Reach the 3 Million

8/12/2019 Reach the 3 Million

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EVERY YEAR 9 MILLION

PEOPLE GET SICK WITH TB.

3 MILLION DON’T GET THE

CARE THEY NEED.

HELP US REACH THEM.

LEAVE NO ONE BEHIND.

HELP ACHIEVE ZERO

DEATHS AND PUT AN END

TO THE GLOBAL

TB EPIDEMIC.



What does missed mean?

“Missed” is the gap between the estimatednumber of people who became ill with TBin a year and the number of people whowere notified to national TB programmes.



In 2012, 8.6 million people fell ill with TB.

More than 1.3 million people died.

Every year 3 million people with

TB are missing out on quality care.

The vast majority of people dying

of TB are missed.

We need to reach them.

Riccardo Venturi,Afghanistan



TB is infectious and spreads through theair. A third of the world’s population hasbeen infected by TB bacteria but onlyone in 10 will fall ill. For those with activeTB, the symptoms may be mild for manymonths, leading to delays in diagnosis andtreatment, while spreading the disease toothers. Most people with TB can be cured

by taking a six-month course of drugs.If treatment is incomplete, TB can comeback, often, in a more resistant form.People with TB also suffer discriminationand stigma, rejection and social isolation.While there has been major progress infighting TB, more needs to be done.

Nearly 22 millionlives have been savedsince 1995. There hasbeen a 45% decrease

in TB deaths since1990. But we need todo more. Now.

Vanessa Vick,Uganda



3

12 countries carry 75% of the burden of missed cases

Vulnerable populations around the globe

South Asiaand Africaaccount fornearly two-thirds of theburden of

missed cases,but peoplewith TB aremissed in allcountries.

The problem

The proportion of missed cases has beennearly the same for the past seven yearsand the number of missed is accumulatingevery year.

Those most vulnerable to falling ill with TBinclude very poor and/or malnourished/undernourished people, people livingwith HIV/AIDS, children and women,contacts of people with TB includinghealth workers, migrants, refugees andinternally displaced persons, minersand mining-affected persons, personswith diabetes, elderly, ethnic minorities,indigenous populations, substance usersand homeless persons.

About 3 million people are “missed” each yearby health systems and many therefore do notget the TB care that they need and deserve.

Many of the missed will die, some will get better,others will continue to infect others.

Carlos Cazalis,Peru



4

Why are they missed?

Weaknesses in recording and reportingwithin public systems.

Non-existent or poor linkages withprivate practitioners, hospitals, labora-tories, or NGO services

Lack of mandatory case notificationby health service providers, or itsenforcement

Limited awareness of TB, as well aswhy and where to seek care

Poverty, marginalization and relatedstigma or discrimination

Limited number and distribution ofhealth facilities

Little community engagement andoutreach

Financial barriers such as user fees,transport and lost income

Conflict or insecurity

People with TB

may not access care

at all

1.

2.

3.

People with TB

may access health services

but are not diagnosed

The reasons are varied, but oftenare related:

For the average patient, half of the costs ofhaving TB are linked to seeking diagnosis– patients spend time and money, withoutgetting proper diagnosis.

This can be due to:

Overburdened and undertrainedhealthcare staff who fail to identify thesymptoms or refer for testing

Diagnostic tests offered are not alwaysthe most accurate and appropriate

Long delays or travel prevent receiptof test results

People with TB

may get diagnosed

but they are not documented

Some people get diagnosed but may notget started on proper treatment or getnotified. The quality of care is unknown.

Underlying barriers include:

Jacob Cresswell,Peru



5

During one of these sessions, Abdul,a three year old child was identifiedas possibly having TB. Abdul’s motherwas supported by outreach workers toget to the local hospital where he wasdiagnosed with TB. Abdul’s grandfatherwho had chronic cough, had died threeyears earlier, when Abdul was 7 monthsold. Abdul’s mother said that she wouldgo to the herbalist of the community orbuy medicine from drug hawkers in the

market.

After receiving proper treatment fromhealth workers, Abdul’s mother wasexcited with the improvement in herchild’s health.

In the North-EasternNigerian state ofAdamawa, lies a

temporary Nomadicsettlement of about200 people that hasno health services.Outreach workersmeet with the nomadic communityleaders and set up opportunities for healthscreening on market days. Samples aretransported to the nearest microscopylabs.

Children account foran estimated half amillion new TB cases

annually and 74, 000deaths (among HIV-negative children).In 2012, only around300, 000 cases werenotified to National TB Programmes. TBin children is often missed or overlookeddue to non-specific symptoms andlimitation of diagnostic tools.

