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 estimated

number of people who became ill with TB
in a year and the number of people who
were notified to national TB programmes.
Riccardo Venturi,
Afghanistan

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.

TB is infectious and spreads through the
air. A third of the world’s population has Nearly 22 million
been infected by TB bacteria but only
one in 10 will fall ill. For those with active
lives have been saved
TB, the symptoms may be mild for many
months, leading to delays in diagnosis and
since 1995. There has
treatment, while spreading the disease to
others. Most people with TB can be cured
been a 45% decrease
by taking a six-month course of drugs. in TB deaths since
If treatment is incomplete, TB can come
back, often, in a more resistant form. 1990. But we need to
People with TB also suffer discrimination
and stigma, rejection and social isolation. do more. Now.
While there has been major progress in
fighting TB, more needs to be done.

Vanessa Vick,
Uganda
 The problem

12 countries carry 75% of the burden of missed cases

South Asia
and Africa
account for
nearly two-
thirds of the
burden of
missed cases,
but people
with TB are
missed in all
countries.

About 3 million people are “missed” each year

by health systems and many therefore do not
get the TB care that they need and deserve.
Many of the missed will die, some will get better,
others will continue to infect others.
The proportion of missed cases has been
nearly the same for the past seven years
and the number of missed is accumulating
every year.

Vulnerable populations
around the globe
Those most vulnerable to falling ill with TB
include very poor and/or malnourished/
undernourished people, people living
with HIV/AIDS, children and women,
contacts of people with TB including
health workers, migrants, refugees and
internally displaced persons, miners
and mining-affected persons, persons
with diabetes, elderly, ethnic minorities,
indigenous populations, substance users
and homeless persons.
Carlos Cazalis,
Peru
3
 Why are they missed?

1. People with TB 3. People with TB

may not access care may get diagnosed
at all but they are not documented
The reasons are varied, but often Some people get diagnosed but may not
are related: get started on proper treatment or get
notified. The quality of care is unknown.
Limited awareness of TB, as well as
why and where to seek care Underlying barriers include:

Poverty, marginalization and related Weaknesses in recording and reporting

stigma or discrimination within public systems.

Limited number and distribution of Non-existent or poor linkages with

health facilities private practitioners, hospitals, labora-
tories, or NGO services
Little community engagement and
outreach Lack of mandatory case notification
by health service providers, or its
Financial barriers such as user fees, enforcement
transport and lost income

Conflict or insecurity

2. People with TB
may access health services
but are not diagnosed
For the average patient, half of the costs of
having TB are linked to seeking diagnosis
– patients spend time and money, without
getting proper diagnosis.

This can be due to:

Overburdened and undertrained

healthcare staff who fail to identify the
symptoms or refer for testing

Diagnostic tests offered are not always

the most accurate and appropriate

Long delays or travel prevent receipt

of test results

Jacob Cresswell,
Peru
4
ECDC/Tobias Hofsäss,
Romania

Long path to care Reaching the missed children

Hard to reach populations with TB
In the North-Eastern Children account for
Nigerian state of an estimated half a
Adamawa, lies a million new TB cases
temporary Nomadic annually and 74, 000
settlement of about deaths (among HIV-
200 people that has negative children).
no health services. In 2012, only around
Outreach workers 300, 000 cases were
meet with the nomadic community notified to National TB Programmes. TB
leaders and set up opportunities for health in children is often missed or overlooked
screening on market days. Samples are due to non-specific symptoms and
transported to the nearest microscopy limitation of diagnostic tools.
labs.
In 2013, a childhood TB roadmap was
During one of these sessions, Abdul, launched - Towards Zero Deaths, to
a three year old child was identified improve the prevention, diagnosis,
as possibly having TB. Abdul’s mother treatment and care for children with TB
was supported by outreach workers to and children living in families with TB.
get to the local hospital where he was The roadmap includes practical actions
diagnosed with TB. Abdul’s grandfather that can be taken today at local, national
who had chronic cough, had died three and global levels to make a difference.
years earlier, when Abdul was 7 months Tens of thousands of children’s lives could
old. Abdul’s mother said that she would be saved if these steps are taken.
go to the herbalist of the community or
buy medicine from drug hawkers in the
market.
Photo credits:
After receiving proper treatment from
health workers, Abdul’s mother was Stephen John, Nigeria (left)
excited with the improvement in her Miguel Bernal, Peru (right)
child’s health.
5
Sailendra Kharel,
Cambodia

