Post on 18-Jul-2015
Tuberculoza o boala de actualitate permanenta
Dr. Cristian Cojocaru Prof. Dr. Traian Mihaescu
Marcus Tullius Cicero 106-43 IC Roman PoliticianCardinal Richelieu 1585-1642 Francez PoliticianAlexander Pope 1688-1744 Englez PoetLuigi Boccherini 1743-1805 Italian MuzicianJohann Wolfgang von Goethe 1749-1832 German ScriitorFriedrich Schiller 1759-1805 German ScriitorRene Theophile Hzacinthe Laennec 1781-1826 Francez MedicNiccolo Paganini 1782-1840 Italian MuzicianFrederic Francois Chopin 1810-1849 Polonez MusicianEmily Bronte 1818-1848 Englez ScriitorFyodor Dostoyevsky 1821-1881 Rus ScriitorEdward Livingston Trudeau1845-1915 American MedicAnton Cekhov 1860-1904 Rus ScriitorMahammed Ali Jinnah 1876-1948 Indian PoliticianIgor Stravinsky 1882-1971 Rus MuzicianFranz Kafka 1883-1924 German ScriitorEleanor Roosevelt 1884-1962 American Sotia
presedinteluiDavid Lwrence 1885-1930 Englez ScriitorGeorge Orwell 1903-1950 Englez ScriitorNelson Mandela 1918- Sud African
Reversing the tuberculosis upwards trend:a success story in Romania
C. Marica*, C. Didilescu*, N. Galie*, D. Chiotan*, J.P. Zellweger#, G. Sotgiu",
L. D’Ambrosio+, R. Centis+, L. Ditiu1 and G.B. Migliori+ Eur Respir J 2009; 33: 168–170
0–24
25–49
50–99
100–299
>300
No estimate
138,8
110
61 55,8
70
102,6
134,1142,2 135,7
0
20
40
60
80
100
120
140
160
1972 1975 1980 1985 1990 1995 2001 2002 2003
Fonduri pentru TB control
3.9
4.7
1. Chile, 2. Peru, 3. Columbia, 4. Venezuela, 5. Mexic, 6. SUA, 7. Canada, 8. Egipt, 9. Iordania, 10. Israel, 11. Rusia, 12. Hawai, 13. China, 14. Japonia, 15. Tailanda, 16. Tonga, 17. Insulele Solomon, 18. Papua Noua Guinee
1. Marea Britanie, 2. Franţa, 3. Portugalia, 4. Spania, 5. Elveţia, 6. Italia, 7. Grecia, 8. Serbia, 9. Turcia, 10. Ungaria, 11. Austria, 12. Cehia, 13. Polonia, 14. Lituania, 15. Germania, 16. Suedia, 17. Norvegia, 18. Danemarca, 19 Finlanda3
Mortalitatea prin tuberculoza in perioada 1938-1993
Morbiditatea prin tuberculoza in perioada 1960-1996
Evolutia indicatorilor epidemiologici în mediul urban şi rural, de la momentul „0” al aparitiei tuberculozei intr-o populatie
Mortalitatea prin tuberculoza, reprezentata in functie de sex si virsta: A. In timpul perioadelor inalt epidemice; B. In timpul perioadelor intermediare; C. Perioada de dupa valul epidemic.
Situatia actuală si tendintele viitoare ale imbolnavirii prin tuberculoza
2000 - opt milioane de bolnavi de tuberculoza1997-2000 crestere cu 1,7%/an crestere in regiunea sub-Sahariană şi în ţările ex-sovietice scădere in Europa Centrală si de Vest, America si Orientul Mijlociu 2000 - 1,8 milioane de decese datorate tuberculozei
Estimated number of cases
Estimated number of deaths
1.7 million*(range: 1.5–2.0 million)
9.4 million(range: 8.9–9.9 million)
440,000(range: 390,000–510,000)
All forms of TB
Mult idrug-resistant TB (MDR-TB)
HIV-associated TB 1.1 million (12%) (range: 1.0–1.2 million)
380,000(range: 320,000–450,000)
*including deaths among PLHIV
Situatia TB -2009
about 150,000
0–24
25–49
50–99
100–299
300 and higher
No estimate available
0–24
25–49
50–99
100–299
>300
No estimate•Highest burden in Asia (55% of 9.4 million cases)
•Highest rates in Africa, due to high HIV infection rate~80% of HIV+ TB cases in Africa
Per 100 000 population
Incidenta TB - 2009
Impactul HIV la pac cu TB
Notified cases per 100,000 pop. 1980-2008
•79% of all TB/HIV cases world-wide are in Africa•50% of all TB/HIV cases world-wide in 9 African countries•23% of the estimated 2 million HIV deaths due to TB
MDR-TB in % la cazurile noi de TB, 1994-2009
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 2010. All rights reserved
Stopping Tuberculosis in EnglandAn Action Plan from the Chief Medical Officer
Action 1: Increased awareness
Aim: Maintain high awareness of TB, particularly among health professionals , highrisk groups and people who work with them, teachers, and the public
