Ending Tb: Building TB free world

1. Ending TB: Building TB
Free World
Dr. Arkadeb Kar
3rd year PGT, Community Medicine, CNMC

2. History
• TB is a disease of ancient times
• Known by different names –
Phthisis
Tabes
White plague
King’s evil
Throughout the 1600-1800s in Europe and America , TB caused 25% of all deaths.

3. • Until the discovery of antibiotics, treatment for TB was limited to warmth,
rest, and good food
• 1854 – Hermann Brehmer – established first sanatorium
• On March 24, 1882, Robert Koch discovered mycobacterium tuberculosis
• In India, the first sanatorium for treatment and isolation of TB patients was
founded in 1906 in Tiluania, near Ajmer,
• Albert Calmette and Jean-Marie Camille Guerin developed the Bacille
Calmette-Guérin (BCG) vaccine in 1921.

4. • Antibiotics were a major breakthrough in TB treatment.
• In 1943, Selman Waksman, Elizabeth Bugie, and Albert Schatz developed
streptomycin.
• Isoniazid (1951),
• Pyrazinamide (1952),
• Ethambutol (1961),
• Rifampicin (1966)

6. • In 1993, WHO declared TB as a global emergency and launched Directly
Observed Treatment – Short Course Strategy.
• 1. Government commitment
• 2. Case detection through predominantly passive case finding
• 3. Standardized short-course chemotherapy to at least all confirmed sputum smear
positive cases of TB under proper case management conditions
• 4. Establishment of a system for regular drug supply of all essential anti-TB drugs
• 5. Establishment and maintenance of a monitoring system, for both programme
supervision and evaluation

7. • In 2006, WHO launched the Stop TB Strategy
• Vision - A TB-FREE WORLD
• Goal - To dramatically reduce the global burden of TB by 2015 in line with the
Millennium Development Goals
• Targets
• MDG 6, Target 8: Halt and begin to reverse the incidence of TB by 2015
– by 2015: reduce prevalence and deaths due to TB by 50% compared with a
baseline of 1990
– by 2050: eliminate TB as a public health problem

8. • Components of Stop - TB
1. Pursue high-quality DOTS expansion and enhancement
2. Address TB/HIV, MDR-TB and other challenges
3. Contribute to health system strengthening
4. Engage all care providers
5. Empower people with TB and communities
6. Enable and promote research

9. MDG 6 TB target achieved
Incidence
1990 2000 2014
43 million lives saved between 2000 and 2014
The MDG era is over
41 per cent
decline in prevalence in 2014
since 1990.

10. TB situation in India

11. Moving from halting TB to ending TB by 2030
SDG TARGET 3.3 – BY 2030
END THE TB EPIDEMIC
Global commitment to End TB

12. Barriers to achieving the targets
1. Weak health system
2. Underlying determinants such as poverty, undernutrition, migration
and risk factors such as smoking and silicosis
3. Lack of effective tools
4. Continuous unmet funding needs

13. THE END TB STRATEGY:

14. PILLARS AND PRINCIPLES

15. PROJECTED GLOBAL TRAJECTORY OF TB
INCIDENCE RATE 2015-2035 REQUIRED TO REACH 2035
TARGETS

17. Early diagnosis of tuberculosis including universal
drug susceptibility testing, and systematic screening of
contacts and high-risk groups
• Ensure early detection of tuberculosis
• Detect all cases of drug resistant TB
• Introducing newer diagnostics
• Systematic screening of high risk groups

19. Treatment of all people with tuberculosis including
drug-resistant tuberculosis, and patient support
• Treat all forms of drug-susceptible tuberculosis
• Treat all cases of drug-resistant tuberculosis
• Strengthen capacity to manage drug-resistant
cases
• Address tuberculosis among children
• Build patient-centered support into the
management of tuberculosis

20. 2015 2017
Global SEAR India Global SEAR India
Estimated TB
incidence
( per 100000)
142 246 217 133 226 204
Deaths due to
TB
( per 100000)
19 37 32 17 32 31

21. CBNAAT laboratories, India, 2017
Existing Additional
India 651 507
West Bengal 38 38

22. DRTB finding and treatment initiation effort, 2007-2017, India

23. Collaborative tuberculosis/HIV activities, and management of
comorbidities
• Expand collaboration with HIV
programs
• Integrate tuberculosis and HIV
services
• Co-manage tuberculosis
comorbidities and non-
communicable diseases

24. Trend in number (%) of registered TB patients with known HIV
status, 2008- 2017, India

25. Preventive treatment of persons at high risk, and
vaccination against tuberculosis
• Expand preventive treatment
of people with a high risk of
tuberculosis
• Continue BCG vaccination
in high-prevalence countries

27. Political commitment with adequate resources
for tuberculosis care and prevention
• Develop ambitious
national strategic
plans.
• Mobilize adequate
resources.

28. Engagement of communities, civil society organizations,
and all public and private care providers
• Engage communities and civil society
• Scale up public–private mix approaches and promote International
Standards for Tuberculosis Care

29. • Focused on community engagement for informing communities about TB care and
control.
• Working in partnership with 7 sub-recipient partners, over 1000 local NGOs and
nearly 15,000 community volunteers
• Reached out to over 17 million people from various vulnerable and marginalized
communities.
• Facilitated identification and testing of nearly 220,000 presumptive TB cases. This
includes collection and transportation of sputum samples of nearly 190,000
presumptive TB cases.
• Facilitated diagnosis and treatment initiation of nearly 20,000 patients.
• Sensitized and engaged 5000 qualified private practitioners, private hospitals and
private laboratories and facilitated notification of over 43,000 patients from the
private sector.