Missed out A typical story

not missed altogether from Asia
Nearly half of the 3 million missed TB cases Hamidah is a low wage worker in the
are in Asia. The majority of these people informal sector. She first tried to self-
with TB first go to the private sector, often medicate her cough, then went to a
seeking care from multiple providers local clinic where she was seen by an
in their journey to access TB treatment, unqualified, unlicensed practitioner.
such as drug sellers, private practitioners, When her condition worsened, a different
hospitals etc. When they fall ill, they must provider referred her to a laboratory for
weigh the options of waiting in long lines a useless and an expensive blood test. A
at overcrowded public clinics where they third attempt got her a diagnosis of TB,
may have to pay a user fee or head to a but she had to pay for her medications
local private clinic where a doctor can be and could not afford to keep buying them.
seen at any time of the day or night and Finally, when her symptoms returned, she
not miss out on a day’s pay. Unfortunately received free diagnosis and treatment
the TB management practices of these at a private clinic that was linked to the
providers are rarely aligned with national national TB programme. Then she finished
or international standards, and they don’t treatment successfully.
notify people under their care to national
health systems for lack of information,
incentives or tools.

6
TB-HIV A Crisis
The need to integrate care The gap in reaching and
treating those ill with
In 2012 only 50% MDR-TB
of the estimated
1.1 million new cases Only 1 in 4
of people with HIV- people falling
related TB were ill with
reached globally. MDR-TB
are diagnosed.
This is of major concern as TB is the
leading cause of death among people Worldwide, only 94, 000 of the 450, 000
living with HIV (PLHIV) and untreated TB people estimated to have developed
in PLHIV can lead to death in weeks. multidrug-resistant TB (MDR-TB) in 2012
were detected. The lowest proportions
TB is more difficult to diagnose in PLHIV as of new MDR-TB patients reached were
they are more likely to have lower levels of in the South-East Asia region (21%) and
TB bacteria, making it difficult to identify. Western Pacific Region (6%), though they
The dual stigma associated with TB and carry over 50% of the global burden of
HIV, often along with discrimination in MDR-TB.
health care settings, further limits access,
particularly among high risk groups such While the pace of expansion of MDR-TB
as people who inject drugs or people with diagnostic testing is increasing, it needs
a history of incarceration. Multi-sectoral further acceleration. Access to quality
engagement, integrated service delivery treatment is also lagging. Financing
and the scale-up of rapid diagnostics in of diagnostics and drugs, need to be
HIV care settings are recommended and secured along with a network of well-
critical to expand access to testing and trained facility-based and community
full TB/HIV care. Accelerated scale-up of care providers. Stronger links between
rapid diagnostic tests is needed. The test the public and private sectors will help
is currently recommended as the primary limit the development of drug-resistance
diagnostic test for TB among PLHIV. and enable improved access or referral.

Andrew Reed Weller,

Kenya
7
Simple and Effective Solutions

Acknowledging and understanding the problem

is the first step.
For solutions to be effective and sustainable, actions from grassroots organizations,
governments, and the global community are needed. Choosing and prioritizing actions
depends 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 are
eliminated, in keeping with aim of Universal Health Coverage

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

Ethiopia Myanmar
Community outreach National response planning
In Ethiopia, rural communities face many Myanmar has framed a national response
access barriers for TB care. A recent to its heavy burden of missed TB patients
partnership involved training, engaging using evidence. It builds on the foundation
stakeholders and communities and active of an active national TB programme,
case-finding by female Health Extension development partners, and an invigorated
Workers (HEWs) who are lay workers agenda for universal health coverage. A
with a small government salary to provide recent national survey showed higher TB
basic services to their communities. HEWs burden in urban areas, in men, and among
identified individuals with TB symptoms the elderly. Over 1% of adults tested in
in their community and also collected urban areas were found to have active
sputum, prepared slides for microscopy TB disease. Other known risk groups
and supervised treatment. In a year’s are PLHIV, TB contacts, persons with
time, TB case notification almost doubled diabetes, prisoners, miners and ethnic
in an area of over 3 million people and minorities. The response builds on the
treatment success improved despite the ongoing roll-out of new rapid TB tests,
added workload. and more effective use of chest x-ray for
TB screening. It involves hospital out-
patient departments, use of mobile x-ray
units for screening in poor urban areas
and selected remote rural areas.

