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Global Tuberculosis Burden. Philippe Glaziou Cancun, December 2009. Outline. What is TB? How do we get TB? Who develops TB? Trends in global burden What is done about it? Why is TB still a problem? Can we get rid of TB?. Tuberculosis: An Ancient Killer.

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global tuberculosis burden

Global TuberculosisBurden

Philippe Glaziou

Cancun, December 2009

outline
Outline
  • What is TB?
  • How do we get TB?
  • Who develops TB?
  • Trends in global burden
  • What is done about it?
  • Why is TB still a problem?
  • Can we get rid of TB?
tuberculosis an ancient killer
Tuberculosis: An Ancient Killer
  • Tubercular decay in skull and spinal bones found in 4000 year old Egyptian mummies

Hippocrates around 400 BC: “Phthisis is the most common disease of humans and it is nearly always fatal”

tuberculosis what s in a name
Tuberculosis: what’s in a name ?

The disease was named Tuberculosis in 1839 by J. L. Schönlein

  • Phthisis
  • Wasting
  • Scrofula
  • Pott’s disease
  • Lupus vulgaris
  • Consumption
  • The Captain of the Men of Death
  • The White Plague
signs and symptoms
Signs and symptoms
  • Early symptoms
      • Common cold symptoms
      • Listlessness, fatigue, fever, a minimally productive cough of yellow or green sputum and a general feeling of malaise.
  • Later symptoms
      • Night sweats, fever, cough with purulent secretions and haemoptysis, dyspnoea, chest pain, and hoarseness appear.
diagnostic discoveries
Diagnostic discoveries
  • 24th March 1882 (Robert Koch) TB Day
    • Discovery of staining technique that identified Tuberculosis bacillus
  • 1890 (Robert Koch)
    • Tuberculin discovered
    • Diagnostic use when injected into skin
  • 1895 (Roentgen)
    • Discovery of X-rays
    • Early diagnosis of pulmonary disease
historical decline of tb 1840 1960
Historical decline of TB, 1840-1960

400

Segregation of poor

consumptives in enlarged and

improved workhouses infirmaries

300

Systematic segregation

of consumptives, rich and poor,

In hospitals and sanatoria

Koch’s

discovery

Standardised notification rate

200

Antibiotic

era

100

Initial effect of

segregation of poor

consumptives in

work house

0

1860

1880

1900

1920

1940

1960

1840

Year

Source: data derived from various sources including T. McKewon. The modern rise of population, London: Edward Arnold 1976.

global burden in 2008
Global burden in 2008

9.4 million new cases

15% infected with HIV

1.4 million deaths excluding HIV

0.5 million deaths in HIV-infected (25% of 2 million HIV deaths)

what causes tb
What causes TB?

Genetic deletion analysis

Source: Brosch et al. PNAS 2002; 99: 3684-3689

slide13

Who develops TB?

From Lonnroth K et Al. Global epidemiology of tuberculosis. Seminars in Respiratory and

Critical Care Medicine, 3 March 2008

evolution of tb control
Evolution of TB Control

The touch of King Charles II was thought to cure Tuberculosis

(17th century)

prevention milestone bcg
Prevention Milestone: BCG
  • BCG developed by Calmette & Guerin in 1907
  • First human immunizations in 1921 in France
  • Protection against serious forms of TB
  • Limited or no protection against pulmonary TB
treatment milestones sanatorium
Treatment Milestones: Sanatorium
  • Isolation of TB patients in sanatorium
    • Prevention of spread of infection
    • Fresh air
    • Sunshine
    • Physical exercise
tb drugs
TB Drugs
  • 1943: Selman Waksman discovers Streptomycin (Nobel Prize in 1952)

Other anti-TB drugs:

  • 1949: PAS
  • 1952: Isoniazid
  • 1954: Pyrazinamide
  • 1955: Cycloserine
  • 1962: Ethambutol
  • 1963: Rifampicin
world health assembly targets for global tb control
World Health Assembly Targets for Global TB Control
  • By 2000:
    • Detect 70% of all new

sputum smear-positive cases

    • Successfully treat 85%
  • Slow progress of many countries led to the revision of the target year to 2005
  • 2005 targets missed:
    • Case detection: 60%; treatment success: 84%
  • HIV/AIDS in Africa, drug resistance in Eastern Europe
emergence of worst case tb scenarios
Emergence of “worst-case” TB scenarios
  • Co-infection between TB and HIV
  • Multidrug-resistant TB (MDR-TB)
    • Resistance to isoniazid and rifampin – the 2 most powerful anti-TB drugs
  • Extensively-drug resistant TB (XDR-TB)
    • MDR-TB plus resistance to any fluoroquinolone and at least 1 second-line injectable (AMI, KAN, CAP)
tb poverty overlap
TB & Poverty overlap

Source: World Economic Forum, 2005

slide28

Central Europe: 5yr+ delay in TB control

Albania, Bulgaria, Czech, Hungary, Poland, Romania

9500

1980

9000

1995

1994

8500

8000

Average number TB cases

7500

7000

1990

6500

1989

2006

6000

4000

6000

8000

10000

12000

14000

Average GDP per capita

can we get rid of tb
Can we get rid of TB?
  • New vaccines
    • BCG does not prevent the disease in adults
  • New diagnostics
    • Smear microscopy and culture: imperfect and slow
    • Drug susceptibility testing too slow
  • New drugs
    • Treatment is still much too long
    • To treat drug resistant TB: MDR-TB, XDR-TB
a vaccine to transform tb control
A vaccine to transform TB control?

Source: Young D and Dye C. Cell 2006: 124; 687, DOI 10.1016

in conclusion
In conclusion
  • Burden exacerbated in the 90s by the rise of HIV
  • Slow progress of TB control performance
  • Slow decline in disease burden since 2004
  • Elimination nowhere in sight, we need
    • New vaccines
    • New drugs
    • New diagnostics