H5N1

Major donor nixes effort to combat tuberculosis crisis in North Korea

Via Science: Major donor nixes effort to combat tuberculosis crisis in North Korea. Excerpt:

By all accounts, malaria control efforts in North Korea have been a clear success. Cases have fallen from 13,500 in 2010 to 2719 in 2016. The Global Fund has provided enough mosquito nets and antimalarial drugs to see the country through the 2018 malaria season, says spokesperson Seth Faison, who is based in Geneva. 

But TB remains a stubborn and worsening problem. A quarter-century ago, North Korea’s TB prevalence—around 50 cases per 100,000 people—was approximately one-third of South Korea’s. But after a severe, prolonged famine in the North in the mid-1990s, the TB bacterium spread rapidly among malnourished survivors. According to WHO, North Korea’s TB incidence, or number of new cases, per 100,000 people shot up from under 200 in 2000 to 513 in 2016 (global incidence in 2016 was 140). An MPH survey carried out in 2015 and 2016—which outside experts laud for its rigor—pegged North Korea’s TB prevalence, or total cases, at 640 per 100,000 people. 

Most North Korean TB patients now under medical care are taking drugs purchased under Global Fund grants. The Eugene Bell Foundation is providing drugs to treat about 1200 North Koreans with multidrug resistant (MDR) TB each year. That represents about 10% to 15% of each year’s new MDR cases, Seung says. MPH had proposed carrying out a drug-resistance survey in the next tranche of money from the Global Fund, he says, but that won’t happen now. 

In announcing its decision last February to end grants to the Democratic People’s Republic of Korea (DPRK)the Global Fund cited its concern that the country’s “unique operating environment” prevented the group from providing “the required level of assurance and risk management” for its grants. 

Humanitarian groups and medical researchers criticized the decision in letters to The Lancet and in other forums. They implored the Global Fund to reconsider, noting that transparency concerns and challenging operating environments exist in many countries with high TB burdens. The Global Fund “has not modified its decision” to close the grants, Faison says. However, he says, “We hope to re-engage with DPRK when the operating environment allows the access and oversight required.”  

Still, “the public outcry did have an effect,” Park says. The Global Fund recently agreed to allow leftover funds from its North Korea grants to be spent on a buffer stock of medications and diagnostics “sufficient to provide for continued treatment for TB patients [through] June 2019,” Faison says. There appear to be enough drugs on hand not only to treat existing patients, but also to enroll new patients through December, Park says. 

“The hope is that will buy enough time” to find a successor to the Global Fund, says Heidi Linton, executive director of Christian Friends of Korea, a nonprofit in Black Mountain, North Carolina, that a few years ago helped establish a National Tuberculosis Reference Laboratory in Pyongyang.

Migrants and refugees: Out of the frying pan and into the fire

Via The Lancet Infectious Diseases, a comment: Out of the frying pan and into the fire. Excerpt:

In 2017, the total number of international migrants worldwide reached about a quarter of a billion people. Over the past 2 years, all eyes have focused on Europe, with more than 1 million new immigrants estimated to have arrived, including about 7500 migrants and refugees entering by sea alone in the first 5 weeks of 2018. The main ports of entry of these migrants were Italy, Greece, and Spain; three countries with high rates of antibiotic resistance to common bacterial infections. 

In their systematic review and meta-analysis published in The Lancet Infectious Diseases, Laura B Nellums and colleagues show that, although pooled prevalence rates for antibiotic resistant bacteria (meticillin-resistant Staphylococcus aureus and multidrug-resistant Gram-negative bacteria) were high, resistance was mostly acquired during transit or in high-migrant community settings in Europe, rather than from the migrants' countries of origin.  

There is growing evidence that travel results in an increased risk of a person being colonised with an antibiotic-resistant bacterium. For non-migrant travellers, the risk is greatest in countries with the highest rates of antibiotic resistance, predominantly India and other countries in south and southeast Asia. Nellums and colleagues suggest that, for migrants, their migration route or final destination might confer an equal risk. 

In a world of blame, migrants have been targets for everything from the economic instability of their host country or region to the health of those populations. However, this systematic review showed that there was no significant dissemination of resistance from migrants to local populations; the reasons for which might be multifactorial. Major factors are likely to be the short duration of colonisation once an antibiotic-resistant bacterium has been acquired6 and segregation of migrants from the local population in high-density community settings, such as camps, transit centres, or detention facilities.  

