“National Tuberculosis Control Programs South East Asia Region”





Indonesia 262 66 90 41

Thailand 218 73 74 20

Estimated WPR Burden from TB and Trends

• Estimated 4 million cases of TB in WPR– 2 million new cases

• Seven high burden countries account for >95% – Cambodia, China, Lao PDR, Mongolia, PNG,

Philippines & Vietnam

• A decline of 15% in prevalence & 12% in mortality between 2000-2004– Annual average of 4% and 3% respectively

ACHIEVEMENTS

• In Leadership terms• In Strategic Planning• Implementation Strategy• Activities• Infrastructure building• Surveillance and Quality monitoring

Incentives

Direct• To the health care providers• To the person with TB• To the community

Indirect?

WP Regional Goals & TargetsRegional Committee WPR, 2000

Goal: • Reduce TB prevalence and mortality by

50% in 2010 compared with 2000

Intermediate Targets (towards this goal):

1. Detect 70% of estimated active cases2. Treat successfully 85% of these cases3. 100% DOTS coverage

Case Detection in WPR

• From < 40% to >70% overall in 5 years• Achieved by:

– Developing a strategic approach, The Global Plan to Stop TB

– Strengthening political commitment– Accelerating DOTS expansion in public facilities– Higher case detection success in many countries – TB care more available and accessible – Improving collaboration of health providers

– Increase in financing and other resources

Treatment Success

• Overall the percentage of registered new TB patients completing anti TB treatment > 85% for last 10 years

• 5 of the 7 high burden of TB countries are achieving this target

Estimated numbers of new cases, 2005

No estimate

0-999

10 000-99 999

100 000- 999 999

1 000 000 or more

1000-9999

Estimated number of new TB cases (all forms)




The barriers – Spread of HIV– Accumulation of MDR-TB cases – Insufficient access to high quality TB care for the poor

and vulnerable populations– Sub-optimal TB management practices in growing

private sector– Lack of National guidelines & training materials– Lack of human resources and their development

AND/OR– the rising population numbers– Incorrect targets for the desired outcome

Future Directions• The current level of detection of 70% will not be sufficient

– Enhancing active case finding approaches– Enhancing lab capacity– New diagnostic tools– Sustaining established mechanisms - e.g. monitoring and

supervision of DOTS implementation


• Conventional DOTS service delivery does not guarantee equitable access to TB Services– In some countries, the same standards of care received

through NTP service delivery are not met by general hospitals, private providers, and for the homeless, drug users, migrants & prisoners

What have we learned from these presentations?

• The current burden of disease remains large• There are important Regional and Country

successes• Some targets are being achieved but • The targets have needed to be revised to

achieve the objects• There are significant barriers• Do we have systems in place to achieve

these targets?

Dr Ral AnticChair Scientific Committee IUATLD-APR

Australia

Pre-Conference Workshop 1

National TB Control Program Concluding remarks for the Workshop

Barriers to success

• Rising MDR-TB• Rising TB & HIV Co-infection• Access to poor & vulnerable populations

– Prisons,homeless

• Aging population• Suboptimal health infrastructure

– Lack of health workers– Suboptimal laboratory facilities

‘Programmatic’ factors

1. Accessibility of treatment services2. Awareness of TB in the community3. Uninterrupted supply of effective TB

drugs4. Treatment adherence through DOTS


The barriers – Spread of HIV– Accumulation of MDR-TB cases – Insufficient access to high quality TB care for

the poor and vulnerable populations and private sector

– Lack of National guidelines & training materials– Lack of human resources and their development

AND/OR– the rising population numbers– Incorrect targets for the desired outcome

The 3 main areas to be addressed

• The current level of 70% detection will not be sufficient


• Conventional DOTS service delivery does not guarantee equitable access to TB Services

The new Strategic Plan for WPR 2006-2010

• To achieve the 50% reduction in prevalence & death, an 8% annual decline is needed

• The current annual decline is 3%• There thus needs to be a change in

approach• This is the basis of the strengthened effort

defined in the new Strategic Plan

Reasons for significant improvements in TB Control

• The rapid expansion of DOTS after WHO declared a global TB crisis in 1993

• Higher case detection and treatment success in many countries

• The Stop TB Partnership, est in 2000, • The Global Plans to Stop TB • The significant increase in resources for TB• TB care more available and accessible

Will achieving WHO targets improve notification rate?

The barriers • Spread of HIV• Accumulation of MDR-TB cases • Insufficient access to high quality TB care for

the poor and vulnerable populations• Sub-optimal TB management practices in

growing private sector• Lack of National guidelines & training materials• Lack of human resources and their

development

No report

0-24

25-49

50-99

100 or more



Notified TB cases (new and relapse) per 100 000 population

Tuberculosis notification rates, 2005

TB Notification rate by population group for South Australia, 2006

0<14 15<2425<34

35<4445<54

55<64>65

Overseas Born

Australian Born

Indigenous

0

5

10

15

20

25

30

35

No

tifi

cati

on

Rat

e/10

0,00

0

Age

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