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Ahead of WHO meeting, experts clash over tuberculosis targets

The deadline for the 2015 Millennium Development Goals (MDGs) is fast approaching, and global governance bodies including the World Health Organization (WHO) are already busy discussing what they might propose for the list of new aims going forward. Tuberculosis was named within goal number 6 in the initial set of MDGs, a set of international developmental targets established by the UN 13 years ago, but the objective was to simply reduce its global incidence. So, as health officials take stock of targets, the tuberculosis community is itching to get its goals included with more definition in the post-2015 development agenda.

They will meet to discuss a consensus on the appropriate post-2015 tuberculosis goals at a two-day meeting, sponsored by the WHO, taking place in Geneva beginning 7 February. “My aim is to reach a consensus right now,” says Mario Raviglione, director of the WHO's Stop TB Department in Geneva. “If we wait, we may miss the train.”

The gathering will be tense. Although the stakeholders all hope to eliminate the pulmonary disease that kills about 1.4 million people worldwide each year, they disagree about what the next ten-year objective should be. One possible target, says Raviglione, would be to cut the projected 2015 annual deaths in half by 2025. The aim echoes Stop TB's earlier goal of a 50% mortality reduction by 2015 from 1990 baseline numbers, which piggybacked on the MDGs.

Although the global numbers are on track to meet Stop TB's 2015 objective, the incidence of tuberculosis is not coming down in certain regions. For example, Eastern Europe and Africa will probably not have halved their mortality rates by the 2015 deadline. To reduce tuberculosis deaths by 50% in the next ten years, the incidence of the disease must decline three times as quickly and the percentage of tuberculosis patients who die from the disease must drop from 16% to 10%. Experts say that progress will require better drugs—only half of patients with drug-resistant tuberculosis are currently cured with the options available—and countries plagued by HIV will have to scale up antiretroviral treatments to protect these particularly vulnerable populations from active tuberculosis.

Spot the difference: Diagnostics tubes in a Tanzania clinic show the need for updating tools. Credit: Amy Maxmen

Shots on goal

Raviglione calls a 50% target feasible yet challenging enough to drive change, given the imperfect tools to prevent, diagnose and treat tuberculosis that currently exist. But some of his contemporaries say that the 50% target will not inspire sufficient action and enthusiasm. “As usual, [health officials] are suffering from a lack of ambition that has marred the fight against tuberculosis all along,” says Mark Harrington, director of Treatment Action Group, an advocacy organization in New York fighting for better treatment of HIV, hepatitis C and tuberculosis. Having been an activist in the early days of HIV, Harrington has seen the progress catalyzed by lofty—but motivating—goals set by the AIDS community, such as the section of MDG goal number 6 that shot for universal access to HIV treatment by 2010. Harrington says that although some people still go without, the objective resulted in a massive scale-up in antiretrovirals, which now reach more than 8 million people per year. “Aspirational goals are better because you need to try harder to get there,” he says.

Even Lucica Ditiu, executive secretary of the Stop TB Partnership—an international group of partners who operate through the Stop TB Department—backs a push for more ambitious targets. She claims that a death reduction of 80% by 2025 would be possible if disease models factor in upcoming changes expected in this decade, including universal access to tuberculosis care, more convenient diagnostics, faster-acting drugs and vaccines against the disease.

The tuberculosis drug Sirturo (bedaquiline) hit the US market in late December, and analysts expect another, delamanid, to gain regulatory approval in the EU this year. However, both are reserved for drug-resistant tuberculosis, which accounts for just 5% of new cases. And, optimistically speaking, the approval date for two leading tuberculosis vaccines now in mid-stage clinical trials is 2021 at the earliest, according to some in the field.

Without better tools, a mortality decline above 50% by 2025 cannot be reached, says Kari Stoever, head of external affairs at Aeras, a product development organization in Rockville, Maryland, with several tuberculosis vaccines in development. As such, she says that the 2025 goals should focus on research and development targets rather than mortality figures. Greater money flowing toward these medical options will drive a more sustainable and profound decline in tuberculosis.

Alan Klein, head of corporate development at Sequella, a small pharmaceutical company in Rockville with a new tuberculosis drug in phase 2/3 clinical trials, says that a mortality-based target does not matter much to their sales or investment in research and development. “We're a for-profit company, and we think there is a commercial market for tuberculosis,” Klein says.

Whatever goal is set, it must be realistic, stresses Raviglione. “Zero deaths by 2025 sounds great,” he says. “But we would be ridiculed later when deaths decline slowly, and we would risk losing the backing of political people and donors.”

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Maxmen, A. Ahead of WHO meeting, experts clash over tuberculosis targets. Nat Med 19, 115 (2013). https://doi.org/10.1038/nm0213-115

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