Transcript: World TB Day National Media Call

RESULTS Education Fund
World Tuberculosis Day Media Call

On the release of the World Health Organization report on drug-resistant Tuberculosis
March 23, 2010, noon ET

Moderator: Joanne Carter
Dr. Mario Raviglione, director of the Stop TB Department at the World Health Organization
Dr. Ken Castro, director of the Division of Tuberculosis Elimination at the Centers for Disease Control and Prevention
Dr. Gerald Friedland, professor of Medicine, Epidemiology, and Public Health at Yale University School of Medicine

Operator: Good afternoon, my name is (Andrea), and I will be your conference operator today. At this time, I would like to welcome everyone to the World TB Day conference call. All lines have been placed on mute to prevent any background noise. After the speaker’s remarks, there will be a question-and-answer session. If you would like to ask a question during this time, simply press star then the number one on your telephone keypad. If you would like to withdraw your question, press the pound key. Thank you. Ms. Carter, you may begin your conference.

Joanne Carter: Thanks very much, Operator, and thanks to all of you for joining this conference call in advance of March 24th World TB Day. I’m Joanne Carter. I’m the executive director of the advocacy organization RESULTS and RESULTS Educational Fund. I’ll be moderating this call, and also providing some perspective on the U.S. response to TB.

Our speakers on the call will be Dr. Mario Raviglione, he’s director of the Stop TB Department at the World Health Organization, who’ll be speaking about the newly released WHO report on multidrug-resistant and extensively-drug resistant TB. Dr. Ken Castro, director of the Division of Tuberculosis Elimination at the Centers for Disease Control and Prevention, who’s going to be providing insights on the linkages between global and domestic TB epidemics, and also some perspective on the TB situation here in the U.S.

And Dr. Gerald Friedland, professor of Medicine, Epidemiology, and Public Health at Yale University School of Medicine, who’s going to be talking about his on-the-ground work in South Africa, where he’s seen the really deadly intersection between MDR and XDR-TB and HIV/AIDS.

So before I turn this over to our other speakers, let me just say a few words of context. As you’re going to hear in a moment, the World Health Organization’s new report on drug-resistant TB confirms what public health experts have been warning for years, that MDR-TB and XDR-TB are major threats to global health. And as you’ll hear from our other speakers, it also has direct linkages with our domestic situation. Unfortunately, we’re not addressing the global TB epidemic with a response commensurate with the scale of the problem or the urgency of the threat. It’s an enormous human toll of nearly two million deaths a year from TB overall, and also a health security threat.

We’re talking about an airborne disease that’s becoming increasingly resistant to available antibiotics we have to treat it. MDR and XDR-TB are much deadlier and far more difficult and costly to treat, and the Department of Homeland Security has identified XDR-TB as an emerging threat to the homeland.

The good news is, again, as you’ll hear, is that when countries take the threat of drug resistant TB seriously, and fully implement effective prevention and treatment, it can have success in curbing and even decreasing the rates of MDR. So the point being, if we’re smart and aggressive, we can save money and save lives by investing in basic TB control and new and better tools to fight TB, we can stop the creation of drug resistance. And if we scale up treatment of drug-resistant TB and infection control and surveillance, we can stop this threat — the spread of this deadly and costly killer.

But that’s going to require especially addressing and scaling up the response to MDR-TB is going to require resources committed by donor governments to support what countries are already doing, it’s critical of the United States to lead in this effort. In 2010, it’s estimated that less than a third of the needed resources to address MDR-TB in high-burden countries are currently available.

So we urgently need the U.S. government to do its part to address this global threat, first to fully fund our fair share for a very important and effective results-oriented mechanism called the Global Fund to Fight AIDS, TB and Malaria. That’s an international financing mechanism, it’s the single most important external meeting donor source of resources for TB programs and malaria programs, as well, in the world.

Second, we also need to expand our bilateral investments in international TB and TB/HIV programs along the lines that Congress boldly set out in 2008. And thirdly, to fully fund domestic TB efforts to a scale where we can actually eliminate TB, and really expand resources for research and development for nearly better tools, which has been massively neglected over the last decades.

Yet the president’s budget in 2011, in his new Global Health Initiative, actually cuts funding for the Global Fund to Fight AIDS, TB and Malaria, and flat-lines international TB programs. And the budget also flat-funds our domestic TB programs, as well. This is hugely short-sighted, and Congress must reverse this. Essentially we know what to do, we just need to do it.

I’m going to stop there, and I’m going to introduce our other speakers, let them make some brief remarks, then I’ll come back and we can open it up for some questions. So first I’m going to ask Dr. Mario Raviglione, Director of Stop TB Department at WHO to give us some perspective on the WHO’s newly released report on multidrug-resistant TB. Mario, if you can go ahead, please.

Mario Raviglione: Thank you very much, Joanne. Let me say a few words regarding the report. As you mentioned, the report that we showed during the past couple of days shows that — and confirms that — the MDR and XDR-TB are a serious threat to global health. With all countries, rich and poor that are at risk, and we just need to remember what happened in the U.S. with the Atlanta lawyer three, four years ago, and more recently, what happened in Australia with the rap singer that has produced actually quite an interesting YouTube exposition in a song of what it means to have MDR-TB.

