TUBERCULOSIS in the Western Pacific Region
ACHIEVEMENTS
The Western Pacific Region has made significant progress in tackling the TB burden with WHO’s DOTS and STOP TB strategies. • In the past 10 years in the Region, over 10 million patients were diagnosed and treated and an estimated 800 000 deaths were averted. TB-related Millennium Development Goals (MDGs) and associated Stop TB Partnership targets have been met in advance of the 2015 deadline. • Incidence rate falling • 50% reduction in prevalence rate by 2015 compared with 1990 • 50% reduction in mortality rate by 2015 compared with 1990
INCIDENCE FELL BY
PREVALENCE FELL BY
SINCE 1990
SINCE 1990
MORTALITY* FELL BY
51 %
45 %
72 %
SINCE 1990 * EXCLUDING HIV
Incidence rate
Case notification rate
200
25
300
Rate per 100 000 population
250
20
150 200
15 100
150 100
50
10
Target: 50% reduction compared to 1990
5
50 0 1990
1995
2000
2005
TREATMENT SUCCESS RATE N THE REGION
85%
2010
0
Target: 50% reduction compared to 1990
1990
1995
2000
2005
2010
0
1990
1995
2000
2005
2010
Treatment success remains high in the Region, with six out of seven regional high burden countries (China, Cambodia, Lao PDR, Philippines, Mongolia and Viet Nam) reaching or maintaining an 85% success rate.
Tuberculosis in the Western Pacific Region 2014. Cover photo: A child from Cambodia nears the end of TB treatment.
CHALLENGES
In spite of this progress, the burden of TB remains significant in the Region. • Every year, 1.6 million people develop TB in the Region, and 110 000 people die of it, even though TB is a curable illness (this is equivalent to one TB death every 5 minutes). • Drug-resistant TB is on the rise and threatens to reverse the declining trend of TB (almost 5% of new TB cases are MDR-TB), as well as needing much more expensive and complex treatment. MDR-TB enrollment vs estimated cases in the region
EMERGENCE OF DRUG RESISTENCE
80 000
78 000
70 000 60 000
MDR-TB cases annually
50 000 40 000
Drug-resistant TB (MDR-TB, XDR-TB)* is a problem created by inappropriate treatment practices. The Western Pacific Region has the second highest burden among the six WHO regions of the world.
Only 8%
30 000
of estimated MDR-TB patients were enrolled in quality assured programmes in 2012
20 000 10 000 0
2008
2009
2010
2011
2012
Estimated MDR-TB cases
Source: WHO Global Tuberculosis Report 2013
COST OF DIAGNOSIS AND TREATMENT $ $ TB
120–200 times
MDR-TB
more expensive to diagnose and treat MDR-TB
TIME FOR TREATMENT TB MDR-TB
6 months
2 years
MDR-TB treatment takes two years or more.
TREATMENT OUTCOME
46 %
Among MDR-TB patients who enrolled on treatment in 2010, only 46% were reported to have been successfully treated. This is below the global target (75%).
* MDR-TB: multidrug-resistant TB; XDR-TB: extensively drug-resistant TB
Suffering of TB patients Physical
Known as “consumption” historically, untreated TB makes a person waste away until death. Regular TB treatment entails taking drugs daily for six months. MDR-TB entails two years of treatment with toxic drugs including eight months of daily painful injections.
Financial
Even though treatment is free through many government programmes, on average 50% of TB patients experience catastrophic financial burden (direct medical expenses, transportation, and lost income exceeding 40% of annual income) due to the disease. Catastrophic expenditure makes completing treatment difficult. Many patients sell household items, request support from relatives, take loans and then end up in debt.
Social and psychological
An MDR-TB patient in the Philippines
Stigma still exists against TB patients who lose friends and work, are rejected by their family, and are ashamed of their condition. Such discrimination can result in anxiety and depression.
REACH THE MISSING CASES
In the Region, 15% of TB patients are not yet reached and are missing out on quality care. “Missed” in the chart represents the gap between the estimated number of people who become ill with TB in a given year and the number of people who were notified to national TB programmes.
15 Missed%
85 %
Diagnosed
TB deaths
REGIONAL SITUATION OF MISSING CASES IN 2012 Among all estimated TB cases (1 600 000) in the Region, 15% (234 000) cases were missed in 2012 by health systems. • Many people are suffering and dying without proper treatment. • Undiagnosed and untreated TB patients continue to transmit the disease to others. Source: WHO Global Tuberculosis Report 2013
Where are missing cases?
2100
Mongolia
110 000 China
28 000
22 000 Viet Nam Cambodia
90 %
of missing cases occurred among six countries on the map
43 000
Philippines 4400
Papua New Guniea
Source: WHO Global Tuberculosis Report 2013
Who are the “missed”? The majority of these cases are people who live in some of the poorest and most vulnerable communities, or are among marginalized populations such as migrants, prisoners, and ethnic minorities. Ensuring TB services for children, the elderly, and people living with HIV is also a challenge due to diagnosis and treatment difficulties as well as health system weaknesses.
Why are they missed? 1. People with TB may not access care at all
2. People with TB may access health services but fail to be diagnosed1
• Limited awareness of TB and where to seek care • Poverty, marginalization and related stigma or discrimination • Financial barriers such as user fees, transport costs, and loss of income
2
• Long delays or travel preventing receipt of test results
• Challenges in recording and reporting within public systems
• Inappropriate or inaccurate diagnostic tests offered
• Lack of enforced mandatory case notification by health service providers
• Overburdened and undertrained health-care staff who fail to identify TB symptoms or refer for testing
• Non-existent or poor linkages with private practitioners, hospitals, laboratories, or NGO services
For the average patient, half of the costs incurred are linked to seeking diagnosis. Some sufferers get diagnosed but may not start on proper treatment or get notified. The quality of care they receive is unknown.
