What will it take to End TB?

The Snell Memorial LectureBritish Thoracic Society 2016

Christopher DyeWorld Health Organization

Snell Memorial Lectures in the MDG era• 2015 BCG – old story with new twists. Paul Fine• 2014 Mycobacterium tuberculosis: where did it come from

and where is it going? Douglas Young • 2012 The pathway to the development of TB

vaccines. Helen McShane• 2009 New anti-TB drugs and how to test them. Denis

Mitchison• 2008 Novel diagnostic approaches to tuberculosis. Ajit

Lalvani• 2006 The current treatment of tuberculosis: Should we be

doing better before new drugs arrive? Peter Ormerod• 2005 The origin of tuberculosis. Stewart Cole• 2003 Taking risks in tuberculosis. John Moore-Gillon• 2001 Tuberculosis: A global view. Philip Hopewell

Sustainable Development Goals: 2016-2030New impetus to End TB?

Sustainable Environments

Health & Well-being

Growing Economies

Inclusive Societies Systems & ServicesUniversal Health Coverage

Systems:Shared inputs,

mutually beneficial outcomes

TB ↔ SDGs

235 indicators 21 important

7 critical 5 UHC>1 R&D

≥ 8 of 17 Goals

Impact of drugs on TB case fatality: Enlgand & Wales

0

50

100

150

200

250

300

350

400

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Cas

e no

tific

atio

ns o

r de

aths

/100

,000

/yea

r

0

0.1

0.2

0.3

0.4

0.5

0.6

Dea

ths/

case

s

deathscasescase fatality

0

200

400

600

800

1000

1960 1970 1980 1990 2000 2010

Pre

vale

nce

TB/1

00k

“Model DOTS" accelerates TB decline in S India

2.1

2.0

14.4

13.27.2

15.84.2

0.8

Intervention1999-2006

Culture+

Smear+

Model: early Dx/Rx cuts transmissionNot model: hard to scale

MDG 6 TB target achieved but still a top 10 cause of death

Target

Mortality

49 million lives saved between 2000 and 2015

Incidence

Falling 1.4% per year (2000-5)

18% drop since 2000

TB epidemic reversed, 47% fall in TB mortality

Millions

Where is TB falling fastest?Decline incidence rate since 2010 >4%/year in:

Zimbabwe (-11%)Lesotho (-7%)

Tanzania (-6.8%)Ethiopia (-6.7%)Namibia (-6.2%)Kenya (-5.0%)Russia (-4.2%)

All countries with increase in incidence 1990sHigh %HIV+, or Russia, high proportion recent infectionWHO Global TB Control 2016

Ref: G

lobal TB C

ontrol Report 2016

TB-HIV: a big problem locally71% HIV+ TB cases in Sub-Saharan Africa

11% new TB cases HIV+ 2015

Drug-resistant TB in every country rise of XDR but no increase in MDR globally

480k new cases of MDR-TB in 2015+100k new rifampicin-resistant TB eligible for MDR-TB treatment

0-2.93-5.96-11.912-17.9>18

% cases with MDR/RR-TB

1

10

100

1000

10000

1990 2000 2010 2020 2030 2040 2050

TB c

ases

/mill

ion/

year

Year

Up to 10%/yr with currenttechnologyBeyond currenttechnology

Elimination <1/M

2%/yr

20%/yr

10%/yr

TB cases: elimination by 2050?

UHC

New tools

20%/yr

TB affected families facing catastrophic costs: 0% by 2030

SDG 3.8Achieve universal health

coverage

UHC: Everyone can get the health services they need without suffering financial hardship when paying for them

Goal 3: Ensure healthy lives and promote well-being for all at all ages

Aaron MotsoalediUSAID’s TB Champion

“time to treat TB with the same urgency… as Ebola or Zika virus.”

Jim KimWorld Bank President

“to meet needs of the poor… functioning health systems in every country in the world.”

World TB Day 2016

Doctors and delays, Bangalore

No. doctors seen by TB patients

02040

6080

100120

140160180

1 2 3 4 5 6 7Number of doctors

No.

fem

ale

patie

nts

0

50

100

150

200

250

No.

mal

e pa

tient

s

WomenMen

0

20

40

60

80

0 1 2 3 4 5 6 7 8Number of doctors

Tota

l dur

atio

n (d

ays)

Each extra doctor seen

adds 12 days

More doctors, longer treatment

Pantoja 2009

Out-of-pocket expenditures on health too high

Mandatory prepayment

Voluntary prepayment

Out-of-pocket

Not-for-profit

Private, other

20%

40%

Shar

e of

tota

l hea

lth e

xpen

ditu

res

(%)

60%

80%

100%

R² = 0.650

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11

Out of p

ocket a

s % expen

diture health

 

Government health spending as % of GDP

Azerbaijan

Sweden

Where governments spend more on health, with financial protection, patients pay less

European countries

WHO EURO

Vertical TB services with in-patient care are often inefficient

WHO EURO

Tallinn Charter: health systems for health and wealth

• Armenia out-patient TB treatment most effective to reduce costs and expand TB services

• Azerbaijan shift to out-patient treatment, TB services in State Benefit Package

• Kazakhstan integration of TB and HIV with primary health, disease management programme emphasizing risk groups

• Kyrgyzstan aligning financing and servicedeliveryWHO EURO

Mean cost of TB episode as

% yearly household income per capita

58%

81% 83%

40%

50%

60%

70%

80%

90%

100%

High livingstandard

Medium livingstandard

Low livingstandard

Bangalore

32%

68%

0%

20%

40%

60%

80%

100%

High living standard Low living standard

Yangon

Inequity ─ measurement exposes the problem

Inequity – few easy solutions?

USAID TB CARE II Project 2013

Thailand long waiting times discourage patients from obtaining services through national health insurance Philippines patients believe they face direct and indirect costs for TB services in the public sector, thus choose private, including pharmacies

General uncoordinated functions of NTPs and insurance agencies

Addis Ababa Action Agenda domestic $$ needed, but international $$ too

Share of global TB burden in 2015 (incident cases)

BRICS 42%

Other middle-income (42%)

Low-income (14%)

High-income (2%)

Shar

e of

ava

ilabl

e fu

ndin

g in

201

6

SDGs 3, 9…“Enhance scientific

research, foster innovation”

R&D for TB 2016

• ≈$2bn/year needed, $1.1bn gap• 4 diagnostic tests recommended by WHO• 9 drugs in advanced clinical trials for drug-

susceptible and drug-resistant TB or latent infection

• 13 vaccine candidates in clinical trials for prevention of infection and prevention of disease in people already infected

Best rapid diagnostic is Xpert MTB/RIF but not “point-of-care”

Treatment Action Group 2015

1

10

100

1990 2000 2010 2020 2030 2040 2050

Cas

es/m

illio

n/yr

Even USA needs more than current tools

Total

US born

Base

IPT HIV-

On course for elimination

Not on course for elimination: needs boost from IPT for HIV-

100

What could the SDGs do for TB?Case incidence: the first 10%• Early diagnosis & treatment

UHC in SDGs has shifted thinking on TB UHC isn’t simple, but good local solutions emerging

Case incidence: the second 10%• R&D critical

Point-of-care diagnosisTreatment latent infection (mass)Vaccination

Mortality• Drug treatment has bigger & quicker effects on

mortality than incidence

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5

6

0

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160

1980 1985 1990 1995 2000 2005 2010 2015

New

 cases ('00

0s)per year ‐

Hun

gary 

New

 cases ('00

0s) p

er year ‐

Russia 

Years 

Undoing: TB and the collapse of the Soviet Union

RussiaHungary