New Numbers On Tuberculosis Burden Must Galvanize India To Act

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Dr. Madhukar Pai

Last week, WHO released its 2016 Global TB Report. The news, unfortunately, is not good. The report shows that the TB burden is actually higher than previously estimated, mainly because of new data from India. In 2015, there were an estimated 10.4 million new TB cases worldwide. Six countries accounted for 60 per cent of the total burden, with India accounting for 27 per cent of the global cases, followed by Indonesia, China, Nigeria, Pakistan and South Africa.

An estimated 1.8 million people died from TB in 2015, of whom 0.4 million were co-infected with HIV. Gaps in testing for TB and reporting new cases remain major challenges, as they have in the past. Of the 10.4 million new cases, WHO estimated that only 6.1 million were detected and officially notified in 2015, leaving a huge gap of 4.3 million cases that are “missing” — either not diagnosed, or managed in large unregulated private sectors and not notified to TB programs.

Global TB elimination is an impossible goal without significant progress in this emerging superpower.

India continues to bear the brunt of the TB epidemic, with 2.8 of the 10.4 million new TB cases that occurred in 2015. TB is also a major killer of Indian people. The latest Global Burden of Disease estimates from Institute of Health Metrics and Evaluation, published earlier this month, show TB to be the sixth leading cause of deaths in India. In 2005, TB was the sixth leading cause of deaths in India, and ten years later, in 2015, it holds its place as a leading killer of people in India.

These new estimates from WHO and GBD are disappointing and underscores the need for greater investments in global TB control. In particular, India really needs to wake up to the enormity of the epidemic in the country, and put some serious money behind its under-funded TB program. Global TB elimination is an impossible goal without significant progress in this emerging superpower.

It is worth comparing China’s TB situation with that of India. China had 0.9 million TB cases in 2015, while India had over 2.8 million. The number of drug-resistant TB cases in China was 57,000, while India was estimated to have over 79,000. TB is no longer a major killer of people in China, and does not make the top 10 most important causes of death.

It is remarkable that China more than halved its TB prevalence over the last 20 years. Marked improvement in quality of TB treatment, driven by a major shift in treatment from hospitals to the China CDC public health centres (that implemented the DOTS strategy) was likely responsible for this effect, which has been demonstrated by repeated national TB prevalence surveys.

So, why does India struggle with a much higher TB burden? There are many reasons. For one, India has many social determinants that fuel the TB epidemic — poverty, malnutrition, smoking, and indoor air pollution. Secondly, India has under-funded TB control for a very long time. And much of the focus was only on the public TB program. It is only recently that the national TB program has seriously started to address the problem of TB in India’s large, dominant, private sector.

With new research, our understanding of the true burden of TB in India is improving. We are now aware that private sector manages over half of all TB in India, new research suggests that enormous quantities of TB drugs are sold in the Indian private market.

For a long time, India ignored TB patients managed in the private sector, and national prevalence and drug-resistance surveys were not periodically done (unlike China and other high TB burden countries). Furthermore, the Indian national TB program was (and still is) heavily reliant on insensitive diagnostic tools such as sputum microscopy. India is “fighting the TB war with 19th century cannons.” All of this meant that India has been under-diagnosing and under-reporting the burden of TB for a long time.

With new research, our understanding of the true burden of TB in India is improving. We are now aware that private sector manages over half of all TB in India, new research suggests that enormous quantities of TB drugs are sold in the Indian private market.

In addition, although India made TB notification mandatory in 2012, it has taken a few years for private sector notifications to accumulate. Now, thanks to several public-private partnership programs, significant increases are being noticed in case notifications from private sector.

Overall, the path forward for India is very clear — acknowledge the reality of a massive TB epidemic, collect better data on true burden of TB, deaths, and drug-resistance, and allocate greater funding to tackle this huge problem. This will not happen without high-level political commitment.

Last week, on the same day of the WHO TB report release, The Lancet published a comment by the Indian Health Minister Mr Jagat Prakash Nadda and Dr Poonam Khetrapal Singh, head of India’s WHO Regional Office for South East Asia.

Overall, the path forward for India is very clear — acknowledge the reality of a massive TB epidemic, collect better data on true burden of TB, deaths, and drug-resistance, and allocate greater funding to tackle this huge problem.

In their Comment, they acknowledged that TB is a bigger problem than imagined in India and other Asian countries, and suggested that TB should be made a top priority on national agendas. They also argue that political commitment should be translated into a comprehensive national TB control plan, and such a plan must be fully funded and implemented promptly by an empowered body that reports to the highest levels of government.

