Christian Gunneberg, Medical Officer WHO, Geneva STB Department Scientific Symposium on the occasion of World TB Day 2009 Commemorating the Anniversary of the discovery of the tubercle bacillus by Robert Koch TB epidemiology the global situation Christian Gunneberg, Medical Officer WHO, Geneva STB Department

2. Trends and Progress against Millenium goal targets What I will talk about: Global burden of TB Incidence, prevalence, mortality (latest WHO estimates) 2. Trends and Progress against Millenium goal targets Incidence, prevalence, mortality 3. Case detection and treatment targets

1. Global burden

Existing data used to estimate incidence, prevalence and mortality Measure The good The not so good Incidence Notifications reported to WHO annually by ~ 200 countries with 99% global population and estimated TB cases Incidence estimates based on major global consultation process in 1997 and subsequently regular (mostly annual) review and analysis of data, including consultations with countries and some special studies Surveillance systems notify only around 50-70% of estimated incident cases in many countries No systematic assessment of quality/coverage of TB surveillance data in many countries Trends in notifications used to assess trends in incidence in many countries – in Africa especially, difficult to separate out effect of HIV on trends in notifications from effect of programmatic efforts to increase case-finding Prevalence Seven (of nine) high-burden countries in Asia have conducted recent population-based surveys and have plans for further surveys. Additional countries now planning surveys Most African countries have not implemented a survey since 1957-61 or survey never done. Only one recent survey (Eritrea, 2005) Many countries planning surveys face bottlenecks e.g. insufficient funding Mortality Can measure from death registrations in vital registration (VR) system in many countries in European region and Americas, and in 3 high TB burden countries – Brazil, S. Africa, Russia Globally, only 10% of estimated TB deaths recorded in VR system and reported to WHO by 2008. Figure less than 5% in Asia, where 55% of estimated TB cases occur

To be published on 24 March (World TB Day) Full of data on progress towards global targets as well as analysis of progress in implementing all aspects of the Stop TB Strategy and Global Plan

The global burden of TB, 2007* 9.27 million incident (newly occurring) cases 9.24 million in 2006 8.3 million in 2000 6.6 million in 1990 (139/100,000 population) 1% fall annually (142/100,000 peak in 2004) 13.7 million prevalent cases (206/100,000 population) 1.8 million deaths *latest year for which estimates have been made

Most cases in Asia and Africa South- East Asia 34% Africa 31% Western Pacific 21% EMR 6% Europe 5% Americas 4% Of 9.27 million: ~ 50% cases in top five countries: India, China, Indonesia, Nigeria, South Africa 2m 1.3m 0.53m 0.46m 0.46m

Estimated TB incidence rate, 2007 Estimated new TB cases (all forms) per 100 000 population No estimate 0-24 25-49 50-99 100-299 Highest incidence rates in Africa, linked to high rates of HIV infection >= 300 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 2009. All rights reserved

Estimated HIV prevalence in new TB cases, 2007 HIV prevalence in TB cases, (%) No estimate 0–4 79% of HIV-positive TB cases in Africa 11% in South-East Asia 5–19 20–49 >= 50 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 2009. All rights reserved

Global rates of TB incidence, prevalence and mortality, including in people with HIV, 1990–2007 139/ 100,000 population 206/ 100,000 population 26/ 100,000 population

Figure 1.7. Estimated incidence of TB and prevalence of HIV for the African subregion most affected by HIV (Africa high-HIV), 1990–2007

Incidence rates falling slowly Figure 1.7. Estimated incidence of TB and prevalence of HIV for the African subregion most affected by HIV (Africa high-HIV), 1990–2007 Incidence rates falling slowly 9.3 in 2007 On track to achieve MDG 6 globally and in at least 5/6 regions

Trends in incidence by region Incidence increasing Incidence falling in seven of nine epidemiological subregions Exceptions: Africa-low HIV E. Europe Incidence stable

Global trends in prevalence and mortality Target for 2015 = 148 Target for 2015 = 14 Falling more slowly now

Prevalence rates: projections to 2015 Four regions on track to achieve target according to latest estimates and projections FAR FROM TARGET Americas, Eastern Mediterranean, South-East Asia Western Pacific World as a whole unlikely to achieve target REACHING TARGET UNLIKELY

Mortality rates: projections to 2015 Three regions on track to achieve target according to latest estimates and projections FAR FROM TARGET Americas, Eastern Mediterranean, South-East Asia World as a whole unlikely to achieve target FAR FROM TARGET

Countries with the largest number of cases of multidrug resistant TB (MDR-TB) 0.5 million cases globally in 2007 57% of cases in three countries: India, China, Russia 27 countries account for 85% and 15 are in the European region.

Summary Large number of TB cases and deaths means TB remains a major global health problem Latest estimates suggest incidence, prevalence and mortality rates are falling globally, BUT For better measurement of global burden of TB and progress in reducing it, the following is needed: Improved surveillance of cases and deaths, and more analysis of existing surveillance data Surveys where surveillance is weak Periodic review/updating of methods Hence establishment and mandate of the WHO Global Task Force on TB Impact Measurement However, Even at maximum DOTS coverage, case detection seems to remain below the 70% target level in most settings (Dye et al 2002) So we need innovative approaches to case detection. The DEWG is a mechanism to do whatever it needs to be done We need to ensure we make good use of it. The 2nd ad hoc Committee produced some recommendations for action, the DEWG is a tool to facilitate/implement some of them.

MDR-TB among new cases 1994-2007 * Sub-national coverage in India, China, Russia, Indonesia. < 3% 3-6 % > 6 % No data 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 2006. All rights reserved

Top 19 settings with MDR among new cases > 6% (1994-2007) Indicates survey data reported in an earlier phase of the project

Countries with confirmed XDR-TB cases as of June 2008 Argentina Italy Armenia Japan Azerbaijan Latvia Australia Lesotho Bangladesh Lithuania Botswana Mexico 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 WHO 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 2005. All rights reserved Brazil Moldova Canada Mozambique Chile Namibia China, Hong Kong SAR Russian Fed. Czech Rep. Netherlands Ecuador Nepal Slovenia Estonia Norway South Africa France Peru Spain Georgia Philippines Swaziland Germany Poland Sweden Ireland Portugal Thailand By the end of 2008 55 countries India Rep of Korea UK Islamic Rep. of Iran USA Ukraine Israel Romania Vietnam Based on information provided to WHO Stop TB Department - May 2008

DOTS expansion 2002-07 5.5 million TB cases notified by DOTS programmes 2.6 million smear +ve cases Case detection rate in smear + cases 63% Case detection rate in all new cases 56%

Progress in case detection by DOTS programmes is stagnating 62% 63% in 2007

Treatment success target reached globally Africa: 75%, Americas: 75%, Europe: 70%

What are the challenges? DOTS not yet fully expanded and of high quality everywhere; only 63% of all cases notified TB/HIV, especially in Africa; MDR-TB, especially in former USSR and China; XDR-TB everywhere and in Africa Weak health systems and services compromising TB care: need by NTP to get engaged in health system strengthening Outside of NTP staff, not all practitioners, non-state and even governmental, working at high standard Communities un-aware, un-involved, not mobilised However, Even at maximum DOTS coverage, case detection seems to remain below the 70% target level in most settings (Dye et al 2002) So we need innovative approaches to case detection. The DEWG is a mechanism to do whatever it needs to be done We need to ensure we make good use of it. The 2nd ad hoc Committee produced some recommendations for action, the DEWG is a tool to facilitate/implement some of them.