TÜBERKÜLOZ ELİMİNASYON

Prof.Dr.Zeki KILIÇASLANİ.Ü.İstanbul Tıpa Fakültesi.

No one ever said this would be an easy fight.However, with the Global Plan to Stop TB 2011–2015 the direction is set with renewed intensity in care and control efforts, and new approaches and tools finally

becoming available. We are now at the start of a roadthat should take us towards the achievable goal of TB elimination.Mario RaviglioneDirector, WHO Stop TB Department

DSÖ’nün önerdiği TB kontrol stratejisi - DOTS

Politik ve finans konusunda kararlılık.

Balgam mikroskopik muayenesi ve TB şüphelilerde kültür.

Doğrudan gözetimli ve standart kısa süreli anti-TB ilaç rejimleri.

Bütün esas anti-TB ilaçların düzenli ve kesintisiz olarak sağlanması.

Standardize kayıt ve raporlama sistemi.

TB Register

World Health OrganizationRegional Office for Europe

2. World Health Organization. Forty-fourth World Health Assembly. Geneva:World Health Organization, 1991.

Bugünkü modern TB Kontrol stratejisi 1990’lar da başladı..

4. World Health Organization. Global Tuberculosis Control. Geneva:World Health Organization, 2008.

DOTS stratejisinin 184 ülkede uygulanması ile132 milyon hastaya tedavi verildi ve bunların125 milyonu kür edildi.

DOTS

1

10

100

1000

10000

2000 2010 2020 2030 2040 2050Year

Inci

denc

e/m

illio

n/yr

Elimination 16%/yr

Global Plan 6%/yrCurrent trajectory 1%/yr

Full implementation of Global Plan: 2015 MDGtarget reached but TB not eliminated by 2050

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

Stop TB Partnership. The Global Plan to Stop TB 2006–2015. Geneva: World Health Organization, 2006.

DOTS 1995- 2005

STOP TB STRATEJİ: 2006

1. 2005 yılında beklenen olguların en az % 70’ini bulmak ve bunların en az % 85’ ini kür etmek (% 84 ile kür hedefine ulaşılmasına rağmen beklenen oluların dünya ölçüsünde ancak % 60’ı yakalanabilmiştir (1)

2.2005 yılında 1990 yılına göre TB prevelansını ve TB’a bağlı ölümleri % 50 azaltmak, Prevelansı 100.000 de 155’e ölümü 100.000 de 14’ e indirmek.

3.2050 yılında Dünyada TB eliminasyonunu sağlamak (< 1/1.000.000)

Stop TB Stratejisinin hedefleri ;

•Yüksek kalitede DOTS uygulamalarının yaygınlaştırılması.

•HIV/TB, ÇİD-TB ve diğer sorunlara yönelmek.

•Genel sağlık sistemlerinin güçlendirilmense katkı yapmak.

•Kamu ve özel tüm hizmet sunucular ile işbirliği sağlanması.

•TB hastalarının ve toplumun TB kontrol programlarına aktif katılımının desteklenmesi.

•Yeni tanı araçları, ilaç ve aşı geliştirilmesi için araştırmalar yapılması.

Stop TB Stratejisinin Temel Uygulamaları:

1.TB bulaşmasını/ hastalığını önleme

2.TB Yönetim Sistemi

3.Gerekli Fonların Elde Edilmesi.

Epidemiology and Challenges to the Eliminationof Global TuberculosisMandeep S. Jassal1 and William R. Bishai2.Clinical Infectious Diseases 2010; 50(S3):S156–S164

Global TB Eliminasyonunu Zorlaştıran Faktörler

a) Daha iyi tanı araçları

Olgu bulama hızında hedefe varılamadı.

HIV PozitiflerAkciğer Dışı TB

1. TB hastalığını önleme

1. Sıvı besiyerleri

2. ÇİD-TB için Line Probe Assays.