Given the very high mortality rates that are also shaded with this form of tuberculosis, the fight must be global, because there is no way that we can reduce the threat of multidrug-resistant and XDR-TB without the contribution of everyone in the world. I think this is a message that has to be very clear, because the disease is everywhere. And of course, there are certain areas which are more affected than others.

In fact, in the report, we showed that the highest level of MDR-TB have been recorded in some parts of the — of Russia, exactly in three Oblasts of northwest Russia, on which we published for the first time the information. In those — in that part of the world, up to 28 percent, and in the — in another couple robust — around 25 percent, so you can say one patient out of four have MDR-TB when they appear, or they are diagnosed for the first time with tuberculosis.

So obviously this has implications, because once you have one out of four people with TB having multidrug-resistant TB, then the treatment becomes complicated, expensive, extremely difficult to take, because the drugs are more toxic, etcetera. So we found that in certain part of Russia, again, this is a huge problem. When it comes to XDR-TB, and I just want to remind everyone in case you don’t have it clear in your mind, XDR-TB is a form of multidrug-resistant TB that is also resistant, not just like in the case of MDR-TB to the first line drug, the conventional drugs that are used for TB, but in the case of XDR-TB, also to the reserved drugs, the second line drugs that we are using. Which makes it virtually in some cases untreatable.

Now XDR-TB has been detected as far as we know at this point in 58 countries around the world, and it’s basically all over the — all over the — all over the world when people start looking for it. The big holes are in some parts of Africa, because Africa does not have the laboratories that are capable of the testing this form of disease.

The third point I wanted to make is that at the same time, however, there are areas which are showing that it is possible with intensified efforts to actually control MDR-TB and to push it down. Two Russian Oblast, again, Russia, two Oblast, two regions, one near Moscow and the other one in Siberia, have shown now consistently over the past three years that MDR-TB that was growing very rapidly until three, four years ago is now declining, declining as the — once again, as the result of intensified efforts in that part of the world.

They — these two Oblasts — are good models that join what we have seen before in couple of Baltic countries, Estonia and Latvia particularly. Or what we have been seeing, although at much lower level, in the U.S. and in Hong Kong where the low level of MDR-TB nevertheless kept declining over the years.

So what to do, that is the last part of our report, it explains what has been done. It emphasizes that many countries are now fortunately putting together plans for action to face MDR-TB. And there are essentially two sets of measures here, the first one is simply that basic TB control must be implemented — and care, I should say, basic TB control and care must be implemented in the most appropriate way, that’s the way to turn the tap off, to stop the production of MDR-TB, that’s paramount.

At the same time, the second set of measures concerns the existing cases of MDR-TB that are already there, that have already been produced because of malpractice in the past, and that we have to take care of, because if we don’t, then they keep simply transmitting the infection besides the individual suffering, and the high potential of death that patients — that people have when they have this form of disease.

So in order to do that, we need urgently laboratories that are capable of making the diagnosis rapidly using the rapid modern tests that are available today. We need a system that procures the drugs, these are difficult drugs at time, rare drugs that have been in a way recovered from the past, because they were abandoned after decades, and now we have to recover them, because they are the only ones available. So we need to have these drugs available, and we need them to have a system in place, a primary care system, I would even call it, in place that allows this patient to be supported throughout this up to 24-month course of difficult treatment.

So all of this is emphasized in the report, and there are a lot of different details of course for each area that I just mentioned. Thank you very much.

Joanne Carter: Thanks very much, Dr. Raviglione. And next I’d like to ask Dr. Ken Castro, who’s the director of the Division of TB Elimination at the Centers for Disease Control and Prevention, again, to provide us some insights on the linkages between the global and domestic TB. Thanks a lot, Ken, if you could go ahead and make some remarks.

Ken Castro: Thank you. This is Ken Castro. As we observe World TB Day in 2010, it is sobering to see how tuberculosis continues to be a leading global killer throughout the world at a time when we should have been better controlling it.

In the United States, we just released on March 19th the provisional data for 2009. And we had 11,500 tuberculosis cases reported in 2009 for a rate of 3.8 TB cases per 100,000 population. This represents the largest decrease that we’ve observed in the United States, an 11.4 percent decrease. However, the global reality is very much seen in the United States, if you look at the foreign-born persons in the United States, who accounted for 60.2 percent of all cases reported in 2009, the TB rate of foreign-born was 11 times higher than the TB rate in U.S.-born persons.

And while we’re looking into what could have accounted for this large decrease, it’s important to remember that one year doesn’t make a trend, and we need to see this decrease, and reported TB cases, is sustained over time.

What we see in the United States is very much like what has been seen and described by Canada, Australia, and western European countries where as progress against tuberculosis is made, the growing fraction of foreign-born cases account for much of the suffering in these very countries, again, reflecting that global situation.

