Getting to zero – elements of a TB elimination campaign for leaders to endorse and implement

1. The Stop TB Partnership vision of a world with 50% less deaths from TB than in 1990 is totally inadequate. Time for a reset.

2. The MDGs didn't even mention TB, which got assumed to be among the "other infectious diseases" along with HIV and malaria, which MDG 6 specifically vowed to "turn back", meaning that there would be at least one less case or death in 2015 than there was in 2000. Again, inadequate, reset.

3. 95% of the world's 8 million new cases of TB can be cured. 70% of the 800,000 cases of MDR-TB can be cured. 30% of the world's cases of XDR-TB can be cured (about 30% of 400,000). This is 0.95x8M, 0.7x800K, 0.3x400K.

4. Thus, with universal access to high quality testing and treatment, 8,172,000 (8.2 million) people could be cured, while 168,000 would not be cured.

5. Better programs can cure more people, and new drugs will be able to cure the rest with better programs.

6. So we should be pursuing zero new infections, zero deaths, zero stigma and discrimination from TB and from TB/HIV.

7. TB kills 350-450,000 people with HIV each year. It is the leading cause of HIV related mortality. But only half of TB patients are tested for HIV; only half of HIV patients are tested for TB (or less). HIV+ TB patients do not get life-saving AR or cotrimoxazole, and most HIV+ patients without TB do not get life-saving isoniazid preventive therapy (IPT) to prevent TB.

8. Not all HIV drugs can be taken with TB drugs, and versa. New drugs can help to alleviate this.

9. People with TB need rapid TB tests which can detect TB and drug resistance. These are not yet widely available. They are expensive and require electricity.

10. People with HIV need TB tests which can detect TB even if it is smear negative or extra-pulmonary. The best test for this costs $17,000 a machine, $17 a cartridge, and only detects two types of resistance (to isoniazid and rifampin).

11. People with HIV need TB treatment literacy. People with TB need HIV treatment literacy. And each needs literacy in their own diseases.

12. Current TB control is a 19th century public health mindset which seeks to control TB (among the poor, disenfranchised, in the south, prisons, migrants, etc.) without either causing the working population or the ruling classes to get sick, or eliminating the disease, though it has been going down for over 100 years in most parts of Europe and America where development has occurred and whenever TB resurges, resources are pumped in.

13. New drugs offer the hope of quicker, all oral cures for both drug-sensitive and drug-resistant disease, in HIV+ and HIV-, adult and pediatric populations.

14. TB is run by middle management in public health bureaucracies. They are unwilling to ask for more. GFATM – the biggest multilateral TB donor – only donates 10% of its resources to TB – because countries don't ask for enough.

15. As a result, TB is out of control.

16. We need high level political commitment to eliminate T. Not Margaret Chan, Ban-Ki Moon. Not Tom Frieden, Barack Obama. Not Stefan Kaufmann, Angela Merkel. Not Aaron Motsoaledi, Jacob Zuma [fill in your leaders here].

The G20 leaders need to commit to starting on the road to TB elimination in the current decade – NOW.

Jeremiah Chakaya (Kenya; Chair of STAG-TB)

--In agreement. Today we in Nairobi Kenya, we have one "unfortunate" woman with XDRTB who is not being treated because my country hasn't prepared itself to deal with this type of TB.

--The needs are real, big and urgent and yes it is time to rethink our strategies and actions.

Gavin Churchyard (Aurum Institute, South Africa)

--TB vaccines, which will be required in the long term if we wish to achieve elimination

--Extending TB control activities beyond health facilities to include community based health programmes (ICF, HIV testing, DOTS, infection control, decentralised MDR TB treatment )

Lucica Ditiu (Stop TB Partnership)

--You could speak for many of us and for sure for me. I know that we all feel the same or, at least, along the same line.

--In one of his speeches at Davos, the UN Secretary General called TB "the orphan diseases" of the 3 and expressed the fact that stronger actions should be done by TB community to raise the TB profile.

--I want to focus a bit our attention on the fact that our TB asks are so small – the applications to the Global Fund, to different donors – for example – are very shy in comparison with HIV and malaria.

--In an effort to support countries on the phase 2 renewals we started looking together with the fund portfolio managers at every single country in their portfolios. And then we looked beyond that on the countries plans. It is shocking – in most of the cases - like 90% – the lack of vision and boldness.

--For example, the plans for enrollment and treatment of MDR TB cases – the national ones – are, in most of the cases limited to a fraction of the total number of estimated cases between now and end of 2015. It is like there is a fear to speak about every single patient having the right to a proper diagnosis and treatment and care.

--What it is included , and therefore budgeted for and therefore reflected into different applications - are much fewer people than the expected numbers. Why in TB we do not press more? Why the NTPs and MoHs are not daring more and asking more?

--We had a fantastic and inspirational talk by the MoH of South Africa in Bangkok. He has a great vision and a great boldness towards great targets. He had the strength, vision and called for ZERO TB/HIV DEATHS. And he moves towards this. High speed.

--So, what we actually need are several inspirational leaders like him out there. That are just going on and do it, without waiting and hesitating too much. Just go ahead, be bold and do it!

--But we need the concerted effort at the country level, people being able to create and push the buzz till it becomes impossible and shameful for the more reluctant MoH or of Finance from a country X to plan enrollment and treatment of 100 patients on MDR TB when the estimate is to have 14,000 MDR TB cases.....

--There is nothing holding us from doing it. Is just that we need to do it and move towards it.

--It is us collectively deciding and just doing it.

