LIGUE PULMONAIRE SUISSE 20th Tuberculosis Symposium, Münchenwiler – 2010

Fighting TB over the last 20 years: did we fail?

No, probably not….

Paul Nunn, WHO, Geneva

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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"Fighting TB" and "Failure" What were we trying to achieve in 1991? Save lives Prevent drug resistance Reduce the size of the problem

Failure "Non-performance"; "Want of success"

(Shorter Oxford English Dictionary, 1973)

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Targets

"70% sputum smear positive case detection and 85% cure rate among those detected " (WHO –2000, postponed to 2005)

Millennium Development Goals: Reduce incidence by 2015

Stop TB Partnership goals: Halving mortality and prevalence by 2015

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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TB Control Efforts Are Saving Lives by More Prompt and More Effective Treatment

5

Estimated number of lives saved annually (in millions), 1996-2009,and projections for 2010-2015

Source: WHO

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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" Between 1995 and 2009, a total of 41 million TB patients were successfully treated in DOTS programmes, and up to 6 million lives were saved including 2 million women and children"

WHO, Global Control Report, 2010

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Factors of success

DOTS and its single-minded dissemination Early focus on bacteriological

diagnosis, reliable drug supplies, direct observation of treatment, outcome evaluation of every single patient Later focus on HIV-associated

TB

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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History of the Global Project on anti-TB drug resistance surveillance

2009

1st ed. DRS guidelines

Global Project launched

SRLN launched

2nd ed. DRS guidelines

1st global DRS report

2nd global DRS report

3rd ed. DRS guidelines

3rd global DRS report

4th global DRS report

4th ed. DRS guidelines

M/XDR-TB report

2003 20081994 1997 2000 2004 2010

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Estimated MDR-TB incidence rate, 2008

MDR‐TB cases emerging annually, per 100,000 populationAfrican countries with 

estimated MDR‐TB incidence rates ≥ 15 MDR‐TB cases per 100,000 populationBotswana: 27 / 100,000South Africa: 26 / 100,000Swaziland: 23 / 100,000Zimbabwe: 19 / 100,000Namibia: 17 / 100,000Rwanda: 16 / 100,000Mozambique: 16 / 100,000

India: 8 / 100,000

Selected countries of the former Soviet Union:Tajikistan: 59 / 100,000Kazakhstan: 57 / 100,000Russia: 27 / 100,000Estonia: 7 / 100,000

China: 7 / 100,000

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Trends of MDR-TB cases in selected settings

China, Hong Kong

SAR

Australia

United Statesof America

All TB cases (new & relapses)

2,000

4,000

6,000

8,000

10,000

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

0

1

2

3

1995 1997 1999 2001 2003 2005 2007 2009Year

% M

DR

am

ong

new

cas

es

New MDR-TB cases

0

20

40

60

80

100

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

All TB cases (new & relapses)

5,000

10,000

15,000

20,000

25,000

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

0

1

2

3

1995 1997 1999 2001 2003 2005 2007 2009Year

% M

DR

am

ong

com

bine

d ca

ses

Combined MDR-TB cases

0

100

200

300

400

500

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

All TB cases (new & relapses)

0

500

1,000

1,500

2,000

2,500

3,000

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

0

1

2

3

1995 1997 1999 2001 2003 2005 2007 2009Year

% M

DR

am

ong

com

bine

d ca

ses

Combined MDR-TB cases

0

10

20

30

40

50

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Trends of MDR-TB cases in selected settings

Estonia

Lithuania

Latvia

All TB cases (new & relapses)

0

200

400

600

800

1,000

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

0

5

10

15

20

25

1995 1997 1999 2001 2003 2005 2007 2009Year

% M

DR

am

ong

new

cas

es

New MDR-TB cases

0

20

40

60

80

100

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

All TB cases (new & relapses)

0

500

1,000

1,500

2,000

2,500

3,000

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

0

5

10

15

20

25

1995 1997 1999 2001 2003 2005 2007 2009Year

% M

DR

am

ong

new

cas

es

New MDR-TB cases

0

50

100

150

200

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

All TB cases (new & relapses)

0

500

1,000

1,500

2,000

2,500

3,000

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

0

5

10

15

20

25

1995 1997 1999 2001 2003 2005 2007 2009Year

% M

DR

am

ong

new

cas

es

New MDR-TB cases

0

50

100

150

200

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Trends of MDR-TB cases in selected settings

Botswana

Tomsk Oblast, Russian FederationAll TB cases (new & relapses)

