Memorandum by RESULTS UK
2. What reliable data exists regarding the
number of people infected globally with the four diseases on which
the committee is focussing particular attention? What trends are
discernable in both number of those infected and the patterns
of infection? And what are the main underlying causes of infection
and any of changes in its incidence and pattern?
The World Health Organization compiles annual
reports which include some of the most up to date figures available
for tracking the global incidence of tuberculosis. However, due
to the complex and time consuming nature of the work involved
in compiling such data these figures are mostly two years out
of date by the time they are published. For example the 2007 report
uses data from 2005. This is significant because, for example,
the Global Plan to Stop TB only came into force in 2006
so the 2007 report will not be able to reflect any advances made
since that date until 2008/09 at the earliest.
The WHO report, Global Tuberculosis Control:
Surveillance, Planning, Financing (2007) provides detailed
statistics on the scale, direction and impact of the epidemic,
expressed in terms of incidence, prevalence and deaths for 22
high-burden countries, for the six WHO regions, for selected sub
regions and for the entire world.
The 2007 report notes a total of 5.1 million
new and relapse cases of TB that had been reported to the WHO.
The actual number of new cases was thought to be closer to 8.8
million (illustrating the difficulty in compiling accurate, verifiable
data). WHO noted that the African Region (23%), South-East Asian
Region (35%) and Western Pacific Region (25%) together accounted
for 83% of all notified new and relapse cases.
Having compiled data on TB for eleven consecutive
years, WHO are able to effectively establish patterns and trends
in global TB incidence. Perhaps the most encouraging trend to
emerge has been the stabilisation or decline of TB incidence in
each of the six WHO regions, suggesting that global TB incidence
may have "reached a peak". However it must still be
noted that overall numbers of new cases continues to slowly rise
because the case-load continued to grow in the African, Eastern
Mediterranean and South-East Asia regions.
In the few remaining areas where incidence of
TB is continuing to rise, including Sub-Saharan Africa, it has
been found that the resurgence in TB can be directly attributed
to high HIV/AIDS prevalence in those areas.
4. Given the continuance of current or planned
intergovernmental programmes to prevent or control the four diseases,
what predictions can be made of their likely spread and pattern
over the next 10 years?
The Stop TB Partnership's Global Plan to
Stop TB, 2006-2015 is a comprehensive strategy developed with
the explicit aim of combating the spread of TB worldwide. If the
Global Plan is implemented fully and successfully it is projected
that 14 million lives will be saved. Furthermore 30 million cases
of TB will have been prevented and the number of new cases will
reduce to less than six million in 2015, thus meeting and even
exceeding the MDG target of "halting and ultimately reversing
the incidence of" TB worldwide. The Global Plan's own ambitious
target of halving the prevalence and death rates from the 1990
baseline will also have been met.
However it must be noted that many significant
challenges must first be overcome if such significant advances
are to be made. HIV and multi-drug resistant strain of TB remain
perhaps the biggest challenge, alongside wider societal and health
system issues. Long-term investment and commitment is essential
to ensure that the Global Plan remains on track to meet these
goals. To ultimately eradicate TB a new, more effective vaccine
will be required. It is very unlikely however that this will be
developed in the next 10 years.
5. What do you consider to be the principal
blockages to achieving progress in the prevention or control of
the four diseases? And how might these blockages be removed by
more, or better-targeted or better-coordinated intergovernmental
action?
Despite being responsible for the deaths of
over eight million people every year, TB often fails to attract
the political attention that other diseases, notably HIV/AIDS
attract. This is particularly problematic as it is evident that
TB will only be bought under control if there is the political
will to do so. The UK should be at the forefront of global efforts
to highlight the serious threat posed by the global TB epidemic,
helping to push the issue of TB up the global political agenda.
Political will must be matched by a significant
scaling up of the funding available to TB control. Furthermore,
funding must be made more consistent and predictable. The total
cost of the Global Plan is US$56.1 billion over 10 years. This
includes US$9 billion for new tools working groups and US$47 billion
for implementation working groups. Today, only about 45% of the
total cost or an estimated US$25.3 billion is likely to be available.
The estimated funding gap is US$30.8 billion (note: this does
not include additional resources needed to address the more recent
emergence of Extensively Drug-Resistant TB or XDR-TB). Existing
gaps in funding and uncertainty about future financing impede
planning and implementation for both treatment and research. Governments,
international organisations and NGOs should act in a coordinated
way to ensure long-term, stable and sustainable funding for TB
prevention, treatment and research.
