WHO - migration and health: the development of global strategies to control and eliminate TB in the European and Mediterranean Regions Pierpaolo de Colombani Medical Officer, TB and M/XDR-TB (TBM), Division of Communicable Diseases, Health Security, and Environment (DCE) WHO Regional Officer for Europe
Estimated number of TB cases; world, 2009 www.worldmapper.org 8.9-9.9 million new TB cases in the world 390-450 000 new TB cases in WHO/Europe Country 22 high-burden countries for TB in the world New TB cases % (cumul.) Country New TB cases % (cumul.) India 2,000,000 21 Viet Nam 180,000 71 China 1,300,000 35 Russian Fed 150,000 72 South Africa 490,000 40 Uganda 96,000 73 Nigeria 460,000 45 Kenya 120,000 75 Indonesia 430,000 50 Mozambique 94,000 76 Pakistan 420,000 54 Thailand 93,000 77 Bangladesh 360,000 58 Zimbabwe 93,000 78 Ethiopia 300,000 61 Brazil 87,000 79 Philippines 260,000 64 UR Tanzania 80,000 79 DR Congo 250,000 67 Cambodia 65,000 80 Myanmar 200,000 69 Afghanistan 53,000 81 Global tuberculosis control: WHO report 2010. Geneva: WHO, 2010 (WHO/HTM/TB/2010.7) Conference on TB, HIV and migration, Rome,
Estimated MDR-TB burden; 2008 World: 440 000 (390 000-510 000) new MDR- TB cases 27 high burden countries WHO/Europe: 81 000 (73 000-90 000) new MDR-TB cases 15 high-burden countries SEAR 30% WPR 28% Africa 16% AMR 2% EMR 5% EUR 19% WHO/Europe: top 15 countries with MDR-TB among new TB cases and top 13 countries with MDR-TB among previously-treated TB cases Multidrug and extensively drug-resistant TB (M/XDR-TB): 2011 global report on surveillance and response (WHO/HTM/TB/2011.3) Conference on TB, HIV and migration, Rome,
Main challenges for TB control in WHO/Europe High prevalence of drug resistant TB (MDR/XDR-TB) Link with HIV epidemic through injecting drugs users Health systems poorly developed or under reform, leading to ineffective TB control (non-dots) Economic recession, poverty and existence of socially vulnerable groups (homeless, unemployed, alcohol abusers, etc.) Very large penitentiary system with poor TB services Migration (East to West, South to North, internal migration) Conference on TB, HIV and migration, Rome,
Estimated TB incidence; WHO/Europe, 2009 <1 202 new TB cases per 100 000 (Monaco Tajikistan) Italy 3.8 (3.4-4.5) per 100 000 population Global tuberculosis control: WHO report 2010. Geneva: WHO, 2010 (WHO/HTM/TB/2010.7) TB cases (all) per 100,000 pop. < 10 11-20 21-50 51-100 > 100 Conference on TB, HIV and migration, Rome,
Stop TB Strategy: vision, goal, objectives, targets Conference on TB, HIV and migration, Rome,
European framework for TB control, elimination in low incidence countries (WHO, 2002) Recommendations by the WHO/IUATLD/KNCV Working Group: 1. Early detection and treatment of all TB cases and prevention of unnecessary deaths 2. Reducing the incidence of TB infection: Risk group management (e.g. active finding of disease and latent infection among immigrants, prisoners, minorities, homeless, contacts, etc.); Prevention of TB infection in institutional settings (jails, hospitals) 3. Reducing the prevalence of latent TB infection: Outbreak management (contacts through DNA fingerprinting) Preventive therapy for specific individuals/groups Broekmans JF, Migliori GB, Rieder HL et al. European framework for tuberculosis control and elimination in countries with a low incidence. Eur Respir J 2002; 19:765-775 Conference on TB, HIV and migration, Rome,
Epidemiological modeling for TB elimination Two routes for developing active TB: Slow route: reactivation of latent infection Fast route: recent infection or reinfection Need of combination of interventions that affect both routes: Treatment of latent TB + treatment of active TB Treatment of latent TB + pre-exposure vaccination (+ treatment of active TB) Need of easier schemes for preventive therapy (H+?) Need of better vaccines than BCG Dye C., Williams BG. Eliminating human tuberculosis in the twenty-first century. J.R.Soc.Interface 2008 (5), 653-662. Conference on TB, HIV and migration, Rome,
TB control and elimination 2010-2050 The way forward: action on 4 fronts 1. Continued scale-up of early diagnosis and treatment in line with the Stop TB Strategy 2. Development and enforcement of bold health system policies 3. Establishment of links with the broader development agenda (socioeconomic factors) 4. Promotion and intensification of research Lonnroth K, Castro KG, Chakaya M, Chauhan LS, Floyd K, Glaziou P, Raviglione MC. Tuberculosis control and elimination 2010-50: cure, care and social development. Lancet. 2010 ;May 22;375(9728):1814-29. Conference on TB, HIV and migration, Rome,
