Testimony of Dr Mario Raviglione to the U.S. House of Representatives
22 March 2007 - Good afternoon. It is an honor to join you today and to represent the World Health Organization in providing this briefing on the TB and XDR-TB epidemic. I would like to begin by thanking Chairman Donald Payne, Ranking Member Chris Smith and the committee staff for organizing today’s hearing. The Global Threat of Drug-Resistant TB is an incredibly important issue—and if we fail to urgently address it, it could reverse the enormous progress we have made in TB and AIDS care and control over the years. I will address, as requested, the global epidemic, and the impact of WHO and partners' efforts in fighting this global killer. This includes efforts by the Stop TB Partnership, representing over 500 institutions today, and in which US institutions play a key role. I am also pleased to be asked to note in what ways the U.S. Government can contribute further in TB control worldwide and particularly in Africa.
The global TB epidemic and the response to date
The global burden of TB is enormous despite being a curable disease in most cases. It is a disease found in all countries of the world without exception, and the developing world is most affected, but so are the poorest and most vulnerable communities in high-income countries. Most affected are the young, economically productive adults. The 2007 WHO Global TB Control Report will be launched tomorrow in lead up to World TB Day this week. Our data and trend analysis are embargoed until tomorrow, but I would like to share some critical information. In 2005, 8.8 million persons fell ill with TB, and 1.6 million died of it, 4400 every day. Nearly 200,000 deaths were among HIV-infected persons. While 60% of TB cases occur in Asia, sub-Saharan Africa has by far the highest TB rates per capita.
The good news, however, is that we have seen enormous progress in TB control. In 1995, less than 15% of all infectious cases were detected by good programmes. The picture has changed dramatically with 60% of cases now detected and 84% of them successfully treated. This is a remarkable progress towards the global operational targets of detecting 70% of cases and curing 85% of them. More concretely, 26 million patients have been treated in 11 years under DOTS, the WHO-recommended TB control approach. In addition, the Global Drug Facility—managed by the Stop TB Partnership—has supplied best priced, high quality TB drugs to over 9 million patients in over 60 countries in six years. The Partnership and WHO also support the Green Light Committee which is enabling access to safe and effective treatment for MDR-TB in over 40 countries to date. Over the past 15 years, WHO has intensively supported its Member States to adopt effective TB control and achieve measurable progress. Today 187 countries have adopted DOTS.
In 2006, to face the new challenges, WHO launched a new and more comprehensive Stop TB Strategy. This is built on DOTS successes, and explicitly addresses the challenges of HIV/TB and MDR-TB, ensures that TB control is integral to the strengthening of health system and services, calls for engagement of all non-state practitioners and communities, and promotes research for better diagnostics, drugs and vaccines.
Last year, the Global Stop TB Partnership, of which WHO, CDC and USAID are key partners, launched a 10-year business plan: The Global Plan to Stop TB 2006-2015. The Global Plan is a uniquely detailed blueprint to cut TB deaths and disease by 50% in the next decade and make TB incidence decline towards elimination. If fully financed, it will save an extra 14 million lives and enable access to new tools. The Global Plan also emphasizes the crucial importance of technical support to countries, so that the large financial investments by the Global Fund, the World Bank and others are as effective as possible.
The bad news, the news that should alarm us and call us to urgent action is the key focus of today’s hearing—the global epidemic of multidrug resistant TB, particularly its deadly synergy with AIDS. MDR-TB, which originates from the failure of programmes to ensure proper treatment support to patients, has been found in every one of more than 110 countries surveyed so far. XDR-TB, which is a more resistant, more deadly form of MDR-TB, has been reported so far in 35 countries, including all of the G-8. Put simply, XDR-TB is the worst thing I have encountered in my 15 years working in TB. I am struck by how swiftly it passes between and kills those with HIV—with death rates above 90%. Standard TB—TB that responds to drugs—can, in fact, be treated in those with HIV. Treatment can extend their lives for years, buying precious time in which to access antiretroviral therapy for those not yet receiving it. But most low-income countries lack the capacity to diagnose MDR-TB and XDR-TB due to lack of laboratories, let alone to clinically manage the disease. XDR-TB linked to HIV means these strains kill far more quickly and spread far more rapidly, including to the general population and to the health workers. Moreover, XDR-TB killed PLHIV who were on ARV treatment, offsetting all the care gains achieved with ARVs.
