By Susan Blumenthal, M.D, M.P.A.
Written in collaboration with Yoonhee Ha, M.Sc.
This Saturday, March 24 is World Tuberculosis Day, marking the 130th anniversary of Dr. Robert Koch's discovery of Mycobacterium tuberculosis, the microbe that causes tuberculosis. This year, the Stop TB Partnership, an international collaborative of governmental and non-governmental organizations, the private sector, and others dedicated to fighting tuberculosis, has adopted "Stop TB in My Lifetime" as its theme for World Tuberculosis Day. Yet, nearly a century and a half after Koch's discovery, stopping tuberculosis in our lifetimes is a formidable challenge. A $1.7 billion dollar shortfall for the Global Fund to Fight AIDS, TB and Malaria over the next five years means that 3.4 million patients may go untreated. This could reverse the important gains that have been made over the past years in the fight against this disease. The Global Fund provides 80 percent of external resources for TB eradication and treatment. Since this public/private partnership was established in 2002, the organization has helped detect and treat 8.6 million cases of TB .
TB is one of the most widespread infectious illnesses in the world -- with an estimated one-third of people globally infected with the bacteria that causes TB according to the World Health Organization (WHO). In 2010, the World Health Organization (WHO) reported that there were an alarming 8.8 million new cases of active tuberculosis and 1.4 million deaths caused by this disease, making it the eighth leading cause of death globally [2,3]. However, these numbers represent a decline in new cases since 2005. With 95 percent of TB deaths occurring in developing countries, tuberculosis is a public health problem that disproportionately affects the poor and young adults in their most productive years . Furthermore, there were 9.7 million orphaned children as a result of their parents' death from TB.
Significantly fewer people die of tuberculosis in developed countries, but the disease nonetheless remains a health threat in the United States, with more than 10,521 cases reported in 2011 [5,1]. TB is a public health tragedy, given that it is both preventable and curable. However, this week there was some good news: TB infections in America have dropped to record lows, falling 6.4 percent in 2011, but still missing a national target for eliminating the disease. TB rates are 12 times higher among people living in the U.S. who were born outside the country. Compared with whites, TB rates were seven times higher for Hispanics, eight times higher for blacks, and 25 times higher for Asians in America last year. Four states -- California, Texas, New York, and Florida -- account for nearly half of all TB cases in the United States. According to a recent CDC report, unless circumstances change significantly, the U.S. will not be able to eradicate TB until 2100.
The symptoms of tuberculosis include coughing, chest pain, fatigue, fever, weight loss, chills, night sweats, and loss of appetite. While TB most often affects the lungs, it can also affect the brain, kidneys, or spine. The disease can spread when an individual with active tuberculosis -- a disease state characterized by actively dividing bacteria -- coughs, sneezes, talks, or spits, releasing droplets containing M. tuberculosis into the air. If other people inhale these droplets, they may acquire the disease. Without treatment, individuals with active TB will infect an average of 10 to 15 people each year, and can ultimately die from the disease. Individuals with latent tuberculosis -- characterized by non-dividing bacteria -- are symptomless and unable to infect others, but they remain at risk of developing active disease if they are not treated. It is estimated that one-third of the world's population currently has latent tuberculosis .
Significant progress has been made in the fight against TB in recent decades. Since 1990, there has been a 40 percent decline in the global death rate for this disease, and the world was on track until the recent funding shortfalls to achieve the Millennium Development Goal 6 target that aims to halt and reverse the tuberculosis incidence rate by 2015 [3,4].
One major advance has been the implementation of Directly Observed Therapy Short-Course (DOTS), a multi-pronged tuberculosis control strategy best known for its use of health care workers to supervise the administration of TB therapy. This approach has dramatically improved treatment rates and patient survival. DOTS has five key components: 1) sustained political and financial commitment; 2) diagnosis by quality-ensured sputum-smear microscopy; 3) standardized short-course anti TB treatment given under direct and supportive observation; 4) a regular, uninterrupted supply of high quality anti-TB drugs; and 5) standardized treatment and reporting. Globally, by 2007, 99 percent of all cases of TB reported to WHO were being treated in DOTS programs. In 2009, DOTS had a treatment success rate of 87 percent -- its highest level to date. Since 1995, 46 million people have been successfully treated and up to 6.8 million lives have been saved through DOTS and the Stop TB Strategy. And this month, the World Health Organization (WHO) announced that its integrated prevention, diagnosis, and treatment efforts for tuberculosis and the human immunodeficiency virus (HIV) prevented an estimated 910,000 deaths in six years .
While these efforts have made a lifesaving difference for many, much more remains to be done. Here is why:
- Tuberculosis prevention is limited by the lack of an effective vaccine. The existing Bacillus Calmette-Guérin (BCG) vaccine has limited success in preventing tuberculosis infection. When successful, protection is estimated to last around 15 years. Furthermore, the vaccine has been shown to cause potentially fatal infection when given to HIV-positive adults or to children with weak immune systems .
