1. The New faces of Tuberculosis
New challenges requiring new
solutions
Dr. Jean-Jacques Bernatas – ADB Medical Doctor -
Health Sector Group - 11 September 2017

2. TB: An old companion of Humankind
• Human TB:
– is caused by Mycobacterium Tuberculosis Complex (MTBC)
bacteria.
– Airborne, inter-human transmission.
– 7 different genetic lineages in different areas of distribution.
– With Humans since the beginning of the journey out of Africa (1)
• Co-evolution:
– bacteria infectivity↔ host resistance
– genetically-based,
– “armed equilibrium” between host and pathogen.

3. Human TB phylogenetic tree
In: Brites D, Gagneux S. Co-evolution of Mycobacterium tuberculosis and Homo sapiens. Immunological
Reviews. 2015;264(1):6-24. doi:10.1111/imr.12264.

4. Human history engraved in TB bacteria
genes
• Ex. of Beijing lineage (2):
– all around the world from Far East
– waves over past 200 years/ Industrial Revolution, WW1, HIV
epidemics,
– 2 MDR (multidrug resistant) clones spread in central Asia at the
same time of the collapse of former Soviet Union
• Drug-Resistant TB:
– man-made (misuse of TB drugs)
– genetically determined.

5. TB by NUMBERS in 2015. BURDEN OF DISEASE
10.4
MILLION
NEW TB CASES
1.0
MILLION
NEW TB CHILDREN
CASES
1.2
MILLION
NEW TB AMONG
PLWHIV)
1.4
MILLION
TB DEATHS
(0.4 M. AMONG
PLWHIV)
-22%
2000
2015
• 25% of global TB burden/ India
• 60% of TB patients from 6 countries (4 in Asia:
India, China, Indonesia and Pakistan)

6. TB by numbers in 2015. Drug-Resistance
580 000
Drug-Resistant TB
CASES
480 000
MDR/XDR-TB
100 000
Rifampicin Resistant
(RR) TB
9.5%
XDR-TB
60% • SEA(RO)
• WP(RO)
• INDIA
• CHINA
• RUS. FED.
45%
MDR-TB treatment:
• Had a success rate of 52% in 2015
• Cost of XDR= x100 the cost of drug sensitive
TB – (cost of MDR-TB is x25 “only”)
20% only
enrolled
for
treatment

7. “TB is curable”: DOTS
• Saved 49 million lives from 2000 to 2015.
• Early detection and treatment of the most contagious cases
• 1.5us$/day for the treatment (6 months) for drug sensitive cases.
• 5 “pillars’:
• Political commitment, long-term planning, adequate human
resources, sustainable financing,
• Case detection through bacteriology, strengthening laboratory
network
• Standardized and supervised treatment,
• Effective and regular drug supply system
• Efficient monitoring system

8. TB is preventable … somehow
• Vaccination:
– doesn’t prevent contagious TB to spread
– saves children lives and disabilities by preventing meningitis and
miliary TB
– New vaccines under study.
• Prevention of transmission:
• conditions of livelihood; air pollution, tobacco smoking, overcrowded
housing
• Early detection of contagious (pulmonary) cases and effective treatment
(accessibility/affordability)= DOTS
• Prevention of progression from latent to active TB:
– Contact tracing and chimioprophylaxis
– nutrition, HIV, parasitic infections, diabetes mellitus, etc.

9. The multiple faces of TB in 21st century (with
a focus on Asia-Pacific region) -1
• Misconception and mismanagement:
– Stigma
– Misdiagnosis and its consequences whether it is over- or under-
diagnosed
– Inadequate treatment
• DR-TB (4), (5):
– In China, estimated proportion of XDR-TB among MDR-TB in 2015
is (20%)=2X the average global figures.
– per patient cost for XDR-TB
• = 4x MDR-TB
• = 100x drug-sensitive TB (estimated 60% of the total cost – data from study
conducted in SAf).

10. The multiple faces of TB in 21st century (with
a focus on Asia-Pacific region) -2
• TB and ageing population (6):
– By reactivation > post-primary infection
– More vulnerable, and HC professional lacking awareness
– 50% of new TB cases in China, Singapore and Japan detected among ≥ 50y.o.
• Migration (7), (8): TB travels with migrants.
– Mobile populations between Myanmar and Thailand  poor treatment outcomes
among mobile TB patients, mainly represented by workers from Myanmar.
– Cross-border tuberculosis prevention program among migrant workers in 2015,
(Kazakhstan, the Kyrgyz Republic, Tajikistan and Uzbekistan,) with Project
HOPE, USAID, and The Global Fund.
– Myanmar: Mobile TB Active Case Finding Clinics (IOM)  internal migrants living
in the outskirts of Yangon.