3. LED mikroskopi.

4. Xpet MTB/RIF Hızlı tanı ve RİF-

direnç yöntemi

Son yıllarda DSÖ’ nün Tanı için yeni yaklaşım ve test yeni yaklaşım önerileri.

b) Genel sağlık sorunları ve sosyal riskler için; Etkin ulusal sağlık stratejileri

1. TB hastalığını önleme

TB Risk faktörleri

TB Rölatif risk Prevelans(22 HBCs)

Population Attributable

Fraction

HIV Infection 8.3 1.1% 7%

Malnutrition 4.0 17.2% 34%

Diabetes 3.0 3.4% 6%

Alcohol Use (>40g / d)

2.9 7.9% 13%

Active Smoking 2.6 18.2% 23%

Indoor Air Pollution

1.5 71.1% 26%

1. TB hastalığını önleme

c) Toplumda sağlık kurumlarında enfeksiyonun bulaşmasını önlemek için gerekli politikalar

Etkili vantilasyon ve maske kullanımı ile sağlık kurumlarında bulaşma çok ileri derecede azaltılabilir !

a)DOTS stratejisine özel ve sivil toplum organizasyonlarının katılımı

b) İlaç direnci gelişimini engelleyecek güçlü TB programı Fon gereksinimi-Çin/Hindistan

c)TB hastaları içinde HIV enfeksiyonun erken tanınması Trimethoprim-sulfamethoxazole.

d) HIV hastaları içinde erken TB tanısı

2. TB Yönetim Konuları

*Morrison J, Pai M, Hopewell. Tuberculosis and latent tuberculosis infection in close contacts of people with pulmonary tuberculosis in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Infect Dis 2008; 8:359–368.

2. TB Yönetim Konuları

HIV infekte kişilerin sadece % 1’ de INH profilaksisi alıyor !

Düşük ve orta gelirli ülkelerde temaslı taraması ve risklilerde koruyucu tedavi etkili olarak kullanılmalıdır (*)

3. TB Kontrolü Bütçe Sorunu

2011-2015

Gereken her yıl 8 Milyar $

Bulunan her yıl 4.8 Milyar$

2015’ e kadar her yıl

2-3 Milyar $ gerekli

Styblo K. Rev Infect Dis. 1989 Mar-Apr;11 Suppl 2:S339-

1980’ ler de Avrupa’ da bazı ülkelerin 2025-2035 yıllarında eliminasyonaUlaşacağına inanıyorlardı.

1989, Styblo bunun düşük insidanslı ülkelerde bile 35-50 yıl alacağını hesapladı.

Avrupa’ da TB Eliminasyonu

Bir çok Avrupa ülkesinde TB insidansı < 20/100.000 Bu ülkeler gayretlerini Tüberkülozu elimine etme amacı doğrultusunda yoğunlaştırmalıdırlar.

TB Eliminasyon fazında ülke;

TB olgu bildirim hızı < 20/10.000 ve TB olgu hızlarında son 5 yıldır kesintisiz azalma olan ülkeler

TB Eliminasyon fazında ülke;

Bir toplumda olgu hızı azaldıkça ülkede hastalığın bulaşma düzeyini ortaya koymakta daha önemli hale gelir.

Bulaşma hızını doğrudan ölçmek için geçerli test yok.Bulaşma hızını dolaylı ölçmekte kullanılan dört parametre.

1. TB Hasta bildirim hızının eğilimi2. ÇİD-TB bildirim hızı eğilimi3. Bildirilen Çocuk TB/Erişkin TB oranının eğilimi4. TB olgularının ortalama yaş eğilimi.

Sürveyans sistemi olguların % 100 ‘nü kapsıyor mu ?Sürveyans sisteminin olguları kapsama gücünde değişim oluyor mu?

TB Bulaşma hızını ölçmek

İndikatör 1. TB Hasta bildirim hızının eğilimi

Hedef: TB olgu bildirim hızındaki 5 yıllık ortalama azalış trendi önceki 5 yılın üzerinde

Bir yılda bildirilen TB sayısı x 100.000

Ülkenin toplam nüfusu

Olgu saptama hızının yüksek olduğu toplumlarda hastalığın gidişi üzerine anlamlı bilgi sağlar.

İndikatör 2. ÇİD-TB bildirim hızı eğilimi

Bir yılda bildirilen ÇİD-TB sayısı x 100.000Ülkenin toplam nüfusu

Hedef: ÇİD-TB olgu bildirim hızındaki 5 yıllık ortalama azalış trendi önceki 5 yılın üzerinde

Koşul: Olguların % 50 den fazlası kültür pozitif ve bunların % 80 den fazlasında RIF ve INH direnci bakılmışsa

Çocuklarda olgu bildirim hızı(<15 yaş)

Erişkinlerde olgu bildirim hızı (> 15 )

Hedef: Çocuk/erişkin TB oranındaki azalış azalış trendi önceki son 10 yıllın üzerinde olmalı.

