Through the CNS Lens

What does the WHO Global TB Report 2012 mean to us?

Through the CNS lens – Connecting dots…
Through The CNS Lens is a CNS series that attempts to read, analyse and summarise strategic publications on health in our context. It is important to connect the dots - local, national, regional or international health programmes; previous reports and other publications; health strategies; community perspectives; and local or national contexts; are some of those dots. This publication is jointly brought out by CNS with partners: Journalists Against Tuberculosis (JATB), Vote For Health campaign; National Alliance of People’s Movements (NAPM) UP; Asha Parivar; and the Global Stop-TB eForum. October 2012
CNS: This content is shared under the Creative Commons License Attribution 3.0 Unported (CC BY 3.0) license

Team led by Editor Shobha Shukla – CNS: Bharathi Ghanashyam, Bobby Ramakant, Rahul Kumar Dwivedi, Ritesh Arya
(in alphabetical order)

The writers of Citizen News Service (CNS) come from affected communities who have something to say on issues they feel for, or are affected by, in their daily lives, and give a voice to those who are seldom heard. CNS syndicates content generated in English and other vernacular languages to a range of media channels and forums under Creative Commons (CC) attribution license. CNS also provides media and communication related services to health and development agencies globally.

CNS: www.citizen-news.org

Citizen News Service (CNS)
C-2211, C-block n s : T h G l o Nagar, R e p o r t 2 0 1 2 2 | T h r o u g h t h e C N S l e crossing,eIndira b a l T BLucknow-226016. India M: +91-98390-73355 | E: editor@citizen-news.org | W: www.citizen-news.org Printed by: APS, Lucknow, Tel. +91-(0)-522-4003022

DRUG-SUSCEPTIBLE TB PROGRAMME ON TRACK - MIGHT MEET 2015 TARGETS
In 2011, there were an estimated 87 lakh (8.7 million) new cases of TB (as compared to 88 lakhs/ 8.8 million in 2010), but only 58 lakh (5.8 million) of them were notified to national TB programmes globally and received treatment consistent with international guidelines. According to a communique of the Stop TB Partnership, this is just 66% of the estimated total number of TB cases, implying that 34% or 30 lakh people (3 million) worldwide either received no diagnosis and treatment or got potentially substandard treatment. Sadly, this figure has not changed over the past three years. With 22 lakh (2.2 million) reported cases of TB in 2011, India continued to hold the dubious distinction of carrying the highest burden of the disease worldwide (26%) followed closely by China (12%). For the first time in its history, the Global TB Report 2012 (17th in the line) has reported some data on TB in children (<15 years). Although data on childhood TB is far from complete, it indicates that globally 5 lakhs (0.5 million) children were ill with TB, out of which 64,000 lost their lives to it. And yet, no one needs to die of TB - a curable disease. There were 14 lakh (1.4million) deaths due to TB in 2011 which was only slightly less by 50,000 than those in 2010. However, the good news is that between 1995 and 2011, 5.1 crore (51 million) people were successfully treated for TB in countries that had adopted the WHO strategy, saving 2 crore (20 million) lives. The TB mortality rate has indeed decreased by 41% since 1990 and the TB control programme globally can hope to achieve the Global Plan to Stop TB target of a 50% reduction in TB deaths by 2015.

34% or 30 lakh people (3 million) worldwide either received no diagnosis and treatment or got potentially substandard treatment. Sadly, this figure has not changed over the past three years -

Stop TB Partnership

OPTIMISM DOES NOT APPLY TO DRUG-RESISTANT FORMS OF TB
This optimism however does not apply to drug resistant forms of TB and progress in responding to multidrug-resistant TB (MDR-TB) remained slow. The Global Plan to Stop TB (2011-2015) envisages universal access to MDR-TB diagnosis, treatment and care, and a treatment success rate of 75%, or higher, among confirmed cases of MDRTB. Sadly MDR-TB related diagnosis, treatment and care services reach a very small percentage of people who are in need of them, making it clear that a lot more needs
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to be done to achieve universal access targets set by the Global Plan. Although 30 out of 107 countries reported 75% or higher treatment success rate for confirmed cases of MDR-TB, 77 countries presumably had alarmingly low treatment success rate below 75%. It is also not clear whether any of the 27 high burden MDR-TB countries reported this high treatment success rate.

