Message from the Regional Director WHO South-East Asia Region World TB Day, commemorated on March 24 every year, is an opportunity to renew our collective commitment to stop TB and to emphasize that this calls for concerted actions globally, nationally and locally. It is also a day to remember and thank those who are helping to cure people affected by TB. National TB Control Programmes in the South-East Asia Region continue to make significant progress in TB control. Over two million patients are being registered for treatment every year and, for the first time in many decades, there is emerging evidence of a reversal in the burden of TB in this Region. As these programmes begin to move into a new phase of implementing an expanded range of activities under the new Stop TB strategy, those who work with TB will need to do much more to ensure that all TB patients, wherever they may be, have access to the highest quality of care. Ministries of health and national TB programmes have recognized this and are working with several partners, both international and national, on implementing a common plan for tuberculosis control in each Member country, in order to achieve the targets set for TB control under the Millennium Development Goals. While the bulwark of the DOTS strategy continues to be strengthened, interventions to treat those with multi-drug resistant TB, establish a wide range of collaborative activities with HIV/AIDS programmes and involve the private sector and civil society are steadily gaining ground. Central to all these efforts are the multitude of health-care workers, private providers, nongovernmental organizations, communities, volunteers and patients themselves, who are helping to ensure that all TB patients, wherever they may be, receive care of the highest quality. The theme this year, “I am stopping TB”, is a message of personal commitment from people in various walks of life to stopping TB. It is a reaffirmation that every individual’s contribution counts. Governments and development partners must, on their part, support these individuals through their commitment at the highest levels of policy and funding. At the Sixtieth session of the Regional Committee of WHO’s South-East Asia Region in Bhutan in 2007, Member countries adopted a resolution to fully implement national plans for TB control incorporating all elements of the new Stop TB Strategy in order to achieve the Millennium Development Goals. I would also take the opportunity that World TB day presents to highlight the fact that we also need to pay attention to other factors impacting tuberculosis control. These include both housing and work environments that easily allow for transmission of tuberculosis, and malnutrition, age, gender-related factors and unhealthy coping strategies that then spur the progression to active disease. While all these factors are heavily influenced by socioeconomic inequalities that we in the health sector alone cannot correct, we must not forget our role in ensuring safer spaces for people to live and work. These are equally important to long-term TB control. Given the commitment at the highest policy levels, continuing support from all partners engaged in supporting TB control and the collective will of people in the Region, I am confident that we will continue to move steadily towards achieving the goal of eliminating TB as a public health problem.
Samlee Plianbangchang, M.D., Dr.P.H. Regional Director
Technical Brief Tuberculosis and the New Stop TB Strategy Goals By 2005: Global targets for directly observed treatment, short-course (DOTS): • • • Full coverage with quality DOTS; At least 70% case detection; and At least 85% treatment success among new cases. Over the past 10 years the DOTS strategy has done more for TB control than had been possible in the previous 50 years. At the same time, the environment for TB control has also changed – new challenges called for a new strategy. A new Stop TB Strategy was therefore developed and launched in early 2006. The new Stop TB strategy underpins the Regional Strategic Plan for TB control 20062015
What does the New Stop TB Strategy aim to do? Ensure equitable access to the highest quality of care (diagnosis and treatment) for all TB patients Accelerate progress and impact of TB control in order to reduce deaths and disease, in line with MDGs, by 2015 Reduce human suffering and socio-economic burden on families and communities Protect populations from TB, TB/HIV and MDR-TB Help address health systems constraints that impede TB control Support the development of new tools and enable their timely and effective use
By 2010: Interim target: • To halve TB deaths and prevalence. By 2015: Target linked to the Millennium Development Goals: • “to have halted and begun to reverse the incidence”.
A resolution supporting the full implementation of the new Stop TB Strategy in Member countries of this Region was endorsed at the 60th Regional Committee of the Region in September 2007.
