End TB strategy: great challenges to conquer20/09/2018 - Eduardo Hage
Tuberculosis is one of the main infectious diseases in the world, representing one of the ten leading causes of death, estimating around 1.6 million deaths and 10 million cases of this disease in 20171. Its association with infection by HIV and some chronic non-communicable diseases have added new challenges in the control perspectives, bringing serious consequences to people with a double burden of diseases. Also, the occurrence of resistance to the drugs used for its treatment has generated new difficulties for its control.
Although tuberculosis affects all countries and population groups, its impact is highest among the most vulnerable groups. The precariousness of housing, hunger and limited access to basic health services, among other factors, generate a greater risk of transmission and vulnerability. Ethnic minorities, migrants, people deprived of their liberty, people with HIV infection and those affected by non-communicable diseases (e.g., diabetes) are also at increased risk of infection and death from tuberculosis.
In the Americas, it was estimated that in 2015, some 268,500 people contracted tuberculosis and 25,000 died, while a reduction in the incidence from 46 to 27 cases per 100,000 inhabitants was observed between 1996 and 20152. Tuberculosis mortality rates have also reduced, from 4.3 to 2.5 per 100,000 inhabitants in the period 2000-20152. In South America there was also a significant reduction in incidence and mortality, as for example, between 2000 and 2015 the incidence rate reduced 22.2% and the mortality rate 37.9%3.
The progress achieved with the reduction of morbidity and mortality indicators was attributed to multiple causes and especially to the use of technologies already available for the control of the disease, in addition to the improvement of socioeconomic conditions in some regions. For example, the implementation of DOTS strategies (Directly Observed Treatment Short) and Stop TB initiative was highlighted in the Americas2.
Meanwhile, in recent years some limits for the maintenance of these advances on the epidemiological situation began to be observed. In the Americas, the rate of decline in incidence and mortality has slowed since 20072. In the South American region, the slowdown in incidence and mortality is more visible until 2010, and since then a stagnation or decrease in the reduction intensity has been observed3. A second limit is related to the very large heterogeneity among the countries in relation to these trends. For example, in the South American region there is a range of variation in incidence rates, between countries, in the period from 2000 to 2015, between – 49.6% (reduction) to + 37.5% (increase)3. These differences are also reflected in the population groups within each country, related to situations of vulnerability.
These limits reflect the persistence or worsening of factors linked to poverty, social inequality and exclusion. In the field of health, the limits reflect differences in the effectiveness of the programs of each country and for each population group, in the access to actions and technologies for diagnosis and treatment. In this field, important gaps are identified that have made it difficult to move towards the goals established to end tuberculosis. As an example, 6.4 million cases reported worldwide in 2017 represented 64% of the 10 million estimated for the same year, which indicates insufficient capacity to detect and diagnose new cases or to notify them, even when they are identified1. Other problems that may affect the maintenance of the intensity of the reduction of tuberculosis indicators are: insufficient proportion of treated cases and in a timely manner, high burden of double TB/HIV infection, increase in the proportion of cases of drug-resistant tuberculosis, among others.
End TB as a global commitment
This situation, in the context of the international commitments assumed in different instances, means that after the successes achieved in the fulfillment of the Millennium Development Goals, there are threats to fulfill the Sustainable Development Goals4. At this pace of deceleration or stagnation, the goal of the SDGs of “End TB” until 20301, meaning a reduction of 90% in deaths and 80% in the incidence of the disease, compared to 2015 levels, would be threatened. As evidence of this threat, to reach the target estimated for 2020 (first evaluation period), a reduction in incidence of 4 – 5% per year, on a global average, would be necessary, while this reduction has been around 2% per year1.
With this scenario, in December 2016, the General Assembly of the United Nations adopted Resolution 71/159, in which it decided to hold a High Level Meeting on the fight against tuberculosis in 20185. In this framework, a World Ministerial Conference on the fight against tuberculosis in the context of public health and the Sustainable Development Goals was held in Moscow in November 20176. This Conference produced the Moscow Declaration, which constitutes an important input for the High Level Meeting, being highlighted through a Resolution of the 71st World Health Assembly of 20187.
The Moscow Declaration6 presents a call to action that covers issues related to: the prevention, diagnosis, treatment and care of the disease; prioritizing high-risk groups and populations in vulnerable situations; multiresistant tuberculosis; integration of actions aimed at prevention, control and care for tuberculosis with those aimed at HIV infection, other coinfections, relevant non communicable diseases, malnutrition, mental health and the harmful use of alcohol and the abuse of other substances; access to new anti-TB drugs; reduction of stigmatization, discrimination and isolation of communities. The issue of management and financing highlights the need to mobilize the national funding needed to strengthen health systems and measures to address catastrophic costs. In the field of research, the inclusion of research on the environmental and social determinants of tuberculosis and effective intervention strategies is highlighted.
In preparation for the High Level Meeting of the General Assembly of the United Nations and from the push of the Moscow Ministerial Conference, many initiatives of countries and regional blocs have taken place in order to mobilize the participation of all interested actors and deepen the discussions on the subject. South American countries have actively participated in these efforts, highlighting, from the Moscow Conference, among others, the meetings of the BRICS, G20 and the Ministers and Secretaries of Health “Contribution of regional integration in the Americas towards the goal of tuberculosis “8.
