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TB Control
The problem of global TB results in the deaths each year of nearly one and a half million people,
from a disease that for many years has been treatable and curable.1 It is not clear though whether
this continuing high level of deaths is due to a failure of global TB control strategies, the impact
of the joint HIV and TB epidemics, the increasing problem of drug resistant TB, a lack of TB
funding or more likely a combination of all four.
We have known how to cure TB for more than 50 years. What we have lacked is the will and
the resources to quickly diagnose people with TB and get them the treatment they need.
Global TB Targets
In 1991 the Fortyfourth World Health Assembly set TB targets for the year 2000, and amongst
other things these were:3
A Global TB Emergency
In 1993 the World Health Organisation (WHO) declared TB to be a global emergency saying
that:
Tuberculosis today is humanitys greatest killer, and it is out of control in many parts of the
world. The disease, preventable and treatable, has been grossly neglected and no country is
immune to it.
DOTS
Subsequently WHO in the mid 1990s further developed their DOTS, or Directly Observed
Treatment Short course strategy. This was to become the internationally recommended approach
to TB control until 2006. The strategy was built on model programmes developed in African
countries from the late 1980s and subsequently expanded worldwide.
At a meeting in Amsterdam in March 2000, the 20 high burden TB countries again confirmed
their commitment to meeting, amongst other goals, the detection of 70% of active TB cases, this
time to be achieved by 2005.7
The Millenium Development Goals (MDGs) were first agreed at the UN Millenium Summit in
September 2000, and the eight MDGs set worldwide objectives for reducing extreme poverty and
hunger, improving health and education, empowering women and ensuring environmental
sustainability by 2015.
TB is not mentioned specifically in the main goals but comes within Goal 6, which is to combat
HIV/AIDS, Malaria, and other diseases. The specific target for Goal 6, target 6c which applies to
TB, is to have halted by 2015 and begun to reverse the incidence of TB.
Global TB Initiatives
In the eighteen months after the Amsterdam Declaration a number of global TB initiatives were
to be started. These included:8
The Global Drug Facility was established in 2001 to expand access to and the availability of high
quality TB drugs, in order that DOTS programs could be expanded. It was established in
response to the difficulties that countries had in the 1990s in finding and funding high quality
supplies of TB drugs. It was believed that patients were developing resistance as a result of poor
quality drugs.9
In 2000 the WHO and some international partners, were beginning to develop an initiative called
DOTS Plus. It was considered that the development of the DOTS strategy had been very
successful in expanding effective TB treatment. However in some areas its success was being
threatened by the emergence of multi drug resistant TB. DOTS Plus was to be developed as a
comprehensive initiative that was to build upon the five elements of DOTS, but would take into
account specific issues, such as the use of second line anti TB drugs, that needed to be used in
areas where there were significant levels of MDR TB.
One of the difficulties with the implementation of some of the DOTS Plus pilot projects, was the
need for quality second line anti TB drugs, which were normally very expensive. WHO and their
partners made an arrangement with the pharmaceutical industry for preferential prices for second
line drugs used for the pilot projects. However, it was considered important that these beneficial
prices were not used in projects that were not organised according to certain standards, and
which might therefore result in resistance developing to these second line drugs. So the Green
Light Committee was established to review project applications, and to decide whether they were
sufficiently in accordance with the guidelines that had been established for the pilot projects.10
The Global Plan to Stop TB 20012005 made a number of commitments including that:13
The TB Alliance had been set up in 2000 as a Product Development Partnership (PDP) to
develop new affordable TB drugs. A PDP is a non- profit organisation that builds partnerships
between the public, private, academic and philanthropic sectors to drive the development of new
products for under-served markets. In 2003 two further PDPs were set up, AERAS to develop
new TB vaccines to replace the BCG vaccine and the Foundation for Innovative New
Diagnostics (FIND) to develop new TB tests.14
In the new global plan for 20062015, the targets were no longer set in terms of the percentage
of people reached in case detection rates, or a treatment success rate of at least 85%. Instead
there were a range of targets covering specific areas such as the development of improved
diagnostics and drugs, and the target set in the Millenium Development Goals.