--We want to have bolder targets and bolder asks – let us do it!

--We want to get money into TB at country level - let us make the pressure there, in the country - with the right people towards the decision makers - till it becomes impossible to avoid TB or to think small in TB.

--We will not be able to succeed in all countries form the beginning – this is why we need to set our priorities right. But, again, is in our hands – us, all of us copied in this e-mail – to change things.

--It can be done. I am personally committed to do so.

Anthony D. Harries (IUTALD, formerly NPT/NAP Malawi)

--A great start Mark and I welcome and fully support.

--I endorse Lucica’s call for boldness. --We should try and be a little more precise.

--We need to reduce those HIV-TB deaths drastically down from 350,000 to zero. it is an aspirational goal, but we should be able to prevent the majority of these deaths

--We have to go after undiagnosed TB in people living with HIV

   a. We need to still aim for a better cheaper easier to use point of care test (Xpert is a wonderful start but it is just a start and probably in current form it will not cover the plight of many poor people);

   b. We need to bring diagnostic and treatment services more to the community (the research studies are great but we have to make this real and routine);

   c. We must look into empirical TB treatment for those most at risk in whom the diagnosis of TB is so difficult; and

   d. We must ensure that we treat as quickly as possible all those whom we diagnose with TB (this does not happen at the moment).

--We have to ensure that TB patients are HIV tested and that all those who are positive are linked to ART. As Mark tells us, we are still doing far too poorly in this area. Co-location of services is key for me – in HIV-TB burden areas where we have TB services we must have HIV care and treatment services and vice versa. At present this does not happen. It needs money, human resources and will – we must advocate for these.

Blessi Kumar (TB/HIV Activist, India)

--Mark what a Vision!! I love your bit on the high level political commitment.

--How do we realize this Vision?? We need now some action. NOW! and FAST! So how do we take this forward?

--Are we thinking of building activists in the different regions? What does that mean, CB? what kind of investment in terms of time and resources. Regional networks of community representatives?? working with existing HIV networks to multiply and intensify our voices??

--Where do we start?

--We also need to change the way we are talking about TB 40/ 50 is so boring and does not reflect concern or commitment.

--I agree with Mark that it has to be ZERO and we as activists need to push it or it will not happen.

Sharonann Lynch (MSF)

--Develop a strategic framework for harmonizing TB strategies and deepening impact to more rapidly bend the epidemic curve. The UNAIDS SIF was smart in its approach to concentrated versus general epidemics.

--Maybe TB can benefit from similar specificity focused on 3 main fronts/priorities:

  – boosting TB detection and treatment in Africa (catch up) and in TB/HIV (globally)

  – scaling up DRTB detection and treatment worldwide (scale-up)

  – maintaining positive gains made elsewhere (I know it doesn't sound make for a great slogan)

--The 3 fronts would benefit or require rapid diagnosis and DST screening, which makes for a nice “wedge” issue, as a “missing technology” always does.

Neil Schluger (Chief of Pulmonology, Columbia University / World Lung Foundation)

--This is great, and I strongly support it.

--Points #12 and 14 are especially important in the overall context of things.

--Based on recent visits to Vietnam, Kazakhstan and Ethiopia that the state of TB control in places like that may be far worse than anyone really knows or admits.

--In particular the problem of MDR may be much more of a disaster than anyone wants to acknowledge. TB needs lots more money and attention, and that the TB community itself must be much more forward thinking in its embrace of new technologies and approaches that are already available.

--Please add my name to those who support your efforts, and let me know if I can help in any way.

Robin Wood (Desmond Tutu Centre, South Africa)

--The WHO model of the impact of DOTS has assumptions which are totally out of line with those of the SA and Southern African Region. The WHO model was produced and validated against post 1950 European data and is applicable to scenarios where TB incidence is low and decreasing. Under the conditions of the WHO model any decrease in TB prevalence is accompanied by decreased transmission.

--My recent paper on TB transmission in Pollsmoor prison(SAMJ) illustrates that DOTS alone has no effect on transmission where crowding and environmental conditions are poor. Similarly TB transmission from parents to children in township conditions is not significantly impacted by the existing TB control program (CID). SA has achieved the DOTS targets set out by the WHO but transmission has not been interrupted among HIV-negatives (PLoS One). The HIV/TB epidemic is a manifestation of failure to control TB transmission in the HIV-negative population. Several SA groups have recently described TB transmission rates to children similar to pre-chemotherapy era. We have also shown that TB transmission rates increase further in adolescence to levels prevalent at the end of 19th Century in Europe and America.

--My feeling is that we need to set up a South African initiative based on sound knowledge of the SA epidemic and to learn from the lessons of history.

--Here are some based on local epidemiological data.

--The highest burden in SA is in Prisons and I have outlined what is required for control. 1, Open access to prison TB data. 2. Decrease overcrowding as per SA national regulations., 3 ventilation, 4 active case finding (cough register) as well as 5. introduction of reasonable DOTS program 6. screening of suspects with rapid TB tests such as GeneXpert. --Highest infection and TB disease rates are in adolescents. 1. Monitoring of school environments, 2. education and 3. active case finding. (School nurses as per 1950's Europe?)

--Highest transmission risk in public transport. 1. Monitor and 2. legislate for air quality in crowded public transport.

--Very high TB transmission to infants. 1. screen and educate mothers (GeneXpert) and immediate family members. 2. education on separation of child and adult sleeping quarters. (health visitors as per 1950's Europe?).

--Simple monitoring of congregate settings with hand held CO2 monitors to quantify TB transmission risk.