Opportunities

Shift in Perspective for Infectious Disease Control

(Porter et al 1999 Health Policy and Planning 14: 322-328)

From: • Disease specificity and

verticality

• Standardised interventions

• Short term orientation

• Emphasis on product/targets

To: • Integrated/ Horizontal

linkages

• Flexibility/context sensitivity

• Longer term objectives/sustainability

• Emphasis on process

Shift in Perspective for Infectious Disease Control

(Porter et al 1999 Health Policy and Planning 14: 322-328)

From:• Limited to health sector

• Focus on individual ‘risk’

• Operating without reference to global processes

• Working on behalf of populations

To:• Linking multiple sectors

• Understanding social vulnerability: risk in the context of everyday life

• Taking globalization as referent and context

• Working in partnership with communities

Tuberculosis Control as an example

1840 1860 1880 1900 1920 1940 1960

0

100

200

300

400Phase 1 Phase 2 Phase 3 Phase 4

Initial effect of segregation of poor

consumptives in work house

Segregation of poorconsumptives in enlarged and

improved workhouses infirmaries

Systematic segregation

of consumptives, rich and poor,

In hospitals and sanatoria

Antibioticera

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

Year

Stan

dard

ised

noti

ficati

on ra

te

Koch’s discovery

Historical decline of TB, 1840-1960

Source: World Economic Forum, 2005

TB & Poverty overlap

Risk factors for TBRisk factor Relative risk

for active TB disease (range)

Weighted prevalence,

total population

Population Attributable

Fraction (Range)

HIV infection 8.3 (6.1-10.8) 1.1% 7.3% (5.2-9.6)

Malnutrition 4.0 (2.0-6.0) 17.2% 34.1% (14.7-46.3)

Diabetes 3.0 (1.5-7.8) 3.4% 6.3% (1.6-18.6)

Alcohol 2.9 (1.9-4.6) 3.2% 5.7% (2.8-10.3)

Active smoking 2.6 (1.6-4.3) 18.2% 22.7% (9.9-37.4)

Indoor pollution 1.5 (1.2-3.2) 71.1% 26.2% (12.4-61.0)

From Lonnroth K et Al. Global epidemiology of tuberculosis. Seminars in Respiratory and Critical Care Medicine, 3 March 2008

WHO-recommended Global Strategy to Stop TBand reach the targets for 2015

1. Pursuing quality DOTS expansion and enhancement• Political commitment • Case detection through bacteriology• Standardised treatment, with supervision and patient support• Effective drug supply system• Monitoring system and impact evaluation

Additional components

2 Addressing TB/HIV and MDR-TB

3. Contributing to health system strengthening

4. Engaging all care providers

5. Empowering patients and communities 6. Enabling and promoting research

Stop TB DepartmentStop TB Department

Global TB Control Targets: the theory

• 2015: 50% reduction in TB prevalence and deaths

• 2050: elimination (<1 case per million population)

• 5-10% declining incidence per year:– 70% detection rate– 85% successful treatment

Global TB Control Targets: the reality

Case detection rate• 61% globally in 2006• 46% in Africa• 52% in European/Eastern Mediterranean regions • 2/3 of missing cases are in China, India, Africa

Treatment success rate• 84.6% globally• 70% in Eastern Europe• 76% in Africa