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Drug-resistant Tuberculosis (Developing Countries)

Volume 563: debated on Tuesday 4 June 2013

It is a pleasure to see you presiding in the Chair, Mr Caton. I will try to get through my remarks as quickly as possible, as a couple of other hon. Members would like to make a contribution and the Minister, whom it is good to see in her place, has very kindly indicated that she would be happy to hear them.

After making a few brief comments on tuberculosis and drug-resistant TB globally and in the UK, I will raise three important points that I hope the Minister will be able to address: support for the Global Fund to Fight AIDS, Tuberculosis and Malaria; investing in innovation; and the need for a national strategy in the UK to include an international target. However, before raising those issues, I would like to make a few observations.

The Minister recently met the all-party group on global tuberculosis to discuss its report, “Drug-Resistant Tuberculosis: Old Disease—New Threat”. Much of what I will speak about today is focused on the conclusion and recommendations of that report, which makes constructive recommendations that are evidence-based. I thank Mr Simon Logan, co-ordinator for the all-party group, for his assistance in preparing my remarks for today’s debate.

Tuberculosis in the UK reflects the global reality. TB is one of the world’s most common deadly infectious diseases. In the 1970s, my wife was a junior hospital doctor. Her consultant told her that by the time she became a consultant, TB would have disappeared, like polio, due to BCG, mass X-ray and drug treatment. How wrong can you be?

One third of the world’s population has latent TB, but only a small percentage goes on to develop the active form of the disease, which makes them sick and can kill if not treated. Unfortunately, little progress has been made towards eliminating TB in the UK—there are about 9,000 new cases each year—and global progress is painfully slow. The disease remains an urgent public health problem around the world, and we now face a new threat—drug-resistant strains that are significantly more expensive and difficult to treat. It should be said that both are curable, albeit with a long course of antibiotics. TB does not get the profile that the death and destruction it causes warrant. This is a serious issue, and we must do more to tackle it. It is not only a moral obligation; it is in our national interest.

The first line of defence against drug resistance is appropriate management of TB and the strengthening of the World Health Organisation’s standard treatment, called directly observed therapy, to prevent resistant strains from developing. However, we also need to take steps to tackle this threat head-on, as it is often airborne and can be passed from person to person in the same way as normal TB.

Rates of drug-resistant TB appear small in terms of the global burden of the disease, accounting for 440,000 of the almost 9 million new cases each year, but only about 10% have access to diagnosis, and the financial and treatment burden is substantial. The number of people affected is increasing and so is the cost. Patients have to take 15 to 20 tablets a day for up to two years to be cured of this more extreme form of the disease and they often experience horrible physical and psychological side effects as a result. It is also on the rise in the WHO European region, particularly in eastern Europe. Almost 80,000 cases occurred in the European region in 2011, accounting for nearly one quarter of all DR-TB cases worldwide.

The UK is not immune to this problem. London has the highest TB rate of any capital city in western Europe, and resistant strains of the disease have gradually but significantly increased since 2000. In my constituency, there are 61 cases of TB per 100,000 people. That is in Tower Hamlets. Neighbouring Newham, which I used to represent before the boundary changes in 2010, has double that amount, giving it the highest rate of TB in the UK. It is comparable to that in some high-TB-burden developing countries. To put that into context, the UK average is 14 cases per 100,000 people.

The threat that this public health concern presents to the UK recently led the chief medical officer for England, Dame Sally Davies, to warn that antimicrobial and infectious disease resistance poses a serious threat. One of her key recommendations was for the Government to campaign for it to be given a higher profile and priority internationally. In that regard, financing mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria plays a crucial role in funding programmes for diagnosing and treating TB in low and middle-income countries. The global fund accounts for almost 90% of international TB funding. For many countries, there would not be a response to TB without the global fund’s support.

The hon. Member for South Derbyshire (Heather Wheeler) and I were on a visit to Ethiopia and visited St Peter’s hospital there. I asked what percentage of the funding for the drugs came from the global fund, and it is 100%—without it, people would die.