- Many resource-poor countries lack the necessary infrastructure, equipment, and trained personnel needed to accurately diagnose tuberculosis and differentiate between drug-resistant strains. As a result, many infected people remain undiagnosed or receive non-effective treatments. The WHO's recent endorsement of the Xpert MTB/RIF, a diagnostic test that is capable of detecting M. tuberculosis and resistance to the drug rifampicin in two hours, represents a major step forward in reducing the time required for diagnosis and detection of multi-drug resistant (MDR) tuberculosis (the type that is resistant to the two most powerful first line TB drugs). However, there is still a need for additional rapid diagnostic tests that are both accurate and affordable for use in the developing world.
- Existing treatment regimens require patients with active tuberculosis to take multiple drugs for months at a time, making treatment adherence challenging. This, along with the prescribing of incorrect drugs, has contributed to the emergence and spread of MDR and extensively drug-resistant (XDR) tuberculosis. In 2010, there was an estimated prevalence of 650,000 cases of multidrug-resistant TB (MDR-TB) and in 2008, 150,000 deaths annually. Because these types of tuberculosis are very difficult and costly to treat, they provide significant challenges to TB control efforts.
- TB control efforts are also complicated by the co-existence of tuberculosis and HIV/AIDS. Tuberculosis is the leading cause of death for people with HIV/AIDS worldwide. Because people with HIV/AIDS have weakened immune systems, they have a 20-37 times greater risk of developing active tuberculosis than people without HIV/AIDS . Yet rates of TB testing among HIV patients and provision of ARV therapy to co-infected individuals remains low.
- Current projected shortfalls in funding are jeopardizing the progress that has been made in tuberculosis care and control. Worldwide, the share of domestic funding for TB provided by affected countries rose to 86 percent. But most low-income countries still depend on external funding with The Global Fund to Fight AIDS, Tuberculosis and Malaria -- an international public-private funding institution to which the United States is the largest contributor -- providing 82 percent of international TB support in 2012. Other important sources of funding include President Obama's Global Health Initiative (TB is one of GHI's six focus areas), PEPFAR, and the Gates Foundation [3, 9]. In March 2010, in response to Congressional reporting requirements to develop a coordinated approach to global TB, several U.S. government agencies released a joint TB strategy to accelerate the diagnosis, treatment, and prevention of TB; scale up prevention and treatment of MDR-TB; expand coverage of interventions for TB-HIV co-infections in coordination with PEPFAR programs; and strengthen national health systems. The United States currently provides bilateral TB assistance to 40 countries. Alarmingly, due to the current economic crisis, U.S. funding for PEPFAR may be cut. Furthermore, the Global Fund to Fight AIDS, Tuberculosis and Malaria has announced that due to limited resources this year, it would postpone all new program grants until at least 2014. Overall funding for tuberculosis is expected to total $4.4 billion in 2012, which falls $1.7 billion short of projected needs. At $0.6 billion, funding for MDR tuberculosis faces a resource gap of $200 million. This lack of resources jeopardizes the gains that have made against this disease in recent years .
Addressing each of these challenges will be essential to eliminating tuberculosis in the years ahead. Many of the tools currently used for TB prevention, diagnosis, and treatment are antiquated and have limited success rates. Given the toll that TB takes on the world's population, an effective vaccine, rapid diagnostic tests, shortened, effective treatment regimens, and more research on the illness are required. That's why increased funding is urgently needed to develop 21st-century approaches. In order to ensure that new tools are developed and today's treatments are provided, governments must prioritize tuberculosis as a public health priority and close the projected gaps in domestic and international funding. In areas with a high burden of HIV/AIDS, scaling up joint HIV/TB prevention, diagnosis, and treatment activities will play a critical role in reducing tuberculosis and HIV-related deaths.
Nearly one and a half centuries have passed since Koch's discovery of the causative agent of tuberculosis; significant progress has been made with declining death rates globally but the disease nonetheless remains a leading killer in the developing world and a public health threat in the United States as well. As UN Secretary-General Ban Ki-moon recently underscored, intensified global solidarity is needed. "Countries must implement policies that not only raise awareness about the issue but provide accessible health care to their citizens." For those affected by the disease, stopping tuberculosis cannot wait a lifetime.
Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Public Health Editor of the Huffington Post. She is the Director of the Health and Medicine Program at the Center for the Study of the Presidency and Congress in Washington, D.C., a Clinical Professor at Georgetown and Tufts University Schools of Medicine, Chair of the Global Health Program at the Meridian International Center, and Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research. Dr. Blumenthal served for more than 20 years in senior health leadership positions in the Federal government in the Administrations of four U.S. Presidents, including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, as a White House Advisor on Health, and as Chief of the Behavioral Medicine and Basic Prevention Research Branch at the National Institutes of Health. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the US Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. She is the recipient of the 2009 Health Leader of the Year Award from the Commissioned Officers Association and was named as a Rock Star of Science by the Geoffrey Beene Foundation and GQ magazine.
Yoonhee Ha, M.Sc., is an M.D.-Ph.D. candidate, Paul and Daisy Soros Fellow for New Americans, and P.E.O. Scholar at the University of Pennsylvania Perelman School of Medicine. She was a Marshall and Truman Scholar and completed graduate studies in public health at London School of Hygiene and Tropical Medicine.
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 Reuters: "Funding cuts put 3.4 million TB patients at risk: NGOS."
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