WHO Global Tuberculosis Report 2013: priorities to sustain progress and achieve TB control

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On October 23, the World Health Organization (WHO) launched the 2013 Global Tuberculosis Report. The 18th report, which has been published since 1997, is a strong reminder to all that tuberculosis (TB) is still part of our society worldwide and can heavily affect our lives – our health, our families, our friends.

WHO estimates that there were 8.6 million new TB cases in 2012 (2.9 million women and 530,000 children). It also estimates that 1.3 million deaths occurred, including 320,000 deaths in HIV-infected people and 170,000 deaths due to multidrug-resistant (MDR)-TB.

The new data confirm that progress has been made in reducing the burden of TB: the mortality rate has fallen by 45% since 1990 (bringing us closer to the UN Millennium Development Goal), 22 million lives were saved between 1995 and 2012, and about half of the 22 countries with the highest burden of TB have reached the three 2015 targets for reductions in incidence, prevalence and mortality.

Despite clear positive trends on the decline of TB incidence and mortality, it is still a threat and its control requires a strong multifaceted approach, where efficient public health interventions are combined with the discovery of a new vaccine for prevention, new tools for rapid diagnosis, and new drugs and regimens for treatment.

Two major challenges threaten to reverse the gains.

First, 3 million "missed" cases. Currently, with 5.7 million cases notified out of 8.6 million estimated, there is a gap of nearly 3 million cases that are missed by the system. While some may be truly missed due to poor access to health, others are probably detected and treated by nonstate providers that do not report the cases and whose quality of care may not be of high standard. This represents one of the top priorities outlined by WHO: expanding the access to high-quality care across public and private providers (such as hospitals and nongovernmental organisations (NGOs)).

Second, MDR-TB "crisis".

Response to testing and treating all those affected by MDR-TB is inadequate. About three quarters of the 450,000 estimated cases in 2012 remained undiagnosed. Further, up till/in 2013, 92 countries had reported at least one case of extremely drug resistant (XDR)-TB. Moreover, of the 94,000 people who were detected as MDR-TB (about 34,000 cases more than in 2011), only 77,000 started treatment, leaving about 18% of cases untreated and potentially spreading MDR strains in the community. Certainly an alarming observation, but not entirely unexpected; in fact, the availability of better and more rapid diagnostic tools, such as GeneXpert that provides a diagnosis of TB and rifampin-resistance in less than 2 hours, has not been properly matched by a similarly fast implementation of treatment capacity in several settings. The end result is thousands of patients queuing for medicines.

As the report states: "Progress remains fragile and could be reversed without adequate funding". In fact, both major challenges have the same root problem: lack of resources.
Of US$ 7─8 billion per year required to fight the disease in low and middle income-countries in 2014 and 2015, only US$ 6 billion has been committed so far. This means a funding gap of US$ 2 billion that, if not filled, could reverse the gains that have been made.

Among the five WHO priorities, there is also a call for innovation, which, as Dr Mel Spigelman, President and Chief Executive Officer of TB Alliance, said "It has the ability to change the world". But innovation needs research and TB research needs more financing. In fact, as described by Treatment Action Group's 2013 Report on Tuberculosis Research Funding Trends, 2005─2012, TB research and development investments dropped by US$ 30.4 million in 2012 compared to 2011. Even more alarming is that this drop occurred in 2012, before the US proposed a 19% (US$ 191 million) cut in the budget of the US Agency for International Development, a major provider of financial resources globally.

Financial difficultiesmay hamper the rationale of the new post-2015 global TB strategy under development, which not only pursues maximisation of current tools, universal health coverage and social protection, but also calls for new vaccines and new prophylaxis regimens, two crucial weapons that need to be in place by 2025 to reach the new art of global targets:

  • A 95% reduction in death, and
  • A 90% reduction in incidence by 2035

But innovation comes from the Latin "innovatio", noun of action from innovare, or "renew something that already exists". In other words, waiting for better times we should optimise the existing tools without ever forgetting to look forward, because as Dr Mario Raviglione, Director of Global TB Programme at WHO, said "Investments in TB research and innovation today means assuring transformation of TB control strategies tomorrow."

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