30. • Foundation for Innovative New Diagnostics (Find) in consultation
with the RNTCP and with funding support from USAID, provides a
comprehensive diagnostic solution for pediatric TB in the intervention
cities.
• Total of 29,369 presumptive pediatric TB and DR TB patients have
been tested over the last one year in the intervention cities.

31. Tuberculosis Health Action Learning Initiative (THALI),
West Bengal
• THALI is implemented by WHP along with John Snow India (JSI) and
Child in Need Institute (CINI)
• supported by USAID in five districts of West Bengal.
• The objectives of THALI are to strengthen urban TB control through
community outreach and mobilization; private sector engagement;
• THALI notifying 11,483 cases (in two years) which was 90% of total cases
notified by the private sector in five districts of West Bengal (as on June
20th 2019).

32. Universal health coverage policy, and regulatory frameworks
for case notification, vital registration, quality and rational use
of medicines, and infection control
• Strengthen regulatory frameworks
• Enforce mandatory notification of tuberculosis cases
• Ensure recording of tuberculosis deaths within vital registration
• Regulate the production, quality and use of tuberculosis diagnostics and
medicines
• Undertake comprehensive infection control measures

33. 2015 2017
Global SEAR India WB Global SEAR India WB
Total notified 6364194 2656560 1 740 435 88 147 6 708 123 2 965 311 1827959 97297
% with known
HIV status
500 564 52 64 57 60 55 67 58
MDR
/RR
TB
Estimat
ed
3,45,000 1,10,000 79 000 - 3 30 000 99 000 65 000 -
Diagnos
ed
1,32,120 35 953 28 876 - 1 60 684 51 788 39 009 -
XDR TB 7 579 3 099 3048 - 10 800 2755 2650 -

34. Case notification rates (new and relapse cases, all forms) (black) compared with
estimated TB incidence rates (green), 2000–2017, globally and for WHO regions.

35. Case notification rates (new and relapse cases, all forms) compared with
estimated TB incidence rates, 2000–2017, India

36. Social protection, poverty alleviation and
actions on other determinants of tuberculosis
• Relieve the economic burden related with tuberculosis
• Expand coverage of social protection
• Address poverty and related risk factors

37. Percentage of the general population facing catastrophic
health expenditures, 2017

38. The impact of social protection and poverty elimination on global
TB incidence: a modelling study
Carter DJ, Glaziou P, Lönnroth K, Siroka A, Floyd K, Weil D, Raviglione M, Houben RMG, Boccia D. The impact of social protection and
poverty elimination on global tuberculosis incidence: a statistical modelling analysis of Sustainable Development Goal 1. Lancet Glob
Health. 2018 May;6(5):e514–22 (https://www.ncbi.nlm.nih.gov/pubmed/29580761, accessed 11 July 2018).
• It was estimated that ending extreme poverty could
reduce global TB incidence by 33% by 2035 (95%
confidence interval: 16–45%)
• while expanding social protection coverage could
reduce incidence by 76% (45–90%) by 2035.
• Together, both pathways were estimated to be able
to reduce TB incidence by 84% (55–95%).
• Full achievement of SDG 1 could thus have a
substantial impact on the global burden of TB.

40. Discovery, development and rapid uptake of new
tools, interventions and strategies
• Develop a point-of-care rapid diagnostic test for tuberculosis
• Develop new drugs and regimens for the treatment of all forms of
tuberculosis
• Enhance research to detect and treat latent infection.

42. TrueNat TB Test
• This test for TB uses a sputum sample taken from each patient. Only about 0.5 ml
of the sample is required
• The test works by the rapid detection of TB bacteria using the polymerase chain
reaction (PCR) technique.
• Any resistance to rifampicin (RR) is detected by doing a second RTPCR (Reverse
Transcription Polymérase Chain réaction)
• It takes about 25 minutes to do the DNA extraction. It takes another 35 minutes to
diagnose TB. It takes an additional one hour for testing for rifampicin resistance

45. • MTBVAC is a attenuated live strain of M. tuberculosis, - The primary
target population is neonates (as a BCG replacement vaccine); the
secondary target population is adolescents and adults (as a booster
vaccine).
• RUTI® is a non-live, polyantigenic vaccine. It is intended as a
therapeutic vaccine, to be used in conjunction with a short, intensive
antibiotic treatment. The main target for RUTI is MDR-TB.

46. • Vaccae™ vaccine - licensed by the China Food and Drug
Administration as an immunotherapeutic agent to shorten TB
treatment for patients with drug-susceptible TB. A Phase III trial to
assess its efficacy and safety in preventing TB disease in people with
LTBI has been completed, and data analysis is underway. It is the
largest TB vaccine trial undertaken in the past decade, involving 10
000 people aged 15–65 years.

47. Research to optimize implementation and
impact, and promote innovations
• Invest in applied research
• Use research to inform and
improve implementation