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Insights into Editorial: The war on TB

Insights into Editorial: The war on TB

Context:

According to recently published WHO’s Global Tuberculosis Report 2017, India stood out as a country in which the budget envelope for TB was substantially increased in 2017 (to US$ 525 million, almost double the level of 2016).

Report also mentioned political commitment from the Prime Minister to the goal of ending TB by 2025. The budget is fully funded, including US$ 387 million (74%) from domestic sources (triple the amount of US$ 124 million in 2016) and the remainder (26%) from international donor sources.

Global tuberculosis report

WHO has published a global TB report every year since 1997.

  • The main aim of the report is to provide a comprehensive and up-to-date assessment of the TB epidemic, and of progress in prevention, diagnosis and treatment of the disease at global, regional and country levels.
  • This is done in the context of recommended global TB strategies and targets endorsed by WHO’s Member States and broader development goals set by the United Nations. 

For the period 2016–2035, these are WHO’s End TB Strategy and the United Nations’ (UN) Sustainable Development Goals (SDGs), which share a common aim: to end the global TB epidemic.

Why is Tuberculosis a major cause of concern?

TB is the ninth leading cause of death worldwide and the leading cause from a single infectious agent, ranking above HIV/AIDS.

  • TB is an infectious disease caused by the bacillus Mycobacterium tuberculosis.
  • It typically affects the lungs (pulmonary TB) but can also affect other sites.
  • The disease is spread when people who are sick with pulmonary TB expel bacteria into the air, for example by coughing.
  • Broader influences on the TB epidemic include levels of poverty, HIV infection, under nutrition and smoking.
  • Diagnostic tests for TB disease include – Rapid molecular test, Sputum smear microscopy, Culture-based methods
  • Without treatment, the mortality rate from TB is high.

Drug-resistant TB(MDR-TB) has been a continuing threat.

  • The bacteria that cause tuberculosis (TB) can develop resistance to the antimicrobial drugs used to cure the disease.
  • Multidrug-resistant TB (MDR-TB) is TB that does not respond to at least isoniazid and rifampicin, the 2 most powerful anti-TB drugs.
  • In 2016, there were 600 000 new cases with resistance to rifampicin (RRTB) of which 490 000 had multidrug-resistant TB (MDR-TB).
  • Globally, the TB mortality rate is falling at about 3% per year. TB incidence is falling at about 2% per year.

Most high TB burden countries have major challenges ahead to reach SDG targets related to these and other determinants.

Strategies to end TB

From 2000 to 2015, global and national efforts to reduce the burden of tuberculosis (TB) disease were focused on achieving targets set within the context of the Millennium Development Goals (MDGs) established by United Nations.

In 2016, the MDGs were succeeded by a new set of goals, known as the Sustainable Development Goals (SDGs).

  • The consolidated goal on health is SDG 3. One of these targets, (Target 3.3), explicitly mentions TB.
  • SDG 3 also includes a target (Target 3.8) related to universal health coverage (UHC) in which TB is explicitly mentioned. This includes an indicator on the coverage of essential prevention, treatment and care interventions.
  • Emphasis is also given to the importance of death registration within national vital registration systems for accurate tracking of causes of death (WHO Global Task Force on TB Impact Measurement).
  • The End TB Strategy
  • The overall goal is to “End the global TB epidemic”, and there are three high-level, overarching indicators and related targets and milestones.
  • The three indicators are: the number of TB deaths per year; the TB incidence rate per year; and the percentage of TB-affected households that experience catastrophic costs as a result of TB disease.
  • The 2035 targets are a 95% reduction in TB deaths and a 90% reduction in the TB incidence rate, compared with levels in 2015.
  • The 2030 targets are a 90% reduction in TB deaths and an 80% reduction in the TB incidence rate, compared with levels in 2015
  • Two new TB drugs, bedaquiline and delamanid, have already received accelerated or conditional regulatory approval based on trial results and is now in next stage trials.

Achieving these targets requires,

  • Provision of TB care and prevention within the broader context of universal health coverage,
  • multi-sectoral action to address the social and economic determinants and consequences of TB
  • Technological breakthroughs by 2025 so that incidence can fall faster than rates achieved historically.

Key facts about the status of TB in India as per Global tuberculosis report, 2017

India registered a slight drop in the number of new tuberculosis cases and TB deaths in 2016 compared with 2015.

  • From an estimated 2.84 million new cases in 2015, the number dropped marginally to 2.79 million in 2016, according to the World Health Organisation’s Global tuberculosis report, 2017.
  • In terms of mortality, the drop was from 0.51 million in 2015 to 0.43 million in 2016. The number of deaths and the incidence rate have been falling both globally and in India.
  • With 1.7 million new cases in 2016, India still continues to be the largest contributor to the global burden with up to a quarter of the 6.3 million new cases of TB (up from 6.1 million in 2015).
  • Funding Source: 74% domestic funding and 26% international funding.
  • More men above the age of 15 suffer from TB than women.

What are the present issues concerning regarding TB in India?

The government has committed to achieve a ‘90-90-90 target’ by 2035 (90% reductions in incidence, mortality and catastrophic health expenditures due to TB). This is premised on improved diagnostics, shorter treatment courses, a better vaccine and comprehensive preventive strategies.

  • However, much work remains to improve case notifications as only 1.9 million TB cases in the public and private sectors were notified in 2016, leaving a 25% gap between incidence and notification, the largest in the world.
  • Though notification was made mandatory in 2012, multiple surveys and surveillance data still show large under-reporting of detected TB cases, especially in the private sector.
  • Top-line drugs are still inadequate to treat people who suffer from the drug-resistant forms of the disease.
  • The number of estimated multi-drug-resistant TB cases increased marginally to 84,000. But the number of people with MDR-TB enrolled for treatment improved marginally between 2015 and 2016.
  • For the first time, steps have been taken to offer preventive TB treatment to a small (5%) number of people who are HIV-positive, and 1.9% of children below five years who are household contacts of people recently diagnosed with pulmonary TB.
  • Notably, domestic funding (74%) for anti-TB work has been more than that from international sources (26%).
  • The surveillance systems remain inadequate.

What should be done to achieve the set targets under End TB strategy?

The targets set in the End TB strategy are global reduction of 20% in incidence and 35% in mortality by 2020, taking 2015 as the base year.

  • To reach that target, the global drop in incidence has to be 4-5% a year — currently it is about 2% a year.
  • The percentage of deaths should come down from the current 16% to 10%.
  • With India accounting for the highest TB incidence (23%) and mortality (26%) globally, success in realising the End TB targets hinges largely on the country strengthening its systems.
  • The major step in defeating the disease and achieving the targets is to record every diagnosed patient through case notification.
  • When a person is diagnosed with TB, it is reported to the national surveillance system, and then on to the WHO.
  • While better funding might help India inch closer to its stated goal of ending TB by 2025, much more is needed in terms of funding and commitment on all fronts.

Way forward

The pipelines for new diagnostics, drugs, treatment regimens and vaccines are progressing, but slowly. Increased investment in research and development is needed for there to be any chance of achieving the technological breakthroughs needed by 2025.

The WHO Global Ministerial Conference on ending TB in the SDG era in November 2017 and the first UN General Assembly high-level meeting on TB in 2018 provide a historic opportunity to galvanize the political commitment needed to step up the battle against TB and put the world and individual countries on the path to ending the TB epidemic.