İndikatör 3. Bildirilen Çocuk TB/Erişkin TB oranının eğilimi

Çocuklarda TB sıklığı özellikle yeni doğanlarda, bulaşmanın çok önemli indirekt göstergesidir

Her bir yaş grubundaki olguların sayısı x grubun ortanca yaşı

Toplam olgu sayısı

Etkili TB kontrolü ile yeni enfeksiyon azalır.Hastalık sayısı özellikle gençlerde düşer.Hastalık yaşlılar ve TB hastalanma riski yüksek olan gençlerde görülür.Hastaların ortalama yaşı artar.

Hedef: TB hastalarının ortalama yaşındaki artış eğilimi önceki 10 yılın üzerinde

İndikatör 4. TB olgularının ortalama yaş eğilimi.

IOM 2000 yılı raporunda 2035 yılında eliminasyon öngördü.

2009 değerlendirmesi:

Bu hızla giderse ( Yılda % 3.5 insidans Azalması)

97 yıl daha gerekli !!

TB Eliminasyonu-ABD

Christopher Dye* and Brian G. William.Eliminating human tuberculosis in thetwenty-first century.J. R. Soc. Interface (2008) 5, 653–662

Tek strateji olarakAktif TB olgularının tedavisi,

2050 de insidansı 1/1 000000’eİndireme hedefine ulaşamaz.

Hedefle ulaşsak ve insidans yılda % 10 azalmaya devam etse bile TB insidansı 2050 yılında 1/1000000 hedefinin 20 katında kalacaktır.

Kaliteli olgu bulma ve tedavi programı ile yeni infeksiyonları önlesek bile eski enfeksiyon havuzundan hasta çıkmaya devam eder.

Latent enfeksiyonun basit araçlarla tanısını koymak ve etkili yöntemle müdahale edilerek hastalanmayı önleme esastır.

Yeni etkili aşı !

TB Eliminasyonu- Yeni Gereksinimler

TB İnsidansı

TB Mortalite

Yeni aşıların muhtemel etkisi

Yeni TB tanı araçlarınınMuhtemel etkisi

TB İnsidansı

TB Mortalite

TB Mortalite

TB İnsidansı

Aktif hastalarda yeni tedaviRejimleri (1,2,3) , KitleselKoruyucu tedavi veRejim 2+Koruyucu tedavi

1.Rejim: 4 aylık tedavi2.rejim : 2 aylık tedavi3.Rejim: 10 günlük tedavi

Yeni doğan aşısı,Tedavi rejimi 2Ve NAAT tanı testi kombinasyonu

TB İnsidansı

TBmortalitesi

25 March 2013 | Cape Town |

"TB elimination can only be possible with intensified research and development particularly for new vaccines,” said Dr. Mario Raviglione, the Director of the WHO’s Stop TB Department.

Eliminasyon gerçekten hedefleniyorsa. Sorunlar çok.!

1. Para garanti değil.2. Beklenen olguların sadece % 63’ i bildiriliyor.

3. Afrika’ da TB/HIV major etkiye sahip.

4. MDR-TB yükü eski Sovyet ülkelerinde , Çin’de Hindistan ‘da ciddi.

5. Sağlık sistem, hizmet ve politikaları yetersiz.

6. Devlet dışı kuruluşlar yeterli işbirliği içinde değil.

7. Toplumlar bilgisiz, katılımsız,hareketsiz durumda.

8. Yeni tanı, tedavi araçları için araştırmalar daha yeni başladı.

Teşekkürler

1. Community-Based Tuberculosis Activities

Action Plans to Accelerate Tuberculosis Elimination among US-born Populations

2. Awareness of Tuberculosis among Healthcare and Service Pro

3. Advocacy and Mobilization

1. Interconnected Health Problems and Social Conditions

2. 2. Strategies for Identifying and Treating Latent Tuberculosis Infection among Foreign-born Residents

