TB can no longer be the neglected sister of HIV and malaria

In the eighth and final paper on the Lancet Series on Tuberculosis, a call to action is made to a wide range of sectors to assist scale-up TB service delivery, research and control. The launch of The Lancet TB Observatory, which will monitor progress on key indicators on an ongoing basis, is also announced. Its multiple contributors, lead by all three series editors (Professor Ben Marais, Stellenbosch University, South Africa; Dr Mario Raviglione, Stop TB Department, WHO; and Professor Alimuddin Zumla University College, London) offer a critical assessment of the status quo and clear guidance on the best way forward.

Since the introduction of standard control practices in 1995, 36 million people have been cured and about 6 million deaths averted. Despite this piece of good news, control and elimination of the global TB epidemic remain elusive and many challenges remain. The authors say: "However, substantial scientific advances and innovative solutions are urgently needed together with creative new strategies. Strong international and national political commitment is essential. Urgent action is needed by national governments to fund their own programmes, and for the G8 countries and other donor governments and organisations to support governmental and non-governmental efforts."

UN agencies, the private sector, professional societies, and human rights groups—as well as communities and individuals directly affected by TB—are all called upon to take action. Urgent action is required to realise both the relevant Millennium Development Goals (MDG 6) and the ambitious targets of the Stop TB Partnership. The partnership's Global Plan to Stop TB aims to reduce the global burden of tuberculosis (prevalence and death rates) by 50% relative to the global burden in 1990 (prevalence lower than 150 per 100 000, and deaths fewer than 15 per 100 000 per year); and, by 2050,eliminate TB as a health threat (defined as global incidence of less than one case of tuberculosis per million population per year).

Of the 9 epidemiological sub-regions 6 have already halved the prevalence rate and 4 the mortality rate compared to 1990 levels, with all others on course to do so before 2015, apart from Africa where it appears highly unlikely that these goals will be met (current prevalence rate in Africa 400-500 per 100 000/year, mortality rate 40-50 per 100 000 per year). Improved diagnosis, treatment and prevention are important, but tuberculosis presents as much a developmental crisis as a health crisis. More funds are required to advance research agendas and improve service delivery, but local ownership of the problem coupled with sustainable funding models and improved efficiency are equally important.

In funding terms, the authors state that TB can no longer be the neglected sister of HIV and malaria, and massive increases in financial commitment, from governments and donors, are needed across the board. They say: "Despite TB killing nearly as many people as HIV/AIDS (about 4500 per day), there has not been a similar increase in funding for TB control and research. For instance, research funds provided by the US National Institutes of Health (the second top donor in the world for TB research) represent roughly a 15th of what is invested in HIV research by the same agency."

The authors also note that the UN MDG Summit to be held in New York on Sept 20󈞂, 2010, will be an excellent opportunity to ensure that the global community assesses the progress towards achievement of the MDG (and Stop TB Partnership) targets related to TB control. Although the main target of halting and beginning to reverse global TB incidence might have been achieved already in 2004, the yearly reduction is minimum and is offset by population increases. Some 700,000 women, most of reproductive age, and tens of thousands of children die each year from TB.

To monitor progress, The Lancet, in collaboration with the Stop TB Partnership, WHO, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the leading experts participating in this Series, is launching a new initiative The Lancet TB Observatory, which will assess and monitor progress in control of and research into tuberculosis, assess domestic and global financing, regularly disseminate information, and advocate for intensified efforts with stakeholders at all levels. The remit of the observatory would be:

• Establish a website that details objectives, outputs, and links with the main TB websites
• Publish quarterly website updates on these objectives
• Publish a yearly update in a report in The Lancet updating progress
• Develop a blog for open discussion on the website
• Hold meetings every 1-2 years to discuss progress and continue innovation to boost progress
• Publish progress reports in a mini-series in The Lancet every 3 years that address the main themes
• Publish an editorial for the UN Millennium Development Goal Summit in September, 2010, to summarise the situation and issue a call to action

The authors conclude*: "In a sense TB can be regarded as an indicator disease that reflects poverty and global health disparities. There has never been a greater need for health and political leaders to join hands in a concerted effort to find sustainable solutions, pursuing bold new policies that are adequately funded and supported to achieve ultimate tuberculosis eradication."

In a Comment with the Series, Lancet Editor-in-Chief Dr Richard Horton and Executive Editor Dr Pamela Das say: "Although epidemiological data and funding flows are routinely collected by WHO and others, there is no formal mechanism to assess this information critically and independently. Nor is there any means to hold the various stakeholders in tuberculosis control to account. The Lancet TB Observatory, an internal and inclusive collection of tuberculosis scientists and physicians, will serve that function."

Professor Ben Marais, Stellenbosch University, Tygerberg, South Africa. T) E) bjmarais@sun.ac.za

Dr Mario Raviglione, Stop TB Department, WHO, Geneva, Switzerland. T) +41 22 791 2663 E) raviglionem@who.int

Professor Alimuddin Zumla, University College, London. T) +44-207-6799311 E) a.zumla@ucl.ac.uk

Glenn Thomas, Senior Communications Adviser, WHO Stop TB Department. T) +41 79 509 0677 E) thomasg@who.int

Lancet Press Office T) +44 (0) 20 7424 4949 E) pressoffice@lancet.com / tony.kirby@lancet.com

For full Series paper 8, see: http://press.thelancet.com/tbsp8.pdf

*Note to editors: Quote direct from authors and cannot be found in paper