Five point plan > Produce multilingual and culturally appropriate public information and education materials for national and local use and make them widely available > Ensure that general practitioners and other primary and community care staff are aware of: the symptoms and signs of the disease; local TB services; and local arrangements for referring patients with suspected TB > Use World TB Day in March each year to increase awareness, particularly among healthcare professionals and high risk communities, and encourage relevant national organisations to do the same Maintain awareness, including through the media and community groups, and develop initiatives to support local awarenessraising among high risk groups Seek greater professional awareness through undergraduate, postgraduate and continuing professional education
Stopping Tuberculosis in EnglandAn Action Plan from the Chief Medical Officer
Action 2: Strong commitment and leadership
Aim: Create a strongly led, well coordinated and adequately resourced national TB programme, with all those working to deliver the programme having a clear focus on what needs to be achieved and best practice for doing this
Stopping Tuberculosis in EnglandAn Action Plan from the Chief Medical Officer
Action 3: High quality surveillance
Aim: Provide the information required at local, national and international levels to
• identify outbreaks
• monitor trends
• inform policy
• inform development of services, and monitor the success of the TB programme
Stopping Tuberculosis in EnglandAn Action Plan from the Chief Medical Officer
Action 4: Excellence in clinical care
Aim: Provide uniformly high quality, evidence based treatment and care for patients with suspected and diagnosed TB, with all patients having their outcome of treatment recorded and at least 85 per cent successfully completing treatment
Stopping Tuberculosis in EnglandAn Action Plan from the Chief Medical Officer
Action 5: Well organised and coordinated patient services
Aim: Provide high quality coordinated services for TB diagnosis, treatment and continuing care, which also meet the needs of individual patients
Action 6: First class laboratory services
Aim: Provide laboratory services of consistent high quality which support clinical and public health needs, in keeping with the overall pathology modernisation programme
Stopping Tuberculosis in EnglandAn Action Plan from the Chief Medical Officer
Action 7: Highly effective disease control at population level
Aim: Increase the evidence base for, and the consistency of application of public health interventions for TB
Action 8: An expert workforce
Aim: Ensure TB control has an appropriately skilled workforce and that physicians and nurses with expertise in TB continue to be recruited, trained and retained
Stop TB Strategy & Global Plan
To save l ives, prevent suffering, protect the vulnerable, & promote
human rights
1. Implementarea DOTS
2. TB-HIV, MDR-TB, la populati i le sarace si vulnerab i le
3. Intarirea sistemului de sanatate
4. Sensibil izarea tuturor funizori lor de sanatate
5. Sustinerea persoanelor cu TB
6. Promovarea cercetari i
2015: Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6c: to have halted by 2015 and begun to reverse the incidence…
*Indicator 6.9: incidence, prevalence and mortality associated with TB*Indicator 6.10: proportion of TB cases detected and cured under DOTS
2015: 50% reduction in TB prevalence and deaths by 20152050: elimination (<1 case per million population)
Tintele Global TB Control
Launched in Johannesburg13 October 2010
Global Plan to Stop TB 2011-2015
*CPT, cotrimoxazole preventive therapy ART, antiretroviral therapy
INDICATOR TARGETNumber of countries with ≥1 smear microscopy lab per 100 000 population
149 (All countries in plan)
Patients notified + treated 6.9 millionTreatment success rate 90%
INDICATOR TARGETNumber of 22 HBCs and 27 MDR-TB HBCs with >1 Cx & DST lab to cover 0.5-1 M population
36/36
Previously treated cases tested for MDR
100%
New cases tested for MDR 20%, all at high-risk
MDR-TB patients treated following WHO guidelines
100%, or ~ 270k
INDICATOR TARGETTB patients tested for HIV 100%
HIV+ TB patients on CPT 100%
HIV+ TB patients enrolled on ART
100%
DOTS/lab strengthening MDR-TB/lab strengthening
TB/HIV
pp17
10 tinte pentru 2015
Realizari pina in prezent
• 41 milloane de patienti vindecati, 1995-2009
• 6 milioane de decese prevenite comparativ cu standardele din 1995
• Mortalitatea reducsa cu 35% din 1990
• Vindecari >85%, ingijirea/HIV imbunatatita
• But…. TB incidence declining too slowly, case detection stagnating, and MDR-TB care only now starting scale-up
