JOINT ACTION STATEMENT ENDING TUBERCULOSIS IN THE ASIAN AND PACIFIC REGIONS

We, a group of leaders and representatives from inter-governmental organisations, governments, financing institutions, implementers, research organisations, product developers, civil society and tuberculosis (TB) survivors, working to end TB in the -Pacific region, met in Sydney, on June 18, 2019 on the margins of the Global Health Security Conference. The Stop TB partnership and Burnet Institute, in association with the Australasian TB forum convened a round table, “Accelerating the impact of innovation and research to end TB in the Asia-Pacific region” to propose the implementation of a set of consensus priority actions to end TB in the region. Whilst acknowledging the encouraging progress towards ending TB to date, there is now an urgent need for a different and rapid approach to address the global TB crisis, in particular the threat to global health security from drug-resistant TB (DR-TB). To this end, we propose urgent implementation of a set of priority actions that we consider essential if we have any hope of meeting the targets set by the recent United Nations High-Level Meeting (UNHLM) on TB and the Sustainable Development Goal (SDG) 3, to end the TB epidemic by 2030. Problem Analysis Tuberculosis is now the leading infectious disease killer in the world with 1.6 million lives lost in 2017. The airborne epidemic spread of TB, and in particular DR-TB, poses a major threat to global health security causing catastrophic costs – both for affected individuals, their families and communities but also economically. DR-TB is estimated to account for one-third of deaths from antimicrobial resistance (AMR) globally.2 It is estimated that deaths attributed to DR-TB in one year will cost the global economy at least US$17.8 billion in future GDP (PPP) loss.3 Unless there is accelerated action to end the TB epidemic and DR-TB epidemic based on optimal scientific knowledge and practice, equitable sustainable development and the stability and security that go with this are at risk. The Asia-Pacific region carries 62 per cent of the global burden of TB and 55 per cent of DR-TB.1 A concerted regional response to TB, focused on DR-TB, could catalyse the action needed to reach regional time bound UNHLM TB targets. Such a regional response to TB recognises the unique yet diverse needs of the Asia-Pacific region and would promote a more comprehensive and effective response through the lens of regional health security.4 The UN SDGs have set a target to end the global TB epidemic by 2030. The UNHLM Political Declaration on TB commits to treating 1.5 million people with drug resistant TB, including 115,000 children. The World Health Organization’s (WHO) End TB strategy and Stop TB Partnership’s Global Plan to End TB articulate that simply continuing with the current response paradigms and approaches to meet the SDG and UNHLM targets will not succeed. A different approach is needed. A comprehensive epidemic response paradigm to TB (active case finding, rapid diagnosis, effective treatment, peer support and care, prevention and management of exposure) is the standard of care in high-income countries and the scientific approach needed to move towards ending TB. Historical data clearly suggests that such comprehensive community-wide approaches to TB epidemic control are essential to achieve and sustain low rates of TB.5 In more recent work, major reductions in rates of all TB have been achieved in regions of Pakistan and Viet Nam through community-wide comprehensive strategies.6 However, in most countries in the Asia-Pacific, successful TB responses are often contingent on available resources and functioning health systems with DR-TB adding new complexities, challenges and extra-ordinary upfront costs. This comprehensive epidemic response, rather than simply containment, is also the optimal strategy to end DR-TB, which is now driven by person to person transmission. Effective responses to DR-TB using this approach have been seen in New York City, Tugela Ferry in South , Chuuk in Federated States of Micronesia and is in the initial stages in Daru, Papua New Guinea.7,8,9,10 Successful responses require substantial political commitment, a change in approach through developing ambitious strategic and implementation plans, on the ground technical assistance to advance TB programmes and strengthen community systems, embedded operational and implementation research and significant front-loading of investment. Whilst DR-TB increases the urgency and focus of the response, these solutions must be applied to the overall regional TB response. Such comprehensive and large-scale TB responses at city, district or country level could support the creation of an integrated community-based care delivery system for other health priorities, thereby strengthening health security and the primary health care system. The long-term reduction in TB achieved through such investments is cost-saving, will free up capacity in the health services and contribute to achieving universal health coverage. Solutions Proposed 1. Create regional partnership. Create a regional partnership mechanism (or value-add to existing) for TB and DR-TB to engender mutual accountability, identify and address barriers to innovation, scale and financing. This mechanism should involve key stakeholders from political leaders, TB affected communities, scientists, service providers, partners, civil society and donors. It should ensure that achieving the UNHLM TB targets and commitments are at the centre of TB efforts in the region and countries are accountable for achieving these. 2. Scale-up implementation and innovation. Implement a science-led comprehensive epidemic response for TB that is community-based and aimed towards ending TB by achieving rapid and sustained reduction in TB burden. Focus on DR-TB hotspots. This approach builds on already existing programmes to (i) implement all components of detection (scaling up active case finding), treatment (and patient-centred care) and prevention (preventive therapy), and (ii) include the rapid uptake of innovations. This will require timely utilisation of quality data, thorough local analysis and implementation research to determine the most effective and efficient ways to deliver and scale within different contexts. 3. Embed research. Continue and expand investments in TB research for the development of novel tools including tests, treatments and vaccines for TB and DR-TB, for clinical research to determine their efficacy and applied and translational research to improve effectiveness and delivery. 4. Empower community. Put people and the affected community at the centre. People affected by TB are most often from the poorest and most marginalised and underserved communities and have no voice at the table. TB affected communities must be involved in the planning, design, implementation, monitoring and evaluation of TB and broader social policies and programmes that affected them. It is essential to construct and implement a TB response engaging with the affected communities as key partners, is gender responsive, and promotes and protects the rights of all people affected by TB11 guided by policies and programmes that respect nondiscrimination and prioritise equal, affordable and appropriate access to information as well as high quality, affordable prevention, diagnosis, treatment, care and support services. 5. Innovation in financing. Explore innovative financing mechanisms, to add-value to existing streams, to achieve optimal long-term return on the huge up-front investment cost of population-based elimination strategies. 18 June, 2019 Sydney, Australia LIST OF SIGNATORIES

