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Global tuberculosis control amid the world economic crisis
Newsdesk
Global tuberculosis control amid the world economic crisis See Leading Edge page 137 For more on the Global Plan to Stop TB and the Stop TB Partners’ Forum see http:// www.stoptb.org
George Tsereteli/USAID
For more on the George Institute for International Health survey see http://www. thegeorgeinstitute.org/research/ health-policy/current-projects/gfind-global-funding-ofinnovation-for-neglected-diseases. cfm
As World TB Day approaches on March 24, the Stop TB Partnership’s Global Plan to Stop TB and the Global Fund to Fight AIDS, Tuberculosis and Malaria face deficits in funding. With many demands on political attention in a global economic downturn, will progress on tuberculosis fall behind? Experts note that tuberculosis efforts could save 14 million lives by 2015 and have broader benefits for nations and economies. Widespread agreement exists that worldwide progress has been remarkable, but the discipline faces new challenges, and now investment could fall rather than increase. When the Global Plan to Stop TB was launched in 2006, the funding deficit was about US$30 billion. Mario Raviglione (WHO; Geneva, Switzerland) and Marcos Espinal (Stop TB Partnership; Geneva, Switzerland) explained to TLID that bridging the funding deficits is key to reaching both the Millennium Development Goal on tuberculosis and the Stop TB Partnership’s goals by 2015. “If realised, these major objectives will set the path for the elimination of tuberculosis by the year 2050”, they note. Since 2002, worldwide funding for tuberculosis has increased at country level every year, but progress has slowed since 2006. World Bank senior health specialists Miriam Schneidman
Tuberculosis patient at a DOTS treatment facility in Tbilisi, Georgia
144
and Joel Spicer told TLID that, “investments have indeed increased; however, so have the needs and areas of intervention”. Before the economic crisis, detection of cases were not increasing, since, says Lee Reichman (New Jersey Medical School Global Tuberculosis Institute, NJ, USA), “the easy-to-find cases had already been found”. Multidrug-resistant (MDR) and extensively drug-resistant tuberculosis are at their highest levels ever, placing a further burden on programmes. The improved directly observed therapy, short course (DOTS) strategy is now in place to address HIV co-infected patients and drug resistance, notes Schneidman and Spicer, but progress has been uneven because of weak health systems and the HIV epidemic. In past recessions, many countries reduced spending on overseas development assistance (ODA). WHO Director-General Margaret Chan says these responses could be as “devastating for health, development, security, and prosperity as they were in the past”. World Bank President, Robert Zoellick, has urged developedcountry policymakers to “avoid putting in place policies and structures that undermine the interests of developing countries” that “are at the mercy of a crisis not of their making”. In January, the Global Fund reiterated these warnings, announcing an estimated $5 billion deficit for the next 2 years. During the World Economic Forum in Davos, Switzerland, in January, partners of the Global Fund said that if the fund cannot maintain its commitment to fund all high-quality programmes, then the G8 will have failed in its pledges. Jeffrey Sachs, special advisor to the UN Secretary-General, notes that “this is absolutely in violation of the life and death pledge that the rich world has made”. He points to bonuses awarded by the banking system, saying “the money’s there”. Yet, many experts believe that the economic crisis will have a major
impact on worldwide tuberculosis efforts, including Raviglione and Espinal. Tuberculosis and drug resistance may increase, with an additional negative impact from tuberculosis/HIV co-infection, they suggest. “Development of new tools (vaccines, drugs, and diagnostics) for tuberculosis may be seriously jeopardised”, they told TLID. The World Bank estimates that the financial crisis has already put 100 million people back into poverty. This, Spicer said, “could easily facilitate the spread of tuberculosis by sharply increasing the number of cases, overwhelming already overstretched health systems, and leading to a sharp increase in drugresistant cases” due to slower casefinding and inadequate tuberculosis treatment. The latter may be due to programmatic issues, but also patients facing a basic lack of food and money for transportation, notes Schneidman. Although the Global Fund is working with countries to contain and treat drug resistance, it remains a thorny issue; the World Bank and a joint initiative involving the Stop TB Partnership are focusing on projects to increase the speed of diagnosis. Reichman notes that the relatively new challenge of drug resistance draws attention away from effective standard treatment programmes, which are the main means of prevention. “Achievements of the last few years must be preserved”, say Raviglione and Espinal. This includes working with emerging economies, “to ensure they assume their responsibilities and preserve and increase their contributions to tuberculosis control and research and development”. This year, three key meetings will involve ministerial representatives from highprevalence countries plus agencies and donors to discuss the way forward in light of the economic crisis. The first meeting is the Stop TB Partners’ Forum on March 23–25 (Rio de Janeiro, Brazil). The upcoming release of WHO’s annual www.thelancet.com/infection Vol 9 March 2009