My hon. Friend reinforces the point that I have just made about how important the global fund is. As I am sure the Minister is aware, the global fund is asking donor Governments, such as the UK Government, for new funding in this replenishment year, and the UK Government have a crucial role to play in ensuring that that process is successful.

In the history of the fight against TB, there have been periods of urgency and periods of innovation, but only rarely have urgency and innovation come together. The rise of this new extreme form of the disease has given a new sense of urgency to global TB efforts, and after a decade of focused investment in TB innovation, we have a promising pipeline of new drugs, diagnostics and vaccines.

It is clear that to address rising rates of drug resistance, action is needed at national and international levels. The all-party group recently published its report, which was the culmination of more than six months’ work consulting world-leading experts on steps that the Government could take to help to address the increasing threat of drug-resistant TB. I shall highlight three key recommendations from the report, and I would be grateful if the Minister focused on those in her response.

I thank the hon. Gentleman for bringing this important issue to Westminster Hall for debate. A group of children and young people from Swaziland were recently in my constituency. They were a Christian choir, and every one of those children had AIDS. In Swaziland, 40% of people have AIDS. Does he feel that we need to address such issues at the highest level? That choir is an example of what can happen when medication is available; if they can survive AIDS and TB, they can make a contribution to their country and ultimately across the world.

I agree with the hon. Gentleman, and I am sure that the Minister will repeat that agreement on the positive outcomes that result from appropriate treatment.

First, the report recommends that we strengthen the global fund by doubling the UK’s contribution. International donor funding, including the majority of the UK’s response to TB in developing countries, comes almost entirely through the global fund. In 22 high-TB-burden countries, six are totally reliant on the fund and in another 15 it accounts for two thirds of their budget. To scale up access and treatment for DR-TB, which remain woefully low, the resources the global fund has at its disposal need to increase. The Government have a key role to play in the replenishment of the fund, having been a key driving force behind the recent reforms it undertook. I commend the Government for that policy. What are their thoughts on our contribution to the fund to address the threat of TB and DR-TB? A lead from the UK should happen as soon as possible, to help leverage more from other donor Governments in this important replenishment year.

Secondly, the report recommends investment in innovation through TB REACH and continued investment in research and development. The Government have already shown leadership in support of developing new, badly needed tools to tackle TB—a policy of successive Governments that I hope will continue. Some of those tools have come to market, specifically new rapid diagnostics, but despite that, 3 million people each year still fail to access diagnosis and treatment for TB, which includes a large portion of people with drug-resistant strains. We need to accelerate our efforts to diagnose TB by rolling out new technologies, and it is clear that we need to think outside the box. TB REACH is one way to do that.

As the Minister knows, TB REACH is a Stop TB Partnership-hosted initiative that gives small grants of up to $1 million to find and treat those who do not have access to TB diagnosis or treatment. It is an incubator for innovation and pushes the frontiers of technology. It works closely with DFID-funded UNITAID. In short, TB REACH goes where others cannot and shows Governments and donors how to reach the unreachable. Critically, it often demonstrates with data what projects could be scaled up. The Minister may wish to express a view on whether she agrees with that assessment. Beyond their contribution of core funding to the Stop TB Partnership, which does not cover TB REACH, I ask that the Government become a donor to TB REACH, to maximise their investments in UNITAID and support the expansion of new diagnostic tools to detect and ultimately treat cases of TB, in addition to the work of the global fund. The funding allocated should be directed by the evaluation of the Stop TB Partnership later this year. I will be interested to hear her view on that recommendation.

Thirdly and finally, I want to mention a national strategy for TB in the UK and the importance of a global target within that. A national strategy for TB has never been developed, despite the public health risk the disease presents. The UK has seen rising rates of TB since the 1980s and DR-TB increased by 26% in the past year alone. I welcome that the Under-Secretary of State for Health, the hon. Member for Broxtowe (Anna Soubry) indicated that her Department is supporting Public Health England to develop a strategy. I bumped into her before the Division and thanked her for her leadership on the matter, in which I have a constituency as well as a personal interest. I was recently invited to a seminar, organised by the Barts and Royal London TB unit, by Dr Veronica White, the consultant in respiratory medicine. Unsurprisingly, it is the biggest TB team in the UK and does sterling work locally and nationally.

