"Statistics South Africa’s 2014 mortality report shows that TB is the single leading cause of death in South Africa, and efforts to address it, are complicated by a range of factors." (Gallo)

Turning the tide against TB: Treatment alone won’t work

The global TB rate has been falling by 1.5% per year – far slower than the 10% yearly declines needed to end TB within twenty years.

Just last month, the World Health Organisation (WHO) released new data showing that, despite being curable, tuberculosis (TB) has overtaken HIV and Aids as the world’s leading cause of death from an infectious disease. According to WHO, TB killed 1.5-million people worldwide in 2014, including an estimated 96 000 South Africans – these figures include those who were living with HIV and died from TB.

The fact that TB is now the world’s deadliest infectious disease, should catalyse unprecedented action to eliminate it. The challenge is significant, most of all because the global TB rate has been falling by roughly 1.5% per year, according to WHO – far slower than the 10% yearly declines that experts say are needed to end TB within twenty years. This is a goal that the WHO has set and which health ministers from around the world endorsed last year.

The situation in South Africa shows how difficult it will be end TB without bold new approaches to fighting the disease. Statistics South Africa’s 2014 mortality report shows that TB is the single leading cause of death in South Africa, and efforts to address it, are complicated by a range of factors, including persistent poverty, undernutrition, high rates of co-infection with HIV, rising rates of diabetes, and widespread antibiotic resistance.

The obvious question is: How do we eliminate a disease that afflicts 9-million individuals every year and kills more people than any other infectious illness?

More than 60 years ago, the husband and wife team of eminent TB experts, Rene and Jean Dubos, wrote that “TB is a social disease and presents problems that transcend the conventional medical approach”. They stressed that in fighting TB, economic and social factors need to be considered as much as the medical.

This approach is the key to success, and it is the foundation that underpins the Global Plan to Stop TB, 2016-2020, a new landmark document published last week by the Stop TB Partnership. The Global Plan is designed to guide global action against TB over the next five years and put us on track to eliminate the disease by 2035.

The Global Plan has set three ambitious targets to achieve by 2020:

Diagnose and treat at least 90% of people in need. Currently, an estimated one-third of people who develop TB each year are not even diagnosed, according to WHO.

Reach at least 90% of people with TB within key affected and vulnerable populations. Vulnerable populations include, for example, people living with HIV, incarcerated persons, people who struggle with substance addiction, people living in poverty, refugees, children and adolescents.

Treat at least 90% of all people diagnosed with TB. This requires delivering affordable health care and providing the social support that patients need to complete treatment. 

Ending TB will take stronger investment in scientific research. Currently, there is no effective TB vaccine. The standard TB medicines are more than 50 years old and require at least six months of use. And the most widely used diagnostic test requires a person to search for TB germs through a microscope, using the naked eye.

But we’ll never end the epidemic through treatment alone. We must revolutionise the approach to TB prevention.

TB spreads from person-to-person through the air when someone sick with TB coughs. TB most heavily impacts the urban poor, where undernourished people live in crowded conditions and commonly face economic, social and cultural barriers to completing the minimum of six months of treatment. This is why in a place such as Khayelitsha in the Cape Flats we see one of the world’s highest rates of TB.

We can make it harder for TB to spread by improving indoor air quality and sanitation, investing in proven antipoverty measures, and expanding the social support that helps patients stay on treatment. People living with HIV, for example, can now participate in strong local, national and even international networks of people who are also living with HIV. They form an empowered constituency that provides peer assistance to individual patients and advocates for global action against HIV. We need the same for people affected by TB. 

None of the aims above will be possible without bold leadership that ensures people’s right to live free from TB. To achieve the seismic shift necessary to end TB, we need a dramatic increase in political will to confront the disease, informed by evidence and advocacy from communities affected by TB.

On Wednesday, the world’s largest gathering of tuberculosis experts, activists, and public health officials meet in Cape Town for the World Conference on Lung Health. We hope that with a new Global Plan in hand, we will look back on this time and place and find the point at which the world finally turned the tide against TB.

Linda-Gail Bekker is professor of medicine and deputy director of the University of Cape Town’s Desmond Tutu HIV Centre. She is also president-elect of the International Aids Society. Paula I Fujiwara is scientific director of the International Union Against Tuberculosis and Lung Disease.

World Aids DaytuberculosisTB drugsStop TB Partnership

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