MATTERS OF PUBLIC INTEREST;World Tuberculosis Day – 23 Mar 2011

I rise today to speak about tuberculosis, known as TB, and the impact that it has on society. World Tuberculosis Day is marked annually on 24 March, tomorrow, to commemorate the day in 1882 when Dr Robert Koch announced that he had discovered the cause of tuberculosis—a bacterium called Mycobacterium tuberculosis. World TB Day is intended to build public awareness that tuberculosis remains an epidemic in much of the world, with the World Health Organisation, WHO, declaring TB a global emergency in 1993.

The World Health Organisation estimates that in 2009 there were 9.4 million new infections and approximately 1.7 million deaths, occurring mostly in developing countries. For those who do not know much about TB, it is an infectious airborne disease. Only people who are sick with TB in their lungs are infectious or otherwise known as having active TB. 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. The World Health Organisation estimates that if left untreated each person with active TB disease will infect, on average, between 10 and 15 people every year. People infected with TB bacilli will not necessarily become sick with the disease. The immune system walls off the TB bacilli, which, protected by a thick waxy coat, can lie dormant for years. This is known as latent TB infection. However, when someone’s immune system is weakened, as in HIV-positive individuals, this may progress to active TB.

According to the National Foundation for Infectious Diseases, one-third of the world’s population is infected with TB and five to 10 per cent of these people will develop the disease at some time in their life. The sad thing about this is that TB is preventable and curable. Its effects on both morbidity and mortality can be significantly reduced with appropriate action. For example, as a result of improved TB control efforts between 1995 and 2009 a total of 41 million TB patients were successfully treated in directly observed treatment short-courses, or DOTS programs, and up to six million lives were saved, including two million women and children. This highlights the need for continued support and funding for TB programs worldwide.

According to the Centres for Disease Control and Prevention, intervention options to control TB include preventing infection by means of vaccination—that is, a live vaccine, but it is not always effective—and treating latent infections and active disease. DOTS refers to the short-course chemotherapy available to treat and cure TB and is the internationally recommended strategy for TB control that has been recognised as a highly efficient and cost-effective strategy.

A course of drugs for standard TB can cost as little as $20. Multidrug-resistant TB, or MDR-TB, poses further problems for TB control as this fails to respond to standard first-line drugs. While generally treatable, it requires extensive chemotherapy—that can be up to two years of treatment—with second-line anti-TB drugs, which are more costly than first-line drugs. The adverse drug reactions produced by second-line anti-TB drugs are more severe but are manageable. The cost of drugs alone for treating the average MDR-TB patient is 50 to 200 times higher than for treating a patient with drug susceptible TB. The overall costs for care have been found to be 10 times higher or more. Extensively drug resistant TB, which is known as XDR-TB, occurs when resistance to second-line drugs develops on top of MDR-TB. Because XDR-TB is resistant to first- and second-line drugs, treatment options are seriously limited, thus posing a serious threat to TB control, particularly in settings where people are also infected with HIV.

The serious nature of XDR-TB in those infected by HIV was displayed by the mortality rates in a cluster of individuals diagnosed with XDR-TB in Natal, South Africa, in 2006. Of the 544 patients studied, 221 had MDR-TB with 53 of these cases defined as XDR-TB. Of these 53 patients, 44 had been tested for HIV and all were HIV-positive. Fifty-two of the 53 patients died within an average of 25 days, including those benefiting from antiretroviral drugs. The emergence of both MDR-TB and XDR-TB highlights the potential consequences of failure to adequately diagnose and provide effective initial treatment of TB, thereby confirming the urgent need to strengthen basic TB control.

According to the World Health Organisation, an estimated 1.7 million people died from TB in 2009, including 380,000 women. The highest number of deaths was in the African region. The World Health Organisation estimates that the largest number of new TB cases in 2008 occurred in the South-East Asia region, which accounted for 35 per cent of incident cases globally. However, the estimated incidence in sub-Saharan Africa is nearly twice that of the South-East Asia region.

The estimates of the global burden of disease caused by TB in 2009 are as follows: 9.4 million incident cases—that is, new infections; 14 million prevalent cases; 1.3 million deaths among HIV-negative people; and 380,000 deaths among HIV-positive people. Most cases were in the South-East Asian, African and western Pacific regions—35 per cent, 30 per cent and 20 per cent respectively. An estimated 11 to 13 per cent of incident cases were HIV-positive. The African region accounted for approximately 80 per cent of these cases.

