lancet new evidence of the tuberculosis burden in asia
Comment
New evidence of the tuberculosis burden in Asia demands
national action
An even larger revision of estimates was announced
in recent years by Indonesia. Indonesia’s national
tuberculosis prevalence survey 2013–14 reported a
bacteriologically confirmed pulmonary tuberculosis
prevalence rate of 759 per 100 000 population in people
aged 15 years and older.5 The prevalence rate of all forms
of tuberculosis in children and adults was estimated to
be 647 per 100 000 population,5 more than double the
earlier estimate developed from case-notification data,
and comparable to nations with severe tuberculosis–HIV
co-epidemics, such as Botswana and Zambia.5
India now accounts for more than a quarter of the
global total of incident tuberculosis cases, and more
than a third of annual deaths.1 Indonesia accounts
for 10% of global incident tuberculosis cases and
7% of worldwide deaths from tuberculosis.1 Several
countries in the WHO South-East Asia Region, and
others across Asia, have unquestionably high burdens
of tuberculosis; in some instances with rates that
exceed all but the sub-Saharan African nations with
the most severe tuberculosis–HIV co-epidemics.1
Tuberculosis is the leading cause of death from any
infectious disease and the highest contributor to
disability-adjusted life-years lost among people aged
15–44 years in the region.6 The costs in suffering,
premature mortality, impoverishment, and foregone
development are incalculable.
www.thelancet.com Published online October 13, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31853-0
Published Online
October 13, 2016
http://dx.doi.org/10.1016/
S0140-6736(16)31853-0
Associated Press
Tuberculosis disease prevalence surveys are showing
that the burden of tuberculosis is even more severe
in Asia than previously recognised, particularly in
the 11 countries that comprise the WHO SouthEast Asia Region (Bangladesh, Bhutan, Democratic
People‘s Republic of Korea, India, Indonesia, Maldives,
Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste).
Indeed, the new data in WHO’s Global Tuberculosis
Report 20161 show that tuberculosis rates in several
Asian countries are higher than those seen elsewhere,
apart from in nations with severe tuberculosis–HIV coepidemics. An exceptional commitment to action is
needed in these countries.
Since 2009 nine high-burden Asian countries have
used national population-based surveys to measure the
prevalence of bacteriologically confirmed pulmonary
tuberculosis in adults and estimate all forms of
tuberculosis prevalence across all ages. In four of these
surveys, the prevalence of tuberculosis disease was much
higher than had been estimated using other sources
of data, including case notification, leading to major
corrections to national estimates of tuberculosis.1
India is the most recent nation in the WHO South-East
Asia Region to undertake such voluntary revisions of
tuberculosis burden estimates. On the basis of evidence
from one statewide prevalence survey, better case
notification,1 household surveys, studies of tuberculosis
drug sales in the private sector, evidence of huge undernotification,2,3 and more accurate national mortality
data,4 the Government of India together with WHO
has revised national tuberculosis estimates upwards.
The 2015 estimate of incident tuberculosis in India
is 2·8 million cases,1 which contrasts with the 2014
estimate of 2·2 million incident cases.1,5 The number
of tuberculosis deaths in India in 2015 has now been
revised to 480 000, more than double the 2014 estimate
of 220 000.1,5 Importantly, these increases reflect the
incorporation of more accurate data, not an increase in
rates, with both tuberculosis incidence and mortality
decreasing from 2000 to 2015.1 Moreover, the revisions
are interim in nature, with further changes likely when
India completes its first national tuberculosis prevalence
survey in 2017–18.
1
Comment
The extent of the challenge, as revealed by the new
data, is immense. But it is also true that tuberculosis
can be effectively controlled in Asia, given the
comparatively low rates of tuberculosis–HIV coinfection and multidrug-resistant tuberculosis in the
region.1 Success is possible, even with the limited
methods of tuberculosis control and treatment
available. This is shown by progress made globally in
tuberculosis control and by better-performing areas
in some countries. The goal of ending the tuberculosis
epidemic by 2030, as committed to by governments in
the Agenda for Sustainable Development, is not wishful
thinking, even in the countries with the highest rates of
tuberculosis. Together, the southeast Asian countries
must implement an intensified approach to tackling
this disease, an approach that addresses the scale and
complexities of the challenge.
