The World Health Assembly
approved the World Health Organization's (WHO) new post-2015 global
tuberculosis strategy and targets for TB In May 2014. The global initiative
aims to achieve the targets for 2035 - 95% decline in TB deaths and 90% decline
in TB incidence rate compared with 2015- less than 10 TB cases per 100, 000
population, and the elimination of catastrophic costs for TB-affected
households. It is a 20 years approach but also includes the expectation to have
by 2025 new revolutionary tools like shorter and better regimens for TB and
So essentially it gives 10
years to research to produce a new vaccine, a new treatment regimen to
facilitate and achieve the targets for 2035. Meanwhile by decreasing poverty
and implementing all that is available today, one can hope to achieve by 2025 a
75% reduction in TB deaths and a 50% reduction in TB incidence compared with
2015 - less than 55 cases per 100,000 population.
In an interview with Citizen
News Service (CNS), Dr Mario C Raviglione, Director of the Global Tuberculosis
Programme at the WHO, said, "There are many new things in this new strategy
which are about thinking out of the box to accelerate the decline in TB
incidence and help to achieve our milestones for 2025 and the targets for 2035
for ending the TB epidemic."
This new strategy is based
upon 3 pillars: (i) 'integrated, patient-centred care and prevention'; (ii)
'bold policies and supportive systems'; and (iii) 'intensified research and
Dr Raviglione said that,
"The emphasis under the first pillar is upon early case detection, community
involvement to ensure treatment completion, and prophylaxis for treatment of
"One out of the box measure
to detect TB early on (so as to minimize transmission of the disease from
infected persons to others) is for the NTPs to map the TB
epidemic—understanding which geographic areas and which groups/communities are
most affected by TB and vulnerable to not only other diseases like HIV,
diabetes but also to smoking and alcohol. This would not only help in early
case detection, but also enable to do corrective therapy in some cases and thus
reduce the pool of people with latent TB infection".
According to Dr Raviglione
TB treatment must be supervised and patient centric so that patients get all
the necessary support to complete the medication through community and civil
society engagement, as well as through educating the people about symptoms.
Communities have to empower themselves to take care of their own health.
He clarified that although
prophylaxis is an old intervention, it is now being proposed on a much wider
scale than before.
"Prophylaxis is a difficult
intervention as it involves people who are not sick. New guidlelines on
prophylaxis not only promote isoniazid for 6/9 months daily but also a new
regimen of isoniazid + rifapentine to be given once a week for 12 weeks. The
latter regimen is much more feasible and user friendly. But the cost of
rifapentine is high and WHO is working on getting the price reduced so that
more countries could adopt it".
The out of box proposal
under the second pillar is to have a much broader commitment from individuals
(like Ministers of Health) and departments other than the National TB Programme
(NTP) Managers for TB control. Without proper and well laid out policies and
systems in place to help them, NTP Managers alone will not be able to change
the TB scenario. Without proper systems in place, just biomedical approaches
are not going to work in TB care and control.
Taking the example of India,
he said that, "The Indian government must ensure that the mandatory
notification system works and all doctors, whether public or private, notify
all TB cases to the NTP. There are other systemic issues also like lack of
proper infection control methods in clinics/hospitals especially in HIV/ART
centres where people wait long hours in unhygenic conditions along with people
coughing, thus exposing PLHIV to TB infection. It is also important to ensure
drug quality and rational use of drugs to avoid creation of resistance".
Dr Raviglione is of the
opinion that it is not just enough to provide free access to TB diagnosis and
treatment. It also needs to be ensured that during the treatment period, the
poor patients have access to some social protection type of mechanism that
gives them the wherewithal to remain on treatment till the end and complete it.
So according to him,
"Another out of box step would be for governments to take social protection
measures that may not necessarily be TB centric, yet complement TB care and
control. It For this there have to be inter linkages between various
departments. WHO would want the Ministers of Health and NTP Managers to enter
into a policy dialogue with Ministries of Finance, Social Welfare,and others to
manage some social protection schemes, like giving incentives, free food
pouches, free transportation to TB clinics etc".
He gave examples of Brazil
and Thailand where such programmes are already in place. Brazil is pushing very
strongly in this direction and has begun to extend such schemes to TB patients.
In Thailand the Minister of Health and NTP Managers together knock at the door
of other Ministries to explore opportunities that get TB inserted into social
protection methods, so that patients can benefit.
"So in the second pillar we
are asking NTP managers to embark on discussions with higher authorities and
other ministries. Social determinants of TB like poverty, bad housing, poor
nutrition can be corrected only when these different Ministries and NTP
managers work together. If we can remove people from poverty, this will benefit
eradication of TB. Even though the focus on diagnosis and treatment remains
very important, but from a political perspective we have to work on other
Third Pillar Emphasizes
Upon Participatory Research
internationally is important. Researchers/institutions from the US or UK will
need the cooperation and collaboration of countries like India to develop
better diagnostics and regimens. Right now we have two new drugs—Bedaquiline
and refapitine and a new diagnostic tool--the GeneXpert. We must help countries
needing them to implement them. So it is an international global call to
national people to find ways and means on how to better implement new
diagnostics and regimens. We are also calling for universal drug susceptibility
tests in all countries which will help in controlling drug resistant TB," he
These out-of-box solutions
assume greater significance in the context of the Global TB Report 2014,
published by the WHO on 22nd October 2014, which shows that, of the estimated 9
million people who developed TB in 2013 (including 1.1 million people living
with HIV), 56% were in the South-East Asia and Western Pacific Regions. India
and China alone accounted for 24% and 11% of the total cases respectively. The
report concedes that even though an estimated 37 million lives were saved
between 2000 and 2013, the death toll from the disease is still unacceptably
high (1.5 million people died from TB in 2013) and an acceleration in current
rates of decline is needed to meet all targets.
Who Global TB Symposium
A Global TB Symposium is
being organized by the WHO at the 45th Union World Conference on Lung Health in
Barcelona to dwell upon out-of-the-box actions needed to take forward the new
TB strategy through country adaptations of quality TB prevention, care and
control for a TB free world. The strategy will fail if it is formulaically
applied in all settings. Defining the right course for adaptation in
2015, and initiating a rapid pace for implementation from early 2016, will be
essential. Business as usual can no longer be enough. Out-of-the-box actions
being taken by some governments, partners and communities demonstrate that the
unusual is possible. All that is needed is the political impetus to succeed.
Ref: Shobha Shukla, Citizen News Service (CNS)