Moving towards tuberculosis elimination: a call for action from Italy and a possible model for other low tuberculosis incidence countries

In 2014 the World Health Assembly endorsed the new End Tuberculosis Strategy that aims at reducing the global incidence of the disease by 90% within 2035 [1].

The World Health Organization (WHO) published, in 2015, a framework for tuberculosis (TB) elimination, e.g. a roadmap on how to reach TB elimination (less than one TB case per million population) in low TB incidence countries (those where TB incidence is lower than 10 cases per 100 000 population) [2]. The document had been jointly promoted by WHO and the European Respiratory Society in Rome in July 2014, followed by a consultation with representatives of low TB incidence countries and partner organisations. In this editorial, we present a roadmap for Italy which could also be used as a model for other low TB incidence countries in Europe.

In order to reach TB elimination by 2050, Italy first needs to lower TB incidence to reach the TB pre-elimination threshold (<10 cases per million population) by 2035 [2].

Over the past 70 years, TB incidence (as derived from TB notifications) in Italy has remained rather stable at around seven cases per 100 000 population [3], or 70 cases per million inhabitants. The rapid decline of TB cases among native Italians and the slower decline among foreign-born individuals has slowly modified the epidemiology of TB in Italy. According to a survey done by Istituto Superiore di Sanità, Rome (unpublished data), aimed at ensuring quality control in reference laboratories, out of 13 030 strains examined between 2008 and 2014, 47% belonged to native Italians (6161) and 53% to foreign-born individuals (6869). Interestingly, out of 410 multidrug-resistant TB (MDR-TB) strains, 77 were identified among native Italians (19%) and 333 among foreign-born individuals (81%).

In Italy and other low TB incidence countries in Europe, the goal of TB elimination is plausible [2]; it requires that the Ministry of Health identifies priority interventions and promotes a budgeted national plan for TB control and elimination with appropriate indicators [4–6].

Mathematical modelling indicates that, in order to reach TB elimination by the fixed deadline, the present annual incidence decline in Europe (2–5%) should gradually increase to approach the level of 20% [2, 3, 7]. According to WHO, this is possible if available prevention, diagnostic and treatment weapons are optimally implemented [2, 8, 9]. These include new generation rapid diagnostics and shorter regimens to treat TB disease (including its resistant forms) and latent TB infection (LTBI) [10, 11].

Examples are available of settings where an “aggressive approach”, based on TB control and elimination interventions, resulted in a rapid reduction in the incidence of TB and an advance towards the pre-elimination phase [12, 13].

This consensus (and call for action) document is aimed at promoting discussion between TB experts, administrators and policymakers in order to ensure that WHO recommendations on TB elimination are implemented in Italy.

In agreement with the principles of the TB elimination framework, we summarise eight core interventions and activities to be included in a roadmap for TB elimination in Italy, which were developed by consensus of representatives of different Italian and international organisations (including the European Respiratory Society) in a meeting organised by the Italian Respiratory Society (SIP/IRS) in Milan on October 5, 2016 (table 1).

• 1) Political commitment with quality anti-TB services. TB control in Italy is presently based on 21 regional plans, which are not necessarily consistent among themselves and with the latest WHO policy documents. The main areas for further work are the management of LTBI and the use of rapid diagnostic tests outside reference centres. TB control and elimination activities need to be adequately funded.

• 2) Improvement of surveillance allowing quality monitoring and evaluation of the programme. Italy should optimise its capacity to submit complete surveillance data to WHO and the European Centre for Disease Prevention and Control in a timely manner, while implementing a consistent plan for national molecular epidemiological surveillance.

• 3) Focus on groups at higher risk of developing TB. A periodic identification of the groups where targeting TB elimination efforts is necessary, based on surveillance data.

• 4) Development of a plan to manage migration-related issues. The number of TB cases among foreign-born individuals has increased and is, today, higher than that of native Italians. In addition, the important migration flow to Europe via land or sea (Italy is among the main migrants' host countries) needs a coherent and coordinated approach [14–16].

• 5) Prioritisation of LTBI testing and treatment in high-risk groups. Diagnosis and treatment of LTBI is the core intervention needed to achieve TB elimination, as it will reduce the “reservoir” of infected individuals from which future cases will be generated [2].

• 6) Prevention and treatment of MDR-TB. Although the absolute number of these cases is not high [17], the complexity and costs of their management, and the potentialities for further nosocomial transmission, call for a targeted approach [2]. Treatment outcome monitoring of MDR-TB should be implemented.

• 7) Fostering of research on new vaccines, diagnostics and drugs. Italy needs to contribute to the global effort towards the acquisition of basic knowledge leading to the development of new anti-TB tools (basic research) and on their optimal implementation (implementation research).

• 8) Global and European coordination of TB elimination efforts. It is common experience that TB does not respect borders and the best way to maintain future generations of TB experts is to actively cooperate in international TB control and elimination activities.

We are confident that TB elimination can be within reach if Italy, together with the other low TB incidence countries in and outside Europe, will seriously embark in a comprehensive plan that incorporates all the core activities discussed above.