Tuberculosis control and elimination 2010–50: cure, care, and social development

Summary

Rapid expansion of the standardised approach to tuberculosis diagnosis and treatment that is recommended by WHO allowed more than 36 million people to be cured between 1995 and 2008, averting up to 6 million deaths. Yet tuberculosis remains a severe global public health threat. There are more than 9 million new cases every year worldwide, and the incidence rate is falling at less than 1% per year. Although the overall target related to the Millennium Development Goals of halting and beginning to reverse the epidemic might have already been reached in 2004, the more important long-term elimination target set for 2050 will not be met with present strategies and instruments. Several key challenges persist. Many vulnerable people do not have access to affordable services of sufficient quality. Technologies for diagnosis, treatment, and prevention are old and inadequate. Multidrug-resistant tuberculosis is a serious threat in many settings. HIV/AIDS continues to fuel the tuberculosis epidemic, especially in Africa. Furthermore, other risk factors and underlying social determinants help to maintain tuberculosis in the community. Acceleration of the decline towards elimination of this disease will need invigorated actions in four broad areas: continued scale-up of early diagnosis and proper treatment for all forms of tuberculosis in line with the Stop TB Strategy; development and enforcement of bold health-system policies; establishment of links with the broader development agenda; and promotion and intensification of research towards innovations.

Introduction

Global control of tuberculosis is far from complete. There were 9·4 million estimated new cases of tuberculosis in 2008;1, 2 multidrug-resistant (MDR) tuberculosis remains a severe threat;3, 4 and HIV continues to fuel the epidemic, especially in Africa.1, 5 With 1·8 million estimated deaths every year, tuberculosis still takes a huge toll, especially for the poorest people. It is a leading cause of death in people in the most economically productive age-groups.⁶ People who are cured from this disease can be left with lifetime sequelae that substantially reduce their quality of life.⁷ The direct and indirect costs of tuberculosis, and the social consequences, are often catastrophic for the individual patient, the family, and the wider community.⁸

Fortunately, available drug regimens can cure most patients,¹ and tuberculosis treatment is among the most cost-effective health interventions.⁹ If applied early in the disease course it can effectively cut transmission and prevent the disease from spreading. It can also yield economic benefits that are ten times the cost of the investment.¹⁰ Therefore, concerted action to ensure universal access to high-quality tuberculosis diagnosis and treatment is being pursued by almost all countries, in line with WHO's Stop TB Strategy (panel 1)¹¹ and the Stop TB Partnership's Global Plan to Stop TB.12, 13 The medium-term target of these actions, set for 2015 in the context of the Millennium Development Goals (MDGs), is to halt and to begin to reverse incidence of this disease. Additional 2015 targets set by the Stop TB Partnership are to halve tuberculosis prevalence and death rates compared with 1990. A more long-term goal is to eliminate the disease as a public health concern by reducing incidence to less than one case per 1 million of the population by 2050.¹⁴

Key messages

• Rapid expansion of a standardised approach to tuberculosis diagnosis and treatment cured more than 36 million people between 1995 and 2008, averting up to 6 million deaths. However, tuberculosis remains a huge global public health concern, with more than 9 million new cases occurring every year.

• The Millennium Development Goal target to halt and begin to reverse tuberculosis incidence by 2015 is estimated to have been reached in 2004 globally. However, the decline is less than 1% per year.

• With present efforts, the targets to halve prevalence and death rates by 2015, compared with 1990 rates, will probably be met in most regions, but might not be met worldwide.

• The long-term elimination target, to reduce incidence to less than one case per million by 2050, will not be reached with existing technologies and approaches.

• Intensified case detection approaches are needed, linked to general health-system strengthening, ensuring universal access to high-quality early diagnosis, treatment, and care for all forms of this disease, including people infected with HIV and those affected by multidrug-resistant tuberculosis.

• Emphasis should be put on preventions, including preventive therapy, development of better vaccines, and actions to address direct tuberculosis risk factors (eg, HIV, undernutrition, diabetes, smoking, and drug and alcohol misuse), and underlying social determinants (eg, poverty, and poor living and working conditions).

• Acceleration of the present decline towards tuberculosis elimination will need invigorated actions in four broad areas: continued scale-up of early diagnosis and proper treatment in line with the Stop TB Strategy; development and enforcement of bold health-system policies; establishment of links with the broader development agenda; and promotion and intensification of research.

In the first paper in the Series, we assess progress towards reaching these targets, with particular focus on the 22 countries with a high burden of tuberculosis that together have more than 80% of the world's cases. We then scrutinise the present model for global tuberculosis control, and review the main challenges related to weak health systems, inadequate medical technologies, MDR tuberculosis, the HIV epidemic, other tuberculosis risk factors, and social determinants. Finally, we identify additional entry points for interventions and describe a way forward towards more effective tuberculosis control.