• the planned global response to MDR-TB / XDR-TB;
• the ongoing response to the TB emergencies in Africa and Europe;
• the use of liquid culture for TB diagnosis;
• a revised TB case definition;
• WHO's planned role in the Stop TB Partnership's TB research movement;
• WHO guidance and plans to support community involvement in TB care, control and prevention.

Goals:

• to reduce TB morbidity and deaths by promoting the world-wide use of DOTS and other effective TB control strategies
• to assess existing strategies, and develop new strategies for the prevention and control of TB through operational, epidemiological, and economic research

Objectives:

• to develop a global plan for the control and prevention of TB, and to assist countries in its implementation
• to promote the wide-spread use of DOTS; the potential of this cheap and effective strategy to reduce TB morbidity and deaths has not yet been realized in all settings
• to assess the impact of DOTS in specific settings and globally
• to design new approaches to TB control addressing the specific problems of TB/HIV, drug resistance and inequalities in access to health services

THE PURPOSE OF THE GLOBAL PLAN
To eliminate tuberculosis (TB) as a public health problem. That and nothing less is the goal of the global Stop TB Partnership. We know it will not happen overnight with a disease that has cast a centuries-long
shadow; still, that is our aim-and we can achieve it.

The Global Plan to Stop TB (GPSTB) assesses the threat of TB based on the most current global evidence. At the same time, it shows why we are confident that TB can be controlled and, eventually, eliminated. The Global Plan describes mechanisms and activities that are already in place, as well as resources urgently needed over the next five years to accelerate our efforts to meet the new global TB control targets. We can control TB. With TB, in contrast to some other modern plagues, we know what needs to be done, we know how to do it and we know how much it will cost. If we effectively apply proven and cost effective strategies for TB control, adapting and improving them to meet the challenges described in this document over the next five years, we will have taken a giant step towards eliminating tuberculosis as a threat to future generations.

THE OBJECTIVES
The Global Plan has four objectives:

• To expand our current strategy- DOTS-so that all people with TB have access to effective diagnosis and treatment.
  
• To adapt this strategy to meet the emerging challenges of HIV and drug resistance.
  
• To improve existing tools by developing new diagnostics, new drugs, and a new vaccine.
  
• To strengthen the Stop TB Partnership so that proven TB control strategies are effectively applied.

A plan is only as good as the effective action it generates.

PLAN COSTS
Effective TB control cannot be imposed from above. National governments and local communities must take responsibility for planning and implementing their TB prevention and treatment programmes.

WHAT WILL BE ACCOMPLISHED?
This plan lays out what needs to be done if we are to control, and eventually eliminate, TB. It describes the strategies and the mechanisms to achieve our goals and what these accomplishments will cost.
What will have been accomplished if we meet the goals of this plan?

• The 22 countries that account for 80% of the world's TB burden will have rapidly expanded DOTS and met control targets-detecting 70% of people with infectious TB, and successfully treating 85% of those detected.
• More than four million patients will survive their tuberculosis through detection and treatment in these newly expanded DOTS programmes. If DOTS programmes are not expanded, they will
  suffer and die from their disease and infect numerous friends and family members along the way.
• We will have defined, adopted and implemented effective strategies to address HIV-related TB.
• We will have incorporated DOTS-Plus protocols for MDR-TB into the DOTS strategy.
• We will have an improved TB diagnostic test for use in high-burden countries.
• Five new anti-TB drug candidates will have completed pre-clinical trials.
• There will be at least one TB vaccine candidate in clinical trials to test efficacy.
  These are enormous accomplishments, planned to counter an equally enormous threat to the health, well-being and development of communities throughout the world. We can control TB. With this plan, Stop TB partners around the world are on the way to doing so. But we need
  your help. Come join us in delivering this "splendid gift" to the generations of the Third Millennium-ending this debilitating disease that we have the capacity to cure.

Tuberculosis (TB) kills approximately 2 million people each year. The global epidemic is growing and becoming more dangerous. The breakdown in health services, the spread of HIV/AIDS and the emergence of multidrug-resistant TB are contributing to the worsening impact of this disease.

In 1993, the World Health Organization (WHO) took an unprecedented step and declared tuberculosis a global emergency, so great was the concern about the modern TB epidemic.

It is estimated that between 2002 and 2020, approximately 1000 million people will be newly infected, over 150 million people will get sick, and 36 million will die of TB - if control is not further strengthened.

TB is a contagious disease. Like the common cold, it spreads through the air. Only people who are sick with pulmonary TB are infectious. When infectious people cough, sneeze, talk or spit, they propel TB germs, known as bacilli, into the air. A person needs only to inhale a small number of these to be infected.

