TWN Info Service on Health Issues (March 08/02)
26 March 2008
Third World Network

Slow progress in battle against TB

WHO reports that progress to combat the TB epidemic has slowed in recent years. This has been aggravated by multi-drug resistant TB (MDR-TB) which has reached the highest levels ever recorded and the lethal combination of TB and HIV which is fuelling the TB epidemic worldwide.

The following story is reproduced with the permission of South-North Development Monitor (SUNS) #6438, 19 March 2007.

With best wishes
Evelyne Hong

Health: Slowing of progress in efforts to combat tuberculosis
By Kanaga Raja, Geneva, 18 March 2008

The pace of the progress to control the tuberculosis (TB) epidemic slowed slightly in 2006, the most recent year for which data were available, the World Health Organization (WHO) reported on Monday.

In its "Global Tuberculosis Control Report 2008", the WHO documented a slowdown in progress on diagnosing people with TB - between 2001 to 2005, the average rate at which new TB cases were detected was increasing by 6% per year, but between 2005 and 2006 that rate of increase was cut in half, to 3%.

The WHO attributed this slowing of progress amongst others to the fact that some national programmes that were making rapid strides during the last five years have been unable to continue at the same pace in 2006. Moreover, in most African countries, there has been no increase in the detection of TB cases through national programmes.

Other studies have also shown that many patients are treated by private care providers, and by non-governmental, faith-based and community organizations, thus escaping detection by the public programmes.

Based on data given to WHO by 202 countries and territories, the report found that there were 9.2 million new cases of TB in 2006, including 700,000 cases among people living with HIV, and 500,000 cases of multi-drug resistant TB (MDR-TB).

An estimated 1.5 million people died from TB in 2006. In addition, another 200,000 people with HIV died from HIV-associated TB.

At a media briefing Monday, WHO Director-General Dr Margaret Chan said that after some years of good trends in TB control, this year's report on trends in 2006 documented a slowing of progress.

Pointing to last month's release of another WHO report that found that MDR-TB was at its highest recorded level (see SUNS #6423 dated 27 February 2008), Dr Chan said that the report issued Monday has added to that concern.

Dr Peter Piot, Executive Director of UNAIDS, said that the report clearly demonstrated how closely interlinked the TB and HIV epidemics really were. Of some 9 million new cases of TB, almost three-quarters of them occur in people living with HIV.

Although TB is both preventable and curable, it causes the death of nearly a quarter of a million people living with HIV in 2006, he said, adding that it is the single most important cause of death in people living with HIV, with Africa being the most affected with over 85% of the TB-HIV burden.

Dr Michael Kazatchkine, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said that TB across Sub-Saharan Africa remains a crisis, largely through the spread of AIDS.

"We cannot stop the TB epidemic in Africa, without at the same time addressing the AIDS pandemic," he said, adding that the progress made in the global fight against TB is being threatened by MDR-TB and extremely drug-resistant TB (XDR-TB).

Asked whether any new drugs for TB that comes to the market should come without patent protection, Dr Kazatchkine was of the view that as it has been with HIV, "we have to find a good balance between incentives for the industry to come with new drugs and then deal with the challenge of prices."

Dr Chan noted that the WHO member states are having a discussion through the Inter-governmental Working Group to look at public health, innovation and intellectual property rights and that hopefully that discussion will provide new ideas on the way forward.

Pointing to a fundamental difference between the AIDS drugs market and the market for TB drugs, Dr Piot said that there are well over 2 million people in high-income countries requiring HIV therapy. There is a market for the pharmaceutical industry in the high-income countries, where a return on investment can be made. That is not the case for TB, he said, arguing the need for another kind of model.

According to the WHO report, there were an estimated 9.2 million new cases of TB in 2006, including 4.1 million new smear-positive cases and 0.7 million HIV-positive cases. This is an increase from 9.1 million cases in 2005, due to population growth.

India, China, Indonesia, South Africa and Nigeria rank first to fifth respectively in terms of absolute numbers of cases, said the report, adding that the African region has the highest incidence rate per capita.

There were an estimated 14.4 million prevalent cases of TB in 2006, and an estimated 0.5 million cases of MDR-TB in 2006. In 2006, said WHO, there were an estimated 1.5 million deaths from TB in HIV-negative people and 0.2 million among people infected with HIV.

