Transcript Slide 1

Looking into the mirror of
tuberculosis
Supervisors’ meeting Vilnius, Lithuania, May
20, 2005
Slightly modified before meeting in the
Directory of Health in Iceland
Thorsteinn Blöndal MD, Med Dr
Content
•
•
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Introduction
Backstage history
TB epidemiology in Lithuania
Thoughts about the future
Þ Blöndal
Introduction
• After a long time of uninterest in TB, WHO
& IUATLD succeeded in bringing TB back
to the global health agenda
• The new parole was DOTS
• DOTS (directly observed treatment, short
course)
Þ Blöndal
Directly observed treatment, short
course = DOTS
A strategy of comprehensive TB control
comprising five essential elements:
1.
2.
3.
4.
5.
Political commitment
Quality assured smear microscopy
Standardized chemotherapy
Uninterrupted drug supply
Recording and reporting system
Þ Blöndal
Political commitment
Sustained
political
commitment
Quality assured smear microscopy
Access to quality
assured TB
microscopy for case
detection among
persons presenting
with symptoms of
TB
WHO 2003
Standardized chemotherapy
Standardized
chemotherapy to all
cases under proper
case management
conditions including
direct observation of
treatment (DOT)
WHO 2003
Uninterrupted drug supply
Uninterrupted supply
of quality-assured
drugs with reliable
drug procurement and
distribution systems
WHO 2003
Recording and reporting system
Recording and
reporting system
enabling outcome
assessment of each
patient and
assessment of the
overall program
performance
WHO 2003
Backstage
Political initiative among
Nordic governments
resulted in:
• Nordic Baltic TB Project
2000-2002
• ‘Task Force’ 2002-2004.
Expansion of DOTS for
prevention and control of
TB in Lithuania
Þ Blöndal
Backstage history
• Annexed by the USSR in 1940
• Became the first of the Soviet republics to
declare its independence March 11, 1990
• Surges in TB followed as well as in
psychiatric illness, particularly affective
disorders and depression
• Treatment interruptions in TB were
common, a situation that promoted the
development of drug resistance
Þ Blöndal
Post-communist transition and
health in Europe
• In 2000 there was a 12 year difference in
life expectancy between the former
Sovient Union countries and W-Europe
• Health gains in the west have been driven
mainly by reductions in cariovascular
disease (diet, treatment for hypertension)
• High alcohol consumption, injury, violence
• Communicable disease, among other TB
BMJ 2004;329,1355-1356
Finances
• Through Lithuanian state budget
• The total budget from Nordic
Baltic for the project in the Baltics
in 1999-2000 was 1,7 million USD
• Lithuania received 400.000 Euros
during the TF period 2002-2004
Þ Blöndal
Tuberculosis notification rates, Europe, 1997
TB notification rate/100 000
< 10
10 to 19
20 to 49
50 and over
not available
EuroTB
Overview
• In 1998 the Lithuanian government
expressed committment to implementation
of DOTS and the National Prevention and
Control Strategy was approved
• In 1998-2000 three pilots
• In 2000-2003 DOTS expansion
• 2004 – DOTS maintainance
100,0
Tuberculosis incidence
80,0
60,0
40,0
20,0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Non-MDR TB, new and relapses. Lithuania. Source: Central registry.
There is a clear downgoing trend after 1998.
INCIDENCE OF TB 1996 - 2004
85,0
INCIDENCE
80,0
75,0
70,0
65,0
1996
1997
1998
1999
2000
2001
2002
2003
YEAR
Non-MDR tuberculosis. Lithuania. Source: Central registry.
2004
TB by sex and site of disese, 2002
• Men
• Women
1979
865
70%
30%
• Pulmonary
2351
• Extrapulmonary 493
83%
17%
Þ Blöndal
TUBERCULOSIS INCIDENCE BY SEX
Men
60,0
Women
Value
50,0
40,0
30,0
20,0
1996
1997
1998
1999
2000
2001
2002
2003
2004
Year
Non-MDR Tuberculosis. Lithuania. Source: Central registry.
Pulmonary TB by sputum
smear/culture. Lithuania, 2002.
• Sputum smear positive 1202
• Smear negative
1149
51%
• Culture positive
• Culture negative
54%
1544
1300
Euro TB
Þ Blöndal
Achievements during 1997 to 2005
• Sustained political commitment: Yes
• Quality assured smear microscopy:
– No of microscopy labs from 200 to 14;
– culture labs from 17 to 5,
– 5 labs doing sensitivity tests to 1st line drugs
– 2nd line drugs from 1 to 2.
– Courses.
• Standard chemo under proper conditions:
– DOT coverage from 0 1997 to 95% 2004.
Courses for nurses & doctors.
Þ Blöndal
Achievements from 1998
• Uninterrupted supply of drugs:
– Almost. Last time was 1998. No policy for
management of drug resistant TB. DOTS plus
beginning in 2006
• Reporting/recording as outcome
assessment:
– Upgrading of hardware, software, furniture at
the premises of Central registry
– Training courses
Þ Blöndal
Supervisors appointed. Regular meetings.