How should we protect migrants to any country from acquiring and becoming infected with a multidrug-resistant bacterium? Admirable national action plans to reduce antibiotic resistance need to be converted into concrete actions with even more solid funding behind them. Only then will society begin to benefit from infection prevention and antibiotic stewardship interventions in humans and animals that can reduce the use of antibiotics, the major driver of resistance, and make our countries safer for all. 

Notably, this systematic review highlights the need to continue to expand our focus from interventions implemented through health-care settings (such as hospitals) to those that will have a major effect on communities, including migrants in community settings (such as refugee camps). 

If high-migrant communities are a risk factor for the spread of antibiotic-resistant bacteria, proper hand hygiene and other measures that prevent infection should be implemented, and those involved in planning for migrant services need to shorten the period of stay in such settings. Nellums and colleagues showed that refugees and asylum seekers were more likely to be colonised by antibiotic-resistant bacteria than those who migrated for economic, family, and other reasons. 

Although their systematic review and meta-analysis did not evaluate the duration of stay of different categories of migrants, asylum seekers are often kept in such settings for prolonged periods while they await integration into their host country or resettlement in a third-party country. In 2016, less than 1% of the 17·2 million worldwide refugees of concern to the UN High Commissioner for Refugees, were resettled. 

The reduction of waiting times to settlement might be an important factor not only in how successfully asylum seekers and refugees integrate economically into their host country, but also on the wider health issues of migrants, including the threat of acquiring multidrug-resistant infections.

The bugs are winning

Via The New York Review of Books, a review of Superbugs: An Arms Race Against Bacteria, by William Hall, Anthony McDonnell, and Jim O'Neill: The Bugs Are Winning. Excerpt:

Superbugs only briefly reviews the science of bacterial resistance; its focus is on the societal consequences. While there are no exact data on the total number of people dying each year from resistant microbes, the authors calculate it to be at least 1.5 million. This number outstrips deaths from road accidents (1.2 million) and approximates the number of deaths from diabetes (1.5 million).

The economic burden on our health care systems is considerable. People with resistant infections spend more time in the hospital, require more care from doctors and nurses, are treated with more expensive drugs, and often have to be isolated from other patients. In the United States, it costs an average of $16,000 to treat a patient with Staphylococcus aureus that is susceptible to the antibiotic methicillin, with an 11.5 percent chance of death; if the bacteria are resistant, the cost jumps to $35,000 and the chance of the patient dying more than doubles. A study from the European Medicines Agency in the European Union, which includes England, estimated the cost to EU health care systems at €900 million ($1.06 billion). 

The impact of bacterial resistance on economic productivity is also significant. The Centers for Disease Control and Prevention in the United States have estimated that resistance costs the American health care system about $20 billion per year, to which productivity losses add a further $35 billion. Using the American estimates, the authors of Superbugs extrapolate the total costs of antimicrobial resistance worldwide to about $57 billion for health systems, with the reduction in world productivity valued at $174 billion. 

Based on these economic calculations, Superbugs provides a set of policy prescriptions, framed in pragmatic terms meant to motivate self-interested politicians:  

"Governments might not want to invest in solutions, but they will ultimately pay either way. Any money not spent now will result in substantial costs in the future—not to mention many lost lives. Serious damage to economic productivity (which by extension threatens governments’ tax incomes) coupled with the higher costs of health care (which is largely government funded) should provide the impetus to deal with this crisis now."

Out of Breath: MDR-TB in North Korea

Via The Lancet Respiratory Medicine, a film review: Out of Breath. Excerpt:

North Koreans know the period from 1994 to 1998 as the arduous march. It was one of the most devastating famines in history. Some estimates put the death toll at 3 million, out of a total population of 23 million. Horrific tales of deprivation emerged from the country: entire families subsisting on tree bark and rice roots. And as malnutrition took hold, so did a tuberculosis epidemic that required a response beyond the capacity of the struggling socialist republic.  

Food shortages are still a fact of life in North Korea, leaving the enervated population susceptible to disease. In 2016, the nation reported around 120 000 cases of tuberculosis. Notifications for multidrug-resistant tuberculosis hover at around 4600 cases per year, although it would not come as a surprise if the actual burden was nearer 10 000. 