Newsdesk
tuberculosis report and the Stop TB Partnership’s report of the first 3 years of the Global Plan are expected to serve as critical tools to remind donors that, while progress has been achieved, the work is not yet over. WHO and Stop TB Partnership are also working to ensure that major economic gatherings place tuberculosis on their agenda. “The key message is to ensure the G8 and G20 see tuberculosis control as a major investment”, since, Raviglione and Espinal note, “85% of tuberculosis cases occur among people in their economic prime”. Last year, a study by the World Bank reported the economic benefits of investing in tuberculosis control, with the benefits of implementing the Global Plan to Stop TB relative to a no-DOTS scenario exceeding costs 15-fold in the 22 high-burden endemic countries. Contributions to the Global Fund, communications officer Nicolas Demey told TLID, also have extended benefits. “There are indications that the availability of Global Fund grants has led to a revitalisation of domestic
tuberculosis programmes, and has also leveraged an increase in domestic funding”, he says. “In several countries, Global Fund tuberculosis financing has led to ground-breaking progress in the roll-out of DOTS and scaleup of MDR tuberculosis treatment”. Overall, these programmes have enhanced health-service capacity, including community outreach services and the training of 8·6 million community workers. The world is now looking to the USA, as the major donor of ODA, directly. The economic crisis is “an overall worry”, says Irene Koek, chief of infectious diseases at the USAID Bureau for Global Health (Washington, DC, USA). However, she explains that the Hyde-Lantos bill, passed last summer, laid out specific targets and funding for infectious disease, including tuberculosis treatment for 4·5 million people, and for 900 000 with MDR tuberculosis. This legislation is part of “a strong US commitment” to tackle infectious diseases and invest in ODA. She said: “we do know for 2009, there will be no cutbacks on tuberculosis
spending”. However, budgets for 2009 and 2010 are now being finalised. Several experts are pointing out that investment in health care can not only ameliorate the effects of recession, but could stimulate economic growth and also have positive effects on development. Reichman notes that, “disease control is one of the most basic ways to protect humankind”, and new findings indicate that diseases other than HIV, malaria, and tuberculosis also need further investment. On Feb 4, the first global survey of research and development on neglected infectious diseases reported that many other key diseases responsible for killing millions of people (including pneumonia and diarrhoeal diseases) remain underfunded. Mary Moran, study leader at The George Institute for International Health, Sydney, Australia, notes that a few donors provide the majority of funding. “In these times of economic crisis, it’s worrying to see all our eggs in one basket”, she said.
Kelly Morris
Infectious disease surveillance update Avian influenza WHO last month reported a further case of H5N1 avian influenza (February, 2009). This year four people have died as a result of H5N1 infection out of 11 confirmed cases. Most of the cases and all of the deaths occurred in China, with the remaining four cases in Egypt. Of the seven cases reported in China this year, patient ages ranged from 2 years to 31 years. The cases are related to exposure to poultry, and not linked epidemiologically. According to Wing-Hong Seto (Queen Mary Hospital, Hong Kong, China), the increase in cases in China—compared with four for the whole of 2008—“is due to enhanced reporting”. Seto told TLID that China has developed stronger surveillance for medical emergencies in recent months, as a result of the www.thelancet.com/infection Vol 9 March 2009
melamine incident. A total of 406 cases worldwide (254 deaths) have been reported by WHO since monitoring began, the majority in Indonesia. The European Centre for Disease Prevention and Control (ECDC; Stockholm, Sweden), in their recent threat assessment, conclude that the China cases do not indicate a change in the characteristics of the virus. Instead they attribute the cases to “increased exposure of populations in contact with poultry, in the context of the preparation for the Chinese New Year”.
Seasonal influenza in Europe According to new data released last month, influenza activity has continued to intensify and progress across Europe. Most countries are now reporting medium to high intensity,
according to the European influenza surveillance scheme. Higher than usual levels of influenza have been reported in Germany, Luxembourg, Poland, Sweden, and Switzerland. Nicola Goddard (UK Health Protection Agency, London, UK) told TLID that the predominant strain this season is H3N2 and “may cause more severe illness on a case-by-case basis”. Overall, the highest rates of infection have been the 0–4 year age-group. The ECDC has called for a strengthening of seasonal influenza vaccination campaigns for at-risk groups. Goddard notes there is great disparity in rates of uptake across Europe with variations of up to 40-fold (2–80%).
