by Editorial, The Lancet
UK, 03 Apr 2009 - Tuberculosis is a preventable and treatable disease that thrives amid poverty and weak health systems. For these reasons, the shortcomings and challenges in WHO's 13th annual report Global Tuberculosis Control 2009, released on March 24, make sombre reading.
Tuberculosis incidence has declined since 2004, but only by less than 1% per year. Case detection is stagnant. Despite progress in several regions, the Stop TB Partnership target of a 50% reduction in 1990 prevalence and mortality by 2015 will not be met. More worrying is the synergy of tuberculosis and HIV/AIDS co-infection in sub-Saharan Africa, and the growth of multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant strains (XDR-TB) in eastern Europe: two factors that complicate treatment and threaten to increase fatality rates.
In 2007, there were 9•3 million incident reports of tuberculosis; half in Asia and a third in Africa. Overall, 1•3 million people were co-infected with HIV. 456 000 co-infected individuals died, making tuberculosis the commonest cause of death in people with HIV/AIDS. Conversely, HIV/AIDS was responsible for almost a quarter of the 1•7 million deaths in people with tuberculosis. 500 000 people were thought to have MDR-TB and perhaps another 40 000 to have XDR-TB. India and China have the world's largest burdens of incident tuberculosis, 2•0 million and 1•3 million people, respectively, and both have over 100 000 people with MDR-TB.
The tragedy—some might say folly—is that established procedures for HIV/AIDS co-infection and MDR-TB have not been implemented widely. In 2004, WHO urged more collaboration between HIV and tuberculosis programmes, with routine testing for HIV in people with tuberculosis and for tuberculosis in people with HIV/AIDS. Testing accelerates diagnosis, improves treatment, and protects immunocompromised patients with HIV from tuberculosis. However, testing and treatment for the two infections often occur at separate sites. In 2007, the Global Plan targets for intensified case finding were missed worldwide. In Africa, the aim was to test 900 000 people with tuberculosis for HIV and 13 million people with HIV for tuberculosis. Only 500 000 and 300 000, respectively, were screened—and few of those diagnosed with co-infection received appropriate treatment.
MDR-TB is encouraged by poor case-detection, treatment with inappropriate drug regimens, and lack of clinical supervision. Almost half of treatment relapses in eastern Europe are from drug-resistant strains. Accurate diagnosis of MDR/XDR-TB requires drug sensitivity testing in a qualified laboratory. Only 2% of the estimated 500 000 people infected with drug-resistant strains were tested in 2007. And even when diagnosed with this more lethal form of tuberculosis, fewer than 3% received treatment recommended by international guidelines.
Mechanisms to ensure best practice have failed at many levels in several countries because of lack of discipline, infrastructure, and resources. Clearly the changing nature of tuberculosis epidemiology demands a reassessment and scaling-up of control measures. To redefine and redirect the actions necessary to combat tuberculosis, resolutions from the Stop TB Partners Forum will be presented in Beijing on April 1—3, when health ministers from the countries most affected by MDR/XDR-TB will discuss strategies for tackling drug-resistant infection. To succeed they will need to build consensus, establish political will, and secure sustainable funding.
The combination of MDR/XDR-TB, HIV/AIDS, weak health systems, and an extra 100 million people in poverty since the economic downturn in 2008, create ideal conditions for tuberculosis. Yet the same factors also provide targets to improve care through collaboration, strengthened health systems, and research. For example, the Article by Marcus Conde and colleagues in The Lancet today shows how a new drug might shorten treatment duration. Shorter treatments improve compliance and increase efficiency. But more developments in diagnosis and treatment are needed. At a time when many US$ billions are spent on failing institutions, the underfunding by $1•6 billion a year for tuberculosis is shameful, particularly when each dollar spent on care generates $15 in productivity.
Attitudes to tuberculosis must change among health professionals and the public. Laboratories and clinicians need to follow best practice in diagnosing, reporting, and managing the disease—and they need to have the tools to do so. Additionally, efforts to control tuberculosis should engage communities to reduce stigma, support care, and develop local solutions. The meeting being held in China this week must be an inflexion point in our collective response to tuberculosis.
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