World TB Day 2014: finding the missing 3 million, by Rt Hon N Herbert MP and others

World TB Day 2014: finding the missing 3 million

The Lancet, Volume 383, Issue 9922, Pages 1016 – 1018 – On April 23, 1993, WHO declared tuberculosis a global health emergency (1). Tuberculosis is now about to come of age as a global emergency—April, 2014 marks the 21st anniversary of that declaration. Arata Kochi, manager of WHO’s tuberculosis programme in 1993, aptly called the disease “a forgotten epidemic” and “humanity’s greatest killer”. Tuberculosis might no longer be humanity’s deadliest disease in terms of annual deaths but, 21 years after the declaration, it remains a serious and substantial threat to the health of people worldwide, causing 1·3 million unnecessary deaths every year (2).

Much progress has been made in the control of tuberculosis in the past 21 years, but we are only halfway to 2035—the target of WHO’s Global Tuberculosis Programme as the year that tuberculosis will no longer be a threat to global public health. At that point, 42 years will have passed from WHO labelling tuberculosis a global health emergency; several more years than the average age of the disease’s victims. So at this halfway point, we stand at a crossroads. Since 1995, 56 million people have been cured of tuberculosis and 22 million lives have been saved,2 showing implementation of more effectivetuberculosis programmes than those in place before WHO’s declaration. However, more than 30 million people have died from tuberculosis in the past 21 years.2 How many more people will die of tuberculosis in the next 21 years is entirely in the hands of governments and donors. Do we let more people die from a disease for which effective treatment has been available for the past 50 years, or is it now time for a resolute change (as envisaged with the more ambitious WHO targets set for 2035) to stop this epidemic from taking its toll?

For rapid progress to be made in tuberculosis control, there are two essential requirements: first, commitment and resolve at the highest political level, and second, the necessary resources. To achieve unity for these aims, on World Tuberculosis Day, March 24, 2014, the UK All Party Parliamentary Group on Global Tuberculosis has joined with parliamentarians from the Group of Eight (G8) countries to call for coordinated global action on tuberculosis. We call for substantial investment in scaling- up existing interventions; in development of new drugs, diagnostics, and vaccines; and in innovative projects and programmes to diagnose and treat all individuals with tuberculosis. These steps will, we hope, see an end to the scourge of tuberculosis, not in 100 years but in the next 20 years.3 This is an ambitious goal, but not an impossible one. Achievement depends on several factors. In particular, to ensure that all people with tuberculosis are diagnosed and given high-quality treatment to cure them effectively and render them non-infectious.

Every year about 3 million people with active tuberculosis are not diagnosed and continue to spread the disease in the community, with many dying.4 Other patients are diagnosed but not officially reported, eluding public health systems. The consequences of failing to diagnose and properly treat these 3 million people will impede gains made in tuberculosis control. Quite simply, unless large increases occur in tuberculosis case-finding and provision of high-quality treatment for both drug-sensitive and drug-resistant tuberculosis, we will never truly get a grip on the disease. The global spread and rise in the number of cases of multidrug- resistant and extensively drug-resistant tuberculosis reached 450000 people in 20132—due, in no small part, to the incomplete or insufficient treatment of patients with tuberculosis. 20% of patients previously treated for tuberculosis who then relapse have multidrug-resistant tuberculosis.2 Of concern, Pietersen and colleagues5

reported on patients in South Africa with multidrug- resistant tuberculosis or extensively drug-resistant tuberculosis being released into the community to die after failure of treatment in hospital. Drug-resistant forms of tuberculosis are much more expensive and difficult to treat, with treatments having a large burden on patients in terms of adverse events and on health service delivery as a whole.

Although the current situation is not optimum, optimism for achievement of WHO’s tuberculosis targets comes from renewed donor commitments. At the 2013 Replenishment Conference of the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria, the UK Government pledged £1 billion to fight the three diseases, including for delivery of treatment to more than 1 million people with tuberculosis. Other donor countries rose to the challenge and pledged a cumulative US$12 billion to the Fund. Although the full amount needed by the Global Fund and its partners has not yet been pledged, these numbers show a remarkable commitment to tackling tuberculosis, malaria, and HIV/AIDS. The Global Fund and its partners will be able to use the money to take advantage of developments in new tuberculosis diagnostics and antituberculosis drugs, to find, test, and treat all patients with tuberculosis. Hopes remain high that new tuberculosis vaccines in early stages of development could tip the balance to favour eradication.

Progress is also being made to strengthen health systems and implement new rapid diagnostics for increased tuberculosis detection through Stop TB Partnership’s TB REACH tuberculosis case-finding initiative, and research projects funded by major grant awarding bodies such as the European and Developing Countries Clinical Trials Partnership’s TB-NEAT,6 EuropeAID’s Active Detection of Active Tuberculosis,7,8 DETECTB,9 and ZAMSTAR.10 Although increased use of existing methods brings down the global tuberculosis rate by 2% every year, further development of new instruments and interventions11–13 is needed to complete tuberculosis eradication.

