Dr Masoud Dara, Senior Advisor at the World Health Organization explains the challenges of tackling TB to Editor Laura Evans, and why antibiotic resistance is such a problem…
According to the World Health Organization, infectious diseases are caused by ‘pathogenic microorganisms, such as bacteria, viruses, parasites and fungi. Such diseases can be spread from person to person, directly or indirectly. Tuberculosis, measles, meningococcal meningitis, chikungunya virus, malaria, plague, HIV/AIDS, rubella, and viral hepatitis all fall under the category of infectious diseases.
Tuberculosis (TB) in particular is a global public health threat which resulted in 1.5 million deaths in 2013 and caused 9 million people to fall ill in the same year. Editor Laura Evans spoke to Dr Masoud Dara from the World Health Organization Regional Office for Europe about tuberculosis (TB), and what the main challenges are in regards to treating this infectious disease.
“There is good news and bad news when we’re talking about TB,” explained Dr Dara. “The good news is that through effective implementation of the WHO recommended strategy, 37 million lives were saved between 2000 and 2013 in the world and the number of TB cases is reducing in Europe. In the last 5 years we have noticed a 6% annual decrease, which is the fastest decline among all WHO regions.
“The bad news, however, is that the rate of drug resistance among new cases is on rise. This form of the disease is very difficult to cure.”
Tackling tuberculosis has become a major public health priority and Dr Dara believes that infectious diseases can be treated by “breaking the transmission cycle”. He believes that it is crucial at a policy level that infectious diseases such as tuberculosis become a priority for governments worldwide, translating to adequate human and financial resources are needed to move towards eliminating the disease.
“If you do not invest now you have to spend much more in the future,” he adds.
“Every case that is not treated correctly is going to infect 10-15 people per year – that’s why it’s important to scale up targeted activities to detect and cure all cases now. TB prevention and control programmes are very cost effective. A recent analysis published in the Economist presented TB control interventions as the fourth most effective value for money intervention to reach the Sustainable Development Goals1 with every $1 spent leading to $43 saving.”
Most people with TB are cured with a 6 month treatment regime, and in many countries 80-90% of people are successfully cured following the recommended treatment. However, drug resistance can occur if medicines not taken properly or are of poor quality. Under these conditions, amplification of resistance can occur and multidrug resistance tuberculosis (MDR-TB) can emerge, which is a form of the disease, resistant to the two most important medicines we have. Resistant strains can then be transmitted to others particularly in crowded settings such as prisons or hospitals, leading to further spread of the disease.
“If the patient has MDR-TB then they need further treatment which can last up to 2.5 years,” says Dr Dara. “This treatment is with 6 or 7 drugs and there can be many adverse events – including suicidal thoughts, liver damage and hearing problems. Due to these side effects, patients often stop the treatment or only take some of their medicines, which can make it even more difficult to treat.”
In 2013, 480,000 people developed multidrug-resistant TB in the world. Currently only half of those patients are successfully cured. It is believed that $2bn per year is needed to fill the resource gaps for implementing the existing TB interventions.
“The treatments success heavily depends on whether you have good diagnostic tools to rapidly detect resistance,” says Dr Dara. “Time is very precious in terms of diagnosing the right pattern of resistance to give the right treatment. If the patient is given treatment that is not based on the resistance pattern, you could create more resistance. This is then called amplification, which you need to avoid because it will lead to more and more resistance and the patient will have no options for treatment.”
In September the World Health Organization launched a new End TB Strategy. The new agenda highlights strategic directions to integrate digital health into TB prevention and care activities.
“The End TB Strategy is quite important and has 3 main pillars to focus on,” explains Dr Dara. “The first is ensuring the best care is given to patients, and all patients. The second is making sure you have a patient-centred health system and supportive environment which can cater for the patient’s needs.
If the patient has to travel and get a bus every day for treatment for example, that could lead to interrupting the treatment.”
Another very important aspect is special support such as nutritional and psychological support to help patients finish their treatment. The third pillar of the End TB Strategy is research and development. Dr Dara emphasises that it is extremely important to scale up research and development for new tools particularly a new effective vaccine and shorter and more effective treatment regime.
“In WHO Office for Europe we have worked with our Member States and partners and adapted the End TB Strategy to the Regional context and prepared a 5 year Tuberculosis Action Plan 2016-2020 with even more ambitious targets than those of the global level. The 65th WHO Regional Committee adopted this plan on 17 September 2015. Together with our partners, we will assist the Member States to implement the Plan.
“The main goal is to decrease TB rates faster and improve treatment outcomes of all TB cases, which are achievable if all countries fully implement the Action Plan” he says.
The question stands as to whether we can eliminate TB altogether, and Dr Masoud is hopeful. Elimination would be less than 1 TB case per million of the population, he believes that to reach this we need substantial increase in investment in research and development for new tools including new vaccines and rapid access to them across the world.
1 The economics of optimism, The Economist 24 January 2015 http://www.economist.com/news/finance-and-economics/21640361-debate-heats-up-about-what-goals-world-should-set-itself-2030
Dr Masoud Dara