The End TB Strategy
G lobal strategy and targets for tuberculosis prevention, care and control after 2015a [A67/11 – 14 March 2014] The End TB Strategy
Global strategy and targets for tuberculosis prevention, care and control after 2015a [A67/11 – 14 March 2014]
WHO’s declaration of tuberculosis as a global In May 2012, Member States at the Sixty- public health emergency in 1993 ended a fifth World Health Assembly requested the period of prolonged global neglect. Together, DirectorGeneral to submit a comprehensive the subsequent launch of the directly observed review of the global tuberculosis situation treatment, short course (DOTS) strategy; to date, and to present new multisectoral inclusion of tuberculosis-related indicators strategic approaches and new international in the Millennium Development Goals; targets for the post-2015 period to the Sixty- development and implementation of the seventh World Health Assembly in May 2014, Stop TB Strategy that underpins the Global through the Executive Board.b The work to Plan to Stop TB 2006–2015; and adoption of prepare this has involved a wide range of resolution WHA62.15 on the prevention and partners providing substantive input into the control of multidrug-resistant tuberculosis and development of the new strategy, including extensively drug-resistant tuberculosis by the high-level representatives of Member States, Sixty-second World Health Assembly have all national tuberculosis programmes, technical helped to accelerate the global expansion of and scientific institutions, financial partners tuberculosis care and control. and development agencies, civil society, nongovernmental organizations, and the private sector.
b See document WHA65/2012/REC/3, summary record of the a See resolution WHA67.1. sixth meeting of Committee B, section 3.
1 The process. WHO’s Strategic and Technical the opening day of the Conference at the Advisory Group for Tuberculosis approved global tuberculosis symposium, which was the broad, inclusive scope of the consultative attended by over 700 stakeholders. In 2013, process for the development of the draft strategy. three special consultations including senior It began with a web-based consultation to seek officials of Member States, technical experts ways in which to strengthen the current strategy and civil society were organized in order and introduce any new components. During to discuss (i) formulation of the post-2015 2012, as part of the annual meetings of national tuberculosis targets; (ii) approaches to building tuberculosis programmes, each regional office on the opportunities presented by expansion of organized consultations on the proposed universal health coverage and social protection new strategic framework and targets with to strengthen tuberculosis care and prevention; health ministry officials, national tuberculosis and (iii) research and innovation for improved programme managers and partners. Officials of tuberculosis care, control and elimination. In countries with a high tuberculosis burden then June 2013, the Strategic and Technical Advisory deliberated on the draft strategic framework at Group for Tuberculosis endorsed the draft, a special consultation organized just before the including the global targets and their rationale.c 43rd Union World Conference (Kuala Lumpur, 13–17 November 2013). Following this, the The framework of the post-2015 global framework was presented and discussed on tuberculosis strategy is presented in Figure 1.
Figure 1. POST-2015 GLOBAL TUBERCULOSIS STRATEGY FRAMEWORK
VISION A world free of tuberculosis – zero deaths, disease and suffering due to tuberculosis GOAL End the global tuberculosis epidemic MILESTONES FOR 2025 75% reduction in tuberculosis deaths (compared with 2015) 50% reduction in tuberculosis incidence rate (less than 55 tuberculosis cases per 100 000 population) – No affected families facing catastrophic costs due to tuberculosis TARGETS FOR 2035 95% reduction in tuberculosis deaths (compared with 2015) 90% reduction in tuberculosis incidence rate (less than 10 tuberculosis cases per 100 000 population) – No affected families facing catastrophic costs due to tuberculosis PRINCIPLES 1. Government stewardship and accountability, with monitoring and evaluation 2. Strong coalition with civil society organizations and communities 3. Protection and promotion of human rights, ethics and equity 4. Adaptation of the strategy and targets at country level, with global collaboration PILLARS AND COMPONENTS 1. INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION A. Early diagnosis of tuberculosis including universal drug-susceptibility testing, and systematic screening of contacts and high-risk groups B. Treatment of all people with tuberculosis including drug-resistant tuberculosis, and patient support C. Collaborative tuberculosis/HIV activities, and management of comorbidities D. Preventive treatment of persons at high risk, and vaccination against tuberculosis 2. BOLD POLICIES AND SUPPORTIVE SYSTEMS A. Political commitment with adequate resources for tuberculosis care and prevention B. Engagement of communities, civil society organizations, and public and private care providers C. Universal health coverage policy, and regulatory frameworks for case notification, vital registration, quality and rational use of medicines, and infection control D. Social protection, poverty alleviation and actions on other determinants of tuberculosis 3. INTENSIFIED RESEARCH AND INNOVATION A. Discovery, development and rapid uptake of new tools, interventions and strategies B. Research to optimize implementation and impact, and promote innovations
2 APPROACHES
Expandingccare, strengthening prevention, delivery of tuberculosis care and prevention. and intensifying research. Addressing the Above them are the national health ministries above challenges will require innovative, that provide critical systemic support, enforce multisectoral, and integrated approaches. The regulatory mechanisms, and coordinate DOTS strategy strengthened public sector integrated approaches through interministerial tuberculosis programmes to help to tackle a and intersectoral collaboration. Above all, large burden of drugsusceptible disease. The the national governments have to provide Stop TB Strategy,d built on DOTS, helped to the overall stewardship to keep tuberculosis begin addressing drugresistant tuberculosis elimination high on the development agenda and HIV-associated tuberculosis while through political commitment, investments and promoting research to develop new tools. It oversight, while making rapid progress towards also helped to expand partnerships with all universal health coverage and social protection. care providers, civil society organizations and communities, in the context of strengthening Elevating leadership and widening ownership. health systems. Ending the tuberculosis Tuberculosis care and control need to be epidemic will require further expansion of strengthened further and expanded to include the scope and reach of interventions for prevention of tuberculosis. For this purpose, tuberculosis care and prevention; institution in-country leadership for tuberculosis control of systems and policies to create an enabling ought to be elevated to higher levels within environment and share responsibilities; and health ministries. This is essential in order to aggressive pursuit of research and innovation effect coordinated action on multiple fronts to promote development and use of new tools and to accomplish three clear objectives: for tuberculosis care and prevention. It will also (1) achieving universal access to early detection require a provision for revisiting and adjusting and proper treatment of all patients with the new strategy based on progress and the tuberculosis; (2) putting supportive health and extent to which agreed milestones and targets social sector policies and systems in place to are being met. enable effective delivery of tuberculosis care and prevention; and (3) intensifying research to Eliciting systemic support and engaging develop and apply new technologies, tools and stakeholders. In practical terms, continuing approaches to enable eventual tuberculosis progress beyond 2015 will require intensified elimination. The three pillars of the global actions by and beyond tuberculosis tuberculosis strategy are designed to address programmes within and outside the health these objectives. sector. The new strategy envisages concrete actions from three levels of governance in close collaboration with all stakeholders and with the engagement of communities. At the core are national tuberculosis programmes or the equivalent structures that are responsible for coordination of all activities related to c Strategic and Technical Advisory Group for Tuberculosis: report of 13th meeting, 11–12 June 2013 (document WHO/ HTM/TB/2013.9). d The six components of the Stop TB Strategy are: (i) pursue high-quality DOTS expansion and enhancement; (ii) address TB/HIV, MDR-TB and other special challenges; (iii) contribute to health system strengthening; (iv) engage all care providers; (v) empower people with tuberculosis, and communities; and (vi) enable and promote research.