Drug resistance poses a serious and growing
threat to global TB control, threatening to undermine all the
progress that has been made to date. Drug resistance can be avoided
if the current DOTS strategy is implemented properly. To prevent
the further spread of drug-resistant TB more money should be made
available to fund the expansion of effective DOTS-plus programmes.
The UK should also encourage and support high burden countries
to develop effective national policies for the treatment and prevention
of drug resistant TB.
TB has formed a deadly partnership with the
HIV virus and the HIV/AIDS epidemic is responsible for fuelling
the TB epidemic in certain parts of the world, particularly in
Sub-Saharan Africa. Neither epidemic can be effectively addressed
without dealing with the two diseases in a coordinated and collaborative
manner. Testing TB patients for HIV and HIV patients for TB would
be a good start and would dramatically improve detection rates
for both diseases and early detection will in turn help to save
lives.
New tools are desperately needed to take advantage
of new technologies and scientific breakthroughs as most tools
used now are outdated: the BCG vaccine is only partially effective;
the main diagnostic test for TB dates back to the 1880s and lacks
precision, and no new TB drugs have been developed since 1966.
The advent of XDR-TB had publicly exposed the limitations of existing
tools—as well as underlining the need for collaboration
between TB and HIV services—and reinforced the need for
a new approach to TB control. There have already been welcome
advances in this area but more investment is needed to accelerate
progress.
Above are mentioned just some of the major blockages
to effective prevention and control of TB. If TB is to be bought
under control and ultimately eliminated it is important that TB
is dealt with in a holistic way, taking into consideration all
of the above factors.
6. What role does your organisation play
in combating the four diseases? Do you believe that it is correctly
configured and adequately resourced to do the job? With which
other organisations do you collaborate? How would you assess the
degree of synergy?
RESULTS is an international grassroots advocacy
organisation working to create the public and political will to
end hunger and the worst aspects of poverty. RESULTS currently
operates in seven countries: Australia, Canada, Germany, Japan,
Mexico, UK and USA. Current campaigns include microfinance, education,
sanitation and global health.
RESULTS has campaigned for many years to generate
increased political will to eradicate diseases of poverty, including
TB, malaria and HIV. Through our network of volunteers we have
written and met with numerous Members of Parliament to raise awareness
and promote policies and initiatives that address these epidemics.
RESULTS UK is a member of, and works closely with, the Stop TB
Partnership, Stop TB Partnership for Europe, Malaria Consortium,
Coalition Against Malaria and UK Consortium on AIDS and International
Development.
For the past three years, RESULTS UK has been
engaged in a project to address and help reverse the global TB
problem through policy analysis, education of policymakers and
advocacy. The "Advocacy to Control Tuberculosis Internationally"
(ACTION) project is currently being implemented by a consortium
of non-governmental organisations in Canada, France, India, Japan,
Kenya, UK and USA. Policy guidance and technical assistance is
provided by experts from the World Health Organization and Stop
TB Partnership. RESULTS UK organises regular educational visits
to high TB burden countries for parliamentarians and currently
supports the secretariat of the All-Party Parliamentary Group
on Global Tuberculosis.
Synergy between non-governmental organisations
in high-income countries and intergovernmental governmental organisations
has been strong and effective to date in relation to TB. Two areas
where synergy could be strengthened are (a) between organisations
in high-income countries and organisations in middle/low income
countries; and (b) between organisations working on TB and organisations
on HIV. In both cases, there is great potential for further collaboration
and sharing of knowledge and skills.
7. What are the main non-health causes (e.g.
global warming, poverty, changes in land use, international travel,
lifestyle, population) of the spread of the four diseases? To
what extent can intergovernmental action in non-health fields
contribute to the alleviation of their spread? What action is
taking place or planned in these areas? And what more needs to
be done? Do you consider that there is sufficient "joined-up"
thinking in approaching the problem?
"TB is the child of poverty—and also
its parent and provider". This quote by Archbishop Desmond
Tutu seems to accurately encapsulate the inextricable link that
exists between TB and poverty. Whilst TB is by no means exclusively
a disease of the poor it is certainly more prevalent in poor communities
and it is the poor who are least equipped to deal with its consequences.
