prezentare studenti Tuberculoza

1. Tuberculoza o boala de actualitate permanenta
Dr. Cristian Cojocaru
Prof. Dr. Traian Mihaescu

2. Marcus Tullius Cicero 106-43 IC Roman Politician
Cardinal Richelieu 1585-1642 Francez Politician
Alexander Pope 1688-1744 Englez Poet
Luigi Boccherini 1743-1805 Italian Muzician
Johann Wolfgang
von Goethe 1749-1832 German Scriitor
Friedrich Schiller 1759-1805 German Scriitor
Rene Theophile
Hzacinthe Laennec 1781-1826 Francez Medic
Niccolo Paganini 1782-1840 Italian Muzician
Frederic Francois Chopin 1810-1849 Polonez Musician
Emily Bronte 1818-1848 Englez Scriitor
Fyodor Dostoyevsky 1821-1881 Rus Scriitor
Edward Livingston Trudeau1845-1915 American Medic
Anton Cekhov 1860-1904 Rus Scriitor
Mahammed Ali Jinnah 1876-1948 Indian Politician
Igor Stravinsky 1882-1971 Rus Muzician
Franz Kafka 1883-1924 German Scriitor
Eleanor Roosevelt 1884-1962 American Sotia
presedintelui
David Lwrence 1885-1930 Englez Scriitor
George Orwell 1903-1950 Englez Scriitor
Nelson Mandela 1918- Sud African

3. Reversing the tuberculosis upwards trend:
a success story in Romania
C. Marica*, C. Didilescu*, N. Galie*, D. Chiotan*, J.P. Zellweger#, G.
Sotgiu",
L. D’Ambrosio+, R. Centis+, L. Ditiu1 and G.B. Migliori+
Eur Respir J 2009; 33: 168–170
0–24
25–49
50–99
100–299
>300
No estimate

4. 138,8
110
61
55,8
70
102,6
134,1
142,2
135,7
0
20
40
60
80
100
120
140
160
1972 1975 1980 1985 1990 1995 2001 2002 2003

5. Fonduri pentru TB control
3.9
4.7

6. 1. Chile, 2. Peru, 3. Columbia, 4. Venezuela, 5. Mexic, 6. SUA, 7. Canada, 8. Egipt, 9.
Iordania, 10. Israel, 11. Rusia, 12. Hawai, 13. China, 14. Japonia, 15. Tailanda, 16.
Tonga, 17. Insulele Solomon, 18. Papua Noua Guinee

7. 1. Marea Britanie, 2. Franţa, 3. Portugalia, 4. Spania, 5. Elveţia, 6. Italia, 7.
Grecia, 8. Serbia, 9. Turcia, 10. Ungaria, 11. Austria, 12. Cehia, 13. Polonia, 14.
Lituania, 15. Germania, 16. Suedia, 17. Norvegia, 18. Danemarca, 19 Finlanda3

15. Mortalitatea prin tuberculoza in perioada 1938-1993

16. Morbiditatea prin tuberculoza in perioada 1960-1996

17. Evolutia indicatorilor epidemiologici în mediul urban şi rural, de la momentul
„0” al aparitiei tuberculozei intr-o populatie

18. Mortalitatea prin tuberculoza, reprezentata in functie de sex si virsta: A. In timpul
perioadelor inalt epidemice; B. In timpul perioadelor intermediare; C. Perioada de
dupa valul epidemic.

19. Situatia actuală si tendintele viitoare ale imbolnavirii prin
tuberculoza
2000 - opt milioane de bolnavi de tuberculoza
1997-2000 crestere cu 1,7%/an
crestere in regiunea sub-Sahariană şi în ţările ex-sovietice
scădere in Europa Centrală si de Vest, America si Orientul
Mijlociu
2000 - 1,8 milioane de decese datorate tuberculozei

20. Estimated
number of cases
Estimated
number of deaths
1.7 million*
(range: 1.5–2.0 million)
9.4 million
(range: 8.9–9.9 million)
440,000
(range: 390,000–510,000)
All forms of TB
Multidrug-
resistant
TB (MDR-TB)
HIV-associated TB 1.1 million (12%)
(range: 1.0–1.2 million)
380,000
(range: 320,000–450,000)
*including deaths among PLHIV
Situatia TB -2009
about 150,000
0–24
25–49
50–99
100–299
300 and higher
No estimate available

21. 0–24
25–49
50–99
100–299
>300
No estimate
•Highest burden in Asia (55% of 9.4 million cases)
•Highest rates in Africa, due to high HIV infection rate
~80% of HIV+ TB cases in Africa
Per 100 000 population
Incidenta TB - 2009

22. Impactul HIV la pac cu TB
Notified cases per 100,000 pop. 1980-2008
•79% of all TB/HIV cases world-wide are in Africa
•50% of all TB/HIV cases world-wide in 9 African countries
•23% of the estimated 2 million HIV deaths due to TB

