Overview of TB in the WHO European Region

Transcription

1 Overview of TB in the WHO European Region "New Trends in Infectious Diseases" Lyon, France - 26 November 2008 Dennis FALZON, MD Stop TB Department - WHO/HQ

2 WHO Regions

3 Number of reported TB cases U.S.A.*, MMWR; May 27, 1994 / 43(20);

4 TB case rates (1) Total cases, * 100 (104 cases / 100,000) TB cases / 100,000 (log10 scale) Non-Baltic FSU New EU states (2004) Western Europe * Countries with data represented in the groupings - Western Europe: Austria, Belgium, Cyprus, Denmark, Finland, France, Germany, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, United Kingdom. New EU states (2004): Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, Slovenia (Malta & Cyprus included under West Europe). Non-Baltic FSU: (former Soviet Union countries; Baltic states included under New EU) Armenia, Azerbaijan, Belarus, Kyrgyzstan, Moldova, Russian Federation, Ukraine. Main source of data : Global Tuberculosis Control: Surveillance, Planning, Financing. WHO/HTM/TB/ ; rest of data from EuroTB

5 TB case rates (2) By treatment history,

6 Mean annual change in TB case rates, * 10% % change in rate EU & West Balkans East 5% 0% -5% -10% * Excluding Monaco, San Marino (EU & West)

7 Mean annual % change in TB incidence rate/yr (Y-axis) vs health expenditure/cap. (Central & Eastern Europe)

8 Mean annual % change in TB incidence rate/yr (Y-axis) , vs. % TB cases of foreign origin (high income countries)

9 TB cases by geographic origin, EU & West,* TB cases National Foreign Unknown * Excluding countries with incomplete data for any one year or change in criterion of origin: Andorra, Bulgaria, Cyprus, Greece, Luxembourg, Monaco, Poland, San Marino, Spain. Cases from Romania (>25,000 yearly; <0.1% foreign) are not included.

10 Foreign TB cases by area of origin, EU & West, 2006 (N=13,478)* Africa EU & West Balkans Former Soviet Union Asia Americas Other / Unknown * Cases native or citizens of a country other than the one of report. Former Soviet Union does not include Baltic States. Pooled for countries with case-based data on country of origin, excluding Bulgaria, France, Israel, Monaco, Norway, San Marino, Spain.

11 TB case rates by ethnicity, England & Wales, TB cases / 100, Black African Pakistani Indian White Source: National Collaborating Centre for Chronic Conditions. Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. London: Royal College of Physicians, 2006.

12 Tuberculosis notification rates (1) Estimated TB incidence rate, 2006* Estimated new TB cases (all forms) per population No estimate or more 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

13 Tuberculosis notification rates (2) European Region, 2006* TB cases per population Not included Not reporting to EuroTB < > 50 Andorra Malta Monaco San Marino Source: EuroTB, 2008

14 TB mortality rates, * TB deaths per population Not included No data or data incomplete < > 10.0 Andorra Malta Monaco San Marino * Source: WHO Mortality Database, October Data shown for latest available year. Including only deaths from TB coded ICD or ICD-10 A15-19.

15 Geographic expansion of the European Union Former Soviet Union countries

16 The EU is an increasingly disparate group of countries TB cases / 100,000 (2005) % TB cases who are foreign (2005) < >50 < >55

17 HIV infection Infectious diseases in the EU Total burden of disease* TB Campylobacteriosis Salmonellosis Influenza EHEC Measles DALYs / yr / 100,000 population TB burden : wide country range = DALY/yr/100K pop Highest in Baltic States, Hungary, Portugal & Poland * 12 countries with data available for all 7 diseases. All estimates incorporate mortality, morbidity, & disability; TB estimates relate to Source: Pilot survey, RIVM (2007)

18 HIV / TB

19 Estimated prevalence of HIV infection in TB cases, global, 2003

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26 HIV infection among TB cases (1) Selected countries*, % TB cases Portugal United Kingdom Estonia Latvia * Completeness of information differs between countries.

27 HIV infection among TB cases (2) East*, % % HIV positive 5% 4% 3% 2% 1% 0% Ukraine (New cases) Russian Federation (New cases) Armenia Uzbekistan Belarus (New cases, 2005) Kazakhstan Georgia Tajikistan (Dushanbe) Azerbaijan (2003) * Completeness of information differs between countries. No data from Kyrgyzstan, Moldova, Turkmenistan.

28 HIV infection among TB cases (3) HIV / MDR-TB LATVIA, UKRAINE,* 2006 * DONETSK OBLAST The WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance

29 Anti-TB Drug Resistance

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31 Diagnostic DST by WHO region, NEW % of new cases tested AFR (8, 10%) AMR (17, 50%) EMR (10, 11%) EUR (45, 77%) SEAR (2, 0.03%) WPR (15, 12%) World (97, 19%) RETREATED % of re-treatment cases tested AFR (11, 14%) AMR (15, 65%) EMR (6, 13%) EUR (40, 82%) SEAR (3, 2%) WPR (12, 3%) World (87, 20%) Numbers under bars represent the number of countries reporting data followed by the percentage of total estimated cases of MDR-TB accounted for by reporting countries. Data for re-treatment cases from India and China excluded because testing of only 26 (India) and 10 (China) cases was reported.

