The countries that report high burden of tuberculosis (TB), particularly, drug-resistant strains of TB, are the ones not moving fast enough to provide life saving treatment. According to the International medical humanitarian organization, Médecins Sans Frontières (MSF) or doctors without borders, less than one percent of those with multi-drug resistant TB (MDR-TB) get access to proper treatment as per the International standards of treatment and care guidelines of World Health Organization (WHO).Even the Stop TB Partnership agrees that about three per cent of those with MDR-TB might be receiving proper treatment.
"Only 3% of people who have MDR-TB have access to effective treatment. We have compelling evidence that we know how to prevent and treat MDR-TB and treatment success rate is 80% in low resource setting. Its intervention is complex but is effective, feasible and is cost-effective" stressed said Dr Ernesto Jaramillo, Medical Officer, Stop TB Department, World Health Organization (WHO) at the 3rd Stop TB Partners' Forum in Rio de Janeiro, Brazil.
Dr Mario Raviglione, Director of the WHO's Stop TB department, said that "the WHO Global Tuberculosis Control Report 2009 confirms the notion that there might be more than half a million MDR-TB cases every year. 54 countries have reported extensively drug-resistant TB (XDR-TB) to us."
As ministers from high-burden multi- and extensively- drug-resistant TB (M/XDR-TB) countries gather from 1-3 April 2009 in Beijing, China, for a high-level ministerial meeting on M/XDR-TB, MSF calls on them to commit to treating more people with MDR-TB, and to conducting necessary research to improve current treatment options.
The WHO reports that there are more than 500,000 new MDR-TB cases each year, but that under 30,000 people were detected and notified last year and only 3,681 are known to have started treatment according to international guidelines and with quality-assured medicines.
“The slow progress in treating people with MDR-TB is particularly striking because high-burden MDR-TB countries are definitely not the least developed in the world,” said Dr. Tido von Schoen-Angerer, Director of MSF’s Access to Essential Medicines Campaign. “They have the capacity to act, and need to make this a priority and put people on treatment.”
MSF is concerned that many countries, particularly those that are classified by WHO as ‘high-burden’, like China, South Africa or India, are not doing enough to provide treatment to patients in need. In addition, not providing appropriate treatment further contributes to the spread of drug-resistant TB.
China, for example, has a quarter of the world’s MDR-TB cases. Answering to an initial request made by the Chinese National TB Programme, MSF then failed to obtain the authorisation to provide care for MDR-TB patients in inner Mongolia, despite two years of negotiations with national, provincial and regional authorities. MSF has now abandoned its attempts to open the project.
“Not being able to act when there are people that need life-saving treatment is extremely frustrating,” said Meinie Nicolai, MSF Director of Operations. “Because we did not manage to reach an agreement, we could not put a single patient on treatment. And because they can’t get treated anywhere else, many people will have died while we were stalled in meetings these past two years.”
“Crucially, high-burden countries have the skills and some of the resources needed to conduct the research to improve MDR-TB treatment,” says Dr. von Schoen-Angerer. “The Beijing meeting is an opportunity for high-burden countries to take the lead in addressing this crisis, by setting targets to put more patients on treatment, by agreeing to import quality-assured drugs, and by establishing a joint research effort to improve existing treatment.”
In 2007, MSF treated 574 patients for MDR-TB in 12 projects including in South Africa, India, Uzbekistan, Georgia and Armenia.
According to the World Health Organization (WHO), the countries with the highest burden of MDR-TB are India (131,000 cases), China (112,000), Russia (43,000), South Africa (16,000) and Bangladesh (15,000).
The High Level Ministerial Meeting on M/XDR-TB is being organized by WHO, the Ministry of Health of the People's Republic of China and the Bill and Melinda Gates Foundation.
This meeting is likely to bring together health ministers and other stakeholders from 27 high M/XDR-TB burdened countries, including justice and science ministry delegations and representatives from international agencies, civil society, research communities and the corporate sector.