As a first step, these governments could declare
tuberculosis control a top priority on national agendas,
rather than viewing the ending of tuberculosis as
just one among the 169 impact targets set out in the
Sustainable Development Goals (SDGs). To meet the
WHO End-TB strategy targets, which are aligned with
the SDGs, of 90% reduction in tuberculosis deaths and
80% reduction in tuberculosis incidence by 2030,7
the political commitment should be translated into
comprehensive national action plans based on the
three pillars of the End-TB Strategy (integrated care
and prevention, bold policies and supportive systems,
intensified research and innovation).7 These national
plans must be fully funded and implemented promptly
by an empowered body that reports to the highest levels
of government.7
Effective measures for controlling tuberculosis
must be massively scaled up. These measures include:
comprehensive epidemic control strategies; outpatient,
primary care, private sector, and community-based
case detection and treatment; adopting new methods
for diagnosis, treatment, and prevention; rational use
of tuberculosis drugs including adoption of newer
drugs and regimens; preventive therapy to those at
risk; active case finding; economic support to affected
households; and, not least, measures that tackle the
biosocial determinants of this disease of poverty, such as
overcrowding and malnutrition.8,9
2
The Global Plan to End TB 2016–2020 emphasises
that at least 90% of all people who need tuberculosis
treatment must be reached, including 90% of people in
key populations, and at least 90% treatment success be
achieved.10 Formalisation of these strategies and other
initiatives such as roll-out of rapid diagnostics and use of
newer drugs into the technical and operational guidelines
of India’s National Tuberculosis Control Programme11 are
examples of best practices toward ending tuberculosis.
The new data in WHO’s Global Tuberculosis Report 20161
establish beyond doubt the high burden of tuberculosis
in Asia. This must result in an informed commitment
to action, so that in the next years Asia can accelerate
progress towards ending tuberculosis.
Jagat Prakash Nadda, *Poonam Khetrapal Singh
Ministry of Health and Family Welfate, New Delhi-70, India (JPN);
and WHO Regional Office for South-East Asia, New Delhi 110002,
India (PKS)
[email protected]
JPN is Minister of Health and Family Welfare, Government of India. PKS is
Regional Director, WHO South-East Asia Region. We declare no other competing
interests.
© 2016. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights
reserved.
1
2
3
4
5
6
7
8
9
10
11
WHO. Global tuberculosis report 2016. 21st Edition. Geneva: World Health
Organization, 2016.
Directorate-General of Health Services. TB India 2016; RNTCP case
notification from private sector. Part 3. 104. New Delhi: Ministry of
Health and Family Welfare, Government of India, 2016. http://www.
tbcindia.nic.in/index1.php?lang=1&level=2&sublinkid=4569&lid=3174
(accessed Oct 6, 2016).
Arinaminpathy N, Batra D, Khaparde S, et al. The number of privately
treated tuberculosis cases in India: an estimation from drug sales data.
Lancet Infect Dis 2016; published online Aug 24. DOI: 10.1016/
S1473-3099(16)30259-6.
Jha P, Gajalakshmi V, Gupta PC, et al. Prospective study of one million deaths
in India: rationale, design, and validation results. PLoS Med 2006; 3: e18.
WHO. Global tuberculosis report 2015 20th edition. Geneva: World Health
Organization, 2015.
Institute of Health Metrics and Evaluation. Global Burden of Disease 2015.
GBD Compare, Viz Hub. University of Washington, 2015. https://vizhub.
healthdata.org/gbd-compare/ (accessed Oct 6, 2016).
WHO. The End-TB Strategy: global strategy and targets for tuberculosis
prevention, care and control after 2015. Geneva: World Health
Organization, 2014.
Das P, Horton R. Tuberculosis—getting to zero. Lancet 2015; 386: 2231–32.
Bloom BR, Atun R. Back to the future: rethinking global control of
tuberculosis. Sci Transl Med 2016; 8: 329ps7.
Stop TB Partnership. The paradigm shift 2016-2020: Global Plan to End
TB. Geneva: Stop TB Partnership, United Nations Office for Project
Services, 2015.
