Global TB Control

The problem of global TB results in the deaths each year of nearly one and a half million people, from a disease that for many years has been treatable and curable.1 It is not clear though whether this continuing high level of deaths is due to a failure of global TB control strategies, the impact of the joint HIV and TB epidemics, the increasing problem of drug resistant TB, a lack of TB funding or more likely a combination of all four.

“We have known how to cure TB for more than 50 years. What we have lacked is the will and the resources to quickly diagnose people with TB and get them the treatment they need.”

Nelson Mandela July 15, 2004 2

Global TB Targets

In 1991 the Forty–fourth World Health Assembly set TB targets for the year 2000, and amongst other things these were:3

  • To intensify collaboration with Member States in strengthening national control programs in order to improve case finding and treatment and attain a global target of cure of 85% of sputum positive patients under treatment and detection of 70% of cases, taking care to ensure that the programmes are integrated as far as possible into primary health care activities.
  • To focus and strengthen the Tuberculosis strategy for the 1990s with a view to elaborating and implementing the World Health Organisation (WHO)’s strategy for Tuberculosis control in order to achieve the global target, and to promote global interest in research on all aspects of Tuberculosis control and elimination.

A Global TB Emergency

In 1993 the World Health Organisation (WHO) declared TB to be a global emergency saying that:

“Tuberculosis today is humanity’s greatest killer, and it is out of control in many parts of the world. The disease, preventable and treatable, has been grossly neglected and no country is immune to it.”

Arati Kochi, Manager WHO Tuberculosis Program 4

DOTS

Subsequently WHO in the mid 1990s further developed their “DOTS”, or Directly Observed Treatment Short course strategy. This was to become the internationally recommended approach to TB control until 2006. The strategy was built on model programmes developed in African countries from the late 1980s and subsequently expanded worldwide.

DOTS has five components, which were initially as follows.5

  • Sustained political and financial commitment.
  • Diagnosis by quality ensured sputum smear microscopy.
  • Standardized short course anti TB treatment (SCC) given under direct and supportive observation (DOT).
  • A regular uninterrupted supply of high quality anti TB drugs.
  • Standardized recording and reporting.

Setting new global TB targets in 2000

By the year 2000 the global TB targets set in 1991 had not been met. So further international meetings were held, at which the same goals were once again set, but this time to be achieved by 2005.6

The Amsterdam Declaration to Stop TB

At a meeting in Amsterdam in March 2000, the 20 “high burden” TB countries again confirmed their commitment to meeting, amongst other goals, the detection of 70% of active TB cases, this time to be achieved by 2005.7

The Millenium Development Goals

Global TB goal 6

The Millenium Development Goals (MDGs) were first agreed at the UN Millenium Summit in September 2000, and the eight MDGs set worldwide objectives for reducing extreme poverty and hunger, improving health and education, empowering women and ensuring environmental sustainability by 2015.

TB is not mentioned specifically in the main goals but comes within Goal 6, which is to combat HIV/AIDS, Malaria, and other diseases. The specific target for Goal 6, target 6c which applies to TB, is to have halted by 2015 and begun to reverse the incidence of TB.

Global TB Initiatives

In the eighteen months after the Amsterdam Declaration a number of global TB initiatives were to be started. These included:8

  • The Stop TB Partnership
  • The Global Drug Facility
  • The Green Light Committee
  • The Global Alliance for Tuberculosis Drug Development
  • The Global Plan to Stop TB 2001–2005

The Stop TB Partnership

The Stop TB partnership was set up in 2001 following the Amsterdam Conference in 2000. Initially the partnership comprised just six organisations and one of its first initiatives was the Global Drug Facility.

The Global Drug Facility

The Global Drug Facility was established in 2001 to expand access to and the availability of high quality TB drugs, in order that DOTS programs could be expanded. It was established in response to the difficulties that countries had in the 1990s in finding and funding high quality supplies of TB drugs. It was believed that patients were developing resistance as a result of poor quality drugs.9

The Green Light Committee

In 2000 the WHO and some international partners, were beginning to develop an initiative called DOTS Plus. It was considered that the development of the DOTS strategy had been very successful in expanding effective TB treatment. However in some areas its success was being threatened by the emergence of multi drug resistant TB. DOTS Plus was to be developed as a comprehensive initiative that was to build upon the five elements of DOTS, but would take into account specific issues, such as the use of second line anti TB drugs, that needed to be used in areas where there were significant levels of MDR TB.

