WHO's Stop TB Department has published new recommendations related to the use of TB Interferon-Gamma Release Assays (IGRAs) as a replacement of the tuberculin skin test (TST) to detect latent TB in low- and middle-income countries (the recommendations are not intended for high-income countries or to supersede existing national guidelines in these countries).
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Steve Lawn, from the University of Cape Town in South Africa, began his talk on diagnostics for HIV associated tuberculosis (TB) by reminding the audience of the enormous burden of TB in his country where one percent of the population develops TB disease each year. He gave his presentation to an audience at the 49th Annual Meeting of the Infectious Diseases Society of America in Boston Friday. In one city of 3.5 million people in South Africa, 30,000 TB cases were reported in 2009 alone and half of those individuals also had HIV infection. He also pointed out that tuberculosis is the only one of the three major infectious diseases that does not have a low-cost point of care diagnostic test.
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WHO's sixteenth annual report on global tuberculosis control, released on Oct 11, presents detailed and encouraging statistics, carefully interwoven with words of caution about the perils of failing to maintain disease-specific funding. Taking a global view, the numbers are undoubtedly sobering, with 8·8 million new cases of tuberculosis estimated in 2010, and about 1·45 million deaths from tuberculosis across populations with and without HIV. In 2009, 9·7 million children are thought to have been orphaned by parental deaths caused by tuberculosis (whether or not accompanied by HIV). The good news is that incidence of tuberculosis seems to have been falling worldwide since 2002.
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Five renowned AIDS and TB activists and public health experts have written an editorial in *The Lancet* welcoming the leadership of Lucica Ditiu of Stop TB. They also call for more vocal leadership from all organisations working to end the TB epidemic. They also say that we need an aspirational goal to galvanise the struggle against TB: TB is treatable and therefore we should aim to have no deaths from the disease.
Time for zero deaths from tuberculosis
Source: [The Lancet, Volume 378, Issue 9801, Pages 1449 - 1450, 22 October 2011](http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61521-3)
Salmaan Keshavjee (a), Mark Harrington (b), Gregg Gonsalves (a), Lucy Chesire (c), Paul E Farmer (a)
When Robert Koch presented his discovery of the tuberculosis bacillus in March, 1882, he hoped it would lead to the eradication of “this terrible plague of mankind”. More than a century later, tuberculosis remains a leading killer of adults: of about 9.4 million people newly infected with tuberculosis each year, 3.5 million are undiagnosed and continue to transmit the disease and more than 1.7 million die. Tuberculosis is the main killer of people with HIV infection; drug-resistant strains continue to spread; and paediatric tuberculosis remains an area of neglect. [2, 3]
In the past decade, the number of new cases of tuberculosis worldwide has barely declined, and the number of deaths remains catastrophic: more than 4,500 per day for this largely treatable disease. As aLancet editorial pointed out, “A status quo in tuberculosis control is unacceptable.”
This status quo is not inevitable. A logical place to look for fresh leadership and vision is the Stop TB Partnership. Created in 2001 as a network of international organisations, countries, technical agencies, and donors, the Partnership was tasked with ensuring that every patient with tuberculosis has access to effective diagnosis and treatment. In its first decade, however, the Stop TB Partnership—housed at WHO headquarters in Geneva—seems to have operated essentially as a subsidiary of WHO's Tuberculosis Department with the majority of funds going to WHO's Tuberculosis Department, rather than external partners. [5, 6]
But this situation may yet change. The newly appointed Executive Secretary of the Partnership, Lucica Ditiu, has initiated steps to address potential financial and administrative conflicts of interest in the Stop TB Partnership's relation with WHO. More importantly, Ditiu has called for a bold new vision in the struggle against tuberculosis. She and her team have started a campaign to prevent a million deaths among patients co-infected with HIV and tuberculosis. 
She should be congratulated for these steps and supported in her efforts by her Board, the WHO Director-General, governments of countries with a high-burden of tuberculosis, and the tuberculosis community. Transforming the Partnership into an effective, independent, and transparent body capable of acting as a locus for innovative thinking is a crucial step in recasting the global struggle against tuberculosis.
Changing the tenor of advocacy around tuberculosis is another important step. Without the networks of grassroots health activists and civil society institutions that define the HIV/AIDS movement, the global tuberculosis community has been unable to successfully scale-up patient-centred approaches to care, or hold governments and key international bodies (including funders) to account with regard to their commitments to tackle this disease. The health-activist community must take urgent steps to remedy this. Investment in tuberculosis-specific efforts of existing HIV/AIDS and civil society organisations—building on such efforts in Brazil, Kenya, India, South Africa, Uganda, and Zambia—or groups working on related social issues would be a start.
