World TB day on March 24 will highlight the aim of the World Health Organisation to eliminate the disease by 2050. Yvonne Parley and Michael Luhan of the Stop TB Partnership talked to Lars Inge Staveland about how case detection is a major problem in tackling the disease. AN: What are the objectives of World TB Day?YP: Stop TB is a partnership of just over 200 private and public NGOs. The objective of this year’s campaign is to increase case detection. Tuberculosis a curable disease and the challenge is not so much to find a cure. The challenge is more for people to have access to the cure. That means that we have got to get to people who have got TB and detect their TB so that we can treat it with DOTS (Directly Observed Treatment Short Course). So the whole focus and objective of the campaign this year is to increase case detection, which is the challenge that we want to highlight and that we want effort put into addressing. In the latter part of the year we will concentrate more on TB and ways in which TB patients can overcome the stigma associated with TB. AN: What does DOTS treatment involve?ML: The main thing in DOTS is that for the first two months of treatment, someone observes TB patients taking their medicines each and every day until they become non-infectious. After that the frequency of their medication goes down. The key is to make sure people take their medicines and meet their course of treatment and to get that reported. Right now, the next global monitoring report to be issued by the WHO on TB will report that, as from now, about 30 per cent of infectious TB cases are being diagnosed and treated under DOTS. That is a conservative figure, and it is likely that the figure is higher than that. But unless people complete their treatment, unless that is reported and unless there is a reporting system to verify that, it is not counted as such in the WHO monitoring system. Theoretically speaking, about 55 per cent of people in the world now have access to DOTS, which is the internationally recommended strategy for fighting TBAN: When was DOTS treatment introduced?ML: DOTS was introduced in China in 1991. Between 1991 and 1995, with the support of a World Bank loan, China was able to expand its DOTS coverage to almost half of the entire country. In India, they got a World Bank loan, which came on stream in 1998. Between 1998 and 2002 they expanded DOTS to almost half of the country. And India now has got a second World Bank loan to expand it to the second half of the country in the next three years. Some countries, like the Philippines, which also have a large burden of TB, are on track to meet the 2005 targets. That is to say that at the same time as they have expanded DOTS facilities throughout the country, they are also maintaining very high cure rates. That shows that they are expanding DOTS and maintaining the quality of their services. AN: Why is there such a stigma attached to TB?ML: The most generalised reason for the stigma of TB is simply that, traditionally, it has been seen as a poor man’s disease. And a disease that comes from lack of proper hygiene, lack of proper sanitation. So, to admit that you have got TB is to put yourself at the bottom of society. There are also other complicating factors. In Africa, for example, WHO is trying to develop a joint strategy for attacking TB/HIV contraction. What they found is, in fact, that HIV stigma has transferred to TB. In a lot of societies in Africa, to have TB is seen as synonymous of having HIV and vice-versa. The clinical differences between the two are not understood by most people. If you have TB symptoms, you may understand that they are symptoms of TB but you assume that you are getting TB because you are HIV infected. It is very difficult to reduce the stigma to TB because of the strength of the association. More than 85 per cent of the global incidents of TB/HIV co-infection are in sub-Saharan Africa. In India and Bangladesh, the stigma of TB has more to do with its symbol of poverty and lack of hygiene and sanitation. AN: Which countries are worst affected by TB?ML: TB is a problem which is widespread both in Asia and Africa. The top four countries with the highest burden of TB are India, China, Indonesia and Nigeria. In Latin-America there is only one country which is among the 22 highest burdened countries for TB and that is Brazil. The incident rate in Brazil is not terribly high but it is because its population is so large that it is among the 22 high burdened countries.AN: How has the WHO’s approach to TB evolved over past 10 years?ML: There has been a major evolution in the approach and the structures to global TB control. In 1993, when WHO declared TB to be a global emergency, it was the first and only time in its history that WHO had made such a declaration. In 1993, TB was killing more people over the age of five than AIDS, malaria, leprosy, diarrhoea and tropical diseases combined. And yet TB was getting less funding than any one of those other diseases. Since WHO declared a global emergency, it had a vertical global TB programme up until 1998. That programme was quite successful in getting TB on the global health agenda and vastly strengthened funding resources devoted to TB. But the vertical programme had obvious structural weaknesses that limited the amount of effectiveness it could have on a country level. So in 1998, the first year of Gro Harlem Brundtland’s tenure as director-general of the WHO, she launched what was initially the ‘Stop TB Initiative’ which in 2000 became the ‘Stop TB Partnership’. Since 2000, you can say that in the global TB efforts WHO continues to play the lead role in its normal function in maintaining normative standards. u can say that in the global TB efforts WHO continues to play the lead role in its normal function in maintaining normative standards. AN: What are your next targets?ML: The Stop TB partnership and the partnership secretariat has been greatly responsible for expanding TB efforts in the 22 highest TB-affected countries. We are now working with those countries to ensure that they have a national plan through to the year 2005, when the next milestone for global TB control is fixed. By the end 2005 the targets of the Stop TB partnership are to identify 70 per cent of all infectious cases of TB under DOTS and to cure 85 per cent of those cases detected. If we reach those targets, we will be in an excellent position to reduce by half the global burden of TB by 2010. So far case detection is the problem, we are lagging far behind the case detection targets. But that is just interim – the ultimate goal is to eliminate TB as a public health threat by 2050. AN: Are donors committed to tackling the problem of TB?ML: In 1990, according to the World Development Report and the World Bank, there was a total of $16 million in external aid from all foreign donors for TB control. It was almost nothing for a disease that was killing two million people every year. Once the global emergency was declared in 1993, the WHO really focused on the advocacy side and was able to generate considerably more financial support for global control. In order to achieve the targets, the plan stipulates that $9.1 billion is needed. The funding gap is now about $3.7 billion. So if you pro-rate it according to where we are time-wise, there is not any funding gap. But I suspect that some of the accounting pledges rather than money in the bank. The principal donors for global TB control are the United States, Canada, Britain, the Netherlands and the World Bank, and they make commitments usually on a biannual basis.