The report identified two aspects of the epidemic that it said could further slow progress on TB. The first is MDR-TB, reported by the WHO last month to have reached the highest levels ever recorded.

To date, said WHO, the response to this epidemic has been inadequate. Given limited laboratory and treatment capacity, countries project that they will provide treatment only to an estimated 10% of people with MDR-TB worldwide in 2008.

The second threat to continued progress highlighted in the report is the lethal combination of TB and HIV, which is fueling the TB epidemic in many parts of the world, especially Africa.

Although TB/HIV remains a massive challenge, some countries are making strides against the co-epidemic, said WHO, observing that almost 700,000 TB patients were tested for HIV in 2006, up from 22,000 in 2002 - a sign of progress but still far from the 2006 target of 1.6 million set by the WHO Global Plan to Stop TB.

The report also found that the number of HIV-positive TB patients enrolled on anti-retroviral therapy (ART) was 67,000 in 2006, more than double the 29,000 reported for 2005 and seven times the 9,800 reported in 2004, but still less than the 220,000 target for 2006 in the Global Plan.

The report said that implementation of interventions to reduce the burden of TB in HIV-positive people was far below the targets set in the Global Plan in 2006. The Global Plan target for 2006 was to screen 11 million HIV-positive people for TB; the actual figure reported was 314,211.

A total number of 23,353 cases of MDR-TB were notified in 2006, of which just over half were in the European region. The total number of MDR-TB cases that countries forecast will be enrolled on treatment in 2007 and 2008 is about 50,000 in both years, said WHO, adding that the projections for 2008 are much less than the target of 98,000 that was set in the Global MDR-TB/XDR-TB Response Plan.

Most of the shortfall is in the European, South-East Asia and Western Pacific regions, and within these regions in China and India, in particular, said the report, stressing that major expansion of services that meet the standards established in WHO guidelines are needed.

The report also documented a shortage in funding. Despite an increase in resources, especially from the Global Fund and some middle-income countries, TB budgets are projected to remain flat in 2008 in almost all of the countries most heavily burdened by the disease.

Total budgets of national TB control programmes (NTPs) in high-burden countries amount to $1.8 billion in 2008, up from $0.5 billion in 2002 but almost the same as budgets for 2007.

NTP budgets for the 90 countries with 91% of global TB cases that reported complete data total $2.3 billion in 2008. To meet the 2008 targets of the Global Plan to Stop TB, the funding shortfall for these 90 countries is about $1 billion, said WHO.

The report also found that the treatment success rate in DOTS programmes (the internationally recommended strategy for TB control) was 84.7% in 2005, just short of the 85% target. Treatment success rates were lowest in the European region (71%), the African region (76%) and the Americas region (78%). The South-East Asia and Western Pacific regions and 58 countries achieved the 85% target.

Globally, said the report, the TB incidence rate per 100,000 population is falling slowly (-0.6% between 2005 and 2006), having peaked around 2003. By 2006, TB incidence per capita was approximately stable in the European region and in slow decline in all other WHO regions. MDG Target 6.C - to halt and reverse the incidence of TB - will be achieved well before the target date of 2015 if the global trend is sustained, said WHO.

Prevalence and death rates per capita are also falling, and faster than TB incidence, added the report. Globally, prevalence rates fell by 2.8% between 2005 and 2006, to 219 per 100,000 population (compared with the 2015 target of 147 per 100,000 population). Death rates fell by 2.6% between 2005 and 2006, to 25 per 100,000 population (compared with the 2015 target of 14 per 100,000 population).

The report said that if trends in prevalence and death rates for the past five years are sustained, the Stop TB Partnership targets of halving prevalence and death rates by 2015 compared with 1990 levels could be achieved in the South-East Asia, Western Pacific and Eastern Mediterranean regions, and in the regions of the Americas.

Targets are unlikely to be achieved globally however, said the report, pointing out that the African and European regions are far from the targets. For example, deaths are estimated at 83 per 100,000 population in 2006 in the African region, compared with a target for the region of 21.

In recognition of World TB Day, Dr Jorge Sampaio, former President of Portugal and the UN Secretary-General's Special Envoy to Stop TB, called for enhanced leadership to address TB/HIV. "TB is a leading cause of death among people living with HIV/AIDS," he said.

"Several countries have shown that targets relating to TB/HIV are achievable and have put in place measures that will have an impact on the lives of those at most risk. But this is a restless battle. We still need to do much more and much better," he added.