Globally, only 60,000 cases of MDR-TB were notified to WHO in 2011, (mostly by European countries and South Africa) which is less than 14% of 440,000--the total number of estimated MDR-TB patients every year. The proportion of TB patients doubted to have MDR-TB (and not the total number of estimated MDR-TB patients) that were actually diagnosed in India was a mere 6% in 2011. Less than 4% of the estimated number of patients who need MDR-TB care, actually received it in 2011 in India. Thus an estimated 96% MDR-TB patients were left to fend on their own, leading to a very dangerous and alarming public health situation in India. According to the Global Plan to Stop TB (2011-2015), all 27 high burden MDR-TB countries should establish a national online database of treatment of MDR-TB patients by 2015. Although 20 countries (out of 27) have established their online national MDR-TB database but India, with the second highest MDR-TB burden in the world, is yet to do so. The Global Plan envisages universal access to MDR-TB diagnostics and treatment services by 2015. However, coverage of Drug Susceptible Testing (DST) in new cases is way below the target of complete ‘universal access’ to such services. Globally, less than 4% of new bacteriologically-positive cases and 6% of previously treated cases were tested for MDR-TB in 2011. With only 37 culture and DST laboratories, India has only one lab per 50 million population as against the WHO target of 1 DST and culture lab per 5 million population. According to the Revised National TB Control Programme (RNTCP) Report 2011, India has an estimated annual incidence of 99,000 MDR-TB cases, which is second only to China that has 100,000 new MDR-TB cases every year. According to the Global TB Report 2012, there were 4237 confirmed cases of MDR-TB in India in the year 2011, out of which only 3384 were started on MDR-TB treatment. It is also not clear whether this figure indicates the number of patients started on treatment in 2011 or the total number currently under treatment. However the RNTCP Annual Report of 2011 says that since the inception of DOTS Plus services in India in 2007, a total of 19,178
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Less than 4% of the estimated number of patients who need MDR-TB care, actually received it in 2011 in India. Thus an estimated 96% MDR-TB patients were left to fend on their own, leading to a very dangerous and alarming public health situation in India

MDR-TB ‘suspects’ have been examined for diagnosis; 5365 MDR-TB cases have been confirmed and 3610 MDR-TB cases have been initiated on treatment.

Clearly India has to scale up its MDR-TB programme radically Clearly India has to scale up its MDR-TB to achieve the programme radically to achieve the targets and reach out to those 97,000 people who need MDR- targets and reach out TB care services every year but are deprived of it to those 97,000 in the public health sector. people who need By the end of 2012, all the states in India are MDR-TB care services expected to provide programmatic management every year but are of drug-resistant TB. deprived of it in the TB – a notifiable disease and ban on public health sector
TB serological tests in India
In May 2012, India made TB a notifiable disease and data collection on TB using a web based system was initiated. In June 2012, India had banned use of TB serological tests country-wide. Although reports from the investigative journalism done in Bangalore and Lucknow both indicate that TB serological tests continue to be done in private laboratories, and the ban needs much stricter enforcement.

XDR-TB
XDR-TB: Extensively drug-resistant TB (XDR-TB) has been reported by 84 countries globally (including India) and the proportion of MDR-TB cases with XDR-TB is 9.0%.

TB-HIV COLLABORATIVE ACTIVITIES
TB-HIV COLLABORATIVE ACTIVITIES: 11 lakh (1.1 million) of the estimated 87 lakh (8.7 million) TB patients were also co-infected with HIV in 2011. However, only 48% of the TB patients known to be living with HIV in 2011 were started on antiretroviral therapy (ART) which is way below WHO’s recommendation of promptly starting all (100%) TB patients living with HIV on ART irrespective of their CD4 count. 79% of the TB patients, known to be HIV-positive, were provided with cotrimoxozole preventive therapy (CPT). Of those without active TB disease, 4.5 lakhs (0.45 million) were provided with Isoniazid Preventive Therapy (IPT). India does not provide IPT through RNTCP. In India, which is one of the five high TB/HIV burden countries, the estimated number of TB patients with known HIV status was 689,000 (45%)—up from 481,000 (32%) in 2010. But only 45% of the notified TB patients were tested for HIV and about 45000
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(6.5%) of the tested TB patients had HIV. Only 59% of these identified HIV positive TB patients could be started on ART—an increase of 2% from 2010. 91% of the identified HIV+ and TB patients were started on CPT. The ratio of TB to ART facilities in India is 30:1 as compared to 1.3:1 in South Africa.

