TB updating

Dr. Asad Ramlawi

DGPHC &PH

Bethlehem
15/11/2013
 the
achieve
ments
 the
burden
TB incidence

target global
10 / 100k 125 / 100k
107
year
92

90 2000 2010 2020 2 79

68
58
50
 the
burden

0.5 1 MILLION 1.4

MILLION
MILLION

A third of all TB
deaths are in OIC
countries People who
Population of
Central Jakarta, died of TB
Indonesia in 2011
 the
burden

1.4
MILLION

.92
People who MILLION
died of TB
in 2011
 the 9 MILLION
burden estimated TB cases
MDR-TB
570,000
estimated cases that
59,000 go undiagnosed
MDR-TB cases & untreated

1.4
diagnosed and
treated

MILLION
6 MILLION
cases diagnosed
and treated
 the TB is the leading cause of death due to an infectious
burden disease in Islamic countries

2.4 million people fell ill with TB in Organization of Islamic

Cooperation (OIC) countries and 500 000 people died,
despite TB being curable - 35% of all TB deaths / 25% of
1
global population MILLION

7 out of the 22 TB high burden countries are OIC Member

States: Afghanistan, Bangladesh, Indonesia, Mozambique,
Nigeria, Pakistan and Uganda
6 out of 12 countries accounting for almost all 3 000 000
missed cases every year
Multidrug-resistant TB (MDR-TB) is rising - $7 000 to
treat/person
10% of all MDR TB cases are XDR TB - XDR TB is virtually
untreatable
we must
act now
to end TB
in our lifetimes
continuous
transmission
9 million
developed TB in 2011

10%
200 million
will develop TB
2 billion people
infected with TB

1 MDR case 1 TB case

infects up to infects up to
4 / year 10 / year

7 billion people
in the world today

WHO 2012 Global Tuberculosis Report; CDC 2013; Styblo 1985; Basu 2009
economic
challenge

micro-economic
impact of TB on
households
30% 15yrs 11%
decrease in of income lost of school
yearly income with TB death children quit
school when
parent has TB

Rajeswari R, Balasubramanian R, Muniyandi M, Geetharamani S, Thresa X, Venkatesan P, 1999. Socio-economic impact of

tuberculosis on patients and family in India. Int J Tuberc Lung Dis 3: 869–877.
Stop TB Partnership. (2000). Tuberculosis and Sustainable Development.
economic
challenge US$ 13 global decline
in worker

billion
productivity
per year due to TB

of TB patients
75 % are in their most
productive years

Source: www.tballiance.org/why/economic-impact.php
http://www.who.int/tb/careproviders/ppm/workplaces/en/index.html
with the tools and
expertise we have

today
we must accelerate our efforts
and investments for tomorrow
 the
lessons
learned

lives saved 25 fold increase doubled

due to TB & HIV cases detected & treated detection & treatment
integration due to prioritized through engagement
(2005-2011) interventions in with TB communities
vulnerable populations
 the
potential
of new
minutes to diagnose
tools
90 Rif resistant TB with Gene
Xpert machine

new vaccine
12 candidates in
the pipeline

months to treat TB
4 with under new treatment
periods, drugs, and regimens in
development (compared with
current 6-24 months)
economic
opport-
unity tuberculosis
case finding
heart attacks & treatment
acute low-cost US$ 30
management
US$ 25
expanded malaria
immunization prevention & treatment

US$ 20 US$ 20
local surgical
HIV
capacity combination prevention
US$ 10 US$ 12

return on investment for every one dollar

spent on the most cost-effective health interventions

Report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda, 2013
the road to 10 / 100,000
TB incidence

• Scale-up to 100% coverage of

proven interventions
today
125 • Prioritized focus on vulnerable
groups- including women and
children
• Integration within country-region
context and system
• New tools

10
2035 2180
 the
achieve
ments Since its creation the Global Fund has contributed
to the following impact in the 22 TB high burden
countries:

people
9.7 mil treated for TB

treatment success
87% increase from 67%

case detection
65% increase from 43%
 Dynamics of Tuberculosis mortality in Tomsk Oblast,
Siberia, and Russian Federation
(per 100,000 population)

40
37.3
35.6
35 33.8 32.3
30.5 29.9 33.3
29.1 29.3
30 28.6 27.9 27.5
26
25 21.9 21.4 22.6
22.6 21.8 21.9 20
19.8 18.4
20
16.9 20.6 17.9
20 16.8 15.4
18.3 17.9 17.7 17.8
15 15.4 16.2
10 12.7 11.9
MDR-TB 10.3
9.4 8.6
5 treatment
5.6
began
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Russia Siberia Tomsk Oblast

Source: Tomsk Oblast TB Services
 Working Stop TB Partnership - OIC
Together
partnering for TB elimination
• Increase political commitment among key decision makers –
zero gap in finding and treating TB, MDR TB and TB/HIV
patients towards achieving the MDGs and post 2015
• Support for steep increase of funding for TB research and
development

• Increase resources for TB interventions and scale up in OIC

countries

• Promote inter/intra-regional collaboration between OIC

countries on *know how on delivery of services* and
research and development of new tools, including basic
science

• Work towards full replenishment of the Global Fund Against

HIV, TB and Malaria and roll out of the New Funding Model

• Raise awareness of TB and appropriate TB Interventions on

a global and regional level
TB In Palestine
 • Palestine has a low burden of tuberculosis
with an estimated number of 200 incident
cases in 2010 (4.9/100,000 population).
• Recently in 2010, this has been revisited to
16% (13%-18%).