For more on avian influenza see http://www.who.int/csr/disease/ avian_influenza/en/ For more on the ECDC threat assessment see http://ecdc. europa.eu/en/health_content/ Articles/article_20090123.aspx For more on the EISS bulletin see http://www.eiss.org/cgi-files/ bulletin_v2.cgi?display=1&code= 290&bulletin=290 For more on influenza in Europe see http://www.eurosurveillance. org/ViewArticle.aspx? ArticleId=19097
Onisillos Sekkides 145
Global tuberculosis control amid the world economic crisis See Leading Edge page 137 For more on the Global Plan to Stop TB and the Stop TB Partners’ Forum see http:// www.stoptb.org
George Tsereteli/USAID
For more on the George Institute for International Health survey see http://www. thegeorgeinstitute.org/research/ health-policy/current-projects/gfind-global-funding-ofinnovation-for-neglected-diseases. cfm
As World TB Day approaches on March 24, the Stop TB Partnership’s Global Plan to Stop TB and the Global Fund to Fight AIDS, Tuberculosis and Malaria face deficits in funding. With many demands on political attention in a global economic downturn, will progress on tuberculosis fall behind? Experts note that tuberculosis efforts could save 14 million lives by 2015 and have broader benefits for nations and economies. Widespread agreement exists that worldwide progress has been remarkable, but the discipline faces new challenges, and now investment could fall rather than increase. When the Global Plan to Stop TB was launched in 2006, the funding deficit was about US$30 billion. Mario Raviglione (WHO; Geneva, Switzerland) and Marcos Espinal (Stop TB Partnership; Geneva, Switzerland) explained to TLID that bridging the funding deficits is key to reaching both the Millennium Development Goal on tuberculosis and the Stop TB Partnership’s goals by 2015. “If realised, these major objectives will set the path for the elimination of tuberculosis by the year 2050”, they note. Since 2002, worldwide funding for tuberculosis has increased at country level every year, but progress has slowed since 2006. World Bank senior health specialists Miriam Schneidman
Tuberculosis patient at a DOTS treatment facility in Tbilisi, Georgia
144
and Joel Spicer told TLID that, “investments have indeed increased; however, so have the needs and areas of intervention”. Before the economic crisis, detection of cases were not increasing, since, says Lee Reichman (New Jersey Medical School Global Tuberculosis Institute, NJ, USA), “the easy-to-find cases had already been found”. Multidrug-resistant (MDR) and extensively drug-resistant tuberculosis are at their highest levels ever, placing a further burden on programmes. The improved directly observed therapy, short course (DOTS) strategy is now in place to address HIV co-infected patients and drug resistance, notes Schneidman and Spicer, but progress has been uneven because of weak health systems and the HIV epidemic. In past recessions, many countries reduced spending on overseas development assistance (ODA). WHO Director-General Margaret Chan says these responses could be as “devastating for health, development, security, and prosperity as they were in the past”. World Bank President, Robert Zoellick, has urged developedcountry policymakers to “avoid putting in place policies and structures that undermine the interests of developing countries” that “are at the mercy of a crisis not of their making”. In January, the Global Fund reiterated these warnings, announcing an estimated $5 billion deficit for the next 2 years. During the World Economic Forum in Davos, Switzerland, in January, partners of the Global Fund said that if the fund cannot maintain its commitment to fund all high-quality programmes, then the G8 will have failed in its pledges. Jeffrey Sachs, special advisor to the UN Secretary-General, notes that “this is absolutely in violation of the life and death pledge that the rich world has made”. He points to bonuses awarded by the banking system, saying “the money’s there”. Yet, many experts believe that the economic crisis will have a major
impact on worldwide tuberculosis efforts, including Raviglione and Espinal. Tuberculosis and drug resistance may increase, with an additional negative impact from tuberculosis/HIV co-infection, they suggest. “Development of new tools (vaccines, drugs, and diagnostics) for tuberculosis may be seriously jeopardised”, they told TLID. The World Bank estimates that the financial crisis has already put 100 million people back into poverty. This, Spicer said, “could easily facilitate the spread of tuberculosis by sharply increasing the number of cases, overwhelming already overstretched health systems, and leading to a sharp increase in drugresistant cases” due to slower casefinding and inadequate tuberculosis treatment. The latter may be due to programmatic issues, but also patients facing a basic lack of food and money for transportation, notes Schneidman. Although the Global Fund is working with countries to contain and treat drug resistance, it remains a thorny issue; the World Bank and a joint initiative involving the Stop TB Partnership are focusing on projects to increase the speed of diagnosis. Reichman notes that the relatively new challenge of drug resistance draws attention away from effective standard treatment programmes, which are the main means of prevention. “Achievements of the last few years must be preserved”, say Raviglione and Espinal. This includes working with emerging economies, “to ensure they assume their responsibilities and preserve and increase their contributions to tuberculosis control and research and development”. This year, three key meetings will involve ministerial representatives from highprevalence countries plus agencies and donors to discuss the way forward in light of the economic crisis. The first meeting is the Stop TB Partners’ Forum on March 23–25 (Rio de Janeiro, Brazil). The upcoming release of WHO’s annual www.thelancet.com/infection Vol 9 March 2009