8
 Solution 2
Expand screening and testing
Enable all healthcare providers to better identify patients with TB symptoms for
further testing.

Perform systematic screening in selected high-risk groups

Improve diagnostic capacity, use of rapid tests, specimen transport and patient
referral 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 Moldova and South Africa

Better screening of people New molecular tests can
attending health facilities identify more people with
TB than smear microscopy
Sometimes people with TB do
attend health facilities. However with Moldova and South Africa, among other
overburdened and untrained health countries are currently working to
staff, these people can go unattended. provide greater access to Xpert MTB/RIF,
Providing training and systematic a rapid diagnostic test, for all people with
screening of people already attending TB symptoms. South Africa is currently
health facilities can yield impressive the largest user of Xpert MTB/RIF in the
results. In Afghanistan, staff across 47 world. There has been a dramatic increase
health facilities were trained in screening, in the numbers of people diagnosed and
to ensure good sputum collection. In one put on treatment for drug resistant TB.
year, these facilities found over 70% more Moldova has been able to identify people
cases than the year before by improving with TB more quickly. Almost twice as
the identification of people who should many people with TB were detected by
be tested, screening almost one million Xpert than by smear microscopy.
people in the process.

Riccardo Venturi,
Afghanistan
9
 Solution 3
Improve information flow for quality care
Expand linkages that enable all those who can screen, test, diagnose or treat TB to
effectively communicate and serve patients

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

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

Pakistan with these institutions have enabled

improved use of national standards of
Engaging private providers care, information exchange and patient
referrals closer to home for treatment
In many countries, a large proportion follow up and support after diagnosis.
of healthcare is provided through the In the Philippines, streamlining hospital
private sector where they have to pay for TB clinics in Manila, increased case
drugs and may receive substandard care. notifications by over 13, 000. The model
A systematic situation assessment helped is now being replicated and scaled up
Pakistan. Its multi-pronged approach nationwide. In India, national and regional
included not only investing in public- task forces set up to involve all public
private mix – the public sector supporting and private medical college hospitals,
private sector to contribute to TB care with related financial aid for operating
and control, but also a private-private hospital-based TB clinics, have helped
mix through the promotion of social contribute up to 15 percent of national
franchising and social business models. case reporting from these facilities.
Currently, every fourth case is notified by
engaging the private sector. A particularly
impressive initiative provides a mix of an
China
incentive-based system to community lay Strengthening surveillance
workers who act as screeners using mobile
phones in a large number of small general
systems to improve
practitioner facilities and a large hospital. notifications
It also involves mass media campaigns,
and a sputum transport network. As In China, the National TB Programme
a result, case notifications from the provides services principally through a
reporting unit in Karachi doubled and it network of TB dispensaries. Yet, a large
became the second largest contributing number of people with TB symptoms
unit in Pakistan in one year. In the second seek care from hospitals, although these
year – the same approach was expanded facilities cannot always enable continuity
to a second area of the city with equally of care during a full course of TB treatment.
impressive results. Until a decade ago, hospitals were not
referring patients to dispensaries, so,
India and The Philippines many patients were “missed”.

Engaging with big hospitals In 2004, in response to the SARS (severe

can bring big gains acute respiratory syndrome) epidemic, the
government established a national web-
In many countries, major hospitals in big based system for mandatory reporting
cities, serve people who seek care and of 37 infectious diseases, including TB,
have signs and symptoms of TB. Efforts by within 24 hours of diagnosis. With this
National TB Programmes to build linkages stimulus, hospitals now contribute nearly
40% of TB notifications in China.
10
The World Bank estimates that each
dollar invested in TB yields US$ 30 in
return, making it great value for money.
We need to invest more to find and treat the
missed 3 million.
Examples from different countries show that modest investments can yield significant results
in finding and treating people among hard to reach populations.

