The burden of TB in million deaths in 2004 – 98% of these in developing world 250,000 deaths due to TB/HIV MDR-TB present in 102 of 109 countries and settings surveyed in million new cases in 2004 – 80% in 22 high-burden countries

– No estimate or more Estimated number of new cases (all forms) AMERICAS 4% EAST. MEDIT. 7% EUROPE 5% Asia has the highest number of cases and TB has resurged in Europe...

Global incidence is rising at 1% due to increases In Africa and E. Europe Estimated TB incidence/100K/yr Africa - high HIV Africa - low HIV World E Europe World exc Afr EEur

WHO European Region 25 EU countries 53 countries 18 high priority countries for TB 1. Armenia 2. Azerbaijan 3. Belarus 4. Bulgaria 5. Estonia 6. Georgia 7. Kazakhstan 8. Kyrgyzstan 9. Latvia 10. Lithuania 11. Moldova 12. Romania 13. Russian Fed. 14. Tajikistan 15. Turkey 16. Turkmenistan 17. Ukraine 18. Uzbekistan

TB case notification rate in EUR, TB case notification rate in EUR, ,240 East+ EUR (18 countries) 354,954 All EUR (53 countries) 54,231 European Union (25 countries) Annual TB cases per 100,000 pop. Year 373,497

TB incidence in EUR TB incidence in EUR l 13/ first fifteen members of the EU l 27/ ten new members of the EU (enlargement in 2004) l 53/ four countries accessing the EU l 98/ countries bordering EU 50/ overall TB incidence in EUR

Mean annual change in TB notification rates, No data / <60 cases/yr -11% to -3% -2% to +1% +2% to +6% >+6% % change EuroTB

Proportion of TB cases of foreign origin, Europe, 2004 No data % cases of foreign origin Andorra Malta Monaco San Marino EuroTB

Global TB control targets 2005: World Health Assembly: - To detect at least 70% of infectious TB cases - To treat successfully at least 85% of detected cases 2015: 50% reduction in TB prevalence and deaths by : Goal 6: Combat HIV/AIDS, malaria and other diseases Target 8: to have halted by 2015 and begun to reverse the incidence… Indicator 23: prevalence and deaths associated with TB Indicator 24: proportion of TB cases detected and cured under DOTS

DOTS in EUR population (%) no DOTS < > countries; countries, 47% population

Plan to Stop TB in EEUR: achievements TARGET STOP TB strategy: DOTS MDR-TB, TB/HIV, prisons Health system All providers ACSM, people, patients Research Note: DOTS achievements in new smear-positive pulmonary TB cases

Proportion of pulmonary cases with positive sputum smear, East*, * including countries where pulmonary classification was applied for three or more consecutive years 15% 30% 45% 60% % of pulmonary cases Moldova, Rep Kyrgyzstan Armenia Georgia Kazakhstan Turkmenistan Azerbaijan

Treatment outcomes, new definite pulmonary cases*, 2003 * Culture positive in EU & West and Centre; smear positive in Macedonia FYR and East. Countries with nationwide representative data; excluding 4 countries with < 10 cases (EU & West) § Mean percentage (country range in brackets) EU & West § 20 countries Balkans § 4 countries East § 6 countries Success76% (54-88%)83% (82-91%)71% (55-84%) Death7% (0-13%)4% (2-4%)5% (2-9%) Failure1% (0-11%)4% (0-5%)10% (3-14%) Still on treatment3% (0-14%)0.6% ( %)0.1% ( %) Other (Default, Transferred, Unknown) 13% (0-25%)8% (4-15%)14% (5-36%) EuroTB

Outcomes among new, definite pulmonary TB cases, EU & other regions, 2003* * Mean for 19 EU countries (EuroTB); data from other regions refer to DOTS cohorts (WHO Global Tuberculosis Control: Surveillance, Planning, Financing. 2006) Despite low mortality rates, the proportion of TB patients notified in the EU who die while on treatment is substantial, even when compared to other regions in the world. This is one limitation keeping many EU countries from achieving the WHO target of 85% success among previously untreated pulmonary TB cases. Region SuccessDeathFailureOther European Union76%7.2%1.1%16.2% Africa72%7.0%1.4%19.8% The Americas82%4.9%1.2%12.4% Eastern Mediterranean82%2.9%1.4%14.1% South-East Asia85%4.5%2.1%8.1% Western Pacific91%2.3%1.1%5.1%

East – West divide EuroTB EastWest Notification dataAggregatedIndividual Culture confirmationNone to lowHigh Main trend in notification rateIncrementalDeclining Epidemic typeDiffuseConcentrated Imported TBLow (<1%)High (29%) Drug resistanceHighLow HIV in TB cases< 1%0-16% Outcomes↑ failures↑ deaths

Vision: A WORLD FREE OF TB Goal: T o dramatically reduce the global burden of TB by 2015 in line with the MDGs and the Stop TB Partnership targets Objectives: Achieve universal access to high-quality diagnosis and patient-centred treatment Reduce the human suffering and socio-economic burden associated with TB Protect poor and vulnerable populations from TB, TB/HIV and multidrug- resistant TB Support development of new tools and enable their timely and effective use Why the new Stop TB Strategy ? Vision, Goals, Objectives