32 High TB burden countries 22 countries with 80% of estimated global TB incidence

33 High MDR-TB burden countries 27 countries with 85% of estimated global MDR-TB incidence 15

34 MDR-TB among new TB cases

35 Combined MDR-TB by area of origin EU & West,* 2005 EU & West Balkans Former Soviet Union Rest of Asia Africa Americas & Oceania Unknown Total Cases tested for INH & RMP 7, ,509 2, ,005 N MDR % * Countries with case-based data (excluding Baltic States - Estonia, Latvia, Lithuania) : Andorra, Austria, Belgium, Cyprus, Czech Republic, Denmark, Finland, Germany, Hungary, Iceland, Ireland, Luxembourg, Malta, Netherlands, Portugal, Slovakia, Slovenia, Sweden, Switzerland, United Kingdom. The 12 countries in the East, and the Baltic States

36 Primary MDR-TB, EU & West, 2006 Cases and prevalence* Cases % 1ary MDR Cyprus Luxembourg Andorra Iceland Norway Finland Slovenia Malta Netherlands Sweden Denmark Slovakia Switzerland Czech Republic Austria Belgium France Israel United Kingdom Estonia Germany Latvia Lithuania * Presence of MDR among previously untreated cases in countries with nationwide representative data in 2006 (sentinel surveillance data in France); proportion MDR calculated as a percentage of new cases with results of initial testing for H & R.

37 Treatment & Control

38 WHA Targets, 1991 Detect at least 70% of new sputum smear positive cases Successfully treat at least 85% of cases detected

39 Millennium Development Goals Target 8. Have halted by 2015, and begun to reverse, the incidence of malaria and other major diseases STB Indicators Prevalence and death rates associated with TB Proportion of TB cases detected and cured under DOTS

40 DOTS coverage by WHO region, WHO target WPR 5.6 Case detection rate (%) AMR SEAR EUR EMR AFR

41 Treatment outcome - Europe * Success Died Failed or Still on treatment Defaulted, Transferred or Unknown % cases 100% 80% 60% 40% 20% 0% EU & West Balkans East * New definite pulmonary cases reported by countries with representative outcome data. EU & West (culture positive): Andorra, Austria, Belgium, Czech Rep, Denmark, Estonia, Germany, Hungary, Iceland, Ireland, Israel, Latvia, Lithuania, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Sweden, United Kingdom. Balkans (smear positive): Albania, Macedonia F.Y.R. East (smear positive): Kazakhstan, Kyrgyzstan

42 DOTS status in 2006: countries close to targets 100 Iceland Bosnia & Herzegovina Target zone Treatment success (%) China El Salvador Kiribati China, Macao SAR Cuba Cambodia Lebanon Samoa Tunisia Bhutan Afghanistan Bangladesh Peru 90 Indonesia Lao PDR Somalia Nepal French Polynesia Philippines Portugal DPR Korea Costa Rica Honduras Sri Lanka Mongolia Turkey Benin Bulgaria India Marshall Islands Maldives Algeria Kyrgyzstan TFYR Macedonia Guam Nicaragua Slovenia Qatar DR Congo Uruguay Myanmar Dominican Republic Kenya Singapore Iran (islamic republic of) Venezuela Jordan Romania Haiti Morocco Turkmenistan 80 Vanuatu Bolivia Brazil Egypt Mexico Poland Liberia Madagascar Thailand Puerto Rico Cameroon Belize Armenia Latvia Estonia Georgia Angola Malaysia Brunei Darussalam Czech Republic Kazakhstan South Africa Fiji Lithuania DOTS case detection rate (new smear-positive, %) 99 countries reported treatment success rates 70% or over and DOTS detection rates 50% or over 32 countries (including 2 countries out of range of graph) have reached both targets.

43 Estimated TB prevalence (a) and death rate (b), for the baseline year 1990 and for 2006, compared with the 2015 target and with prevalence and death rates projected for 2015 based on current trends (a) TB prevalence per population (b) TB death rate per population AFR AMR EMR EUR SEAR WPR World 0 AFR AMR EMR EUR SEAR WPR World (current trends) MDG target (current trends) MDG target

44 30 Country projections of M(X)DR-TB patients to be enrolled on treatment in 2007 compared with the Global Plan 25 Russian Federation South Africa India China 5 0 Global Country Global Projected Global Projected Plan report Plan Plan AFR AMR EMR EUR SEAR WPR

45 MDR-TB treatment outcomes Selected countries, 2003 cohort Percentage of cohort Germany (94) Lithuania (310) Brazil (316) Estonia (106) Latvia (165) Romania (585) Peru (1508) Success Died Failed Lost to F/U Numbers under bars are the number of patients in the cohort

46 Total TB control costs by country, High-burden countries, a All other HBCs DR Congo US$ millions Kenya UR Tanzania Indonesia Nigeria Brazil India China South Africa Russian Federation a Total TB control costs for are based on expenditure data, whereas those for are based on budget data

47 Conclusion Huge disparity between and within countries in the EUR Region (even in EU!) Overall decrease in rates BUT countries far from TB elimination (1 TB case /10 6 pop) TB in vulnerable groups becomes more crucial M(X)DR-TB with/-out HIV

48 Action points More investment in prevention and control Targeting of risk and vulnerable groups Support for innovative technologies in diagnostics and treatment Operational research

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