One of the difficulties with the implementation of some of the DOTS Plus pilot projects, was the need for quality second line anti TB drugs, which were normally very expensive. WHO and their partners made an arrangement with the pharmaceutical industry for preferential prices for second line drugs used for the pilot projects. However, it was considered important that these beneficial prices were not used in projects that were not organised according to certain standards, and which might therefore result in resistance developing to these second line drugs. So the Green Light Committee was established to review project applications, and to decide whether they were sufficiently in accordance with the guidelines that had been established for the pilot projects.10

The Global Alliance for Tuberculosis Drug Development

The Global Alliance for Tuberculosis Drug Development (now called the TB Alliance) was launched in October 2000, at a time when there were no TB drugs in clinical development. Since then the resulting organisation has, amongst other things, launched the first clinical trial to test multiple new drugs, and co–founded the Critical Path to TB Drug Regimens (CPTR) initiative.11

The Global Plan to Stop TB 2001–2005

By the time the first Stop TB Partners’ Forum took place in October 2001 the partnership had grown from six to over 120 organisations. At the Forum the launch took place of the Global Plan to Stop TB 2001–2005. Its aim was to provide a “roadmap” towards a TB free world, and it was considered that the 2005 TB control targets were realistic.12

The Global Plan to Stop TB 2001–2005 made a number of commitments including that:13

  • Within the next 50 months — by the end of 2005:
  • A global DOTS case detection rate of at least 70% would have been achieved, while maintaining a treatment success rate of at least 85%
  • Effective responses to TB–HIV and MDR–TB would have been developed and scaled up
  • A Global Plan to Stop TB for the period 2006–2010 would have been developed

Global TB control - new organisations

The TB Alliance had been set up in 2000 as a Product Development Partnership (PDP) to develop new affordable TB drugs. A PDP is a non- profit organisation that builds partnerships between the public, private, academic and philanthropic sectors to drive the development of new products for under-served markets. In 2003 two further PDPs were set up, AERAS to develop new TB vaccines to replace the BCG vaccine and the Foundation for Innovative New Diagnostics (FIND) to develop new TB tests.14

The Global Plan to Stop TB 2006–2015

Once again the targets set in a Global Plan to Stop TB had not been reached. This time it was the targets in the Global Plan to Stop TB 2001–2005, and these targets had been considered realistic back when they were set in 2001.

Global Plan logo

In the new global plan for 2006–2015, the targets were no longer set in terms of the percentage of people reached in case detection rates, or a treatment success rate of at least 85%. Instead there were a range of targets covering specific areas such as the development of improved diagnostics and drugs, and the target set in the Millenium Development Goals.

The Global Plan to Stop TB 2006–2015 has as its main targets:15

  • To meet the MDG target to have halted and begun to reverse the incidence of TB by 2015
  • To meet the Stop TB partnerships own targets, to by 2015, halve prevalence and death rates from the 1990 baseline
  • Over the ten years of the plan, 50 million people will be treated under DOTS Plus, 800,000 people will be treated for MDR TB, and three million people with TB and HIV co–infection will start antiretroviral therapy.
  • By 2010 simple tests for use at peripheral levels of the health system, will enable rapid, sensitive detection of active TB at the first point of care, and by 2015 there will be tests to identify those at greatest risk of progressing to active disease.
  • The first new TB drug for 40 years will be introduced in 2010, and by 2015 the target will have nearly been reached of a new regime that will achieve cure in 1–2 months, and that also will be effective against MDR TB
  • By 2015 there will be the first of a series of new, safe, effective TB vaccines.
  • There were also aims of involving communities and TB control featuring on the political agendas of countries.

