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An extensive insight to the Sustainable Development Goal to End TB
Ending TB
TUBERCULOSIS (TB) is the world’s leading curable infectious killer.
“The 13 countries – Bangladesh, Democratic Republic of Congo, Indonesia, Myanmar, Nigeria, Pakistan, Philippines, South Africa, Tanzania, Ukraine, Kenya, Mozambique and India – together account for 75% of missing people with TB globally.”
TB patient in Myanmar Read insights from The Global Fund to step up the fight against TB. 02
STOP TB Partnership UN TB targets and commitments are the most powerful tools we have to end TB.
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World Health Organization We need to double the current level of investment to reach the annual target of US$2bn to advance TB research and innovation.
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The Union We know from data modeling that ending TB is not realistic without much stronger prevention efforts.
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TB ALLIANCE ONLINE TB Courage: Read Jerick’s story of fighting drug-resistant TB on globalcause.co.uk
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In the coming three years, the world needs to dramatically improve access to TB services for people who are affected by TB – especially diagnosis. So far, and in spite of the good work done last two years, we still have to find and treat three million ‘missing’ people with TB.
What does ’accountability’ look like for ending TB? RESULTS UK discusses the vital importance of the Secretary-General report in September 2020. Dr Lucica Ditiu Executive Director, Stop TB Partnership
13 Multi-drug resistant TB Dr Eric Goosby on global health security and the economic impact of MDR-TB.
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Millions of people need treating for TB, but we have to find them first
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N TB targets and commitments are the most powerful tools we have to end TB. But we must also resolve the huge challenge of drug-resistant TB, where we need 1.5 million people diagnosed and treated by end of 2022. The 2018 figure stands at a paltry 180,000 people treated. The UN High Level Meeting on TB (UNHLM) produced a very ambitious and comprehensive TB Political Declaration on TB, which includes targets and commitments to be achieved by every single member state between January 2018 and the end of December 2022. Speaking specifically on the concrete targets, the declaration will be a collective effort in which every single TB programme should contribute their share to make the total of 40 million people with TB, 1.5 million people with drugresistant TB, 3.5 million children with TB and 30 million people infected with TB that are getting treated.
Making it easier and simpler to gauge country by country progress To make things clearer and to make monitoring easier, the global targets were
unpacked by each country and shared as ‘indicative targets’. These are to be used in all discussions and dialogues taking place for the development of the National Strategic Plans, Global Fund applications and so on. In this manner, it is much easier to monitor the progress towards achievement of all the targets. The ‘indicative targets’ will provide easy-to-understand indicators at national level, but also at sub-national level. They will make sure that the TB response is accelerated in the areas that need it the most, for the interventions lagging behind.
The ‘indicative targets’ will provide easy-tounderstand indicators at national level, but also at sub-national level
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‘TB is expected to cost the world economy $1 trillion by 2030’
He grieved to see his children, six and eight, go to bed hungry some nights.
How TB affected this diamond cutter Aftab Ansari left his village in northern India to work as a diamond cutter in Mumbai. But his dreams for a better life for his family suffered a blow when he got drug-resistant tuberculosis
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oo weak to work, Aftab was forced to spend his savings, sell his wife’s jewellery and withdraw his children from school to buy food and pay the rent on his two-room cinder block home. He grieved to see his children, six and eight, go to bed hungry some nights. To pay bills he took out loans, and sank $US 2,000 into debt, equivalent
to ten months’ salary. Aftab, 32, is today back at work and paying his debts after completing the treatment that cured his TB. Infectious diseases like TB put an enormous burden on households worldwide, particularly in lower-income countries, draining billions in medical costs and lost productivity.
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TB in Tigerpass Railway Slum, Bangladesh
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hittagong is Bangladesh’s second most populous city, and home to many of the country’s booming garment factories. Because tuberculosis is generally transmitted in crowded and poorly ventilated spaces, residents of Chittagong’s Tigerpass Railway slum are at high risk of falling ill with TB. With Global Fund support, the government
of Bangladesh is working in partnership with civil society organizations to provide thousands of poor residents with treatment and care for tuberculosis. Through the programme, services delivered by community health workers are bringing hope to the slums. Ending the epidemics of AIDS, TB and malaria is embedded within Sustainable Development Goal 3: Ensure healthy lives and promote well-being for all.