Left untreated, each person with active TB will infect on average between 10 and 15 people every year. But people infected with TB will not necessarily get sick with the disease. The immune system 'walls off' the TB bacilli which, protected by a thick waxy coat, can lie dormant for years. When someone's immune system is weakened, the chances of getting sick are greater.

• Someone in the world is newly infected with TB every second.
  
• Nearly 1% of the world's population is newly infected with TB each year.
  
• Overall, one third of the world's population is currently infected with the TB bacillus.
  
• 5-10% of people who are infected with TB (but who are not infected with HIV) become sick or infectious at some time during their life.

Each year, more people are dying of TB. In Eastern Europe and Africa, TB deaths are increasing after almost 40 years of decline. In terms of numbers of cases, the biggest burden of TB is in south-east Asia.

Factors Contributing to the Rise in TB

• TB kills about 2 million people each year (including persons infected with HIV).
  
• More than 8 million people become sick with TB each year.
  
• About 2 million TB cases per year occur in sub-Saharan Africa. This number is rising rapidly as a result of the HIV/AIDS epidemic.
  
• Around 3 million TB cases per year occur in south-east Asia.
  
• Over a quarter of a million TB cases per year occur in Eastern Europe.
  

HIV is accelerating the spread of TB

HIV and TB form a lethal combination, each speeding the other's progress. HIV weakens the immune system. Someone who is HIV-positive and infected with TB is many times more likely to become sick with TB than someone infected with TB who is HIV-negative. TB is a leading cause of death among people who are HIV-positive. It accounts for about 11% of AIDS deaths worldwide. In Africa, HIV is the single most important factor determining the increased incidence of TB in the past 10 years.

Poorly managed TB programmes are threatening to make TB incurable

Until 50 years ago, there were no drugs to cure TB. Now, strains that are resistant to a single drug have been documented in every country surveyed and, what is more, strains of TB resistant to all major anti-TB drugs have emerged. Drug-resistant TB is caused by inconsistent or partial treatment, when patients do not take all their drugs regularly for the required period because they start to feel better, doctors and health workers prescribe the wrong treatment regimens or the drug supply is unreliable. A particularly dangerous form of drug-resistant TB is multidrug-resistant TB (MDR-TB), which is defined as the disease due to TB the two most powerful-bacilli resistant to at least isoniazid and rifampicin anti-TB drugs. Rates of MDR-TB are high in some countries, especially in the former Soviet Union, and threaten TB control efforts.

From a public health perspective, poorly supervised or incomplete treatment of TB is worse than no treatment at all. When people fail to complete standard treatment regimens, or are given the wrong treatment regimen, they may remain infectious. The bacilli in their lungs may develop resistance to anti-TB drugs. People they infect will have the same drug-resistant strain. While drug-resistant TB is treatable, it requires extensive chemotherapy (up to two years of treatment) that is often prohibitively expensive (often more than 100 times more expensive than treatment of drug-susceptible TB), and is also more toxic to patients.

WHO and its international partners have formed the DOTS-Plus Working Group , which is attempting to determine the best possible strategy to manage MDR-TB. One of the goals of DOTS-Plus is to increase access to expensive second-line anti-TB drugs for WHO-approved TB control programmes in low- and middle-income countries.

Movement of people is helping the spread of TB

Global trade and the number of people travelling in aeroplanes have increased dramatically over the past 40 years. In many industrialized countries, at least one-half of TB cases are among foreign-born people. In the United States, nearly 40% of TB cases are among foreign-born people.

The number of refugees and displaced people in the world is also increasing. Untreated TB spreads quickly in crowded refugee camps and shelters. It is difficult to treat mobile populations, as treatment takes at least six months and should ideally be suvervised. As many as 50% of the world's refugees could be infected with TB. As they move, they may spread TB.

Effective TB Control

The WHO-recommended treatment strategy for detection and cure of TB is DOTS. DOTS combines five elements: political commitment, microscopy services, drug supplies, surveillance and monitoring systems and use of highly efficacious regimes with direct observation of treatment.

Once patients with infectious TB (bacilli visible in a sputum smear) have been identified using microscopy services, health and community workers and trained volunteers observe patients swallowing the full course of the correct dosage of anti-TB medicines (treatment lasts six to eight months). The most common anti-TB drugs are isoniazid, rifampicin, pyrazinamide, streptomycin and ethambutol.

Sputum smear testing is repeated after two months, to check progress, and again at the end of treatment. A recording and reporting system documents patients' progress throughout, and the final outcome of treatment.

