1. Opportunities

2. Shift in Perspective for Infectious Disease Control (Porter et al 1999 Health Policy and Planning 14: 322-328) From: Disease specificity and verticality Standardised interventions Short term orientation Emphasis on product/targets To: Integrated/ Horizontal linkages Flexibility/context sensitivity Longer term objectives/sustainability Emphasis on process

3. Shift in Perspective for Infectious Disease Control (Porter et al 1999 Health Policy and Planning 14: 322-328) From: Limited to health sector Focus on individual risk Operating without reference to global processes Working on behalf of populations To: Linking multiple sectors Understanding social vulnerability: risk in the context of everyday life Taking globalization as referent and context Working in partnership with communities

4. Tuberculosis Control as an example

5. 1840 186018801900192019401960 0 100 200 300 400 Phase 1 Phase 2 Phase 3 Phase 4 Initial effect of segregation of poor consumptives in work house Segregation of poor consumptives in enlarged and improved workhouses infirmaries Systematic segregation of consumptives, rich and poor, In hospitals and sanatoria Antibiotic era Source: data derived from various sources including T. McKewon. The modern rise of population, London: Edward Arnold 1976. Year Standardised notification rate Kochs discovery Historical decline of TB, 1840-1960

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

7. Risk factors for TB Risk factorRelative risk for active TB disease (range) Weighted prevalence, total population Population Attributable Fraction (Range) HIV infection8.3 (6.1-10.8)1.1%7.3% (5.2-9.6) Malnutrition4.0 (2.0-6.0)17.2%34.1% (14.7-46.3) Diabetes3.0 (1.5-7.8)3.4%6.3% (1.6-18.6) Alcohol2.9 (1.9-4.6)3.2%5.7% (2.8-10.3) Active smoking2.6 (1.6-4.3)18.2%22.7% (9.9-37.4) Indoor pollution1.5 (1.2-3.2)71.1%26.2% (12.4-61.0) From Lonnroth K et Al. Global epidemiology of tuberculosis. Seminars in Respiratory and Critical Care Medicine, 3 March 2008

8. WHO-recommended Global Strategy to Stop TB and reach the targets for 2015 1.Pursuing quality DOTS expansion and enhancement Political commitment Case detection through bacteriology Standardised treatment, with supervision and patient support Effective drug supply system Monitoring system and impact evaluation Additional components 2Addressing TB/HIV and MDR-TB 3. Contributing to health system strengthening 4. Engaging all care providers 5. Empowering patients and communities 6. Enabling and promoting research Stop TB Department

9. Global TB Control Targets: the theory 2015: 50% reduction in TB prevalence and deaths 2050: elimination (<1 case per million population) 5-10% declining incidence per year: – 70% detection rate – 85% successful treatment

10. Global TB Control Targets: the reality Case detection rate 61% globally in 2006 46% in Africa 52% in European/Eastern Mediterranean regions 2/3 of missing cases are in China, India, Africa Treatment success rate 84.6% globally 70% in Eastern Europe 76% in Africa