Central TB Division. Technical and operational guidelines for TB control in
India 2016. Ministry of Health, Government of India. http://tbcindia.gov.
in/index1.php?lang=1&level=2&sublinkid=4573&lid=3177
(accessed Oct 4, 2016).
www.thelancet.com Published online October 13, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31853-0
New evidence of the tuberculosis burden in Asia demands
national action
An even larger revision of estimates was announced
in recent years by Indonesia. Indonesia’s national
tuberculosis prevalence survey 2013–14 reported a
bacteriologically confirmed pulmonary tuberculosis
prevalence rate of 759 per 100 000 population in people
aged 15 years and older.5 The prevalence rate of all forms
of tuberculosis in children and adults was estimated to
be 647 per 100 000 population,5 more than double the
earlier estimate developed from case-notification data,
and comparable to nations with severe tuberculosis–HIV
co-epidemics, such as Botswana and Zambia.5
India now accounts for more than a quarter of the
global total of incident tuberculosis cases, and more
than a third of annual deaths.1 Indonesia accounts
for 10% of global incident tuberculosis cases and
7% of worldwide deaths from tuberculosis.1 Several
countries in the WHO South-East Asia Region, and
others across Asia, have unquestionably high burdens
of tuberculosis; in some instances with rates that
exceed all but the sub-Saharan African nations with
the most severe tuberculosis–HIV co-epidemics.1
Tuberculosis is the leading cause of death from any
infectious disease and the highest contributor to
disability-adjusted life-years lost among people aged
15–44 years in the region.6 The costs in suffering,
premature mortality, impoverishment, and foregone
development are incalculable.
www.thelancet.com Published online October 13, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31853-0
Published Online
October 13, 2016
http://dx.doi.org/10.1016/
S0140-6736(16)31853-0
Associated Press
Tuberculosis disease prevalence surveys are showing
that the burden of tuberculosis is even more severe
in Asia than previously recognised, particularly in
the 11 countries that comprise the WHO SouthEast Asia Region (Bangladesh, Bhutan, Democratic
People‘s Republic of Korea, India, Indonesia, Maldives,
Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste).
Indeed, the new data in WHO’s Global Tuberculosis
Report 20161 show that tuberculosis rates in several
Asian countries are higher than those seen elsewhere,
apart from in nations with severe tuberculosis–HIV coepidemics. An exceptional commitment to action is
needed in these countries.
Since 2009 nine high-burden Asian countries have
used national population-based surveys to measure the
prevalence of bacteriologically confirmed pulmonary
tuberculosis in adults and estimate all forms of
tuberculosis prevalence across all ages. In four of these
surveys, the prevalence of tuberculosis disease was much
higher than had been estimated using other sources
of data, including case notification, leading to major
corrections to national estimates of tuberculosis.1
India is the most recent nation in the WHO South-East
Asia Region to undertake such voluntary revisions of
tuberculosis burden estimates. On the basis of evidence
from one statewide prevalence survey, better case
notification,1 household surveys, studies of tuberculosis
drug sales in the private sector, evidence of huge undernotification,2,3 and more accurate national mortality
data,4 the Government of India together with WHO
has revised national tuberculosis estimates upwards.
The 2015 estimate of incident tuberculosis in India
is 2·8 million cases,1 which contrasts with the 2014
estimate of 2·2 million incident cases.1,5 The number
of tuberculosis deaths in India in 2015 has now been
revised to 480 000, more than double the 2014 estimate
of 220 000.1,5 Importantly, these increases reflect the
incorporation of more accurate data, not an increase in
rates, with both tuberculosis incidence and mortality
decreasing from 2000 to 2015.1 Moreover, the revisions
are interim in nature, with further changes likely when
India completes its first national tuberculosis prevalence
survey in 2017–18.
1
Comment
The extent of the challenge, as revealed by the new
data, is immense. But it is also true that tuberculosis
can be effectively controlled in Asia, given the
comparatively low rates of tuberculosis–HIV coinfection and multidrug-resistant tuberculosis in the
region.1 Success is possible, even with the limited
methods of tuberculosis control and treatment
available. This is shown by progress made globally in
tuberculosis control and by better-performing areas
in some countries. The goal of ending the tuberculosis
epidemic by 2030, as committed to by governments in
the Agenda for Sustainable Development, is not wishful
thinking, even in the countries with the highest rates of
tuberculosis. Together, the southeast Asian countries
must implement an intensified approach to tackling
this disease, an approach that addresses the scale and
complexities of the challenge.