3 VISION, GOAL, MILESTONES AND TARGETS
The vision for the post-2015 global tuberculosis 2030. Table 1 presents key global indicators, strategy is “a world free of tuberculosis”, milestones and targets for the post-2015 also expressed as “zero deaths, disease and strategy. suffering due to tuberculosis”. The goal is to end the global tuberculosis epidemic. A key milestone is a 75% reduction in tuberculosis deaths by 2025, compared with 2015. This will The Millennium Development Goal target require two achievements. First, the annual “to halt and begin to reverse the incidence decline in global tuberculosis incidence rates of tuberculosis by 2015” has already been must accelerate from an average of 2% per year achieved. The related Stop TB Partnership in 2015 to 10% per year by 2025. A 10% per year targets of reducing tuberculosis prevalence and decline in tuberculosis incidence is ambitious death rates by 50% relative to 1990 are on track yet feasible; it has been projected on the basis to be achieved by 2015. Under this strategy, of the fastest rate documented at national new, ambitious yet feasible global targets are level, which occurred in the context of universal proposed for 2035. These include achieving access to health care and rapid socioeconomic a 95% decline in deaths due to tuberculosis development in Western Europe and North compared with 2015, and reaching an equivalent America during the second half of the past 90% reduction in tuberculosis incidence rate century. Secondly, the proportion of incident from a projected 110 cases/100 000 in 2015 to cases dying from tuberculosis (the case-fatality 10 cases/100 000 or less by 2035. These targets ratio) needs to decline from a projected 15% are equivalent to the current levels in some low- in 2015 to 6.5% by 2025. It has been modelled incidence countries of North America, western that rapid progress towards universal access to Europe and the Western Pacific. An additional existing tools combined with socioeconomic target proposed to ascertain progress of development can lead to a 75% reduction in universal health coverage and social protection tuberculosis deaths. Furthermore, improved is that by 2020, no tuberculosis-affected person tools, such as a rapid point-of-care test and or family should face catastrophic costs due to improved tuberculosis treatment regimens tuberculosis care. are likely to emerge soon from the research and development pipeline thus facilitating Milestones that will need to be reached before achievement of the milestones. 2035 are also proposed for 2020, 2025, and
Table 1. Key global indicators, milestones and targets for the post-2015 tuberculosis strategy
Milestones Targets Indicators with baseline values for 2015 2020 2025 2030 2035 Percentage reduction in deaths due to tuberculosis 35% 75% 90% 95% (projected 2015 baseline: 1.3 million deaths) Percentage and absolute reduction in 20% 50% 80% 90% tuberculosis incidence rate (<85/100 000) (<55/100 000) (<20/100 000) (<10/100 000) (projected 2015 baseline 110/100 000) Percentage of affected families facing catastrophic costs due to tuberculosis Zero Zero Zero Zero (projected 2015 baseline: not yet available)
4 In order to sustain progress beyond 2025 and be remarkable, but would not be sufficient to achieve by 2035 a reduction in tuberculosis maintain the rate of progress required to achieve deaths of 95% and a 90% reduction in the the 2035 targets. For new tools to be available incidence rate from 110 cases/100 000 to for introduction by 2025, greatly enhanced less than 10 cases per 100 000, there must be and immediate investments in research and additional tools available by 2025. In particular, development will be required. Figure 2 shows a new vaccine that is effective pre- and post- the projected acceleration of the decline exposure, and better diagnostics, as well as in global tuberculosis incidence rates with safer and easier treatment for latent tuberculosis optimization of current tools combined with infection, will be needed. Achievements with progress towards universal health coverage and existing tools complemented by universal social protection from 2015, and the additional health coverage and social protection would impact of new tools by 2025.
Figure 2. Projected acceleration in the decline of global tuberculosis incidence rates to target levels
100 Current global trend: -1.5%/year
75 Optimize use of current & new tools -10%/year by 2025 emerging from pipeline, pursue universal health 50 coverage and social protection
Rate per 100,000/year Introduce new tools: a vaccine, new drugs & -5%/year treatment regimens, and 25 a point-of-care test for treatment of active TB disease and latent TB -17%/year infection 10
2015 2020 2025 2030 2035
The milestone that no families affected by have access to appropriate social protection tuberculosis face catastrophic costs implies schemes that cover or compensate for direct minimizing direct medical costs, such as fees non-medical costs and income losses. With for consultations, hospitalization, tests and sufficient political commitment, tuberculosis- medicines as well as direct non-medical costs related costs could be rapidly reduced in all such as those for transport and any loss of income countries, and therefore many countries may be while under care. It requires that tuberculosis able to reach the target by 2020. patients and tuberculosis-affected households
5 THE PRINCIPLES OF THE STRATEGY
countries include a treatment success rate of at Government least 85%, and testing of 100% of tuberculosis patients for drug susceptibility and HIV. stewardship and accountability with Strong coalition monitoring and with civil society evaluation organizations and Activities under the tuberculosis strategy communities span the health and social sectors and beyond, including finance, labour, trade and The affected communities must also be development. Stewardship responsibilities a prominent part of proposed solutions. should be shared by all levels of the government Community representatives and civil society – local, provincial, and central. The central must be enabled to engage more actively government should remain the “steward of in programme planning and design, service stewards” for tuberculosis care and prevention, delivery, and monitoring, as well as in working with all stakeholders. information, education, support to patients and their families, research, and advocacy. To The success of the post-2015 global tuberculosis this end, a strong coalition that includes all strategy will depend on effective execution of stakeholders needs to be built. Such a coalition key stewardship responsibilities by governments of partners can assist people in both accessing in close collaboration with all stakeholders: high-quality care and in demanding high- providing the vision and direction through quality services. A national coalition can also the national tuberculosis programme and the help drive greater action on the determinants health system; collecting and using data for of the tuberculosis epidemic. progressive improvements in tuberculosis care and prevention; and exerting influence through regulation and other means to achieve the Protection and stated goals and objectives of the strategy. promotion of human To ensure accountability, regular monitoring and evaluation need to be built into strategy rights, ethics and implementation. Progress will need to be measured against ambitious national targets and indicators. Table 2e presents an illustrative equity list of key global indicators that should be Policies and strategies for the design of the adopted and adapted for national use and for overall national tuberculosis response, and the which country-specific targets should be set. delivery of tuberculosis care and prevention, These indicators should be supplemented by have to explicitly address human rights, others considered necessary to capture progress ethics and equity. Access to high-quality in the implementation of all essential activities. tuberculosis care is an important element of Examples of targets that could apply in all the right to health. This strategy is built on a rights-based approach that ensures protection e See page 87.