The Global Fund to Fight AIDS, Tuberculosis and Malaria recently announced its intention to withdraw from North Korea. The national tuberculosis programme is heavily reliant on the fund. The decision has raised fears that the country will see sharp rises in multidrug-resistant tuberculosis. 

Meanwhile, western foreign policy focuses exclusively on persuading North Korea to give up its nuclear programme. A wide range of tough economic sanctions have been applied and tightened. The US administration is determined to exert as much pressure as possible on the North Korean regime. The well-padded Supreme Leader Kim Jong-un inherited the dictatorship from Kim Jong-il (1941–2011), whose catastrophic policies were responsible for the 1990s' famine. He shares his father's distrust for outsiders and obsession with nuclear weaponry.  

All of this means that foreign aid agencies and non-governmental organisations are absent from North Korea. But there is one notable exception. For the past decade or so, the Eugene Bell Foundation has been providing treatment for multidrug-resistant tuberculosis. The US–South Korean partnership operates a dozen centres in North Korea, treating around 1000 patients every year. Cure rates exceed 70%, compared with a global average of roughly 50%. Out of Breath, which is scheduled to screen on UK and Australian television later this year, outlines the foundation's activities. 

It is a fascinating insight into the intricacies of operating in the mysterious and misunderstood nation. “I would not do this project. I would not have done this project, and if I was asked to do this project now, I would refuse. It is impossible”, opines KJ Seung, medical director at Eugene Bell. 

And yet they manage. Despite the difficulties associated with raising funds for a state widely considered to be an international pariah. Despite the interminable journey from South Korea to Pyongyang, which necessitates travelling via China. Despite the sanctions and export strictures: at one point, the team in South Korea have to remove an X-ray machine from a shipment. Despite lacking a reliable electricity supply, running water, or continuous paved roads; the journey to one treatment centre is likened to being in a washing machine. 

The team visit North Korea every 6 months. In the interim, they have no contact with the treatment centres, meaning that each expedition has to be meticulously planned, particularly in terms of resupply. The North Korean equipment is ageing and unreliable; we see one device labelled “made in Czechoslovakia”. When there are malfunctions, the team have to do the repairs themselves. Jung Chul, a fresh-faced North Korean tuberculosis specialist, turns out to be something of a mechanical whizz.

Prevalence of drug-resistant tuberculosis and imputed burden in South Africa

Via The Lancet Infectious Diseases: Prevalence of drug-resistant tuberculosis and imputed burden in South Africa: a national and sub-national cross-sectional survey. The summary:

Background 

Globally, per-capita, South Africa reports a disproportionately high number of cases of multidrug-resistant (MDR) tuberculosis and extensively drug-resistant (XDR) tuberculosis. We sought to estimate the prevalence of resistance to tuberculosis drugs in newly diagnosed and retreated patients with tuberculosis provincially and nationally, and compared these with the 2001–02 estimates.  

Methods 

A cross-sectional survey was done between June 15, 2012–June 14, 2014, using population proportionate randomised cluster sampling in the nine provinces in South Africa. 343 clusters were included, ranging between 31 and 48 per province. A patient was eligible for inclusion in the survey if he or she presented as a presumptive case during the intake period at a drug resistance survey enrolling facility. Consenting participants (≥18 years old) completed a questionnaire and had a sputum sample tested for resistance to first-line and second-line drugs. Analysis was by logistic regression with robust SEs, inverse probability weighted against routine data, and estimates were derived using a random effects model.  

Findings 

101 422 participants were tested in 2012–14. Nationally, the prevalence of MDR tuberculosis was 2·1% (95% CI 1·5–2·7) among new tuberculosis cases and 4·6% (3·2–6·0) among retreatment cases. The provincial point prevalence of MDR tuberculosis ranged between 1·6% (95% CI 0·9–2·9) and 5·1% (3·7–7·0). Overall, the prevalence of rifampicin-resistant tuberculosis (4·6%, 95% CI 3·5–5·7) was higher than the prevalence of MDR tuberculosis (2·8%, 2·0–3·6; p=0·01). 

Comparing the current survey with the previous (2001–02) survey, the overall MDR tuberculosis prevalence was 2·8% versus 2·9% and prevalance of rifampicin-resistant tuberculosis was 3·4% versus 1·8%, respectively. The prevalence of isoniazid mono-resistant tuberculosis was above 5% in all provinces. The prevalence of ethionamide and pyrazinamide resistance among MDR tuberculosis cases was 44·7% (95% CI 25·9–63·6) and 59·1% (49·0–69·1), respectively. The prevalence of XDR tuberculosis was 4·9% (95% CI 1·0–8·8). 