In 2013, a childhood TB roadmap was

launched - Towards Zero Deaths, toimprove the prevention, diagnosis,treatment and care for children with TBand children living in families with TB.The roadmap includes practical actionsthat can be taken today at local, nationaland global levels to make a difference.Tens of thousands of children’s lives couldbe saved if these steps are taken.

Reaching the missed children

with TB

Long path to care

Hard to reach populations

ECDC/Tobias Hofsäss,Romania

Photo credits:

Stephen John, Nigeria (left)Miguel Bernal, Peru (right)



6

Missed out

not missed altogether

Nearly half of the 3 million missed TB casesare in Asia. The majority of these peoplewith TB first go to the private sector, oftenseeking care from multiple providers

in their journey to access TB treatment,such as drug sellers, private practitioners,hospitals etc. When they fall ill, they mustweigh the options of waiting in long linesat overcrowded public clinics where theymay have to pay a user fee or head to alocal private clinic where a doctor can beseen at any time of the day or night andnot miss out on a day’s pay. Unfortunatelythe TB management practices of theseproviders are rarely aligned with nationalor international standards, and they don’tnotify people under their care to nationalhealth systems for lack of information,incentives or tools.

A typical story

from Asia

Hamidah is a low wage worker in theinformal sector. She first tried to self-medicate her cough, then went to alocal clinic where she was seen by anunqualified, unlicensed practitioner.When her condition worsened, a differentprovider referred her to a laboratory fora useless and an expensive blood test. Athird attempt got her a diagnosis of TB,but she had to pay for her medicationsand could not afford to keep buying them.Finally, when her symptoms returned, shereceived free diagnosis and treatmentat a private clinic that was linked to thenational TB programme. Then she finishedtreatment successfully.

Sailendra Kharel,Cambodia



7

TB-HIV

The need to integrate care

In 2012 only 50% of the estimated

1.1 million new casesof people with HIV-related TB werereached globally.

This is of major concern as TB is theleading cause of death among peopleliving with HIV (PLHIV) and untreated TB

in PLHIV can lead to death in weeks.

TB is more difficult to diagnose in PLHIV asthey are more likely to have lower levels ofTB bacteria, making it difficult to identify.The dual stigma associated with TB andHIV, often along with discrimination inhealth care settings, further limits access,particularly among high risk groups suchas people who inject drugs or people witha history of incarceration. Multi-sectoral

engagement, integrated service deliveryand the scale-up of rapid diagnostics inHIV care settings are recommended andcritical to expand access to testing andfull TB/HIV care. Accelerated scale-up ofrapid diagnostic tests is needed. The testis currently recommended as the primarydiagnostic test for TB among PLHIV.

A Crisis

The gap in reaching and

treating those ill with

MDR-TB

Only 1 in 4 people fallingill withMDR-TBare diagnosed.

Worldwide, only 94, 000 of the 450, 000people estimated to have developed

multidrug-resistant TB (MDR-TB) in 2012were detected. The lowest proportionsof new MDR-TB patients reached werein the South-East Asia region (21%) andWestern Pacific Region (6%), though theycarry over 50% of the global burden ofMDR-TB.

While the pace of expansion of MDR-TBdiagnostic testing is increasing, it needsfurther acceleration. Access to quality

treatment is also lagging. Financingof diagnostics and drugs, need to besecured along with a network of well-trained facility-based and communitycare providers. Stronger links betweenthe public and private sectors will helplimit the development of drug-resistanceand enable improved access or referral.

Andrew Reed Weller,Kenya



8

Simple and Effective Solutions

For solutions to be effective and sustainable, actions from grassroots organizations,governments, and the global community are needed. Choosing and prioritizing actionsdepends on the local barriers identified.

Solution 1

Expand access to care

Identify and focus on underserved and vulnerable communities

Improve awareness and education to reduce stigma and increase help-seeking

Expand community-based care and outreach and empower communities

Ensure catastrophic out-of-pocket expenses for seeking and receiving care areeliminated, in keeping with aim of Universal Health Coverage

Increase the number of public, voluntary, private and corporate health facilities thatprovide quality TB care especially in under-served communities

Ethiopia

Community outreach

Myanmar

National response planning

In Ethiopia, rural communities face manyaccess barriers for TB care. A recentpartnership involved training, engagingstakeholders and communities and activecase-finding by female Health ExtensionWorkers (HEWs) who are lay workers

with a small government salary to providebasic services to their communities. HEWsidentified individuals with TB symptomsin their community and also collectedsputum, prepared slides for microscopyand supervised treatment. In a year’stime, TB case notification almost doubledin an area of over 3 million people andtreatment success improved despite theadded workload.

