By Dr. Mario Raviglione, Director, WHO Global TB Programme and Dr. Ariel Pablos-Méndez, Assistant Administrator for Global Health, U.S. Agency for International Development
This week, the World Health Organization released its 2014 Global TB Report. The report highlights the world-wide response to the epidemic of tuberculosis and multidrug-resistant tuberculosis (MDR-TB), commemorating 20 years of work on the world's first antimicrobial resistance surveillance project. These findings offer an opportunity for both of us to reflect where we personally first saw the impact of MDR-TB and how disease surveillance is necessary to drive public health action.
In the late 1980s, when we were both residents at the Cabrini Medical Center of New York City, one of the infectious disease doctors at the hospital proposed treating a homeless TB patient with four drugs instead of the standard two to three drugs. The homeless were considered at risk for TB due to their limited access to health services and congregate housing in shelters. They were also susceptible to drug-resistant TB as they would often stop treatment once they felt better and would return seeking help when they felt sick again, thus making them vulnerable to developing drug-resistant forms of TB. As testing for drug-resistance took weeks to even months at the time, treating with more drugs than usual was the recommendation.
We decided to study whether drug-resistant TB was more common among the homeless than other patients and a review of past records at our hospital confirmed that homeless individuals were extraordinarily affected by drug-resistant forms of TB. At the time, almost no data were available on the prevalence of drug-resistant TB in New York. We submitted our findings to a leading medical journal calling attention to the emergency. Unfortunately, our submission was rejected (there was no blogging back then!) but we were able to publish in another journal two years after we detected the problem.
The outbreak of MDR-TB among HIV-positive patients in New York City only became major news in 1991 when the media picked up on a report by the Centers for Disease Control and Prevention calling attention to the epidemic. Coincidentally, Ariel Pablos-Méndez, then a Fellow at Columbia University, was involved in this city-wide study, which also included our hospital findings from the late 1980's. As a result, the budget for the New York City Bureau of Tuberculosis control was increased tenfold the following year. Laboratory capacity and infection control were strengthened, and a massive service-based and outreach treatment program was implemented to reach the poor and marginalized falling ill from TB. This all carried a large price tag - over $400 million was spent to halt the spread of TB in New York.
At the same time in the early 1990s, new global data were emerging on the growing burden and very real threat of tuberculosis. The attention raised by the outbreak of MDR-TB in New York and in some European countries served as a trigger for WHO to declare TB a global health emergency in 1993. In the mid 1990's Mario Raviglione coordinated the establishment of a new WHO global TB surveillance and monitoring system, with a drug-resistance surveillance component. Together again, we led the publication of WHO's first global report on drug-resistant TB in 1997. The report covered 35 countries, revealed high levels of drug-resistant TB in the new republics of the former Soviet Union, and catalysed additional support for global TB control. In 2000, Dr. Pablos-Méndez, then with The Rockefeller Foundation, led the establishment of the Global Alliance for TB Drug Development, which served as a model public-private partnership to help overcome MDR-TB with new drugs and shorter treatment.
Today, WHO receives TB data from every country in the world, including unprecedented trend data on MDR-TB. Thanks to these data, we can now better assess disease burden and response. The good news is that the average percentage of MDR-TB among new cases globally remains low at 3.5 percent. The bad news is that in a subset of countries, over a third of new TB cases have multidrug-resistant disease. These countries urgently need to bolster their defences and prevent the emergence of further drug resistance by ensuring comprehensive care of susceptible cases and instituting infection control measures to stop transmission of MDR-TB. Our agencies are working closely with countries, as well as many other domestic and international partners, to further expand MDR-TB surveillance and response capacity, to reinforce public health systems so they may provide quality care, and to pursue needed research so that together we can target zero deaths and end the global epidemics of both drug-sensitive and drug-resistant TB.There has been real progress. 37 million lives have been saved through TB treatment since 2000. The TB death rate has dropped nearly 45 percent compared to 1990 and new tests that rapidly detect drug-resistant disease are being rolled-out in over 100 countries. However, a $2 billion funding gap for testing and treatment, and the nearly $1.5 billion gap for research, keep progress dismally slow.
WHO's 2014 Global TB Report estimates the worldwide burden of TB at 9 million new cases, with 1.5 million needless deaths, including 360,000 deaths among HIV-positive people.
These deaths can and must be prevented. There is no excuse for patients to not have access to low-cost diagnostic tests, to be on waiting lists for treatment once diagnosed, or to drop out of treatment because of economic hardship or the suffering caused by debilitating side-effects.We need to increase financial commitment by both the public and the private sectors and strengthen the provision of high-quality TB care by all providers to accelerate TB control today. Fresh evidence and creative leadership are needed to face challenges in the fight against TB and MDR-TB.
Without a sense of urgency, disease epidemics like MDR-TB will continue to claim lives and become less containable. Time is running out for resource-poor, low-income countries already crippled by the burden of fighting deadly epidemics. We must help them now.