Tuberculosis control in crisis-causes and solutions.

Tuberculosis (TB) incidence is projected to decline at too slow a rate to meet the targets set at the UN high level meeting on ending TB, convened in New York in 2018. To understand the causes of the slow progress in TB control, the Bill and Melinda Gates Foundation supported a patient-pathway analysis that identified significant gaps with patients being "lost" at all points along the care cascade. Although each country differed in the reasons for failure, some commonalities were identified. Most striking was the failure to diagnose and report TB patients to a national registry making finding the missing patients a priority for TB control globally. The analysis also found that optimal use of existing tools will not accelerate the rate of decline in TB incidence sufficiently, necessitating the development of new and improved tools for TB control. Finally, it was recognized that gaps in our understanding of TB pathogenesis and protective immunity as well as limited knowledge about the host pathogen interactions in granulomas of infected tissues, hinder the progress needed to develop the new tools for improved TB control. A commitment of all governments to support research, develop new tools such as new diagnostics, better drug regimens and efficacious vaccines, and improving service delivery by TB control programs will be needed to accelerate the reduction in incidence and reduce disease burden globally.