6 of human rights and promotion of rights- enhancing policies and interventions. These Adaptation of the include engagement of affected persons and communities in facilitating implementation of strategy and targets all pillars and components of the strategy with special attention to key affected populations. at country level, with Tuberculosis care and prevention pose ethical dilemmas. National tuberculosis programmes global collaboration should acknowledge and address these with No global strategy can apply similarly to all settings due respect to relevant ethical values. These across or within countries. The tuberculosis may include, for example, the conflict between strategy will have to be adapted to diverse country the public interest in preventing disease settings, based on a comprehensive national transmission and patients’ rights to demand strategic plan. Prioritization of interventions a supportive care environment or refuse should be undertaken based on local contexts, treatment; the response to the stigmatization needs and capacities. A sound knowledge of attached to the disease and the discrimination country-specific disease epidemiology will be against those affected; the lengthy treatment essential, including mapping of people at a and the challenges of adherence to treatment; greater risk, understanding of socioeconomic ensuring patient-centred service provision and contexts of vulnerable populations, and a grasp balancing the risk of infection to health care of health system context including underserved workers; the care to be offered when there are areas. Adoption of the global strategy should be not effective treatment options; and setting immediately followed by its national adaptation of priorities for research and for delivery of and development of clear guidance on how the interventions. Ways to address these dilemmas different components of the strategy could be should be guided by globally recognized implemented, based on local evidence when principles and values, should be sensitive to possible. local values and traditions, and should be informed by debates among all stakeholders. In a globalized world, diseases like tuberculosis can spread far and wide via international travel The strategy aims to promote equity through and trade. Tackling tuberculosis effectively identification of the risks, needs and demands requires close collaboration among countries. of those affected, to enable equal opportunities Effective intercountry collaboration also to prevent disease transmission, equal access requires global coordination and support to diagnosis and treatment services, and equal to enable adherence to the International access to means to prevent associated social Health Regulations (2005) and ensure health impacts and catastrophic economic costs. The security. Countries within a region can benefit process through which to meet the targets, and from regional collaboration. Migration within achieve the goals, of the strategy will be better and between countries poses challenges served by applying a rights-based approach, and addressing them will require in-country developing and maintaining the highest ethical coordination and cross-border collaboration. standards in every action taken, and ensuring Global coordination is also essential for that inequities are progressively reduced and mobilizing resources for tuberculosis care eliminated. and prevention from diverse multilateral, bilateral and domestic sources. WHO’s global tuberculosis report, which annually provides an overview of the status of the tuberculosis epidemic and implementation of global strategies, demonstrates and symbolizes the benefits of close collaboration and global coordination.
7 Strengthening and expansion of core strategies and to embrace new strategies and functions of tuberculosis programmes. Pillar technologies for providing universal access to one comprises patient-centred interventions drug susceptibility testing; to expand services required for tuberculosis care and prevention. to manage tuberculosis among children; The national tuberculosis programme, or to provide additional outreach services to equivalent, needs to engage and coordinate underserved and vulnerable populations; closely with other public health programmes, and to embark on systematic screening social support programmes, public and private and preventive treatment of relevant high- health care providers, nongovernmental and risk groups – all in partnership with relevant civil society organizations, communities and stakeholders. Use of innovative information patient associations in order to help ensure and communication technologies for health provision of high-quality, integrated, patient- (eHealth and mHealth) could particularly help centred tuberculosis care and prevention to improve tuberculosis care provision including across the health system. Pillar one is meant logistics and surveillance. to help countries to progress from previous
8 PILLAR 1
INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION
How pillar 1 works : Key actions
A. Early diagnosis B. Treatment of of TB including all people with TB universal drug- including drug- susceptibility resistant TB, and testing, and patient support systematic screening of contacts and high-risk groups
D. Preventive C. Collaborative TB/ treatment of HIV activities; and persons at high risk; management of co- and vaccination morbidities against TB
9 systems in many low- and middle-income Early diagnosis countries. Capacity to diagnose drug- resistant tuberculosis is limited in most of tuberculosis places where it is sorely needed. Only a fraction of the estimated cases of multidrug- including universal resistant tuberculosis receive a laboratory test to confirm the disease. Adequate drug susceptibility capacity to diagnose all cases of drug- resistant tuberculosis is essential to make testing, and further progress in global tuberculosis care and control. systematic screening • Scale up introduction of new diagnostics. Wide introduction of new molecular of contacts and diagnostic testing platforms will allow early and accurate diagnosis of tuberculosis and high-risk groups drug resistance. It could help to diagnose less advanced forms of tuberculosis and facilitate • Ensure early detection of tuberculosis. early treatment, contributing potentially to Currently an estimated two thirds of global decreased disease transmission, reduced incident tuberculosis cases are notified to case fatality, and prevention of adverse national tuberculosis control programmes sequelae of the disease. Introduction of and reported to WHO. Ensuring universal the new molecular diagnostics will require access to early and accurate diagnosis of change of diagnostic policies and training tuberculosis will require the strengthening at all levels. More sensitive and rapid and expansion of a network of diagnostic diagnostics will increase the number of facilities with easy access to new molecular reliably diagnosed patients. The new realities tests; information and education to prompt of the additional workload will mean lining people with symptoms of tuberculosis to up additional human and financial resources. seek care; engagement of all care providers in service delivery; the abolition of barriers • Implement systematic screening for that people encounter in seeking care; and tuberculosis among selected high- systematic screening in selected high-risk risk groups. The burden of undetected groups. Although the current most frequently tuberculosis is large in many settings, used test for tuberculosis – sputum-smear especially in high-risk groups. There can be microscopy – is a low-cost option providing long delays in diagnosing tuberculosis and specific diagnosis, it significantly lacks initiating the appropriate treatment among sensitivity. As a result, health services miss people with poor access to health services. many tuberculosis patients or identify them Many people with active tuberculosis do not only at advanced stages of the disease. experience typical symptoms in the early Screening for symptoms alone may not stages of the disease. These individuals may suffice; additional screening tools such as not seek care early enough and may not be a chest radiograph may facilitate referral identified for testing for tuberculosis if they for diagnosis of bacteriologically negative do. Mapping of high-risk groups and carefully tuberculosis, extrapulmonary tuberculosis planned systematic screening for active and tuberculosis in children. disease among them may improve early case detection. Early detection helps to reduce • Detect all cases of drug-resistant the risks of tuberculosis transmission, poor tuberculosis. Diagnosis of drug resistance treatment outcomes, undesirable health remains a particular challenge for laboratory sequelae, and adverse social and economic
