Countries need to step up to end tuberculosis.

A declaration made by the G20 leaders during the 2017 Hamburg Summit acknowledged that there is a “growing threat to public health and economic growth” posed by antimicrobial resistance (AMR) [1]. Accordingly, a pledge was made to make AMR a priority for increased research and development; tuberculosis (TB) was highlighted as a particularly important issue.

This should come as no surprise given the grave threat the disease poses to low and middle-income countries. In the time taken by an average reader to scan the words preceding these, 18 lives were lost to TB globally. While TB is curable, some 1.8 million people die and 10.4 million new cases of TB develop every year, making TB the world's deadliest infectious disease [2].

In a lead-up to this G20 summit, Médecins Sans Frontières (MSF) and the Stop TB Partnership released the 3rd edition of their report Out of Step [3]. These reports aim to identify gaps and monitor progress in implementing international standards as national TB policies and practices. While the first edition (2014), and the second edition (2015), monitored progress in 8 countries and 24 countries, respectively, this third in the series provides a vital clue as to why TB continues to wreak havoc.

Based on surveys of TB policies and practices in 29 countries - accounting for 82% of the global TB burden- the publication highlights the disjoint between what is being endorsed on the global stage and what is both practice and policy in each respective country [3]. It focuses on 5 essential areas: diagnostics, models of care, treatment for drug-sensitive and drug-resistant TB, drug regulation, and prevention.

The report found that many countries are not implementing tools and international recommended policies and guidance that are known to be effective and lifesaving [3]. Countries are lagging in tackling the disease and introducing modern tools. This failure proves to produce devastating consequences for both patients and their families [4].

The report points out a huge diagnostic gap: in 2015, over 4 million people were living with undiagnosed TB. In other words, 40% of people with TB are not being diagnosed or not being notified. Rapid diagnosis and treatment are integral to disease containment and this statistic represents a grave failure in TB care.

For decades, the TB field has desperately sought new tools. And new tools are now available. Yet, new technologies are underutilized or not widely accessible [5]. The Xpert MTB/RIF (Xpert) diagnostic was endorsed by WHO in 2010, and promised to revolutionize the TB diagnostic field with a faster turnaround time, more accurate results and information about first-line drug sensitivity. But, while 15 (52%) of the countries surveyed in the report have introduced Xpert as the initial test for TB, only 7 of these countries have applied this strategy broadly [3]. The consequences of late or inadequate diagnosis can delay lifesaving treatment, and put patients at risk of drug-resistance [5].

It seems that countries are also slow to introduce newer TB drugs and regimens into their programs. For example, only 4 countries in the report have widely introduced child- and caregiver-friendly pediatric TB medications in the form of fixed dose combinations (FDCs) [3]. These were specifically designed to take into account some of the unique barriers implicit in treating children with TB and overcome some of the difficulties in their administration.

Given certain prerequisites, multidrug-resistant TB (MDR-TB) treatments can be shortened to 9 months [6]. Considering the harsh side effects that go along with these treatments, a shortened regimen is extremely welcome by patients and practitioners alike. However, only 13 countries (45%) in the report recommend these new shorter treatments in their guideline and none have made them widely available [3].

For years, TB advocates have been rallying for new second-line drugs in the treatment of MDR-TB. But while 79% (23) of the countries surveyed in the report have included the newer drug, bedaquiline, and 62% (18) of countries include delamanid in their national guidelines, only about 5% of people with drug-resistant TB, globally, have access to treatment regimens including these new medicines [3]. As MDR-TB survivors can attest, new TB drugs and shorter regimens would be extremely welcome and there is a sense of frustration that access to these treatments are restricted despite very few suitable alternative treatments [5].

Tackling the reservoir of latent TB infection is an emerging priority. With nearly 25% of the world's population infected by TB, preventive therapy can stop people with latent TB infection from developing active TB disease, especially those who are most vulnerable to succumbing to the illness. Though all of the countries surveyed provide such care to their most vulnerable groups i.e. child contacts of adult TB patients, and HIV-infected individuals, 31% (9) of these countries have not implemented it widely. Furthermore, only 4 countries provide preventive therapy to other high-risk populations that would surely benefit from such therapy [3].

Regarding where TB treatment is administered, it remains far away from where patients live and work; centralized management of TB is not ideal for several reasons [7]. Unfortunately, while more than 80% of the countries (24) in the report recommend starting treatment for drug-sensitive TB close to their homes (in a primary health care setting), only 20 of these countries have implemented it widely [3]. 19 of the countries in the report have included drug-resistant TB treatment initiation at district level in their national policies, but only 11 of these countries have implemented the policy broadly. There is thus a long way to go for decentralized TB care to become a reality in most settings.

India perfectly illustrates the shortcomings identified in the Out of Step report. Despite India accounting for approximately 27% of the world's new TB cases, and 29% of the TB deaths globally, TB has not received nearly enough funding, with health itself a low priority in the country [8], [9]. The Out of Step report shows that India is yet to widely scale-up tools such as the drugs bedaquiline and delamanid or Xpert MTB/RIF [4]. India also has yet to implement WHO policies on the shorter 9-month MDR-TB regimen and administer comprehensive latent TB therapy for high-risk populations [3].

With such a compelling case made for a stronger response to what can only be described as a public health emergency, it is now up to us, patients, civil society, doctors, researchers, and TB controllers to come together and clamour for change. It is we who are to blame for our complacency and it is we who must stop settling for less, demand our governments for more [10].

Conflicts of interest

None