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Q&A: Dr. Paul Nunn of the WHO talks tuberculosis


Dr. Paul NunnToday marks yet another moment in the “holidays without greeting cards” series: World Tuberculosis Day. Each year, there are 9 million new cases of TB and close to 2 million people die from the disease. An estimated 10 percent of people with TB also are co-infected with HIV, further compounding the diseases’ burden. Dr. Paul Nunn, a self-described “physician-turned-bureaucrat,” is responsible for coordinating TB control efforts throughout the WHO system — took some time to talk with me about his work on TB. I’ve taken the liberty of paraphrasing some of his answers below:

Today is World TB Day. What does that mean to you?
Travel! [Ed note: Dr. Nunn was off to mark World TB day with a speech at the Swiss Anti-Tuberculosis Association]. Besides that, I see it as a key advocacy moment to drive awareness of TB, highlight the progress we’ve made, and motivate the global community to do more on TB.

What sort of progress have we made on TB in the last decade?
There are still more than 9 million cases per year, but we have made significant progress. The incidence rate of TB flattened in 2004, and it has fallen (albeit fractionally) in the years since, in part thanks to the DOTS strategy. We’ve also significantly decreased the prevalence (total number of cases at any given time) and mortality from TB overall.

Millennium Development Goal 6 set the target of reversing and reducing the incidence of TB along with AIDS, malaria, and other diseases — and for TB that has been achieved. The Stop TB Partnership also set additional goals by 2015: that we would halve the prevalence rate and mortality relative to 1990. It looks like we’re almost there on prevalence rate and may just barely achieve the mortality reduction treatment — although not for Africa specifically.

What work still needs to be done on TB? Where are we having the most difficulty, and what steps are in place to achieve progress?
The achievement of MDG 6 for TB is tempered by the fact that the absolute number of people getting TB continues to rise due to the rising overall world population. Africa also lags far behind many other regions when it comes to TB. The big challenge there is that HIV drives the TB epidemic, and the quality of health services overall is poor. We need to ensure that efforts to fight HIV in both prevention and treatment also take on TB. TB patients tend to be ignored — in part because TB is highly infectious in social settings, and thus stigmatizing — but it’s important that services for HIV and TB are integrated to reach those who are vulnerable and missed in the health system.

MDR-TB and XDR-TB are serious and growing threats to TB control. It’s estimated that there were 440,000 cases of MDR-TB last year, of which 67 percent were identified by the health care system; of those identified, we only managed to treat 30,475 cases (the WHO launched a new report on the topic this week). 69 countries have reported at least 1 case of XDR-TB through 2010, as well. Still, 95 percent of TB remains treatable with existing drugs—and that needs to be the primary focus.

Current tools to diagnose and prevent TB are outdated, but hope is on the horizon. A new diagnostic test Xpert can tell within a few hours if someone has TB and whether the TB is multi-drug resistant. It’s already being used extensively in parts of the world, and we’re hoping to roll it out even further in the coming years, including through the Global Fund’s next round of grants. The currently existing TB vaccine, BCG, works to prevent the worst forms of childhood TB, but is too risky for many with compromised immune systems, including many who are HIV positive. New vaccines are still in the research phase; it’s likely we will go another 10 years before we see a new TB vaccine delivered to patients, yet it’s still an important future tool. Lastly, a few new drugs are nearly certified which, in 3-5 years, could be used to cure TB patients in high burden countries, especially those with MDR-TB.

Who are key partners working on TB around the world?
The Global Fund is key—it’s probably our most important partner—providing countries with financial support to do the work they need to do on TB. We also work closely with countries themselves, particularly those with high disease burdens. Technical agencies from many European capitals are strong partners, as well as the Gates Foundation and USAID, among others.

What messages about TB can advocates use that are the most compelling?

  • Investments in HIV (especially in antiretroviral treatment) must be accompanied by investments in TB, or else you risk losing your investments in both
  • Everybody who has TB should have access to treatment, regardless of their political, economic, or demographic situation
  • If you can provide TB treatment, it’s very cost effective; we estimate you can save a life with just $100 ($20 for medicines and $80 for care provided) for 95 percent of TB cases
  • New technological advances stand to make a huge difference in the fight, and stand to make our work even more cost-effective