Responding to drug-resistant tuberculosis (DR-TB) is the critical step on the pathway to ending TB. It's a complex global health challenge that affects the most vulnerable. It requires innovative solutions, including high quality science, public health action and community-driven solutions.
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Resurgence of the leading infectious killer
The airborne epidemic spread of TB, in particular DR-TB, is a major threat to global health security carrying catastrophic costs in terms of human lives and health systems. Despite being preventable and curable, TB is the world's leading infectious disease, and the numbers around it are telling:
- 1.6 million lives lost in 2017
- 1.7 billion people, one quarter of the world's population, infected with latent TB (LTBI)
- One-third of all deaths from antimicrobial resistance attributed to DR-TB
- Future GDP costs to the global economy of AUD$26 billion from DR-TB deaths in one year.
Since the World Health Organization (WHO) declared TB a global health emergency in 1993, we have seen better outcomes and reductions in mortality with the expansion of simplified treatment programs for drug-susceptible TB.
But these gains have been offset by the emergence of DR-TB and the co-epidemics of TB and HIV.
At the current trajectory, we are not going to eliminate TB within the next 200 years.
The number of people estimated with DR-TB - 558,000 in 2017 - is increasing each year, but only 14 per cent of them are being successfully treated, the majority either dying and/or transmitting to others in their community.
Recent neglect and lack of funding in TB research and development has been a major contributor to this situation. From the 1950s to the 1980s, TB research was thriving. High-income countries including Australia conducted mass screening and treatment programs. These successes resulted in declining TB rates, but also the de-funding of TB research.
The global burden is especially heavy in the Asia-Pacific region, which accounts for 62 per cent of the 10 million new TB cases each year and 55 per cent of DR-TB cases. Facing a major epidemic, the situation in Papua New Guinea (PNG) is compounded by alarming rates of multidrug-resistant TB (MDR-TB) in several hotspots.
What can be done?
Despite the complexities, the solutions are simple - political will, empower affected communities and mobilise resources, and invest in research.
What's needed is a science-based and person-centred approach to TB care and addressing the epidemic.
Detection, effective treatment and care, prevention and management of exposure are standard in high-income countries, but in low-resource settings these measures are contingent on available resources and functioning health systems, with DR-TB adding new complexities, challenges and costs.
Novel strategies include molecular diagnostic tests, shorter regimens and scaling up preventive treatment of LTBI, particularly for those at high-risk.
As well, it's critical that people and communities affected by TB be at the centre of the response and at the decision-making table.
Elimination involves ending TB over the longer term so it's not a major public health challenge, and that's defined as an incidence of less than 10 per 100,000 population.
The elimination of MDR-TB in specific locations is a goal in its own right and arguably one of the most important steps towards TB elimination.
TB elimination cannot be achieved without a strategy to address LTBI, and this also applies for MDR-TB. This is a key focus of implementation research for Burnet.
The importance of partnerships
Burnet works collaboratively with communities, governments, and partners such as laboratories, implementers and research agencies. Currently, we are working with Gadjah Mada University and local partners to launch a TB elimination initiative, 'Zero TB Yogyakarta'.
Image: Dr Rina Triasih (right) with staff at the launch of a mobile TB screening service in Yogyakarta, Indonesia.
With Australian government support, Burnet has had a leading role to improve patient treatment outcomes on Daru Island in PNG's Western Province, which is the centre of an unprecedented outbreak of MDR-TB. Our current focus is to expand community-based household screening and preventive treatment to eliminate the outbreak.
The response in Daru has been a successful example of a large partnership where Burnet has had a leading role working with the national and provincial governments, World Vision and WHO.
Another innovative initiative in PNG is our TB peer-counselling project that trains TB and MDR-TB survivors to support patients. It has helped to empower the affected community and establish patient representatives at a local level.
Working with advocacy partners such as RESULTS and the Australasian TB Forum, we have been engaging with parliamentarians and supporting TB survivors and experts to speak at national and regional forums.
Whilst there is a long way to go to end TB, there is considerable cause for optimism.
A range of new diagnostic tests and MDR-TB treatment regimens is expected to be available over the next few years, and TB vaccine candidates are undergoing field trials.
A regional research collaboration with the Menzies School of Health Research has been highly productive in building capacity in PNG and Indonesia, and Burnet is a key part of the NH MRC Centre of Excellence in TB Research, which is spearheading Australian and regional research.
