OPPORTUNITIES AND CHALLENGES FOR TB CONTROL Zay Yar Phyo Aung - - PowerPoint PPT Presentation

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MSc in International Health and Tropical Medicine Centre for Tropical Medicine and Global Health Nuffield Department of Medicine

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The following is part of a training exercise for MSc Students in International Health and Tropical Medicine, University of Oxford

OPPORTUNITIES AND CHALLENGES FOR TB CONTROL

Zay Yar Phyo Aung (Burma), Rachel Hounsell (South Africa), Mesulame Namedre (Fiji), Naima Nasir (Nigeria), Claudia Paul (Australia)* * equal contribution from all co-authors listed by alphabetic order

Presentation Outline

1.

Global burden & commitments

Global burden of TB // Key challenges // Globalcommitments

2.

TB in theUK

Overview of TB burden and control strategies in the UK,with a focus on England.

3.

Opportunities & challenges

A series of actions and insights to scale the support forTB control in the UK andglobally.

4.

Concluding messages

Thoughts for action

10 million cases of active TB worldwide in 2017

Global TB burden & challenges

TB is the leading cause of death from a single infectious agent: 1.6 million deaths due to TB in 2017 23% of the world’s population (1.7bn) are estimated to have a latent TB infection and are thus at risk of active infection TB is a curable, treatable infectious disease Drug-resistant TB is a public health crisis (>0.5 million in 2017) TBdisproportionately affects poor and vulnerable populations, with catastrophic costs & income losses 30 high burden countries account for 87% of TB cases worldwide TB/HIV co-infection is a common and seriouschallenge

Source: WHO’s Global Tuberculosis Report2018

Global targets & commitments

40 million by2022

By 2035, compared to2015:

• 1. Reduce TB deaths by 95%
• 2. Reduce new cases by 90%
• 3. Zero catastrophic costsfor

TB-affected families

Sep 2018 March 2016 May 2014

SDG Goal3 End TB Strategy

The UK has backed all three global commitments towards ending TB and is well positioned to support the scale up of local and international TB control efforts. By 2030: End the epidemicsof AIDS, tuberculosis, malaria and neglected tropical diseases By 2022, provide diagnosis& treatment for TBto:

• 1. 40 million people
• 2. 3.5 million children
• 3. 1.5 million people with drug-

resistant TB

• Second highest rate of TB among Western

European countries

• Between 2011 and 2017, there was a 38%

decline in number of TB notifications

• Incidence rate of 9.2 per 100,000

population, the first time under the 10 per 100,000 WHO definition of a low incidence country

• People born outside the UK accounted for

71% of TBnotifications

• 31% of pulmonary TB patients experience a

delay of more than four months between symptom onset and treatment start

• The rate of TB in the most deprived 10% of

the population was over 7 times higher than in the least deprived (18.4 vs 2.5 per 100,000)

TB Burden in England(2017)

TB Control: Collaborative TB Strategyfor England

• 1. PHE and NHS England launched the strategy as a guiding framework for

health and social services on the management of TB (2015 – 2020)

• 2. A two-way monitoring framework enables regular reporting to PHE and

feedback of surveillance data to the local and national stakeholders 3. Partnerships & action is coordinated through formally established regional TB controlboards

Source: Public Health England. Tuberculosis in England: 2018 Report

1 2 3

Increased UK support for global TBcontrol

Challenges &

• pportunities

to reach the missing millions

4 5 6 7 8

Greater funding for research & development Strengthening local & globalpartnerships Strengthening active casefinding Addressing latent TB infection Reducing delays in access to care Improving education & training Intensifying pre-entry screening to theUK

The Global Plan estimates that at least US$56 billion will be required for implementing the first 5 years of the End TB Strategy (2016-2020) The UK invested £3.3b (approx. US$5.4b) from 2001 – 2016 into the Global Fund for Tuberculosis, Malaria and HIV/AIDS. The US contribution to the Global Fund for the same period was US$13.2b The UK’s opportunity for impact is greatest in supporting global TB control efforts through multilateral funding

Increasing UK support for global TB control

3.5 5.4 6.1

3 2 1 4 5 6 7 2018 2020 2022

Billion USD

Financial gap

Source: https://www.who.int/tb/features_archive/WHO-urgent-action-to-end-TB/en/

Vaccine Development

14 new vaccines are being developed for better efficiency across all age groups

New Drugs forMDR-TB

To treat latent TB and combat drugresistance

Shorter Regimens

To improve adherence and reduce likelihood

• f resistance

Rapid and readily available diagnostics

Improved Diagnostics

Funding forresearch and development

The UK’s investment in R&D has the potential to make significant leaps forward in the fight against TB worldwide

Strengthening local and globalpartnerships

Global: international support for HBCs mainly towards diagnosis andtreatment. Local: collaborations for clinical care, social support and reaching underserved populations.

