COULD DO BETTER

Waiting room That’s the verdict after ten years of global TB control, reports Anna Poppa. Still, TB remains the most common cause of death worldwide for people with HIV

Speaking on World TB Day this year (24 March), UK Secretary of State for International Development Clare Short described the challenges that lie ahead: "Curing 10 million TB patients is a massive achievement. But TB remains a significant problem for the world and hits poor communities very hard. We must make better progress. We can only do that by working in partnership with governments and other agencies to build sustainable systems that can deliver treatment to all."

Xray A month later, the World Health Organisation (WHO) announced that thanks to an unprecedented international collaboration, the virus that had led them to issue a global health alert over a new and deadly form of pneumonia, had been conclusively identified. The SARS virus (Severe Acute Respiratory Syndrome), which by then had notched up over 3,000 cases and 159 deaths, was identified just five weeks after SARS was first reported - testament to what scientists can achieve with adequate organisation and investment!

Let’s hope, despite its quick identification, the SARS virus doesn’t prove to have as much longevity as the tubercle bacillus, which nineteenth century über-scientist, Robert Koch, identified in 1882 as the cause of tuberculosis (TB). Some one hundred and twenty-one years later this particular severe respiratory disease still kills over two million people every year and causes illness in around eight million - even though there is cheap and effective treatment for it.

Initial TB treatment targets have fallen short

2003 marks the tenth anniversary of TB being declared a global health emergency by the WHO. In 1994, world health leaders established a transferable TB control programme called DOTS (Directly Observed Therapy Short-course). Still the internationally recommended response to TB, the DOTS programme recommends five priorities in fighting the spread of TB:

Government commitment to sustained TB control
Appropriate case detection systems
Standardised short-course chemotherapy, including direct observation of treatment
Adequate supply of drugs
Standardised recording and reporting systems.

DOTS programmes have since been used to treat 10 million people with TB, the vast majority in developing countries where the burden of TB is greatest. Though more WHO member states are added to the list of DOTS-compliant countries each year, the most recent report from the WHO Global Tuberculosis Control Programme suggests previously agreed targets for the detection and containment of the disease have not been met.

WHO’s goals for 2005 were twofold: to ensure that 70 per cent of TB cases would be detected, and that 85 per cent would be treated successfully. In fact, just 32 per cent of the estimated incident cases of infectious TB were notified to the WHO by DOTS programmes during 2001.

More alarming has been the rate of success in detecting cases. This has not improved significantly since 1995 when DOTS surveillance first began in earnest. Although the global average for treatment achieved was 82 per cent, this fell short in high-risk areas like Africa. Without substantial improvement, it's estimated WHO's original TB targets will not be met before 2013.

Dr Jong Wook Lee, Director-General nominee of WHO recently described the effect of HIV on latent TB infection: "Like putting a match to petrol."

Some successes where TB and HIV are linked

Interestingly, it’s the changes in global access to medicines, which have been brought about by activity in the broader HIV community, which now seem likely to have the greatest bearing on the future control of TB.

In a matter of years, attitudes and action on treatment access have changed dramatically, encouraged by political pressure, and supported by state, corporate, institutional and private donors.

The Global Drug Facility, established in 2001 by the Stop TB Partnership, has reduced the cost of TB drugs by 30 per cent to less than $10 for a full course of treatment, ensuring people in developing countries have access to adequate treatment.

And the Global Fund to Fight Aids, Tuberculosis and Malaria has so far allocated nearly $250 million in its first two years to TB control programmes. This includes a sizeable chunk given to India in the hope that their recent successes can be maintained. In India, more than one million people have been treated for TB under DOTS programmes since 1998, and some 50,000 people are started on TB treatment there every month. So there is some hope.

TB Facts

TB, short for tuberculosis, is an infectious disease caused by bacteria called Mycobacterium tuberculosis.
TB bacteria are able to survive inside the body for many years without causing illness. This is called latent TB disease.
Active TB disease occurs when the TB bacteria start to grow. This usually happens in the lungs or glands, but can occur anywhere in the body.
TB is spread when people with active, infectious TB disease in their lungs cough, talk or sneeze. This allows the bacteria to enter the airways of those around them.
Not everyone with active TB in their lungs is infectious, and it is usually necessary to be exposed to a person with infectious TB for some time before becoming infected oneself.
Anyone can get TB but some people are more at risk than others, for example, because they live in a region where TB is common. Young children and older people are also more vulnerable, as are people with HIV.
The symptoms of active TB include coughing, being short of breath, loss of appetite, weight loss, fever, and fatigue.
People who are in close contact with someone with active TB disease should be screened to see if they have acquired the infection. Currently, this involves skin tests and sometimes a chest X-ray.
TB can be cured using antibiotic drugs taken for at least six months. People with active TB will usually feel better and stop being infectious after the first two weeks of treatment, but it is vital that the full treatment course is completed. Antibiotics are also used to prevent latent TB from ever becoming active.
A vaccine is available which offers some protection against TB, but it is less effective in people with HIV. Early detection and appropriate treatment are essential TB prevention tools.
Resistance to the drugs used to treat TB is a common problem, and is caused by inadequate use of treatments - either missing doses or not taking treatment for the proper length of time.
The HIV epidemic has fuelled the re-emergence of TB, particularly in the poorer countries of the world, though the problems of HIV/TB co-infection are not limited to these settings.
A third of the world's population is infected with TB, and a third of the estimated 40 million people with HIV are co-infected with TB. It is the most common cause of death in people with HIV worldwide.
Being HIV positive increases the risk of developing active TB, and can mean that TB is harder to treat. Drug resistant TB is often more common in people who have HIV.

TB on the Web

The Stop TB Partnership http://www.stoptb.org
TB Alert http://www.tbalert.org
Health Protection Agency UK TB section visit: http://www.phls.co.uk/facts/TB

Anna Poppa is a freelance writer. Email annapoppa@tiscali.co.uk

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