10 consequences of the disease. Contacts of • Treat all cases of drug-resistant tuberculosis. people with tuberculosis, especially children Resistance to medicines poses a major aged five years or less, people living with HIV, threat to global progress in tuberculosis and workers exposed to silica dust should care and prevention. Globally, about 4% always be screened for active tuberculosis. of new tuberculosis patients and about Other risk-groups should be identified and 20% of patients receiving retreatment have prioritized for possible screening based on multidrug-resistant tuberculosis. Providing national and local tuberculosis epidemiology, universal access to services for drug-resistant health system capacity, resource availability, tuberculosis will require a rapid scale up and the feasibility of reaching the identified of laboratory services and programmatic risk-groups. A screening strategy should management. New models of delivering be monitored and assessed continuously, patient-centred treatment will need to be to inform a re-prioritization of risk groups, devised and customized to diverse settings re-adaptation of screening approaches, and contexts. Ambulatory services should and discontinuation of screening if be given preference over hospitalization, indicated. Screening strategies should which should be limited to severe cases. follow established ethical principles for Expansion of services for management of infectious disease screening, should protect drug-resistant tuberculosis will require bold human rights, and should minimize the policies and investments to abolish health risk of discomfort, pain, stigmatization and system bottlenecks that impede progress. discrimination. • Strengthen capacity to manage drug-resistant cases. The proportion of drug- Treatment of resistant tuberculosis patients successfully completing treatment varies substantially all people with between countries and averaged 48% globally in 2012. Currently available treatment tuberculosis including regimens for drug-resistant tuberculosis remain unsatisfactory in terms of duration, drug-resistant safety, effectiveness and cost. New safer, affordable and more effective medicines tuberculosis, and allowing treatment regimens that are shorter in duration and easier to administer are key patient support to improving treatment outcomes. Linkages with existing pharmacovigilance mechanisms • Treat all forms of drug-susceptible will contribute to promoting safer use and tuberculosis. The new tuberculosis strategy management of medicines. Interventions will aim to ensure provision of services for to improve quality of life for patients while early diagnosis and proper treatment of enabling adherence to treatment include all forms of tuberculosis affecting people management of adverse drug reactions and of all ages. New policies incorporating events; access to comprehensive palliative molecular diagnostics will help to and end-of-life care; measures to alleviate strengthen management of smear-negative stigmatization and discrimination; and pulmonary tuberculosis and extrapulmonary social support and protection. Importantly, tuberculosis as well as tuberculosis among all care providers managing drug-resistant children. Key affected populations and risk tuberculosis should have access to continued groups with suboptimal treatment uptake training and education, enabling them or treatment success will need to be given to align their practices with international priority attention in order to accelerate the standards. decline in case fatality required in order to reach the ambitious targets for reductions in tuberculosis mortality.
11 • Address tuberculosis among children. With to treatment interruption. It must help to an estimated 500 000 cases and 74 000 alleviate stigmatization and discrimination. deaths occurring annually, tuberculosis Patient support needs to extend beyond is an important cause of morbidity and health facilities to patients’ homes, families, mortality among children. In countries with workplaces and communities. Treatment a high prevalence of tuberculosis, women of and support must also extend beyond cure childbearing age also carry a heavy burden of to address any sequelae associated with the disease. Maternal tuberculosis associated tuberculosis. Examples of patient-centred with HIV is a risk factor for transmission of support include providing treatment partners tuberculosis to the infant and is associated trained by health services and acceptable to with premature delivery, low birth-weight of the patient; access to social protection; use of neonates, and higher maternal and infant information and communication technology mortality. National tuberculosis programmes for providing information, education and need to address systematically the challenges incentives to patients; and the setting up of of caring for children with tuberculosis, and mechanisms for patient and peer groups to child contacts of adult tuberculosis patients. exchange information and experiences. These may include, for instance, developing and using child-friendly formulation of medicines, and family-centred mechanisms Collaborative for enabling adherence to treatment. tuberculosis/ • Integrate tuberculosis care within maternal and child health services. Proper management of tuberculosis among children HIV activities, and will require the development of affordable and sensitive diagnostic tests that are not management of based on sputum specimens. Tuberculosis care should be integrated within maternal comorbidities and child health services to enable provision • Expand collaboration with HIV programmes. of comprehensive care at the community The overall goal of collaborative tuberculosis/ level. An integrated family-based approach HIV activities is to decrease the burden of to tuberculosis care would help to remove tuberculosis and HIV infection in people at access barriers, reduce delays in diagnosis risk of or affected by both diseases. HIV- and improve management of tuberculosis in associated tuberculosis accounts for about women and children. one quarter of all tuberculosis deaths and a • Build patient-centred support into the quarter of all deaths due to AIDS. The vast management of tuberculosis. Patient-centred majority of these cases and deaths are in care and support, sensitive and responsive to the African and South-East Asia regions. All patients’ educational, emotional and material tuberculosis patients living with HIV should needs, is fundamental to the new global receive antiretroviral treatment. Integrated tuberculosis strategy. Supportive treatment tuberculosis and HIV service delivery has supervision by treatment partners is essential: been shown to increase the likelihood that a it helps patients to take their medication tuberculosis patient will receive antiretroviral regularly and to complete treatment, thus treatment, shorten the time to treatment facilitating their cure and preventing the initiation, and reduce mortality by almost 40%. development of drug resistance. Supervision • Integrate tuberculosis and HIV services. must be carried out in a context-specific and Although there has been an encouraging patient-sensitive manner. Patient-centred global scaleup of collaborative tuberculosis/ supervision and support must also help to HIV activities, the overall coverage of services identify and address factors that may lead
12 remains low. Further, the level and rate of progress vary substantially among countries. Preventive treatment There remains a mismatch between the coverage of HIV testing for tuberculosis of persons at high patients and that of antiretroviral treatment, cotrimoxazole preventive treatment, and HIV risk, and vaccination prevention. Reducing delays in diagnosis, using new diagnostic tools and instituting against tuberculosis prompt treatment can improve health outcomes among people living with HIV. • Expand preventive treatment of people with Tuberculosis and HIV care should be further a high risk of tuberculosis. Latent tuberculosis integrated with services for maternal and infection is diagnosed by a tuberculin skin child health and prevention of mother-to-child test or interferon-y release assay. However, transmission of HIV in high-burden settings. these tests cannot predict which persons will develop active tuberculosis disease. Isoniazid • Co-manage tuberculosis comorbidities preventive therapy is currently recommended and noncommunicable diseases. Several for the treatment of latent tuberculosis infection noncommunicable diseases and other among people living with HIV and children health conditions including diabetes under five years of age who are contacts of mellitus, undernutrition, silicosis, as well patients with tuberculosis. It has a proven as smoking, harmful alcohol and drug use, preventive effect but severe side effects can and a range of immune-compromising occur, especially among the elderly. Although disorders and treatments are risk factors regimens with similar efficacy and shorter for tuberculosis. Presence of comorbidities duration have been studied, more evidence on may complicate tuberculosis management efficacy and safety are needed. More studies and result in poor treatment outcomes. are also required to assess the effectiveness Conversely, tuberculosis may worsen or and feasibility of undertaking preventive complicate management of other diseases. treatment among other high-risk groups Therefore, as a part of basic and coordinated such as, for example, people in congregate clinical management, people diagnosed settings like prisons and workplaces, health with tuberculosis should be routinely care workers, recent converters of a test of assessed for relevant comorbidities. WHO’s infection, and miners exposed to silica dust. f Practical Approach to Lung Health is an Management of latent tuberculosis infection example of promoting tuberculosis care in people with a high risk of developing active as an integral part of management of tuberculosis could be an essential component respiratory illnesses. The local situation of tuberculosis elimination, particularly in low should determine which comorbidities tuberculosis-incidence countries. should be systematically screened for among people with active tuberculosis. A national • Continue BCG vaccination in high-prevalence collaborative framework can help integrated countries. BCG vaccination prevents management of noncommunicable diseases disseminated disease including tuberculous and communicable diseases including meningitis and miliary tuberculosis, which tuberculosis. are associated with high mortality in infants and young children. However, its preventive efficacy against pulmonary tuberculosis, which varies among populations, is only about 50%. Until new and more effective vaccines become available, BCG vaccination soon after birth should continue for all infants except for those persons with HIV living in f Document WHO/HTM/TB/2008.410; document WHO/ NMH/CHP/CPM/08.02. high tuberculosis prevalence settings.
