Progress towards global targets for TB control

Katherine FloydStop TB DepartmentWorld Health Organization

IUATLD conferenceStop TB SymposiumCancun, 3 December 2009

To be published on 8 December

1. The global burden of TB (2008) and global targets for TB control

2. Progress towards global targets Treatment success and case detection TB/HIV and MDR-TB Financing Disease burden – incidence, prevalence, mortality

3. Summary

Overview

1. The global burden of TB and global targets for TB control

Estimated number of

cases

Estimated number of

deaths

1.3 million*(range, 1.1–1.7 million)

9.4 million(range, 8.9–9.9 million)

0.5 million

All forms of TB

Multidrug-resistant TB (MDR-TB)

HIV-associated TB 1.4 million (15%) (range, 1.3–1.6 million)

0.52 million(range, 0.45–0.62 million)

The global burden of TB in 2008

*excluding deaths among HIV+ people

Most cases still in Asia

South-East Asia

34%

Africa31%

Western Pacific

20%

EMR7%

Europe5%

Americas3%

54% cases in Asia

Highest incidence rates in Africa

Linked to high rates of HIV infection:78% of estimated HIV+ TB cases in Africa

1. Millennium Development Goals Halt and reverse incidence (MDG 6, Target 6.c)

2. Stop TB Partnership Halve 1990 prevalence and mortality rates (per 100 000

population)

Global targets for reductions in disease burden set for 2015

1. Detect 84% of smear-positive cases, and successfully treat 87% of them, by 2015

2. TB/HIV 85% TB patients tested for HIV by 2010 95% HIV+ TB patients on CPT* by 2010 320,000 HIV+ TB patients enrolled on ART* by 2010

3. MDR-TB 80% of smear and/or culture-positive cases diagnosed

and treated by 2015 (equivalent to ~400,000 cases in 2015)

4. Financing US$5–9 billion per year for TB control, 2009–2015

Major targets in the Global Plan

*CPT, cotrimoxazole preventive therapy; ART, antiretroviral therapy

2. Progress towards global targets

a) treatment success and case detection rates

Treatment success target reached globally

Succ

essf

ul tr

eatm

ent r

ate

(%)

in D

OTS

coh

orts

85

77

79

77

79

81

80

82

82

82

83

84 85

87

40

50

60

70

80

90

92 88 82 7967

88

020406080

100

W Pacific

SE Asia EMR

America

sAfri

ca

Europe

But not in the Americas, Africa and Europe

5.7 million notified casesX.X million sm+ notified cases

30405060708090

30405060708090

30405060708090

Africa-high HIV Africa-low HIV Eastern Europe

Red line: Global Plan milestones and 2015 target for CDRBlack line: actual CDR

South-East AsiaLatin AmericaEastern Mediterranean

GLOBALWestern Pacific

Case detection stagnating globally, gap with Global Plan widening

CDR stable at ~70% since 2005

2002 2008 2015

61% in 2008vs. Global Plan milestone of 71%

201520082002201520082002

Gap especially large in Africa

Cas

e de

tect

ion

rate

(%)

Three regions ahead or on track compared with Global Plan

Estimated case detection rates in 2008, by region

78 7870

6557

47

0102030405060708090

EMR = Eastern Mediterranean Region

Cas

e de

tect

ion

rate

(%)

2. Progress towards global targets

b) TB/HIV and MDR-TB

TB/HIV intervention scale-up, Africa*

Intervention, 2008 Actual Global Plan

% TB patients tested 45% 68%

% HIV+ TB on CPT 73% 90%

HIV+ TB on ART (000s) 89 279

TB patients tested for HIV HIV+ TB patients on CPT

*Africa has 78% HIV+ TB cases globally

HIV+ TB patients on ART

20

40

60

80

100

2005 2006 2007 2008

Thou

sand

s

31%

100200300400500600700

2005 2006 2007 2008

Thou

sand

s

0

40

80

120

160

200

240

2005 2006 2007 2008

Thou

sand

s

73%45%

11%

MDR-TB treatment expected to expand from currently low levels in 2009 and 2010

1923

30 2937

55

0

10

20

30

40

50

60

70

2005 2006 2007 2008 2009 2010

Num

ber o

f pat

ient

s (th

ousa

nds) non-GLC

GLC-approved

GLC = Green Light Committee

*Global MDR/XDR-TB Response Plan, 2007, updated for high-level Ministerial meeting on MDR/XDR-TB in Beijing, April 2009

But still behind Global Plan* in 27 high MDR-TB burden countries

0

50

100

150

200

250

300

350

400

2007 2008 2009 2010 2011 2012 2013 2014 2015

Num

ber o

f pat

ient

s (th

ousa

nds)