"We have been able to convince the ministers of health of 27 high burden M/XDR-TB countries to come to the Beijing meeting and commit to achieve the targets of the Global Plan to Stop TB" said Dr Ernesto Jaramillo, Medical Officer, Stop TB Department, WHO at the 3rd Stop TB Partners' Forum in Rio de Janeiro, Brazil.
"The 2nd Global Plan to Stop TB which was launched in 2006 had laid out specific targets for MDR-TB, to provide universal access to diagnosis and treatment of MDR-TB by year 2015" said Dr Jaramillo.
The 27 countries represented will be Armenia, Azerbaijan, Bangladesh, Belarus, Bulgaria, China, the Democratic Republic of Congo, Estonia, Ethiopia, Georgia, India, Indonesia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, the Republic of Moldova, Myanmar, Nigeria, the Philippines, the Russian Federation, Pakistan, South Africa, Tajikistan, Ukraine, Uzbekistan and Viet Nam.
The highest levels of MDR-TB ever recorded were reported by WHO in its 'Anti-tuberculosis Drug Resistance in the World' report in February 2008 with nearly half a million new MDR-TB cases emerging worldwide. According to the new WHO report (Global Tuberculosis Control report 2009), the levels of multi-drug resistant TB might be more than half a million as previously thought.
The threat of MDR-TB and XDR-TB can be halted but few of the 27 high MDR-TB burdened countries have response plans in place. Many of these countries are not even properly equipped to diagnose drug-resistant TB.
"We need political commitment from the countries. The XDR-TB task force had met in April 2008 in order to assess the progress we had made in response to MDR-TB and XDR-TB. The Task Force came up with lot of positive things, major progress in many areas. However the number of people on treatment was far below the target. One of the clear recommendations coming out of the XDR-TB Task Force meeting was to convene a high level ministerial meeting where we can get ministers of countries responsible for the 85% of the global M/XDR-TB burden, to achieve the target of universal access to diagnosis and treatment of MDR-TB by 2015" explained Dr Jaramillo.
Countries with low resources are building their capacities to make things happen. Lesotho was able to make a state-of-the-art laboratory for diagnosis of MDR-TB in six months. "We have countries like Nepal, Philippines, Peru that despite of weakness in health systems are providing universal access to MDR-TB diagnosis and treatment" said Dr Jaramillo.
"So far the Green Light Committee (GLC) mechanism, which is an initiative of WHO, and has played an instrumental role in leading the response, began with only one country in the year 2000 - Philippines. Now 8 years later we have 58 countries that have 116 projects approved by GLC. However we have less than 20% of countries that are moving towards scale up country wide of these interventions" said Dr Jaramillo.
Dr Jaramillo expressed his concern that "Countries are not moving fast enough in order to prevent the death of 1000 people with MDR-TB every day."
Vice Premier of China, the Director-General of WHO and very likely that Bill Gates and ministers of health confirmed so far from 21 high burden M/XDR-TB countries will be taking part in the Beijing meeting opening next week.
"We are expecting that this will be a watershed meeting in response to M/XDR-TB" said Dr Jaramillo.
"After this meeting we will like to move towards a World Health Assembly (WHA) resolution. The resolution of WHA is powerful in the sense that countries really commit to do things. After the Beijing meeting, one month later, the Government of China has agreed to submit a proposal of a resolution to the WHA in order to accelerate the response to M/XDR-TB" shared Dr Jaramillo.
Investing in research is also necessary. Treating MDR-TB is complex, lengthy and involves the use of drugs that can cause severe side effects and are not optimally effective. There is therefore an urgent need to speed up the development of newer, better tests and drugs, and to conduct studies to optimise MDR-TB treatment.
(The author is a World Health Organization (WHO) Director General’s WNTD Awardee 2008, coordinates the Stop-TB eForum Resource Team of HDN, and writes extensively on health and development. Email: firstname.lastname@example.org)