Director-General’s message on World TB Day
Dr Margaret Chan
Director-General of the World Health Organization
Ladies and gentlemen,
I am pleased to brief you on the TB situation, together with WHO staff and Dr Mark Dybul, the Executive Director of the Global Fund. The Global Fund provides the vast majority of international donor funding for TB.
Twenty years ago, in 1993, WHO declared the spread of tuberculosis a global public health emergency. That unprecedented step was sparked by an explosion of cases, in rich and poor countries alike, largely fueled by the AIDS epidemic.
Two decades later, it is appropriate to ask: have we conquered, or at least tamed, the TB emergency? Yes, and no.
On many levels, TB control is a glowing success story. In the mid-1990s, WHO promoted the DOTS approach and then refined it as a six-pronged strategy to stop TB.
Within a decade, the strategy had been adopted in nearly every country in the world. It worked. In fact, it had a dramatic impact.
The epidemic which, in 1993, looked set to spiral out of control, peaked ten years ago and began a slow but steady decline. The Millennium Development target of halting and reversing the TB epidemic by 2015 has already been achieved. Overall, the world is on track to meet the target of a 50% reduction in deaths compared with 1990.
Between 1995 and 2011, 51 million people were successfully treated for TB using the WHO strategy, saving 20 million lives.
Such success is all the more impressive considering that TB care and control have relied on antiquated tools. TB is unique among the major infectious diseases in that no point-of-care diagnostic test is available.
The humble microscope has remained the principal diagnostic tool for a century. Moreover, no easy-to-use and accurate test for detecting TB in children exists.
This situation, too, is beginning to change. An unprecedented number of vaccines are now at various stages of development. The end of last year saw regulatory approval of the first new TB drug in 50 years.
In late 2010, WHO endorsed a rapid molecular test that can reliably diagnose TB and drug resistance, even in patients co-infected with HIV, within hours instead of weeks or even months. The test has been rolled out in 77 low- and middle-income countries, and the price of tests has dropped by more than 40%.
This is the positive side.
The negative side has three dimensions.
The first dimension is scale. Despite recent success in shrinking the epidemic, the global TB burden remains enormous. In 2011, an estimated 8.7 million people developed TB, and 1.4 million died. This makes TB second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent.
The second dimension is the rise of TB strains that are resistant to multiple first-line drugs or extensively resistant to second-line drugs as well.
MDR-TB has been detected in virtually every country that has looked for it. XDR-TB, confined to just a handful of countries a few years ago, has now been reported in 84 countries.
Worldwide, an estimated 630,000 people are ill with MDR-TB. The significance of that number is amplified considerably by the extreme burden it places on patients, families, and health systems.
Drug-resistant TB is notoriously difficult to diagnose and extremely difficult and costly to treat. Though cure of MDR-TB is feasible, it takes 20 to 24 months of treatment with expensive and toxic drugs, some of which need to be administered by injection and some of which are in short supply.
The costs of treating MDR-TB can be several hundred times higher than costs for treating drug-susceptible TB. On average, only around 50% of MDR-TB cases are cured.
The emergence of MDR-TB, at dramatic levels in some settings, is a signal that care and control measures have failed. When patients are given too little treatment, stop taking their medicines, or are treated with sub-standard medicines, only the weakest TB bacteria are killed.
This leaves the heartier ones to survive in a drug-resistant form. In other words, the emergence of MDR- and XDR-TB can be attributed to poor quality treatment.
However, this situation is changing.
Worldwide, nearly 4% of people newly ill with TB are resistant to multiple drugs right at the start. This means that MDR-TB is being transmitted directly from one person to another.
In some countries, as many as 35% of new cases have MDR-TB at the start. This gives you an idea of the powder keg we are sitting on.
We must learn from countries that have contained the threat and urgently support those where MDR-TB is nearly the norm.
We are just treading water when we desperately need to scale up the MDR-TB response. What has been gained through impressive international collaboration can be so easily lost.
The final dimension is financial. The funding gap for TB care and control is substantial. You will hear in just a few minutes what the gaps are in low- and middle-income countries that are eligible to receive Global Fund grants.
We are calling for the investment that this global epidemic deserves.