These statements by the Indian Health Minister is very impressive and progressive, as is the commitment from Dr Soumya Swaminathan, India’s Secretary of the Department of Health Research about India’s plans conduct prevalence surveys, develop innovative new tools for TB, address social determinants such as malnutrition, and create an India TB Research Consortium.

Hopefully, these leaders will deliver on the vision that they have articulated, and make TB a national priority in India. In fact, India has already started the process for creating the National Strategic Plan for TB Control in India (2017-2023). This plan must be ambitious, and fully funded by the Indian government. Otherwise, future TB reports will continue to bring bad news.

Madhukar Pai is the Director of McGill Global Health Programs, and the Associate Director of McGill International Tuberculosis Centre. (@paimadhu)


This article was originally published in The Huffington Post. See the original article here.

Canada is Leading the Fight to End AIDS, TB and Malaria for Good

 

Introduction by Patrick Bidulka 

McGill University was fortunate to participate in the Global Fund Replenishment conference held in Montreal this September. The Global Fund side event at McGill, organized by the McGill Global Health Programs office, saw a high turn-out of world-class global health researchers and students. With its contribution of nearly $800 million, Canada has repositioned itself as a key contributor to the field of global health, and a stakeholder in the mission of the Global Fund to end HIV/AIDS, TB, and Malaria for good. However, as the Honorable Jane Philpott said as she addressed the event, these goals will not translate into tangible results until society collectively deems current health disparities as “outrageous, and solvable”. It is outrageous that a third of the world is infected with TB, with the majority of those infected being in developing countries. It is outrageous that here in Canada, we have a TB epidemic concentrated in our Aboriginal communities, where the rate of TB in Indigenous populations is 34 times higher than in non-Indigenous Canadians. It is outrageous that here in Canada, there are 50 new infections of HIV every week, and this rate has not changed in the last two decades. And so, it is these glaring inequalities that must be recognized, and deemed outrageous by more than just researchers and health care workers, but collectively by the global population. Progress has been paralyzed by barriers such as stigma, racism, gender inequality, and prejudice against LGBTQ people. It is not until these basic issues surrounding human rights are resolved that we can truly put an end to AIDS, TB and Malaria. As Mark Dybul, CEO of The Global Fund said at the McGill side event, “To end these diseases, we must become better humans”.

Panelists at the McGill event (from left to right): the Honourable Jane Philpott, Mark Dybul, Lucica Ditiu, Peter Singer, Mark Wainberg, Philippe Gros, and Marcel Behr.

Panelists at the McGill event (from left to right): the Honourable Jane Philpott, Mark Dybul, Lucica Ditiu, Peter Singer, Mark Wainberg, Philippe Gros, and Marcel Behr.

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Dr. Madhukar Pai & Dr. David Eidelman

As Montreal gears up to host the biggest leaders in global health, it is our hope that Canada will go well beyond provision of international aid, and find a way to harness the abundant scientific talent in Canada. Doing so will not only amplify the financial contributions by Canadians, but also show our global solidarity.

The past year has seen the re-emergence of Canada in the international development arena. In addition to maternal and child health, if there is one area where Canada is showing tremendous leadership, it is in the fight against the “big three” — AIDS, tuberculosis, and malaria — infections that kill over 3 million people each year.

To tackle the big three, The Global Fund to Fight AIDS, TB and Malaria was created in 2002. The Global Fund raises resources, engages a variety of partners, and invests funds in supporting programs to tackle the epidemics. Programs supported by theGlobal Fund have saved 20 million lives, by providing 9.2 million people with antiretroviral therapy for HIV, 15.1 million people with testing and treatment for TB, and 659 million mosquito bed nets to prevent malaria.

Canada is blessed with some of the best academic researchers and innovators working in global health.

If the Global Fund is to continue making progress towards ending these epidemics for good, it needs to be replenished by donor governments, private foundations, corporations, and philanthropists — and Canada is showing the world how to get this done!

On September 16-17, 2016, the Government of Canada will host the Fifth Replenishment Conference in Montreal that will bring world leaders to set funding for the next three years. The Global Fund has set a target of raising US$13 billion. Canada has already pledged CAN$785 million, a 20 increase compared to the last round. The USA has pledged up to US$4.3 billion, France has pledged €1.08 billion, and Germany has pledged €800 million. These pledges, hopefully, will inspire others to contribute and meet the target of US $13 billion which can save an additional 8 million lives.