Myanmar has framed a national responseto its heavy burden of missed TB patientsusing evidence. It builds on the foundationof an active national TB programme,development partners, and an invigoratedagenda for universal health coverage. A

recent national survey showed higher TBburden in urban areas, in men, and amongthe elderly. Over 1% of adults tested inurban areas were found to have activeTB disease. Other known risk groupsare PLHIV, TB contacts, persons withdiabetes, prisoners, miners and ethnicminorities. The response builds on theongoing roll-out of new rapid TB tests,and more effective use of chest x-ray forTB screening. It involves hospital out-

patient departments, use of mobile x-rayunits for screening in poor urban areasand selected remote rural areas.

Acknowledging and understanding the problemis the first step.



9

Solution 2

Expand screening and testing

Enable all healthcare providers to better identify patients with TB symptoms forfurther testing.

Perform systematic screening in selected high-risk groups

Improve diagnostic capacity, use of rapid tests, specimen transport and patientreferral systems

Implement or strengthen outreach to the contacts of persons with TB

Develop and enable access to new and better screening and diagnostic tools

Afghanistan

Better screening of peopleattending health facilities

Sometimes people with TB doattend health facilities. However withoverburdened and untrained healthstaff, these people can go unattended.Providing training and systematicscreening of people already attendinghealth facilities can yield impressiveresults. In Afghanistan, staff across 47health facilities were trained in screening,to ensure good sputum collection. In oneyear, these facilities found over 70% morecases than the year before by improvingthe identification of people who shouldbe tested, screening almost one millionpeople in the process.

Moldova and South Africa

New molecular tests canidentify more people with

TB than smear microscopy

Moldova and South Africa, among othercountries are currently working toprovide greater access to Xpert MTB/RIF,a rapid diagnostic test, for all people withTB symptoms. South Africa is currentlythe largest user of Xpert MTB/RIF in the

world. There has been a dramatic increasein the numbers of people diagnosed andput on treatment for drug resistant TB.Moldova has been able to identify peoplewith TB more quickly. Almost twice asmany people with TB were detected byXpert than by smear microscopy.

Riccardo Venturi,Afghanistan



10

Pakistan

Engaging private providers

India and The Philippines

Engaging with big hospitals

can bring big gains

China

Strengthening surveillance

systems to improve

notifications

In many countries, a large proportionof healthcare is provided through theprivate sector where they have to pay fordrugs and may receive substandard care.A systematic situation assessment helpedPakistan. Its multi-pronged approachincluded not only investing in public-private mix – the public sector supportingprivate sector to contribute to TB careand control, but also a private-privatemix through the promotion of social

franchising and social business models.Currently, every fourth case is notified byengaging the private sector. A particularlyimpressive initiative provides a mix of anincentive-based system to community layworkers who act as screeners using mobilephones in a large number of small generalpractitioner facilities and a large hospital.It also involves mass media campaigns,and a sputum transport network. Asa result, case notifications from the

reporting unit in Karachi doubled and itbecame the second largest contributingunit in Pakistan in one year. In the secondyear – the same approach was expandedto a second area of the city with equallyimpressive results.

In many countries, major hospitals in bigcities, serve people who seek care andhave signs and symptoms of TB. Efforts byNational TB Programmes to build linkages

In China, the National TB Programmeprovides services principally through a

network of TB dispensaries. Yet, a largenumber of people with TB symptomsseek care from hospitals, although thesefacilities cannot always enable continuityof care during a full course of TB treatment.Until a decade ago, hospitals were notreferring patients to dispensaries, so,many patients were “missed”. In 2004, in response to the SARS (severeacute respiratory syndrome) epidemic, the

government established a national web-based system for mandatory reportingof 37 infectious diseases, including TB,within 24 hours of diagnosis. With thisstimulus, hospitals now contribute nearly40% of TB notifications in China.

Solution 3

Improve information flow for quality care

Expand linkages that enable all those who can screen, test, diagnose or treat TB toeffectively communicate and serve patients

Strengthen TB recording and reporting systems so that data on all patients tested anddiagnosed by all care providers within and outside TB programmes is available andused effectively.

Implement mandatory TB case notification systems along with tools and/or incentivesthat promote notification of all TB cases while maintaining patient confidentiality

with these institutions have enabledimproved use of national standards ofcare, information exchange and patient

referrals closer to home for treatmentfollow up and support after diagnosis.In the Philippines, streamlining hospitalTB clinics in Manila, increased casenotifications by over 13, 000. The modelis now being replicated and scaled upnationwide. In India, national and regionaltask forces set up to involve all publicand private medical college hospitals,with related financial aid for operatinghospital-based TB clinics, have helpedcontribute up to 15 percent of nationalcase reporting from these facilities.



11

Examples from different countries show that modest investments can yield significant resultsin finding and treating people among hard to reach populations.

Small interventions

can have big impacts for

vulnerable groups

In Karachi, Pakistan, community healthworkers are using electronic scorecardson mobile phones to identify peoplethat need a TB test. At a low cost, healthworkers identified six times the numberof cases of childhood TB compared toprevious years.