3. 3. Enhanced Tuberculosis Control Tools for Working with Foreign-born Populations

4. 4. Programmatic Strategies for Ensuring Continuity of Care

5. 5. Investment in Global Tuberculosis Control and Elimination

VI. Tuberculosis in Low-incidence Areas

1. Stopping the Loss of Infrastructure and Capacity

2. Regional Collaboration among State Tuberculosis Control Programs

3. Collaboration among Disease Programs

4. Education and Training to Build Public Awareness and Provider Expertise

5. 5. Interstate Collaboration for Access to Special Facilities

6. 6. Enhancing Laboratory Capacity and Access to Services

7. 7. Public and Community Health Teams

CONCLUSIONS

Evidence of these gaps is that the global rate of decreasein the number of TB cases is less than what would be requiredto achieve the Millennium Development goal of TB eliminationby 2050. Moreover, these gaps have led to the increase in thenumber of drug-resistant cases most prominently in population-dense countries, such as China and India. The deadly duoof TB and HIV coinfection is fueling the TB epidemic in manycountries.

Strategies that should be considered include policies thatenhance DOTS by improving diagnostics to increase case detection,including using private practitioners and closing thefunding gap in DOTS-based programs. Risk factors for continuedTB transmission could be addressed by reducing socioeconomichealth disparities and improving financial supportto national TB-control programs. Better management of HIVand TB coinfection may occur by enhancing diagnostic applicationsof both disease processes and using isoniazid prophylactictherapy. These strategies could serve as part of the foundationto address the emergence of drug-resistant TB and,ultimately, the elimination of the disease. Underlying any effortin TB elimination, however, will be increased funding and politicalwill from both the international community and nationalhealth sectors.

MDG 6: HIV/AIDS, Malarya ve diğer hastalıklar.Hedef 6.

Indikatör 6.9 TB insidans, prevelans ve ölüm hızlarıİndikatör 6.10 DOTS programı altında saptanan ve kür edilen TB olguları

2015 yılına kadar 1990 yılına göre prevelans ve ölüm hızlarını % 50 azaltmak

2050 yılına kadar TB’ u bir halk sağlığı sorunu olarak elimine etmek ( İnsidans < 1/1.000.000 )

TB Kontrolü ile ilgili Global amaç ve hedefler:

Rapid communicationsEpidemiology of tuberculosis in the EU/EEA in2010 – monitoring the progress towards tuberculosiseliminationA Sandgren (Andreas.Sandgren@ecdc.europa.eu)1, V Hollo1, E Huitric1, C Ködmön11. European Centre for Disease Prevention and Control (ECDC), Stockholm, SwedenCitation style for this article:Sandgren A, Hollo V, Huitric E, Ködmön C. Epidemiology of tuberculosis in the EU/EEA in 2010 – monitoring the progress towards tuberculosis elimination.Euro Surveill. 2012;17(12):pii=20124. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20124Article published on 22 March 2012

Indicator Target EU/EEA Number of Member Statesreaching the targetStates reporting

Number of Member

status

Epidemiological indicatorsTrend in TB case notification rate Mean five-year decline -4.4%a 22 29Trend in MDR-TB case notification rate Mean five-year decline -3.4%a 7 22Trend in ratio of notification rate inchildren versus adults Mean 10-year decline -0.3%a 7 25Trend in mean age of TB casesb Increasing trend over 10 years 0.0%a 10 24

96 Horne NW. Eradication of tuberculosis in Europe—so near andyet so far. Eur. J. Respir. Dis. 1983; 126: 169–73.97 Styblo K. Overview and epidemiological assessment of thecurrent global tuberculosis situation with an emphasis andcontrol in developing countries. Rev. Infect.Dis. 1989; 11: S339–46.98 Sutherland I, Springett VH, Nunn AJ. Changes in tuberculosisnotification rates in ethnic groups in England between 1971and 1978/79. Tubercle 1984; 65: 83–91.99 Roche PW, Krause V, Konstantinos A et al. Tuberculosis notificationsin Australia, 2006. Commun. Dis. Intell. 2008; 32: 1–11