Getting to the situation with multidrug-resistant TB in the United States, drug susceptibility data is consistently obtained from all persons whose cultures are positive for tuberculosis. These data lag one year behind, so the most recent data we have is for 2008. As a result of many years of concerted efforts, 1.1 percent of all culture-positive cases in the United States had multidrug-resistant tuberculosis.

Again, looking back at how does this compare for foreign-born versus U.S.-born persons? If you look at people who’ve never had TB, or new cases of tuberculosis, the rate of multidrug-resistant TB in the foreign-born was 1 percent, compared to 0.4 percent for U.S.-born. So you see that the rates are at least more than twice higher.

If you then look at people who’ve had TB previously, who are usually at higher risk of multidrug-resistant TB for the reasons mentioned by Dr. Raviglione, 4.3 percent of foreign-born persons who had TB previously had multidrug-resistant TB compared to 1.4 percent of U.S.-born. So it is clear that the United States need to be a full-fledged partner in the global efforts to control tuberculosis and multidrug-resistant TB. We need to pay close attention to the basics of TB control, to prevent the selection of resistant strains, and we also need to take care of those who are now manifesting with multi or extensively-drug resistant TB, and who are going to need treatment, and are — and are running out of treatment options right now.

So in the United States, what we’ve tried to do is improve the screening of persons who apply to come in as immigrants or refugees to make sure that we reduce the importation of TB, but equally and importantly, we need to invest in improving programs in countries where many of these foreign-born patients come from. In a study published a few years ago in the New England Journal of Medicine by Kevin Schwartzman, and other colleagues, they showed that these type of investments would provide a return for the investment, so it would be a cost-savings intervention, which is a very unusual occurrence for health interventions.

So they showed how if the United States invested in improving TB control in Mexico, Haiti, Dominican Republic, and other countries where our cases come from, we would in turn reduce the future investment by multiples of millions of dollars. So I will end here, and be happy to answer any questions.

Joanne Carter: Thanks a lot for that, Dr. Castro. And that’s a really good example of where the right thing to do is actually the smart thing to do as well. And last, just let me check if Dr. Friedland is on the line. Is — Dr. Friedland, are you on the line?

Gerald Friedland: Yes, I am on the line.

Joanne Carter: OK, great, thanks. Sorry, I knew you were coming in late from a — from another call. So I’m just — now I’m going to ask Dr. Gerald Friedland, professor of Medicine Epidemiology and Public Health at Yale University School of Medicine, to just talk a bit about his on the ground work in KwaZulu-Natal in South Africa, and about really where he’s seeing the deadly intersection between drug-resistant tuberculosis and HIV/AIDS. Dr. Friedland, please go ahead.

Gerald Friedland: Thank you. Good afternoon, everybody, thanks for the opportunity. (Inaudible) doctor who has worked with HIV/AIDS since the (inaudible) epidemic in the U.S., and 10 years ago, it (inaudible) in South Africa, because that was where the greatest force of the HIV/AIDS epidemic was. And (inaudible) and HIV care and treatment, that’s a very logical and cost-effective thing to do, because both diseases occur with (inaudible).

Joanne Carter: I think — we’ve having a little bit of trouble hearing Dr. Friedland, I don’t know, Dr. Friedland, if you can hear us? Operator, I’m wondering if you can try dialing out, if you have a different number, or just try redialing that number —

Operator: Yes, ma’am, we’ll —

Joanne Carter: — to Dr. Friedland.

Operator: Yes, ma’am, we’ll rejoin him. We’ll dial out to him.

Joanne Carter: In the meantime, why don’t — thank you very much. Just let us know when he’s back on the line. Thanks very much, and we’ll take that up again hopefully with a little bit betterconnection, apologies.

I just want to come back in the meantime before we open it up for questions, just very quickly with a bit more of an elaboration just kind of on the U.S. situation. And just to reiterate that in terms of mechanisms for funding these programs globally, the Global Fund to Fight AIDS, TB and Malaria is the single largest source of funding for TB control in low and middle-income countries, external source along with the government’s own funding. Between 2002 and 2009, the Global Fund supported treating some six million people sick with TB, nearly half of all new basic DOTS, TB treatment scale-up, and also supported the treatment of nearly 30,000 people with multidrug-resistant TB. So a very important source for this.

However, without increased funding — the Global Fund is now going through a process to replenish its funding for the next three years — progress toward reversing TB, as well as AIDS and malaria, is going to be stagnated, or even reversed.

So just to say in terms of the U.S. response, we need to actually do much more to provide our fair share around tuberculosis response. In 2008, Congress very boldly, with a lot of vision, authorized $48 billion over the next five years for our international response on AIDS, TB, and malaria, with some $4 billion for TB programs targeted over the next five years, and a bold target of treating four and a half million people and some 90,000 people with drug-resistant TB, and also something like $2 billion per year for the Global Fund to Fight AIDS, TB and Malaria.

So our own bilateral programs, plus the global programs. And as a senator, Mr. Obama — Senator Obama and Senator Biden both supported this legislation, and as a candidate, Mr. Obama also made a pledge to saying “I will strengthen the healthcare infrastructure crucial to reducing the spread of TB, and increase U.S. funding for the Global Fund partnership that’s already saved mi