Continuing our series in honor of World TB Day, the following is a guest blog post by Ernesto Jaramillo, Paul Nunn and Mario Raviglione of the Stop TB Department at the World Health Organization (WHO) discussing WHO’s new report issued today:
Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis by 2015: WHO progress report 2011
Major progress has been made in tuberculosis (TB) control over the past 15 years, with 41 million people cured and up to 6 million deaths averted thanks to the wide implementation of proper TB control practices since 1995. The global TB incidence rate peaked in 2004 and has since started a slow decline. However, despite these achievements, TB is far from being conquered globally, with 1.7 million people dying of this curable disease every year. In addition, the emergence of multidrug-resistant TB [MDR-TB] and extensively drug-resistant TB [XDR-TB] in many countries worldwide is a serious threat to the progress achieved. Drug-resistant TB is more difficult and costly to diagnose, treat and cure than drug-susceptible TB; it is particularly lethal in people living with HIV/AIDS.
In 2008, the World Health Organization (WHO) estimated that 440,000 cases of MDR-TB emerged globally, with 85 percent of the global burden occurring in 27 countries. It is well accepted that weak health care systems are at the root of M/XDR-TB, hampering progress on two major fronts: prevention of the M/XDR-TB epidemic and treatment of those affected. Reflecting that notion, this report updates the progress being made and the gaps remaining on the two major fronts in the response to M/XDR-TB: diagnosis, treatment and care of people affected by M/XDR-TB; and prevention of M/XDR-TB through basic TB control.
As recently as 10 years ago, few options for treatment and care were available to those affected by M/XDR-TB. Later, accumulating evidence indicated that the programmatic management of M/XDR-TB was not only feasible but also cost effective. WHO has recognized drug resistant TB as a major challenge to be addressed as part of the Stop TB strategy, launched in 2006.
In April 2009, WHO convened a ministerial meeting of countries with a high burden of MDR-TB in Beijing, paving the way in May 2009 for the 62nd World Health Assembly to adopt resolution WHA62.15 on prevention and control of MDR-TB and XDR-TB. The resolution urges member states to take action on multiple fronts towards achieving universal access to diagnosis and treatment of M/XDR-TB by 2015.
This report, which is being released on the occasion of World TB Day (March 24, 2011), describes the progress being made globally towards achieving universal access to diagnosis and treatment of M/XDR-TB since 2009. Special focus is given to progress in the 27 countries where the MDR-TB burden is highest. The report shows that, despite the achievements of these countries on several fronts, severe bottlenecks are hampering the response to the M/XDR-TB epidemic. Indeed, in 2009 only 10 percent (24,511 out of 250,000) of the estimated number of MDR-TB cases among notified TB cases in the 27 countries, and 11 percent (30,475 out of 280,000) globally, were enrolled in treatment. Some of these countries are making progress by implementing policy changes that rationalize the use of hospitals, such as South Africa, or treating patients through community-based models of care, such as the Philippines. However, diagnostic capacity remains limited. Furthermore, the price of some quality-assured, second-line drugs has not fallen and shortages of drugs still occur.
Overall, there is recognition that the response to MDR-TB must be built across health systems, and corresponding plans have been made. Human and financial resources are grossly insufficient and frequently inadequate. The Global Plan to Stop TB 2011–2015 estimates that $0.9 billion is needed in 2011 to address MDR-TB worldwide (excluding the costs associated with scaling up laboratory services). Funding for MDR-TB care and treatment has increased five-fold since 2009, from $0.1 billion to $0.5 billion in 2011 in 23 out of the 27 countries. Despite this important progress, the Global Fund may become the sole source of funding for second-line drugs and MDR-TB management in seven of the 27 countries in 2011 if domestic funding is not urgently mobilized.
Developing and adopting new tools might help to accelerate the scale up of adequate M/XDR-TB management, and the introduction of new rapid diagnostic tests is promising in Ethiopia, India and South Africa, for example. Although the Xpert MTB/RIF test recommended by WHO in 2010 for introduction in endemic countries may bring rapid diagnosis closer to patients, it is not yet a point-of-care assay, and the need for increased research investment into novel rapid tests therefore remains. Five candidate anti-TB drugs are being evaluated in clinical trials, and preliminary results are encouraging: new anti-TB drugs are anticipated to be on the market in the next two to three years. However, no technological or managerial innovation will make a meaningful difference to the response if access to care for the poorest and most vulnerable groups is not increased through strengthened and properly funded health care systems. Beyond more rapid implementation of available tools, there is an urgent need to fully fund a robust and comprehensive research portfolio that ranges from basic science to efforts to develop new vaccines, diagnostics and treatments.
New and more effective tools will likely facilitate care and control of MDR-TB, as long as they become accessible to the poorest populations worldwide. MDR-TB is one of the greatest areas of unmet need for TB research. Besides scaling up implementation of available and new tools, research providing evidence that countries can use to reach the global target of achieving universal access to MDR-TB care in line with resolution WHA62.15 is equally needed.
The involvement of civil society organizations and communities in the global and national responses to M/XDR-TB also remains very limited. In October 2010, WHO organized a consultation meeting to strengthen their active involvement in the response to TB, highlighting MDR-TB as an urgent priority. It is time to focus advocacy efforts at the country level, and not only the global level, to ensure that the health sector receives the necessary resources and the M/XDR-TB response is prioritized on the global health policy agenda.
Global progress is being made, but the threat of M/XDR-TB calls for a much more rapid response. This report emphasizes the need for countries to implement all necessary measures to address M/XDR-TB; if not, the target for universal access, as set by the World Health Assembly, will not be achieved by 2015, and further hundreds of thousands of lives will be lost.