Transcript TB - Asiam
La tubercolosi nel terzo millennio Lucio Casali Firenze, 21 novembre 2015 The Global Burden of TB - 2013 Estimated number of cases All forms of TB 9 million 126 per 100,000 • 550,000 in children • 3.3 m in women Estimated number of deaths 1.5 million* • 80.000 in children • 510.000 in women HIV-associated TB 1.1 million (13%) 360,000 Multidrug-resistant TB 480,000 210,000 Source: WHO Global TB Report 2014 * Including deaths attributed to HIV/TB TB cases and deaths in slow decline, 1990-2013 All TB deaths Incidence peaked at 9.5 million in 2004 9 million in 2013 Total mortality peaked in 2002 at 1.7 million 1.5 million in 2013 Accelerating response to TB/HIV means cutting suffering, transmission and mortality Estimated HIV prevalence in new TB cases, 2013 78% of TB/HIV cases in Africa Ref: Global TB Control Report 2014 Other co-morbidities emerging in other regions Addressing MDR-TB as a crisis The “orphan” disease Percentage of new TB cases with MDR-TB Ref: Global TB Control Report 2014 Highest % in the former USSR countries India, China, Russia, Pakistan and Ukraine have 60% of all MDR-TB cases Who carries the burden of tuberculosis? …mostly, the most vulnerable TB spreads in poor, crowded & poorly ventilated settings 510,000 women and 80,000 children die of TB each Migrants, prisoners, minorities, year; 10 million “TB” refugees face risks, discrimination orphans & barriers to care TB linked to HIV infection, malnutrition, alcohol, drug and tobacco use, diabetes Health in all policies, UHC, public health Poverty-disease trap Poverty Undernutrition Poor housing Risk factors for infectious diseases and NCDs Poor health care access • Worse health and stigma – loss of income • Catastrophic health expenditure: • 10-50% of annual income lost! TB diagnosis and treatment • • • • Social and financial support Wealth and wealth distribution as applied to TB TB Patient Total Health C.S. Conclusion This review suggests that there is an unacceptable time delay before the diagnosis of pulmonary tuberculosis is made. There is a need to revise the current case finding strategies. Global progress on impact - 2013 37 million lives saved since 2000 Reduction in TB mortality rate 45% since 1990 Incidence falling slowly (1.5%/yr): 2015 MDG on track 4.8 million lives saved since 2005 through TB/HIV collaborative activities 86% cure rate 61 million patients cured, 1995-2013 Challenges: Priorities for action 2015 5 PRIORITIES FOR ACTION Reaching the “missed” cases (3 million not in the system) Address MDR-TB as crisis Accelerate response to TB/HIV Increase financing to close resource gaps Intensify research and ensure rapid uptake of innovations Reaching the "missed" cases early means cutting transmission (nearly 3 million not diagnosed or reported) Share of total missed cases 9 million estimated 6 million notified Estimated incidence Global notifications 10 countries account for 74% (2.4 million) of the estimated “missed” cases globally India: 1 million cases “missed” Ref: Global TB Control Report 2013 Vision, goal, targets, milestones Vision: A world free of TB Zero TB deaths, Zero TB disease, and Zero TB suffering Goal: End the Global TB epidemic (<10 cases per 100,000 population) MILESTONES INDICATORS Reduction in number of TB deaths compared with 2015 (%) Reduction in TB incidence rate compared with 2015 (%) TB-affected families facing catastrophic costs due to TB (%) TARGETS 2020 2025 SDG 2030 End TB 2035 35% 75% 90% 95% 20% (<85/100 000) 50% (<55/100 000) 80% (<20/100 000) 90% (<10/100 000) Zero Zero Zero Zero The End TB Strategy: 3 pillars and 4 Principles Integrated, patientcentered TB care and prevention Bold policies and supportive systems Intensified research and innovation Le nuove metodiche diagnostiche • La più recente novità nella diagnosi di laboratorio è il GeneXpert Le nuove metodiche diagnostiche Xpert MTB/RIF: performance Hot-spot gene rpoB Campioni clinici Identificazione casi di TBC Specificità 98-99% Sensibilità 97-100%, BAAR-pos. 75-84%, BAAR-neg. Identificazione casi resistenti alla rifampicina Specificità 97-99% Sensibilità 91-97% Casi di co-infezione TBC-HIV Sensibilità 86% (HIV-neg: 92%) Boehme CC et al 2011. Lancet 377(9776):1495-505 Theron G et al 2011. Am J Respir Crit Care Med 184:132-140 Political commitment needs to be backed by financing IMPLEMENTATION $2 billion Funding gap RESEARCH $1.32 billion Funding gap $8 billion funding required for TB prevention, diagnosis and treatment $677 M $2 billion funding required for research and development TAG TB R&D report 2013 Funding gaps, US$ billions by region Rest of the World 19% Asia 22% • Biggest gaps in Africa: 59% of total gap, 2014-16 • Gap in Asia could be bigger if domestic funding (in India, Indonesia, Philippines etc.) does not grow at projected level • Smaller gaps in Rest of World but critical to fill for MDR response and quality TB care, esp. in Europe Africa 59% Asia Africa 2.0 2.0 1.5 1.5 1.0 1.0 0.5 0.5 0.0 0.0 2014 Rest of World 2015 2016 2014 2015 2016 Impact if funding gap closed: lives saved Millions Millions 0.25 Lives saved (TB) Lives saved (MDR-TB) 0.20 0.15 0.2 million 0.10 0.05 0.00 Status Quo Full funding Status quo implies: 1.2 million lives lost Failure in MDR response Failure to adopt rapid diagnostic tests Flat lining Status Quo Five priority actions to address the global MDR-TB crisis ACTIONS NEEDED ON ALL FRONTS FROM PREVENTION TO CURE Projected acceleration of TB incidence decline to target levels Current global trend: -1.5%/year Optimize use of current & new tools emerging from pipeline, pursue UHC and social protection Average -10%/year by 2025 Introduce new tools: a vaccine, a new easier prophylaxis & Average treatment regimen, a PoC test -17%/year -5%/year