Beyond the current efforts to prevent, detect and cureTB, new tools are needed to radically transform thefight against TB and seriously target elimination by2050. In the 1980s, it was estimated that some countriesin Europe would reach the elimination targetaround 2025–2035.96 In 1989, Styblo estimated that itwould take at least 35–40 years to eliminate TB incountries where the prevalence was low.97 However, itwas already recognized that continued immigrationfrom high-TB-incidence areas had a substantial effecton slowing the downward trend of national TB notificationrates at that time.98

While the TB notification rate in non-IndigenousAustralian-born population was 0.9/100 000 in 2006,those in people born overseas and Indigenous Australianswere 20.7 and 6.6, respectively. As a result, thecrude notification rate in Australia was 5.8 in 2006 upfrom5.3 in 2005.99 Between 1996 and 2005, the State ofConnecticut, USA, experienced 53.6% decline of TBnotifications among USA-born persons. However,that in foreign-born persons was only 8.7%. Themedian annual notification rates were 1.5 and 19.7,respectively.100 Progress towards TB elimination evenin a limited geographical area will rely not only onmaintenance of high standard of TB care and controlpractices, but also on regional and global TB controlefforts due to the unlikely capacity to stop an air-borndisease such as TB from rapidly spreading acrossborders.

Eliminating Tuberculosis One Neighborhood at a TimeJ. Peter Cegielski, MD,

Objectives. We evaluated a strategy for preventing tuberculosis (TB) in communities most affected by it.Methods. In 1996, we mapped reported TB cases (1985–1995) and positive tuberculin skin test (TST) reactors (1993–1995) in Smith County, Texas. We delineated the 2 largest, densest clusters, identifying 2 highest-incidence neighborhoods (180 square blocks, 3153 residents). After extensive community preparation, trained health care workers went door-to-door offering TST to all residents unless contraindicated. TST-positive individuals were escorted to a mobile clinic for radiography, clinical evaluation, and isoniazid preventive treatment (IPT) as indicated. To assess long-term impact, we mapped all TB cases in Smith County during the equivalent time period after the project.Results. Of 2258 eligible individuals, 1291 (57.1%) were tested, 229 (17.7%) were TST positive, and 147 were treated. From 1996 to 2006, there were no TB cases in either project neighborhood, in contrast with the preintervention decade and the continued occurrence of TB in the rest of Smith County.Conclusions. Targeting high-incidence neighborhoods for active, community-based screening and IPT may hasten TB elimination in the United States. (Am J Public Health. Published online ahead of print October 18, 2012: e1-e9. doi:10. 2105/AJPH.2012.300781)

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 3, March 2011

Globally, this implementation gap has been closing asa result of reliance on the evidence-based strategy for TBcontrol, originally known as Directly Observed TreatmentShort-course (DOTS

Furthermore, TB control hasbeen demonstrated to be among the most cost effective ofhealth interventions (13).

Evenwhen all countries of the world have adopted policiesconsistent with the DOTS strategy, a sizable proportion ofestimated cases (≈37%) are undetected, and those infectedare likely not receiving optimal treatment regimens

Implementation GapIn his 1963 lecture

Most recently,technologic advances have demonstrated the ability to relyon detection of bacterial DNA by PCR. The WHO policyrecommendation to rely on Xpert MTB/RIF (Cepheid,Sunnyvale, CA, USA) for same-day diagnosis accentuatesand magnifi es this implementation gap (18)

Effortsmust now focus on tackling social determinants of illnessassociated with TB by expanding and facilitating access toimpoverished persons in densely populated urban areas andremote villages.

An analysis from India has reported that 72% ofTB patients who had a low standard of living (e.g., earningUS $1–$2/d) fi rst saw private providers and spent, onaverage, $145 before starting treatment with the RevisedNational TB Program, thus documenting the devastatingeconomic toll incurred by poor persons with TB

A growing concern has to do with the gap insuccessfully addressing concurrent conditions associatedwith TB, such as HIV, diabetes, smoking, indoor airpollution, alcoholism, and malnutrition (16).

