This week sees the launch of the WHO Global Tuberculosis Report 2012. This annual report provides the latest data and analysis about the tuberculosis epidemic and progress made in prevention, care, and control of the disease from 182 member states and a total of 204 countries and territories with over 99% of the disease burden. As well as improvements in measurement and reporting, which include more country and prevalence surveys, for the first time the burden of tuberculosis in women and children and estimates of lives saved by the implementation of collaborative tuberculosis/HIV activities are documented. The report is a sobering read with good and bad news.
The number of tuberculosis cases and deaths continues to fall—at a rate of 2·2% between 2010 and 2011. The tuberculosis mortality rate has decreased 41% since 1990 and, overall, the world is on track to achieve the global target of a 50% reduction by 2015. Since 1995, access to tuberculosis care based on the WHO's directly observed treatment, short course (DOTS) has expanded substantially, and the report highlights the crossing of a milestone, with 51 million people having been cured of tuberculosis and 20 million lives saved in the past 15 years. In response to the coepidemics of tuberculosis and HIV, the report estimates 1·3 million lives have been saved since 2004 when new policies were made to address the dual burden. There has been substantial progress towards new drugs and diagnostics, which are predicted to have an impact in the coming years.
However, the global burden of tuberculosis remains huge with an estimated 8·7 million new cases (of which 13% represent co-infections with HIV) and 1·4 million deaths from tuberculosis in 2011. There were almost 1 million deaths among HIV-negative individuals and 430 000 deaths among people who were HIV positive. Furthermore, in 2011, there were an estimated 500 000 deaths among women, and 500 000 cases and 64 000 deaths among children. African and European regions are not on track to achieve a 50% decline in tuberculosis mortality by 2015, and the report notes that the overall decline in tuberculosis incidence is too slow to expect elimination in this century. In addition, although HIV testing in patients with tuberculosis has increased, prompt initiation and coverage with antiretrovirals among patients with HIV and tuberculosis is yet to meet WHO's recommendations.
The most troubling findings in the report are the alarming levels of multidrug—resistant (MDR) and extensively drug-resistant (XDR) tuberculosis, which are also highlighted by an Article in this week's issue by Tracey Dalton and colleagues. The response to the problem is woefully insufficient. India, China, and Russia are responsible for about 60% of the global burden of MDR tuberculosis and, as the report shows, these countries need to intensify identification and care of patients with MDR tuberculosis, as well as mobilise more of their own resources if the world is going to accelerate progress.
Overall, the approach to tuberculosis control is not returning the kind of impact the world should expect to see. Insufficient attention and funding over several decades have allowed the global epidemic to remain a deep scar on the reputation of global health. And looking ahead, the report warns the situation could worsen and the gains be reversed if the substantial funding gap is not filled. The existing control approach has taken a short-term view with heavy reliance on treatment and cure. But the health systems of many countries have simply been ill-equipped to deal with the complexities of managing tuberculosis, a fact proven by the escalating rates of MDR and XDR disease.
It is clear that new tools and effective, safe, affordable vaccine(s) will be absolutely crucial to control this disease. Ahead of the report's launch, a media advisory in London highlighted the prospects of the current tuberculosis vaccine portfolio. Encouragingly, there are over a dozen diverse candidates in clinical and preclinical development. An effective vaccine would target adolescents and adults, who carry the greatest burden of tuberculosis transmission and disease. There is optimism that there will be at least one vaccine within the next decade.
It is time to re-examine the current tuberculosis control approach. The status quo is unacceptable. To break this gridlock in thinking, we propose that a Global Commission on Tuberculosis Elimination be initiated by the UN Secretary-General, Ban Ki-moon. This Commission should be led by a person independent of the tuberculosis community and it needs to work to a tight timeline. We suggest a final report, with recommendations about a fresh strategic approach, be submitted by September, 2013, in time for discussions about the post-2015 development agenda.
The Lancet
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2961772-3/fulltext?rss=yes