1. Country Office for Bangladesh Towards reaching the Millennium Development Goals Dr Erwin Cooreman Medical Officer (TB) WHO-Bangladesh

2. 2 |2 | Country office for Bangladesh Estimated TB incidence rate, 2005 No estimate 0–24 50–99 100–299 300 or more 25–49 Estimated new TB cases (all forms) per 100 000 population 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. TB in South-East Asia 4.8m prevalent cases 2.9m new cases and 512k deaths/ yr 150k new MDR-TB /year 3.9m TB/HIV co-infected

3. 3 |3 | Country office for Bangladesh TB Control Goals Achieve full coverage with DOTS, reach and then sustain/surpass the 70% case detection and 85% treatment success targets among new cases  By 2010:  To halve TB deaths and prevalence (Stop TB Partnership goals, preponed by the SEAR TWG on TB)  By 2015:  “to have halted and begun to reverse the incidence” (Target 8, Goal 6, of the Millennium Development Goals)  By 2050:  To have eliminated TB (<1 per million pop.)

4. 4 |4 | Country office for Bangladesh Millennium Development Goals  Goal 1: Eradicate extreme poverty and hunger  Goal 2: Achieve universal primary education  Goal 3: Promote gender equality and empower women  Goal 4: Reduce child mortality  Goal 5: Improve maternal health  Goal 6: Combat HIV/AIDS, malaria and other diseases  Goal 7: Ensure environmental sustainability  Goal 8: Develop a global partnership for development

5. 5 |5 | Country office for Bangladesh Millennium Development Goals  Goal 6: Combat HIV/AIDS, malaria and other diseases  Target 8: Halt and begin to reverse the incidence of malaria and other major diseases ― Indicator 23: Prevalence and death rates associated with tuberculosis –Series 23.1: Tuberculosis prevalence rate per 100,000 population –Series 23.2: Tuberculosis death rate per 100,000 population ― Indicator 24: Proportion of tuberculosis cases detected and cured under DOTS –Series 24.1: Tuberculosis detection rate under DOTS, percentage –Series 24.2: Tuberculosis treatment success rate under DOTS, percentage

6. 6 |6 | Country office for Bangladesh Progress towards the 70% case-detection target

7. 7 |7 | Country office for Bangladesh Global targets: what has been achieved in the SEA Region?  Full coverage with DOTS  15 million patients treated over past 10 years  Nearly 2 million TB patients registered for treatment annually  66% case detection and over 85% treatment success rates in the Region as a whole (2005)  Emerging evidence in some settings of falling prevalence, deaths due to TB Target zone

8. 8 |8 | Country office for Bangladesh Impact on global prevalence rates (1990-2005)

9. 9 |9 | Country office for Bangladesh Impact on global mortality rates (1990-2005)

10. 10 | Country office for Bangladesh Impact on global incidence rates (1990-2005)

11. 11 | Country office for Bangladesh The Context General Health Services Policy, planning, Capacity building Implementation Monitoring, evaluation Surveillance and research National TB programmes Broader determinants of health impacting TB control services Poverty Malnutrition Low awareness High risk behaviour Increased vulnerability Delayed treatment seeking Poor access TB/HIV + MDR TB

12. 12 | Country office for Bangladesh New challenges required a new Stop TB Strategy The strategy underpins and strengthens the Global Plan to Stop TB, 2006-2015 The Strategy & the Plan...

13. 13 | Country office for Bangladesh The new Stop TB Strategy & the Regional Strategic Plan, 2006-2015  Sustaining and enhancing DOTS to reach all TB patients, improve case detection and treatment success  Establishing interventions to address TB/HIV and MDR- TB  Forging partnerships, including with communities, to ensure equitable access to international standards of TB care for all  Contributing to strengthening health systems

14. 14 | Country office for Bangladesh What does the plan aim to do? Ensure equitable access to the highest quality of care (diagnosis and treatment) for all TB patients Accelerate progress and impact of TB control in order to reduce deaths and disease, and reach the TB targets under the MDGs by 2015 Reduce human suffering and socio-economic burden on families and communities Protect vulnerable populations from TB, TB/HIV and MDR-TB Help address health system constraints that impede TB control Support development of new tools and enable their timely and effective use

15. 15 | Country office for Bangladesh What will be achieved? If the plan is fully and effectively implemented,  TB deaths will reduce to a third of current levels  TB prevalence will halve to 175/100,000  TB incidence will fall to <100/100,000