Community health workers are bringing hope to the slums
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To end TB, we must invest in research and innovation
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Journalist Kate Sharma P H OTO : V I N C EN T B EC K ER
f the world is to get anywhere near ending TB, a disease that killed more than 1.5 million people in 2018, something significant needs to change. TB remains the world’s leading infectious killer and yet, in the last 50 years, only three new drugs and regimes have been developed to combat the disease. “What we need is more research and more tools in the pipeline; better diagnostics, more effective vaccines, and safer, shorter drug regimes,” explains Dr Tereza Kasaeva, Director of the World Health Organization Global Tuberculosis Programme. Global leaders have committed to making TB research a priority, but commitments need to be backed up by financial investment. “Research is chronically underfunded,” continues Kasaeva. “We need to double the current level of investment to reach the annual target of US$2bn, which is required to meaningfully advance TB research and innovation.”
Rewida AlHmoud and her three young girls. Rewida has been through tough times. Her home was destroyed by a rocket. She, her husband and her daughters survived, and decided to make the trip overland to Syria’s border with Jordan, searching for a place where they could feel safe. They eventually found shelter in a simple shack, inside a refugee camp in Azraq, Jordan. Rewida and her two eldest daughters were diagnosed with TB in 2017 and on treatment.
Breakthrough on the horizon Kasaeva hopes that a recent breakthrough in the development of a new TB vaccine could help to accelerate progress. At the end of 2019, researchers confirmed that a vaccine candidate found to be effective in treating individuals with latent TB infection was ready to enter phase three clinical trial.
Research is everyone’s concern “There’s the impression that research is a luxury that belongs to the scientists and institutions, but our reality is changing. It must be driven by the interests of our patients who are dying every day,” says Kasaeva. “The broader TB community including civil society should be engaged in design and implementation of research and data sharing”. That innovation needs to lead to developments in prevention, diagnosis and treatment that can easily be accessed and implemented by communities who bear the highest burden of TB – most of whom are desperately poor. For example, fast, accurate diagnostic tests do exist, but they are not widely accessible to all who need them. Unless affordable, rapid point-of-care diagnostic tests become available, people with TB will continue to access care late leading to increased transmission, be misdiagnosed, and have bad outcomes including loss of life. When it comes to treatment, the World Health Organization has released new recommendations on better treatment options for drugresistant TB, but these still need to be widely rolled out. Importantly, the world needs newer, safer, more effective drugs that work much faster, too. Currently, the shortest treatment cycle is six months for drugsusceptible TB, with even longer duration for drug-resistant TB. Of the half a million individuals with multidrug-resistant TB, only one in three is receiving treatment.
Despite the many challenges, there is fresh optimism within the TB community who are seeking new approaches to innovate solutions.
Collaboration is essential Despite the many challenges, there is fresh optimism within the TB community who are
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seeking new approaches to innovate solutions. WHO is currently spearheading efforts to develop and roll-out a new Global Strategy on TB Research and Innovation to create an enabling environment for research, optimise global data sharing and analysis, increase investments and ensure equitable access to the benefits of research and innovation. As part of this, Kasaeva is keen to support greater collaboration between the countries that bear the greatest TB burden.
Their engagement is essential in ensuring that the needs of patients remain central to all innovations and developments. “Sometimes it’s difficult to find sufficient domestic resources, but we have promising models of collaboration led by high burden countries,” says Kasaeva. “They have made progress in analysing priorities and research. It’s a model that we’re seeing other countries following.” If we’re going to break the stronghold of TB, a killer that has ravaged the world for centuries, our approach needs to change with research and innovation playing a more integral role.
Dr Tereza Kasaeva Director, World Health Organization Global Tuberculosis Programme
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To end TB, we must prevent TB Tuberculosis is a terrible illness caused by a bacteria that spreads from person to person through the air. Left untreated the disease typically causes a person to lose tremendous amounts of weight and become increasingly short of breath, withering the body to nothing if left untreated. Through their participation in the United Nations, governments committed to ending the TB epidemic by the year 2030. As we enter the year 2020, however, we are far from reaching that goal. A key part of ending TB is prevention.
We are far from reaching our 2030 goal to end TB We know from data modeling that ending TB is not realistic without much stronger prevention efforts. We can prevent people from becoming infected with TB, we can prevent people from developing TB disease and we can prevent people dying from TB. Despite having this knowledge, we are not (with some important exceptions) making nearly enough progress as we need to on TB prevention.
According to the World Health Organization, young children especially are missing out on TB prevention. Every child exposed to TB in their household needs TB preventive therapy before they become sick. Yet only one in four such children receives that therapy. People living with HIV (PLHIV) are also eligible for TB preventive therapy, yet half of PLHIV are going without it. Against this gloomy backdrop, however, there is hope. There is growing recognition that people at risk of TB have a right to know whether they’re living with a TB infection and to make informed decisions about how to safeguard their own health, including through receiving preventive therapy.