Newsdesk
tuberculosis report and the Stop TB Partnership’s report of the first 3 years of the Global Plan are expected to serve as critical tools to remind donors that, while progress has been achieved, the work is not yet over. WHO and Stop TB Partnership are also working to ensure that major economic gatherings place tuberculosis on their agenda. “The key message is to ensure the G8 and G20 see tuberculosis control as a major investment”, since, Raviglione and Espinal note, “85% of tuberculosis cases occur among people in their economic prime”. Last year, a study by the World Bank reported the economic benefits of investing in tuberculosis control, with the benefits of implementing the Global Plan to Stop TB relative to a no-DOTS scenario exceeding costs 15-fold in the 22 high-burden endemic countries. Contributions to the Global Fund, communications officer Nicolas Demey told TLID, also have extended benefits. “There are indications that the availability of Global Fund grants has led to a revitalisation of domestic
tuberculosis programmes, and has also leveraged an increase in domestic funding”, he says. “In several countries, Global Fund tuberculosis financing has led to ground-breaking progress in the roll-out of DOTS and scaleup of MDR tuberculosis treatment”. Overall, these programmes have enhanced health-service capacity, including community outreach services and the training of 8·6 million community workers. The world is now looking to the USA, as the major donor of ODA, directly. The economic crisis is “an overall worry”, says Irene Koek, chief of infectious diseases at the USAID Bureau for Global Health (Washington, DC, USA). However, she explains that the Hyde-Lantos bill, passed last summer, laid out specific targets and funding for infectious disease, including tuberculosis treatment for 4·5 million people, and for 900 000 with MDR tuberculosis. This legislation is part of “a strong US commitment” to tackle infectious diseases and invest in ODA. She said: “we do know for 2009, there will be no cutbacks on tuberculosis
spending”. However, budgets for 2009 and 2010 are now being finalised. Several experts are pointing out that investment in health care can not only ameliorate the effects of recession, but could stimulate economic growth and also have positive effects on development. Reichman notes that, “disease control is one of the most basic ways to protect humankind”, and new findings indicate that diseases other than HIV, malaria, and tuberculosis also need further investment. On Feb 4, the first global survey of research and development on neglected infectious diseases reported that many other key diseases responsible for killing millions of people (including pneumonia and diarrhoeal diseases) remain underfunded. Mary Moran, study leader at The George Institute for International Health, Sydney, Australia, notes that a few donors provide the majority of funding. “In these times of economic crisis, it’s worrying to see all our eggs in one basket”, she said.
Kelly Morris
Infectious disease surveillance update Avian influenza WHO last month reported a further case of H5N1 avian influenza (February, 2009). This year four people have died as a result of H5N1 infection out of 11 confirmed cases. Most of the cases and all of the deaths occurred in China, with the remaining four cases in Egypt. Of the seven cases reported in China this year, patient ages ranged from 2 years to 31 years. The cases are related to exposure to poultry, and not linked epidemiologically. According to Wing-Hong Seto (Queen Mary Hospital, Hong Kong, China), the increase in cases in China—compared with four for the whole of 2008—“is due to enhanced reporting”. Seto told TLID that China has developed stronger surveillance for medical emergencies in recent months, as a result of the www.thelancet.com/infection Vol 9 March 2009
melamine incident. A total of 406 cases worldwide (254 deaths) have been reported by WHO since monitoring began, the majority in Indonesia. The European Centre for Disease Prevention and Control (ECDC; Stockholm, Sweden), in their recent threat assessment, conclude that the China cases do not indicate a change in the characteristics of the virus. Instead they attribute the cases to “increased exposure of populations in contact with poultry, in the context of the preparation for the Chinese New Year”.
Seasonal influenza in Europe According to new data released last month, influenza activity has continued to intensify and progress across Europe. Most countries are now reporting medium to high intensity,
according to the European influenza surveillance scheme. Higher than usual levels of influenza have been reported in Germany, Luxembourg, Poland, Sweden, and Switzerland. Nicola Goddard (UK Health Protection Agency, London, UK) told TLID that the predominant strain this season is H3N2 and “may cause more severe illness on a case-by-case basis”. Overall, the highest rates of infection have been the 0–4 year age-group. The ECDC has called for a strengthening of seasonal influenza vaccination campaigns for at-risk groups. Goddard notes there is great disparity in rates of uptake across Europe with variations of up to 40-fold (2–80%).
For more on avian influenza see http://www.who.int/csr/disease/ avian_influenza/en/ For more on the ECDC threat assessment see http://ecdc. europa.eu/en/health_content/ Articles/article_20090123.aspx For more on the EISS bulletin see http://www.eiss.org/cgi-files/ bulletin_v2.cgi?display=1&code= 290&bulletin=290 For more on influenza in Europe see http://www.eurosurveillance. org/ViewArticle.aspx? ArticleId=19097
Onisillos Sekkides 145