With all that in mind and given the clear link between global and UK rates, will the Government set a specific target on their contribution internationally to tackling DR-TB as part of a comprehensive TB strategy, led by Public Health England?

I thank the hon. Gentleman for highlighting the all-party group on global tuberculosis, which it is my privilege to chair—I am not paid. Not only does the work on TB help to deliver the Government’s international development objectives, but it is also in Britain’s interest to get it right.

The hon. Gentleman makes a critical connection between our national interest and the international case, which the Minister and her team acknowledge. I am grateful that she is here. I look forward to her response. I thank her and her officials for the excellent work that they have been doing on this subject. I know that members of the all-party group are also grateful for the engagement that she and her team have had with them, and we look forward to it continuing.

It is a a pleasure to serve under your chairmanship, Mr Caton. I congratulate the hon. Member for Poplar and Limehouse (Jim Fitzpatrick) on securing this important debate on the evil that is TB. I draw your attention, Mr Caton, to my declaration in the Register of Members’ Financial Interests. I want to make a short contribution today.

Earlier in the year, I was fortunate to visit Ethiopia, with my colleague the hon. Member for Workington (Sir Tony Cunningham), to study the changes that it had made to eradicate the scourge of TB, organised by the charity, RESULTS. Although I represent the leafy semi-rural seat of South Derbyshire, I became aware of the consequences of TB when a child at a neighbouring secondary school was diagnosed with it following a trip to see her extended family on the Indian subcontinent. What I saw in Ethiopia was frankly a success story, but a story based on years and years of diligent health care. We met Drs Amara and Abseno from St Peter’s hospital, who, having qualified as doctors 10 years ago, had given their professional life to that TB hospital on the outskirts of Addis Ababa. In other clinics, we saw that ordinary TB is being managed and now the next steps are to deal with the rising rates of DR-TB.

Outside of that specialist hospital, we visited the rural area of Awasa, where we saw the integrated Ethiopian Ministry of Health extension programme, which has been successful in delivering primary health care to communities, by training 36,000 health extension workers. That TB REACH programme has already doubled TB detection rates during a two-year period. I sincerely hope that our Government will consider joining the Canadian Government to fund existing and new programmes for case-finding and treatment in hard-to-reach populations. That is desperately needed: 90% of children in Addis Ababa are covered, but only 10% in the region of Afar are. Much has been achieved with our aid packages, but there is so much more to do. I hope that our Minister can respond positively.

I pay tribute to my hon. Friend the Member for Poplar and Limehouse (Jim Fitzpatrick) for choosing a topic of huge significance and importance. I was delighted to be able to go to Ethiopia with the hon. Member for South Derbyshire (Heather Wheeler), whose work I pay tribute to. I was in Geneva at the global fund meeting with the right hon. Member for Arundel and South Downs (Nick Herbert), and I also pay tribute to his work in this field. The global fund is of huge importance. I do not want to spend time on it, because it has already been touched on, but I shall reiterate the question that we want the Minister to answer: what steps are the UK Government taking to support the future replenishment of the global fund in 2013? It is important because, as I said when I intervened, the entire budget of many of the hospitals dealing with TB comes from the global fund, so without it, they will have serious problems.

To put TB REACH, which the hon. Lady touched on, into context, of the estimated 9 million people who get ill with TB every year, 3 million go without proper diagnosis or treatment. Put simply, we fail to reach far too many people—often in the poorest and most vulnerable communities—with quality TB care. TB REACH offers a lifeline to the people in that missing 3 million. It is hugely important.

The hon. Lady mentioned the 36,000 health extension workers. The health extension programme in Ethiopia is successful for two reasons: the health extension workers are predominantly women and they are predominantly, or almost entirely, local. When we asked them, “What hours do you work?” they said, “We work nine to five, Monday to Friday, but everyone in the village knows where we live.” So they are available around the clock.