Preventative therapy is becoming more straightforward And preventive therapy itself is improving, becoming easier for people to take. Whereas standard therapy used to take nine months, today we’re seeing effective preventive options that require taking only one pill weekly for three months, or one pill daily for one month. We’ve also seen a new TB vaccine candidate that could have a significant impact if late-stage testing is successful. It is inexcusable that people are dying from this entirely preventable disease. The Union is committed to doing all that we can to help countries prevent TB. The rationale is simple: to end TB, we must prevent TB.
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One of the most alarming aspects of The Union’s work to end the global tuberculosis epidemic, is knowing TB is both the leading infectious killer globally and at the same time a very preventable illness.
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José Luis Castro Executive Director, The Union
Polina Kisel, a patient with multidrugresistant TB, with an x-ray photo of her chest in Minsk, Belarus. In Belarus, 38% of new TB cases in 2018 are drug-resistant, which means a longer, costlier, and more difficult treatment for patients like Polina. To stop drug-resistant TB we need better diagnosis, better drugs, and better treatment procedures.
Arim, a patient with extensively drug-resistant tuberculosis (XDRTB), holds an X-ray of his damaged lungs. Arim, from Kurdistan, had to go to Jordan to get adequate treatment for his disease.
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Arim’s TB story... XDR-TB is particularly complex, and requires prolonged treatment. Arim has been on a treatment regime for more than two years, and has responded well to new drugs that have become available. His personal journey has been arduous, and he is stoic about the challenges that have come his way.
Drug-susceptible TB and XDR TB are spread the same way. TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, shouts, or sings. These bacteria can float in the air for several hours, depending on the environment. Persons who breathe in the air containing these TB bacteria can become infected.
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Latent TB is the basis for the world’s deadliest infectious disease – but it can be cured
Journalist Meredith Jones-Russell Image and content provided by The Global Fund
Testing is difficult and some countries do not feel the cost is justifiable Around 10% of people with LTBI will develop active TB during their lifetime. However, for some people, including underfives and HIV patients or other immune-suppressed groups, the risk is much higher. However, current testing tools are the best ever available but still challenging to use, requiring blood samples. Rather than a typical, point-of-care testing as saliva or urine samples. On top of this, some country programmes are reluctant to spend money on treating latent infection that has no symptoms and does not represent a public health threat. Due to a collective push coordinated by Stop TB partnership, the first ever United Nations High-Level Meeting on TB
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ith almost one third of the world carrying the latent tuberculosis infection, education and research are vital to eradicate the planet’s deadliest infectious disease once and for all. Latent tuberculosis infection (LTBI) is the name for the stage when tuberculosis (TB) bacteria have entered the body, but are lying dormant without causing any symptoms. If they start growing, LTBI will turn into active TB, the world’s deadliest infectious disease, and one of the top 10 causes of death worldwide. Lucica Ditiu, Executive Director of the STOP TB Partnership, says LTBI is a real danger. “The biggest concern is the scale. A huge number of people are infected globally and, although latent TB is a dormant infection, it has the potential to become active. The biggest threat lies in the fact the numbers we are talking about are so big.”
A community health worker in the city of Narela, north of Delhi, talks to a group of women as part of an awareness-raising campaign about tuberculosis. India has the world’s largest TB epidemic.
in 2018 saw member states agree that 30 million people should be able to access TB preventive treatment by 2022. Private sector partners have now also joined the fight against TB.
Education and awareness around latent TB must be improved Patient website www.ltbi.com has recently been launched to support patients with LTBI and educate people on the infection. An e-learning platform* was also launched at the 50th Union World Conference on Lung Health in October 2019 to train clinicians, healthcare workers and national TB programme managers in the successful treatment of LTBI. “We need to ensure that we are letting people know about this problem,” says Ditiu. “Very few people are aware of TB, so education and the spread of information are important.
Very few people are aware of TB, so education and the spread of information are important
“We also need urgent research to understand much better the basic science on TB - why some people get infected and others do not, why some develop the disease and others do not. If we can find a way to predict who gets infected and, from those infected who gets sick, that will be huge.” World TB Day, celebrated on 24 March, aims to build public awareness of TB and efforts to eliminate the disease. “The more undiagnosed people are left without diagnosis and treatment, the more TB infection we will see,” explains Ditiu. “Country programmes should include comprehensive packages for TB response, including treatment for Latent TB. We must keep in mind that we will never end TB without addressing those infected with TB. “On World TB Day, we hope people outside the TB community will understand more about LTBI and all UNHLM on TB targets, and heads of state will realise their responsibilities and take their commitments seriously.”