13 PILLAR 2
BOLD POLICIES AND SUPPORTIVE SYSTEMS
How pillar 2 works : Key actions
A. Political B. Engagement of commitment with communities, civil adequate resources society organizations, for TB care and and all public and prevention private care providers
D. Social protection, C. Universal health poverty alleviation coverage policy, and and actions on other regulatory frameworks determinants of TB for case notification, vital registration, quality and rational use of medicines, and infection control
14 • Sharing of responsibilities. The second clinical care; protection from catastrophic pillar encompasses strategic actions that will economic burden due to the disease; social enable implementation of the components interventions aimed at reducing vulnerability under pillar one through sharing of to the disease; and protection and promotion responsibilities. These include actions by and of human rights. beyond national tuberculosis programmes, across ministries and departments. Such actions address medical and non-medical Political needs of those ill with tuberculosis and also help to prevent tuberculosis. This will require commitment with a well-resourced, organized and coordinated health system with government stewardship adequate resources backed up by supportive health policies and regulations as well as broader social and development policies. National tuberculosis for tuberculosis care programmes, their partners and those overseeing the programmes need to engage and prevention actively in the setting of a broader social and • Develop ambitious national strategic plans. economic development agenda. Similarly, Scaling up and sustaining interventions leaders in development must recognize for tuberculosis care and prevention will tuberculosis as being among the social require high-level political commitment concerns that deserve priority attention. along with adequate financial and human resources. Continuous training and • Social determinants of tuberculosis. Pillar two supervision of personnel are fundamental further includes actions beyond the health to sustain significantly expanded activities sector that can help to prevent tuberculosis for tuberculosis care and prevention. Central by addressing underlying social determinants. coordination under government stewardship Proposed interventions include reducing is essential. This must lead to, as a first poverty, ensuring food security, and improving step, development of a national strategic living and working conditions as well as plan embedded in a national health sector interventions to address direct risk factors plan, taking into account tuberculosis such as tobacco control, reduction of harmful epidemiology, health system structure and alcohol use, and diabetes care and prevention. functions including procurement and supply Tuberculosis prevention will also require systems, resource availability, regulatory actions on the part of governments in order to policies, links with social services, migrant help to reduce vulnerabilities and risks among populations and crossborder collaboration, people most susceptible to the disease. the role of communities, civil society • Multidisciplinary and multisectoral organizations and the private sector, and approach. The implementation of pillar two coordination with all stakeholders. A components demands a multidisciplinary national strategic plan should be ambitious and multisectoral approach. Accountability and comprehensive, and incorporate five for pillar two will rest not only with health distinct sub-plans: a core plan, a budget ministries, but also other ministries including plan, a monitoring and evaluation plan, an finance, labour, social welfare, housing, operational plan and a technical assistance mining and agriculture. Eliciting actions plan. from across diverse ministries will require • Mobilize adequate resources. The expansion commitment and stewardship from the of tuberculosis care and prevention across highest levels of government. This should and beyond the health sector will be possible translate into ensuring adequate resources only if adequate funding is secured. The and accountability for optimal and integrated
15 national strategic plan should be properly integrate community-based tuberculosis budgeted with clear identification of gaps care into their work, and widen the network in finances. A well-budgeted plan should of facilities engaged in tuberculosis care facilitate resource mobilization from diverse and prevention. Civil society should also international and national sources for full be engaged in policy development and implementation of the plan. In most low- planning as well as periodic monitoring of and middle-income countries, the currently programme implementation. available resources are inadequate or sufficient only for modestly ambitious plans. • Scale up public–private mix approaches Coordinated efforts are required to mobilize and promote International Standards for additional resources to fund truly ambitious Tuberculosis Care. In many countries, national strategic plans with a progressive tuberculosis care is delivered by diverse increase in domestic funding. private care providers. These providers include pharmacists, formal and informal practitioners and nongovernmental and faith- Engagement of based organizations, as well as corporate health facilities. Several public sector providers communities, outside the purview of national tuberculosis programmes also provide tuberculosis care. These include, inter alia, large public civil society hospitals, social security organizations, prison health services and military health organizations, and services. Leaving a large proportion of care providers out of an organized response all public and private to tuberculosis control has contributed to stagnating case notification, inappropriate care providers tuberculosis management, and irrational use of tuberculosis medicines leading to • Engage communities and civil society. A the spread of drug-resistant tuberculosis. robust response to end the tuberculosis National tuberculosis programmes will have epidemic will require the establishment of to scale up country-specific public–private lasting partnerships across the health and mix approaches already working well in many social sectors and between the health sector countries. To this effect, close collaboration and communities. Informed community with health professionals’ associations will members can identify people with suspected be essential. The International Standards tuberculosis, refer them for diagnosis, for Tuberculosis Care, other tools and provide support during treatment and help guidelines developed by WHO as well as to alleviate stigmatization and discrimination. modern information and communication Civil society organizations have specific technology platforms can be used effectively capacities and tuberculosis programmes for this purpose. can benefit from harnessing them. Their competencies include reaching out to vulnerable groups, mobilizing communities, channelling information, helping to create demand for care, framing effective delivery models and addressing determinants of the tuberculosis epidemic. National tuberculosis programmes should reach out to civil society organizations not currently engaged in tuberculosis care, encourage them to
16 infection control, vital registration and disease Universal health surveillance systems are powerful levers that are essential for effective tuberculosis care coverage policy, and prevention. In countries with a high tuberculosis burden, these frameworks need and regulatory to be urgently strengthened and enforced. The strategy calls for improvements in frameworks for case several areas outlined below. • Enforce mandatory notification of notification, vital tuberculosis cases. Many tuberculosis cases are not notified, especially those managed registration, quality by private care providers that are not linked to national tuberculosis programmes. Under- and rational use notification of cases hampers disease surveillance, contact investigation, outbreak of medicines, and management, and infection control. An effectively enforced infectious disease law, infection control or equivalent, that includes compulsory notification of tuberculosis cases by all health • Move with urgency to universal health care providers, is essential. coverage. Universal health coverage, defined as, “the situation where all people • Ensure recording of tuberculosis deaths are able to use the quality health services within vital registration. Most countries with that they need and do not suffer financial a high burden of tuberculosis do not have hardship paying for them” is fundamental for comprehensive vital registration systems effective tuberculosis care and prevention. and the quality of information about the Universal health coverage is achieved number of deaths due to tuberculosis is often through adequate, fair and sustainable inadequate. An effective vital registration prepayment financing of health care with system has to be in place to ensure that full geographical coverage, combined each death due to tuberculosis is properly with effective service quality assurance and recorded. monitoring and evaluation. For tuberculosis specifically, this implies: (a) expanding access • Regulate the production, quality and use of to the full range of high-quality services tuberculosis diagnostics and medicines. Poor recommended in this strategy, as part of quality tuberculosis medicines put patients at general health services; (b) expanding great risk. Irrational prescription of treatment coverage, including costs of consultations regimens leads to poor treatment outcomes and testing, medicines, follow-up tests and and may cause drug resistance. Use of all expenditures associated with staying in inappropriate diagnostics such as serological complete curative or preventive treatment; tests leads to inaccurate diagnosis. and (c) expanding access to services for all Regulation and adequate resources for in need, especially vulnerable groups faced enforcement are required for the registration, with the most barriers and worst outcomes. importation and manufacturing of medical products. There should be regulation of • Strengthen regulatory frameworks. National how medical products are subsidized and policy and regulatory frameworks for health a determination of which types of health care financing and access, quality-assured professional are authorized to prescribe or production and use of medicines and dispense tuberculosis medicines. diagnostics, quality-assured health services,