The Global Plan to Stop TB 20062015 has as its main targets:15
To meet the MDG target to have halted and begun to reverse the incidence of TB by 2015
To meet the Stop TB partnerships own targets, to by 2015, halve prevalence and death
rates from the 1990 baseline
Over the ten years of the plan, 50 million people will be treated under DOTS Plus,
800,000 people will be treated for MDR TB, and three million people with TB and HIV
coinfection will start antiretroviral therapy.
By 2010 simple tests for use at peripheral levels of the health system, will enable rapid,
sensitive detection of active TB at the first point of care, and by 2015 there will be tests
to identify those at greatest risk of progressing to active disease.
The first new TB drug for 40 years will be introduced in 2010, and by 2015 the target
will have nearly been reached of a new regime that will achieve cure in 12 months, and
that also will be effective against MDR TB
By 2015 there will be the first of a series of new, safe, effective TB vaccines.
There were also aims of involving communities and TB control featuring on the political
agendas of countries.
The Global Plan was subsequently updated in 2010, to become the "Global Plan to Stop TB
20112015".17
Tuberculosis today is out of control in many parts of the world. The disease, preventable and
treatable, has been grossly neglected and no country is immune to it.
Over the last twenty five years the HIV/AIDS epidemic has developed and millions have died.
However, a new diagnostic test has been developed, and there is now a range of drugs together
with tools to monitor their use. Although the drugs are not a cure they do save peoples lives, and
they are provided at affordable cost to people in both developing and developed countries.
Almost every country in the world has set up a national HIV/AIDS control program, in many
instances quite effectively.
In the same period there has been very limited progress in developing a really simple, cheap
point of care diagnostic test, few new drugs have been developed, many TB control programs
still have problems, MDR TB and XDR TB are spreading and millions still die.19 The global
community should be able to do better with TB. Every one of us must ensure that we do not
allow another 30 million people to die in the next few years.
Where next?
Get some more TB facts, or learn about TB in India.
References
1. "Global Tuberculosis Control 2011", WHO, Geneva, 2011, 9
www.who.int/tb/publications/global_report/
2. Remarks by Nelson Mandela: "Confronting the Joint HIV/TB Epidemics", XV
International AIDS Conference, Bangkok, 2004 http://quod.lib.umich.edu/c/cohenaids/
3. "Forty-fourth World Health Assembly Tuberculosis control programme"
www.who.int/entity/tb/publications/tbresolution_wha44_8_1991.pdf
4. "WHO Calls Tuberculosis a Global Emergency", Los Angeles Times, 1993
//articles.latimes.com/1993
5. "What is DOTS? WHO Tuberculosis Factsheet", WHO, 2006
www.tbfacts.org/Whatisdots.pdf
6. "Amsterdam Declaration to Stop TB", Amsterdam, The Netherlands, 24th March 2000
www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/decla.pdf
7. "Amsterdam Declaration to Stop TB", Amsterdam, The Netherlands, 24th March 2000
www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/decla.pdf
8. "First Stop TB Partners' Forum", Washington, 22 October 2001, 6
www.stoptb.org/events/meetings/partners_forum/2001/
9. "What is the GDF?", www.stoptb.org/gdf/
10. "DOTS-Plus & the Green Light Committee",
www.who.int/tb/publications/2000/en/index.html
11. "TB Alliance History and Impact", http://www.tballiance.org/about/history.php
12. "First Stop TB Partners' Forum", Washington, 22 October 2001, 6
www.stoptb.org/events/meetings/partners_forum/2001/
13. "First Stop TB Partners' Forum", Washington, 22 October 2001, 6
www.stoptb.org/events/meetings/partners_forum/2001/
14. "AERAS - Global Efforts", AERAS www.aeras.org/about-tb/global-efforts.php
15. "The Global Plan to Stop TB 2006-2015", WHO, Geneva, 2011, 9
www.stoptb.org/global/plan/
16. "The Global Plan to Stop TB 2006-2015: Progress Report 2006-2008", WHO, 2009
www.stoptb.org/resources/publications/plans_strategies
17. "The Global Plan to Stop TB 2011-2015", WHO, Geneva, 2010
www.stoptb.org/global/plan/
18. "WHO Calls Tuberculosis a Global Emergency", Los Angeles Times, 1993
//articles.latimes.com/1993
19. "Better to have HIV than TB", 2011 www.health24.com/medical/