WHO: Funding needed to support global TB decline

Despite the overall decline in tuberculosis cases each year and a decrease in the number of deaths in the past 10 years, this progress is at risk because of underfunding, WHO officials said during a press conference today. New data on the global TB epidemic were presented with the release of the 2011 Global Tuberculosis Control Report.

“The findings of the 2011 Global Report reflect a significant milestone in global health,” Mario Raviglione, MD, director of WHO’s Stop TB department, said during the conference. “These results offer hope for communities most affected by this infectious killer.”

Raviglione presented key findings of the report:

The number of people infected with TB decreased from 9 million cases in 2005 to 8.8 million in 2010.
TB mortality decreased from 1.8 million in 2003 to 1.4 million in 2010; one-third of deaths are in women.
TB mortality rate decreased by 40% between 1990 and 2010. All regions, except Africa, are on track to achieve a 50% decline in TB mortality by 2015.
In 2009, 87% of treated patients were cured of TB, with 46 million people successfully treated and 7 million lives saved since 1995.

Raviglione said the most significant progress was observed in China. The TB death rate decreased by nearly 80% between 1990 and 2010. Compared with 55,000 deaths in 2010, there were 216,000 deaths in 1990. The prevalence of TB decreased from 215 per 100,000 population to 108 per 100,000 population.

However, about one-third of worldwide estimated TB cases were not reported, according to the report.

“We fear most are detected late and their outcomes are uncertain,” Raviglione said. “Assuring, therefore, quality care for all people with TB, which also implies the strengthening of basic services must be our focus from now on.”

He said this progress is at risk from underfunding, especially for efforts to treat the most dangerous and difficult to treat form of TB — multidrug-resistant TB.

“History teaches that we cannot be complacent about TB,” Raviglione said. “Worldwide, major funding hurdles now need to be overcome. Countries have reported a funding shortfall of $1 billion for TB implementation in 2012. Continued international funding is more critical than ever, especially for the lower-income countries so that they can build and strengthen the measures that will save more lives and protect more people from TB.”

For more information, please visit www.who.int/tb.

David Cohn, MD

The decreases in global incidence and TB-related mortality associated with increased rates of cure during the past decade are indeed gratifying. These accomplishments in global TB control are in large part related to development of the DOTS strategy by WHO more than 15 years ago and its subsequent implementation in high burden countries, many of which had poor national TB control programs with inadequate funding, personnel and infrastructure. The progress highlighted in China, as the country with the second highest number of TB cases in the world (after India), is a striking example. Between 1990 and 2000, marked decreases in TB incidence, prevalence and mortality were documented in 13 provinces in China in a DOTS expansion project funded by a World Bank loan, wherein ‘barefoot doctors’ and other outreach workers delivered directly-observed therapy with standardized regimens to patients with TB. This model was then expanded to other provinces in China, with similar results and further decreases in incidence nationwide between 2000 and 2010 — a public health ‘home run’.

Nonetheless, despite recent successes, Raviglione’s admonition about underfunding and complacency is well taken. The current global economic crisis has led to significant budget reductions by donors from the richest countries, which are the lifeblood of international public health agencies, their programs and partners. The outbreaks of nosocomial MDR-TB in AIDS patients in New York City in the 1990s and XDR-TB in Tugela Ferry, South Africa a few years ago, which were both associated with high mortality and secondary transmission, serve as sobering reminders of worst case scenarios when programs fail, in part due to lack of or decreases in funding. The co-epidemics of TB and HIV, and the specter of MDR-TB and XDR-TB in numerous countries remain as the greatest challenges to global TB control. In these tough times of shrinking resources, every program wants to save its piece of the pie, and is required to do more with less. Let’s hope the homeruns in infectious diseases and public health during recent decades are not diminished to base hits and strike-outs by political wrangling, shortsightedness and misplaced priorities.

This commentary is dedicated to the memory of John A. Sbarbaro, MD, MPH, professor of medicine at the University of Colorado School of Medicine, former director of Denver Public Health, WHO consultant,and the pioneer of directly-observed therapy for treatment of TB in the United States.

-David Cohn, MD

Infectious Disease News Editorial Board member

Disclosure: Dr. Cohn reports no relevant financial disclosures.

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