Plan to Stop TB in EEUR: Planned milestones Milestones Year Population covered by DOTS services (%) TB cases accessing quality-assured culture and drug susceptibility testing (%) Population covered by adequate MDR-TB management services. (%) Countries implementing collaborative TB/HIV activities (%) Countries with TB care in prisons of equivalent standards than outside (%) Countries where TB care is integrated at primary health care level (%) Countries where communities are involved to ensure quality TB care (%)

What are the main challenges ? 1.DOTS not yet fully expanded and of high quality everywhere 2.TB/HIV, especially in Africa, and MDR-TB, especially in former USSR and China 3.Weak health systems and services impeding proper TB control and care 4.Not all practitioners engaged 5.Communities un-aware and un-involved 6.Research not producing yet new tools and outside of the interest of TB "controllers"

Western and Central Europe l Today, mainly sexual transmission in Western and Central Europe l Exceptions: significant IDU epidemics in ESP, POR, ITA, SWI, POL l 25-65% of all cases are among MSM l Up to 75% of all heterosexual cases are among immigrants from high prevalence countries and women are >50% of all heterosexual cases l Vulnerable Groups: MSM & immigrants, specially immigrant women

Eastern Europe l Mainly IDU related transmission in Eastern Europe l 68-85% of all cases are male l Up to 30% of infected females are IDU and 50% are partners of IDU l 30-50% of all HIV infections are among those under 25 years l Vulnerable Groups: IDU, sex workers, prisoners, ethnic minorities, migrants

84 % 2% <20% 20-40% 40-60% 60-80% 50% 6% 6.1% 13% 10% >80% 81% 25.5% 11% 8.2% 90% 57% 83% 29% 64% 74% 60% 16% 4% 19.4% 7% 15% 16% <1% 24% 87% 60% 68% 14.5% 71% 5% 6% IDU as % of all HIV/AIDS cases NOTE: % of AIDS cases in countries not reporting HIV Sources: EuroHIV; national reports; 0% 11% 17% 20% 5% 82% 2% 51% 3% 14% 16% 1.8% 16% 32% 29% 16% 34% 82% 80% 86% 71%

76 % 85% <20% 20-40% 40-60% 60-80% 83% 61% 76% 78% 72% >80% 73% 25.5% 80% 70% 77% 78% 89% 80% 73% 77% 16% 69% 75% 97% 90% 63% 81% 75% 80% 71% 75% 71% 80% 78% Males as % of all HIV/AIDS cases NOTE: % of AIDS cases in countries not reporting HIV Sources: EuroHIV; national reports; 62% 78% 71% 66% 63% 68% 79% 80% 61% 80% 85% 74% 82% 72% 83% 64% NA 84% 81% 72%

RUS ARM KAZ KYZUZB TKM TJK GEO AZE EST LAT LITBEL UKR BUL ROM MOL ALB no HAART ( 70%) poor access ( 1-10%)partial coverage (10-70%) BIH, FYM, YUG TUR Access to HAART, 03/2003

RUS* ARM* KAZ* UZB* TKM TJK* AZE* BEL UKR* no HAARTvery poor coverage ( 1-10%) * in the process of scaling up ART poor coverage (10-50%) moderate coverage (50-75%) disputed coverage estimates or insufficient data available good coverage (over 75%) Access to HAART, 01/2006

HIV infection among TB cases, * * Excluding countries with less than 2 datapoints in the last 3 years or less than 50 TB notifications annually The proportion of TB cases with HIV infection has increased in Estonia and Latvia, but is still highest in Portugal and Spain. In other countries of the Balkans and East providing data, levels have remained below 1%.

Reported to WHO (2005) 52,800 TB patients HIV tested 5,800 tested positive 14 started the ART

Estimated HIV prevalence 2005 CountryHIV prev. (%)CountryHIV prev. (%) Pop. (2003) TB (2005) Pop. (2003) TB (2005) Ukraine1.48.3Armenia Russian Federation1.16.8Uzbekistan Estonia1.16.6Kyrgyzstan Latvia0.63.9Lithuania Belarus0.52.9Azerbaijan< Moldova0.21.4Tajikistan< Georgia0.11.3Turkmenistan< Kazakhstan0.21.2Europe4.7 Source: UNAIDS (2004); WHO Global TB Report (2006) % HIV prevalence estimated in general population and TB patients (adults)

European Framework for TB/HIV Interim policy on collaborative TB/HIV activities a.Establish the mechanism for collaboration a.Set up a coordinating body for TB/HIV b.Conduct surveillance of HIV prevalence among TB patients c.Joint TB/HIV planning d.Conduct monitoring and evaluation Decrease the burden of TB in people living with HIV/AIDS Intensified TB case finding Introduce INH preventive therapy Ensure TB infection control in health care and congregate settings Decrease the burden of HIV in TB patients Provide HIV testing and counselling Introduce HIV prevention methods Introduce co-trimoxazole preventive therapy Ensure HIV/AIDS care and support ART

l Cat 1: national adult HIV prevalence >1% or HIV prevalence in TB pts >5%: all activities recommended in the Interim policy to be considered for implementation l Cat 2: national adult HIV prevalence below 1% and administrative areas with adult HIV prevalence >1% - combination of Cat 1 and Cat.3 l Cat 3: national adult HIV prevalence below 1% and no administrative areas with adult HIV prevalence >1%: l Conduct surveillance of HIV prevalence among TB patients l Decrease the burden of TB in people living with HIV/AIDS with focus on groups at high risk for TB and HIV – IDUs, MSM, sex workers, those living in congregate settings)