0

200

400

600

800

1,000

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

0

5

10

15

20

25

1995 1997 1999 2001 2003 2005 2007 2009Year

% M

DR

am

ong

new

cas

es

New MDR-TB cases

0

20

40

60

80

100

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

All TB cases (new & relapses)

0

3,000

6,000

9,000

12,000

15,000

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

0

1

2

3

4

1995 1997 1999 2001 2003 2005 2007 2009Year

% M

DR

am

ong

new

cas

es

New MDR-TB cases

0

10

20

30

40

50

1995 1997 1999 2001 2003 2005 2007 2009Year

Cas

es n

otifie

d

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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68 countries reported at least one XDR-TB case by end 2010

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 2011. All rights reserved

Argentina Bhutan France Kazakhstan Nepal Republic of Moldova TogoArmenia Cambodia Georgia Kenya Netherlands Romania TunisiaAustralia Canada Germany Kyrgyzstan Norway Russian Federation UkraineAustria Chile Greece Latvia Pakistan Slovenia United Arab EmiratesAzerbaijan China India Lesotho Peru South Africa United KingdomBangladesh Colombia Iran (Islamic Rep. of) Lithuania Philippines Spain United States of AmericaBelgium Czech Republic Ireland Mexico Poland Swaziland UzbekistanBotswana Ecuador Israel Mozambique Portugal Sweden Viet NamBrazil Egypt Italy Myanmar Qatar TajikistanBurkina Faso Estonia Japan Namibia Republic of Korea Thailand

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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0

2000

4000

6000

8000

10000

12000

2003 2004 2005 2006 2007 2008 2009 2010

Year

Green Light Committee annual enrolment

Expected enrolment

Reported enrolment

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Preventing drug resistance Verdict – Probably failing Reasons for failure: Insufficient quality of basic TB care Management of MDR-TB is difficult, complex, &

expensive DOTS obsession, started management of MDR-TB

too late? Diagnostic tools too slow, until just now Private sector creating it Nosocomial transmission

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No TB control programme can treat MDR-TB as fast as a bad programme can create it

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Reducing the size of the problem…

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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…even in the presence of HIV

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Progress towards Millennium Development Goals - India

586

185293

0

200

400

600

800

1990 2007 2015 (MDG-Target)

Cas

es p

er 1

00,0

00 p

opul

atio

n

42

24 21

0

20

40

60

1990 2007 2015 (MDG-Target)

Cas

es p

er 1

00,0

00 p

opul

atio

n

68%44%

Prevalence rate of TB

Mortality rate of TB

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Progress of implementation of TB/HIV collaborative activities 2003-2009

-200,000400,000600,000800,000

1,000,0001,200,0001,400,0001,600,0001,800,0002,000,000

Teste

d for

HIVHIV-po

sitive CPT

ARTScre

ened

for T

BDiag

nose

d with

TB

TB on ART r

egiste

r IPT

2003200420052006200720082009

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Reasons for success in reducing the size of the problem

Standardised approach, even with Stop TB strategy

Expanding the partners addressing TB (Amsterdam Ministerial meeting, and Cairo, DOTS expansion meeting, 2000)

Increased technical assistance

Increased funding – Global Fund for AIDS TB and Malaria

Political response in big countries

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Annualised New S+ve CDR Success rate

•Population projected from 2001 census•Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)

New Smear-Positive Case Detection Rate and Treatment Success Rate in DOTS Areas, India, 2000-2009*

87%

72%

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Targets "70% sputum smear

positive case detection and 85% cure rate among those detected " (WHO –2000, postponed to 2005)

Millennium Development Goals: Reduce incidence by 2015

Stop TB Partnership goals: Halving mortality and

prevalence by 2015

Case detection – failed (63% in 2008)

Cure rate – succeeded (86% in 2008)

MDG – succeeded 2004 (assuming no reversal before 2015)

Likely success – except Africa (HIV) and Europe (MDR), and non-responsive governments in both

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Conclusions Tremendous progress over the past several decades Must do better with current tools, eg faster diagnosis

(expand Xpert) and ARVs Need new tools and strategies to control TB – most of

the “easy work” has already been done – drugs and vaccines in the pipeline

Core business + Health sector policies + research + determinants

More attention to the human behavioural aspects of managing TB control: persistence, patient-centeredness, zealous adherence to technical rigour and programmeexcellence

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20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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Acknowledgements

Dennis Falzon Katherine Floyd Haileyesus Getahun Philippe Glaziou Wieslaw Jakubowiak Mario Raviglione Suvanand Sahu Matteo Zignol

20th Swiss TB-Symposium in Münchenwiler 24.03.2011 Dr. Paul P. Nunn, Stop TB Department, WHO Geneva

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