Determinants of TB Upstream (social determinants) Weak and inequitable economic, social, environmental policy Weak health system, poor access Inappropriate health seeking Globalization, migration, urbanization, demographic transition Poverty, low social-economic status, low education Unhealthy behaviour Dow wnstream Active TB cases in community Crowding, poor ventilation High level contact with infectious droplets Tobacco smoke, air pollution HIV, malnutrition, lung diseases, diabetes, alcoholism, etc. Impaired host defence Age, sex, genetic factors Exposure Infection Disease Consequences National TB Programme Other health programmes Other sectors Lönnroth K et al. Drivers of TB epidemics: the role of risk factors and social determinants. Social Science and Medicine 68 (2009) 2240-2246 Conference on TB, HIV and migration, Rome,
TB prevalence and public wealth; EU, 2006 Proportion foreign-born among TB patients (GDP in PPS / income inequality) Suk JE, Manissero D, Buscher G, Semenza JC. Wealth inequality and tuberculosis elimination in Europe. Emerging Infectious Diseases 2009; 15 (11) Conference on TB, HIV and migration, Rome,
TB and migration in Europe (WHO, 1994) Recommendations by the European Task Force on TB/migration: 1. Notification system based on mandatory laboratory and physician reports of each TB case, to be possible to trace. 2. TB screening targeted at entering foreign populations from sufficient high TB incidence country, aimed at providing early TB prevention and treatment, not linked to deportation 3. Existing governmental and nongovernmental organizations to provide culturally and socially sensitive services 4. All costs (screening, prevention, treatment) paid by the government 5. On going evaluation of TB screening (yield, costs) Rieder HL, Zellweger JP, Raviglione M et al. Tuberculosis control in Europe and international migration. Eur Respir J, 1994, 7, 1545-1553 Conference on TB, HIV and migration, Rome,
TB and migration in Europe (WHO, 2008) Recommendations by the IUATLD Working Group on TB/migration: 1. Easy access to low-threshold facilities where undocumented migrants who are TB suspects can be diagnosed and treated under confidentiality 2. Undocumented migrants with TB are not deported until completion of treatment 3. Awareness among undocumented migrants about TB and free-ofcharge diagnostic and treatment services irrespective of the migration status Heldal E et al. Diagnosis and treatment of tuberculosis in undocumented migrants in low or intermediate-incidence countries. Int J Tuberc Lung Dis 12(8):878-888 Conference on TB, HIV and migration, Rome,
Resolution WHA 61.17 Calls for: Migrant-sensitive health policies Equitable access to services Information systems to assess migrant health Sharing information on best practices Raising cultural and gender sensitivity and specific training of health service providers and professionals Bi/multilateral cooperation among countries Reducing the global deficit of health professionals Conference on TB, HIV and migration, Rome,
TB on the move TB in migrants is ongoing challenge in low TB countries Interventions among migrants in the context of TB elimination TB screening using large resources, different approaches (responsibility, objectives, targets, location, methods, yield of detection, follow up), not linked to prevention and treatment (limited epidemiological impact), deportation instead of treatment, missing undocumented migrants, need of cost- effectiveness studies Need to improve TB surveillance in many countries Need of easy access to TB diagnosis and treatment (free, cultural sensitive, confidentiality, no deportation), a minimum package for uninterrupted cross-border treatment Need of more investment by host countries in global tuberculosis control, collaboration with origin countries Alvarez GG et al. A comparative examination of tuberculosis immigration medical screening programs from selected countries with high immigration and low tuberculosis incidence rates. BMC Infectious Diseases 2011, 11:3 Conference on TB, HIV and migration, Rome,