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This blog summarizes major findings from the 2016 WHO Report on TB control activities in South East Asia Region.

TB in South East Asia

Countries in the WHO South-East Asia (SEA) Region have made significant progress towards the Millennium Development Goals relating to tuberculosis (TB). The estimated incidence of all forms of TB, estimated prevalence of all forms of TB and estimated TB mortality all continue to show a downward trend. The treatment success rate among new smear-positive pulmonary TB cases has remained above 85% since 2005, and was 89% in 2010. But although there has been progress, TB control remains a huge challenge in the SEA Region. Approximately 40% of the estimated global number of cases 8.8 million occurs in the Region (based on current estimates) as well as more than a quarter of cases of multi-drug-resistant TB. The national TB and AIDS control programmes in seven countries are jointly extending a comprehensive package of interventions for those affected by both HIV and TB. The long-term goal is to eliminate TB as a public health problem.

2016 – A Foundation Year to End TB

The start of 2016 marks the beginning of a new era in global health and development. The United Nations has adopted the Sustainable Development Goals (SDGs), providing a new development framework for 2016-2030, replacing the 2000-2015 Millennium Development Goal (MDG) framework. Under goal 3 of the SDGs specifically pertaining to health, targets 3.3 states – “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, waterborne diseases and other communicable diseases.” The year 2016 also marks the beginning of implementation of the WHO End TB strategy based on the principles and targets stated in the World Health Assembly resolution. The 3 pillars of End TB strategy include integrated, patient centered care and prevention, bold policies and supportive systems, and intensified research and innovation. Thus there is a reinforced emphasis on ending the global TB epidemic, and 2016 will be the year to lay the foundation for TB control globally as well as in the South-East Asia (SEA) Region.

Global Challenges

Tuberculosis remains a major health problem. Worldwide, 9.6 million people are estimated to have fallen ill with TB in 2014 of which 1.5 million people die comprising of 890,000 men, 480,000 women and 140,000 children. The WHO SEA Region accounts for 41% of global burden in terms of TB incidence. In 2014, there were an estimated 5.4 million prevalence and 4 million incidence of TB and about 460,000 people died due to TB in SEAR. An estimated 340,000 children in the region developed TB in 2014. TB case notification in the Region was about 2.6 million in 2014 whereas in 2013 they were 2.3 million. TB treatment success rate in the region continues to be more than 88% since 2009. The region also faces the challenge of treating an estimated 99,000 multidrug- resistant (MDR) cases among the notified pulmonary cases and about 210,000 cases co-infected with HIV.

Drug Resistant TB

Globally 123 000 people were diagnosed with MDR-TB in 2014, about one fourth of the total 480 000 new cases of MDR-TB that occurred in 2014. A total of 111 000 people started MDR-TB treatment in 2014, an increase of 14% compared with 2013. 43 countries reported cure rates for MDR-TB patients of ≥75%. Nevertheless, globally, data show an average cure rate of only 50% for treated MDR-TB patients. Extensively drug-resistant TB (XDR-TB) has been reported by 105 countries by 2015. An estimated 9.7% of people with MDR-TB have XDR-TB. In SEAR, 33 264 cases were confirmed as Rifampicin resistant or multidrug resistant TB and 28 536 cases were started on MDR-TB treatment in 2014, which represented only 34% and 29 % respectively out of the estimated 99 000 MDR-TB cases among notified TB cases. Globally only 50% of MDR-TB patients were successfully treated and 49% in SEAR in 2014

However, the SEA region has relatively low (2.2%) levels of multidrug resistant (MDR) among newly detected cases. The estimated level of MDR-TB among retreatment cases is 16%. However , given the large number of TB cases in the SEA region, this translates to a total of 99,000 estimated MDR-TB cases among notified pulmonary TB cases accounting for approximately 30% of the world’s MDR-TB cases among notifies pulmonary TB cases in 2014. Six of the 30 high MDR-TB burden countries are in the SEA region (Bangladesh, Korea, India, Indonesia Myanmar and Thailand).

