Perspective

WHO: Ending TB will take greater political commitment

Mario Raviglione, MD
Mario Raviglione

Health experts warned that progress to end tuberculosis has stalled and that greater political commitment is needed to address the burden of the world’s No. 1 infectious disease killer.

There were 10.4 million new TB infections in 2016, with 10% occurring in patients who also have HIV, according to a new WHO report outlining the burden. Around 1.7 million people died from the disease, including nearly 400,000 patients who were coinfected with HIV.

WHO has adopted a strategy to end the TB epidemic by 2030.

“The sheer numbers show that we are not accelerating fast enough. That’s the big message. We need to do much more,” Mario Raviglione, MD, director of WHO’s Global Tuberculosis Programme, said during a teleconference today. “The main solution remains a political one. We need attention that goes beyond ministers of health.”

Experts hope two upcoming meetings will intensify the spotlight on TB. Next month, the disease will be the focus of a WHO conference in Moscow that Raviglione said will be attended by representatives from 100 countries. That will be followed by a U.N. General Assembly high-level meeting in 2018 that will seek a greater commitment from heads of state on TB.

It will be just the fifth time in the history of the U.N. that a global health topic has been discussed at the General Assembly, including last year’s high-level meeting on antimicrobial resistance. In a statement, WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, said the meeting in Moscow and at U.N. headquarters will “build momentum” to end TB at a global level.

‘Grim’ statistics

According to the WHO report, there has been a 37% decline in TB mortality since 2000. But the agency noted several “grim” statistics, including that TB is the leading cause of death related to antimicrobial resistance and the leading killer among patients with HIV.

The report outlined several main areas of concern, including what it said is an estimated 4.1 million “missing” cases of TB worldwide — patients who have not been detected, diagnosed or reported. Three countries — India, Indonesia and Nigeria — account for nearly half of these infections, according to the report. Raviglione said large, unregulated private sectors in these countries might be treating cases but not reporting them.

“We do not know exactly what is going on — if the cases exist, do not exist, if they are treated properly or not treated properly,” he said. “There is concern that it might even create the conditions for drug resistance.”

According to the report, in 2016, there were an estimated 600,000 new cases of TB with resistance to the key first-line drug rifampin, including 490,000 multidrug-resistant infections (MDR-TB). Only around 20% of these patients were started on appropriate treatment — a global gap that is particularly a problem in China and India.

Even when MDR-TB is detected and diagnosed, patients face a significant challenge. In 2016, just 54% of them experienced treatment success, according to the report.

Although a majority of patients with TB worldwide are tested for HIV, 15% of coinfected patients are not put on antivirals as recommended, a gap that is especially seen in Africa, according to the report.

The report highlighted the need to increase preventive treatment in two priority risk groups: people living with HIV and children aged younger than 5 years. It said most patients eligible for TB preventive treatment are not accessing it.

Gaps in funding, research

According to the report, investment in TB care and prevention in low- and middle-income countries falls around $2.3 billion short of the $9.2 billion that is needed in 2017. Shortfalls also exist in funding for new vaccines, diagnostics and medicines, the report said.

It names 10 high-burden countries — India, Indonesia, Nigeria, the Philippines, South Africa, Pakistan, Bangladesh, the Democratic Republic of the Congo, China and Tanzania — where progress is particularly needed. Seven of these countries accounted for 64% of the total TB burden in 2016, with India at the top.

“It’s TB’s time,” Eric Goosby, MD, the U.N. special envoy for TB, said during the teleconference. “We can make this leading infectious disease killer a killer that has a cure and use every tool we have to defeat it.”

Raviglione said funding for TB research and development should match the investment made for HIV that has produced so many antivirals over the past several decades.

“What is the common denominator on all of these challenges to be addressed? It’s political commitment and investment,” Raviglione said. “If we want to face tuberculosis the way we should face it, we should invest much more.” – by Gerard Gallagher

Reference:

WHO. Global tuberculosis report 2017. http://www.who.int/tb/publications/global_report/en/. Accessed October 30, 2017.

Disclosures: Goosby, Raviglione and Tedros report no relevant financial disclosures.

Mario Raviglione, MD
Mario Raviglione

Health experts warned that progress to end tuberculosis has stalled and that greater political commitment is needed to address the burden of the world’s No. 1 infectious disease killer.

There were 10.4 million new TB infections in 2016, with 10% occurring in patients who also have HIV, according to a new WHO report outlining the burden. Around 1.7 million people died from the disease, including nearly 400,000 patients who were coinfected with HIV.

WHO has adopted a strategy to end the TB epidemic by 2030.

“The sheer numbers show that we are not accelerating fast enough. That’s the big message. We need to do much more,” Mario Raviglione, MD, director of WHO’s Global Tuberculosis Programme, said during a teleconference today. “The main solution remains a political one. We need attention that goes beyond ministers of health.”

Experts hope two upcoming meetings will intensify the spotlight on TB. Next month, the disease will be the focus of a WHO conference in Moscow that Raviglione said will be attended by representatives from 100 countries. That will be followed by a U.N. General Assembly high-level meeting in 2018 that will seek a greater commitment from heads of state on TB.

It will be just the fifth time in the history of the U.N. that a global health topic has been discussed at the General Assembly, including last year’s high-level meeting on antimicrobial resistance. In a statement, WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, said the meeting in Moscow and at U.N. headquarters will “build momentum” to end TB at a global level.

