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The World Health Organization (WHO) has declared March 24, 2016 as World Tuberculosis (TB) Day [1]. Over the month of March, the Global Health Office will be publishing a series of blog posts about TB in hopes of raising awareness of its worldwide impact. WHO’s “End TB Strategy” has a goal of ending the TB epidemic by 2030, by targeting poverty, improving testing and treatment, ending stigma and discrimination, and driving research and innovation. Put simply, TB is not yet a disease of the past, but if we unite and focus our efforts, we can make TB history.

Last week we talked about diagnosing TB, and the importance of determining an appropriate treatment course along with that diagnosis. But how is TB treated, and why is drug resistance an issue with TB in particular?

Although those with latent TB infection do not present symptoms, and cannot spread TB bacteria to others, treatment can still be provided to stop them from developing TB disease. This step is important in eliminating and controlling TB around the world, but should only be initiated once the possibility of TB disease has been excluded. In the United States, four treatment regimens are approved, using combinations of isoniazid, rifampicin and rifapentine. Treatment for latent TB can last anywhere from 3 months to 9 months, necessitating between 12 and 270 doses (minimum) of anti-TB drugs [2].

Treating those with active TB disease is a much more pressing matter, as they have the potential to spread the disease to others. Treatment regimens for active TB disease can last between 6 and 30 months depending on resistance, a process which burdens patients and treatment providers alike [3]. With a treatment course this long, some patients inevitably fail to complete the full regimen, for many reasons including finances, social pressures and inadequate access to proper treatment. To provide a glimpse at the financial burden of TB, each case in Canada cost the healthcare system $47,290 [4]. This can lead to acquired drug resistance, which can then be passed on to others when the infected person, coughs, sneezes or spits, releasing TB bacteria into the air [5].

There are two types of drug-resistant TB: multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB). MDR-TB bacteria does not respond to (at least) the two most widely used and powerful first line TB drugs: isoniazid and rifampicin [6]. XDR-TB involves resistance to isoniazid and rifampicin, in addition to resistance to any of the fluoroquinolones (ofloxacin, etc.), and to at least one of three injectable second-line drugs (amikacin, capreomycin or kanamycin) [7]. Both MDR-TB and XDR-TB take longer than regular TB to treat (at least 18 months) and have lower treatment success rates. Furthermore, patients often experience more harsh side effects from treatment, leading to increased hospitalization [8]. In order to maximize the potential for positive treatment outcomes, it is important that further tests are undertaken after initial diagnosis to determine whether bacteria is drug-resistant, and provide appropriate treatment [7].

According to the WHO Global TB Report, in 2014 an estimated 3.3% of new TB cases and 20% of previously treated cases had MDR-TB. More than half of these cases occur in India, China and the Russian Federation. Additionally, an estimated 190,000 people died of MDR-TB in 2014. As of 2015, XDR-TB had been reported in 105 countries. The map below shows the number of patients in these countries with laboratory-confirmed XDR-TB who started treatment in 2014 [9].

Map of the world, showing the number of laboratory-confirmed cases of XDR-TB receiving treatment by country, 2014. (Source: World Health Organization).

In response to treatment non-adherence, and to combat the spread of drug-resistant TB, the directly observed therapy, short-course (DOTS) strategy was developed by WHO in 1994. Health workers meet with patients regularly to help with treatment, adherence, and to provide support and education. This strategy also advocates for increased allocation of domestic and international funding and resources to combat TB [10]. Tuberculosis is also highlighted in two recent worldwide strategies, the WHO End TB Strategy, and the UN Sustainable Development Goals (SDGs), which will be discussed in our next post.

By: Maria Wilson

Global Health Office Outreach Assistant

SDGs-GlobalGoalsForSustainableDevelopment-05

As a follow-up to the MDGs, the UN has developed 17 Sustainable Development Goals (SDGs), which will come into effect on January 1 2016. As with the MDGs, each SDG has specific targets, which can be found on the UN website, and a set of indicators to measure progress, which will be finalized by March 2016. This ambitious agenda has been proposed to shape the policies and actions of UN member states through to 2030:

End poverty in all its forms everywhere
End hunger, achieve food security and improved nutrition and promote sustainable agriculture
Ensure healthy lives and promote well-being for all
Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all
Achieve gender equality and empower all women and girls
Ensure access to water and sanitation for all
Ensure access to affordable, reliable, sustainable and modern energy for all
Promote inclusive and sustainable economic growth, employment and decent work for all
Build resilient infrastructure, promote sustainable industrialization and foster innovation
Reduce inequality within and among countries
Make cities inclusive, safe, resilient and sustainable
Ensure sustainable consumption and production patterns
Take urgent action to combat climate change and its impacts
Conserve and sustainably use the oceans, seas and marine resources
Sustainably manage forests, combat desertification, halt and reverse land degradation, halt biodiversity loss
Promote just, peaceful and inclusive societies
Revitalize the global partnership for sustainable development

What makes the SDGs different from the MDGs? The most obvious answer is that there are more than double the number of SDGs than there are MDGs, but there are more differences than just that! More SDGs translates to the UN being able to tackle a more broad range of issues related to development. The MDGs were grounded in anti-poverty, however, they often failed to address the root causes of poverty, opting instead to treat the symptoms. The SDGs aim to address the systemic issues that allow poverty to persist, including human rights, governance, peace and stability. The SDG targets also move beyond poverty, examining issues such as climate change and sustainable consumption, which will impact everyone, regardless of their socioeconomic status.

The MDGs were primarily developed by member countries of the Organization for Economic Co-operation and Development and donor agencies focusing their efforts on low and middle-income countries. The process for determining the MDGs barely involved those who were most affected by their targets. The SDGs, however, have come out of international negotiations where low and middle-income countries were granted input. Furthermore, the SDGs are regarded as universal, applying to all countries and actors, rather than creating a divide between “rich donors” and “poor recipients.”

More opportunities for partnership will (hopefully) be a product of, and a driver of, the SDGs. These include public-private partnerships, trade partnerships, global partnerships, local partnerships, and most importantly equitable partnerships. In order to meet the ambitious targets set out in the SDGs, a multidisciplinary and multi-stakeholder approach will be vital.

The MDGs are about to expire, and though there has been considerable progress made on many of the targets, there is still much work to be done. About 1 billion people still live on less than $1.25 per day worldwide, gender inequality persists as women worldwide continue to face discrimination in their everyday lives and over 800 million people still suffer from hunger. The SDGs hope to finish the job of the MDGs, and ensure that this time around, no one is left behind. Over the next 15 years, we are excited to see how the SDGs will impact global health, as health is a key outcome of development.

World Tuberculosis Day Part III – Treatment & Drug Resistance

When One Door Closes, Another Door Opens: From the MDGs to the SDGs Part 2

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