Active (lower graph) and passive case finding
INCIDENCE OF TUBERCULOSIS 1998 - 2004
Incidence
40,0
ACTIVE
30,0
PASSIVE
20,0
10,0
1998
1999
2000
2001
2002
2003
2004
YEAR
New pulmonary tuberculosis. Mode of detection. Source: Central registry.
Bacteriological confirmation. Pulmonary TB new.
Sputum smear and or culture positivce
70,0
Percentage
65,0
60,0
55,0
50,0
1996
1997
1998
1999
2000
YEAR
2001
2002
2003
2004
PEDIATRIC TUBERCULOSIS IN LITHUANIA
INCIDENCE 1996-2004
22,0
INCIDENCE
21,0
20,0
19,0
18,0
17,0
16,0
1996
1997
1998
1999
2000
YEAR
2001
2002
2003
2004
Total
Newpp
Newpm
Newexp
3.000
Relapspp
Relapspm
Number of cases
Relapsexp
2.000
1.000
0
1996
1997
1998
1999 2000
2001
2002
2003
2004
Year
Comparison of reported case finding. Lithuania 1996 – 2004. Registry.
Treatment outcome %
new pulmonary Sm+ and/or C +
(MDR excluded)
90
80
70
60
tr success
failure
died
default
tr out
50
40
30
20
10
0
2000
2001
2002
2003
Lithuanian TB register
Treatment outcome. Success and default
Pulmonary tuberculosis, smear and or culture positive
Success %
Default %
Percentage
80,0
60,0
Success
40,0
20,0
Default
0,0
1996
1997
1998
1999
2000
2001
Year
Source: Central Registry
2002
2003
2004
Tx outcome 2003. Pulmonary, new
vs relapses. MDR excluded
90
80
70
60
%
tr success
failure
died
defaulted
tr out
50
40
30
20
10
0
new
relapses
Lithuanian TB register
INCIDENCE OF MORTALITY IN TUBERCULOSIS
14,00
TUBERCULOSIS MORTALITY IN LITHUANIA 1988-2004
12,00
10,00
8,00
6,00
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
YEAR
Source: Central TB Registry
DOTS-Plus
DOTS-Plus is a case-management
strategy designed to manage MDR-TB
using 2nd line drugs within the DOTS
strategy in low- and middle-income
countries
DOTS-Plus means DOTS first
Þ Blöndal
Anti-TB drug resistance by entry category, Europe, 2001
isoniazid
55
West (15 countries)
rifampicin
multidrug resistant
ethambutol
streptomycin
Centre (6 countries)
East (3 Baltic countries)
% of resistance (mean)
50
45
40
35
30
25
20
15
10
5
0
New
(n=6 290)
Retreated
(n=1 067)
New
(n=2 258)
Retreated
(n=872)
EuroTB
Prevalence of resistance, Lt 2002
Never treated
•
•
•
•
•
INH
Rifampicin
INH+R
Etambutol
Strepto
24%
9%
9%
7%
20%
Previous treatment
61%
51%
51%
36%
55%
Implications for tx
Int J Tuberc Lung Dis 9(2):170-174, 2005
Resistance pattern, 2002, Lt
70
61
60
55
51 51
50
36
40
%
30
24
20
20
9
9
7
H
R
H+R
E
S
10
0
New cases
Previously treated
Int J Tuberc Lung Dis 9(2):170-174, 2005
Treatment outcome 2001.
MDR vs other new pulmonary cases
80
70
60
tr success
failure
died
default
tr out
50
% 40
30
20
10
0
New pulmonary
New MDR
Lithuanian TB register
Incidence MDR-TB entry categories. 1999-2004
4,00
Relapses
New cases
Relapses
3,00
Defaulters
Incidence
Failures
Transfer in
2,00
1,00
0,00
1999
2000
2001
2002
Year
2003
2004
MDR-TB PER 100 000 POPULATION
NEVER TREATED AND PREVIOUSLY TREATED CASES
PREVIOUSLY TREATED
8,0
MDR-TB PER 100 000
NEVER TREATED
6,0
4,0
2,0
0,0
1999
2000
2001
2002
YEAR
2003
2004
Incidence nonMDR-TB
Lithuania 1996-2004
New cases
80,00
Relapses
Defaulters
Failures
Transfer in
Incidence
60,00
40,00
20,00
0,00
1996
1997
1998
1999 2000
Year
2001
2002
2003
2004
Thoughts
• Public health differs from clinical medicine
in being particularly sensitive to the
financial income of the state (among other
factors)
• The conncection of TB and poverty is well
established. With economical development
and higher GNP TB in Lithuania will
probably go away
Þ Blöndal
GDPchange
% change in GDP / TB incidence
40,0
Incichange
20,0
0,0
-20,0
-40,0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Percentual change from previous year’s GDP and TB in Lithuania.
New cases and relapses. Data source: Central registry and www.std.lt
More thoughts
• TB prevalence depends on a vast number
of factors. Now in 2005 there is a clear
improving trend in the overall TB situation
in Lithuania
• The MDR threat however is appalling
• DOTS must remain strong
• DOTS-plus must start as soon as possible
Þ Blöndal
Edita Davidaviciene and Dalia Gaidamoniene
nurturing the NTB flower