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This is an archived USAID document retained on this web site as a matter of public record.
Remarks by Irene Koek,
Chief, Infectious Diseases Division,
Bureau for Global Health
Chair of the Stop TB Partnership Coordinating Board
For World TB Day
At the Pan American Health Organization
March 23, 2007
I would like to thank the Pan American Health Organization (PAHO) for hosting this event, and many thanks to PAHO and the Global Health Council for working with USAID to organize it. It is indeed an honor to be here.
World Tuberculosis Day is a day to renew and accelerate commitment to the fight against TB.
This fight is not only a public health imperative - TB anywhere is TB everywhere - it is a moral one.
About 1.6 million people die each year due to TB. Most of those who die are in developing countries; they are usually the poor, the disenfranchised and the marginalized.
TB strikes people in the prime of their lives - it robs children of their parents, it takes sons, daughters, sisters and brothers, and all too frequently the breadwinners.
It is a disease that can be stopped and must be stopped. World TB day is also a day to take stock of where we are in the fight against TB.
Each year on World TB day, the World Health Organization (WHO) issues the Global TB Control Report. This seminal publication reports on surveillance data from 199 countries, including treatment success, case detection, mortality, TB/HIV co-infection, and funding for TB as well as progress in directly observed short course (DOTS) implementation, the WHO recommended treatment strategy as well as the Stop TB Strategy.
The Global TB Control 2007 report was released yesterday. This report presents data as of the end of 2005. The 2005 data is particularly important for two reasons.
First, it provides the baseline year for measuring progress for the Global Plan to Stop TB 2006-2015. The Global Plan was launched by the Stop TB Partnership in January 2006. It represents a concrete set of actions that if taken, will treat 50 million people for TB and 800,000 people for multi-drug resistant (MDR) TB, and save 14 million lives.
The 2005 data is also significant because 2005 was the target year for reaching the global targets of detecting 70% of estimated cases worldwide, and successfully treating 85% of those cases.
So how did we do?
The short answer is we came very close. Globally, case detection in 2005 was 60%. Even though this fell short of the goal, this is an extraordinarily impressive achievement. In 2000, the WHO projected that we would not achieve the 70% target until 2013.
Instead, through focused and coordinated effort by country programs and the international community, the case detection trends were turned around, and rapidly accelerated. WHO and the Stop TB partnership worked closely with National Tuberculosis Programs (NTP) to revise their strategies, intensify country level efforts, reach out to the private sector, and evolve the standard approach to DOTS. This is an excellent example of what strong commitment and coordinated action can achieve.
While globally the case detection rate was 60%, the target of 70% was met in the Western Pacific region - which includes giants such as China, the Philippines and Vietnam.
The treatment success target of 85% was very narrowly missed - the average rate at the end of 2005 was 84% - again a very impressive achievement. In the Western Pacific and South East Asia region - where the bulk of global TB cases are - treatment success targets were met.
Case detection and treatment success targets were met in 26 countries. 67 countries achieved at least 70% case detection; and 57 countries reported a treatment success of 85% or greater.
The Global TB Control Report presents a wealth of information. I'd like to take a few minutes now to walk through some of the data from the report.
In 2005, there were an estimated 8.8 million new TB cases: 1.6 million people died of TB, including 195,000 patients infected with HIV.
The body of surveillance data collected by WHO over the last several years indicates that the global TB incidence rate - representing new cases of TB - probably peaked sometime between 2000 and 2005, although the number of new cases is still rising slightly each year. If this is correct, the global TB epidemic may well be on the threshold of decline.
Of the 15 countries in the world with the highest incidence rates, 13 are in Africa, in part due to high HIV prevalence.
Using time series data from 1990-2005, WHO conducted an analysis of incidence rates (for all forms of TB) for 9 epidemiologically different subregions of the world. In 6 of these regions, the incidence rate was stable or falling for most of this period; in Africa and Eastern Europe, the incidence rates increased for most of the period but how appear to have stabilized or begun to fall.