In addition to supporting the Global Fund, the Government of Canada has made a renewed investment of CAN$85 million for the Stop TB Partnership’s TB REACH initiative, to reach, treat and cure many of the 3.6 million people affected by TB who every year go without proper care. The Government of Canada has also invested inGrand Challenges Canada, an agency that is funding several innovative projects in TB, HIV and Malaria.

We can be proud of all these developments that show commitment and leadership from the Canadian Government. However, in addition to providing development assistance, Canada has much more to offer. Canada is blessed with some of the best academic researchers and innovators working in global health. For example, an experimental Ebola vaccine developed by Canadian scientists has already attracted international attention.

In the area of HIV, TB and Malaria, Canadian researchers are making valuable contributions. Canada has led the way in identification of anti-retroviral drug targets, development and promotion of the Treatment as Prevention strategy, development and evaluation of new diagnostics, treatment of HIV and hepatitis co-infections, and leadership roles in prestigious societies to influence policy and advocacy.

Epidemics such as SARS, Ebola and Zika have shown us that infectious diseases respect no boundaries.

Canada has a rich history of research in tuberculosis, a disease that still affects our Aboriginal communities. Canadian researchers have identified the genetic basis of susceptibility to TB, used innovative DNA fingerprinting methods to track the epidemic, evaluated novel tests for TB, conducted clinical trials to develop shorter drug therapies, and contributed to international policies. Canadian researchers have identified promising malaria drug targets, documented malaria strain variations, and developed a global molecular surveillance system for drug-resistant malaria.

McGill University and its affiliated hospitals are home to several teams that focus on HIV, TB and parasitic diseases. With over 100 scientists working on infectious diseases, McGill has much to offer in global health, from fundamental science to policy, and, in particular, training of the next generation of researchers. McGill Global Health Programs coordinates the University’s global health work, and is making strategic investments and partnerships to make sure McGill’s faculty and students are actively engaged as global citizens, in solving the biggest global health challenges.

Epidemics such as SARS, Ebola and Zika have shown us that infectious diseases respect no boundaries. We are excited that Canada is showing impressive leadership in global health, and particularly thrilled that the Global Fund Replenishment Conference is being held in Montreal. We hope the Global Fund replenishment targets will be met, and Canadian researchers will be actively engaged to translate the dollars into saved lives.

Madhukar Pai is the Director of McGill Global Health Programs, and the Associate Director of McGill International Tuberculosis Centre. (@paimadhu)

David Eidelman is the Vice Principal of Health Affairs at McGill University, and Dean of the Faculty of Medicine. (@VPDeanEidelman)

This article was originally published in The Huffington Post. See the original article here.

Why The World Needs An Essential Diagnostics List

Lee Schroeder, Timothy Amukele and Madhukar Pai

This article was originally posted on Forbes website. See the original post here.

Without diagnostics, medicine is blind. And yet, diagnostics receive much less attention than vaccines and drugs. Imagine a sick infant with bacterial sepsis in sub-Saharan Africa. Without diagnostics, they will likely get incorrectly treated for malaria. Every year, 1 million patients with TB in India are either not diagnosed or not reported. Pregnant women with anemia, syphilis and diabetes are often missed in low-income countries where laboratory capacity is severely lacking. And where there is testing, it is often of low quality.

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Hepatitis and HIV diagnostic tool. Photo by Dr. Nitika Pai.

recent NEJM article proposes a simple way to improve access to critical diagnostics: make a list. In 1977, the World Health Organization started (and has since maintained) a Model List of Essential Medicines (EML). The EML, a global health success, has improved access to medicines. Sadly, there is no equivalent Model List of Essential Diagnostics (EDL). Such a list would be impactful for these reasons:

1.  Improve patient care and clinical outcomes

Patients will get consistent access to quality essential diagnostics that will be affordable and always available. When a diagnostic is added to an EDL, governments, funders and manufacturers will work to ensure availability and access.

2. Help detect emerging infectious threats

The Ebola and Zika epidemics have underscored the need for surveillance. While many countries have reference laboratories, laboratory capacity at lower health system tiers is often weak. By increasing laboratory capacity at all tiers, an EDL could help countries better prepare for epidemics and implement international health regulations.

3. Increase affordability

Bulk and advanced purchasing, volume discounts and pooling mechanisms are widely used for vaccines and drugs. Without such mechanisms, quality diagnostics can be unaffordable. Xpert MTB/RIF is a good TB test, but affordability is limited. An EDL could promote group purchasing by international organizations (e.g., Global Fund). With larger, predictable volumes, manufacturers can lower prices. Countries can use EDL to impose price controls and waive import duties to ensure affordability.