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www.LTBI.com recently launched global website dedicated to latent TB infection. Its key objectives are to raise awareness of TB prevention and to educate patients and the general public in a simple and accessible way. *Learn more on courses.theunion.org
Dr Lucica Ditiu Executive Director, Stop TB Partnership
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INSIGHT
Testing and treating TB – the challenges The World Health Organization (WHO) declared tuberculosis (TB) a global emergency 25 years ago, yet TB remains among the top 10 causes of death worldwide and the leading infectious disease killer. TB is preventable and curable, yet millions of people with TB do not have access to affordable diagnostic tests and treatment – especially in developing countries.
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he WHO estimates that nearly one-quarter of the global population has latent TB infection (LTBI). Unless they receive the right diagnosis and treatment, around 10% of those carrying latent TB infection will develop the contagious form of the disease – continuing the vicious cycle of putting themselves, and those around them in harm’s way and reseeding the pool of tomorrow’s TB with LTBI. Global experts agree that the solution to ending the global TB epidemic is twopronged. We must detect and treat people with active TB, but also reduce the large reservoir of latent TB infection, to end the cycle of the disease.
The world’s deadliest infectious disease Worldwide, TB is the leading cause of death from a single infectious agent (surpassing even HIV/AIDS). According to the WHO, ”a total of 1.5 million people died from TB in 2018 (including 251,000 people with HIV)”. “In 2018, an estimated 10 million people fell ill with tuberculosis (TB) worldwide. 5.7 million men, 3.2 million women and 1.1 million children. There were cases in all countries and age groups.” “In 2018, 1.1 million children fell ill with TB globally, and there were 205,000 child deaths due to TB (including among
children with HIV). Child and adolescent TB is often overlooked by health providers and can be difficult to diagnose and treat.”2 Preventative regimes are much better tolerated by children compared to adults, but, sadly, programmes for children over the age of five who are exposed to TB do not exist in highburden countries and are often poorly implemented for children under age five.
Preventative testing and treatment saves lives The WHO End TB Strategy, launched in 2015, carried a bold vision statement: ”A world free of tuberculosis – zero deaths, disease and suffering due to tuberculosis”. Can this vision ever be reached? Although some progress has been made, millions continue to lose their lives to TB. Current TB control measures seem unlikely to meet 2020 and 2025 milestones set out in the End TB Strategy (respectively, a 35% and 75% reduction in TB deaths compared with 2015).3 Globally, TB incidence is falling at about 2% per year. This needs to accelerate to a 4–5% annual decline to reach the 2020 milestones of the End TB Strategy.2 However, in September 2018, the first ever UN High-level meeting on TB was held and world leaders agreed that only expanded testing and treatment of latent TB infection can end the
cycle of disease transmission. As a first major international step, they passed the Political Declaration Of The High-Level Meeting Of The United Nations General Assembly On The Fight Against Tuberculosis.4 Among its key proclamations, it calls for preventive treatment of 30 million persons by 2022, and for international agencies to fund and rapidly scale up the WHO’S End TB Strategy. The Assembly also committed to mobilise sufficient and sustainable financing for universal access to quality prevention, diagnosis, treatment and care of tuberculosis, from all sources, with the aim of increasing overall global investments for ending tuberculosis and reaching at least 13 billion United States dollars a year by 2022.
Targeted testing and treatment of latent TB People with active TB can infect five to 15 other people, through close contact, over the course of a year. Treatment of LTBI eliminates the bacteria before infection become contagious, preventing spread of the disease. Treatment of the latent infection is also easier, less costly, and less toxic than treating active TB disease. In 2018, The World Health Organization released new guidelines on the programmatic management of LTBI that harmonised preventative screening and
treatment protocols in countries with high and low TB burden and regardless of country income. In the new guidelines, the WHO5: • Finds clear evidence for the benefit of systematic testing and treatment of LTBI • Supports IGRA (interferon-gamma release assay) testing globally for at-risk populations The WHO places emphasis for latent TB testing on high-risk groups, including people living with HIV, household contacts of active TB cases, and patients receiving anti-TNF treatment.
Everyone has the right to know their TB status Treatment regimes are becoming more streamlined, but they remain burdensome. Universal access to affordable diagnostics for latent TB will enable at-risk populations to make informed treatment decisions. Accurate TB testing also streamlines care, allowing providers to focus on true positives, reduce unnecessary treatment, and improve programmatic success.
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Dr Kamal Al Ayass is the Tuberculosis doctor at the Sanitorium in Lebanon. Here he oversees all of the patients that are residing here for the start of their treatment. He is often found reviewing chest X-rays to diagnose or reviewing the treatment of the disease.
Latent tuberculosis is “the seedbed for active TB”
Latent TB must be tackled with targeted testing and treatment of at-risk populations, rather than giving people blanket treatment. It’s more cost-effective — and more ethical.