Since DOTS was introduced on a global scale in 1991, about 10 million patients have received DOTS treatment. In half of China, cure rates among new cases are 96%. In Peru, widespread use of DOTS for more than five years has led to the successful treatment of 91 %of cases and a decline in incidence.

By the end of 2000, all 22 of the highest burden countries which bear 80% of the world's estimated incident cases had adopted DOTS. Fifty-five percent of the global population had access to DOTS, double the fraction reported in 1995. In the same year, 27% of estimated TB patients received treatment under DOTS, two and a half times the fraction reported in 1995.

• DOTS produces cure rates of up to 95% even in the poorest countries.
  
• DOTS prevents new infections by curing infectious patients.
  
• DOTS prevents the development of MDR-TB by ensuring the full course of treatment is followed.
  
• A six-month supply of drugs for DOTS costs as little as US$ 10 per patient in some parts of the world.
  
• The World Bank has ranked the DOTS strategy as one of the "most cost-effective of all health interventions."

WHO targets are to detect 70% of new infectious TB cases and to cure 85% of those detected. Ten countries had achieved these targets in 2000. Governments, nongovernmental organizations and civil society must continue to act to improve TB control if we are to reach these targets worldwide.

India has provided an environment in which tuberculosis can thrive. Because the disease carries a social stigma, many leave treatment too soon, becoming chronic and drug-resistant cases. TB has often been misdiagnosed and treated ineffectively. Drug supplies have been erratic. Against these odds, India today is prepared to fight and defeat TB.

Where TB Has Lurked in the Shadows, New Light Breaks Through

Among the more than 900 million people in India today, every second adult is infected with the tuberculosis bacterium. Each year, more than 2 million people develop active tuberculosis, and up to 500,000 people die. The pool of infection – and the resulting risk of becoming infected with the disease – is as great as in any country on earth.

Tuberculosis carries a heavy stigma, and rejection by neighbors, employers and co-workers is still a fear of TB patients in many communities. Young brides who develop symptoms of tuberculosis could in many cases expect to be returned to their parents as unfit to bear children, their dowries forfeited.

The problems facing effective tuberculosis control in India appear at first glance to be much the same as those that too often exist throughout much of southern Asia. There are real and potential conflicts between the interests of private physicians and the public sector. The quality and supply of drugs is erratic. Errors in diagnosis, based predominantly on X-ray and sometimes symptoms alone, are common. Infectious cases are frequently missed, while other people are mistakenly diagnosed with TB and inappropriately treated. Training, support and supervision of staff is not adequate. In some places, morale among health workers has been low.

As a result, at least two thirds of TB patients have dropped out of treatment early, often becoming chronic sufferers; sources of infection to others. Very often these chronic cases become incubators for deadly drug-resistant bacteria.

Against this outlook pointing to a dark future, India has decided to take decisive action to halt the spread of tuberculosis. The core strategy: shrink the pool of contagion and the risk of becoming infected with the disease by attacking TB aggressively. To date, a strategy consistent with DOTS has been applied in demonstration areas covering over 12 million people. This strategy has achieved a cure rate over 80 percent among detected patients.

In fact, several of the fundamental principles of DOTS were first developed in India. The ability to treat TB patients effectively at home, without the cost and duress of hospitalization, was first tested and documented in India in the 1950s and 60s.

Everyone's Problem

In these pilot areas, staff receive intensive training in the DOTS strategy. Microscopy services for sputum testing are in place; and a new drug supply system procures drugs and supplies high-quality medications.

With this community-based system, health workers watch their patients take and swallow their drugs. This additional responsibility – which might have overwhelmed busy health workers – now serves to raise these health workers' status in their communities and to motivate them to approach this important work with real dedication.

Patients have responded positively in most cases to the DOTS strategy. The personal attention of the DOTS strategy makes them feel cared for. The strategy also shows them that they can be cured of TB without going to a private doctor – who usually charges a fee they can seldom afford and then fails to achieve a real cure. Today, in the pilot DOTS areas, the drop-out rate from treatment has plummeted. Tuberculosis is now cured in 4 out of every 5 patients.

The Challenge of Expansion

The DOTS pilot projects have demonstrated convincingly that supervised short-course treatment can work in India. Some states, like Kerala, have already begun to implement the DOTS strategy in new districts and plan to provide ready access to DOTS treatment for all TB patients within a few years.

