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Global Tuberculosis Burden

Global Tuberculosis Burden. Philippe Glaziou Cancun, December 2009. Outline. What is TB? How do we get TB? Who develops TB? Trends in global burden What is done about it? Why is TB still a problem? Can we get rid of TB?. Tuberculosis: An Ancient Killer.

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Global Tuberculosis Burden

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  1. Global TuberculosisBurden Philippe Glaziou Cancun, December 2009

  2. Outline • What is TB? • How do we get TB? • Who develops TB? • Trends in global burden • What is done about it? • Why is TB still a problem? • Can we get rid of TB?

  3. Tuberculosis: An Ancient Killer • Tubercular decay in skull and spinal bones found in 4000 year old Egyptian mummies Hippocrates around 400 BC: “Phthisis is the most common disease of humans and it is nearly always fatal”

  4. Tuberculosis: what’s in a name ? The disease was named Tuberculosis in 1839 by J. L. Schönlein • Phthisis • Wasting • Scrofula • Pott’s disease • Lupus vulgaris • Consumption • The Captain of the Men of Death • The White Plague

  5. Signs and symptoms • Early symptoms • Common cold symptoms • Listlessness, fatigue, fever, a minimally productive cough of yellow or green sputum and a general feeling of malaise. • Later symptoms • Night sweats, fever, cough with purulent secretions and haemoptysis, dyspnoea, chest pain, and hoarseness appear.

  6. How do we get it?

  7. Lung cavities rich in TB bacilli

  8. Diagnostic discoveries • 24th March 1882 (Robert Koch) TB Day • Discovery of staining technique that identified Tuberculosis bacillus • 1890 (Robert Koch) • Tuberculin discovered • Diagnostic use when injected into skin • 1895 (Roentgen) • Discovery of X-rays • Early diagnosis of pulmonary disease

  9. Historical decline of TB, 1840-1960 400 Segregation of poor consumptives in enlarged and improved workhouses infirmaries 300 Systematic segregation of consumptives, rich and poor, In hospitals and sanatoria Koch’s discovery Standardised notification rate 200 Antibiotic era 100 Initial effect of segregation of poor consumptives in work house 0 1860 1880 1900 1920 1940 1960 1840 Year Source: data derived from various sources including T. McKewon. The modern rise of population, London: Edward Arnold 1976.

  10. Global burden in 2008 9.4 million new cases 15% infected with HIV 1.4 million deaths excluding HIV 0.5 million deaths in HIV-infected (25% of 2 million HIV deaths)

  11. Incidence of TB in the world

  12. What causes TB? Genetic deletion analysis Source: Brosch et al. PNAS 2002; 99: 3684-3689

  13. Who develops TB? From Lonnroth K et Al. Global epidemiology of tuberculosis. Seminars in Respiratory and Critical Care Medicine, 3 March 2008

  14. What is done about it?

  15. Evolution of TB Control The touch of King Charles II was thought to cure Tuberculosis (17th century)

  16. Prevention Milestone: BCG • BCG developed by Calmette & Guerin in 1907 • First human immunizations in 1921 in France • Protection against serious forms of TB • Limited or no protection against pulmonary TB

  17. Treatment Milestones: Sanatorium • Isolation of TB patients in sanatorium • Prevention of spread of infection • Fresh air • Sunshine • Physical exercise

  18. TB Drugs • 1943: Selman Waksman discovers Streptomycin (Nobel Prize in 1952) Other anti-TB drugs: • 1949: PAS • 1952: Isoniazid • 1954: Pyrazinamide • 1955: Cycloserine • 1962: Ethambutol • 1963: Rifampicin

  19. World Health Assembly Targets for Global TB Control • By 2000: • Detect 70% of all new sputum smear-positive cases • Successfully treat 85% • Slow progress of many countries led to the revision of the target year to 2005 • 2005 targets missed: • Case detection: 60%; treatment success: 84% • HIV/AIDS in Africa, drug resistance in Eastern Europe

  20. Emergence of “worst-case” TB scenarios • Co-infection between TB and HIV • Multidrug-resistant TB (MDR-TB) • Resistance to isoniazid and rifampin – the 2 most powerful anti-TB drugs • Extensively-drug resistant TB (XDR-TB) • MDR-TB plus resistance to any fluoroquinolone and at least 1 second-line injectable (AMI, KAN, CAP)

  21. The Stop TB Strategy (2005)

  22. Why is TB still a problem?

  23. Nairobi

  24. Nairobi

  25. Global burden of TB/HIV

  26. TB & Poverty overlap Source: World Economic Forum, 2005

  27. TB burden vs. Gross National Income

  28. Central Europe: 5yr+ delay in TB control Albania, Bulgaria, Czech, Hungary, Poland, Romania 9500 1980 9000 1995 1994 8500 8000 Average number TB cases 7500 7000 1990 6500 1989 2006 6000 4000 6000 8000 10000 12000 14000 Average GDP per capita

  29. Slow decline of global incidence

  30. Trends in incidence by subregion

  31. Trends in TB mortality by subregion

  32. http://www.who.int/tb/challenges/xdr/xdr_map_sep09.pdf

  33. Can we get rid of TB? • New vaccines • BCG does not prevent the disease in adults • New diagnostics • Smear microscopy and culture: imperfect and slow • Drug susceptibility testing too slow • New drugs • Treatment is still much too long • To treat drug resistant TB: MDR-TB, XDR-TB

  34. A vaccine to transform TB control? Source: Young D and Dye C. Cell 2006: 124; 687, DOI 10.1016

  35. In conclusion • Burden exacerbated in the 90s by the rise of HIV • Slow progress of TB control performance • Slow decline in disease burden since 2004 • Elimination nowhere in sight, we need • New vaccines • New drugs • New diagnostics

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