16. 16 | Country office for Bangladesh What has been done so far? ChallengesResponses Sustaining political commitment and resources High level commitment: Amsterdam declaration; Washington commitment; “Call to stop TB in Asia”; WHA and Regional Committee resolutions of WHO Funding: through the GFATM, Stop TB Partnership, Global Drug Facility; domestic and external resources; Technical support : WHO and partner agencies Access to quality services, health systems DOTS Expansion to 98% population Partnerships: Private-public mix DOTS being scaled up in 8 countries; Community based interventions in 8 countries; Medical schools involved in 6 countries; DOTS at workplaces; promotion of policy of non- discrimination, job security; Innovations in health service delivery in difficult areas Risk behaviour, low adherence to treatment Patient support and motivation for treatment, innovative approaches to bring care ‘closest to home’ Poverty, inability to pay Free diagnosis and treatment under DOTS; Patient enablers; Community approaches to ensure equity; cost analyses to drive policy

17. 17 | Country office for Bangladesh What has been done so far? ChallengesResponses Lack of awareness, stigmatization Behaviour change strategies— better public education, communication, counselling skills, (health and non-health staff) Migrants, at-risk population Cross-border disease programmes; (but limited) targeted interventions for most at risk populations, in “hard to reach” areas Urban TB control “DOTS in big cities” India, Bangladesh, Myanmar and Thailand Multidrug resistance Upgrading National laboratory networks; “DOTS-Plus” on-going in Bangladesh, India, Nepal; Planned: Timor Leste, Indonesia, Myanmar, and Sri Lanka TB/HIV TB/HIV interventions in 5-year national plans Nationwide implementation: Thailand; India Collaborative pilots: Indonesia, Myanmar, Bhutan; Planned: Bangladesh, Sri Lanka, Nepal and Timor Leste

18. 18 | Country office for Bangladesh Indonesia: fall in TB prevalence (1980-2004) % fall cf 1990 42% 28% 54% 35% Source: Ministry of Health, Indonesia

19. 19 | Country office for Bangladesh Impact of DOTS on Case-fatality: India

20. 20 | Country office for Bangladesh Reduction in TB prevalence Model DOTS Project (Thiruvallur, South India) Source: TRC, Chennai

21. 21 | Country office for Bangladesh Bangladesh 19902005Difference Abs.% Estimated prevalence (all forms) 655607 630/100k 575391 406/100k -80216 -224/100k -12% -36% Estimated mortality 78904 76/100k 66423 47/100k -12481 -29/100k -16% -38% Estimated incidence (all forms) 274460 264/100k 321966 227/100k +47506 -37/100k +17% -14% Estimated incidence (NSP) 123507 119/100k 144880 102/100k +21373 -17/100k +17% -14% Source: WHO Report 2007, Global Tuberculosis Control – Surveillance, planning, financing

22. 22 | Country office for Bangladesh Assessment of vital registration systems in South-East Asia BANBHUKRDINDINO MAV MMR NEPSRLTHATLS What % of deaths are registered? (national estimate) < 50% 51%-69% 70%-89% 90% or more Year of last population census 20012005199320012000 19832001 20002004 Did it include a question on mortality Is there any of the following sources to estimate the mother / child or adult mortality? Periodic household survey Sample registration system Other microcensus/ sample surveys Routine health service records

23. 23 | Country office for Bangladesh Assessment of vital registration systems in South-East Asia BANBHUKRDINDINO MAV MMR NEPSRLTHATLS Is the “cause of death” collected in countries with death registration system? Is the Medical Certification of cause of death as per ICD-10 used? % of deaths registered by: Physicians90%15%60%50%12%90%60%35% Other medico-legal authority 40%50%15% Other % of deaths occurring in hospitals90%25% 50%12%6%40%35% % of deaths with autopsy doneAll15%<5% Who determines underlying cause of death on the certificate and assigns an ICD-10 code? Certifier Doctor other than certifier Medical record officer Other

24. 24 | Country office for Bangladesh Lessons learned and challenges ahead  Sustaining current success and progress: ensuring resources and quality implementation  Weak laboratory networks and surveillance mechanisms  Difficulties in addressing TB/HIV and drug-resistant TB  Low community awareness and utilization of services  National public health services overstretched: limited management capacity, infrastructure

25. 25 | Country office for Bangladesh Measuring progress against MDGs  High importance:  Strengthen routine surveillance systems for routine TB cases; to be extended with testing for HIV and drug-resistance  Strengthen death registration systems; evaluate the reliability of methods for classifying TB deaths  Moderate importance:  Undertaking disease prevalence surveys (where information is scarce)  Evaluate the reliability of treatment outcomes in patient cohorts  Low importance:  Conducting two or more tuberculin surveys, mainly to measure change in risk of infection

26. 26 | Country office for Bangladesh Conclusions: opportunities for meeting the TB-related MDGs  Good progress so far achieved in the Region  Enhanced resources for TB control:  Sustained/increased funding for national budgets  Additional support through bilateral and international initiatives (GFATM, GDF, Stop TB Partnership)  Growing partnership  Clear plans with set targets (what gets measured, gets done!)  Intensified technical support to maintain quality and to implement and sustain necessary, additional interventions

27. 27 | Country office for Bangladesh Thank you!