17 • Undertake comprehensive infection control protect and promote human rights, including measures. Appropriate regulation is required addressing stigma and discrimination, with to ensure effective infection control in health special attention to gender, ethnicity, and care services and other settings where the risk protection of vulnerable groups. These of disease transmission is high. Managerial, instruments should include capacity-building administrative, environmental and personal to enable affected communities to express measures for infection control should be their needs and protect their rights, and to part of infectious disease legislation, and call to account those who impinge on human regulations related to the construction and rights, as well as those who are responsible organization of health faculties. for protecting those rights.
• Address poverty and related risk factors. Social protection, Poverty is a powerful determinant of tuberculosis. Crowded and poorly ventilated poverty alleviation living and working environments often associated with poverty constitute direct risk factors for tuberculosis transmission. and actions on other Undernutrition is an important risk factor for developing active disease. Poverty is determinants of also associated with poor general health knowledge and a lack of empowerment to tuberculosis act on health knowledge, which leads to risk of exposure to several tuberculosis risk • Relieve the economic burden related factors. Poverty alleviation reduces the risk with tuberculosis. A large proportion of of tuberculosis transmission and the risk of people with tuberculosis face a catastrophic progression from infection to disease. It also economic burden related to the direct helps to improve access to health services and indirect costs of illness and health and adherence to recommended treatment. care. Adverse social consequences may include stigmatization and social isolation, • Pursue “health-in-all-policies” approaches. interruption of studies, loss of employment, Actions on the determinants of ill health or divorce. The negative consequences through “health-in-all-policies” approaches often extend to the family of the persons ill will immensely benefit tuberculosis care with tuberculosis. Even when tuberculosis and prevention. Such actions include, for diagnosis and treatment are offered free example: (a) pursuing overarching poverty of charge, social protection measures are reduction strategies and expanding needed to alleviate the burden of income social protection; (b) improving living and loss and non-medical costs of seeking and working conditions and reducing food staying in care. insecurity; (c) addressing the health issues of migrants and strengthening cross- • Expand coverage of social protection. Social border collaboration; (d) involving diverse protection should cover the needs associated stakeholders, including tuberculosis with tuberculosis such as: (a) schemes affected communities, in mapping the likely for compensating the financial burden local social determinants of tuberculosis; associated with illness, such as sickness and (e) preventing direct risk factors for insurance, disability pension, social welfare tuberculosis, including smoking and harmful payments, other cash transfers, vouchers use of alcohol and drugs, and promoting or food packages; (b) legislation to protect healthy diets, as well as proper clinical care people with tuberculosis from discrimination for medical conditions that increase the risk such as expulsion from workplaces, of tuberculosis, such as diabetes. educational or health institutions, transport systems or housing; and (c) instruments to
18 PILLAR 3
INTENSIFIED RESEARCH AND INNOVATION
How pillar 3 works : Key actions
A. Discovery, development B. Research to optimize and rapid uptake of new tools, implementation and impact; interventions and strategies and promote innovations
19 • Enhancing investments in research. Progress but also facilitate their seamless integration in global tuberculosis control is constrained into ongoing programmes. It is important not only by the lack of new tools to better that tuberculosis becomes a key domain of detect, treat or prevent tuberculosis but investigation within national health research also by the weaknesses of health systems in agendas. delivering optimal diagnosis and treatment with existing tools. Ending the tuberculosis epidemic will require substantial investments Discovery, in the development of novel diagnostic, treatment and prevention tools, and for development and ensuring their accessibility and optimal uptake in countries alongside better and rapid uptake of new wider use of existing technologies. This will be possible only through increased investments and effective engagement tools, interventions of partners, the research community and country tuberculosis programmes. and strategies • Develop a point-of-care rapid diagnostic • Embarking on research for tuberculosis test for tuberculosis. Since 2007, several elimination. Revolutionary new technology new tests and diagnostic approaches and service delivery models are needed to have been endorsed by WHO, including: achieve tuberculosis elimination. This will liquid culture with rapid speciation as the require an intensification of research, from reference standard for bacteriological fundamental research to drive innovations confirmation; molecular line probe assays for improved diagnostics, medicines and for rapid diagnosis of multidrug-resistant vaccines, to operational and health systems tuberculosis; non-commercial culture and research to improve current programmatic drug-susceptibility testing methods; light- performance and introduce novel strategies emitting diode fluorescence microscopes; and interventions based on new tools. and a nucleic acid amplification test for rapid To highlight the need for reinvigorated and simultaneous diagnosis of tuberculosis tuberculosis research and catalyse further and rifampicin-resistant tuberculosis. efforts, an International Roadmap for However, an accurate and rapid point-of-care Tuberculosis Research has been developed. test that is usable in field conditions is still The Roadmap outlines priority areas for missing. This requires greater investments future scientific investment across the in biomarker research, and the overcoming research continuum. It provides a framework of difficulties in transforming sophisticated for outcome-oriented research. A mapping of laboratory technologies into robust, accurate the efforts carried out in the various research and affordable point-of-care platforms. areas will also be necessary, so as to follow up on progress made. Embarking on research • Develop new drugs and regimens for the for tuberculosis elimination will require a treatment of all forms of tuberculosis. multi-dimensional approach informed by The pipeline of new drugs has expanded stakeholders including scientists, public substantially over the last decade. There health experts, tuberculosis programme are nearly a dozen new or repurposed managers, financial partners, policy-makers tuberculosis drugs under clinical investigation. and civil society representatives. Guided by Bedaquiline, the first new tuberculosis drug clinical and programmatic needs, such an for decades, was approved in 2013 by WHO approach should not only help undertake for the treatment of multidrug-resistant public health oriented research for the tuberculosis. A second new drug, delamanid, development of new tools and strategies also for the treatment of multidrug-resistant
20 tuberculosis, is in the process of review by WHO. Novel regimens, including new or Research to optimize repurposed medicines and adjuvant and supportive therapies, are being investigated implementation and early results appear promising. In order for further progress to be made, investments and impact, and are required in both research and capacity- building to implement trials in accordance promote innovations with international standards, and to identify means of shortening the duration of • Invest in applied research. Investments tuberculosis medicines trials. in fundamental research need to be complemented with those for applied • Enhance research to detect and treat research that supports rapid adoption, latent infection. Globally, more than adaptation, and implementation of 2000 million people are estimated to be evidence-based policies. Research aimed at infected with Mycobacterium tuberculosis, improving understanding of the challenges but only 5% to 15% of those infected and developing interventions that result will develop active disease during their in improved policies, better design and lifetime. Ending the tuberculosis epidemic implementation of health systems and will require the elimination of this pool of more efficient methods of service delivery infection. Research is needed to develop is critical to produce evidence for improving new diagnostic tests to identify people with current strategies and introducing new tools. latent tuberculosis infection who are likely Research is also needed to identify and to develop tuberculosis disease. Further, address bottlenecks to implementation of treatment strategies that could be safely existing and new policies, and to provide used to prevent development