Sources: 1: https://www.cdc.gov/tb/publications/ factsheets/general/ltbiandactivetb.htm; 2: https://www.who.int/news-room/fact-sheets/ detail/tuberculosis, World Health Organization. (2014) WHO End TB Strategy. https://www.who. int/tb/post2015_strategy/en/. UN General Assembly. Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis. A/RES/73/; 3: World Health Organization. Latent tuberculosis infection – Updated and consolidated guidelines for programmatic management. WHO/ CDS/TB/2018.4.
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eople with latent tuberculosis infection (LTBI) can feel well, and not display any outward signs of TB, but still go on to develop active TB in the future. Worryingly, a suspected 1.7 billion people around the world are living with LTBI. “That’s a quarter of the world’s population!” says Dr. Masae Kawamura, Senior Director of Medical and Scientific Affairs at molecular diagnostics and precision medicine company, QIAGEN. “They are the seedbed for tomorrow’s active TB. The problem is, we don’t know
who is going to get it, when, or where it’s going to happen. It’s like a time bomb or landmine that detonates only 10% of the time.” So, if you live in a country with a high incidence of TB, or have a condition which puts you at greater risk of developing the disease, it’s important to know your TB status. Diagnosis is simple and can be confirmed via skin or blood tests.
Testing and treatment need to be targeted From a medical practitioner’s perspective,
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Dr. Kawamura believes it’s vital to test and then treat patients, rather than give entire populations blanket treatment, ‘just in case’ they have the latent form of the disease. “Analysis shows that testing before Dr Masae treating is costKawamura effective, because Senior Director, fewer people will TB Medical and be treated,” she Scientific Affairs, says. “But it’s about QIAGEN more than just the cost of the drugs. TB treatment requires complex infrastructure and is extremely labour intensive, so the resources required are immense.” There’s also an ethical challenge to consider with blanket treatment, which is: would you take a drug if you didn’t need it? “That’s a patients’ rights issue,” says Dr. Kawamura. “Also, while treatments for TB are getting shorter and safer, they do carry a small risk of side-effects, including liver damage.” For these reasons, the focus should be on first testing those most at risk of TB exposure, including contacts to known TB, those living and working in congregate settings like hospitals, and those with immunosuppression or diseases that increase the likelihood of progression from latent to active TB, such as diabetes or HIV. Certainly, more needs to be done on LTBI testing and treatment if ambitious UN High Level Meeting targets are to be met by 2030. “For too long, the whole focus has been on active TB,” says Dr. Kawamura. “Now we have to combine prevention and active disease control to really accelerate the decline of tuberculosis. TB isn’t always in the headlines. But it is always in the background, killing people.”
Journalist Tony Greenway
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Keeping our promises: 2020 and the fight against TB In 2018, people all around the world joined forces to raise the alarm to world leaders about a disease that kills over four thousand people a day, is increasingly resistant to drugs, and is spread through the air. This was met with surprise – many thought this disease had been beaten decades before.
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hat disease was tuberculosis (TB) and, in September, world leaders came together in New York to make new commitments to end this ancient, deadly disease, once and for all.
The world’s new commitment The United Nations High-Level Meeting on TB (UNHLM on TB) was a huge success. With almost 18 months’ hindsight, it’s clear the meeting was a turning point in the fight against the disease, not least because the new commitments that were made include: • Successfully treating 40 million people with TB by 2022 • Ending stigma and all forms of discrimination, including removing discriminatory laws, policies and programmes against people with TB • Delivering new, Aaron Oxley safe, effective, and Executive Director, affordable tools RESULTS UK including drugs, diagnostics, and
vaccines for TB • Committing to dramatically increasing funding to $13 billion per year, with an additional $2 billion for research and development in the fight against TB • Robust commitments to accountability at the national and global level. It’s the last of those commitments that, in many ways, was the most important: it meant that world leaders want us to hold them accountable to delivering their promises.