Conditions of poverty, especially overcrowding
continue to fuel the TB epidemic. People who live in dark, unventilated
and crowded rooms prove to be particularly susceptible to the
disease and such conditions allow for the rapid spread of the
disease from person to person. Malnutrition is another factor
that is conducive to the spread of TB. Poorer communities are
also more heavily afflicted by HIV, which reduces a person's resistance
to TB significantly, allowing the spread of TB amongst an already
vulnerable population.
TB continues to thrive in areas of poverty because
the poor often have diminished access to medical facilities and
ensuring a full programme of treatment proves to be far more difficult
to accomplish. People's ignorance of the disease and the continued
stigma attached to it also hinder both treatment and efforts at
prevention.
TB also perpetuates the cycle of poverty and
deprivation with families afflicted by TB often losing 20-30%
of their annual income due to loss of work whilst being treated
and because of travel costs to and from clinics. If a patient
dies the family loses on average 15 years of income. Poverty alleviation
strategies rarely deal with the issue of TB explicitly, which
is an oversight that should be rectified if the root causes of
TB and its spread are to be effectively dealt with.
8. Cases of tuberculosis fell progressively
in the UK until the mid-1980s but started to rise again in the
early 1990s. Around 6,500 cases are now reported each year, an
increase of about a quarter since the early 1990s. What are the
main factors of the revival of tuberculosis infections in Britain?
And how could intergovernmental action help to reverse the trend?
According to the Health Protection Agency, a
total of 8,497 cases of TB were reported in 2006 in the UK (7,862
cases in England, 189 in Wales, 62 in Northern Ireland and 384
in Scotland).
Levels of TB among the general population continue
to be low (14 cases per 100,000 population) but in some areas
of the UK, such as London and the West Midlands, rates of TB remain
high. The majority of TB cases in the UK occurred in young adults
aged 15-44 years with the London region accounting for the largest
proportion of cases (40%) and the highest rate (44.8 per 100,000).
72% of TB cases were found among people born
outside of the UK. Among the non-UK born population, most cases
belonged to the Indian, Pakistani and Bangladeshi communities
(45%), and the highest rate was among those belonging to the black
African ethnic group (395 cases per 100,000 population). Immigration
is commonly cited as the reason for growing rates of TB in the
UK but many other countries in Western Europe experience equal
or higher rates of immigration. Further research is required by
the UK government, in collaboration with relevant intergovernmental
organisations into the correlation between the ethnic origin of
TB patients and patterns of migration to the UK and other Western
European countries.
Only one out of five non-UK born cases arrived
in the UK in the two years prior to their TB diagnosis. 30% had
entered the UK two to four years prior, 21% five to nine years
prior and 29% had entered 10 or more years prior. These statistics
suggest that the majority of patients became infected with TB
in their country of origin and carried the latent TB infection
for many years. Further research is needed to establish why latent
TB infection becomes active disease, for example if there are
correlations with poverty, malnutrition, HIV or other conditions.
Furthermore, further research is required into more effective
and systematic ways of identifying individuals who enter the UK
with latent infection so that they can be treated before developing
active disease. Global and national awareness campaigns are needed
to encourage patients (and health professionals) to recognise
the symptoms of TB, to reverse stigma and to increase both case
detection and treatment success rates.
In order to reverse the revival of TB infections
conclusively, national governments should work in partnership
with intergovernmental organisations to control TB worldwide.
As patterns the UK's experience demonstrates, controlling TB in
one country will not prevent it from returning in the future.
A global approach must be taken to tackling a disease that knows
no borders.
9. Tuberculosis is potentially curable by
long-term antimicrobial therapies. Yet the number of reported
cases worldwide seems to be rising. Are the necessary medicines
not getting through to patients? What are the barriers to effective
long-term therapy? Are we now seeing infections which stem from
other conditions e.g. HIV/AIDS? Or are there other reasons why
a treatable disease should be spreading? How might intergovernmental
action help to deal with this situation?
Much progress has been made in improving the
distribution of Drugs to treat TB. The Global Drug Facility (GDF)
has been a particularly useful mechanism for helping to increase
access to life-saving drugs at comparatively affordable prices.
In addition to continuing to provide first-line treatments—a
projected additional 15 million first-line treatments will be
provided from 2006 to 2015—the GDF will expand its catalogue
to include second-line and paediatric drugs as well as diagnostic
kits. This will be a welcome development that will no doubt save
many lives. However, numerous barriers continue to exist which
impede efforts to ensure that these drugs reach those in need.