I want to give the Minister plenty of time to respond, so my final question is: does she agree that initiatives such as the one we visited in Ethiopia—the one that I have just mentioned—support innovative and effective techniques to find people with TB quickly, avert deaths and stop the disease spreading? I hope that such initiatives will be supported by this Government.

What a pleasure it is to serve under your chairmanship, Mr Caton. I congratulate the hon. Member for Poplar and Limehouse (Jim Fitzpatrick) on securing this important and timely debate, and I thank him for having done so. I will try to get through all the points that have been raised, but if I do not we will contact hon. Members afterwards.

Tuberculosis is an age-old disease. It is tenacious and persistent, and affects the poorest people in the world and those who are socially marginalised. Every year there are 9 million new cases and nearly 1.4 million deaths. Although its incidence has been declining slowly since a peak in 2004, and mortality rates have fallen by 41% since 1990, the vast majority of TB deaths—more than 95%—are in the developing world.

Despite some progress, there were 400,000 cases of multi-drug resistant TB in 2011. As honourable colleagues will be aware, MDR-TB is more difficult and more expensive to treat than TB. Its spread is threatening the global response to TB, and makes TB control even more difficult. It is true, therefore, that TB continues to affect the poorest people in the poorest countries, and remains a serious threat to global health, especially through the rise of MDR-TB.

The coalition Government share the concerns about drug resistance, and we remain committed to the global goal of halving deaths from TB by 2015. The emergence of drug-resistant strains of tuberculosis poses a serious threat to the achievement of that goal and, indeed, to the effectiveness of our current armoury of medicines and treatments.

Our priorities for TB, and for MDR-TB, are to help to increase access to effective diagnosis and treatment of TB; to invest in research and product development in more effective treatment, diagnostics and vaccines; to support countries to strengthen health systems to deliver quality TB programmes—a really important point—and to work with our partners to tackle the risk factors for TB, including poverty and malnutrition. That is not always highlighted, and most of the work of the Department for International Development focuses on dealing with poverty and malnutrition.

As highlighted by the hon. Member for Poplar and Limehouse, Public Health England is developing a national strategy for TB, and engaging with key partners such as local government, the National Institute for Health and Care Excellence, NHS England, academia, the voluntary sector and the Department of Health. DFID will obviously input into the process, and will work with the partners on their strategy, to produce national and international policy and to ensure that there is co-ordinated action on domestic and global approaches to reducing rates of TB.

Our first priority is to improve basic TB control. Basic control includes early detection and diagnosis, effective and complete treatment, and contact tracing. Basic control is also critical in preventing the further spread of drug-resistant tuberculosis. If we do not deal with basic TB, the incidence of MDR-TB will be accelerated. We also help to strengthen all aspects of TB control through direct and indirect funding channels in a range of high-burden countries.

I will quickly give three examples. We are working with the Government of South Africa to expand the quality of and access to public sector services, including that of TB control, and are increasing the speed with which new TB drugs get registered. We have engaged in a new partnership with the private sector in South Africa and the World Bank that aims to reduce TB in mining communities, which I think will be welcomed on both sides of the House.

In India, DFID is working with Indian pharmaceutical manufacturers to improve the price and security of supply of high-quality drugs for resistant TB and the manufacture of new low-cost diagnostic products. In Burma, we are providing bilateral funding to the 3MDG fund, a multi-donor fund for the health sector, which is supporting disease control among the poorest communities.

I, too, am a member of the all-party group on global tuberculosis, and I visited South Africa recently with Lord Fowler. Is that country not a good example of the problem of drug-resistant TB? A full third of the budget that South Africa has to deploy in dealing with TB is spent on drug-resistant TB, yet the incidence of such TB is only 2%. That underlines the importance of getting on top of that form of TB so that the costs do not run further out of control and undermine the fight against the disease.

My right hon. Friend makes an excellent point. South Africa is an epicentre, so far as its spend on what is a relatively confined industry is concerned.

I was talking about Burma. It is estimated that between 2013 and 2016, the 3MDG fund will spend $20 million on tuberculosis. Funding is an important strand. DFID also supports a number of global partnerships that work on strengthening basic TB control. For example, the Stop TB Partnership plays a critical role in helping countries to strengthen their TB policies, and in supporting the improvement of funding applications for large TB-control grants.