What does ‘accountability’ look like? Accountability is never just one thing. The World Health Organization (WHO) was tasked with producing an ‘Accountability Framework’1 that helps us put the world’s accountability efforts into context. It shows how the WHO’s own powerful monitoring, through the Global TB Report2, must be complemented with other monitoring. It must review activities such as the MSF/STBP ‘Out Of Step’3 report on countries’ performance in implementing the best TB policies, the TAG ‘Tuberculosis Research Funding Trends’4 report to track investments in TB R&D, and accessible country-level monitoring tools5 that look at the role of communities, rights, and gender.6
In September 2020, the Secretary General of the UN will deliver a report on how well countries have progressed towards the commitments they made. The UN Secretary General must celebrate success and highlight areas for concern in ending TB. It’s vital that the Secretary General plays a leading role in ensuring
The Secretary General shouldn’t shy away from naming those countries where progress is not being made. accountability for TB commitments by praising countries and leaders who have increased efforts and achieved success. The 2019 Global TB Report saw a dramatic increase in finding and treating people with TB, and we are hopeful of
more progress to report in 2020. But, at the same time, the Secretary General shouldn’t shy away from naming those countries where progress is not being made. Where funding for TB – either in domestic health budgets or overseas aid budgets – is going down, not up. Or, where the level of ambition has not been commensurate with the need, nor with the promises that were made. He also should make sure that the work of accountability is not seen as a top-down endeavour: it is essential that civil society and communities affected by the disease are empowered and engaged throughout. Above all, it is vital that the Secretary General’s report does exactly what world leaders called on him to do: make sure that we keep our promises to end TB once and for all. Sources: 1: https://www.who.int/tb/publications/MultisectoralAccountability/en/ 2: https://www.who.int/tb/publications/global_report/en/ 3: https://msfaccess.org/out-of-step 4: https://www.treatmentactiongroup.org/resources/tbrd-report/ 5: http://www.stoptb.org/resources/cd/ 6: http://stoptb.org/communities/default.asp#CRG
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Traditional medicine & TB in Tanzania
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AR ES SALAAM, Tanzania - Ramadhan Milanzi, 35, a traditional healer from the Kingugi Kwamnyani slum in Dar es Salaam, holds incense over the head of Hadijah Bakari, 59, who complained of stomach pains. A local hospital diagnosed her with ulcers but she says the medicine they gave her has not worked.
Ramadhan has been trained by MUKIKUTE, a local NGO, in how to recognise TB and connect those with symptoms to a community health worker for treatment. He has been practicing traditional medicine for 12 years. As a teenager he disappeared for three days while fishing, and the community believed that spirits took him in and endowed him with powers.
Tuberculosis continues to be a major public health problem in Tanzania, more than 20 years after launching the national TB programme. The rapid increase of TB in Tanzania is mainly attributed to the HIV epidemic, but factors like population growth and urban overcrowding have also contributed.
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PANEL
The political will to end TB The Global TB Caucus is an international network of parliamentarians united by their shared commitment to end the TB epidemic. With over 2,500 members in 150 countries, the Caucus aims to transform the response to TB through targeted interventions at national, regional and global levels. DR AKAKI ZOIDZE MP:
MDR TB and co-infection
Dr Akaki Zoidze MP Former Co-Chair, GTBC EECA Region*
Multidrug-resistant (MDR) TB and HIV/TB co-infections are new, grave threats posed by the old enemy of humankind – tuberculosis (TB).
Universal access to treatment is vital for HIV/ TB co-infection. The East Europe and Central Asia (EECA) region carries one of the heaviest burdens of MDR TB globally and has a long way to go to ensure universal access to necessary treatments.
TB has been known since ancient Egypt and has killed more people than all other infectious diseases combined. MDR TB is found in every country in the world, with only one in five people given the drugs they need to combat the disease. Of that small fraction, fewer than half are cured.
This calls for immediate action from all parties, including us, parliamentarians, who are willing and capable to consolidate political will globally and across EECA for accelerating progress towards End-TB, which will not happen without addressing threats posed by MDR TB and co-infection.
HON WARREN ENTSCH MP:
Hon Warren Entsch MP Co-Chair, Asia Pacific TB Caucus and Australian TB Caucus*
TB is the leading infectious disease killer in the world with a total of 1.5 million deaths in 2018, according to the latest WHO TB report. Despite this, the vaccine we use hasn’t changed since 1921 – and this vaccine only prevents children from the most dangerous forms of TB. For too long have we accepted that people should die of a preventable and treatable disease.
TB research and development is essential to achieving the targets set in the Sustainable Development Goals (SDGs) and the End TB Strategy. A new vaccine and new techniques of prevention, diagnosis and cure are required to meet the targets and end TB by 2030. We must urge for more investment in the field and end these senseless deaths.
RT HON NICK HERBERT CBE:
2018 was a landmark year in the global effort to tackle TB with the first UN High-Level Meeting (UNHLM) on TB, which saw heads of state and government from around the world make public commitments to end TB. The caucus played a major role in the success of the UNHLM, and was explicitly acknowledged and thanked for its work at the UN.
However, one year on, we are not seeing enough of a sense of urgency to follow through on the commitments that were made at the UN. We risk seeing the response slip back into business as usual, which isn’t close to what we need to achieve the treatment and prevention and financing targets, among other commitments.
