Progress in TB control can be substantially accelerated by addressing these challenges
23 October 2013 | LONDON/GENEVA -Tuberculosis (TB) treatment has saved the lives of more than 22 million people, according to the WHO "Global tuberculosis report 2013" published today. The report also reveals that the number of people ill with TB fell in 2012 to 8.6 million, with global TB deaths also decreasing to 1.3 million.
The new data confirm that the world is on track to meet the 2015 UN Millennium Development Goals (MDGs) target of reversing TB incidence, along with the target of a 50% reduction in the mortality rate by 2015 (compared to 1990). A special "Countdown to 2015" supplement to this year's report provides full information on the progress to the international TB targets. It details if the world and countries with a high burden of TB are "on-track" or "off-track" and what can be done rapidly to accelerate impact as the 2015 deadline approaches.
According to the report, the Region of the Americas has the lowest TB burden of all WHO regions and has already met the Millennium Development Goal (MDG) of reversing TB's spread. TB incidence, prevalence, and deaths are down by more than half since 1990, and a number of countries are within reach of eliminating the disease.
According to the report, in 2012 some 220,000 cases of TB were reported in the region, 16% of them in patients with HIV co-infections. Some 20,000 people died of TB in the region, the majority from vulnerable urban population groups.
The America region has also made major progress in managing cases of TB-HIV and in treating multi-drug-resistant TB. However, an estimated 60,000 new TB infections remain undiagnosed in the region each year, most of them in urban areas.
The Pan American Health Organization/World Health Organization (PAHO/WHO) is currently implementing a TB control initiative in major cities in Latin America and the Caribbean, using an integrated approach that addresses the needs of the most vulnerable communities in areas including education, employment, urban development, social protection and health.
The report underlines the need for a quantum leap in TB care and control which can only be achieved if two major challenges are addressed.
- Missing 3 million — around three million people (equal to one in three people falling ill with TB) are currently being 'missed' by health systems.
- Drug-resistant TB crisis — the response to test and treat all those affected by multidrug-resistant TB (MDR-TB) is inadequate.
Insufficient resources for TB are at the heart of both challenges. TB programmes do not have the capacity to find and care for people who are "hard-to-reach", often outside the formal or state health system. Weak links in the TB chain (a chain that includes detection, treatment and care) lead to such people being missed.
"Quality TB care for millions worldwide has driven down TB deaths," says Dr Mario Raviglione, WHO Director of the Global TB Programme. "But far too many people are still missing out on such care and are suffering as a result. They are not diagnosed, or not treated, or information on the quality of care they receive is unknown." WHO estimates that 75% of the three million missed cases are in 12 countries.
On the second challenge, the problem is not only that the links in the MDR-TB chain are weak, but that the links are simply not there yet, the report suggests.
WHO estimates that 450 000 people fell ill with MDR-TB in 2012 alone. China, India and the Russian Federation have the highest burden of MDR-TB followed by 24 other countries.
While the number of people detected worldwide with rapid diagnostic tests increased by more than 40% to 94 000 in 2012, three out of four MDR-TB cases still remain without a diagnosis. Even more worrying, around 16 000 MDR-TB cases reported to WHO in 2012 were not put on treatment, with long waiting lists increasingly becoming a problem. Furthermore, many countries are not achieving high cure rates due to a lack of service capacity and human resource shortages.
"The unmet demand for a full-scale and quality response to multidrug-resistant tuberculosis is a real public health crisis," says Dr Raviglione. "It is unacceptable that increased access to diagnosis is not being matched by increased access to MDR-TB care. We have patients diagnosed but not enough drug supplies or trained people to treat them. The alert on antimicrobial resistance has been sounded; now is the time to act to halt drug-resistant TB."
A further challenge identified relates to the TB and HIV co-epidemic. While there has been significant progress in the last decade in scaling-up antiretroviral treatment for TB patients living with HIV, less than 60% were receiving antiretroviral drugs in 2012. This, the report urges, must improve.
Five priority actions
The WHO report recommends five priority actions that could make a rapid difference between now and 2015.
- Reach the 3 million TB cases missed in national notification systems by expanding access to quality testing and care services across all relevant public, private or community based providers, including hospitals and NGOs which serve large proportions of populations at risk.
- Address with urgency the MDR-TB crisis. Failure to test and treat all those ill with MDR-TB carries public health risks and grave consequences for those affected. High-level political commitment, ownership by all stakeholders, adequate financing and increased cooperation are needed to solve bottlenecks in drug supply and build capacity to deliver quality care.
- Intensify and build on TB-HIV successes to get as close as possible to full antiretroviral therapy (ART) coverage for people co-infected with TB and HIV.
- Increase domestic and international financing to close the resource gaps — now estimated at about US$ 2 billion per year — for an effective response to TB in low- and middle-income countries. Full replenishment of the Global Fund is essential, given that most low-income countries rely heavily on international donor funding, with the Global Fund providing around 75% of financial resources in these countries.
- Accelerate rapid uptake of new tools — through technology transfer and operational research to ensure that countries and communities most at risk benefit from these innovations.
"The WHO Global TB report highlights the very big gains the global community has made in the fight against tuberculosis," says Osamu Kunii, Head of the Strategy, Investment and Impact Division of the Global Fund to Fight AIDS, Tuberculosis and Malaria. "We are now at a crucial moment where we cannot afford to let these gains go into reverse. We need the commitment of the international community to address the significant funding gap to fight this disease."
The report is based primarily on data provided by WHO's Member States. In 2013 data were reported by 178 Members States and a total of 197 countries and territories that collectively have more than 99% of the world's TB cases.
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