23. MDR-TB in % la cazurile noi de TB, 1994-2009
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on
maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2010. All rights reserved

24. Stopping Tuberculosis in England
An Action Plan from the Chief Medical Officer
Action 1: Increased awareness
Aim: Maintain high awareness of TB, particularly among health
professionals , highrisk groups and people who work with them, teachers,
and the public
Five point plan
> Produce multilingual and culturally appropriate public information and
education materials for national and local use and make them widely available
> Ensure that general practitioners and other primary and community care staff
are aware of: the symptoms and signs of the disease; local TB services; and
local
arrangements for referring patients with suspected TB
> Use World TB Day in March each year to increase awareness, particularly
among healthcare professionals and high risk communities, and encourage
relevant
national organisations to do the same
Maintain awareness, including through the media and community groups, and
develop initiatives to support local awarenessraising among high risk groups
Seek greater professional awareness through undergraduate, postgraduate

25. Stopping Tuberculosis in England
An Action Plan from the Chief Medical Officer
Action 2: Strong commitment and leadership
Aim: Create a strongly led, well coordinated and adequately resourced
national TB programme, with all those working to deliver the
programme having a clear focus on what needs to be achieved and
best practice for doing this

26. Stopping Tuberculosis in England
An Action Plan from the Chief Medical Officer
Action 3: High quality surveillance
Aim: Provide the information required at local, national and
international levels to
• identify outbreaks
• monitor trends
• inform policy
• inform development of services, and monitor the
success of the TB programme

27. Stopping Tuberculosis in England
An Action Plan from the Chief Medical Officer
Action 4: Excellence in clinical care
Aim: Provide uniformly high quality, evidence based treatment and
care for patients with suspected and diagnosed TB, with all patients
having their outcome of treatment recorded and at least 85 per cent
successfully completing treatment

28. Stopping Tuberculosis in England
An Action Plan from the Chief Medical Officer
Action 5: Well organised and coordinated patient services
Aim: Provide high quality coordinated services for TB diagnosis,
treatment and continuing care, which also meet the needs of individual
patients
Action 6: First class laboratory services
Aim: Provide laboratory services of consistent high quality which
support clinical and public health needs, in keeping with the overall
pathology modernisation programme

29. Stopping Tuberculosis in England
An Action Plan from the Chief Medical Officer
Action 7: Highly effective disease control at population level
Aim: Increase the evidence base for, and the consistency of application
of public health interventions for TB
Action 8: An expert workforce
Aim: Ensure TB control has an appropriately skilled workforce and that
physicians and nurses with expertise in TB continue to be recruited,
trained and retained

30. Stop TB Strategy & Global Plan
To save lives, prevent suffering,
protect the vulnerable, & promote
human rights
1. Implementarea DOTS
2. TB-HIV, MDR-TB, la
populatiile sarace si
vulnerab ile
3. Intarirea sistemului
de sanatate
4. Sensibilizarea tuturor
funizorilor de
sanatate
5. Sustinerea
persoanelor cu TB
6. Promovarea

31. 2015: Goal 6: Combat HIV/AIDS, malaria and other diseases
Target 6c: to have halted by 2015 and begun to reverse the incidence…
*Indicator 6.9: incidence, prevalence and mortality associated with TB
*Indicator 6.10: proportion of TB cases detected and cured under DOTS
2015: 50% reduction in TB prevalence and deaths by 2015
2050: elimination (<1 case per million population)
Tintele Global TB Control

32. Launched in Johannesburg
13 October 2010
Global Plan to Stop TB 2011-2015

33. *CPT, cotrimoxazole preventive therapy
ART, antiretroviral therapy
INDICATOR TARGET
Number of countries with ≥1
smear microscopy lab per
100 000 population
149
(All countries
in plan)
Patients notified + treated 6.9 million
Treatment success rate 90%
INDICATOR TARGET
Number of 22 HBCs and 27
MDR-TB HBCs with >1 Cx &
DST lab to cover 0.5-1 M
population
36/36
Previously treated cases tested
for MDR
100%
New cases tested for MDR 20%, all at
high-risk
MDR-TB patients treated
following WHO guidelines
100%, or
~ 270k
INDICATOR TARGET
TB patients tested for HIV 100%
HIV+ TB patients on CPT 100%
HIV+ TB patients enrolled
on ART
100%
DOTS/lab strengthening MDR-TB/lab strengthening
TB/HIV
pp17
10 tinte pentru 2015

34. Realizari pina in prezent
• 41 milloane de patienti vindecati, 1995-2009
• 6 milioane de decese prevenite comparativ
cu standardele din 1995
• Mortalitatea reducsa cu 35% din 1990
• Vindecari >85%, ingijirea/HIV imbunatatita
• But…. TB incidence declining too slowly,
case detection stagnating, and MDR-TB care
only now starting scale-up