In the past 21 years, tuberculosis has claimed many millions of lives, orphaned at least 10 million children, ruined the lives of hundreds of millions of people, and trapped individuals, families, and entire communities in poverty. World Tuberculosis Day provides a unique forum for everyone, from parliamentarians to patients, from drug developers to health personnel and academic researchers, to come together and call for action with one

For more on the 2013 Replenishment Conference for the Global Fund see http://www. replenishment/fourthWorld TB Day 2014: finding the missing 3 million

united voice. We must not miss this unique opportunity to make the strongest possible case for tuberculosis, push it up the political agenda, and secure global commitment and leadership that will steer a new path to end tuberculosis forever.

Rt Hon Nick Herbert MP, Andrew George MP,

Baroness Masham of Ilton, Virendra Sharma MP, Matt Oliver,

Aaron Oxley, Mario Raviglione, *Alimuddin I Zumla

All Party Parliamentary Group on Global Tuberculosis, Houses of Parliament, London, UK (NH, AG, SM, VS); RESULTS UK, London, UK (MO, AO); Global TB Department, WHO, Geneva, Switzerland (MR); and Division of Infection and Immunity, University College London, UCL Royal Free Campus, and UCL Hospitals NHS Foundation Trust, London NW3 2PF, UK (AIZ)

We declare that we have no competing interests. AIZ and AO have an expert advisory role to the UK All Party Parliamentary group on global tuberculosis.

  1. WHO. TB—a global emergency. WHO press release. WHO/31. Geneva: World Health Organisation, 1993.
  2. WHO. Global tuberculosis report 2013. Geneva: World Health Organization, 2013. (accessed Jan 29, 2014).
  3. Raviglione M. Post-2015 TB strategy and targets: draft document and results of consultations. Presentation from 3rd Stop TB Partnership Coordinating Board Meeting; July 11–12, 2013; Ottawa, Canada.http:// Presentations/Session%2006_Post%202015%20Strategy_Raviglione.pdf (accessed Feb 28, 2014).

4 Zumla A, George A, Sharma V, Herbert N, Baroness Masham of Ilton. WHO’s 2013 global report on tuberculosis: successes, threats, and opportunities. Lancet 2013; 382: 1765–67.

5 Pietersen E, Ignatius E, Streicher EM, et al. Long-term outcomes of patients with extensively drug-resistant tuberculosis in South Africa: a cohort study. Lancet 2014; published online Jan 16. 6736(13)62675-6.

6 Bates M, O’Grady J, Mwaba P, et al. Evaluation of the burden of unsuspected pulmonary tuberculosis and co-morbidity with non-communicable diseases in sputum producing adult inpatients. PLoS One 2012; 7: e40774.

7 O’Grady J, Bates M, Chilukutu L, et al. Evaluation of the Xpert MTB/RIF assay at a tertiary care referral hospital in a setting where tuberculosis and HIV infection are highly endemic. Clin Infect Dis 2012; 55: 1171–78.

8 Bates M, Ahmed Y, Chilukutu L, et al. Use of the Xpert® MTB/RIF assay for diagnosing pulmonary tuberculosis comorbidity and multidrug-resistant TB in obstetrics and gynaecology inpatient wards at the University Teaching Hospital, Lusaka, Zambia. Trop Med Int Health 2013;

18: 1134–40.
9 Corbett EL, Bandason T, Duong T, et al. Comparison of two active case-finding

strategies for community-based diagnosis of symptomatic smear-positive tuberculosis and control of infectious tuberculosis in Harare, Zimbabwe (DETECTB): a cluster-randomised trial. Lancet 2010; 376: 1244–53.

10 Ayles H, Muyoyeta M, Du Toit E, et al. Effect of household and community interventions on the burden of tuberculosis in southern Africa: the ZAMSTAR community-randomised trial. Lancet 2013; 382: 1183–94.

11 Zumla AI, Gillespie SH, Hoelscher M, et al. New antituberculosis drugs, regimens, and adjunct therapies: needs, advances, and future prospects. Lancet Infect Dis 2014; published online March 24. S1473-3099(13)70328-1.

12 Kaufmann SHE, Lange C, Rao M, et al. Progress in tuberculosis vaccine development and host-directed therapies—a state of the art review. Lancet Respir Med 2014; published online March 24. http://dx.doi. org/10.1016/S2213-2600(14)70033-5.

13 McNerney R, Maeurer M, Abubakar I, et al. Tuberculosis diagnostics and biomarkers: needs, challenges, recent advances, and opportunities. J Infect Dis 2012; 205 (suppl 2): S147–58.





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