of tuberculosis evidence from the perspective of patients as in latently infected persons will also need well as from health systems. to be identified. These strategies should include new medicines or combinations as • Use research to inform and improve well as interventions to identify and mitigate implementation. Most innovations cannot risk factors for progression. Further research be translated into effective local action will be required to investigate the impact without careful planning and adaptation, and and safety of targeted and mass preventive partnership with stakeholders. In addition to strategies. routine surveillance, well-planned and well- conducted research is required to assess • Aim for an effective vaccine against national and local epidemiological and tuberculosis. The century-old BCG vaccine health system situations, socio-behavioural is useful to protect against severe forms of aspects of health care seeking, adherence to tuberculosis in infants and young children treatment, stigmatization and discrimination, but has limited efficacy against other forms and to evaluate different implementation of tuberculosis. Much progress has been models. made in the development of new vaccines; currently there are 12 vaccine candidates in • Create a research-enabling environment. clinical trials. More research and investments Fostering better and more relevant are required to address a series of major operational, health system and social science scientific challenges and identify priorities research will help implementation and for future tuberculosis vaccine research. A contribute to the development of national post-exposure vaccine that prevents the and global policies. For this purpose, good disease in latently infected individuals will be systems for research prioritization, planning essential to eliminating tuberculosis in the and implementation need to be in place at foreseeable future. country level. Indicators to measure progress
21 should include investments in outcomes as stakeholders to work together. An enabling well as in the impact of research activities. environment for performing programme- A broad-based, concerted effort is needed based research and translating results into to develop research capacity, allocate policy and practice is necessary to achieving appropriate resources, and encourage the full potential of tuberculosis programmes. ADAPTING AND IMPLEMENTING THE STRATEGY
from domestic and international sources. Initiating and Development of new national strategic plans or modifications to existing ones should take into sustaining strategic consideration the recommended framework of the new strategy. dialogue
Engage all stakeholders in strategy adoption Epidemiological and adaptation. A first step in adapting and implementing the strategy would be for Member and health systems States to hold inclusive national consultations with a wide range of stakeholders, including mapping communities most affected by tuberculosis, in order to consider, adopt and prepare for Undertake a detailed epidemiological adaptation of the strategy. Blanket application of and health system context assessment. A a global strategy could be inappropriate if it does prerequisite for adoption of the strategy and not adequately respond to an assessment of preparation for its adaptation will be a detailed local needs that is derived from the nature of the assessment of the national epidemiological tuberculosis epidemic, the health system context, and health system situation. Proper mapping the social and economic development agenda should provide important information, such and the expressed demands of the populations at as population groups most affected by the risk. Furthermore, it must build on the capacities disease and most at risk of developing it; age of health systems and those of partners. and sex characteristics and trends; prevalence of different forms of tuberculosis and dominant Use a multidisciplinary approach. A meaningful comorbidities, including HIV, undernutrition, implementation of this strategy will demand the diabetes, tobacco use, and alcohol misuse; involvement of many actors and their sharing important subnational and urban–rural of responsibilities. The scope of existing variations; distribution and types of care tuberculosis advisory panels will need to be providers; available social protection schemes expanded beyond clinical, epidemiological and and their current and potential linkages for the public health expertise. It will need to include a benefit of tuberculosis care and prevention. wider range of capacities from civil society and from the fields of finance and development Collect and use data to improve systems policy, human rights, social protection, mapping. Some of the information for context regulation, health technology assessment, the assessment can be derived from routine social sciences, and communications. The work reporting and, in some countries, from national to adapt the new global tuberculosis strategy or regional tuberculosis prevalence survey to national contexts may be an adjunct to results. Other required information may have to overall national health strategic planning, but be obtained from the review of periodic national will need a significant and specific effort. programme evaluations, field assessments and local quantitative and qualitative studies. For Prepare to develop new strategic plans. this purpose, countries need to build capacities Countries follow different development planning in order to establish an information system that cycles. Existing strategic and operational plans monitors the characteristics of the tuberculosis may need to be modified, building on any epidemic, and make appropriate use of the new approaches. Detailed national strategic data generated from the system at all levels. plans are also essential to mobilize funding
23 MEASURING PROGRESS AND IMPACT
Target setting and monitoring of progress in high-income countries with high-performance implementing each component of the global tuberculosis surveillance and health systems, strategy are essential. Monitoring should be case notification systems capture all, or almost done routinely using standardized methods all, incident cases. However, in other countries, based on data with documented quality. Table routine case notifications provide biased data 2 below provides examples of the indicators due to under-diagnosis (cases not diagnosed) that can be used to monitor progress in and under-reporting (cases diagnosed by implementing different components and health practitioners but not reported to public subcomponents of this strategy. The main health authorities). In such settings, inventory indicators of disease burden are incidence, studies and capture–recapture modelling may prevalence and mortality. Given the overarching be used to estimate tuberculosis incidence. 2035 targets of the strategy, particular attention to measurement of trends in mortality and Accurate measurement of trends in tuberculosis incidence is required. incidence requires the performance of tuberculosis surveillance systems to be Mortality data are critical in order to enable strengthened so that they cover all providers prioritization of public health interventions of health care and minimize the level of under- and the measurement of progress made in reporting. WHO has developed a tuberculosis disease control and the overall health of the surveillance checklist, the “standards and population, including health inequalities. A benchmarks for tuberculosis surveillance robust national vital registration system that and vital registration systems”, to assess includes recording of data on causes of death a national surveillance system’s ability to is essential for measurement of trends in measure tuberculosis cases accurately. The mortality due to tuberculosis. Vital registration checklist defines 10 surveillance standards that data can also be used to identify subgroups must be met in order for notification and vital of the population that have higher mortality registration data to be considered as a direct over casenotification ratios, thereby allowing measurement of tuberculosis incidence and targeting of interventions. The quality of these tuberculosis mortality, respectively. Countries data is documented globally by WHOg and that meet all standards can be certified as statistical methods can be used to account for having an appropriate surveillance system. incomplete coverage or miscoding. Countries The WHO checklist should be used to improve that already have vital registration systems tuberculosis surveillance progressively towards need to ensure that data are of sufficient the ultimate goal of measuring trends in quality. Those without such systems need to tuberculosis cases directly from notification introduce them. An interim solution being data in all countries. adopted by an increasing number of countries is the introduction of a sample vital registration Prevalence is a very useful indicator of system. the tuberculosis disease burden. It is directly measureable through population- Globally, incidence is estimated to be declining based surveys.h Prevalence surveys also slowly, at a rate of about 2% per year. The 2025 provide information that is useful for policy and 2035 targets mean that, in the post-2015 improvements, in particular those related to period, great attention will need to be given access to health and to tuberculosis diagnosis. to measuring how fast incidence is falling. In Measurement of tuberculosis prevalence using g Mathers CD, Fat DM, Inoue M, Rao C, Lopez AD. h World Health Organization. Tuberculosis prevalence Counting the dead and what they died from: an assessment surveys: a handbook. Geneva 2011. http://www.who.int/ of the global status of cause of death data. Bull World tb/advisory_bodies/impact_measurement_taskforce/ Health Organ. 2005;83(3):171–7. resources_documents/thelimebook/en/index.html.