4. Reduce antimicrobial resistance (AMR)

Indiscriminate antimicrobial use drives AMR. Without adequate diagnosis,antimicrobials get widely abused. In half of malaria-endemic African countries over 80% of malaria treatments are applied without diagnostic testing, leading to legitimate concern for the emergence of drug resistance.

5. Improve regulation and quality of diagnostics

Unlike developed countries, regulatory agencies that approve the accuracy of diagnostic devices either do not exist or are weak in resource-poor settings. An EDL could focus such agencies on priority tests and help to harmonize regulation at the regional level. An EDL could aid in the identification of sub-standard diagnostics, as is already occurring formalaria rapid tests.

6. Facilitate laboratory accreditation and training

Even if a diagnostic test is of high quality, its impact can be crippled by improper use. In Kampala, Uganda, 95% of all laboratories failed to get the lowest score on the WHO laboratory quality checklist. Country-level laboratory accreditation groups could use the EDL to establish targeted and appropriate quality assurance programs. An EDL could also help shape in-country training of laboratorians.

7. Improve supply chain and laboratory infrastructure

As is too often the case in low-income settings, poor infrastructure and inconsistent supply chains render laboratory devices unusable. An EDL could encourage ministries of health to strengthen necessary infrastructures and develop targeted supply chains for the essential tests.

8. Facilitate change in healthcare provider behavior

Healthcare professionals trained in countries where laboratory testing is either unavailable or of low quality are likely to treat based on clinical suspicion. The impact of the Xpert MTB/RIF TB test has been blunted because of such issues. Likewise, in several settings, providers continue to give anti-malarial therapies, despite negative rapid test results. An EDL could improve providers’ confidence in test results and strengthen thediagnostic-treatment cascade.

9. Inform new technology development

Several teams are now developing point-of-care diagnostics for global health. An EDL could help develop target product profiles that can inform new product development. In fact, such initiatives already exist for several key diagnostics.

10. Facilitate epidemiological surveys, program evaluation and disease elimination

Policy makers need data on disease burden. An EDL could support national surveys and help track changes in disease burden and efficacy of interventions (e.g., diagnostics to support polio elimination).

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TB diagnostic tools. Photo by Dr. Madhukar Pai.

In summary, essential medicines require essential diagnostics. The NEJM article has proposed an EDL to set the ball rolling. While many agencies could establish an EDL, WHO is the obvious choice, since they maintain the EML, make health policies, run prequalification programs and oversee international health regulations. So, we call upon WHO to take the lead in creating a List of Essential Diagnostics. We also call on key stakeholders (e.g., FINDPATHTDRCHAIASLMGHTCStop TB PartnershipRoll Back MalariaUNAIDS), civil society (e.g., MSFTAGACTION) and donors (e.g., Global FundBill & Melinda Gates FoundationUNITAIDUSAID) to support WHO to make this happen.

 

Dr. Lee Schroeder is assistant professor at the University of Michigan,  where he is director of Point-of-Care Testing and associate director of Chemical Pathology. Dr. Timothy Amukele is an assistant professor at the Johns Hopkins University School of Medicine, where he is the director of the Bayview Medical Center Clinical Laboratories. Dr. Madhukar Pai is a Canada Research Chair in Epidemiology & Global Health at McGill University, Montreal, Canada. He serves as the director of McGill Global Health Programs and associate director of the McGill International TB Centre.

 

This article was originally posted on Forbes website. See the original post here.

McGill Summer Institute 2016 – An Infectious Series of Presentations!

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Patrick Bidulka

And that’s a wrap! The 2nd annual Summer Institute on Infectious Diseases and Global Health has ended after two weeks of exciting discussion covering a variety of topics including TB, HIV, worms, malaria, and more worms. With the addition of two courses to the Summer Institute arsenal, things got pretty busy!

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TB Research Methods Small Group Session

As a member of the organizing team for the Summer Institute, I had the opportunity to observe the mechanics of what goes on front and back stage. As participants got to hear from an extensive lineup of top-quality researchers and diagnostic industry specialists, the Institute’s top-notch organizing committee worked tirelessly to ensure operations went as smoothly as possible — easier said than done. Between organising the catering, and dashing between classrooms pretending to be an AV specialist, I managed to slip into a few lectures to get a feel for what the Summer Institute is all about.