Opportunities forpartnerships:

• Explore innovative collaborations with the private sector
• Learn from and replicate successful partnerships such as London’s

“Find and Treat”model

• Link with groups tackling TB co-morbidities such as diabetes, HIV

and malnutrition

• Prioritise inter-sectoral partnerships (such as the criminal justice

system, social & economic welfare)

• Contribute to and share learnings with international collaborations

Onset of symptoms Treatment TB in theUK

• Over a third of patients diagnosed with

pulmonary TB experienced a delay of more than four months between onsetof symptoms and treatment

• MDR-TB cases increase from 46 (1.2%of

cases) in 2004 to 54 (1.6% of cases) in 2015

• Financial and religious beliefs
• Access to efficient &newer diagnostic tools
• Insufficient community level healthcare

provision

Low and middle incomecountries

• Private and traditional healers

Reducing delays in access to care

Source: Public Health England. Tuberculosis in England: 2018 Report

DELAY ACCESS

Increase transmission Social Problems Drug resistant TB Financial

Challenges

• Children are difficult to diagnose for latent vs active TB
• Need for more sensitive diagnostics, provision of

appropriate treatment and integration of TB services into

• ther programmes

Reactivation ofTB

• Majority of cases in the UK are due to reactivation of TB
• Higher risk for reactivation are PLWHIV,

immunosuppressant therapy, diabetes,undernutrition, smoking and alcohol consumption

Latent TB Screening

• Testing & treatment of new entrants from high burden countries

is effective, cost efficient and a good prevention method

• May be used to complement pre-entry screening

Addressing latent TB infection in the UK

Pre-entry screening to the UK

People born outside the UK accounted for 71% of TB notifications and the rate of TB among this population was 13 times higher than among those born in the UK

Opportunities for scaleup:

• Reduce incidence benchmark
• Include applicant applying for short

term visas <6months

• Community based screening
• Migrants from low risk & EU countries
• Targeted partnerships withNigeria,

India, China andPakistan

Source: Public Health England. Tuberculosis in England: 2018 Report

Opportunities for low-burden countries

• Locally: Expansion to other high-burden areas in the UK
• Internationally: Adapted to other low-burden countries

A robust case findingstrategy

• Effective community and private sectorengagement
• Systematic TB screening for high riskpatients

Find and Treat

A model of success from London Opportunity for scaleup Cost effective Compromises robust case finding strategies

Strengthening active casefinding

• Scale-up of childhood case findingstrategies

Opportunities for high-burden countries

• Effective distribution of primary healthcare facilities
• Improve functioning of sub-district hospitals

Source: UCLH: Find and Treat Outreach Service 2018: https://www.uclh.nhs.uk/ourservices/servicea-z/htd/pages/mxu.aspx

Improving education and training in the UK

Implementation of mandatory training for health & social care workers

• Increasing awareness of TB burden & control measures
• Use of diagnostictools
• Establishing reliable referral pathways

Improvingtraining

Example: The Royal College of General Practitioners, Public Health England, TB Alert

• Free e-learning course on TBin general practice to increase the understanding of

TB, its diagnosis andtreatment

CPD Programmes

• Particularly in areas of high TB incidence acrossLBCs
• Should be part of health workers annual CPD requirements

Collaboration

Source: Public Health England, Health matters: reducing the burden of tuberculosis 2016

Concluding messages Opportunities & challenges for TB control

TB is a curable, preventable infectious disease that causes

• est. 10 million cases & 1.6 million deaths per year globally

New global commitment to diagnose & treat 40 million people with TB by 2022, UK’s share projected to be 23,000 There are many multi-sectoral opportunities for the UK to strengthen its national TB control efforts UK’s impact on the “40 million by 2022” target can be maximized by supporting high burden countries through increased global funding andR&D