It has been more than 125 years since the discovery, and the world, especially the developing countries, is striving to control the menace. World Health Organization (WHO) and International Union against Tuberculosis & Lung Diseases initiated the commemoration of World TB Day on 24th March, 1992, exactly 100 years after the discovery of the causative agent to raise awareness among the general public and to advocate for the strengthening and sustaining the tuberculosis control activities.
According to the 2009 estimates by WHO, there were 14 million tuberculosis cases worldwide. In that particular year, an estimated 9.4 million new cases and an estimated 1.7 million persons died due to causes related to Tuberculosis, including 0.4 million HIV positive cases. The tuberculosis problem has been further complicated by HIV epidemic as those infected with HIV have 10 percent risk of developing tuberculosis every year compared to 10 percent lifetime risk of developing tuberculosis in HIV negatives. Tuberculosis is also being complicated by the emergence of Multi Drug Resistant Tuberculosis (form of Tuberculosis in which the bacteria are resistant to the two most potent drugs to treat – INH and Rifampicin). As per latest estimates, 0.44 million cases of Multi Drug Resistant Tuberculosis emerged in the year 2008.
An estimated 2.7 million people develop TB with about 1.2 million being smear positive infectious cases in the year 2009 in the SAARC region. This region with about 23 percent of the global population has disproportionate burden of tuberculosis, having about 29 percent of the global incidence of tuberculosis. It is estimated that about 1,28,000 cases of MDR-TB occurred in the SAARC region in 2009. Afghanistan, Bangladesh, India and Pakistan, in the SAARC region are amongst the 22 high burden countries globally.
At the Global level, WHO recommended Stop TB Strategy is being followed including in 22 high burden countries. The new Stop TB Strategy, launched by WHO in 2006, sets out the major interventions that should be implemented to achieve the MDGs, Stop TB Partnership and World Health Assembly targets. These are divided into six broad components: (i) pursuing high-quality DOTS expansion and enhancement; (ii) addressing TB/HIV, MDR-TB and the needs of poor and vulnerable populations; (iii) contributing to health-system strengthening based on primary health care; (iv) engaging all care providers;(v) empowering people with TB, and communities through partnership; and (vi) enabling and promoting research. The major indicators for gauging performance of National Tuberculosis Control Programs are Case Detection and Treatment Success rates. At the global level, the case detection rate was 63 percent and the treatment success rate was 86 percent in 2008/09, whereas in the SAARC region, the case detection rate was 72.5 percent and success rate was 87.9 percent in 2008/09.
The Stop TB Partnership under WHO has endeavored to achieve the MGD of halting and beginning to reverse the incidence of tuberculosis by 2015 and has targeted to halve the prevalence and mortality rates by 2015 compared to 1990 levels. The incidence of tuberculosis is already in decline. SAARC countries are on the track to achieve the MDG and targets for tuberculosis by 2015. The Stop TB Partnership is striving to eliminate tuberculosis by 2050- less than 1 TB case per million populations.
But all said, are we on track to achieve the TB Elimination Goal? The National TB Control Programs are doing well in the area of TB Control. Considerable advances have been made to reduce the morbidity and mortality arising due to tuberculosis. Tuberculosis control is on the agenda of the national governments and international community and organizations and there has been immense increase in the pumping of financial resources for tuberculosis control. The Global Fund for Tuberculosis has emerged as a major contributor apart from bilateral and multilateral assistance sources. New Drugs and Diagnostics for Tuberculosis are being developed. While some new diagnostics have been recommended for adoption by the National Programs, their use is limited by their high expenses. The new drugs for treatment of tuberculosis will still take some time to be available for use by the National Programs. While, the National TB Control Programs of all the High Burden countries have started addressing the threats of HIV and MDR-TB for TB Control, the action is still slow and the National Programs need to gain momentum in these areas.
It has been estimated through modeling that even if all the achievements under the Global Plan to Stop TB are made, there still would be about 100 cases per million populations by 2050-more than 100 times the target of TB elimination.
It is well known that there are many direct and indirect factors responsible for development of Tuberculosis. On an average, people from groups of low socioeconomic status are more likely to have more frequent contact with people with active TB disease; more crowded and poorly ventilated living and working conditions; more limited access to safe cooking facilities; more food insecurity; lower levels of awareness or less power to act on existing knowledge concerning healthy behavior (for example safe sex, smoking, diet and alcohol consumption); and more limited access to high-quality health care.
The industrialization brought about rapid economic growth but uneven distribution of wealth and limited social reform. The most rapid declines in TB incidence and death rates ever recorded, on the other hand, were in places where economic growth was coupled with social and health sector reforms and important medical advances. Progress in TB control in the industrialized countries over the past century was brought about by a combination of economic, social, public health and medical advances. The future success of TB control may depend on progress in all of these areas, especially because rapid urbanization, inequitable economic growth, widening income gaps and the presence of large pockets of social deprivation are still common in many countries with a high TB burden.
So, do we continue to address the TB problem in the same vein or do we need to do something more. Indeed, a lot more is required. While the health ministries need to address the problem through strengthening of the health policies, strengthening health systems, inter program collaborations, addressing inequities and health systems access issues, tackling the factors directly responsible for development of tuberculosis and investing increased financial and human resources. The National Governments need to strengthen development policies and address inequities in development. The ultimate responsibility to address the social determinants that drive TB epidemics rests with several stakeholders, both governmental and nongovernmental. The responsibility goes well beyond the traditional realm of national TB programs and well beyond the boundaries of ministries of health.
Writers are director of SAARC TB &HIV/AIDS Centre and National TB Centre (Dr Jha) and deputy director of SAARC TB &HIV/AIDS Centre (Dr Salhotra)
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