Progress towards global targets for TB control
Katherine FloydStop TB DepartmentWorld Health Organization
IUATLD conferenceStop TB SymposiumCancun, 3 December 2009
To be published on 8 December
1. The global burden of TB (2008) and global targets for TB control
2. Progress towards global targets Treatment success and case detection TB/HIV and MDR-TB Financing Disease burden – incidence, prevalence, mortality
3. Summary
Overview
1. The global burden of TB and global targets for TB control
Estimated number of
cases
Estimated number of
deaths
1.3 million*(range, 1.1–1.7 million)
9.4 million(range, 8.9–9.9 million)
0.5 million
All forms of TB
Multidrug-resistant TB (MDR-TB)
HIV-associated TB 1.4 million (15%) (range, 1.3–1.6 million)
0.52 million(range, 0.45–0.62 million)
The global burden of TB in 2008
*excluding deaths among HIV+ people
Most cases still in Asia
South-East Asia
34%
Africa31%
Western Pacific
20%
EMR7%
Europe5%
Americas3%
54% cases in Asia
Highest incidence rates in Africa
Linked to high rates of HIV infection:78% of estimated HIV+ TB cases in Africa
1. Millennium Development Goals Halt and reverse incidence (MDG 6, Target 6.c)
2. Stop TB Partnership Halve 1990 prevalence and mortality rates (per 100 000
population)
Global targets for reductions in disease burden set for 2015
1. Detect 84% of smear-positive cases, and successfully treat 87% of them, by 2015
2. TB/HIV 85% TB patients tested for HIV by 2010 95% HIV+ TB patients on CPT* by 2010 320,000 HIV+ TB patients enrolled on ART* by 2010
3. MDR-TB 80% of smear and/or culture-positive cases diagnosed
and treated by 2015 (equivalent to ~400,000 cases in 2015)
4. Financing US$5–9 billion per year for TB control, 2009–2015
Major targets in the Global Plan
*CPT, cotrimoxazole preventive therapy; ART, antiretroviral therapy
2. Progress towards global targets
a) treatment success and case detection rates
Treatment success target reached globally
Succ
essf
ul tr
eatm
ent r
ate
(%)
in D
OTS
coh
orts
85
77
79
77
79
81
80
82
82
82
83
84 85
87
40
50
60
70
80
90
92 88 82 7967
88
020406080
100
W Pacific
SE Asia EMR
America
sAfri
ca
Europe
But not in the Americas, Africa and Europe
5.7 million notified casesX.X million sm+ notified cases
30405060708090
30405060708090
30405060708090
Africa-high HIV Africa-low HIV Eastern Europe
Red line: Global Plan milestones and 2015 target for CDRBlack line: actual CDR
South-East AsiaLatin AmericaEastern Mediterranean
GLOBALWestern Pacific
Case detection stagnating globally, gap with Global Plan widening
CDR stable at ~70% since 2005
2002 2008 2015
61% in 2008vs. Global Plan milestone of 71%
201520082002201520082002
Gap especially large in Africa
Cas
e de
tect
ion
rate
(%)
Three regions ahead or on track compared with Global Plan
Estimated case detection rates in 2008, by region
78 7870
6557
47
0102030405060708090
EMR = Eastern Mediterranean Region
Cas
e de
tect
ion
rate
(%)
2. Progress towards global targets
b) TB/HIV and MDR-TB
TB/HIV intervention scale-up, Africa*
Intervention, 2008 Actual Global Plan
% TB patients tested 45% 68%
% HIV+ TB on CPT 73% 90%
HIV+ TB on ART (000s) 89 279
TB patients tested for HIV HIV+ TB patients on CPT
*Africa has 78% HIV+ TB cases globally
HIV+ TB patients on ART
20
40
60
80
100
2005 2006 2007 2008
Thou
sand
s
31%
100200300400500600700
2005 2006 2007 2008
Thou
sand
s
0
40
80
120
160
200
240
2005 2006 2007 2008
Thou
sand
s
73%45%
11%
MDR-TB treatment expected to expand from currently low levels in 2009 and 2010
1923
30 2937
55
0
10
20
30
40
50
60
70
2005 2006 2007 2008 2009 2010
Num
ber o
f pat
ient
s (th
ousa
nds) non-GLC
GLC-approved
GLC = Green Light Committee
*Global MDR/XDR-TB Response Plan, 2007, updated for high-level Ministerial meeting on MDR/XDR-TB in Beijing, April 2009
But still behind Global Plan* in 27 high MDR-TB burden countries
0
50
100
150
200
250
300
350
400
2007 2008 2009 2010 2011 2012 2013 2014 2015
Num
ber o
f pat
ient
s (th
ousa
nds)
Global PlanActual or expected progress To reach