11. The multiple faces of TB in 21st century (with
a focus on Asia-Pacific region) -3
Private health sector
– TB control usually under the responsibility/lead of Public sector
– Low quality of diagnosis and treatment in private healthcare
facilities.
– Underreported cases (uncomplete notifications)
Private-Public Mixed approach (10) (11):
– DOTS implemented by public health sector is at low cost and more
effective than for many private health care facilities. PPM-DOTS
implementation in India.
– The Government of India:
• Engaged private sector/ creating a ICT-based network of providers (2014)
• Incorporated direct benefit transfers and improved social protection

12. The multiple faces of TB in 21st century (with
a focus on Asia-Pacific region) -4
Poverty (12), (13) (14), (15) (17):
– Strong association between TB prevalence and total health
expenditure per capita, governmental health expenditure per capita,
hospital beds, and access to improved water and sanitation.
– In Indonesia, (2011) total economic burden = 2.1 US$ billions, with
63% due to loss of productivity by premature deaths.
– Poverty  Limited access to adequate diagnosis and treatment 
decentralization (17)
– Poverty-related living conditions,: overcrowded housing, malnutrition,
limited access to healthcare facilities (cost of transportation)
– indoor air pollution (estimated to count for 28.5% of attributable risk
in a study conducted in India (14), tobacco smoking.

13. Post-2015 agenda: SDG3
• TB elimination: a core activity of SDG3
– Ending the TB epidemic by 2030  SDG 3, target 3.3
• Other SDGs have an impact on TB control, and thus on poverty
reduction:
– Nutrition (SDG2: “Zero hunger”) ↓ susceptibility to TB infection and
progression to active TB, and ↑ treatment outcomes,
– Air quality (SDG11, target6): indoor pollution (+smoking)-  ↑ TB infection and
activation
– Sustainable transport (SDG11 target 2)↔accessibility of TB diagnosis and
treatment.
– Better housing (SDG11 target 1).
– SDG4: quality education  education to health, school health
– SDG5: gender equality  women less affected BUT: more vulnerable to TB,
more stigmatized, underdiagnosed. Involvement of women in TB control
increase treatments outcomes. Societal context.
• Last but not least: SDG1= Poverty reduction

14. ADB initiatives with an impact on TB
• Bangladesh Second Urban Primary Health Care Project (2005-
2012):
– 92 health facilities offered DOTS in urban areas.
– Reduction of notified TB cases from 176/100,000 in 2006 to 164 in
Dhaka City Corporation, Khulna City Corporation, and Rajshahi City
Corporation.
• The RECAP TA / Regional Malaria and other Communicable
Diseases Threats Trust Fund (RMTF): 20132018; health
system strengthening, improvement quality of drugs by
strengthening the local FDA
• GMS Health Security project: strengthening capacity of
laboratory network at the district level. Rapid tests for resistance
implemented at National TB lab (Cambodia).

15. The way forward (with ADB) -1
• The Operational Plan for Health 2015-20, in line with
ADB 2020 Strategy; priority to:
–investments in health infrastructure,
–health governance
–financing,
• Strategy:
–strengthening ICT
–PPP - public-private partnerships.

16. The way forward (with ADB) -2
• Infrastructures:
– Urban health: Ex. of “Bangladesh Urban Primary Care Project
– Transport project or project with people resettlement (Energy, as
a for dam construction)
– Health Impact Assessment (HIA)
• Health governance:
– regional collaboration on migrants health: cross-border TB
control in Asia-Pacific region.
– Strengthening health information system: supporting 1
pillar of DOTS
– quality control for TB drugs,

17. The way forward (with ADB) -3
• Health financing and Private-Public Partnerships
– Strengthen the partnership with the Global Fund for AIDS,
Tuberculosis and Malaria (GFATM).
• GFATM= partner in the Bangladesh Second Urban Primary Health Care
Project and in the Regional Malaria and other Communicable Diseases
Threats Trust Fund and the Asia Pacific Leaders Malaria Alliance
(APLMA).
•  ADB may contribute to smooth financing transition for TB programs
• Discussions in Myanmar
– India: strategy to eliminate TB with component based on Private-
Public Partnership  other DMCs?

18. Implementing partnerships for better
global health is the way forward
Sixty-ninth session Agenda item 124 Global health and
foreign policy Global health and foreign policy Note by
the Secretary-General (Sept. 2014).
“The coordination of these streams, in connection with
the global health agenda, poses significant coordination
challenges for effective global health governance.”

19. Conclusion and open question:
What is the share that ADB wants to take to contribute
to fight {Poverty/TB}, putting at disposal its expertise,
in line with its vision and strategy as a partner of
choice for development ?

20. THANK YOU
• To HSG members, especially to Susann Roth, Gerard
Servais, and Brian Chin.
• To you for attending this presentation …

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