In what is becoming a ritual at the Union Conference on World Lung
Health,
Dr Chris Dye from the World Health Organization (WHO) Stop TB
Department
presented the year's statistical round-up in the pre-conference opening
session. What do the numbers say? Dr Dye examined progress towards the
TB
control targets set in 1991 by the World Health Assembly, and the
potential
for meeting the Millennium Development Goals (MDGs) relating to TB.
TB detection and cure rates are still below the targets, which are 70%
and
85% respectively. The global average 84% cure rate reported this year
is
undeniably good, but five years too late - unless you go with revised
targets for the year 2005. Detection rates are lagging at 59% on
average,
although 57 countries have reportedly met this target, as has the West
Pacific (WHO) region as whole. Approximately 25 countries have met
both
targets, although suspect recording and reporting cannot be ruled out
in
some cases.
Whether you define it as creep, surge or march, the upward trend in
global
TB incidence figures of the last decade appears to be over. Cases
continue
to rise, but at lower rates than for decades. For some regions,
incidence
may be inching down; Eastern Europe, which suffered a sharp rise in the
1990s, has at least reached a plateau by all accounts. This is
promising
with respect to the relevant MDG: To halt and reverse incidence, and
halve
prevalence and deaths, by 2015. But will we meet these targets?
Before answering that question, Dr Dye invited closer scrutiny of the
regional statistical details. In measures of both case detection and
treatment success, Africa and eastern Europe are lagging, whilst
South-east
Asia has shown rapid improvement. Even in countries with good rates of
detection and cure, subtle shifts in affected demographics may be
causing
the figures to level off. In Viet Nam for example, falling incidence in
the
25-65 age range is offset by a sharp rise in cases in the 15-24 age
bracket.
This may be a general phenomenon, with similar statistics arising in
Sri Lanka. As a result it is often difficult to determine whether falling
rates
of case notification are real. It is also possible that case
notification
has simply not reached its peak, as may be happening in India - where
despite huge DOTS expansion, no state shows an obvious decline in
incidence.
So, asks Dye, "Did we meet the targets? Will we meet the MDGs? My
answers to
those questions are 'no, but.' and 'yes, if.' ". The 'if' is quite a
big
'if' - around 30 billion US Dollars to be more specific, the current
gap in
the 56 US$ billion estimated funding requirements of the Global Plan.
To
that add the 95 US$ millionthat Dr Mario Raviglione, head of the WHO
Stop TB
Department, says will be necessary to fight extremely drug-resistant TB
(XDR-TB) in the foreseeable future.
Shortfalls in TB-HIV advocacy, planning, and resources will also hinder
progress, Dye continued. A lack of operations research, advocacy,
communication and social mobilisation (ACSM) projects and a slowed
increase
in national budgets for TB control are also factors against. Although
reflexive TB-HIV testing was scaled up massively in Africa over the
last
three years, the numbers again fall well short of the targets. More
action,
says Dye, will be needed in conjunction with increased resource
mobilisation
to control TB.
The take-home message seemed to be that we must not be overly
pessimistic
and should celebrate what progress we have made. Neither must we rest
on our
laurels or underestimate the potential for political apathy, drug
resistance
and HIV co-infection to undermine our best efforts.