In the remote villages of Lesotho, healthworkers on horseback reached out tocommunities which previously had littleor no access to healthcare. The healthworkers pick up samples from villagersand take them to laboratories foranalysis. The test results are reported viatext messages and people with TB areprovided with life-saving drugs.

The World Bank estimates that eachdollar invested in TB yields US$ 30 inreturn, making it great value for money.We need to invest more to find and treat the

missed 3 million.

In Mbeya, Tanzania, a mobile laboratoryoffers a rapid diagnostic test (Xpert) andHIV testing in rural areas. The van servesas a test centre during the day and amobile cinema with educational films atnight. Other countries that have adoptedthis approach include Zimbabwe andCambodia.

In London, UK, where TB rates areamong the highest in Western Europe,an outreach program using mobile digitalx-ray units helps homeless people, drugor alcohol users, vulnerable migrants,and people who have been in prison, toaccess TB care. The team includes former

TB patients, health and social workers.Leading evaluating agencies in the UKhave assessed the program to be highlycost-effective and suggest it could evensave costs.

Samuel George Nuttall,Lesotho



12

Ongoing massive number of fully-preventable deaths

Risk of disease transmission: onepatient can infect up to 10 people ayear

Catastrophic costs to patients;grave burden for health systems andeconomy

Increasing risk of drug resistance

There are major health security andeconomic consequences of failure to actnow:

Cost of TB care vs. MDR-TB care

The promise

of new tools

The cost

of inaction

The opportunityof new strategic plans

and Global Fund’s

new funding model

Given recent advances in moleculartechnologies, research interest in TBdiagnostics is at an all-time high. Morethan 50 companies are currently involved

in developing new TB tests including foruse at point-of-care. Research pipelinesfor new drugs and vaccines are alsounder progress. However, bottlenecksin financing are slowing basic science,diagnostics, drugs and vaccine research.Less than a third of the US$ 2 billionneeded for TB research and development,is currently available.

Reaching the unreached with TB care isat the heart of national efforts moving to2015 and beyond. Many countries in allregions are working on new national TBstrategic plans and setting new targetsfor driving down deaths and cases. Allof this depends on fast progress towardsuniversal access to care and engagingnew partners. These plans aim toprioritize interventions, leverage best useof domestic resources, and lay out thefinancing gaps for TB control. The GlobalFund has a new funding model whichseeks to help countries fill those gaps,along with bilateral and other sources.The focus is on meeting the needs of the

most vulnerable in high-disease burdensettings. Inclusive country dialogue andprioritization interventions for impact arefundamental to the new funding model,and to finding the missed 3 million.

South Africa

Myanmar

TB MDR-TB

MDR-TBTB

10 000

$

8 000

$

600

$

170

$



13

Fill the current funding gap of US$ 2 billion per year for TB interventions

Fill the US$ 1.39 billion annual gap for research and development

Eliminate access barriers to all recommended TB diagnostics and drugs

Address TB and MDR-TB as global health security threats

Support the post-2015 global strategy for TB, and a global plan to end the globalTB epidemic.

Priorities for action on TB

Reaching the missed 3 million each year is one

element of the wider effort to reach the 2015target of halving TB deaths.

Governments, civil society, health and development partners, and researchers can:

Jacob Cresswell,Ethiopia



14

Samuel George Nuttall,Lesotho



15

REACH

THE

3 MILLION





Cover photo credits (left to right):

Vanessa Vick, UgandaJacob Cresswell, MyanmarDavid Rochkind, India

The designations employed and thepresentation of the material in thispublication do not imply the expressionof any opinion whatsoever on thepart of the World Health Organizationconcerning the legal status of any country,territory, city or area or of its authorities,or concerning the delimitation of itsfrontiers or boundaries. Dotted lines onmaps represent approximate borderlines for which there may not yet be fullagreement. Stop TB Partnershipwww.stoptb.org

World Health OrganizationGlobal TB Programmewww.who.int/tb 20, Avenue AppiaCH-1211 Geneva 27

© World Health Organization 2014

Printed by theWHO Document Production Services

Geneva, Switzerland

Designed by Tashira MuqtadaThe Bright Sunwww.thebrightsun.com



Reach the 3 million.

Find. Treat. Cure TB.

FIND

Every year 3 million

people with TB aremissed. Failure to

reach the missed has

devastating human,

health and economic

consequences.

TREAT

A person with TB infectsabout 10 people in a year.

Without treatment, half of

the people with TB die.

CURE

With urgent action and

increased investment,

we can cure the missed3 million and ensure we

leave no one behind.

ACCESS TO

TUBERCULOSIS CAREIS A RIGHT.

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Reach the 3 Million