What is happening with TB?
How did we end up in this situation? Many people think we defeated TB long ago, but this epidemic is much worse than we thought last year -- worse than we thought five years ago, than ten years ago. We all are denying a reality which has been slowly unfolding in front of us - TB is the new global emergency and since it is airborne, a TB emergency in one country makes it an emergency for every country.
Let me present you with a few numbers:
In the Global TB Report 2011, WHO estimated that the number of people who developed TB dropped below 9 million for the first time ever - reporting an estimated 8.8 million new TB cases (confidence range: 8.5 to 9.2 million). Every year, WHO revises the Global TB Report and the data it contains, and every year since 2012, the estimated number of people who develop TB each year gets higher and higher. In 2015, we believe 10.4 million people fell ill with TB. These consistent upward revisions mean the number of people who are thought to have died from TB each year has also grown - from 1.5 million in 2011 to 1.8 million in 2015, a 20% increase. With a person dying of TB every 18 seconds, TB is and remains the largest cause of death from an infectious disease.
The number of people treated for TB as notified by countries, remained almost constant around 6 million for the last eight years, despite the large upward revisions in estimated TB burden to 10.4 million people in 2015. We used to speak about the missing three million (remember that campaign?) - now, we miss 4.3 million people. We cannot end the TB epidemic unless we close this gap because people with TB who are untreated can infect up to 15 others every year. The SDGs speak about Universal Health Coverage (UHC) and I believe the number of people with TB missed by health services is the best UHC indicator.
The gap between multidrug-resistant TB (MDR-TB) estimates and people diagnosed and treated is highly worrying. There are an estimated 580,000 people who developed MDR-TB in 2015. However, only 132,000 were diagnosed (only 9,000 more than in last year’s report) and 126,000 were started on treatment (only 15, 000 more people).
I will tell you what is going on. We are denying the fact that we are losing the battle with TB. A bacteria is outsmarting us. We are denying the fact that TB is the new global health emergency. We do not seem to understand that in order to end TB, we need to fight a full-fledged war.
And to win this, there are four things we must do:
1. Know our enemy
The (multiple) upward revisions of TB burden are based on the fact that we have better and better data every year. However, every year the picture of the epidemic appears bigger and bigger. The yearly revised TB burden estimates, makes it very difficult for the TB community to run after this moving target in a meaningful way. It is time to seriously look over the data we have and maybe more importantly, data we do not have. We should look over other sources of data: prevalence surveys, IHME data, Global Fund data, other open source data and better understand TB. And this cannot be a global-level exercise: data must be collected, analyzed and used at country, regional, district and site level. The TB programmes and the partners should collect data, not "to report" to global-level institutions, but to use the data for planning and monitoring their own interventions and work using real time data and new technology.
2. Prepare our weapons and strategies
Microscopy test for TB was developed over 130 years ago, yet it remains (mostly unchanged) our main test to diagnose TB. Would we fight a war today with 19th century cannons? Six years ago, we entered the era of rapid, accurate and affordable molecular testing for TB and drug-resistance. The Global Plan to End TB 2016-2020, which acts as the investment plan for the first five years of the End TB Strategy, calls for every person suspected of having TB to be tested for drug resistance. Despite this, only 20% of the newly diagnosed TB patients get rapid molecular testing. This means most people start TB treatment without knowing if it is appropriate for their form of the disease. Why do we still accept microscopy as our weapon of choice when there are better alternatives? We have new medicines - bedaquiline and delamanid, new child friendly medicines formulations, new short regimens to make MDR-TB treatment cheaper, shorter and more effective, but their uptake is worryingly slow.
The TB programmes must have the strength and vision to start using at scale all these new tools. The TB community and people affected by TB must demand the best available tests and standard of care FOR ALL! I know South Africa makes incredible progress, isn’t it time for other countries to step up as well?
Even the best tools in the world will not work if the policies are restricting their use. All countries and programmes should update their TB policies in line with the latest science. The 2015 Out Of Step report released by Stop TB Partnership and MSF found that many countries have yet to do so. Additionally, our arsenal is far from where it should be to end TB. We need a point of care test, a shorter non-toxic treatment for all forms of TB and an effective vaccine. R&D funding for TB is terribly insufficient and decreasing. Why are the investments in R&D for TB so low? With other diseases like Ebola and Zika we have seen what is possible in a short timespan; why not with TB?
3. Create a strong and united army
To win a war, we must align and shoot in the same direction. It is time for all stakeholders from governments to grass roots organizations and people affected by TB to come together and be united to end TB. Our messages are too often different, divergent and confusing and nobody will win. Irrespective of our own agendas, institutions and personalities, let’s align and ensure that the message that we send to the world is clear and strong and supporting those most in need, rather than institutional interests.
4. Have the commander lead the battle
The real battle is happening in countries - in governments, communities, and households. Therefore, we must have heads of state or governments leading the battle to end TB. But for too long, TB was not on the agenda of any commander. For many reasons, TB never reached the attention of heads of state. It remained to be battled by small groups of soldiers and captains, without the real leaders even knowing about their fight. We cannot accept anymore this status.
If we are serious about ending TB by 2030 - this battle must be led at a different level.
We must all push to have a United Nations High Level Meeting on TB in September 2017. Let’s all align ourselves to make this happen and win this battle!