Rt Hon Nick Herbert CBE Chairman, Global TB Caucus* *Full names and profiles online at globalcause.co.uk
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INSIGHT
How to stop multi-drug resistant TB
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ulti-drug resistant TB is a global health threat, a global economic threat and, for many, a death threat. More resources are urgently needed in the fight against multi-drug resistant TB across the globe. TB is the number-one infectious killer in the world. It is a contagious, airborne bacterial disease, which takes more than 4,000 lives a day. Moreover, when it comes to multi-drug resistant TB (MDR-TB), only one in five people who contract this deadly disease are ever treated. TB and drug resistance MDR-TB is TB that doesn’t respond, at least, to the two most powerful anti-TB drugs. Drug resistance can emerge when anti-TB medicines are used inappropriately or because of weak health systems leading to drug shortages or intermittent access to treatment. However, a lot of recent data has also shown that most outbreaks of drug-resistant TB (DR-TB) occur through direct transmission from one person to another. Access to new medicines While new treatments with novel drugs are revolutionising how we treat DR-TBs, in many settings these new medications are still not available. Access to these new drugs, development of faster, more effective treatments, and ultimately the creation of a preventative vaccine, are urgently needed to make a dent in current figures.
Pooja, who lives near New Delhi, was suffering from drug resistant tuberculosis, a more aggressive strain of the disease that does not respond to first-line medication. After being diagnosed and treated by a community-based health programme, Pooja was cured, and today leads a healthy and normal life. Community engagement is critical to ending TB. India has about 27 percent of the estimated global cases of TB, as well as a quarter of drugresistant TB patients.
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Antimicrobial resistance and TB According to a recent article in The Economist, DR-TB poses a significant threat to global health security. This is because bacteria and viruses’ ability to develop resistance to drugs – antimicrobial resistance (AMR) – is a major threat to global health security as it undermines the ability to treat infectious diseases. DR-TB is estimated to cause a third of deaths due to AMR worldwide, killing around 230,000 people in 2017 alone. AMR deaths look set to rise more than ten-fold, to 10 million annually, by 2050. Without action, DR-TB would be responsible for 25 million of these deaths. The economic impact of MDR-TB While MDR-TB takes a tragic human toll, with an estimated 480,000 people developing the disease in 2019, it also has a heavy economic cost. Estimates are that MDR-TB could cost the world $16.7 trillion by 2050. Those figures do not account for lost opportunity costs, or the burden on health systems. Just think what that money could do if actually directed at Dr Eric Goosby diagnosis, treatment and prevention. Director of Global It is clear that more resources are Health, Delivery, desperately needed to help reduce the Diplomacy and incidence – and pain and suffering – of Economics, UCSF; Former UN Special all forms of TB. Envoy on TB The Stop TB Partnership has estimated that at least US$13 billion will be needed for the implementation of TB programmes by 2022, to meet the targets of the Global Plan to End TB. For DR-TB the total funding requirement is also expected to increase, from US$2.5 billion 2018 to $US3.6 billion in 2020. TB has been on this planet since ancient times. It is unconscionable that people are still dying from this disease. TB is preventable, treatable and curable. Now let’s make that doable.
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Success means finding all people with TB
The goal is to find an additional 1.5 million people with TB every year A team of educators from Médecins du Monde set up a mobile unit in the Yopougon neighbourhood of Abidjan to conduct awareness and prevention education as well as HIV and TB testing near a ”fumoir” where drug users consume cannabis, crack and heroin. The program is supported by The Global Fund. Abidjan, Côte d’Ivoire. 22/05/2019.
In the last two years, a coalition of global health partners has invested vigorously in the goal to find more missing people with TB. These efforts are bearing fruit.
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n today’s interconnected world, nobody is safe from tuberculosis (TB). Like other diseases that spread from person to person through coughing and sneezing, TB represents a potentially catastrophic risk to global health security. One person with active, untreated TB can spread the disease to as many as 15 other people in a year. We will only end TB as an epidemic if we find more ‘missed’ people with the disease. ‘Missed’ refers to people who are undiagnosed, untreated or unreported to the health systems. In the last two years, a coalition of global health partners has invested vigorously in this goal of finding more missing people with TB. In 2018, seven million people with TB were found globally, up from 6.4 million in 2017. The percentage of people missed by health systems dropped significantly in 2018 to around 30%.
