1. Christian Gunneberg, Medical Officer WHO, Geneva STB Department
Scientific Symposium on the occasion of World TB Day 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. 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

3. 1. Global burden

4. 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 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 Figure less than 5% in Asia, where 55% of estimated TB cases occur

5. 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

6. 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

7. 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 m m m m

8. Estimated TB incidence rate, 2007
Estimated new TB cases (all forms) per population
No estimate
0-24
25-49
50-99
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 All rights reserved

9. 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 All rights reserved

10. 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

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

12. 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

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

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

15. 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

16. 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

17. 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.

18. 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.

19. 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 All rights reserved

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

21. 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 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

22. DOTS expansion
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%

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

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

25. 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.