The 2016 edition of the Summer Institute offered 5 different week-long courses:

1. Global Health Diagnostics

2. TB Research Methods

3. Advanced TB Diagnostic Research

4. Molecular & Genetic Epidemiology *New*

5. Tropical & Parasitic Diseases (including Ultrasound and Microscopy tutorials) *New*

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Clinical Ultrasound course at the Summer Institute

All the courses provided lectures in varying format, including tech pitches from industry specialists, clinical case studies, panel discussions, and small group sessions. During breaks, participants from all different courses had the chance to mingle, and discuss the hottest topics in global health research (all while drinking record amounts of coffee!)

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Global Health Diagnostics Course Panel Discussion

Some personal highlights from the Summer Institute:

• Having my entire abdomen, from bladder to heart, examined via ultrasound in front of the Tropical and Parasitic Disease Ultrasound class, held at the Glen Site

• Being reassured that everything in my ultrasound was normal (phew!)

• Seeing my global health-fanatic McGill professors Drs Pai and Gyorkos debating diagnostics and treatment centre stage

• Lunch!

• And finally, being introduced to so many accomplished global health professionals, and hearing the energetic debate these people brought to the conference

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Lunch at the Summer Institute

Boasting about 400 participants from 46 different countries, the Summer Institute was a huge success. The conference fostered a welcoming environment for global health experts and novices alike, to engage in academic discussions centred around pertinent global health issues the world faces today. See the Summer Institute 2016 Dashboard for a brief overview of the conference statistics.

I’m glad I had the opportunity to be a part of such a fast-paced and information-packed two weeks! Taking part in the conference gave me valuable insight into the many different facets of global health, and allowed me to envision which stream I would like to pursue as I move towards my own post-graduate education.

Planning is already underway for 2017’s Summer Institute – stay tuned at the Summer Institute and the McGill Global Health Programs websites for more details to come!

patrick

 

About the author:

Patrick is a recent graduate from the undergraduate pharmacology program at McGill. Now working at the GHP office, Patrick is happy to be immersed in the field of global health. His interests include infectious diseases, learning languages, and ‘The Office’.

How Drug-Resistance TB Can Show The Path To Tackling Antimicrobial Resistance

Madhukar Pai

India, TB, MDR-TB, XDR, drug resistance, tuberculosis

Antimicrobial resistance (AMR) is a global health threat, and it is estimated that by 2050, 10 million lives a year and a cumulative 100 trillion USD of economic output are at risk due to the rise of drug-resistant infections, if we do not find solutions to tackle the rise of drug resistant pathogens.

Since the introduction of antibiotics, microbes have evolved a variety of methods to resist antibiotics. We are now dealing with ‘superbugs’ that are virtually untreatable, including colistin-resistant E. coli, drug-resistant gonorrhea, carbapenem-resistant enterobacteriaceae, methicillin-resistant Staphylococcus aureus, extensively drug-resistant tuberculosis, and extended-spectrum-beta-lactamase producing strains. The antibiotic pipeline is running dry, and AMR is threatening to undo major gains made in the control of infectious diseases.

AMR is driven by several factors, but major causes include over-use of antibiotics, poor adherence to standard treatment protocols, over-use of antibiotics in livestock, poor infection control in health facilities, poor sanitation, and challenges with new antibiotic R&D.

According to the State of the World’s Antibiotics report (2015), antibiotic consumption is increasing globally, with 20-50% estimated to be inappropriate. Countries like India and China are rapidly becoming the most important consumers of antibiotics.

Drug-resistant tuberculosis (DR-TB) is a prime example of the threat posed by AMR. The most common form drug-resistant TB is multi-drug resistant TB (MDR-TB), which refers to TB that is resistant to two key first-line antibiotics – isoniazid and rifampicin. Globally in 2014, WHO estimated 3.3% of new cases and 20% of previously treated cases to have MDR-TB. Drug resistance surveillance data show that an estimated 480 000 people developed MDR-TB in 2014 and 190 000 people died. Even children are impacted by DR-TB, with recent estimates suggesting that MDR-TB in children may be far more prevalent than previously understood.

It is much smarter and cheaper to prevent DR-TB than treat it.

Extensively drug-resistant (XDR-TB) strains are resistant to at least four of the core anti-TB drugs [i.e. isoniazid and rifampin, plus any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin)], and XDR-TB has been reported by 105 countries in 2014. About 10% of people with MDR-TB have XDR-TB. Some studies have also reported totally drug-resistant strains of TB, resistant to all antibiotics tested. This scary form of TB takes us back to the pre-antibiotic era, where TB patients were managed in sanatoria, and mortality rates were extremely high.