In Africa, as you might expect, the annual change in TB incidence runs parallel to the change in HIV prevalence. Since 1990 both HIV prevalence and TB incidence have been increasing more slowly each year and by 2005, both were falling.
While the trends in incidence rates are encouraging - and would satisfy the MDG target for halting and reversing the incidence rate, the Stop TB Partnership has also set more ambitious goals - to cut prevalence and death rates in half by 2015 compared to 1990 levels.
The good news is that it appears these targets have almost been reached in the Americas. As Dr. Barbosa will describe, there has been strong commitment and effective action in this region. And let me just say, I am proud of the contributions USAID's programs have made in this region, working closely with the countries and with PAHO.
If the current trends are maintained, the targets will also be reached in South East Asia and the Western Pacific. These indicators are currently falling too slowly to meet the targets in the Eastern Mediterranean region.
When the analysis for the Global Plan was done a year and a half ago, it was clear that the targets would not be met in Africa or in Europe. However at that time it did appear at a global level, the targets would be met. Current trends suggest that that may not happen.
DOTS was implemented in 187 countries - at least at some level in 2005. Nearly 5 million TB patients were notified under DOTS in 2005. However the implementation varied by region - 35% of smear positive case detection through DOTS was reported in Europe, compared to 76% of smear positive cases reported under DOTS in the Western Pacific.
Much progress has been made over the last five years in implementing collaborative TB/HIV activities. Of 60 countries reporting data on TB/HIV (nearly all the 63 TB/HIV focus countries), between 58 and 71% had appointed a TB/HIV focal point and developed a national plan for TB/HIV.
However, looking ahead to the targets set for 2006 in the Global Plan for TB/HIV, activities have not yet accelerated sufficiently. Only 8.8% of HIV positive people attending HIV services were screened for TB. 6.6% of all notified TB cases were tested for HIV. Clearly there is much work to be done.
Control of MDR TB has taken on renewed urgency in the light of Extensively Drug Resistant (XDR) TB. Among 22 high burden countries, 11 had carried out national drug resistance surveys by 2006.
The Green Light Committee (GLC) has approved 53 projects for more than 25,000 MDR TB patients in 42 countries. GLC projects were reporting better treatment outcomes than non GLC projects - with cure rates of 57% compared to 50%.
The WHO surveillance system also collects extensive information on funds available from all sources to the NTP at the country level.
In 2007, the NTP budgets in 90 countries totals $1.6 billion - with a funding gap (compared to their plans) of $307 million. However, it should be noted that this is only part of the resources needed. It does not include general health service staff and infrastructure.
While much progress has been made, many challenges remain. Human resources are inadequate in many countries. Laboratories - an absolutely critical component of effective TB control remain weak in many countries. National TB Programs in all regions reported drug stock-outs, too few laboratories, weak quality control and limited facilities to carry out culture and drug susceptibility testing.
With XDR, this last limitation has taken on a critical urgency and is a high priority in the global strategy to respond to XDR.
Our current drugs and diagnostics are inadequate. The Global Plan projects that we will have a new diagnostic by 2008 and a new drug by 2010.
In the meantime, we need to deploy the currently available rapid diagnostics more widely, and we must protect the drugs we have - both first line and second line - by ensuring their appropriate use by all health care providers. We must do everything in our power to support patients until they are cured, including engaging local communities. Patients don't fail treatment, we fail them when we don't provide adequate support or engage them as partners in our efforts.
The Global TB Control Report for 2007 gives us a great deal of good news - the global targets are within reach, and have been reached in a number of countries. However, the data also show where attention is needed and where we are in danger of slipping back from reaching the Stop TB partnership targets.
The global TB community has demonstrated that it can come together and accelerate action, foster strong commitment - and - as was done for case detection rates a few years ago - reverse trends that are going in the wrong direction. The path is clear and we must all work together to stay on the path and reach the goals set out in the Global Plan to Stop TB.
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