Tuberculosis

in Developing
Countries:
Dilemmas
Erik Post, MD MSc
Royal Tropical Institute Amsterdam
Global Plan 2006-2015
World Health Assembly:
•Detect 70% of infectious TB
•Treat successfully 85% of detected cases

Millenium Development Goals 2015:

•Halt and reverse TB prevalence and deaths
by 2015, as compared to 1990
 DOTS - STRATEGY
1. Political commitment

2. Diagnosis by smear-microscopy

3. DOT with standard regimen

4. Continuous drug supply

5. Standardised recording and

reporting
DOTS Strategy: on target?
(a)
C ase detection rate, smear-positive cases (% ) 70% case detection target
80

WHO target 70%

70

60
All cases
50
All cases, DOTS only
40

30
average rate of progress
DOTS begins 1995–2000
20

10

0
1990 1995 2000 2005 2010 2015

Year
DOTS Strategy: unsuccessful
treatment outcome

Max. 15% bad outcome

TB Global Plan 2006-2015
Expansion of the DOTS strategy

Additional, in view of MDG‘s:

•Address TB-HIV and MDR-TB
•Health system strengthening
•Engage all health care providers
•Empower patients and communities
•Enable and promote research
TB Global Plan 2006-2015
Filling the funding gap will mean:
14 million lives saved
50 million people treated
3 million HIV+ TB patients on ART

Advocacy, communication and social mobilization integral

part of TB control

New drugs, new tests, new vaccine

Political commitment: funding gap…
Diagnosis: clinical considerations
Correlation Between Extent of HIV-Induced Immuno-
Suppression and Clinical Manifestation of Tuberculosis
500 Pulmonary tuberculosis
Median CD4 cell count / mm3

400
Lymphatic, serous tuberculosis

300 Tuberculous meningitis

D
u
ra
tio
n
o
fH
IV
in
fe
ctio
n
200 Disseminated tuberculosis

100

De Cock KM, et al. J Am Med Assoc 1992;268:1581-7

 Laboratory challenges

Diagnosis under HIV conditions…...

Capacities

External Quality Assurance

Culture + Drug Susceptibility Testing (DST)

New diagnostic approaches

•LED, concentration, serum,…
 DOT with standard treatment

•Provider-observed
•Caretaker-observed
•Community based DOTS

New standard treatment

required, due to rising
MDR?
Continuous drug supply

Not many problems:

•Supplies nationally or through GDF
•Financing nationally or through grants of
GFATM or GDF or loans from World Bank
•Sometimes problems in supply chain

But….. quality of drugs….

Rigorous Recording & Reporting
 Electronic TB Register (eRR)

http://www.who.int/tb/err/catalogue/
 Expand TB-HIV
National management priority programmes
es
a vi c
H DS a ri er
MC TB AI al s
M H

intermediate management priority programmes

TB AIDS TB AIDS TB/AIDS ??

intermediate management priority programmes

PHC level
MDR-TB: notified cases (2004–2006) and
projected to be treated in 2007–2008.
50 non-GLC
47 46
GLC
40 500,000 MDR-TB yearly
Target for MDR-TB patients on treatment:
2006: 14 thousand
30 2007: 52 thousand L !!
2008: 98 thousand RO
23 N T
CO
20 18 N
18
TIO
EC
10
INF

0
2004 2005 2006 2007 2008
Infection control
Some points:
•30% of TB staff likely to get infected
•Cough hygiene
•Reducing droplets
•Sputum sampling outside!
•Regular HIV and TB testing of at risk groups
•MDR-TB outside HIV clinics
 Health systems strengthening
National plan/framework
25
exists

20 NTP plan and budget

aligned with national plan or
framework
15

10

0
Plan nat. health Poverty Plan nat. HR for Medium-term SWAp
developm. reduction health expend. for
strategy health
 Engage all health providers: PPP?
None Some All No response
Public gen.hosp.

Teaching Hosp

Military HFs

Prison HFs

NGO/mission

HFs of HI inst.

Corp h. services

Priv hospitals

Priv pract

0 5 10 15 20 25
countries
 Advocacy, Communication and
Social Mobilisation (ACSM)
•Advocacy to decision makers
•Communication to civic society
•Community mobilisation to increase service utilisation
100

80

Community
60
participation
40
in TB control,
all countries,
20 2006
0
AFR AMR EMR EUR SEAR WPR HBCs World
Yes No No response
Enable & promote research

Better vaccins

New diagnostics

New drugs

Operational research to improve

implementation of expanded DOTS strategy
 Information on TB

www.findtbresources.org/
www.who.int/tb/en/
www.iuatld.org/
www.stoptb.org/