Three million people affected by TB missed from healthcare systems in 2018 Despite this progress, there were still around three million people who were missed by health systems in 2018. Additionally, only one in three people with drug-resistant TB accessed care. To turn the tide on TB, the Global Fund is working with the Stop TB Partnership and the World Health Organization (WHO), focusing on 13 countries with the highest disease burden. The goal is to find an additional 1.5 million people with TB every year, starting in 2019. The 13 countries – Bangladesh, Democratic Republic of Congo, Indonesia, Myanmar, Nigeria, Pakistan, Philippines, South Africa, Tanzania, Ukraine, Kenya, Mozambique and India – together account for 75% of missing people with TB globally. The results recorded in these countries in the last year are tremendously encouraging. The
Global TB Report 2019 shows that the gap between TB notifications and TB incidence in the 13 countries fell to 34% in 2018, down from 49% in 2014. This is the steepest drop on record.
Political support to end TB is increasing This progress can get even better with strong political support, which seems to be gaining momentum. For the first time, there is tremendous political leadership at the highest levels of government for a plan to accelerate the fight against TB. The UN High-Level Meeting on TB in 2018 was a historic milestone in the fight against the disease. The meeting set an ambitious goal of finding and treating 40 million people by 2022. TB has afflicted humanity for millennia, but we don’t have to accept it. TB can be treated and cured. But first we must find all the missing people with TB.
Dr Eliud Wandwalo Senior Disease Coordinator, TB, The Global Fund
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INSIGHT
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To beat TB, we need quality TB care for all people, by all providers
F R I EN D S FO R I N T ER N AT I O N A L T B R EL I EF
As countries move towards achieving UHC as part of the Sustainable Development Goals, efforts to engage all health providers to close gaps in care have gained more significance. Ensuring universal access to quality TB services is a significant challenge since over a third of the 10 million people estimated to have developed TB in 2018 were not detected or not notified to national TB programmes.
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his gap is more pronounced in countries with large private sectors1, especially those with a high burden of TB. Patient pathways analyses2 in 13 countries clearly show that over half of all TB patients begin seeking care in the private and informal sectors. There is plenty of evidence that quality of TB care is suboptimal3 in the private sector. Standardised patient studies4 in four countries clearly show that quality of TB care in the private health sector is suboptimal. Failure to engage the full range of healthcare providers for TB leads to serious consequences, including increased transmission due to delayed diagnosis and treatment, excess mortality and morbidity as a result of inappropriate treatment, increased drug resistance as a result of incomplete treatment, catastrophic costs to patients and their 3 families because of outof-pocket expenditures for private care, and incomplete monitoring and evaluation of TB services. Engaging private and other care providers can also contribute to easing the heavy burden on NTPs and to accelerating the introduction of new technologies.
There is plenty of evidence that quality of TB care is suboptimal in the private sector.
For these reasons, the WHO policies and global and national TB strategies have long acknowledged the need to engage all providers, including those in the private sector.
However, despite public-private mix (PPM) pilots, which have shown positive results, a large number of private health providers, who are often the first point of care for patients, remain unengaged in most low- and middleincome countries (LMICs). PPM is still not sufficiently mainstreamed into TB care and control programmes. To advocate for greater engagement of private healthcare providers in efforts to end TB, World Health Organization (WHO), the PPM Working Group of the Stop TB Partnership, and global partners released a new Roadmap5 in October 2018 that identifies clear actions needed to expand the engagement of all care providers towards universal access to care. One of the challenges to implementation of the PPM Roadmap is the fact that there is not enough guidance or sharing of experience on how to implement it at the country level. In other words, there is big know-do gap. Also, there are few PPM champions, either individuals or organisations, within the TB field, which suffers from insufficient engagement of relevant people and organisations from outside the realm of TB. While there is published literature on PPM (journal articles, WHO guidance), these are soon dated and poorly disseminated, and the wealth of practical insights and data that lies with isolated groups in the field never makes it into peer-reviewed literature. An active, vibrant learning network around TBPPM could address these gaps and build global capacity on private provider engagement (PPE).
References: 1. https://www.who.int/tb/publications/2018/PPMLandscapeAnalysis. pdf?ua=1 2. https://academic.oup.com/jid/article/216/suppl_7/S675/4595547 3. https://blogs.plos.org/speakingofmedicine/2019/10/31/if-we-are-serious-about-ending-tb-we-must-put-quality-on-the-agenda/ 4. https://www.qutubproject.org/ 5. https://www.who.int/tb/publications/2018/PPMRoadmap.pdf?ua=1
Petra Heitkamp McGill International TB Centre, McGill University, Montreal, Canada
Madhukar Pai McGill International TB Centre, McGill University, Montreal, Canada
www.tbppm.org is a learning network launched by several stakeholders, led by the Stop TB Partnership’s PPM Working Group. It’s main aim is to activate or invigorate the nascent PPM community of practice by creating, nurturing and leveraging an online resource center on PPM and provide resources to facilitate active engagement between PPM Working Group meetings.
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