MSc in International Health and Tropical Medicine Centre for Tropical Medicine and Global Health Nuffield Department of Medicine ` The following is part of a training exercise for MSc Students in International Health and Tropical Medicine, University of Oxford OPPORTUNITIES AND CHALLENGES FOR TB CONTROL Zay Yar Phyo Aung (Burma), Rachel Hounsell (South Africa), Mesulame Namedre (Fiji), Naima Nasir (Nigeria), Claudia Paul (Australia)* * equal contribution from all co-authors listed by alphabetic order `
Presentation Outline 1. Global burden & commitments Global burden of TB // Key challenges // Globalcommitments 2. TB in theUK Overview of TB burden and control strategies in the UK,with a focus on England. 3. Opportunities & challenges A series of actions and insights to scale the support forTB control in the UK andglobally. 4. Concluding messages Thoughts for action
TB is a curable, treatable infectious disease 10 million cases of active TB Drug-resistant TB is a public worldwide in 2017 health crisis (>0.5 million in 2017) Global TB TBdisproportionately affects poor TB is the leading cause of death from burden & and vulnerable populations, with a single infectious agent: 1.6 million catastrophic costs & income losses challenges deaths due to TB in 2017 30 high burden countries account for 23% of the world’s population (1.7bn) are 87% of TB cases worldwide estimated to have a latent TB infection and are thus at risk of active infection TB/HIV co-infection is a common and seriouschallenge Source: WHO’s Global Tuberculosis Report2018
Global targets & commitments End TB Strategy SDG Goal3 40 million by2022 May March Sep 2014 2016 2018 By 2035, compared to2015: By 2030: By 2022, provide diagnosis& treatment for TBto: 1. Reduce TB deaths by 95% End the epidemicsof 1. 40 million people 2. Reduce new cases by 90% AIDS, tuberculosis, 2. 3.5 million children 3. Zero catastrophic costsfor malaria and neglected TB-affected families 3. 1.5 million people with drug- tropical diseases resistant TB The UK has backed all three global commitments towards ending TB and is well positioned to support the scale up of local and international TB control efforts.
TB Burden in England(2017) TB Control: Collaborative TB Strategyfor England Second highest rate of TB among Western • European countries Between 2011 and 2017, there was a 38% • decline in number of TB notifications Incidence rate of 9.2 per 100,000 • population, the first time under the 10 per 100,000 WHO definition of a low incidence country People born outside the UK accounted for • 71% of TBnotifications 31% of pulmonary TB patients experience a • delay of more than four months between symptom onset and treatment start 1. PHE and NHS England launched the strategy as a guiding framework for health and social services on the management of TB (2015 – 2020) The rate of TB in the most deprived 10% of • the population was over 7 times higher 2. A two-way monitoring framework enables regular reporting to PHE and than in the least deprived (18.4 vs 2.5 per feedback of surveillance data to the local and national stakeholders 100,000) 3. Partnerships & action is coordinated through formally established regional TB controlboards Source: Public Health England. Tuberculosis in England: 2018 Report
Increased UK support for global TBcontrol Challenges & 1 opportunities Greater funding for research & development 2 to reach Strengthening local & globalpartnerships 3 the missing Reducing delays in access to care 4 millions Addressing latent TB infection 5 Intensifying pre-entry screening to theUK 6 Strengthening active casefinding 7 Improving education & training 8
Increasing UK support for global TB control Financial gap The Global Plan estimates that at least 7 US$56 billion will be required for implementing the 6.1 first 5 years of the End TB Strategy (2016-2020) 6 5.4 5 The UK invested £3.3b (approx. US$5.4b) from 2001 – 4 Billion USD 2016 into the Global Fund for Tuberculosis, Malaria 3.5 and HIV/AIDS. The US contribution to the Global Fund 3 for the same period was US$13.2b 2 The UK’s opportunity for impact is greatest in 1 supporting global TB control efforts through 0 multilateral funding 2018 2020 2022 Source: https://www.who.int/tb/features_archive/WHO-urgent-action-to-end-TB/en/
Funding forresearch and development Shorter Improved Vaccine New Drugs Regimens Diagnostics Development forMDR-TB 14 new vaccines are To treat latent To improve Rapid and being developed for TB and combat adherence and readily available better efficiency across drugresistance reduce likelihood diagnostics all age groups of resistance The UK’s investment in R&D has the potential to make significant leaps forward in the fight against TB worldwide
