EVERY YEAR 9 MILLIONPEOPLE 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 estimatednumber 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 dyingof TB are missed.

We need to reach them.

TB is infectious and spreads through theair. A third of the world’s population has
been infected by TB bacteria but only
one in 10 will fall ill. For those with active
TB, the symptoms may be mild for many
months, leading to delays in diagnosis andtreatment, while spreading the disease toothers. Most people with TB can be cured
by taking a six-month course of drugs.
If treatment is incomplete, TB can comeback, often, in a more resistant form.
People with TB also suffer discriminationand stigma, rejection and social isolation.
While there has been major progress infighting TB, more needs to be done.

Vanessa Vick,
UgandaNearly 22 million
lives have been saved
since 1995. There has
been a 45% decrease
in TB deaths since1990. But we need to
do more. Now.

The problem
12 countries carry 75% of the burden of missed cases

South Asia
and Africa
account fornearly twothirds of theburden 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 beennearly 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 livingwith HIV/AIDS, children and women,
contacts of people with TB including
health workers, migrants, refugees andinternally 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
may not access care
at allThe reasons are varied, but often
are related:
Limited awareness of TB, as well as
why and where to seek care

3. People with TB
may get diagnosed
but they are not documented
Some people get diagnosed but may not
get started on proper treatment or get
notified. The quality of care is unknown.
Underlying barriers include:

Poverty, marginalization and related
stigma or discrimination

Weaknesses in recording and reporting
within public systems.

Limited number and distribution ofhealth facilities

Non-existent or poor linkages withprivate practitioners, hospitals, laboratories, or NGO services

Little community engagement andoutreachFinancial barriers such as user fees,transport and lost income

Lack of mandatory case notificationby health service providers, or its
enforcement

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
andundertrained
healthcare staff who fail to identify thesymptoms or refer for testing
Diagnostic tests offered are not always
the most accurate and appropriateLong delays or travel prevent receiptof test results

4

Jacob Cresswell,Peru

ECDC/Tobias Hofsäss,
RomaniaLong path to care
Hard to reach populations

Reaching the missed children
with TB

In the North-Eastern
Nigerian state ofAdamawa, lies a
temporary Nomadic
settlement of about
200 people that has
no health services.
Outreach workers
meet with the nomadic community
leaders and set up opportunities for healthscreening on market days. Samples aretransported to the nearest microscopylabs.

Children account foran estimated half amillion new TB cases
annually and 74, 000
deaths (among HIVnegative children).
In 2012, only around300, 000 cases were
notified to National TB Programmes. TB
in children is often missed or overlooked
due to non-specific symptoms andlimitation of diagnostic tools.

During one of these sessions, Abdul,
a three year old child was identified
as possibly having TB. Abdul’s motherwas supported by outreach workers to
get to the local hospital where he wasdiagnosed with TB. Abdul’s grandfather
who had chronic cough, had died three
years earlier, when Abdul was 7 months
old. Abdul’s mother said that she would
go to the herbalist of the community or
buy medicine from drug hawkers in themarket.
After receiving proper treatment fromhealth workers, Abdul’s mother was
excited with the improvement in her
child’s health.

In 2013, a childhood TB roadmap waslaunched - Towards Zero Deaths, toimprove the prevention, diagnosis,
treatment and care for children with TB
and children living in families with TB.
The roadmap includes practical actions
that can be taken today at local, nationaland global levels to make a difference.
Tens of thousands of children’s lives could
be saved if these steps are taken.

Photo credits:
Stephen John, Nigeria (left)
Miguel Bernal, Peru (right)

5

Sailendra Kharel,
Cambodia

Missed out
not missed altogether

A typical story
from Asia

Nearly half of the 3 million missed TB cases
are in Asia. The majority of these people
with TB first go to the private sector, often
seeking care from multiple providers
in their journey to access TB treatment,such as drug sellers, private practitioners,
hospitals etc. When they fall ill, they must
weigh the options of waiting in long lines
at overcrowded public clinics where they
may have to pay a user fee or head to a
local private clinic where a doctor can beseen at any time of the day or night andnot miss out on a day’s pay. Unfortunately
the TB management practices of theseproviders are rarely aligned with national
or international standards, and they don’t
notify people under their care to national
health systems for lack of information,
incentives or tools.

Hamidah is a low wage worker in theinformal sector. She first tried to selfmedicate her cough, then went to a
local clinic where she was seen by an
unqualified,unlicensed
practitioner.
When her condition worsened, a different
provider referred her to a laboratory fora useless and an expensive blood test. A
third attempt got her a diagnosis of TB,
but she had to pay for her medications
and could not afford to keep buying them.
Finally, when her symptoms returned, she
received free diagnosis and treatment
at a private clinic that was linked to thenational TB programme. Then she finishedtreatment successfully.