As a first step, these governments could declare
tuberculosis control a top priority on national agendas,
rather than viewing the ending of tuberculosis as
just one among the 169 impact targets set out in the
Sustainable Development Goals (SDGs). To meet the
WHO End-TB strategy targets, which are aligned with
the SDGs, of 90% reduction in tuberculosis deaths and
80% reduction in tuberculosis incidence by 2030,7
the political commitment should be translated into
comprehensive national action plans based on the
three pillars of the End-TB Strategy (integrated care
and prevention, bold policies and supportive systems,
intensified research and innovation).7 These national
plans must be fully funded and implemented promptly
by an empowered body that reports to the highest levels
of government.7
Effective measures for controlling tuberculosis
must be massively scaled up. These measures include:
comprehensive epidemic control strategies; outpatient,
primary care, private sector, and community-based
case detection and treatment; adopting new methods
for diagnosis, treatment, and prevention; rational use
of tuberculosis drugs including adoption of newer
drugs and regimens; preventive therapy to those at
risk; active case finding; economic support to affected
households; and, not least, measures that tackle the
biosocial determinants of this disease of poverty, such as
overcrowding and malnutrition.8,9
2
The Global Plan to End TB 2016–2020 emphasises
that at least 90% of all people who need tuberculosis
treatment must be reached, including 90% of people in
key populations, and at least 90% treatment success be
achieved.10 Formalisation of these strategies and other
initiatives such as roll-out of rapid diagnostics and use of
newer drugs into the technical and operational guidelines
of India’s National Tuberculosis Control Programme11 are
examples of best practices toward ending tuberculosis.
The new data in WHO’s Global Tuberculosis Report 20161
establish beyond doubt the high burden of tuberculosis
in Asia. This must result in an informed commitment
to action, so that in the next years Asia can accelerate
progress towards ending tuberculosis.
Jagat Prakash Nadda, *Poonam Khetrapal Singh
Ministry of Health and Family Welfate, New Delhi-70, India (JPN);
and WHO Regional Office for South-East Asia, New Delhi 110002,
India (PKS)
[email protected]
JPN is Minister of Health and Family Welfare, Government of India. PKS is
Regional Director, WHO South-East Asia Region. We declare no other competing
interests.
© 2016. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights
reserved.
1
2
3
4
5
6
7
8
9
10
11
WHO. Global tuberculosis report 2016. 21st Edition. Geneva: World Health
Organization, 2016.
Directorate-General of Health Services. TB India 2016; RNTCP case
notification from private sector. Part 3. 104. New Delhi: Ministry of
Health and Family Welfare, Government of India, 2016. http://www.
tbcindia.nic.in/index1.php?lang=1&level=2&sublinkid=4569&lid=3174
(accessed Oct 6, 2016).
Arinaminpathy N, Batra D, Khaparde S, et al. The number of privately
treated tuberculosis cases in India: an estimation from drug sales data.
Lancet Infect Dis 2016; published online Aug 24. DOI: 10.1016/
S1473-3099(16)30259-6.
Jha P, Gajalakshmi V, Gupta PC, et al. Prospective study of one million deaths
in India: rationale, design, and validation results. PLoS Med 2006; 3: e18.
WHO. Global tuberculosis report 2015 20th edition. Geneva: World Health
Organization, 2015.
Institute of Health Metrics and Evaluation. Global Burden of Disease 2015.
GBD Compare, Viz Hub. University of Washington, 2015. https://vizhub.
healthdata.org/gbd-compare/ (accessed Oct 6, 2016).
WHO. The End-TB Strategy: global strategy and targets for tuberculosis
prevention, care and control after 2015. Geneva: World Health
Organization, 2014.
Das P, Horton R. Tuberculosis—getting to zero. Lancet 2015; 386: 2231–32.
Bloom BR, Atun R. Back to the future: rethinking global control of
tuberculosis. Sci Transl Med 2016; 8: 329ps7.
Stop TB Partnership. The paradigm shift 2016-2020: Global Plan to End
TB. Geneva: Stop TB Partnership, United Nations Office for Project
Services, 2015.
Central TB Division. Technical and operational guidelines for TB control in
India 2016. Ministry of Health, Government of India. http://tbcindia.gov.
in/index1.php?lang=1&level=2&sublinkid=4573&lid=3177
(accessed Oct 4, 2016).
www.thelancet.com Published online October 13, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31853-0