Nationally, the estimated numbers of cases of rifampicin-resistant tuberculosis, MDR tuberculosis, and isoniazid mono-resistant tuberculosis for 2014 were 13 551, 8249, and 17 970, respectively.  

Interpretation 

The overall prevalence of MDR tuberculosis in South Africa in 2012–14 was similar to that in 2001–02; however, prevalence of rifampicin-resistant tuberculosis almost doubled among new cases. Furthermore, the high prevalence of isoniazid mono-resistant tuberculosis, not routinely screened for, and resistance to second-line drugs has implications for empirical management.

‘Our greatest fear’: Highly drug-resistant gonorrhea confirmed by health officials

Via The Washington Post: ‘Our greatest fear’: Highly drug-resistant gonorrhea confirmed by health officials. Excerpt and then a comment:

A super-resistant strain of gonorrhea has been reported in the United Kingdom following warnings from global public health officials that the common sexually transmitted disease is becoming more difficult to treat.  

Health officials in England said it is the first time that a case of gonorrhea could not be treated successfully with antibiotics that are commonly used to cure it. 

Earlier this year, a man, who was not named, sought treatment there for symptoms that he developed about a month after he had sexual contact with a woman in Southeast Asia, according to a case report from Public Health England. The bacterial infection was treated with two antibiotics, azithromycin and ceftriaxone, but subsequent tests still came back positive for the disease, the officials said.

“This is the first time a case has displayed such high-level resistance to both of these drugs and to most other commonly used antibiotics,” Gwenda Hughes, who leads the sexually transmitted infection section at Public Health England, said Wednesday in a statement. 

Gonorrhea, which is caused by the bacterium, Neisseria gonorrhoeae, is one of the most common sexually transmitted diseases around the world.  

Each year, there are an estimated 78 million cases across the globe — about 820,000 of which are reported in the United States, according to data from the Centers for Disease Control and Prevention and the World Health Organization. 

But public health officials said it is becoming more and more resistant to drugs. 

Teodora Wi, medical officer of human reproduction at WHO, said in a news release last year that the bacteria that cause gonorrhea are highly intelligent, explaining that “every time we use a new class of antibiotics to treat the infection, the bacteria evolve to resist them.” 

It's not certain how the patient in England contracted the super-resistant strain. Although he had contact with a woman in Asia, he also had one female partner in the United Kingdom, according to the recent report from Public Health England. She avoided infection. 

Following treatment, a throat swab revealed that the man's infection was still present.  

The patient was then treated intravenously with another antibiotic called ertapenem, and preliminary tests show that the medication may be working. 

He will be tested again next month.

As Maryn McKenna pointed out in a recent tweet, all the attention has been paid to this man—not to the woman he had sex with in Asia, or to her other possible contacts. But I hope that Public Health England, ECDC, and WHO are working hard to trace that woman and her contacts.

CIDRAP: In world first, UK reports high-level gonorrhea resistance

Via CIDRAP, Lisa Schnirring writes: In world first, UK reports high-level gonorrhea resistance. Excerpt:

Health officials in the United Kingdom announced today that they are investigating a gonorrhea infection contracted abroad that marks the first global detection of high-level resistance to recommended dual-antibiotic treatment as well as to other commonly used drugs. 

Gwenda Hughes, PhD, consultant scientist at Public Health England (PHE) and head of its sexually transmitted infection section said in a statement that the patient's Neisseria gonorrhoeae infection is very resistant to first-line treatment, a combination of two antibiotics—azithromycin and ceftriaxone.  

"We are following up this case to ensure that the infection was effectively treated with other options and the risk of any onward transmission is minimised," she said, adding that the PHE actively monitors the spread of antibiotic resistance in gonorrhea and potential treatment failures. 

In 2017, the World Health Organization (WHO) released new data on the global rise in multidrug-resistant gonorrhea, warning that widespread treatment failure is likely in the years ahead unless new antibiotics are developed. At the time of the report, three countries had reported strains of gonorrhea resistant to all current treatment: Japan, France, and Spain. 

