For the first time ever, global health is a major part of the G20 agenda. Ahead of the summit, international medical humanitarian organisation Doctors Without Borders/Médecins Sans Frontières (MSF) along with Stop TB released a report, Out of Step 2017, that reveals that many countries among the 29 surveyed still lag behind in ensuring full implementation of the WHO guidelines and policies for reducing tuberculosis incidence and death.
The report includes 23 of the 24 countries from the 2015 edition plus six additional nations where there is a Stop TB Partner or MSF project and the country has a high burden of TB and/or TB/HIV and/or multidrug-resistant (MDR)-TB according to WHO criteria.
India has the world's highest TB burden; in 2015, 2.8 million people fell ill with TB and 480,000 people died from it. However the diagnostic gap remains massive.
The 29 countries surveyed for this edition of Out of Step are home to 82% of the global TB burden. These are: Armenia, Afghanistan, Bangladesh, Belarus, Brazil, Cambodia, Central African Republic (CAR), China, Democratic Republic of Congo (DRC), Ethiopia, Georgia, India, Indonesia, Kazakhstan, Kenya, Kyrgyzstan, Mozambique, Myanmar, Nigeria, Pakistan, Papua New Guinea (PNG), Philippines, Russian Federation, South Africa, Swaziland, Tajikistan, Vietnam, Ukraine and Zimbabwe.
A grim reality
The third edition of Out Of Step, produced in collaboration with the Stop TB Partnership, looks at policies and implementation anti-TB tools (rapid diagnosis, newer paediatric drugs, shorter treatments, etc) in 29 countries where 86% of people infected by TB worldwide live. The key findings are pretty shocking in many ways. Despite some progress in making care more accessible and introducing newer treatments, many people are still not diagnosed in time. And when they are, they often do not have access to appropriate treatment.
The report also shows that many countries fail in adopting and implementing internationally recognised TB policies and guidelines from the World Health Organisation (WHO)—which are fundamental to ending TB by 2030.
The first step to closing the deadly diagnostic gap is initial testing for all with Xpert MTB/RIF, a rapid molecular test that can diagnose TB and detect rifampicin resistance in two hours. For people with rifampicin-resistant (RR) TB, additional drug-sensitivity testing (DST) should be available so that they can be treated with medicines most likely to be effective.
In the 29 countries surveyed, 52% (15) have adopted a policy of "Xpert for all" and 47% (7/15) of them have widely implemented the test. Of all countries that provide initial testing with Xpert MTB/RIF only to high-risk groups (people living with HIV and people at risk for drug-resistant forms of TB), only 54% (15/28) have widely implemented it. Universal DST must be scaled up: 62% (18) of countries recommend it and 50% (9/18) of those have widely implemented it.
Only seven countries in the report have made Xpert MTB/RIF (a rapid molecular test to diagnose TB and test for resistance to first-line TB drugs) widely available. India is not one of them.
Community health workers can improve drug-resistant (DR) TB treatment adherence by providing education, support and counselling and they facilitate decentralisation of DR-TB treatment.
None of the 29 countries surveyed list all of the anti-TB medicines recommended by WHO for the treatment of DR-TB in their national Essential Medicines List (EML), and only 25% (7/28) include Bedaquiline or Delamanid in their national EML.
In all of the countries surveyed, Bedaquiline and Delamanid—the first new medicines in nearly 50 years—only reach 5% of people who can benefit from them.
A recent study of anti-TB medicines from private-sector pharmacies in 19 cities reported that 9% of all tested medicines were substandard—over 16% in 11 African countries, over 10% in India, and nearly 4% in Brazil, China, Russian Federation, Thailand and Turkey.
The situation in India
In February this year, Finance Minister Arun Jaitley advanced India's resolve to eliminate TB, the new deadline being 2025. India has the world's highest TB burden; in 2015, 2.8 million people fell ill with TB and 480,000 people died from it. However the diagnostic gap remains massive. Only seven countries in the report have made Xpert MTB/RIF (a rapid molecular test to diagnose TB and test for resistance to first-line TB drugs) widely available. India is not one of them. This means that the majority of people in the countries surveyed are still tested with a method that fails to detect many cases, or that requires a wait of up to several months to confirm the disease.
India is, however, in the list of 20 countries where treatment for TB (both drug-resistant and drug-sensitive types) is accessible to patient at a primary healthcare centre.
The report shows that India does not widely follow WHO guidance on Bedaquiline use for adults and does not, at all, follow WHO recommendations on use of Delamanid.
MSF has TB treatment projects in 24 countries, and in 2015 supported more than 20,000 TB patients on treatment, including 2000 with drug-resistant tuberculosis (DR-TB). Bedaquiline and and Delamanid, newer TB medicines recommended for people with few or no TB treatment options, are included in 79% (23) and 62% (18) of national guidelines among countries, respectively. Bedaquiline is registered in India while Delamanid is not. The report also shows that India does not widely follow WHO guidance on Bedaquiline use for adults and does not, at all, follow WHO recommendations on use of Delamanid. India however does follow WHO guidelines for treatment of DR-TB.
India also does not have a targeted government programme to treat HIV/TB co-infection. To fill this gap, MSF delivers free healthcare to people with HIV/AIDS and tuberculosis (TB) in Mumbai, where such services can be difficult to access for many because of lack of availability, the cost of treatment and the social stigma associated with the diseases.
Every 18 seconds a person dies from TB, but this can change if governments implement the current policies and practices recommended by WHO. The #StepUpforTB campaign, a collaboration between MSF and the Stop TB Partnership, aims to increase awareness about how the gaps in TB policies and practices lead to unnecessary deaths around the world. The goal of the #StepUpforTB campaign is to encourage governments to adopt and implement up-to-date TB policies and guidelines by World TB Day 2018. #StepUpforTB is a communication platform that uses social media posts and petitions; it also provides personal stories from TB survivors and activists, along with evidence supporting the best policies and practices. These resources will inform and empower campaigners to push governments towards closing the deadly TB diagnosis and treatment gaps.