6

TB-HIV
The need to integrate care

In 2012 only 50%of the estimated
1.1 million new casesof people with HIVrelated TB werereached globally.
This is of major concern as TB is theleading cause of death among people
living with HIV (PLHIV) and untreated TB
in PLHIV can lead to death in weeks.
TB is more difficult to diagnose in PLHIV asthey are more likely to have lower levels of
TB bacteria, making it difficult to identify.
The dual stigma associated with TB andHIV, often along with discrimination in
health care settings, further limits access,particularly among high risk groups suchas people who inject drugs or people witha history of incarceration. Multi-sectoral
engagement, integrated service delivery
and the scale-up of rapid diagnostics inHIV care settings are recommended andcritical to expand access to testing andfull TB/HIV care. Accelerated scale-up of
rapid diagnostic tests is needed. The test
is currently recommended as the primary
diagnostic test for TB among PLHIV.

Andrew Reed Weller,
Kenya

A Crisis
The gap in reaching andtreating those ill with
MDR-TB

Only 1 in 4
people falling
ill with
MDR-TBare diagnosed.
Worldwide, only 94, 000 of the 450, 000
people estimated to have developed
multidrug-resistant TB (MDR-TB) in 2012were detected. The lowest proportionsof new MDR-TB patients reached werein the South-East Asia region (21%) andWestern Pacific Region (6%), though they
carry over 50% of the global burden of
MDR-TB.
While the pace of expansion of MDR-TB
diagnostic testing is increasing, it needs
further acceleration. Access to quality
treatment is also lagging.
Financingof diagnostics and drugs, need to be
secured along with a network of welltrained facility-based and community
care providers. Stronger links between
the public and private sectors will help
limit the development of drug-resistanceand enable improved access or referral.

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 thatprovide quality TB care especially in under-served communities

Ethiopia
Community outreach

MyanmarNational response planning

In Ethiopia, rural communities face many
access barriers for TB care. A recent
partnership involved training, engaging
stakeholders and communities and active
case-finding by female Health Extension
Workers (HEWs) who are lay workers
with a small government salary to provide
basic services to their communities. HEWs
identified individuals with TB symptoms
in their community and also collected
sputum, prepared slides for microscopy
and supervised treatment. In a year’stime, TB case notification almost doubled
in an area of over 3 million people andtreatment success improved despite theadded workload.

Myanmar has framed a national response
to its heavy burden of missed TB patientsusing evidence. It builds on the foundationof an active national TB programme,development partners, and an invigorated
agenda for universal health coverage. A
recent national survey showed higher TBburden in urban areas, in men, and among
the elderly. Over 1% of adults tested inurban areas were found to have active
TB disease. Other known risk groups
are PLHIV, TB contacts, persons withdiabetes, prisoners, miners and ethnic
minorities. The response builds on theongoing roll-out of new rapid TB tests,
and more effective use of chest x-ray for
TB screening. It involves hospital outpatient departments, use of mobile x-ray
units for screening in poor urban areasand selected remote rural areas.

8Solution 2
Expand screening and testing
Enable all healthcare providers to better identify patients with TB symptoms forfurther testing.
Perform systematic screening in selected high-risk groups
Improve diagnostic capacity, use of rapid tests, specimen transport and patientreferral 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
Better screening of people
attending health facilities
Sometimes
peoplewithTB
doattend health facilities. However withoverburdened and untrained healthstaff, these people can go unattended.
Providingtraining
andsystematic
screening of people already attending
health facilities can yield impressive
results. In Afghanistan, staff across 47
health facilities were trained in screening,
to ensure good sputum collection. In one
year, these facilities found over 70% morecases than the year before by improving
the identification of people who shouldbe tested, screening almost one million
people in the process.

Riccardo Venturi,
Afghanistan

Moldova and South Africa
New molecular tests canidentify more people with
TB than smear microscopy
Moldova and South Africa, among othercountries are currently working
toprovide greater access to Xpert MTB/RIF,
a rapid diagnostic test, for all people with
TB symptoms. South Africa is currently
the largest user of Xpert MTB/RIF in theworld. There has been a dramatic increasein the numbers of people diagnosed andput on treatment for drug resistant TB.
Moldova has been able to identify people
with TB more quickly. Almost twice as
many people with TB were detected by
Xpert than by smear microscopy.

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 anddiagnosed by all care providers within and outside TB programmes is available andused 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
Engaging private providers
In many countries, a large proportionof healthcare is provided through theprivate sector where they have to pay for
drugs and may receive substandard care.
A systematic situation assessment helped
Pakistan. Its multi-pronged approach
included not only investing in publicprivate mix – the public sector supporting
private sector to contribute to TB careand control, but also a private-private
mix through the promotion of social
franchising and social business models.
Currently, every fourth case is notified byengaging the private sector. A particularly
impressive initiative provides a mix of an
incentive-based system to community lay
workers who act as screeners using mobile
phones in a large number of small generalpractitioner facilities and a large hospital.
It also involves mass media campaigns,
and a sputum transport network. As
a result, case notifications from thereporting unit in Karachi doubled and it
became the second largest contributing
unit in Pakistan in one year. In the second
year – the same approach was expanded
to a second area of the city with equally
impressive results.