The meeting of Ministers and Secretaries of Health was held in February of this year, organized by the ORAS-CONHU and was attended by representatives of 15 countries in South America, Central America, Cuba, the Dominican Republic, in addition to PAHO and 4 regional and subregional organizations (ISAGS/UNASUR, ORAS-CONHU, SECOMISCA and MERCOSUR-Health)8. Among other contributions, this meeting highlighted the need to strengthen the National Tuberculosis Programs in a sustained manner, with adequate funding, investment in the stability and training of human resources, equipment and supplies for the laboratory (and the strengthening of existing laboratory networks in the region), technological capacities and information systems for appropriate analysis of the socio sanitary situation and invest in the joint procurement of medicines. As well as the need to resolve the great inequalities in the distribution of wealth, to approach the problem from the perspective of the right to health and universal access to health, to develop processes of intersectoriality to address the social determination of health, prioritizing the approaches to the most vulnerable groups and improving health systems and services within the framework of the SDGs.
Some contributions to the discussions in the context of the High Level Meeting on Tuberculosis of the United Nations General Assembly
Thus, in the framework of the preparation for the High Level Meeting and with these contributions mentioned here, discussed in different meetings, spaces of articulation and based on the accumulated knowledge throughout the production on the subject, it is important to have in account:
a) the relationships between access to health technologies, social vulnerability and health inequality – the populations that are most vulnerable are the same as those that the determining factors for the production and dissemination of the disease present these effects, as well as those in which access barriers are more strongly expressed;
b) to improve the effectiveness of national tuberculosis programs, regarding the capacities of case detection, timely treatment, tackling with the double burden of HIV/AIDS infection (or the double burden of non-communicable diseases) and drug-TB resistant, and facilitate access to the most vulnerable populations, it is necessary to reduce inequalities in health9 and from the perspective of the right to health and universal access to health, as indicated at the meeting of Ministers and Secretaries of Health “Contribution of regional integration in the Americas towards the end of tuberculosis”8. This proposal must also be inserted in the framework of the ongoing discussions for the 40th anniversary of the Declaration of Alma-Ata on Primary Health Care.
c) To reverse the current trend of stagnation or worsening on the epidemiological and operational indicators of the disease, it is necessary, in addition to offering safe, accessible and effective health technologies, to work on the social determinants of health. In this particular, it is an emblematic fact that at this moment when discussing how to “end TB”, according to the report published by the FAO this month, “Hunger has increased in the last three years, returning to the levels of a decade ago, “including in South America10.
Finally, it is possible to project that ending TB in this short time is a possible goal, although it represents a very broad challenge, considering the current state of epidemiological trends – not favorable – in the world and in particular in the South American region. Addressing this challenge means a major change in the policies and processes used to address the problem in more recent years, for which the commitment of Heads of State from the High Level Meeting will be critical, involving other sectors of government and the actors of society. It means adopting the spirit of the construction of SDGs, which considered that for the improvement of the health and well-being of the world population it is necessary to reduce inequalities, which is implicit in the statement “no one left behind “.
- World Health Organization. Global tuberculosis report 2018. Geneva: World Health Organization; 2018. Disponible en: http://apps.who.int/iris/bitstream/handle/10665/274453/9789241565646-eng.pdf?ua=1. Acceso en: 19.09.2018
- Organización Panamericana de la Salud. Salud en las Américas+, edición del 2017. Resumen: panorama regional y perfiles de país. Washington, D.C.: OPS; 2017. Disponible en: https://www.paho.org/salud-en-las-americas-2017/wp-content/uploads/2017/09/Print-Version-Spanish.pdf. Acceso en: 19.09.2018
- World Health Organization. Global Health Observatory. Disponible en: http://www.who.int/gho/en/. Acceso en: 19.09.2018
- Programa de las Naciones Unidas para el Desarrollo, Objetivos del Desarrollo Sostenible. Disponible en: http://www.undp.org/content/undp/es/home/sustainable-development-goals.html. Acceso en: 19.09.2018
- United Nations General Assembly. Options and modalities for the organization of the high-level meeting on tuberculosis convened by the President of the General Assembly. Disponible en: http://www.who.int/tb/features_archive/UNGA_report_on_HLMN_TB.pdf. Acceso en: 19.09.2018
- World Health Organization. Primera Conferencia Ministerial de la OMS: Poner fin a la tuberculosis en la era del desarrollo sostenible: una respuesta multisectorial. Moscú (Federación de Rusia), 16-17 de Noviembre de 2017. Disponible en: http://www.who.int/tb/endtb-sdg-ministerial-conference/es/. Acceso en: 19.09.2018
- 71ª World Health Assembly, 2018. Preparación para la Reunión de Alto Nivel de la Asamblea General sobre el fin de la tuberculosis. Disponible en: http://apps.who.int/iris/handle/10665/274071. Acceso en: 19.09.2018
- Organismo Andino de Salud Convenio Hipolito Unanue. Reunión de Ministros y Secretarios de Salud “Contribución de la integración regional en las Américas hacia la meta fin de la tuberculosis”. Disponible en: https://www.orasconhu.org/node/3251. Acceso en: 19.09.2018
- Gomes et al. End TB strategy: the need to reduce risk inequalities. BMC Infectious Diseases, 16:132, 2016
- FAO, FIDA, UNICEF, PMA y OMS. 2018. El estado de la seguridad alimentaria y la nutrición en el mundo. Fomentando la resiliencia climática en aras de la seguridad alimentaria y la nutrición. FAO, Roma.
Especialista en Vigilancia en Salud de ISAGS