WHO data also showed that N gonorrhea, known for its ability to quickly mutate and develop resistance, is becoming resistant to cefixime and ceftriaxone, the drugs the WHO recommends for use in combination with azithromycin for treatment of most gonococcal infections.

See also this report in The Guardian.

Concrete action now: UN high-level meeting on tuberculosis

Via The Lancet Infectious Diseases: Concrete action now: UN High-Level Meeting on Tuberculosis. Excerpt:

World Tuberculosis Day, March 24, 2018, will mark 136 years since the discovery of Mycobacterium tuberculosis by Robert Koch. Having been declared a global health emergency a quarter of a century ago, the Sustainable Development Goals and the WHO End TB Strategy envision ending the tuberculosis pandemic by 2030. 

Today, tuberculosis remains the leading cause of death from an infectious disease and the ninth leading cause of death worldwide. In 2016, an estimated 10·4 million people developed tuberculosis and 1·67 million people died as a result of the disease, exceeding the combined number of deaths from HIV and malaria during the same period. The need for coherent and concrete action in the fight against tuberculosis has never been so urgent. 

Antimicrobial resistance now poses a serious threat to global public health and economic stability. An estimated one third of all deaths associated with antimicrobial resistance are now caused by multidrug-resistant (MDR) tuberculosis. Drug-resistant strains of M tuberculosis continue to emerge and spread due to inadequacies in national tuberculosis programmes. In 2016, an estimated 490 000 people developed MDR tuberculosis, and an additional 110 000 people developed rifampicin-resistant tuberculosis. WHO estimated that only up to 50% of patients with MDR tuberculosis are cured. 

Aside from the economic effect on health systems themselves, tuberculosis predominantly affects people of working age and thus has a sizeable impact on the world's economy. At current rates of progress, an estimated 161 million tuberculosis cases will be diagnosed and 28 million deaths will occur before 2030. The global economy lost around US$600 billion because of the disease between 2000 and 2015 alone, and this figure is expected to rise by a further $1 trillion by 2030 if left unaddressed. 

With no country unaffected and an estimated 50% of tuberculosis cases being in G20 countries, the urgent need for a comprehensive global response is self-evident. Without major progress in global tuberculosis control efforts and increased investments over the coming years, the 2030 targets will not be met for more than 160 years. 

For decades, the global response has suffered due to a paucity of political engagement and investment. However, the collaborative action of WHO, the Stop TB Partnership, civil society groups, and parliamentarians—engaged in advocacy through networks such as the Global TB Caucus and TB Europe Coalition—is starting to pay off. After recognition at both the G7 and G20 summits last year, the first ministerial meeting on tuberculosis was hosted by WHO and the Russian Federation in Moscow (Nov 16–17, 2017). 

In the closing declaration, all 120 participating delegations committed themselves to “fundamentally transforming the fight against TB”, through increased investment, coordination, and accountability. The tuberculosis community, from parliamentarians to people affected by the disease, now have a once-in-a-generation opportunity to transform the global response at the first UN General Assembly (UNGA) High-Level Meeting on Tuberculosis,13 to be held on Sept 26, 2018, in New York (NY, USA). Only unprecedented coordination and collaboration can ensure success.

World Tuberculosis Day 2018 and Special issue–Screening and prevention of infectious diseases in newly arrived migrants in Europe

An editorial: Eurosurveillance | Note from the editors: World Tuberculosis Day 2018 and Special issue–Screening and prevention of infectious diseases in newly arrived migrants in Europe.

World Tuberculosis Day (WTBD) on 24 March commemorates the day in 1882 when Robert Koch presented his discovery of the bacterium that causes tuberculosis (TB). It is a good opportunity to raise awareness about the still-existing burden of TB worldwide and in Europe.  

According to the latest figures published on 19 March 2018 in the TB surveillance report by the European Centre for Disease Prevention and Control (ECDC)/World Health Organization (WHO) Regional Office for Europe, the European Union and European Economic Area (EU/EEA) countries reported 58,994 TB cases in 2016 and that the notification rate has declined by 4.5% in the last 5 years [1]. 

While this is good news in principle, this annual rate of decline is unfortunately still insufficient to achieve the United Nations’ Sustainable Development Goal target of ending TB by 2030 [2]. Furthermore, resistance against the drugs to cure TB poses a problem in Europe. The rate of notified multidrug-resistant (MDR) TB cases in the EU/EEA has remained unchanged at 0.3 per 100,000 population since 2012, but the proportion of extensively drug-resistant (XDR) TB cases among MDR TB cases increased from 13.9% to 20.6%. 