What is required? Better programme management and implementation, including human resource planning and development Quality assured laboratory networks for microscopy, culture and drug susceptibility testing Improved surveillance, impact evaluations, use of data to guide programme policy, interventions Closer collaboration between TB and HIV programmes for joint services beyond pilots DOTS-Plus for management of multidrug-resistant TB under national programmes Improved procurement, logistics management for uninterrupted supplies of high-quality first- and secondline drugs; rational use of drugs Cross-border activities, targeted interventions to reach at-risk populations Advocacy, community involvement, empowerment Research for new tools
What are the main challenges? Uncertainties regarding sustainable financial and operational resources Overstretched national public health care systems; limited technical and management capacity Weak national laboratory networks and surveillance mechanisms Difficulties in establishing interventions for TB/HIV and emerging drug resistance Provision of care by private and public sectors not sufficiently linked to national programmes
Low community awareness and utilization of services
Expected outcomes Over the next 10 years, towards achieving the Millennium Development Goals in the Region: Treat and cure 25 million TB patients including those with HIV co-infection and drug-resistant TB Save at least 5 million people from dying of TB Prevent at least 1 million cases of multidrug-resistant TB
Reaching the Millennium Development Goals: The New Stop TB Strategy and Regional Plan 2006-2015
Tuberculosis in the SEA Region
With 25% of the world’s population, the 11 Member countries of the South-East Asia Region (SEAR) carry more than one-third of the global burden of TB. Three million people develop active TB and over half a million die of the disease every year in the Region. While the proportion of cases with multidrug-resistance is low at 2.2%, the absolute numbers of TB patients with multi-drug resistance is large. The HIV epidemic has had a variable impact in the Region. Of the nearly 4.0 million people living with HIV/AIDS in the Region, 40% are estimated to be co-infected with TB.
What has been achieved so far? Case detection and treatment success rates Treatment success rate (cohort of patients registered in 2005)
Many National TB control programmes have achieved or are close to achieving the Millennium Development Goal 70% case detection and 85% treatment success targets and beginning to demonstrate the impact of interventions on TB prevalence and mortality. It has been recognized that that the progress in this Region is driving global progress in the Region. • • • • Private and public partnerships and community initiatives are being scaled up in 8 countries.
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Medical schools are involved in teaching and 60% 2000 2001 1997 1998 1999 implementation in 6 countries. 2005 2006 2002 2003 2004 TB/HIV interventions are commencing or being scaled 50% up in 7 countries. 0% 20% 40% 60% 80% 100% Pilots to manage multi-drug resistant TB (MDR-TB) cases Case detection rate (cohort of patients registered in 2006) are now scaling up in India and Nepal; plans are being Source: Annual reports on TB programmes in SEAR, WHO/SEARO 2007 developed in Bangladesh, Bhutan, Myanmar, Sri Lanka, and Timor-Leste, in consultation with the Green Light Committee. Global Fund support is being provided in nine countries; Global Drug Facility support in ten countries; the funding gap is less than 5%, with the exception of DPR Korea and Myanmar. All eleven Member countries have prepared multi-year national plans for TB control that incorporate all the elements of the new Stop TB Strategy.
MDR and XDR-TB • • • • • XDR-TB is defined as resistance to both Rifampicin and Isoniazid (MDR-TB), with in addition, resistance to two second-line drugs — fluroquinolones and one injectable drug Prevention of both MDR and XDR-TB is based on good quality DOTS Levels of MDR-TB remain low in the Region; less than 3%, XDR-TB has been reported in three countries (India, Thailand, Bangladesh) where second-line drug testing results are available to date; more systematic surveys are required SEARO has prepared an MDR/XDR-TB response plan and established an Expert Group on XDR-TB to advise countries on operationalizing this plan. The plan covers proposed actions for strengthening surveillance, building laboratory and programme capacity for diagnosis and case arrangement, ensuring drugs, and infection control. An inter-country workshop on MDR-TB management was also held in August 2007 involving all national programmes; several initiatives are on-going in many countries.
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Technical briefs are produced by the Department of Communicable Diseases, WHO Regional Office for South-East Asia. This information reflects current knowledge and may change, given the dynamic nature of infectious disease. Comments are welcome. For further information, contact cdsunit@searo.who.int or visit our website: http://www.searo.who.int/en/Section10.htm