Strengthening local and globalpartnerships Global: international support for HBCs mainly towards diagnosis andtreatment. Local: collaborations for clinical care, social support and reaching underserved populations. Opportunities forpartnerships: Explore innovative collaborations with the private sector • Learn from and replicate successful partnerships such as London’s • “Find and Treat” model Link with groups tackling TB co-morbidities such as diabetes, HIV • and malnutrition Prioritise inter-sectoral partnerships (such as the criminal justice • system, social & economic welfare) Contribute to and share learnings with international collaborations •
Reducing delays in access to care TB in theUK Increase • Over a third of patients diagnosed with transmission pulmonary TB experienced a delay of more than four months between onsetof symptoms and treatment • MDR-TB cases increase from 46 (1.2%of cases) in 2004 to 54 (1.6% of cases) in DELAY Drug Social Onset of 2015 Treatment resistant Problems symptoms ACCESS TB Low and middle incomecountries • Private and traditional healers • Financial and religious beliefs Financial • Access to efficient &newer diagnostic tools • Insufficient community level healthcare provision Source: Public Health England. Tuberculosis in England: 2018 Report
Addressing latent TB infection in the UK Challenges • Children are difficult to diagnose for latent vs active TB • Need for more sensitive diagnostics, provision of appropriate treatment and integration of TB services into other programmes Reactivation ofTB Majority of cases in the UK are due to reactivation of TB • Higher risk for reactivation are PLWHIV, • immunosuppressant therapy, diabetes,undernutrition, smoking and alcohol consumption Latent TB Screening • Testing & treatment of new entrants from high burden countries is effective, cost efficient and a good prevention method • May be used to complement pre-entry screening
Pre-entry screening to the UK People born outside the UK accounted for 71% of TB notifications and the rate of TB among this population was 13 times higher than among those born in the UK Opportunities for scaleup: Reduce incidence benchmark • Include applicant applying for short • term visas <6months Community based screening • Migrants from low risk & EU countries • Targeted partnerships withNigeria, • India, China andPakistan Source: Public Health England. Tuberculosis in England: 2018 Report
Strengthening active casefinding A robust case findingstrategy A model of success from London • Effective community and private sectorengagement • Systematic TB screening for high riskpatients Find Opportunities for low-burden countries and • Locally: Expansion to other high-burden areas in the UK • Internationally: Adapted to other low-burden countries Treat Cost Opportunity effective for scaleup Opportunities for high-burden countries • Effective distribution of primary healthcare facilities Compromises robust case • Improve functioning of sub-district hospitals finding strategies • Scale-up of childhood case findingstrategies Source: UCLH: Find and Treat Outreach Service 2018: https://www.uclh.nhs.uk/ourservices/servicea-z/htd/pages/mxu.aspx
Improving education and training in the UK Implementation of mandatory training for health & social care workers • Increasing awareness of TB burden & control measures Improvingtraining • Use of diagnostictools • Establishing reliable referral pathways • Particularly in areas of high TB incidence acrossLBCs CPD Programmes • Should be part of health workers annual CPD requirements Example: The Royal College of General Practitioners, Public Health England, TB Alert Collaboration • Free e-learning course on TBin general practice to increase the understanding of TB, its diagnosis andtreatment Source: Public Health England, Health matters: reducing the burden of tuberculosis 2016
Concluding messages Opportunities & challenges for TB control TB is a curable, preventable infectious disease that causes est. 10 million cases & 1.6 million deaths per year globally New global commitment to diagnose & treat 40 million people with TB by 2022, UK’s share projected to be 23,000 There are many multi-sectoral opportunities for the UK to strengthen its national TB control efforts UK’s impact on the “40 million by 2022” target can be maximized by supporting high burden countries through increased global funding andR&D
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