Estimari globale ale prevalentei si mortalitati i
2015
Mortalitatea
1990
35
25
15
0
target
Prevalenta
1990
300
200
100
0
2015
target
shaded area = uncertainty band
Incidenta globala - scadere <1%/an
Peak in 2004
Incidence (all forms, incl. PLHIV)
TB Notifications
Incidence TB in PLHIV
shaded area = uncertainty band
Notif ication gap
shaded area = uncertainty band
6.7
9.4
3.7
5.8Notificari (negru)
incidenta estimata (albastru)
TB
cases (millions)
Detectia cazurilor gap: 1/3
Cresterea notif icari lor (public-privat)
Source: 2010 WHO global TB control report, Table 7, page 16
NATIONAL PARTS OF COUNTRY
Succesul treatmentului - 86% global
Global WHO Regions
Progres in majoritatea regiunilor, Europeramine in urma
W. Pacific
SE Asia
EMR
Africa
93
88
80
Americas77
66Europe
Testarea HIV la pacienti i cu TB
Africa
World
Tinta 100% in Global Plan
Citeva tari inregistreaza rate de testare f bune
Rwanda: 97%Kenya: 88%Tanzania: 88%Malawi: 86%Mozambique: 84%P
ercentag
e of T
B p
atients
Provocari pentru 2011
1. Fonduri nesigure
2. slabaDoar 61% din cazuri sunt raportate
3. TB/HIV major impact in Africa
4. MDR-TB in tarile ex-URSS si China
5. Politici slabe de sanatate
6. Practica medicala in afara sistemului de notificare
7. Communitati neinteresate de politicile de sanatate
8. Cercetare
Fonduri necesare, Global Plan
Implementation
Plan component US$ bil l ions, 2011–2015
% total
IMPLEMENTATION 36.9 79%DOTS 22.6 48%MDR-TB 7.1 15%TB/HIV 2.8 6%Lab strengthening 4.0 8%Technical assistance
0.4 1%
R&D 9.8 21%TOTAL 46.7 100%
PLUS: Target that diagnosis should be free-of-charge or fully reimbursable by health insurance in all 22 high-burden countries (HBCs)
Fonduri 2010−2011 vs. funduri necesare Global Plan, 2011−2015
Imbunatatirea controlului TB
1. Remove financial barriers (UHC)2. Ensure well trained and sufficient human resources3. Establish a network of labs where rapid tests are also
available4. Ensure availability of quality drugs5. Regulate the use of all anti-TB drugs6. Introduce infection control7. Establish proper surveillance8. Promote R&D9. Mobilize resources domestically and internationally
Document WHA 62.15, 2009
•Public and private medical colleges (yellow) diagnose a huge number of cases, but many of them are from outside the city and need to be refereed for treatment elsewhere.
•The increase in diagnosed cases represents increased notification after medical colleges and other providers started to report to NTP in a standardised way
Bangalore, 1999-2005
Cresterea numarului de notif icari
Limitari ale diagnosticului, medicamentelor, vaccinului
Diagnostics - More than 100 years old • Detects only half of the cases in patients tested• Ineffective for diagnosing TB in PLHIV• Rapid tests for MDR strains available, but not yet in the field
Drugs – Last drug 40 years old • Four drugs, taken for at least 6 months• Not compatible with some HIV/AIDS antiretrovirals• MDR-TB treatment lengthy, with low cure rates, expensive, toxic
Vaccine – Nearly 90 years old• Unreliable protection against pulmonary TB• No apparent impact on the TB epidemic
1
10
100
1000
10000
2000 2010 2020 2030 2040 2050
Year
Inc
ide
nc
e/m
illio
n/y
r
Elimination 16%/yr
Global Plan 6%/yr
Current trajectory 1%/yr
Implementarea completa a Global Plan
Elimination target: 1 / million / year by 2050
TB incidence 10x lower than today, but >100x higher than elimination target in 2050
Current rate of decline
Impactul potential al unui nou vaccin, test si medicament in SE Asia
Sou
rce:
L. A
bu R
adda
d et
al,
PN
AS
200
9
Add. Effects = effects also on latency and infectiousness of cases in vaccinated
•Led & NAAT at microscopy lab level•Dipstick at point of care
•Regimen 1 = 4-month, no effect on DR•Regimen 2 = 2-month, 90% effective in M/XDR•Regimen 3 = 10-day, 90% effective in M/XDR
Eliminarea TB in 2050 interventi i sinergice
Dye
C &
Will
iam
s B
G, J
.R.
Soc
. Int
erfa
ce 2
007
NOT by preventing infection & treating active
TB(both act on cutting
transmission)
But by treating latent infection and active TB or by preventing and treating latent infection (cutting transmission and reactivation)
1. Declin din 2015
2. acces universal la resurse
3. Cercetare si dezvoltare
Concluzii