XDR-TB has already created a major alarm in South Africa. A few weeks ago, 8 XDR-TB patients were transported by healthcare workers—who were wearing full-body protective suits—to a South African hospital. At the site of them, roughly 100 patients, 100 very sick patients, got up from their beds and walked out.
Preventing and treating MDR-TB and XDR-TB
So what must we do? In March 2006, CDC and WHO reported for the first time on XDR-TB. To further clarify: XDR-TB is TB that is resistant to both first line anti-TB drugs AND the most effective classes of second-line drugs—the back-up drugs. Treatment is therefore highly complex, costly, and in over 50% of cases ineffective. Following the description of XDR-TB among PLHIV in the KwaZulu-Natal Province of South Africa and its over 90% mortality, in October 2006, a WHO Task Force urgently identified priorities for a worldwide response. First and foremost was the call for immediate strengthening of DOTS programmes to prevent drug resistance to evolve. Then, it called for rapid diagnostic methods and much strengthened laboratories, for access to proper treatment regimens and supervision, for infection control measures, as it is suspected that many cases acquire XDR-TB in hospitals.
In responding to XDR-TB, Southern Africa is the priority and over the last six months, WHO has been guiding development of country and global XDR-TB response plans.
To pursue an effective and comprehensive XDR-TB response immediately, the Global Plan to Stop TB must be fully implemented. The Global Plan remains badly under-funded, despite investments by affected countries themselves and the important contributions of the Global Fund. For instance, in 2007, the Global Plan requires over US$ 5 billion globally for implementation, technical support and research. Of those, over 1 billion is needed to urgently and effectively respond to MDR-TB and XDR-TB worldwide. This funding will jumpstart the response by providing newer diagnostics and drugs, and by expanding surveillance, training, and infection control practices. This is necessary especially in Africa, where previously model programmes are depleted and fragile due to both HIV and, now, XDR-TB. A clear example is that of laboratory capacity, which is essential for finding drug-resistant TB and for surveillance. But in all of Africa, there are only 25 reference laboratories with the capacity to grow TB cultures and test them for drug resistance, and most of them in South Africa.
Increased investment is needed to provide fast access to life-saving drugs, and also needed is more investment in the systems to support their safe and effective use. And when I say “investment,” I do mean investment. TB control is one of the most cost-effective known health interventions. Investing in TB control, besides averting un-necessary deaths, saves money in the long run, while inaction levies costs.
Role for expanded us government engagement
The last item that you requested me to address is the role the US Government has and can play in TB control, including preventing the spread of XDR-TB. WHO is highly appreciative of the US Government’s financial support for TB control since the late 1990s to affected countries, WHO, the Stop TB Partnership, and technical partners. The officials of USAID, CDC, and the Office of the Global AIDS Administrator who will be speaking today I am sure will describe in detail their commitments to date.
However, the Global Plan and MDR and XDR-TB response plans require that all partners expand their support substantially. We therefore encourage the U.S. Government to consider significantly increased financing through all of its institutions currently engaged in TB control. Increased disease control financing already committed this year for PEPFAR and the Global Fund has been tremendously important. However, scaled-up support for TB implementation, technical assistance, surveillance and research via USAID, CDC, OGAC and NIH will also be essential to reach affected countries, to prevent global spread of TB, and to quickly find new tools to replace the existing ones. U.S. leadership has transformed efforts in the AIDS arena. We can and must do the same for TB. A study published in the New England Journal of Medicine in 2005 showed that investing in TB control abroad actually prevents illness and death and saves money at home over the long run. The consequences of inaction will be millions of lives lost, the undermining of progress on both AIDS and TB, and the potential to push us back to the pre-antibiotic era of the TB fight, when TB was a hopeless death sentence in most cases.