targets, scale-up required in India, China and Russian Federation in particular
2. Progress towards global targets
c) financing
Funding has increased substantially in recent years
technical assistance and R & D not includedData based on ~ 100 countries each year with ~ 94% estimated global cases
0
1
2
3
4
5
2006 2007 2008 2009 2010
US$
bill
ions
Unknown
Global Fund
Grants (excl. GF)
Loans
Government (health system)
Government (NTP budget)
2.7
4.1
But still falls short of Global Plan targets, except in E. Europe
Sources: WHO TB database, Global Plan; technical assistance and R & D not included
All regions except Eastern Europe
Data based on ~ 100 countries each year with ~ 94% estimated global cases
Eastern Europe
0
1
2
3
4
GP AF GP AF GP AF GP AF GP AF
2006 2007 2008 2009 2010
Other
TB/HIV
MDR-TB
DOTS
US$
bill
ions
0
1
2
3
4
GP AF GP AF GP AF GP AF GP AF
2006 2007 2008 2009 2010
3.8
1.7
2.7
1.3
GP = Global PlanAF = Available Funding
2.2
1.2
2. Progress towards global targets
d) impact targets for reductions in disease burden
1990 1995 2000 2005
Rat
e pe
r 100
,000
pop
ulat
ion
150
145
140
135
130
125
120
Incidence rates falling globally after peak in 2004
Peak in 2004
World as a whole on track to achieve MDG target 6.c
Number of cases in millions
02468
10
1990 1993 1996 1999 2002 2005 2008
Incidence rates in 9 subregions
Incidence falling in all sub-regions except African countries with low HIV prevalence
*EME = Established Market Economies
Rat
e pe
r 100
,000
pop
ulat
ion
Central EuropeAfrica-low HIVAfrica-high HIV
Eastern Europe EME* E. Mediterranean
W. PacificSouth-East AsiaLatin America
200300400500600700
100
150
200
250
406080
100120140160
1990 1995 2000 2005
200
250
300
350
400
10152025303540
200
300
400
500
1990 1995 2000 2005
20406080
100120
100150200250300350400
100150200250300350400
1990 1995 2000 2005
Africa-high HIV
Rat
e pe
r 100
,000
pop
ulat
ion
Prevalence rates in 9 subregionsCentral EuropeAfrica-low HIV
Eastern Europe EME* E. Mediterranean
W. PacificSouth-East AsiaLatin America
*EME = Established Market Economies
Five regions appear to have reached target of halving 1990 prevalence rate already (green)
SE Asia and E. Mediterranean may be able to achieve target
African countries far from target, such that target unlikely to be reached globally
Black line marks target level at 50% of 1990 prevalence rate
20
40
60
80
100
15
20
25
30
35
40
5
10
15
20
1990 1995 2000 2005
2025303540455055
1.0
1.5
2.0
2.5
20
30
40
50
60
1990 1995 2000 2005
2
4
6
8
10
12
14
20
40
60
80
100
20
30
40
50
60
70
1990 1995 2000 2005
Mortality rates in 9 subregionsAfrica-high HIV Africa-low HIV Central Europe
Eastern Europe EME* E. Mediterranean
Latin America South-East Asia W. Pacific
Rat
e pe
r 100
,000
po
pula
tion
Four regions appear to have reached target of halving 1990 mortality rate already (green)
SE Asia, E. Mediterranean and E. Europe may be able to achieve target
African countries far from target, such that target unlikely to be reached globally
*EME = Established Market EconomiesBlack line marks target level at 50% of 1990 mortality rate
Summary of progress towards targets
Successful treatment rate 87%
Case detection rate 61%TB/HIV Major progress: need to scale up
further to reach targets
MDR-TB treatment Progress but far short of targetsFunding Increased substantially in recent years
but still not high enoughIncidence Slowly falling, on target
Prevalence and mortality Several regions on track to reach 2015 targets, but unlikely achievable at global level due to high levels of prevalence and mortality in Africa
Acknowledgements
all those from 198 countries that contributed to reporting of data to WHO in 2009 (www.stoptb.org/tme)
Core Report TeamLéopold Blanc, Dennis FalzonChristopher Fitzpatrick, Katherine Floyd, Inés Garcia, Philippe Glaziou, Christian Gunneberg, Tom Hiatt, Hazim Timimi, Mukund Uplekar, Lana Velebit
USAID
WHO Regional OfficesAmal Bassili, Andrei Dadu, Daniel KibugaKhurshid Hyder, Rafael Lopez-OlarteDaniel Sagebiel, Henriette Wembanyama
To be published on 8 December