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Global funding for infectious diseases: TB or not TB? Editorial
  The Lancet 22 October 2011

WHO's sixteenth annual report on global tuberculosis control, released on Oct 11, presents detailed and encouraging statistics, carefully interwoven with words of caution about the perils of failing to maintain disease-specific funding. Taking a global view, the numbers are undoubtedly sobering, with 8·8 million new cases of tuberculosis estimated in 2010, and about 1·45 million deaths from tuberculosis across populations with and without HIV. In 2009, 9·7 million children are thought to have been orphaned by parental deaths caused by tuberculosis (whether or not accompanied by HIV). The good news is that incidence of tuberculosis seems to have been falling worldwide since 2002.

Impressive falls in tuberculosis mortality have been achieved in various countries and regions, including Uganda, Tanzania, Cambodia, and the Americas. But the most striking achievements are in China, where in the period 1990-2010 prevalence of tuberculosis infection is reported to have halved and mortality reduced by 78%. Underpinning confidence in the new findings, mortality estimates in the WHO report have been based on greatly improved methods compared with previous iterations, including vital registration data from 91 countries and direct measurements from India and China.

The success in China has been based on sustained efforts that have progressively achieved coverage of the country's vast population by tuberculosis treatment and surveillance. Initially supported in part by a US$58 million loan from the World Bank in the early 1990s, algorithmic directly observed treatment (DOTS) was expanded from 13 of China's 31 provinces to nationwide coverage. Subsequent improvements in infectious disease surveillance systems have led to mortality estimates suggesting that deaths from tuberculosis have fallen by 8·6% per year during the past 20 years.

National successes in tuberculosis control are unfortunately balanced by serious challenges. In Africa, some 39% of the 2·3 million people diagnosed with tuberculosis in 2010 were carriers of HIV. Globally, despite efforts to increase coverage with proven antiretroviral drugs, fewer than half of the people with tuberculosis and HIV are receiving this treatment. In a disease for which innovations in drug treatment have been few in recent decades, there were estimated to be about 290 000 cases of multidrug-resistant tuberculosis in 2010. This form of tuberculosis is difficult to diagnose and treat, and the quoted figures are probably underestimates. Only 16% of patients with multidrug-resistant tuberculosis are thought to be undergoing treatment.

Donor funding of about $600 million for tuberculosis control is expected in 2012, which Lucica Ditiu, executive secretary of the Stop TB Partnership, argues is "completely inadequate and almost $1·5 billion short, when you consider that the funding gap for meeting the 2012 implementation targets of the Global Plan to Stop TB remains $2 billion." Although more than 80% of this donor funding is provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria, comparative figures for malaria ($1·8 billion in 2009) and HIV/AIDS ($6·9 billion in 2010) suggest that tuberculosis programmes have struggled to attract external support. Across the 22 countries with high burdens of tuberculosis, domestic money will contribute about 87% of future funding, reflecting growing but uneven economic success-and emphasising the continued imperative for targeted funding for tuberculosis activities in high-burden countries.

What of future prospects for improvements in disease diagnosis and treatment? WHO has endorsed Xpert MTB/RIF, a rapid diagnostic test for Mycobacterium tuberculosis that is currently being rolled out. Although existing drug treatments for tuberculosis are cumbersome and protracted, especially in multidrug-resistant disease, several drug candidates are in development. Substitutions of rifapentine, gatifloxacin, or moxifloxacin into existing regimens have advanced to phase 3 trials, while the new agents bedaquiline and delamanid are undergoing phase 2b trials in multidrug-resistant tuberculosis. Of the candidates for new vaccines against tuberculosis to supersede or provide an alternative to BCG, the most advanced are three vaccines in phase 2b trials, which implies that no new vaccine can be licensed before 2018.

In a Comment in today's Lancet, Salmaan Keshavjee and colleagues call for a startling global target of zero deaths from tuberculosis. Successes in disease control in China and other countries show what sustained political and economic support can achieve. Rather than waiting for the elixir of economic success to arrive in all high-burden countries, committed action by donors, agencies, and governments in the most challenging settings is needed in the global campaign against tuberculosis.

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