Why should we care about DR-TB? Drug-resistant TB requires extensive treatment (for 2 years or longer) with multiple, potentially toxic drugs and outcomes are poor. One in two patients with drug-resistant TB die because of it. Treatment of DR-TB is also very expensive because of the high cost of second-line TB drugs. Thus, it is much smarter and cheaper to prevent DR-TB than treat it.

WHO has proposed 5 priority actions to tackle the global DR-TB crisis:

1) prevent the development of drug-resistance through high quality treatment of drug-susceptible TB;

2) expand rapid testing and detection of DR-TB cases;

3) provide immediate access to effective treatment and proper care;

4) prevent transmission through infection control; and

5) increase political commitment with financing.

Unfortunately, high TB burden countries are yet to seriously address these priority actions to tackle DR-TB. In many countries, not even half of all patients with DR-TB are on second-line drug therapy. Quality of TB care for even drug-susceptible TB remains suboptimal in many countries, especially in countries with large numbers of private health care providers. In such settings, doctors prescribe irrational drug regimens, and adherence monitoring is poor.

TB is a low priority for many developing countries, and current TB budgets are insufficient to make progress in addressing DR-TB.

Empirical antibiotic use is widespread in many countries with weak regulation, and healthcare providers tend to use antibiotics as diagnostic tools; this further increases the risk of AMR. Also, over-the-counter (OTC) antibiotic abuse is widespread in many high TB burden countries. OTC use of fluoroquinolones, a widely used antibiotic, can delay the diagnosis of TB, and also increase the risk of DR-TB. This is particularly relevant, since some of the emerging new TB drug regimens contain fluoroquinolones (i.e. Moxifloxacin).

Xpert cartridges [1032133]

Xpert cartridges

While highly accurate and rapid molecular tests such as Xpert MTB/RIF are now available to quickly detect TB as well as drug-resistance, most high-burden countries are still reliant on sputum smear microscopy, a technology that is not only insensitive but also incapable of detecting drug-resistance. This means patients are often managed with no information on drug-susceptibility test results. This approach of treating TB ‘blindly’ is no longer tenable in places such as Mumbai, where DR-TB is a widespread problem.

A recent report called ‘Out of Step‘ by MSF and Stop TB Partnership surveyed 24 high TB burden countries, to see how already existing TB policies and interventions are being implemented. This survey found major gaps in how TB tools and policies are implemented. For example, only 8 countries included in the survey had revised their national policies to include Xpert MTB/RIF as the initial diagnostic test for all adults and children with presumptive TB, replacing smear microscopy. Six of 24 countries, including India, still recommended intermittent treatment for drug-sensitive TB (which is less effective than daily therapy). Even simple interventions such as fixed dose combination pills to improve treatment adherence are not routinely used in all countries. Such implementation gaps are most definitely generating DR-TB and have to be urgently addressed.

A major reason behind poor TB control is the fact that TB is a low priority for many developing countries, and current TB budgets are insufficient to make progress in addressing DR-TB. Most National TB Programs in high burden countries are seriously under-funded, and, sadly, even emerging economies such as India are not spending enough on TB.

It may be more impactful for DR-TB control to be seen as one component of a comprehensive strategy to address AMR.

In this context, it may be more impactful for DR-TB control to be seen as one component of a comprehensive strategy to address AMR. Unlike TB, AMR is increasingly seen as a global health emergency and a security threat. Policy makers and donor agencies have prioritized AMR as a key issue for the global health security agenda. The door is wide open for the TB community to leverage this interest, and advocate for a well-funded, comprehensive AMR initiative that includes DR-TB as a key component. In fact, DR-TB could well be a pathfinder for successfully tackling AMR in low and middle income countries, and help make the case for greater investments.

The End TB Strategy and the Global Plan to End TB offer excellent blueprints for ending the epidemic of TB, including DR-TB. It is time for the TB community to step up and make sure TB features prominently in the broader agenda to tackle AMR globally, and receives adequate funding and support.

Dr_Pai

Madhukar Pai is director, Global Health Programs, McGill University, Montreal, Canada. Twitter: @paimadhu

Author’s competing interests: None declared.

This blog post was first published on the Huffington Post website.

Blog authors are solely responsible for the content of the blogs listed in the directory. Neither the content of these blogs, nor the links to other web sites, are screened, approved, reviewed or endorsed by McGill University. The text and other material on these blogs are the opinion of the specific author and are not statements of advice, opinion, or information of McGill.