A patient’s story – The long road to TB care for TB patients
“I had to spend all my savings before I was told I had TB.” –Gloria Urban community in the Philippines
© Marcin Gabruk / www.flickr.com/marcingabruk / cropped from original
1
3. People with TB may be diagnosed but remain undocumented2
“Gloria lives in a makeshift hut in a squatter area of a large Asian city. She works long hours selling simple handicrafts on the street to provide food for her children. Their situation was precarious already, but then Gloria contracted tuberculosis, though she didn’t know it. It started with a cough, then she became weak, and then she felt feverish. Soon, she couldn’t work at all. Gloria tried to get treatment from local healers and doctors who prescribed medicine she could hardly afford, but her health still did not improve. After all her money was exhausted and her debts grew too high to borrow more, and after many hungry nights and days, she was finally taken to a health centre. Gloria was diagnosed with TB and received free treatment. After several days, her health improved, and she went back to work. A catastrophe was averted, but recovering from the massive debt she incurred will take some time. ’Gloria‘ [a symbolic character] stands for the hundreds of thousands of real people across Asia and the Pacific, and indeed millions all over the world, who experience immense suffering from what is a curable illness with free treatment provided by governments across the region.” - Dr Shin Young-soo, published in South China Morning Post for World TB Day in 2014
RESPONSE
Our vision is to reach all TB patients at an early stage of their disease and to ensure universal access to TB diagnosis, treatment and care for all, regardless of socioeconomic status, ethnicity, gender or age. Here are examples of activities in the Region aiming to smooth the patient pathway.
ACTIVE CASE FINDING (SHORTCUT FOR EARLY DIAGNOSIS) PHARMACY
INFECTED
PATIENT DELAY
ACTIVE TB Active case finding (ACF) • Instead of waiting for patients to present at health facilities, TB programmes may proactively screen and diagnose TB patients among certain high risk groups if resources permit. • TB screening for active TB covers: -- Household contacts and other close contacts of TB patients -- People living with HIV -- Current and former workers in workplaces with silica exposure -- Prisons and other penitentiary institutions -- Subpopulations with poor access to health care
SYMPTOMS RECOGNIZED & PATIENT SEEKS CARE Community engagement/ Improved health communication: • Communication -- Promote behaviour change communication which aims to change knowledge, attitudes and practices toward early care seeking. • Social mobilization
HEALTH CARE UTILIZATION Minimizing access barriers • Make TB services available through the primary health care network • Ensure essential TB services are provided free of charge • Address sociocultural barriers • Provide means to cover indirect costs
-- Engage community and society to empower TB patients and the affected community to achieve timely diagnosis.
Information, Education and Communication (IEC) materials (Viet Nam): Viet Nam has created IEC materials for childhood TB to increase awareness and improve case finding.
Transportation subsidy and living allowances for internal migrant patients (China): Providing modest financial support for migrant TB patients to stay in care plays an important role in removing barriers to access health care, which contributes to better treatment outcomes.
© www.flickr.com/dcmaster
Engaging the mining sector in TB control (Viet Nam): To facilitate early diagnosis and prompt treatment of TB among miners, the NTP in collaboration with local mining companies implemented an active case finding activity. More than 7000 miners from two coal mines (Vang Danh and Mao Khe) were screened for TB by mobile chest radiography and the latest molecular diagnostic method.
ACCESS DELAY
Coal miners in Viet Nam
Informational TB pamphlet in Viet Nam
Urban poor in China
HEALTH SERVICE DELAY
DELAY IN NOTIFICATION
TB DIAGNOSIS
ACCESS TO QUALITY CARE
NOTIFICATION
TREATMENT
Engaging all care providers
Improved reporting
Improved quality of care
• Promote public and private collaboration
• Promote mandatory notification
• Ensure uninterrupted supply of quality assured TB drugs
• Engage all care providers such as pharmacies and traditional healers
• Electronic reporting and recording system
Improved diagnostic tools
• Collaborate with national drug regulatory authorities on quality assured TB drugs and regulatory activities • Promote patient support organizations
• New tools -- WHO-endorsed molecular diagnostics -- Fluorescent LED microscopes -- Digital X-ray
• Use IT technology to improve adherence to TB treatment
• Effective use of chest radiography • More sensitive algorithms for diagnosis A new technology for diagnosing TB and MDR-TB: Xpert MTB/RIF is a fully-automated diagnostic test to detect genetic elements of TB bacteria from sputum specimens. It provides accurate results in less than two hours which is considerably shorter than the conventional culture method with 2 to 4 weeks of turnaround time.
Xpert MTB/RIF
Internet-based notification system in China: An online system is now used in health care facilities nationwide, including facilities operating outside the national TB programme that in the past have not been notifying cases to the programme. This system contributed to dramatic improvement of TB notification rates and quality of care in China.
Online reporting in China
Health staff in the Philippines
Towards a region free of TB WHO Regional Office for the Western Pacific gratefully acknowledges the financial support of our TB control partners. Department of Foreign Affairs and Trade (DFAT), Australia The Global Fund to Fight AIDS, Tuberculosis and Malaria Korea Centers for Disease Control & Prevention (KCDC) Ministry of Health, Labour and Welfare (MOHLW), Japan United States Agency for International Development (USAID)
Š World Health Organization 2014 All rights reserved. The designations employed and the presentation of the material in this publication 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. Photo credits: WHO except where indicated.
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