Knowledge GapThere remain critical areas of collective ignorancewith regard to M. tuberculosis. These include knowledgeof rapid, simple, and inexpensive methods of detection;molecular mechanisms of resistance to chemotherapy;virulence; host defense correlates of susceptibility to andprotection against the organism; and optimal targets fordevelopment of new antimicrobial drugs.Until the past 2 decades, defi nitive detection of M.tuberculosis relied exclusively on culture, which takesweeks because of the requisite generation time of 18–24hours, giving rise to the apt descriptor of M. tuberculosisas “slow growing” bacteria. In low resource settings, evenculture may not be available and diagnosis must be basedon smear microscopy, which fails to detect nearly half ofpatients with TB (14).

Only relatively recently has a promising newmolecular diagnostic test become available, the Xpert TB/RIF, that is both simple and accurate (21). However, evenwith concessionary pricing for low-income countries, coststill remains an issue.

Similarly, detection of drug resistance almost solelyrelies on phenotypic culture-based methods. Here, also,advances in molecular biology are moving the fi eld forward,but the situation is more complex than for detection ofthe organism. Fortunately, for the most important anti-TB drug, rifampin, >95% of resistance can be attributedto mutations in 1 gene, which has greatly simplifi edthe development of molecular tests to detect rifampinresistance (22). Commercial assays that use line-probe andmolecular beacon technologies have been produced thatare rapid and accurate (22,23). However, for other fi rst-linedrugs (such as isoniazid and ethambutol) and second-linedrugs, the molecular mechanisms

Virulence of M. tuberculosis, especially variationamong strains, is also poorly understood. There is evidencesuggesting some strains may result in higher rates of diseaseprogression, treatment failure, and relapse (25). Identifyinggenetic markers of M. tuberculosis virulence would enableadditional attention to be focused on patients infected withstrains manifesting such markers and who are therefore atthe greatest risk for poor outcomes.

ceptibility to and protection against M. tuberculosis hasstymied progress in 2 key areas: vaccine development andprevention through treatment of latent TB. A vaccine thatuses an attenuated strain of M. bovis (M. bovis BCG) hasbeen available for nearly a century and is one of the mostwidely used vaccines in the world. Although the vaccinedoes offer substantial protection against disseminationof M. tuberculosis infection in children, it only providesmodest and highly variable protection against TB in general(26,27). Clearly, more effi cacious and safe vaccines areneeded; these are only likely to be produced through abetter understanding of immunologic mechanisms andcorrelates of protection. A related knowledge gap isthe lack of understanding of why only a small fraction(≈5%–10%) of persons infected with M. tuberculosis laterexhibit disease (28).

Ambition GapThe report from the 1959 Arden House Conferenceon TB made a daring statement, possibly well ahead of itstime, indicating that TB control “has progressed to the pointwhere virtual elimination of the disease as a public healthproblem appears to be within reach” (31). However, it wasnot until 3 decades later that the Centers for Disease Controlpublished a formal consensus plan for the elimination ofTB in the United States (32). This plan was ambitious,yet initially naive about the full extent of the effects onTB incidence due to HIV infection; multidrug resistance;institutional transmission of M. tuberculosis; and the timelag for the development of new technologies for moreeffective prevention, prompt diagnosis and detection ofdrug resistance, and superior treatment of TB. These variousfactors converged to produce the unprecedented resurgenceof TB experienced in the United States during 1985–1992(33). The rapid dissemination of multidrug-resistant TBamong HIV-infected persons and their caregivers wasaccompanied by unacceptably high mortality rates andserved as a clarion call to elicit concerted efforts andmobilize new resources to implement the 1992 NationalAction Plan to Combat Multidrug Resistant TB (34). TheUS Federal TB task force coordinated interagency workand successfully worked with health department-basedTB programs across the nation to reverse this trend overensuing years. In 2000, the Institute of Medicine reaffi rmedthe goal of TB elimination and recommended additionalsteps required for accelerated progress, including the needto commit to elimination as a national goal and to monitorprogress (35).In recent years

In recent years, the risk of renewed complacency,resource limitations experienced by local healthdepartments, and the direct effects of global TB on USdisease rates (nearly 60% of incident TB cases reported inthe United States in 2009 occurred in foreign-born persons)challenges advances to TB elimination in the near future.Bold ambition and expectations with sustained actions are arequisite to successfully eliminating TB in the United Statesand globally. The report of the 1997 Dahlem Workshopon the Eradication of Infectious Diseases recognizes that“[t]he success of any disease eradication initiative dependsstrongly on the level of societal and political commitment…Elimination and eradication are the ultimate goals of publichealth, evolving naturally from disease control. The basicquestion is whether these goals are to be achieved in thepresent or some future generation” (36).

