U.S. Role Critical to Addressing Increases in Drug Resistant TB
October 30, 2013
Nellie Bristol, Research Fellow
Global Health Policy Center, Center for Strategic and International Studies
The world is facing a stealthy and alarming increase in drug resistant tuberculosis, the World Health Organization (WHO) indicated in its yearly global TB report, released last week. While the 2012 incidence of TB continued its slow, steady decline from prior years, there were an estimated 450,000 new cases of multiple drug-resistant TB (MDR-TB) in 2012, according to the Global Tuberculosis Report 2013. Worse, fewer than 25 percent of people suspected of having MDR-TB were identified last year and 16,000 people diagnosed with the disease were not put on treatment, the international health organization said. Treatment waiting lists are continuing to grow, it added.
MDR-TB should be treated as a public health crisis, WHO says. “In high MDR-TB burden countries, increased capacity to diagnosis MDR-TB must be matched with supplies of quality drugs and scaled-up country capacity to deliver effective treatment and care,” the report states. “This will require high-level political will and leadership and more collaboration among partners, including drug regulatory authorities, donor and technical agencies, civil society and the pharmaceutical industry.”
WHO classifies 27 countries as “high burden” for MDR-TB, including India, China, and Russia. In several countries in eastern Europe and central Asia, more than 20 percent of new cases and more than 50 percent of previously treated cases have MDR-TB. Globally, the corresponding figures are 3.6 percent and 20.2 percent. An even more dangerous strain, extensively drug-resistant TB (XDR-TB) has been reported by 92 countries, up from 84 in 2011. WHO estimates that on average 9.6 percent of MDR-TB cases have XDR-TB, a disease that responds to few if any available drugs and frequently is fatal. Beyond the need to expand access to treatment, the report also addresses prevention by calling for strengthening infection control activities in and around clinics and hospitals in order to reduce the spread of all forms of TB, including drug resistant strains.
Spurring at least some of the increased attention to MDR-TB are new diagnostic tests that more quickly indicate whether a specific TB infection is drug resistant. But treating the disease is difficult and costly and new tools are needed. “We need a breakthrough in treatment options to transform [drug resistant tuberculosis] treatment from an agonizing, toxic and prohibitively expensive two-year ordeal, to a shorter, more tolerable, more effective and more affordable treatment course,” said Grania Brigden, TB Advisor for Médecins Sans Frontières’ Access Campaign. To support countries in scaling up their efforts, Brigden called for increased funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria, the largest international donor to national tuberculosis programs. WHO projects $1.6 billion will be needed from international donors annually for 2014 and 2015 to supplement domestic TB spending.
The United States is another key international player. Through the United States Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), and the President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. provides either directly or indirectly more than 70 percent of external technical assistance provided to national TB programs, according to WHO estimates. The U.S. also is a major supporter of the Global Fund, pledging nearly a third of the organization’s funding since its creation in 2002.
While U.S. programs focus on all forms of TB, drug resistant strains are a particular worry. “The increased presence of MDR-TB is a major public health concern,” said Cheri Vincent, Chief of the Infectious Diseases Division at USAID. “USAID is building the capacity of countries to develop first ever MDR-TB treatment programs or improve or expand existing ones.” CDC officials also call for greater capacity. “Stemming the tide of drug resistance requires strengthening basic TB control measures to prevent transmission, ensure prompt diagnosis, and appropriate therapy,” said Dr. Eugene McCray, Chief of the International Research and Programs Branch of the CDC’s Division of TB Elimination.
But adequate funding continues to be an issue. TB already has the smallest budget of the three largest infectious disease programs prioritized by the U.S. The fiscal year 2012 HIV budget under PEPFAR totaled $5 billion while U.S. funding for malaria control that year reached $806 million, according to the Kaiser Family Foundation. By contrast, funding for U.S. programs aimed at global TB totaled $256 million. The funding pattern persists even though the number of global deaths from TB rivals those from HIV: while 1.7 million people died from AIDS-related illness in 2011, 1.4 million deaths were associated with TB that year, according to WHO data.
Donors other than the U.S. should increase contributions to ensure countries can tap the expertise they need to build sustainable, self-sufficient national TB programs that can effectively treat TB and reverse trends in drug resistance. In the meantime, U.S. efforts to help countries with the task need to continue, and to the extent possible, be increased. TB too often is considered a disease of the past and is marginalized both in terms of funding and political attention. But the ancient affliction has taken on a frightening new face that needs to be countered aggressively before it becomes an even greater threat.