HIV and TB form a lethal combination, each speeding the other’s progress. HIV weakens the immune system. TB is a leading cause of death among people who are HIV-positive, as I have already mentioned. In Africa, HIV is the single most important factor contributing to the increase in the incidence of TB since 1990. TB is the leading cause of death in people who are HIV-positive, with one in four affected by HIV-AIDS dying from TB. Without proper treatment, 90 per cent of people living with HIV-AIDS who with access to antiretroviral therapy could otherwise lead relatively healthy lives die within months of developing TB. Despite this, only 4.1 per cent of people living with HIV-AIDS are regularly screened for TB. There is a dual epidemic of TB and HIV. Therefore, collaboration between TB and HIV-AIDS programs is necessary in order to reduce the burden of TB among people living with HIV-AIDS and to reduce the burden of HIV among TB patients.

TB is now the third leading cause of death among women aged 15 to 44, killing some 700,000 women every year and causing illness in millions more. In 2008, 700,000 women died of TB, including 200,000 women living with HIV, while 3.6 million women fell sick with active TB. TB is a leading cause of ‘healthy years lost’ for women of reproductive age. Gender roles and norms in many societies affect a woman’s ability to access health information and services and to obtain appropriate treatment. These statistics clearly show that TB is a major women’s health issue, with particularly serious implications for women living with HIV.

The Gillard government’s $210 million pledge to the Global Fund to Fight AIDS, Tuberculosis and Malaria represents a 55 per cent increase on Australia’s previous commitment. This shows that the government is committed to this important global health issue. I am pleased to be part of the Gillard government, which has initiated an innovative funding arrangement to combat TB in Indonesia—that is, the Debt2Health swap through the global fund. The Debt2Health swap with the government of Indonesia will cancel debt owed by Indonesia to Australia in parallel with increased Indonesian government investment in programs combating tuberculosis.

The reduction and control of tuberculosis is an international health priority under Millennium Development Goal 6. It is also a national health priority for the Indonesian government, with tuberculosis one of Indonesia’s leading health burdens. The initiative will cancel up to $75 million in debt over six years owed by Indonesia to Australia. At the same time, the Indonesian government is expected to invest $37.5 million in the Global Fund to Fight AIDS, Tuberculosis and Malaria for approved tuberculosis programs.

There is an important new weapon in the fight against TB, and that is the Xpert diagnostic technology. It is fast, accurate, easy to use and has been endorsed by the World Health Organisation. This test could revolutionise TB care and control by providing an accurate diagnosis for many patients in about 100 minutes, compared to current tests that can take up to three months to have results. Many countries still rely principally on sputum smear microscopy, a diagnostic method that was developed over a century ago. But this new ‘while you wait’ test incorporates modern DNA technology that can be used outside of conventional laboratories. It also benefits from being fully automated and therefore easy and safe to use. Evidence to date indicates that implementation of this test could result in a threefold increase in the diagnosis of patients with drug-resistant TB and a doubling in the number of HIV associated TB cases diagnosed in areas with high rates of TB and HIV.

Dr Giorgio Roscigno, the Chief Executive Officer of the Foundation for Innovative New Diagnostics, has said of this test:

For the first time in TB control, we are enabling access to state-of-the-art technology simultaneously in low, middle and high income countries. The technology also allows testing of other diseases, which should further increase efficiency.

While testing methods are improving, there is currently no effective vaccine for TB. The TuBerculosis Vaccine Initiative, TBVI, is an independent non-profit foundation that facilitates the development of new vaccines to protect future generations against tuberculosis. Research conducted by the mostly European based network has already resulted in promising vaccine discoveries.

New vaccines are urgently needed to stop tuberculosis. Every year around nine million new cases of this infectious disease are recorded. Investment in more effective tuberculosis vaccines is predicted to result in cost savings and a reduction in TB related deaths. Collaboration and funding are some of the major requirements for delivering new, more effective and safer vaccines against tuberculosis. Research shows that the introduction of a new vaccine could reduce the number of new TB cases by 90 per cent within 30 to 40 years. This makes the development of vaccines an essential part of the global strategy to stop TB.

The Gillard government are committed to health on an international level. We are committed to working with other nations to help those countries most at risk of terrible diseases such as TB. I would urge all members of the Senate and the House to recognise that 24 March is World Tuberculosis Day, as I mentioned in the beginning, in observance of the disease that still unfortunately claims the lives of 1.7 million people every year.