15 minute read
The Union
Keeping our promises: 2020 and the fi ght 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.
That 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.
Aaron Oxley Executive Director, RESULTS UK 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 fi ght 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, safe, eff ective, and aff ordable tools 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 fi ght 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 eff orts 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 tools 5 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
accountability for TB commitments by praising countries and leaders who have increased eff orts and achieved success. The 2019 Global TB Report saw a dramatic increase in fi nding 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 aff ected 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
Traditional medicine
& TB in Tanzania
DAR 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.
Image provded to Mediaplanet by The Global Fund. See more stories online at:
globalcause.co.uk
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:
Dr Akaki Zoidze MP Former Co-Chair, GTBC EECA Region*
MDR TB and co-infection
Multidrug-resistant (MDR) TB and HIV/TB co-infections are new, grave threats posed by the old enemy of humankind – tuberculosis (TB).
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 fi ve people given the drugs they need to combat the disease. Of that small fraction, fewer than half are cured. 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.
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 Co-Chair, Asia Pacifi c TB Caucus and Australian TB Caucus*
Rt Hon Nick Herbert CBE Chairman, Global TB Caucus* HON WARREN ENTSCH MP:
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 fi eld and end these senseless deaths.
RT HON NICK HERBERT CBE:
2018 was a landmark year in the global eff ort to tackle TB with the fi rst 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 fi nancing targets, among other commitments.
PHOTO: ATU L LOK E
Pooja, who lives near New Delhi, was suff ering from drug resistant tuberculosis, a more aggressive strain of the disease that does not respond to fi rst-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.
globalcause.co.uk INSIGHT
How to stop multi-drug resistant TB
Multi-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 fi ght 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 fi ve 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 eff ective treatments, and ultimately the creation of a preventative vaccine, are urgently needed to make a dent in current fi gures.
Antimicrobial resistance and TB According to a recent article in The Economist, DR-TB poses a signifi cant 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 fi gures do not account for lost opportunity costs, or the burden on health systems. Just think what that money could do if actually directed at diagnosis, treatment and prevention. It is clear that more resources are desperately needed to help reduce the incidence – and pain and suff ering – of all forms of 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. Dr Eric Goosby Director of Global Health, Delivery, Diplomacy and Economics, UCSF; Former UN Special Envoy on TB
Success means fi nding all people with TB
P H OTO : T H E G LO B A L F U N D / J B R U S S E L / PA N O S FOTO: NAME SURNAME
In the last two years, a coalition of global health partners has invested vigorously in the goal to fi nd more missing people with TB. These eff orts are bearing fruit. I 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 fi nd 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 fi nding 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 signifi cantly in 2018 to around 30%. Three million people aff ected 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 fi nd 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 notifi cations 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 fi rst time, there is tremendous political leadership at the highest levels of government for a plan to accelerate the fi ght against TB.
The UN High-Level Meeting on TB in 2018 was a historic milestone in the fi ght against the disease. The meeting set an ambitious goal of fi nding and treating 40 million people by 2022. TB has affl icted humanity for millennia, but we don’t have to accept it. TB can be treated and cured. But fi rst we must fi nd all the missing people with TB.
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.
Dr Eliud Wandwalo Senior Disease Coordinator, TB, The Global Fund
PHOTO: THINH HUNG DO VIETNAM
To beat TB, we need quality TB care for all people, by all providers
FRIEN D S FOR INTERNATIONAL TB RELIEF
As countries move towards achieving UHC as part of the Sustainable Development Goals, eff orts to engage all health providers to close gaps in care have gained more signifi cance. Ensuring universal access to quality TB services is a signifi cant challenge since over a third of the 10 million people estimated to have developed TB in 2018 were not detected or not notifi ed to national TB programmes.
This gap is more pronounced in countries with large private sectors 1 , especially those with a high burden of TB. Patient pathways analyses 2 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 suboptimal 3 in the private sector. Standardised patient studies 4 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 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 3 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 fi rst point of care for patients, remain unengaged in most low- and middleincome countries (LMICs). PPM is still not suffi ciently mainstreamed into TB care and control programmes. To advocate for greater engagement of private healthcare providers in eff orts to end TB, World Health Organization (WHO), the PPM Working Group of the Stop TB Partnership, and global partners released a new Roadmap 5 in October 2018 that identifi es 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 fi eld, which suff ers from insuffi cient 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 fi eld 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 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.