The UK’s contribution to UNITAID, of up to €60 million per year, has funded new laboratory infrastructure in 18 countries, 10 of which now routinely diagnose MDR-TB. The network will have detected approximately 12,000 MDR-TB cases by the end of 2011, compared with only 2,300 cases in the same countries in 2008.

I will move on to the Global Fund to Fight AIDS, Tuberculosis and Malaria, because I know it is of particular interest—this is not the first occasion on which it has been raised with me. The majority of UK funding to global TB control is channelled through the Global Fund to Fight AIDS, Tuberculosis and Malaria, and we have increased and accelerated our funding and are on track to meet our £1 billion commitment to the fund for 2008 to 2015. The fund is, as hon. Members have mentioned, absolutely critical to achieving many of the UK’s health-related international development objectives, so it is important to us that it continue to deliver ever-more impressive results. The UK intends to increase its contribution, pending, as we have said, progress on the implementation of crucial reforms. That obviously falls within my portfolio, and I have had reports from all DFID offices around the world, having asked them to report to me on the fund. Recently I was in Nigeria and had a meeting with recipients of global funding from across the three diseases, to understand the changes that are being heralded in with the reforms at the global fund—so far so good.

We are committed to working with others to ensure that the planned autumn replenishment is a success. We are a world leader, but sometimes it would be nice to be at least equalled in some of these things by other donor countries. We will use our influence to draw in more overall financing. I understand the call to go early, but there are many multinational decisions to be made and, as I have said, this all depends on progress.

On investment in research and innovation, which I think all Members would agree is critical, DFID has a strong record of supporting research and development for effective treatments, diagnostics and vaccines. An example of that is our effort to increase the affordability of diagnostic testing for MDR-TB. DFID’s support of the Foundation for Innovative New Diagnostics has contributed to the development of a rapid molecular test, GeneXpert, which has the potential substantially to improve the diagnosis of TB and drug-resistant TB.

DFID aims to continue our strong record of supporting investment in TB research and development, including through product development partnerships, and we will strive for value for money in such investments. On DFID’s support for innovation, we will consider the hon. Gentleman’s request that we fund TB REACH against, obviously, the competing priorities and commitments in our international health financing decisions.

Will the Minister recognise the importance of TB REACH? We can have all the drugs in the world, but if we cannot find the people with TB, we cannot use those drugs.

Absolutely. The point is that we are waiting for the evaluation. TB REACH worked by giving a small amount to a great number of organisations to test how to reach people in difficult circumstances. It had precise pre-specified targets and cost-effectiveness benchmarks, and we have to await the evaluation of that first phase to assess what our funding might be for the second phase. We cannot go ahead of that, although I understand that reaching people is critical. We should also work to strengthen health systems, because ultimately we want health systems that are able to reach every individual in a country and dispense whatever medical care is necessary, but I understand the point in relation to TB.

On Ethiopia, about which I have not yet responded, DFID provides significant support to its health system, directly supporting community health workers, and we agree that they do a great job, including on TB. I have been to Ethiopia myself—twice, in fact.

In conclusion, I am very proud to serve in the coalition Government who, even in tough times, have protected the development budget and will reach the target of 0.7% of gross national income this year. I am also proud that we have cross-party consensus in this Parliament: it is one of our finer moments. We are equally clear about the responsibilities that come with those resources, particularly when this country is itself struggling for survival. Those responsibilities are to spend taxpayers’ money well, to deliver aid that is accounted for transparently, and to ensure that our support delivers value for money and gets to where it is most needed.

Significant progress has been made in controlling TB since 1995, with more than 51 million cases treated and 20 million lives saved. That progress was rooted in improved partnership, policy, innovation and leadership, so there is cause for optimism. I thank all hon. Members here, because the issue is really important and I appreciate their continued pressure. The issue needs to be worked on in all the ways they have proposed if we are to get the better of this disease: our progress is good, but not remarkable. The UK is playing its part, but as I have said, we are all clear that significant challenges remain.

Question put and agreed to.

Sitting adjourned.