‘Grim’ statistics

According to the WHO report, there has been a 37% decline in TB mortality since 2000. But the agency noted several “grim” statistics, including that TB is the leading cause of death related to antimicrobial resistance and the leading killer among patients with HIV.

The report outlined several main areas of concern, including what it said is an estimated 4.1 million “missing” cases of TB worldwide — patients who have not been detected, diagnosed or reported. Three countries — India, Indonesia and Nigeria — account for nearly half of these infections, according to the report. Raviglione said large, unregulated private sectors in these countries might be treating cases but not reporting them.

“We do not know exactly what is going on — if the cases exist, do not exist, if they are treated properly or not treated properly,” he said. “There is concern that it might even create the conditions for drug resistance.”

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According to the report, in 2016, there were an estimated 600,000 new cases of TB with resistance to the key first-line drug rifampin, including 490,000 multidrug-resistant infections (MDR-TB). Only around 20% of these patients were started on appropriate treatment — a global gap that is particularly a problem in China and India.

Even when MDR-TB is detected and diagnosed, patients face a significant challenge. In 2016, just 54% of them experienced treatment success, according to the report.

Although a majority of patients with TB worldwide are tested for HIV, 15% of coinfected patients are not put on antivirals as recommended, a gap that is especially seen in Africa, according to the report.

The report highlighted the need to increase preventive treatment in two priority risk groups: people living with HIV and children aged younger than 5 years. It said most patients eligible for TB preventive treatment are not accessing it.

Gaps in funding, research

According to the report, investment in TB care and prevention in low- and middle-income countries falls around $2.3 billion short of the $9.2 billion that is needed in 2017. Shortfalls also exist in funding for new vaccines, diagnostics and medicines, the report said.

It names 10 high-burden countries — India, Indonesia, Nigeria, the Philippines, South Africa, Pakistan, Bangladesh, the Democratic Republic of the Congo, China and Tanzania — where progress is particularly needed. Seven of these countries accounted for 64% of the total TB burden in 2016, with India at the top.

“It’s TB’s time,” Eric Goosby, MD, the U.N. special envoy for TB, said during the teleconference. “We can make this leading infectious disease killer a killer that has a cure and use every tool we have to defeat it.”

Raviglione said funding for TB research and development should match the investment made for HIV that has produced so many antivirals over the past several decades.

“What is the common denominator on all of these challenges to be addressed? It’s political commitment and investment,” Raviglione said. “If we want to face tuberculosis the way we should face it, we should invest much more.” – by Gerard Gallagher

Reference:

WHO. Global tuberculosis report 2017. http://www.who.int/tb/publications/global_report/en/. Accessed October 30, 2017.

Disclosures: Goosby, Raviglione and Tedros report no relevant financial disclosures.

    Perspective
    David Cohn

    David Cohn

    The Global Tuberculosis Programme has produced an annual report on the state of global TB control since 1997, each year with a bit more sophistication, and always with a wealth of information. This year’s report lived up to expectations, comprising 262 pages, with eight chapters and four annexes and many informative figures, maps and tables, interspersed with compelling photography of persons with TB — not exactly light bedtime reading but worth a look. In 1993, when WHO declared TB to be a global emergency and many TB control programs in the world were in disarray, the publication of such a comprehensive document describing so many accomplishments was a pipedream.

    This year’s theme was “Leave No One Behind: Unite to End TB,” with an emphasis on the disparity of the number of cases actually diagnosed and reported by different countries and the estimates that are required to give a more accurate picture of global incidence and prevalence. Since these methods have been consistently used for several years, the trend data for annual comparisons are valid. The good news is that morbidity and mortality have continued their slow, steady decline since 2000, with a decrease in incidence of 2% and in mortality of 3% this past year. In addition, a high proportion of persons are tested for HIV, and of those who are coinfected, most (but not all) are started on life-saving ART — a major advance over the past decade. In contrast, there are numerous cases of multidrug-resistant TB, most which are undetected, unreported and untreated or receive inadequate therapy. The report also notes the gaps in funding for TB care and prevention, and the need for additional funding for research, given the slow pace of new drug and vaccine development.

    To seek greater attention by governments and to enhance political will, two major international, intergovernmental meetings will be held with TB as the focus: the Global Ministerial Conference on Ending TB in the Sustainable Development Era from Nov. 16-17 in Moscow, and the U.N. General Assembly high-level meeting on TB in New York City next year. The high-level meeting is only the fifth General Assembly to feature a health topic, the others having been HIV, noncommunicable diseases, Ebola and antimicrobial resistance. The United States government has a major role in funding TB care, research and control through its U.S. agencies, including the CDC, NIH and USAID, and is the largest donor to WHO, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and PEPFAR. Hopefully at these upcoming meetings, the current administration will be more collaborative and supportive than it is has been at recent international summits. Under any circumstances, continued advocacy and activism are necessary to convince Congress and other organizations to maintain or increase funding, so that ultimately the elimination of one of humanity’s oldest and deadliest scourges can be achieved.

    • David Cohn, MD
    • Infectious Disease News Editorial Board member
      Professor of medicine, University of Colorado Denver

    Disclosures: Cohn reports no relevant financial disclosures.