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The TB response: the road taken, and the journey ahead

Dr Mario Raviglione, Director, WHO Global TB Programme

Commentary
22 October 2014

In the late 1980s, as part of my clinical training in infectious diseases, I had the chance to work on tuberculosis (TB) in New York City and in Boston. The term “multi-drug resistant tuberculosis (MDR-TB)” was not yet commonly used, but for those of us working in the United States, cases were emerging in front of our eyes.

Emergence of drug-resistant TB

Dr Mario Raviglione, Director of the WHO Global TB Programme.

Nowhere was this more apparent than in cities like New York where the former TB control system had been dismantled and where a lack of coordination among health services coincided with a growing burden of large socially deprived populations. Hospital doctors had to use limited knowledge to administer different combinations of drugs in an attempt to cure their poor, often homeless, patients.

In 1987, together with Ariel Pablos-Mendez, I organized a study on the frequency of drug-resistant TB in our homeless patients. The results revealed that the disease was much more wide spread than anyone had realized.

Unfortunately, the paper we wrote on the study was rejected by a well-known journal. If published, the paper would have sounded the alarm on MDR-TB at a much earlier stage of the epidemic, possibly preventing the health scare triggered when the issue finally came to light through a 1991 CDC report.

A global approach to TB care and control

Shortly after I joined WHO. Our small TB team grew rapidly as the global health importance of the disease was recognized and WHO was called upon to lead the global action against it. Public health authorities learnt that TB was not extinct, but was, at that time, affecting millions of people annually and killing 2 million of them.

"The progress I have seen in front of my eyes over the past two decades is huge and I feel privileged to have been part of this WHO history."

Dr Mario Raviglione, Director, WHO Global TB Programme

In 1991 we lacked both a global strategy to combat the disease and a uniform surveillance system. We had no knowledge about the extent of the emerging MDR-TB threat and we had only just begun to realize the tragedy of the deadly association between TB and HIV/AIDS. There were no new diagnostics, drugs or vaccines, nor was there a global aid and financing mechanism.

DOTS becomes a standard

In 1994, WHO launched the strategic package to control TB that became known as DOTS. It was soon to prove a standard, cost-effective and simple way to promote the basic elements of TB care and control. Since then, WHO at all levels has been supporting countries in the implementation of our evolving recommendations and in measuring impact.

As there was no homogenous system to collect information on notified cases, numbers treated and cured, or on the proportion of drug-resistant cases, we had to set up a surveillance system from scratch and then work with Member States to promote its adoption and annual reporting. It worked. The information now available for TB is among the best that exists.

WHO TB drug resistance surveillance initiative

For instance, the WHO TB drug resistance surveillance initiative, the 20th anniversary of which we are now celebrating, has provided information on the extent of the MDR/TB problem and informed the response. I consider this as a pathfinder for the wider antimicrobial resistance (AMR) initiative that WHO now envisages.

Overall, the progress I have seen in front of my eyes over the past two decades is huge and I feel privileged to have been part of this WHO history. However, as we launch the WHO Global TB Report 2014, we must recognise that we are still far from victory against this ancient disease that continues to kill 4000 people every day! Our report, as always, shows achievements, failures and challenges and describes needs.

Targets for elimination of TB

In May 2014, the World Health Assembly adopted the new “End TB” strategy and targets for the elimination of TB. There is an urgent need for the implementation of this strategy by all ministries of health and for sufficient allocation of resources to combat the disease assertively. Critically, TB must be visibly included in the post-2015 sustainable development goals.

Indeed, with perseverance, innovation and strong motivation we could achieve elimination by 2050. The Global TB Programme stands ready to keep supporting our Member States. The aim is noble and the hopes are high. Let us get rid of TB once and for all.