Name Position Aneesa Arur Senior Public Health Specialist, World Bank Catharina Boehme Executive Director, Foundation for Innovative and New Diagnostics (FIND) Claire Bonnel Director of External Relations, Asia Pacific Leaders Malaria Allianc (APLMA) Bill Bowtell AO Executive Director, Pacific Friends of the Global Fund Warwick Britton Chief Investigator, TB Centre for Research Excellence Willo Brock Senior Vice-President, External Affairs, TB Alliance Josephine Chandler Journalist, MDR-TB Survivor Amelia Christie CEO, RESULTS Australia Shawn Clackett Project Officer, Pacific Friends of the Global Fund Ronan Collins Global Communications & External Affairs Leader, Global Public Health, Johnson and Johnson AC Director and CEO, Burnet Institute, Australia Paison Dakulala Deputy Secretary of Health, National Department of Health, Papua New Guinea Lucica Ditiu Executive Director, Stop TB Partnership Philipp du Cros Co-Head Tuberculosis Elimination & Implementation Science Burnet Institute Helen Evans AO Associate Professor, University of , Australia Paul Field Senior Advisor, Foundation for Innovative and New Diagnostics (FIND), Australia Greg Fox Senior Lecturer, Respiratory Medicine, Central Clinical School, University of Sydney, Australia Joshua Francis Clinical Fellow, Menzies School of Health Research Ian Fraser Chair, Australian Medical Research Advisory Board, Medical Research Future Fund (MRFF)

Steve Graham Professor of International Child Health, & Burnet Institute, Australia

Michelle Imison Advocacy Officer, Stop TB Partnership Angela Kelly Head, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research Ivana Kvesic Senior Manager, Grants & Foundations, Global Citizen Moses Laman Deputy Director, Papua New Guinea Institute of Medical Research Patrick Johannes Laurens TB Survivor Evelyn Lavu Director Central Public Health Laboratory, National Department of Health, PNG Sharon Lewin Director, Doherty Institute, Australia Andrew Mace Senior UK Government Relations Officer, Bill & Melinda Gates Foundation Suman Majumdar Deputy Program Director, Health Security, Burnet Institute, Australia Ben Marais Co-Director, Marie Bashir Institute, Australia President, International Union Against TB and Lung Disease; Scientia Professor UNSW, Guy Marks Australia Name Position Sarah Meredith Country Director, Global Citizen, Australia Mary Moran Director, Policy Cures, Australia Roslyn Morauta Vice-Chair, Board, Global Fund to Fight AIDS, TB and Malaria (GFATM) Alex Munamua Surgeon, Solomon Islands Ministry of Health Darryl O’Donnell Executive Director, Australian Federation of AIDS Organisations Patrick Osewe Chief of Health Sector, Asian Development Bank Murray Proctor Consultant, Foundation for Effective Markets and Governance Eric Rafai Public Health Physician, Chair AMR Secretariat, Fiji Ministry of Health Anna Ralph Head of Global Health Division, Menzies School of Health Research Ben Rolfe CEO, Asia Pacific Leaders Malaria Allianc (APLMA) Amrita Ronnachit Infectious Diseases Fellow, Australasian TB Forum, Prince of Wales Hospital Peter Sands Executive Director, Global Fund to Fight AIDS, TB and Malaria (GFATM) Swarup Sarkar Senior Advisor, Indian Council of Medical Research, India Joyce Sauk TB Survivor and District Medical Officer, National Department of Health, PNG Gabriella Scandurra Chair, Australasian TB Forum Meirinda Sebayang Chair, Jaringan Indonesia Positif (HIV Positive Indonesian Network) Shiva Shrestha Global Health Campaign Manager, RESULTS Australia Melvin Spigelman CEO, TB Alliance Nakapi Tefurani Dean, School of Medicine and Health Sciences, University of Papua New Guinea Adrian Thomas Vice President, Global Market Access, Global Public Health, Johnson and Johnson Paediatrician, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada, Rina Triasih Indonesia Kerri Viney Research Fellow, Australian National University Paran Sarimita Winarni Chair, Pejuang Tangguh (Tough Fighter)

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