For both MDR TB and XDR TB, treatment success rates are below the 75% target set for the WHO European Region by 2020 [3]. Initiatives have been started to further improve the TB situation in the EU/EEA and to address the threat of TB and MDR TB. For example, a pilot project by the ECDC on the use of whole genome sequencing (WGS) that will establish common standards and build capacity for WGS to improve the detection and investigation of TB outbreaks [4]. At the global level, the United Nations General Assembly will for the first time hold a high-level meeting on TB in September this year to discuss actions to accelerate the pace of TB elimination. 

To mark WTBD 2018, Eurosurveillance published the first articles of the ‘Special issue–Screening and prevention of infectious diseases in newly arrived migrants in Europe’ on 15 March 2018 and this week’s issue features a further article from the series. In total, eight contributions were selected for the special issue from the 24 manuscripts submitted in response to a call for papers in March 2017 [5]. They will be published successively in the coming weeks and the whole series will be made available for download as a single PDF thereafter. 

Five of the articles cover matters pertaining to TB. The ones published so far are on TB treatment outcomes among screened newly-arrived asylum seekers in Germany [6], the acceptance of integrating hepatitis B, hepatitis C and HIV screening into TB entry screening for migrants in the Netherlands [7], and the outcome of TB screening asylum seeking children and adolescents from countries with high and low TB prevalence in reception centres in two German cities [8]. Two systematic reviews on the effectiveness and cost-effectiveness of screening for active and latent TB among migrants in the EU/EEA will follow [9,10] – stay tuned.

ECDC: 4% annual decrease too slow to end TB by 2030

A March 19 news release from ECDC: 4% annual decrease too slow to end TB by 2030 – call for Europe’s commitment to increase investment to end TB. Excerpt:

Low detection and inadequate treatment of multidrug-resistant TB (MDR-TB) are major drivers of the epidemic in Europe 

Despite progress, TB - especially in its drug-resistant forms - remains a major public health concern in the WHO European Region. The latest data from the TB surveillance and monitoring report indicate that one in four MDR TB cases are not detected in the WHO European Region. While diagnosis of MDR TB patients increased from 33% in 2011 to 73% in 2016, it remains below the regional target of 85% defined in the European TB action plan.  

Treating cases with drug resistance is another challenge: the observed increase in treatment success from 46% in 2013 to 55% in 2016 is still insufficient for European countries to achieve the 75% target for 2020 that they committed to in the action plan. 

The spread of extensively drug-resistant TB (XDR TB) is an additional threat to ending TB in the WHO European Region. With the rapid rollout of drug-susceptibility testing and improved surveillance, countries detected 5000 XDR TB cases in the WHO European Region in 2016, however on average only one in three patients with XDR-TB is cured.  

MDR-TB in the EU/EEA 

In the European Union/European Economic Area (EU/EEA), the rate of notified MDR-TB cases has remained unchanged since 2012, at 0.3 per 100 000 population. However, the proportion of XDR-TB cases among MDR-TB cases increased from 13.9% to 20.6% during the same period. Treatment success rates for both MDR-TB and XDR-TB remain low. 

To address this threat, ECDC launched a pilot project in 2017 on the use of whole genome sequencing (WGS) technology to improve the detection and investigation of Mycobacterium tuberculosis in the EU/EEA. The project will establish common standards for WGS in investigating MDR-TB bacteria strains and tracing outbreaks. It will also enable all EU/EEA countries without WGS capacity to utilise the technology by linking them to institutes with robust experience in WGS.   

Commitment to end TB by 2030 

With 2018 marking the 10th anniversary of the Berlin Declaration ‘All Against Tuberculosis’, and as the world prepares for the first-ever United Nations General Assembly High-Level meeting on tuberculosis in September this year, there is a dire need for further commitment to accelerate the pace of TB elimination.  

This entails using existing modern and rapid diagnostic technologies; enhancing research for new tools; developing and implementing regulations to scale up access to new medicines and shorter treatment regimens; and working together with all sectors, including civil society, patients and communities, in a whole-of-society approach. 

Increased collaboration and intensified allocation of resources are crucial to ensure that every TB-affected person has access to quality health services for early detection, successful treatment and people-centred care.