Global PlanActual or expected progress To reach

targets, scale-up required in India, China and Russian Federation in particular

2. Progress towards global targets

c) financing

Funding has increased substantially in recent years

technical assistance and R & D not includedData based on ~ 100 countries each year with ~ 94% estimated global cases

0

1

2

3

4

5

2006 2007 2008 2009 2010

US$

bill

ions

Unknown

Global Fund

Grants (excl. GF)

Loans

Government (health system)

Government (NTP budget)

2.7

4.1

But still falls short of Global Plan targets, except in E. Europe

Sources: WHO TB database, Global Plan; technical assistance and R & D not included

All regions except Eastern Europe

Data based on ~ 100 countries each year with ~ 94% estimated global cases

Eastern Europe

0

1

2

3

4

GP AF GP AF GP AF GP AF GP AF

2006 2007 2008 2009 2010

Other

TB/HIV

MDR-TB

DOTS

US$

bill

ions

0

1

2

3

4

GP AF GP AF GP AF GP AF GP AF

2006 2007 2008 2009 2010

3.8

1.7

2.7

1.3

GP = Global PlanAF = Available Funding

2.2

1.2

2. Progress towards global targets

d) impact targets for reductions in disease burden

1990 1995 2000 2005

Rat

e pe

r 100

,000

pop

ulat

ion

150

145

140

135

130

125

120

Incidence rates falling globally after peak in 2004

Peak in 2004

World as a whole on track to achieve MDG target 6.c

Number of cases in millions

02468

10

1990 1993 1996 1999 2002 2005 2008

Incidence rates in 9 subregions

Incidence falling in all sub-regions except African countries with low HIV prevalence

*EME = Established Market Economies

Rat

e pe

r 100

,000

pop

ulat

ion

Central EuropeAfrica-low HIVAfrica-high HIV

Eastern Europe EME* E. Mediterranean

W. PacificSouth-East AsiaLatin America

200300400500600700

100

150

200

250

406080

100120140160

1990 1995 2000 2005

200

250

300

350

400

10152025303540

200

300

400

500

1990 1995 2000 2005

20406080

100120

100150200250300350400

100150200250300350400

1990 1995 2000 2005

Africa-high HIV

Rat

e pe

r 100

,000

pop

ulat

ion

Prevalence rates in 9 subregionsCentral EuropeAfrica-low HIV

Eastern Europe EME* E. Mediterranean

W. PacificSouth-East AsiaLatin America

*EME = Established Market Economies

Five regions appear to have reached target of halving 1990 prevalence rate already (green)

SE Asia and E. Mediterranean may be able to achieve target

African countries far from target, such that target unlikely to be reached globally

Black line marks target level at 50% of 1990 prevalence rate

20

40

60

80

100

15

20

25

30

35

40

5

10

15

20

1990 1995 2000 2005

2025303540455055

1.0

1.5

2.0

2.5

20

30

40

50

60

1990 1995 2000 2005

2

4

6

8

10

12

14

20

40

60

80

100

20

30

40

50

60

70

1990 1995 2000 2005

Mortality rates in 9 subregionsAfrica-high HIV Africa-low HIV Central Europe

Eastern Europe EME* E. Mediterranean

Latin America South-East Asia W. Pacific

Rat

e pe

r 100

,000

po

pula

tion

Four regions appear to have reached target of halving 1990 mortality rate already (green)

SE Asia, E. Mediterranean and E. Europe may be able to achieve target

African countries far from target, such that target unlikely to be reached globally

*EME = Established Market EconomiesBlack line marks target level at 50% of 1990 mortality rate

Summary of progress towards targets

Successful treatment rate 87%

Case detection rate 61%TB/HIV Major progress: need to scale up

further to reach targets

MDR-TB treatment Progress but far short of targetsFunding Increased substantially in recent years

but still not high enoughIncidence Slowly falling, on target

Prevalence and mortality Several regions on track to reach 2015 targets, but unlikely achievable at global level due to high levels of prevalence and mortality in Africa

Acknowledgements

all those from 198 countries that contributed to reporting of data to WHO in 2009 (www.stoptb.org/tme)

Core Report TeamLéopold Blanc, Dennis FalzonChristopher Fitzpatrick, Katherine Floyd, Inés Garcia, Philippe Glaziou, Christian Gunneberg, Tom Hiatt, Hazim Timimi, Mukund Uplekar, Lana Velebit

USAID

WHO Regional OfficesAmal Bassili, Andrei Dadu, Daniel KibugaKhurshid Hyder, Rafael Lopez-OlarteDaniel Sagebiel, Henriette Wembanyama

To be published on 8 December