Aiming to bring TB cases to zero

(First Published in Deccan Herald)
Anti -TB activists at the recently concluded 43rd Union World Conference on Lung Health held in Kuala Lumpur made strident demands for getting to zero.  For a post 2015 (MDG goals) strategy, they demanded zero new infections of TB, zero deaths from TB and zero stigma.  At the other end of the scale were the doctors, scientists and academicians, who made very cautious commitments and advocated for the setting of realistic targets for TB control post 2015. The situation raises questions. Is asking for zero an unreasonable demand, especially for a disease such as TB which has been among us for as long as civilisation itself? There’s been very little progress down the years on new prevention and diagnosis tools, and treatment options.

The only vaccine we have against TB (BCG) is 125 years old, we have had no new drugs for the past 40 years and the only reliable diagnostic tool we had (till the GeneXpert was recently approved for use by the WHO), was the smear microscopy test which misses half of all cases.  This situation exists where large numbers of people continue to succumb to it every day, despite TB being entirely preventable and curable.  The WHO Global Tuberculosis Report 2012 reveals some stark figures, modest successes and large challenges in TB control.

Between 1995 and 2011, 5.1 crore (51 million) people were successfully treated for TB in countries that had adopted the WHO strategy, saving 2 crore (20 million) lives. The report also points out that India (26 per cent) and China (12 per cent) together account for almost 40 per cent of the world’s TB cases.

Small percentage

Only 58 lakh (5.8 million) people were notified to national TB programmes globally and received treatment consistent with international guidelines. According to the Stop TB Partnership, this is just 66 per cent of the estimated total number of cases and leaves around 30 lakh (3 million) people who either received no diagnosis and treatment or got potentially substandard treatment.

This figure has not changed for the past three years. According to the report, India had the largest number (2.2 million) of cases of TB in 2011. TB mortality rate has decreased by 41 per cent since 1990 and the TB control programme globally seems to be on track in terms of achieving the global target of a 50 per cent reduction in TB deaths by 2015. While we are struggling to control what is an entirely preventable and curable disease, and achieving some progress as the above data suggests, with alarming rapidity, prefixes such as MDR, XDR and TDR threaten to make the situation with regard to TB difficult.  As Dr Lucica Ditiu, executive secretary of the Stop TB Partnership points out, “In 2011, there were an estimated 440 000 new cases of MDR-TB. Considering the detection and notification rate globally, we would have expected to have found around 300,000 MDR-TB cases.

However, we are far away from reaching this number because we only found 56,000 people with MDR-TB and enrolled them on treatment. The difference between these figures represents a huge number of people who should have been provided with TB care. The shocking reality is that only 3.8 per cent of new cases and 6 per cent of previously treated cases had access to a MDR-TB diagnostic test.”

The above situation demonstrates progress, but not quite at the pace that is required.  So a ‘zero’ demand does not seem unreasonable at all.  We have done it for smallpox; polio is soon going to be a disease that was.  Then why not zero for TB?

 As William Foege, an American epidemiologist who is credited with devising the global strategy that led to the eradication of smallpox in the late 1970s observed, “Thousands of people participated in the global eradication effort...they were optimists...they were risk takers; there was no shortage of people telling them that the effort was futile.

It wasn’t science that threatened to stop us. It wasn’t even nature per se. Rather, it was human nature...”  TB deserves global eradication efforts with not cautious, but ambitious, visionary targets to get to zero.

(First Published in Deccan Herald)

Bharathi Ghanashyam