35. Estimari globale ale prevalentei si
mortalitatii
2015
Mortalitatea
1990
35
25
15
0
target
Prevalenta
1990
300
200
100
0
2015
target
shaded area = uncertainty band

36. Incidenta globala - scadere <1%/an
Peak in 2004
Incidence (all forms, incl. PLHIV)
TB Notifications
Incidence TB in PLHIV
shaded area = uncertainty band
Notification gap

37. shaded area = uncertainty band
6.7
9.4
3.7
5.8
Notificari (negru)
incidenta estimata (albastru)
TBcases(millions)
Detectia cazurilor gap: 1/3

38. Cresterea notificarilor (public-privat)
Source: 2010 WHO global TB control report, Table 7, page 16
NATIONAL PARTS OF COUNTRY

39. Succesul treatmentului - 86% global
Global WHO Regions
Progres in majoritatea regiunilor, Europeramine in
urma
W. Pacific
SE Asia
EMR
Africa
93
88
80
Americas
77
66
Europe

40. Testarea HIV la pacientii cu TB
Africa
World
Tinta 100% in Global Plan
Citeva tari
inregistreaza rate de
testare f bune
Rwanda: 97%
Kenya: 88%
Tanzania: 88%
Malawi: 86%
Mozambique: 84%
PercentageofTB

41. Provocari pentru 2011
1. Fonduri nesigure
2. slabaDoar 61% din cazuri sunt raportate
3. TB/HIV major impact in Africa
4. MDR-TB in tarile ex-URSS si China
5. Politici slabe de sanatate
6. Practica medicala in afara sistemului de notificare
7. Communitati neinteresate de politicile de sanatate
8. Cercetare

42. Fonduri necesare, Global Plan
Implementation
Plan component US$
billions,
2011–2015
%
total
IMPLEMENTATION 36.9 79%
DOTS 22.6 48%
MDR-TB 7.1 15%
TB/HIV 2.8 6%
Lab strengthening 4.0 8%
Technical
assistance
0.4 1%
R&D 9.8 21%
TOTAL 46.7 100%
PLUS: Target that diagnosis should be free-of-charge or fully reimbursable by
health insurance in all 22 high-burden countries (HBCs)

43. Fonduri 2010−2011 vs. funduri necesare
Global Plan, 2011−2015

44. Imbunatatirea controlului TB
1. Remove financial barriers (UHC)
2. Ensure well trained and sufficient human resources
3. Establish a network of labs where rapid tests are also
available
4. Ensure availability of quality drugs
5. Regulate the use of all anti-TB drugs
6. Introduce infection control
7. Establish proper surveillance
8. Promote R&D
9. Mobilize resources domestically and internationally
Document WHA 62.15, 2009

45. •Public and private medical colleges (yellow) diagnose a huge number of cases, but many of them are from outside the city
and need to be refereed for treatment elsewhere.
•The increase in diagnosed cases represents increased notification after medical colleges and other providers started to
report to NTP in a standardised way
Bangalore, 1999-2005
Cresterea numarului de notificari

46. Limitari ale diagnosticului, medicamentelor,
vaccinului
Diagnostics - More than 100 years old
• Detects only half of the cases in patients tested
• Ineffective for diagnosing TB in PLHIV
• Rapid tests for MDR strains available, but not yet in the field
Drugs – Last drug 40 years old
• Four drugs, taken for at least 6 months
• Not compatible with some HIV/AIDS antiretrovirals
• MDR-TB treatment lengthy, with low cure rates, expensive, toxic
Vaccine – Nearly 90 years old
• Unreliable protection against pulmonary TB
• No apparent impact on the TB epidemic

47. 1
10
100
1000
10000
2000 2010 2020 2030 2040 2050
Year
Incidence/million/yr
Elimination 16%/yr
Global Plan 6%/yr
Current trajectory 1%/yr
Implementarea completa a Global Plan
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

49. Impactul potential al unui nou vaccin, test si
medicament in SE Asia
Source:L.AbuRaddadetal,PNAS2009
Add. Effects = effects also on latency
and infectiousness of cases in vaccinated
•Led & NAAT at microscopy lab level
•Dipstick at point of care
•Regimen 1 = 4-month, no effect on DR
•Regimen 2 = 2-month, 90% effective in M/XDR
•Regimen 3 = 10-day, 90% effective in M/XDR

50. Eliminarea TB in 2050 interventii
sinergice
DyeC&WilliamsBG,J.R.Soc.Interface2007
NOT by preventing
infection & treating active
TB
(both act on cutting
transmission)
But by treating latent infection and active TB or
by preventing and treating latent infection (cutting transmission and reactivation)

51. 1. Declin din 2015
2. acces universal la resurse
3. Cercetare si dezvoltare
Concluzii