Firstly, detection rates for TB remain unimpressive
despite improvement in many areas. Many countries continue to
fall short of the 70% target detection rate set by WHO. This not
only results in infected people not receiving the treatment they
need, but also increases the risk of the infected person passing
on the disease to other people, helping to fuel the spread of
TB. The earlier the disease is detected, the easier it is to treat.
The drugs regimen for treating TB is complex
and long, lasting on average six to eight months. Without correct
supervision an alarming number of patients fail to successfully
complete their course of drugs, a factor that is fuelling the
spread of MDR and XDR-TB worldwide. Efforts to simplify and shorten
TB treatment should be supported and well funded to increase the
success rate of such treatments and reduce the risk of drug resistance.
As has already been mentioned, the HIV epidemic
is continuing to fuel the TB epidemic. Despite this fact being
almost universally acknowledged, efforts at tackling both diseases
remain largely independent of one another. This oversight is continuing
to cost lives. If either disease is to be dealt with effectively
more TB/HIV collaboration is needed. Much more intergovernmental
effort is needed to promote a more collaborative approach to the
two diseases and the UK should be at the forefront of such efforts.
12. To what extent do you consider that
the rise in infections in the four diseases is attributable to
increased microbial resistance to antibiotics? What intergovernmental
action is taking place in this area?
The emergence of drug resistant forms of TB
has been a worrying development. Multi-Drug Resistant TB (MDR-TB)
is a form of TB that does not respond to standard treatment using
first line drugs and is now present in virtually all countries
recently surveyed by WHO. Treatment for MDR-TB is much longer
than treatment for standard TB, lasting about two years. It is
also many times more expensive and has many more side-effects
for the patient. If the treatment of MDR-TB is mismanaged, even
more deadly strains of TB can develop, most notably Extensively
Drug Resistant TB (XDR-TB) which is virtually untreatable.
The World Health Organization estimates that
up to 50 million persons worldwide may be infected with drug resistant
strains of TB. Also, 300,000 new cases of MDR-TB are diagnosed
around the world each year and 79% of the MDR-TB cases now show
resistance to three or more drugs.
If the emergence of drug resistance TB is not
dealt with effectively, the number of cases could spiral out of
control, posing a health risk to millions of people throughout
the world. Efforts have been made to ensure that this does not
happen and the WHO has made MDR-TB surveillance and control an
important component of its overall TB strategy. It has developed
what is known as "DOTS-plus" and the "green light
committee" as a means of effectively combating MDR-TB and
it is important that the UK supports such efforts to ensure that
they can be implemented swiftly and effectively.
19. What resources does the UK Government
commit to intergovernmental bodies to help in the fight against
the four diseases listed?
The Department for International Development
(DFID) currently provides support for TB control through the following
international technical organisations and global health partnerships:
— £100 million committed to the
Global Fund to Fight AIDS, TB and Malaria (GFATM) for 2007 bringing
the UK's total contribution to date to £359 million. In September
2007, the Secretary of State announced a further eight-year pledge
of £1 billion to the GFATM (including £360 million for
the period 2008-10).
— DFID provides core resources to the
World Health Organisation (currently £12.5 million per annum),
leaving it to WHO to determine the allocation of resources to
the AIDS, TB, and Malaria cluster within WHO.
— DFID supports the Stop TB Partnership
and is committed to providing a total of £8.98 million from
2002-08. This will help the partnership to advocate for commitment
to the Global Plan to Stop TB, 2006-2015 and monitor progress.
— DFID is a founder member of UNITAID
(International Drug Purchase Facility), which was launched in
September 2006 at the United Nations General Assembly. UNITAID
funds drugs and diagnostics for AIDS, TB and malaria. The UK has
made a 20-year commitment, starting with £15 million in 2007,
and, subject to the outcome of a joint assessment of the performance
of UNITAID, rising to £40 million a year by 2010. UNITAID
will provide additional funding for drugs to treat multi-drug
resistant TB (MDR-TB) as well as paediatric formulations of TB
drugs.
— DFID currently funds two research
programme consortia on communicable disease with London School
of Hygiene and Tropical Medicine and Nuffield Centre for International
Health at Leeds University. Both programmes will receive £5
million each over five years.
— DFID supports the research and development
of TB drugs and diagnostics via WHO's programme on Tropical Disease
Research (TDR) and the public/private Product Development Partnership
(PDP), the Global Alliance for TB drugs. The Global Alliance will
receive £6.5 million from 2005-08 for the development of
new drugs.
1 February 2008
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