1. Nazir Ismail CTB/NICD & WHO-SRL & UP
The epidemiology and drivers of the TB epidemic in high burdened HIV settings
Nazir Ismail
CTB/NICD & WHO-SRL & UP

2. Overview
Situational analysis
TB … DR TB
Ending TB
Drivers
Conclusion

3. Global Distribution of TB incidence
WHO Global TB report 2015

4. Top 10 countries

5. TB is a killer

6. Regional TB notifcations by Age, 2014
KYE…KYR

7. Trends in burden and mortality
in millions Source: WHO Global Report 2015

8. True Burden…
Blue – estimates using notification data Red – measured by Survey

9. Population attributable fraction
Among the 22 High TB Burden Countries (HBC = 80% of the estimated global TB burden)
Malnutrition (27%),
Smoking (23%),
HIV (19%),
Diabetes (6%),
harmful alcohol use (13%) and
Indoor air population (26%) evidence base still weak
However regionalized PAF …HIV is a much more important risk factor in the Africa
>50%)

10. HIV co-infection

11. HIV survival
Murray, Christopher J L et al. “Global, Regional, and National Incidence and Mortality for HIV, Tuberculosis, and Malaria during 1990–2013: A Systematic Analysis for the Global Burden of Disease Study 2013.” Lancet  (2014): 1005–1070. PMC. Web. 3 Aug

12. HIV survival on ART
Murray, Christopher J L et al. “Global, Regional, and National Incidence and Mortality for HIV, Tuberculosis, and Malaria during 1990–2013: A Systematic Analysis for the Global Burden of Disease Study 2013.” Lancet  (2014): 1005–1070. PMC. Web. 3 Aug

13. TB outcomes in PLHIV

14. mPTB trends SA 2004-12 Provincial variation Role of ART
+ other factors
Nationwide and regional incidence of microbiologically confirmed pulmonary tuberculosis in South Africa, : a time series analysis. Nanoo A, Izu A, Ismail NA, Ihekweazu C, Abubakar I, Mametja D, Madhi SA. Lancet Infect Dis Sep;15(9): doi: /S (15) Epub 2015 Jun 22.

15. Age specific mPTB incidence
Levels in age group
>2000/ in EC
¼ of that in LP

16. 2015 targets

17. ENDing TB 70% CDR 85% Cure rate = annual decline ~6% Observed ~1-2%
Eliminate TB = incidence < 1 new case per million population per year by 2050
Lo¨nnroth, K., et al., Drivers of tuberculosis epidemics: The role of risk factors and social determinants, Social Science & Medicine (2009), doi: /j.socscimed

18. TB in Europe Pre-antibiotic era Role of…
Europe TB death rates were close to 1% per year
> current high HIV prevalence areas
Role of…
Industrialization and improvement of socioeconomic conditions
Sanatoria/Isolation
Lo¨nnroth, K., et al., Drivers of tuberculosis epidemics: The role of risk factors and social determinants, Social Science & Medicine (2009), doi: /j.socscimed

19. TB cycle (individual)
Hargreeves. Am J Public Health April ; 101(4): 654–662. doi: /AJPH

20. Proximate vs Upstream factors
Lo¨nnroth, K., et al., Drivers of tuberculosis epidemics: The role of risk factors and social determinants, Social Science & Medicine (2009), doi: /j.socscimed

21. Risks are not uniform in space and time
Time and Space
Risks are not uniform in space and time

23. Drivers Socioeconomic gradient
Poorest have the highest risk
Confounded – economic development migration to urban slums
Interventions – treatment is prevention?
TB/ART (untreated individuals)
IPT/BCG?
Role of other factors age group and social network!
Catalyst in space and time
Targeting hotspots of transmission greatest impact

24. Drug Resistant TB

25. Global burden of DR TB

26. SA TB DRS 2012-14 Stable MDR rate Doubling in RMR DS Cure Rate…
2.8% overall ( )
2.9% overall (2001-2)
Doubling in RMR
New cases: 1.8% … 3.4%
?Transmission
DS Cure Rate…
Vs … undetected DR TB
Available at

27. Global DR – TB outcomes
MDR ~ 50% success
XDR ~ 20% success

28. Conclusion Declining burden of TB but not fast enough DR TB
Role of HIV important
KYE/KYR is essential
Catalysts of proximal factors are low hanging fruit
Upstream factors vital to accelerate decline
DR TB
Stable but outcomes horrific
Role of DS TB
Important role of transmission (catalyst)

29. Acknowledgments