Doing TB Diagnosis With Shopkeepers and Bicycles? Not a Sustainable Strategy

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There were plenty of frightening statistics and unsettling trends highlighted at today’s World TB Day briefing on Capitol Hill. But one photo captured the true scope of the problem in scaling up diagnosis and treatment of the global TB epidemic.

Celine Gounder, MD, an IDSA member and TB/HIV specialist at Johns Hopkins University, described a recent trip to Malawi, where she saw shopkeepers volunteering to collect sputum samples from customers with chronic coughs. The accompanying photo: a man transporting the sputum samples to a laboratory in a small wooden box balanced on the back of his bicycle.

Dr. Celine Gounder discusses the TB epidemic at a Senate briefing

As Dr. Gounder noted, this small community had overcome one of the hurdles in getting suspected TB patients access to proper care. But many others remain. For starters, those specimens so carefully balanced on the bike would be examined using sputum smear microscopy, the only widely available diagnostic test for TB in Malawi. But Malawi has one of the highest HIV prevalence rates in the world, and the vast majority of HIV-related TB cases will be missed by sputum smear microscopy. A more accurate TB test, culture, is not available in the country because of lack of funding. So many of the patients will get false negative results, and continue to transmit the TB bug.

Her presentation provided compelling evidence of the need for more resources devoted to increased laboratory capacity and better diagnostics for TB. But she noted the gap between rhetoric and reality when it comes to TB funding. See Dr. Gounder’s power point here: CGounder_US Senate Briefing_20100324 and below is a video of her presentation.

“Despite the clear need for a heightened response to the global TB problem, funding that has been appropriated for these activities falls short of what was authorized by the Lantos-Hyde Act and what is needed to make decisive progress,” she said. “USAID, which is the primary US agency conducting global TB activities, received only $225 million in FY 2010 of the $650 million dollars authorized.”

She noted in particular that the White House’s Global Health Initiative includes TB treatment targets that are much lower than those set out in the Lantos-Hyde Act, which reauthorized PEPFAR. And she said HIV/TB co-infection was getting particularly short-shrift.

“Little more than lip service has been paid to delivery of TB-related interventions by HIV programs,” Gounder said.  “Only 16% of all TB patients were tested for HIV in 2007. Only 2.2% of HIV patients were screened for TB. And only 30,000 of HIV patients, 2% of the target, received isoniazid preventive therapy, which has been proven to reduce the risk of TB and mortality by one-third to two-thirds.”

Gounder’s remarks came at a Senate briefing on the global TB epidemic, which included a special focus on drug-resistant TB. The event, entitled “Bringing Methods to Scale: New Perspectives in the Changing World of TB,” also featured a presentation by Ernesto Jaramillo, team leader for MDR-TB for the World Health Organization’s Stop TB Department, who detailed the WHO’s newest data on drug-resistant TB.

The WHO estimates that 440,000 of MDR-TB cases emerge each year, claiming at least 150,000 lives. “This is not a theoretical threat,” said Dr. Jaramillo. “We are talking about a tragedy that is unfolding now,” he said. By the end of the day, he added, 500 people will be dead from this disease.

The new “capital of MDR-TB” is a region in the Russian Federation called Murmansk, where 28.3 percent of the new TB cases were MDR-TB. “We have never seen such a high rate,” he said. He warned of a scenario in which the epidemic of drug-susceptible TB is “replaced by MDR-TB,” with grave consequences.

A major problem, he noted, is that only 7 percent of the world’s MDR-TB cases are being detected because of poor surveillance, inadequate labs, and out-of-date diagnostics. “We are unable to understand very well the global picture until we have the capacity to go beyond this 7 percent,” he said. In Africa, for example, “we don’t know what’s going on there [with MDR-TB] because of the lack of labs.”

He said the WHO is working with other international partners to address this crisis, coordinating with countries to craft and implement basic TB control programs and “turn off the tap” of drug-resistant TB. But funding remains a major stumbling block. He pointed to WHO estimates that to treat MDR-TB in the 27 most heavily affected countries, it would cost about $16 billion over six years, starting with $1.3 billion for 2010. But the anticipated available funding is drastically lower—.5 billion in 2010, for example.

“There is a huge gap between what countries are committing and what is needed,” he said.

Rachel Nugent, deputy director for global health at the Center for Global Development, discussed how drug-resistant TB was indicative of a broader problem of emerging drug-resistance, citing, for example, new strains of drug-resistant malaria and HIV.

Many of these new resistant bugs had “common drivers,” such as a lack of good surveillance data, an inadequate pipeline for new drugs and diagnostics, and weak health systems, Nugent said. She also noted that the use of drugs to treat one disease could adversely impact efforts to control other health threats.

“That’s a reason why we need to have these disease groups talking to each other, but our disease programs are not set up very well to do that,” she said. “There needs to be a web of responsibility looking across the common drivers to improve and maintain drug efficacy” and address this issue more comprehensively.

Jeffrey Sturchio, CEO of the Global Health Council, wrapped up the event with this observation.

“It’s not an exaggeration to say that TB is a 19th Century disease that we’re trying to fight with 20th Century tools, but we’re in the 21st Century,” he said. And there are “still too many people dying from what’s essentially a curable illness.” If we hope to conquer TB in the 21st century, the US and other donors need to provide adequate resources for the battle.

The Global Center outlined the urgent action needed to address drug-resistant TB in a new issue brief released today. It is available here: DeathbyDrugResistantTB

You can also click here to see USAID’s new five-year TB strategy, also released today.

Watch Dr. Gounder’s presentation:

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