Small interventions In Mbeya, Tanzania, a mobile laboratory

offers a rapid diagnostic test (Xpert) and
can have big impacts for HIV testing in rural areas. The van serves
vulnerable groups as a test centre during the day and a
mobile cinema with educational films at
In Karachi, Pakistan, community health night. Other countries that have adopted
workers are using electronic scorecards this approach include Zimbabwe and
on mobile phones to identify people Cambodia.
that need a TB test. At a low cost, health
workers identified six times the number In London, UK, where TB rates are
of cases of childhood TB compared to among the highest in Western Europe,
previous years. an outreach program using mobile digital
x-ray units helps homeless people, drug
In the remote villages of Lesotho, health or alcohol users, vulnerable migrants,
workers on horseback reached out to and people who have been in prison, to
communities which previously had little access TB care. The team includes former
or no access to healthcare. The health TB patients, health and social workers.
workers pick up samples from villagers Leading evaluating agencies in the UK
and take them to laboratories for have assessed the program to be highly
analysis. The test results are reported via cost-effective and suggest it could even
text messages and people with TB are save costs.
provided with life-saving drugs.

Samuel George Nuttall,

Lesotho
11
The promise The cost
of new tools of inaction
Given recent advances in molecular There are major health security and
technologies, research interest in TB economic consequences of failure to act
diagnostics is at an all-time high. More now:
than 50 companies are currently involved
in developing new TB tests including for Ongoing massive number of fully-
use at point-of-care. Research pipelines preventable deaths
for new drugs and vaccines are also
under progress. However, bottlenecks Risk of disease transmission: one
in financing are slowing basic science, patient can infect up to 10 people a
diagnostics, drugs and vaccine research. year
Less than a third of the US$ 2 billion
needed for TB research and development, Catastrophic costs to patients;
is currently available. grave burden for health systems and
economy

Increasing risk of drug resistance

The opportunity
of new strategic plans
and Global Fund’s Cost of TB care vs. MDR-TB care
new funding model
Myanmar
Reaching the unreached with TB care is 8 000
at the heart of national efforts moving to
2015 and beyond. Many countries in all
regions are working on new national TB
strategic plans and setting new targets

$
for driving down deaths and cases. All 170
of this depends on fast progress towards
universal access to care and engaging
new partners. These plans aim to
$
prioritize interventions, leverage best use TB MDR-TB
of domestic resources, and lay out the
financing gaps for TB control. The Global
South Africa
Fund has a new funding model which
seeks to help countries fill those gaps, 10 000
along with bilateral and other sources.
The focus is on meeting the needs of the
most vulnerable in high-disease burden
settings. Inclusive country dialogue and
prioritization interventions for impact are

$
fundamental to the new funding model,
and to finding the missed 3 million. 600

$
TB MDR-TB

12
 Priorities for action on TB

Reaching the missed 3 million each year is one

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

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

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 global
TB epidemic.

Jacob Cresswell,
Ethiopia
13
Samuel George Nuttall,
Lesotho
14
rEach
thE
3 million

15
Cover photo credits (left to right):

Vanessa Vick, Uganda

Jacob Cresswell, Myanmar
David Rochkind, India

The designations employed and the

presentation of the material in this
publication do not imply the expression
of any opinion whatsoever on the
part of the World Health Organization
concerning the legal status of any country,
territory, city or area or of its authorities,
or concerning the delimitation of its
frontiers or boundaries. Dotted lines on
maps represent approximate border
lines for which there may not yet be full
agreement.

Stop TB Partnership
www.stoptb.org

World Health Organization

Global TB Programme
www.who.int/tb

20, Avenue Appia

CH-1211 Geneva 27

© World Health Organization 2014

Printed by the
WHO Document Production Services
Geneva, Switzerland

Designed by Tashira Muqtada

The Bright Sun
www.thebrightsun.com
Reach the 3 million.
Find. Treat. Cure TB.

FIND
Every year 3 million
people with TB are
missed. Failure to
reach the missed has
devastating human,
health and economic
consequences.

TREAT
A person with TB infects
about 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 missed
3 million and ensure we
leave no one behind.

ACCESS TO
TUBERCULOSIS CARE
IS A RIGHT.