The Global Plan to Stop TB 2011–2015

In 2009 the Stop TB Partnership produced a report on the progress that had been made in global TB control between 2006 and 2008.16 Many different areas were highlighted, and in some significant progress had been made, whereas in others, such as screening HIV positive people for TB, it was noted that much less progress had occurred. It was particularly noted that the provision of funding for TB was an area of particular difficulty with a funding gap still existing of over US$1 billion per year.

The Global Plan was subsequently updated in 2010, to become the "Global Plan to Stop TB 2011–2015".17

2013 — TB is still a Global Emergency

In 1993 the WHO declared TB to be a global emergency, stating that the disease would claim more than 30 million lives in the next ten years unless sufficient action was taken. Since then some action has been taken, but TB still claims one and a half million lives a year, and more than 30 million people have died since the global emergency was declared. What was said by WHO in 1993 is still probably true today.

“Tuberculosis today … is out of control in many parts of the world. The disease, preventable and treatable, has been grossly neglected and no country is immune to it.”

Arati Kochi, Manager WHO Tuberculosis Program 18

Over the last twenty five years the HIV/AIDS epidemic has developed and millions have died. However, a new diagnostic test has been developed, and there is now a range of drugs together with tools to monitor their use. Although the drugs are not a cure they do save people’s lives, and they are provided at affordable cost to people in both developing and developed countries. Almost every country in the world has set up a national HIV/AIDS control program, in many instances quite effectively.

In the same period there has been very limited progress in developing a really simple, cheap point of care diagnostic test, few new drugs have been developed, many TB control programs still have problems, MDR TB and XDR TB are spreading and millions still die.19 The global community should be able to do better with TB. Every one of us must ensure that we do not allow another 30 million people to die in the next few years.

References

  1. "Global Tuberculosis Control 2011", WHO, Geneva, 2011, 9 www.who.int/tb/publications/global_report/
  2. Remarks by Nelson Mandela: "Confronting the Joint HIV/TB Epidemics", XV International AIDS Conference, Bangkok, 2004 http://quod.lib.umich.edu/c/cohenaids/
  3. "Forty-fourth World Health Assembly Tuberculosis control programme" www.who.int/entity/tb/publications/tbresolution_wha44_8_1991.pdf
  4. "WHO Calls Tuberculosis a Global Emergency", Los Angeles Times, 1993 //articles.latimes.com/1993
  5. "What is DOTS? WHO Tuberculosis Factsheet", WHO, 2006 www.tbfacts.org/Whatisdots.pdf
  6. "Amsterdam Declaration to Stop TB", Amsterdam, The Netherlands, 24th March 2000 www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/decla.pdf
  7. "Amsterdam Declaration to Stop TB", Amsterdam, The Netherlands, 24th March 2000 www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/decla.pdf
  8. "First Stop TB Partners' Forum", Washington, 22 October 2001, 6 www.stoptb.org/events/meetings/partners_forum/2001/
  9. "What is the GDF?", www.stoptb.org/gdf/
  10. "DOTS-Plus & the Green Light Committee", www.who.int/tb/publications/2000/en/index.html
  11. "TB Alliance History and Impact", http://www.tballiance.org/about/history.php
  12. "First Stop TB Partners' Forum", Washington, 22 October 2001, 6 www.stoptb.org/events/meetings/partners_forum/2001/
  13. "First Stop TB Partners' Forum", Washington, 22 October 2001, 6 www.stoptb.org/events/meetings/partners_forum/2001/
  14. "AERAS - Global Efforts", AERAS www.aeras.org/about-tb/global-efforts.php
  15. "The Global Plan to Stop TB 2006-2015", WHO, Geneva, 2011, 9 www.stoptb.org/global/plan/
  16. "The Global Plan to Stop TB 2006-2015: Progress Report 2006-2008", WHO, 2009 www.stoptb.org/resources/publications/plans_strategies
  17. "The Global Plan to Stop TB 2011-2015", WHO, Geneva, 2010 www.stoptb.org/global/plan/
  18. "WHO Calls Tuberculosis a Global Emergency", Los Angeles Times, 1993 //articles.latimes.com/1993
  19. "Better to have HIV than TB", 2011 www.health24.com/medical/

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