With support from the World Bank, the DOTS strategy is now being expanded gradually throughout the country. A first step will be to cover 270 million people in 102 districts during the first five year phase from 1997 to 2002. At the same time, systematic reporting and monitoring of patient outcomes and a regular drug supply system will be set up in preparation for further expansion to the whole population.

As the DOTS treatment network is being built, India must pay close attention to the interests of the private practitioners who have long treated TB patients on a fee basis. It is pivotal to incorporate this key group into the DOTS expansion process, and to provide them a role in tuberculosis control. Practitioners who see DOTS as a financial threat could undermine the programme.

The success of the pilot programmes have shown patients that tuberculosis can be cured, and health workers that their efforts can save lives. Demand for DOTS services has grown and momentum continues to build. No less important, the stigma attached to tuberculosis can now begin to diminish.

2,058,600 new TB cases annually - 82% DOTS cure rate!

Several of the fundamental principles of DOTS were first developed in India. The ability to treat TB patients effectively at home, without the cost and duress of hospitalization, was first tested and documented in India in the 1950s and 60s.

The World Health Organization (WHO) Regional Committee for Africa comprising health ministers from 46 Member States has declared tuberculosis an emergency in the African region - a response to an epidemic that has more than quadrupled the annual number of new TB cases in most African countries since 1990 and is continuing to rise across the continent, killing more than half a million people every year.

The declaration was made in a resolution adopted today at the end of the Committee's fifty-fifth session in Maputo, Mozambique. The resolution urges Member States in the African Region to commit more human and financial resources to strengthen DOTS programmes and scale up collaborative interventions to fight the co-epidemic of TB and HIV. These and other measures recommended by the Committee encompass those laid out in a "blueprint" developed by the global Stop TB Partnership, which calls for US $2.2 billion in new funding for TB control in Africa during 2006-2007.

"Despite commendable efforts by countries and partners to control tuberculosis, impact on incidence has not been significant and the epidemic has now reached unprecedented proportions,” said WHO Regional Director for Africa, Dr. Luis Gomes Sambo. “Urgent and extraordinary actions must be taken, or else the situation will only get worse and the TB targets in the Abuja Declaration and the Millennium Development Goals will not be achieved."

Globally, TB is second only to HIV/AIDS as a cause of illness and death of adults, accounting for nearly nine million cases of active disease and two million deaths every year. Although it has only 11% of the world's population, Africa accounts today for more than a quarter of this global burden with an estimated 2.4 million TB cases and 540,000 TB deaths annually.

In the late 1970s and early 1980s, African countries like Tanzania, Mozambique and Malawi were among the first to apply what became the global TB control strategy now known as DOTS. But in the past 15 years, TB incidence rates have soared in the region - to as high as four-fold in Malawi and five-fold in Kenya, to cite some typical examples -due largely to the link with HIV/AIDS, poverty and weak health systems. Although countries have made efforts to treat the rising tide of TB cases, they are still being outpaced by the epidemic.

"It is tragic that this disease has not been brought under control, because I am living proof that TB can be effectively treated and cured," said Nobel laureate Archbishop Desmond Tutu, who along with former South African President Nelson Mandela is a survivor of the disease. "The problem is huge and medical authorities cannot overcome it alone, they need help. A full course of TB drugs that costs 15 dollars will save the lives of TB patients - and in the case of people who are co-infected with HIV, extend their lives by precious years until ARVs become more widely available in Africa."

Among the constraints to fighting the epidemic cited in the Maputo meeting is the inadequate financial support currently available for TB control. A large majority of African countries that provided financial data to WHO in 2003 reported funding gaps, including eight of the nine countries with the highest TB burden. Many national TB programmes are relying extensively on grants from external donor agencies, including the Global Fund to Fight AIDS, TB and Malaria (GFATM). At the same time, few African countries have included TB in their poverty alleviation strategies.

But more financial resources alone will not solve the TB problem. Dedicated efforts must also be made to strengthen health systems and respond to the crisis of health workforce attrition in the region. The specific actions called for by the Regional Committee to address the TB emergency are:

• improve the quantity and quality of staff involved in TB control;
• rapidly improve TB case detection and treatment success rates with expanded DOTS coverage at national and district levels;
• reduce the combined TB patient default and transfer out rates to 10% or less;
• scale up interventions to manage TB and HIV together, including increased access to anti-retroviral therapy for TB patients who are co-infected with HIV, and to chemoprophylaxis against TB for people with HIV;
• expand national TB partnerships, public-private collaboration and community participation in TB control activities.

In the other four WHO regions of the world, TB trends are either stable or in decline and are on track to reach the MDG targets of halving TB prevalence and deaths by 2015.