Co-epidemics of TB and HIV

In 2014, an estimated 1.2 million (12%) of the 9.6 million people who developed TB worldwide were HIV positive. In SEAR, an estimated 210,000 cases (5.2%) of the 4 million incident cases were HIV positive. This corresponds to 11 per 100,000 and 5% of all estimated TB incident cases. Globally, the number of people dying from HIV- associated TB peaked at 570,000 in 2004 and had fallen to 390,000 in 2014(32% decrease). In SEAR, an estimated 62,000 cases died of HIV-associated TB in 2014.

In 2014, 51% of TB patients globally had a documented HIV test result. In the African Region, which has the highest TB/HIV burden, 79% of TB patients knew their HIV status. Globally, 77% of TB patients known to be living with HIV in 2013 were started on antiretroviral therapy (ART). Nevertheless, only one third of the 1.2 million people living with HIV estimated to have developed TB in 2014 had been placed on antiretroviral therapy. The number of people living with HIV who were treated with isoniazid preventive therapy reached 933 000 in 2014, an increase of about 60% compared with 2013. Over half of these people (59%) were in South Africa. Thirteen of the 41 high TB/HIV burden countries reported provision of IPT in 2014 and coverage among people living with HIV who were newly enrolled in care was 41%. In SEAR, 45% of notified TB patients had a documented HIV test result in 2014. Out of the TB patients known to be living with HIV, 85 % were on ART in the Region. SEAR maintained 85% CPT enrolment of all notified HIV positive TB patients from 2003. IPT uptake is still low with only 3049 cases reported in 2014.

TB Financing

The funding required for a full response to the TB epidemic in low- and middle income countries is estimated at US$ 8 billion per year in 2015, excluding research and development. Based on reporting by countries, US$ 6.6 billion was available for TB prevention, diagnosis and treatment in 2015, leaving a funding gap of US$ 1.4 billion. Overall, 87% (US$ 5.8 billion) of the US$ 6.6 available in 2015 is from domestic sources. International donor funding dominates in the group of 17 high- burden countries outside the BRICS (72% of the total funding available) and in low-income countries (81% of the total funding available). In 2015, US$ 0.8 billion in international donor funding was available to countries. Of this amount, 77% was from the Global Fund. For research and development, the most recent estimate of the annual funding gap is about US$ 1.3 billion.

Challenges in the SEA Region

Overreliance on donor funding: Funding supplemented considerable by international bilateral and multilateral funding agencies and national governments meet an average of 40% of current budget for NTPs

Low notification rates of TB cases: More than 35% of the estimated incident cases in the region are not notified. These include cases that are either not being detected at all or being detected in sectors that do not notify the case to the national programmes. Issues with delayed diagnosis and treatment, inadequate laboratory capacity and outreach and insufficient strategies to address targeted screening/active case finding are also prevalent.

Persisting weakness in the health systems: Limited access to quality health services; overstretched and weak performance of health services; poor governance and weak accountability mechanisms; shortages of well-trained, motivated and supported health workers and unfair distribution of them within and across countries; lack of knowledge or capability; insufficient data collection, quality and use of data; limited social sector linkages and limited programme management capacity with limited involvement of NTPs in decision-making in sectors where they are directly affected by the decisions being made.

Insufficient management of co-morbidities: Risk factors and comorbidities of TB such as diabetes, tobacco smoking, silicosis, alcohol and drug misuse, and under nutrition ignored and not addressed adequately

Insufficient regulatory systems and mechanisms: Absence of universal health coverage and access to free treatment and other social protection mechanisms; weak regulatory mechanisms essential to ensure effective infection control, rational use of tuberculosis diagnostics and medicines, mandatory disease notification, functioning vital registration systems, and protection of the legal rights of people with tuberculosis.