8/24/2024 21
 Reported cases of extraPulmonary TB
In Palestine 2008-2012
Year WB Gaza Total

2008 5 14 19

2009 8 6 14

2010 1 11 12

2011 3 10 13

2012 3 4 7

8/24/2024 22
 Reported cases of Pulmonary TB In
Palestine 2008-2012

Year WB Gaza Total

2008 10 10 20

2009 7 12 19

2010 10 9 19

2011 6 13 19

2012 12 12 24

8/24/2024 23
 Inventory Study
• The inventory study targeted the under-detected
(under-diagnosed and/or under-reported) TB cases by
non-NTP providers for patients having access to health
services in the Palestinian health system.
• However, there is a small proportion of Bedouin
population living in West Bank that does not have
access to health services. For this group, a community-
based study carried carried out to determine the
extent of under-detected pulmonary TB patients
among this high risk group.

8/24/2024 24
 Objectives of the study
• General objective:
• To determine the extent of TB case
ascertainment by NTP and non-NTP providers
and in the community and estimate TB
incidence accordingly.

8/24/2024 25
 General comments
❑ Launched at 1 April 2013 and ended 30 June
2013
❑ Data entry can be completed by November 2013
and the data validation and analysis mission
planned for December 2013.
❑ the final report will be prepared after the analysis
of the data by WHO consultant at the end of
2013.

8/24/2024 26
 Areas covered by Inv. Study

❖ Private and Public Health Providers (Non NTP): 17 Districts WB&GS,

(around 500 facilities with around 3000 cards collected; 6 visits per
facility during the study that is one visit every two weeks).
– 52 suspects were reported by non NTP and followed up by NTP.

❖ High Risk Groups (Bedouins: 15 years and above):

❖10 districts in West Bank (excluding Tulkarem and Jenin),
❖ Total Bedouins eligible for the study: around 6000 of which 99%
were screened for TB.
❖Total number of suspects 87.

8/24/2024 27
• Total # of suspect T.B : 52 + 87 = 139.
• Total # of positive cases = 4 ???

8/24/2024 28
 B.C.G
The international union against Tuberculosis & lung disease (IUATLD) has suggested
criteria under which it may be reasonable for a country to shift from routine BCG
vaccination to selective vaccination of high risk groups.

The IUATLD recommends that BCG be discontinued only if:

• An efficient notification system is in place and either.

• The average annual notification rate of smear positive pulmonary tuberculosis is < 5
per 100.000, or

• The average annual notification rate of tuberculosis meningitis in children under 5

years of age is less than 1 per 10 million population over the previous 5 years, or

• The average annual risk of tuberculosis infection is < 0.1%

 Efficacy
1. Childhood tuberculosis & tuberculosis meningitis:
Average protection on the order of 80%.
2. Adult pulmonary tuberculosis:
Efficacy estimates ( 0 to approximately 80%)
3. Leprosy & other mycobacteriosis:
20 to 80%
4. BCG provides some protection against Buruli ulcer (M. ulceran infection & M avium-
intracellulare):
85%
5. Booster doses:
The only controlled trial evaluation of the efficacy of BCG booster in protection of
tuberculosis was carried out in Malawi, & found no evidence for protection. On
the basis of such data the WHO has not encouraged revaccination.
 Reasons for variable efficacy
1. Differences between BCG vaccines.
a- Genetics of the mycobacterial strains.
b- Physical properties of the vaccine preparations.

2. Environmental mycobacteria:
M. Fortuitum, M. avium or M. kansasii

3. Human genetics:
Several geneswhich control cellular immune mechanisms ( HLA-DQ, Vit. D Receptor &
INFg receptor polymorphisms, & NRAMP) influence suseptability to Tuberculosis &
other mycobacterial infections.
4. Differences in M. tuberculosis:
Strains of M. Tuberculosis
Cont.
5. Several other explanations:
a- UV light exposure may be relevant.BCG bacilli are acutely sensitive to UV exposure,
as are the dermal langerhans cells which are important in antigen presentation, &
this could explain the tendency for the differences in protection to be lower in
tropical than Temperature regions. However it doesn’t explain the differences in
protection against tuberculosis & leprosy in the same population.

b- nutritional differences.

c- local natural history of tuberculosis.

 Management of reactions &
complications
1. Local site lesions:
Systemic treatment with erythromycin.

2. Keloids.

3. Local gland involvement:

An adherent or fistulated lymph gland may be drained & an anti-tuberculosis drug
may be instilled locally. Systemic treatment with anti-tuberculosis drug is
inffective.
thank you