Much would be achieved if leaders of global health initiatives—the Global Fund to Fight AIDS, Tuberculosis and Malaria, the US President's Emergency Plan For AIDS Relief, the US Global Health Initiative, and UNICEF—became more vocal in their demand for better tuberculosis outcomes and innovative approaches to stemming the disease. These organisations have the capacity to bring key stakeholders to the table: the diagnostic and pharmaceutical industries; partners addressing social antecedents to tuberculosis (for example poverty, discrimination, and detention); those who provide treatment of tuberculosis comorbidities (HIV and diabetes); and, in many settings, private providers of tuberculosis diagnosis and care.
Most vitally, an aspirational goal must define the struggle ahead.  Effective treatment for tuberculosis has been available since the 1940s, and there is little reason for large numbers of people to be dying from this disease. 
New diagnostics and treatment approaches are needed—especially for children, patients co-infected with HIV, those with extra-pulmonary disease, and patients with multidrug-resistant and extensively drug-resistant tuberculosis. But even today, when appropriate and tailored programmes have been put in place, a clear movement towards zero deaths has been observed in places as daunting as the prisons of Tomsk, Russia—where previously as many as a quarter of all patients had died.  Therefore, as UNAIDS and UNICEF embark on their own campaigns for zero deaths, [11, 12] it is critical that the tuberculosis community as a whole aspires to the same demonstrably achievable goal, and works in solidarity to accomplish it.
*SK has chaired and participated in the Green Light committee at the Stop TB Partnership and WHO, is a member of the MDR-TB working group at the Stop TB Partnership, and has received research funding from the Eli Lilly Foundation. MH is director of Treatment Action Group, has been a member of WHO's Strategic Advisory Group for Tuberculosis, and has been involved in working groups with the Stop TB Partnership. LC is director of the TB ACTION group in Kenya, has participated in working groups at the Stop TB Partnership, is a member of WHO's Strategic Advisory Group for Tuberculosis, and an alternate member of the communities delegation to the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria. GG and PF declare that they have no conflicts of interest.*
1 Koch R. Die aetiologie der tuberculose, a translation by Berna Pinner and Max Pinner with an introduction by Allen K Krause. Am Rev Tuberc 1932; 25: 285-323.
2 Lönnroth K, Castro KG, Chakayah JM, et al. Tuberculosis control and elimination 2010—50: cure, care, and social development.Lancet 2010; 375: 1814-1829.
3 Keshavjee S, Farmer PE. Picking up the pace—scale-up of MDR tuberculosis treatment programs. N Engl J Med 2010; 369: 1781-1784.
4 The Lancet. A new era for global tuberculosis control?. Lancet 2011; 378: 2.
5 Treatment Action Group (TAG). Steps being taken by the Coordinating Board to reduce conflict of interest and improve transparency in the Stop TB Partnership. http://www.treatmentactiongroup.org/base.aspx?id=4462. (accessed Sept 10, 2011).
6 Stop TB Partnership Secretariat Financial Management Report Summary Statement of Income and Expenditure for the year ending 31 December 2010. Expenditures. March, 2011. Washington DC, p 6.http://www.stoptb.org/assets/documents/about/cb/meetings/20/1.11-07%20The%20Stop%20TB%20Partnership%20Financial%20Report%202010/1.11%20-%207.2%20Financial%20Report.pdf. (accessed Sept 29, 2011).
7 Stop TB Partnership/World Health Organization. Time to act: save a million lives by 2015. Prevent and treat tuberculosis among people living with HIV. Geneva: World Health Organization, 2011.http://www.stoptb.org/assets/documents/resources/publications/acsm/TB_HIV_Brochure_Singles.pdf. (accessed Sept 26, 2011).
8 Castro KG, LoBue P. Bridging implementation, knowledge, and ambition gaps to eliminate tuberculosis in the United States and globally. Emerg Infect Dis 2011; 17: 337-342.
9 Dye C, Williams BG. Eliminating human tuberculosis in the twenty-first century. J R Soc Interface 2008; 5: 653-662.
10 Keshavjee S, Gelmanova I, Pasechnikov A, et al. Treating multi-drug resistant tuberculosis in Tomsk, Russia: developing programs that address the linkage between poverty and disease. Ann N Y Acad Sci 2008; 1136: 1-11.
11 UNICEF. Believe in zero—achieving zero. http://www.unicef.ie/Content.aspx?PageDetailId=84&AspxAutoDetectCookieSupport=1. (accessed Sept 26, 2011).
12 UNAIDS. UNAIDS: 2011—2015 Strategy. Getting to zero. Geneva: UNAIDS, 2010.http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2010/JC2034_UNAIDS_Strategy_en.pdf.(accessed Sept 26, 2011).
a Program in Infectious Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA
b Treatment Action Group, New York, NY, USA
c TB ACTION Group, Nairobi, Kenya
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