Absence of long-term strategies to address the underlying social determinants: Need for effective TB prevention strategies that require action resulting in poverty reduction, improved nutrition, and better living and working conditions as well as strategies to mitigate the impact of migration; focus on ageing populations that are at-risk factors for tuberculosis.

TB Programme in Nepal

Key achievements and Success

In this fiscal year, NTP has expanded 20 DOTS Centers and 25 Microscopic Centers in the public and private sectors of Nepal. Similarly one DR Centre and two Subcentres have been expanded in the districts for the management of DR TB cases. Along with this, NTC has procured all the necessary items for the establishment of a solid culture and DST facility in the three regions - Eastern Development Region, Western Development Region and Mid-Western Region of Nepal. Furthermore NTC has expanded three GeneXpert centers in the Accham, Okahaldhuna and Palpa districts respectively. In addition, NTC has strengthened the National Reference Laboratory with the facility of liquid C/DST and a LPA facility. As a result, its capacity has been strengthened in the management of DR TB cases. All preparatory work for the Prevalence Survey that is going to be conducted from July 2016 has been completed. Accordingly in 2015, NTP conducted an appraisal with technical support from WHO and some of the recommendations of the appraisal have been addressed in the coming year’s FY budget and programme, which includes piloting of tracking referral childhood TB cases from the national child hospitals located in Kathmandu as well as tracking and enrolling the primary lost to follow up TB cases on treatment.

Programmatic Challenges in Nepal

Achieving universal access to TB prevention, care and control services

• Low service coverage in hard-to-reach populations and TB contacts
• Hard to access and test all DR presumptive cases in the country as only two Culture and DST labs are available and functional in the country
• Low involvement of private sector in the national programme leading to low case notification from the private sector
• TB and HIV cross-referral services are still not functioning well leading to only 9% TB patients being tested for HIV

Expansion of MDR-TB services

• Stigma still prevalent among patients, health workers and the community towards MDR-TB patients resulting in low commitment of health workers towards DR-TB management
• Insufficient human resources to address the demand-supply gap
• Difficult to manage second-line TB drugs because of long treatment duration, short expiry date, no facility of proper storage system of drugs especially to maintain the temperature in the store
• Insufficient infection control measures in health facilities
• Insufficient expertise in the country for management of DR-TB

Operational Plan of Nepal for 2016/2017

The following are the major operational plans for Nepal in controlling the TB problem:

• Expansion of TB diagnostic services
• Expansion of active case-finding activities to access hard-to-reach and vulnerable population through microscopic camp; contact tracing of TB patients’ families, neighbors, friends, schools and work place; and Mobilizing mobile van with GeneXpert and digital x-ray machines in strategic location
• Enhance TB diagnosis among children by strengthening the skills of doctors through trainings; introduction of the newer technology and system for the confirmatory diagnosis among children; strengthening the recording and reporting system and mobilization of TB volunteers in metro/ sub metropolitan cities
• Establishment of sputum courier mechanism in all districts to ensure the screening of all DR presumptive TB cases, contacts of TB patients, access hard-to-reach and vulnerable populations
• Strengthening the infection control measures in labs, DR centers and DOTS centers
• Promotion of psychosocial support to TB patients
• Meaningful engagement of patients and community in the diagnosis and treatment of TB patients – expansion of community/family DOTS
• Strengthening TB-HIV collaboration between NCASC and NTC at all levels

Conclusion

Ending TB epidemic is not mere biomedical but a developmental challenge. The global, regional, national and local level response to ending TB epidemic must therefore be a part of an inclusive response designed to meet the overall development goals. The progress towards ending the TB epidemic will depend as much on achieving overall health improvements as it will on optimizing current strategies, developing new tools and technologies to diagnose, treat and prevent TB, and reaching them to all who need them. Ending the TB epidemic will require an expansion of the scope and reach of interventions for TB prevention, care and control.