India and The Philippines
Engaging with big hospitals
can bring big gains
In many countries, major hospitals in big
cities, serve people who seek care andhave signs and symptoms of TB. Efforts by
National TB Programmes to build linkages
10with these institutions have enabled
improved use of national standards ofcare, information exchange and patientreferrals closer to home for treatment
follow up and support after diagnosis.
In the Philippines, streamlining hospital
TB clinics in Manila, increased casenotifications by over 13, 000. The model
is now being replicated and scaled up
nationwide. In India, national and regional
task forces set up to involve all public
and private medical college hospitals,
with related financial aid for operating
hospital-based TB clinics, have helped
contribute up to 15 percent of nationalcase reporting from these facilities.

China
Strengthening surveillancesystems to improve
notifications
In China, the National TB Programme
provides services principally through a
network of TB dispensaries. Yet, a large
number of people with TB symptoms
seek care from hospitals, although thesefacilities cannot always enable continuityof care during a full course of TB treatment.
Until a decade ago, hospitals were notreferring patients to dispensaries, so,many patients were “missed”.
In 2004, in response to the SARS (severe
acute respiratory syndrome) epidemic, thegovernment established a national webbased system for mandatory reportingof 37 infectious diseases, including TB,
within 24 hours of diagnosis. With thisstimulus, hospitals now contribute nearly
40% of TB notifications in China.

The World Bank estimates that eachdollar invested in TB yields US$ 30 inreturn, 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 resultsin finding and treating people among hard to reach populations.

Small interventions
can have big impacts forvulnerable groups
In Karachi, Pakistan, community healthworkers are using electronic scorecards
on mobile phones to identify people
that need a TB test. At a low cost, healthworkers identified six times the numberof cases of childhood TB compared toprevious years.
In the remote villages of Lesotho, healthworkers on horseback reached out tocommunities which previously had little
or no access to healthcare. The healthworkers pick up samples from villagers
and take them to laboratories foranalysis. The test results are reported via
text messages and people with TB areprovided with life-saving drugs.

Samuel George Nuttall,
LesothoIn Mbeya, Tanzania, a mobile laboratoryoffers a rapid diagnostic test (Xpert) andHIV testing in rural areas. The van serves
as a test centre during the day and amobile cinema with educational films atnight. Other countries that have adopted
this approach include Zimbabwe andCambodia.
In London, UK, where TB rates areamong the highest in Western Europe,
an outreach program using mobile digital
x-ray units helps homeless people, drugor alcohol users, vulnerable migrants,
and people who have been in prison, toaccess TB care. The team includes former
TB patients, health and social workers.
Leading evaluating agencies in the UK
have assessed the program to be highly
cost-effective and suggest it could evensave costs.

11

The promiseof new tools

The costof inaction

Given recent advances in moleculartechnologies, research interest in TB
diagnostics is at an all-time high. Morethan 50 companies are currently involved
in developing new TB tests including foruse at point-of-care. Research pipelines
for new drugs and vaccines are also
under progress. However, bottlenecks
in financing are slowing basic science,
diagnostics, drugs and vaccine research.
Less than a third of the US$ 2 billion
needed for TB research and development,
is currently available.

There are major health security andeconomic consequences of failure to act
now:

The opportunityof new strategic plans
and Global Fund’s
new funding model
Reaching the unreached with TB care isat the heart of national efforts moving to2015 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. Allof this depends on fast progress towards
universal access to care and engaging
new partners. These plans aim toprioritize interventions, leverage best useof domestic resources, and lay out thefinancing gaps for TB control. The Global
Fund has a new funding model whichseeks to help countries fill those gaps,
along with bilateral and other sources.
The focus is on meeting the needs of themost vulnerable in high-disease burden
settings. Inclusive country dialogue andprioritization interventions for impact are
fundamental to the new funding model,
and to finding the missed 3 million.

12

Ongoing massive number of fullypreventable deaths
Risk of disease transmission: onepatient can infect up to 10 people a
year
Catastrophic
costs
topatients;
grave burden for health systems andeconomyIncreasing risk of drug resistance

Cost of TB care vs. MDR-TB care
Myanmar
8 000

$

$

TB

MDR-TB

170

South Africa
10 000$$TB

MDR-TB600

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,
Ethiopia13

Samuel George Nuttall,
Lesotho14

rEachthE
3 million

15

Cover photo credits (left to right):
Vanessa Vick, Uganda
Jacob Cresswell, Myanmar
David Rochkind, India

The designations employed and thepresentation of the material in thispublication do not imply the expressionof any opinion whatsoever on thepart 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 onmaps represent approximate borderlines for which there may not yet be fullagreement.
Stop TB Partnershipwww.stoptb.org
World Health Organization
Global TB Programmewww.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 toreach the missed has
devastating human,
health and economic
consequences.
TREAT
A person with TB infects
about 10 people in a year.
Without treatment, half ofthe people with TB die.
CURE
With urgent action andincreased investment,
we can cure the missed
3 million and ensure weleave no one behind.

ACCESS TO
TUBERCULOSIS CARE
IS A RIGHT.