Are any world leaders at the UN in New York today really thinking seriously about MDR-TB? (Part 1)
In the last reported years 6.4 million TB cases were notified to the WHO (of the total 10 million estimated cases), of whom 82% saw successful outcomes (i.e. a total of 5.25 million of the estimated 10 million annual TB cases or 52.5% of all estimated cases). Similarly, 139,114 of the globally estimated 580,000 annual MDR cases were put on treatment, but only 55% of them achieved successful outcome (69,600 successful outcomes or just 12% of all estimated MDR cases).[I]
But things are believed to be about to change because right now as this blog is published the leaders of the world at the UN High Level Meeting (HLM) on TB in New York are demanding that 40 million TB cases must not just be found but must also be successfully treated over the next four years. This target has been described as a “flagship initiative” by the WHO, and literally everyone's up for it.
It amounts to a good 80% hike on existing case finding and notification, and pretty much a 100% hike on treatment successes so it's no small ambition - and is creditable on this account alone.
But there’s an additional small but far from insignificant addition to this flagship initiative which is even more ambitious. It relates to MDR-TB which demands that 1.5 million MDR-TB cases are successfully treated by 2022 as well – which amounts to being a whole different ball game.
Given the momentous occasion of the day when we imagine that many will be congratulating themselves (rightfully) on what has been a monumental challenge to see this HLM happen, we still feel it’s timely to make a couple of points about this. Because while 1.5 million as a target may be coherent with the current estimate of the percentage proportion of new TB cases that are drug-resistant (just recently rounded downwards to 3.5%) that’s about as far, we think, as current realities relate to it.
As mentioned above, in the last reported year 139,114 MDR-TB cases were put on treatment. So if we consider this number in the light of the target of 1.5 million MDR cases needed to be found by 2022, then we need to divide thise target by four (i.e. to give us an annual target for the next four years till 2022).
This amounts to an annual target (STARTING RIGHT NOW, please note!) for each for the next four years of finding 375,000 MDR cases annually (ones that we know are going to be out there).
Superficially this amounts to huge hike compared to what’s being currently achieved in terms of case detection of MDR-TB (a hike of 270% instead of one of 80% for DS-TB). Or (put another way) it amounts to a requirement for a scale up for MDR-TB case finding that is over three times more challenging than what’s being ambitiously demanded of ‘all’ TB (finding and treating those 40 million).
But actually this key demand (which is beholden on all member nations to see happen) is quite a bit more challenging still, because it requires not just that these 1.5 million are found – it also demands that they are ‘successfully treated’ (and the current success rate for treating MDR-TB is a paltry 55%). If we apply this percentage success rate to the current global numbers on treatment, we can see that of the 139,114 annual MDR cases found and treated under current health care actually only 76,500 have successful outcomes. But starting right now the new target has been set to successfully treat 375,000 each year - five times as many.
In other words while treating TB generally needs to be ramped up by about 100%, the treatment for MDR-TB needs to be ramped up by very nearly 500%! So we have to ask a simple question: does anyone in New York today signing up to this declaration today seriously believe this is possible without a sea change of commitment BY EVERY SINGLE UN MEMBER STATE that is above and beyond the already ambitious commitments that are more obvious?
And here is the relevant text of the Political Declaration itself that is being approved today (the first operational commitment):
Para 24. Commit to provide diagnosis and treatment with the aim of successfully treating 40 million people with tuberculosis from 2018 to 2022, including 3.5 million children, and 1.5 million people with drug-resistant tuberculosis including 115,000 children with drug-resistant tuberculosis, bearing in mind varying degrees of the burden of tuberculosis among countries and recognize the constrained health system capacity of low-income countries, and thereby aiming at achieving effective universal access to quality diagnosis, treatment, care, and adherence support...