24 nationwide surveys is not feasible everywhere. surveys at country level and works with countries Nationwide prevalence surveys are important and other partners to support implementation for high-burden settings and will be especially and analysis of surveys. The Task Force closely relevant and useful for direct measurement of monitors the implementation of all surveys to impact in countries that implemented a repeat ensure international comparability through or baseline survey around 2015. The WHO the use of WHO-recommended methods Global Task Force on TB Impact Measurement and standards. The Task Force also assesses has set criteria for prioritization of prevalence progress towards prevalence reduction targets.
Table 2. Illustrative list of key global indicators for the post-2015 global tuberculosis strategy
COMPONENT ILLUSTRATIVE INDICATORS PILLAR ONE: INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION A. Early diagnosis Percentage of people with suspected tuberculosis tested using WHO recommended rapid diagnostics Percentage of all tuberculosis patients for whom results of drug susceptibility testing were available Percentage of eligible index cases of tuberculosis for which contact investigations were undertaken B. Treatment Tuberculosis treatment success rate Percentage of patients with drug-resistant tuberculosis enrolled on second-line treatment C. Tuberculosis/HIV and Percentage of tuberculosis patients screened for HIV comorbidities Percentage of HIV-positive tuberculosis patients on antiretroviral therapy D. Preventive treatment Percentage of eligible people living with HIV and children aged under-five who are contacts of tuberculosis patients being treated for latent tuberculosis infection PILLAR TWO: BOLD POLICIES AND SUPPORTIVE SYSTEMS A. Government commitment Percentage of annual budget defined in tuberculosis national strategic plans that is funded B. Engagement of communities Percentage of diagnosed tuberculosis cases that were notified and providers C. Universal health coverage Percentage of population without catastrophic health expenditures and regulatory frameworks Percentage of countries with a certified tuberculosis surveillance system D. Social protection, social Percentage of affected families facing catastrophic costs due to tuberculosis determinants Percentage of population without undernutrition PILLAR THREE: INTENSIFIED RESEARCH AND INNOVATION A. Discovery Percentage of desirable number of candidates in the pipelines of new diagnostics, drugs and vaccines for tuberculosis B. Implementation Percentage of countries introducing and scaling-up new diagnostics, drugs or vaccines
25 THE ROLE OF THE SECRETARIAT
The Secretariat, at all levels of the WHO will continue to strengthen its Organization, will provide support to Member stewardship role in generating global demand States in reviewing, adopting, adapting and for research, prioritizing among tuberculosis implementing their post-2015 tuberculosis research needs, and supporting with partners strategies, building on the framework the effective conduct of research to inform provided in the strategy. WHO will draw on its global and national strategy and policy design comparative advantages in areas of the core and implementation. This will entail further functions outlined below and use its Strategic work with basic scientists, epidemiologists, and Technical Advisory Group for Tuberculosis social scientists and innovators in the public, and regional advisory bodies, as well as the private and academic communities, as well Organization’s governing bodies, in order to as affected populations. It will also mean that guide, support and evaluate its work. national tuberculosis programmes need to work with academic partners and associated WHO will continue its policy and norms-setting research institutions, research-focused public work, building on a range of available and partnerships and public–private partnerships. future guidance documents on tuberculosis. The Secretariat will provide the strategic WHO will foster effective partnerships to support guidance and tools needed for adaptation the work proposed under the three pillars of the and implementation of the strategy in diverse new strategy. This work in partnership aims to country settings. These tools will need to support Member States in achieving universal be iterated as further evidence on effective access to tuberculosis care and prevention and approaches and best practices becomes in reaching out to vulnerable populations and available. Periodic guidance will be needed communities most affected by the tuberculosis on the use of new tuberculosis diagnostics, epidemic worldwide. WHO will work with medicines susceptibility testing methods the Stop TB Partnership, and will seek out and new treatment regimens as they become new partnerships that can leverage effective available. WHO will work with partners to commitment and innovation in the non-health stimulate further evidence generation and sector driven elements of the strategy. policy recommendations on how national tuberculosis programmes can engage in The launch of the Stop TB Strategy 2006– the development agenda to address social 2015 by WHO led to its swift translation into a determinants of tuberculosis. comprehensive, costed global plan of action by the Stop TB Partnership. Similarly for the post- To enable this strategy to have a rapid impact 2015 global tuberculosis strategy, WHO will and to support Member States, the Secretariat actively support the development of a global will pursue its core function of technical support investment plan by the Stop TB Partnership, coordination. It will continue to stimulate outlining activities and defining financing contributions from partners, at global, national requirements to meet the ambitious targets and local levels. The tuberculosis technical while achieving the stated milestones on the assistance mechanism (TBTEAM) managed by way. WHO will work closely with the Stop TB WHO helps to facilitate and mobilize financing Partnership and will contribute to preparing for technical assistance by partnering with major the global action and investment plan to guide development agencies. The gaps in technical post-2015 efforts for tuberculosis care and expertise among supporting agencies will prevention by providing the required strategic, need to be filled by collaborating with experts scientific and technical input. working in global health disciplines beyond tuberculosis, and by drawing more young collaborators into the field.
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