NEW DRUGS
NEW DRUGS: Of the 11 new and/or repurposed anti-TB drugs in clinical studies, one compound has recently moved to a Phase-III large scale efficacy study and another is expected to do so before the end of 2012. A novel three-drug combination regimen that could be used to treat both drug-sensitive TB and MDR-TB and shorten treatment duration has been tested in a Phase-II study of early bactericidal activity, with encouraging results.

VACCINES

VACCINES: There are 12 vaccine candidates in clinical studies - 11 in Phase-I or Phase-II and one in Phase III study. There is a possibility of licensing at least one new vaccine by 2020.

In India the estimated number of TB patients with known HIV status was 689,000 (45%)—up from 481,000 (32%) in 2010. But only 45% of the notified TB patients were tested for HIV and about 45000 (6.5%) of the tested TB patients had HIV. Only 59% of these identified HIV positive TB patients could be started on ART—an increase of 2% from 2010.

FUNDING GAP
FUNDING GAP: There is a funding gap of USD 3 billion per year for TB care and control for 2013-2015 compared to the requirement of USD 8 billion per year in low- and middle-income countries. There are also critical funding gaps for research and development (R&D). USD 2 billion per year is needed; the funding gap was USD 1.4 billion in 2010 with only USD 600 million going into TB R&D. Funding for TB research and development at USD 630 million in 2010, fell short by USD 1.4 billion of the annual target of USD 2 billion specified in the Global Plan to Stop TB (2011–2015). The total TB control budget in India in 2011 was USD 139 million, out of which 44% was funded domestically and 49% came from the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund).
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 Most commonly used TB diagnostic tool, sputum microscopy, is more than 100 years old. It detects only half of the cases of TB in patients tested, and is particularly ineffective for diagnosing TB in people with HIV.  First-line TB drugs are more than 40 years old and must be taken for 6-9 months. Rifampin, a cornerstone of current TB treatment, cannot be used concurrently with certain commonly-used antiretrovirals (ARVs).  TB vaccine (BCG), which is more than 85 years old, provides some protection against severe forms of TB in children but is unreliable against pulmonary TB, which accounts for most of the worldwide disease burden. The BCG vaccine is not recommended for infants known to be infected with HIV, due to increased risk of serious BCG-related complications. (Source: FIND)

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Media Dialogue
Media Dialogue is regularly hosted by Vote For Health campaign coordinated by CNS with partners. On 22nd October 2012, Media Dialogue was hosted in Lucknow, India, bringing together about 14 journalists from leading English and Hindi media channels, and some connected through Webinar. Bharathi Ghanashyam, senior journalist who leads Journalists Against Tuberculosis (JATB), was one of the discussants along with Shobha Shukla, Managing Editor, CNS. This media dialogue focussed on the latest World Health Organization (WHO)’s Global Tuberculosis (TB) Report 2012 which was read and summarised in the context of the Global Plan to Stop TB (2011-2015), Revised National TB Control Programme (RNTCP) of India, and Global TB Reports of previous years. We are sharing some of the news stories published in the leading newspapers in English and Hindi languages after this media dialogue. It was jointly organized by: Citizen News Service (CNS), Journalists Against TB (JATB), Vote For Health (V4H) campaign, Health Writers, Asha Parivar, National Alliance of People’s Movements (NAPM) and Global Stop-TB eForum.

For more information please contact: Rahul Dwivedi – CNS
E: rahul@citizen-news.org | M: +91-983-999-0966 | F: +91-(0)-522-2358230

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GLOBAL TARGETS WHERE WE ARE WHERE WE SHOULD BE
Achievement Number of people whose TB was detected and treated Percent of previously treated TB patients tested for MDR-TB Number of people treated for MDR-TB following WHO guidelines Percent of HIV-positive TB patients receiving antiretroviral therapy Percent of TB patients tested for HIV 2011 5.8 million 6% 60 000 48% 40% 2011 goal 6.1 million 40% 130 000 82% 100% 2015 goal 6.9 million 100% 270 000 100% 100%

Data derives from the 2012 World Health Organization Global Tuberculosis Report, www.who.int/tb www.who.int/tb

NOTE: This table (and image below) is part of the snapshot of the global TB pandemic and gaps in funding which was published by the Stop TB Partnership and WHO. It is available online at:
http://www.stoptb.org/assets/documents/news/TB_CurableA4folded.pdf

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We can
eradicate

TB
HAVE YOUR SAY!
To join the online dialogue on tuberculosis, send an email to: Stop-TB-subscribe@yahoogroups.com

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