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TB 'Trouble Spots' Jeopardize Global Control Efforts

WHO, The TB Treatment Observer - Issue 5

May 1, 1998. An international committee of TB and public health experts called on world leaders to give their urgent attention to TB 'trouble spots' that jeopardize global control of the epidemic. The group cited lack of political will as the main constraint that 16 high-burden countries face in establishing and sustaining effective TB control programmes.

The committee met in London on March 17-19 to review new data released by the World Health Organization that showed global TB control targets for the year 2000 would not be met because the 16 key countries, shouldering more than half of the world's TB burden, have moved too slowly in using the DOTS treatment strategy, or have not adopted it at all.

In a statement released after the meeting, the committee said "intensified technical efforts will not by themselves bring about the acceleration and expansion needed. It is the primary responsibility of the political and health leaders of the countries faced with the epidemic to execute an effective response."

The TB experts examined data in the newly released publication entitled Global Tuberculosis Control 1998, which highlighted 22 countries that account for more than 80 per cent of the world's TB burden. Of the 22 countries analyzed, 16 were targeted for immediate action.

Half of the trouble spots are middle- or upper-middle income countries-Brazil, Indonesia, Iran, Mexico, Philippines, Russian Federation, South Africa and Thailand. These countries have the financial means to tackle TB, but some have delayed too long in pressing for the successful implementation or expansion of DOTS. The other eight countries are low-income economies-Afghanistan, Ethiopia, India, Myanmar, Nigeria, Pakistan, Sudan and Uganda. These countries also delayed the adoption or the expanded use of the DOTS strategy so that too little progress has been made. In at least four of them, there has been deterioration in TB control efforts, as shown by worsening treatment success rates. Most of these countries will need financial assistance to fully adopt DOTS and quickly expand their TB control efforts.

"Some governments did not take WHO's declaration of a global TB emergency seriously," said Dr Arata Kochi, Director of the WHO Global TB Programme. "Countries that did-such as Bangladesh, Viet Nam and Peru-are making excellent progress toward controlling TB."

The committee cited six principal constraints retarding action by health authorities: financial shortages, human resource problems, organizational factors, lack of a secure supply of quality anti-TB drugs, public information gaps about TB's danger, and lack of political will to develop and sustain effective TB control programmes, the latter being the greatest of the constraints.

WHO warned that no country is safe from TB as long as the epidemic is allowed to thrive in parts of the world. "TB is certain to spread wherever it is ignored," said Dr Carlyle Guerra de Macedo, chair of the committee and the former Director of the Pan American Health Organization. "If we allow TB to prosper and multiply in any corner of the world, we do so at our own peril."

The committee acknowledged that any efforts to turn back the tide of TB will require global cooperation. "A coordinated partnership of the WHO, the World Bank, bilateral development assistance agencies, the IUATLD, other NGOs and the global research community is needed urgently," according to the committee's statement.

"These institutions can help sustain the environment to encourage political will. Then they can methodically and persistently alleviate the other identified constraints through policy and technical collaboration with the endemic countries and by financing and supporting the DOTS strategy, including the research to permit its wider and easier use."

According to WHO, the TB epidemic will become more difficult to contain the longer extensive control efforts are delayed. A lethal combination of HIV and TB is leading to sharp increases in the TB epidemic, particularly in Africa. Poorly managed TB programmes, especially in the former Soviet Union and Asia, are causing drug-resistant strains of TB to emerge that could render TB incurable. Asia shoulders almost two-thirds of the burden of the epidemic, accounting for 64 per cent of the world's notified TB cases. Without more effective action, 70 million people will die from TB between now and 2020.

In contrast to the 16 countries, TB control is succeeding in many parts of the world, such as Armenia, Cambodia, Cuba, Kenya, Malawi, Mongolia, Morocco, Nicaragua, Oman and Slovenia, to name a few.

It has become clear that the DOTS strategy can achieve high cure rates and steady expansion in any country that is determined to control TB. DOTS is being used extensively in large countries such as Bangladesh and in half of China, as well as in small countries such as Equatorial Guinea, Maldives and Seychelles.

There is hope that many trouble spots can soon become TB control success stories. Ten countries-Afghanistan, Iran, Mexico, Myanmar, Philippines, Russian Federation, South Africa, Sudan, Thailand and Uganda -have all begun to implement DOTS since 1996, and the treatment outcome data from these initial efforts will be available for analysis late this year.

Few health initiatives have expanded as quickly and as successfully as the DOTS strategy. Globally, use of DOTS has risen 26 per cent, from 704,920 notified patients in 1995 to 887,731 patients in 1996. According to Global Tuberculosis Control 1998, 96 countries have begun to use the DOTS strategy, compared with only 19 in 1993.

The treatment success rate of cases in DOTS areas was 78 per cent, compared with 45 per cent in non-DOTS areas.