World Health Organization. The global plan to stop TB 2011–2015:transforming the fi ght towards the elimination of tuberculosis [cited2011 Jan 3]. http://www.stoptb.org/assets/documents/global/plan/TB_GlobalPlanToStopTB2011-2015.pdf

This frame of mind was aptlyrecognized in 1963 by William Brown, who advocatedfor syphilis eradication during the 1960s. He arguedthat diseases targeted for eradication (or elimination)should attain a “status of intolerability” by both healthauthorities and the public, such that any occurrence of thedisease, “no matter how small,” gives cause for immediateaction (37). Public clamor would help ensure sustainedpolitical commitment and ongoing work. With relatively

Christopher Dye and Brian G. WilliamsSlow Elimination of Multidrug-Resistant Tuberculosis

Sci Transl Med 1, 3ra8 (2009);

where there may be regions in which drug-resistant strains are self-sustaining. Thus, present efforts at eradication,that the R for each of the drug-resistant strains tested in each country is less than 1, with the exception of Russiaresistant to rifampicin, isoniazid, or both drugs. When analyzed with a model of disease spreading, the data indicateKingdom, and others), Russia, Hong Kong, and the United States to estimate the values of R for bacterial strains(though the years differ among countries) from European countries (Estonia, Germany, Latvia, Lithuania, Unitedtrack for disease elimination. Dye and Williams used data reported to the World Health Organization from 1996 -2008M. tuberculosis. With this information, ongoing eradication efforts can be adjusted to keep R at less than 1 and on

The total cost of the Global Plan was $56 billion, ofwhich $47 billion was slated for implementation of currentlyavailable interventions and $9 billion for researchand development [9, 12]. However, even whenlaunched in 2006 (a time when the global economy wasrelatively strong), the overall estimated funding gap forthe Global Plan was 1$30 billion [13]. In past recessions,several countries had reduced spending on overseasdevelopmental programs [14–16].

9. Raviglione MC. The new Stop TB Strategy and the Global Plan to StopTB, 2006–2015. Bull World Health Organ 2007; 85:327.10. Stop TB Partnership. The Global Plan to Stop TB 2006–2015. Geneva:World Health Organization, 2006.11. Komatsu R, Low-Beer D, Schwartla¨nder B. Global Fund-supportedprogrammes contribution to international targets and the MilleniumDevelopment Goals: an initial analysis. Bull World Health Organ2007; 85:805–811.12. Young DB, Perkins MD, Duncan K, Barry CE. Confronting the scientificobstacles to global control of tuberculosis. J Clin Invest 2008;118:1255–1265.

14. International Monetary Fund. The implications of the global financialcrisis for developing countries. Washington, DC: IMF, 2009.15. Calı` M, Massa I, te Velde DW. The global financial crisis: financialflows to developing countries set to fall by one quarter. ODI backgroundpaper. London, Overseas Development Institute, 2009

Son Rapor

MDR

Dağılım

IV

Diğerler

TB FUNDING ISSUESClose the funding gap for DOTS.

if DOTS was sustained at 2005 coveragelevels in key countries with a high burden of TB, there wouldbe an estimated economic gain of $1.6 trillion (during 2006–∼2015), ranging from $0.74 billion (95% CI, $0.64–$0.84) inZimbabwe to $748 billion (95% CI, $638–$857) in China

The existing funding gapamong the 94 countries with 93% of global cases in 2009 is$1.6 billion [26].

Among the 94 countriesthat reported 93% of TB cases, a total of $4.2 billion is requiredfor full implementation of country plans in 2009. Eighty-sevenpercent of funding derives from national governments (includingloans), 9% from the Global Plan, and 4% from donorsother than the Global Plan.

Fully fund TB-control programs

Greater funding to integrate TB and HIV services.

Of thetotal of $2.9 billion required for full implementation of thecountry plans in the 22 countries with the highest burden ofTB in 2009, only 3% is dedicated to joint TB and HIV–relatedactivities [26].

Cost-effective strategiesmay be immediately implemented using currently availabletechnologies in resource-limited settings