Paul Sommerfeld, Executive Trustee, TB Alert and Chair, TB Europe Coalition, walks us through tackling tuberculosis. We hear that while there are continuing problems, there are finally grounds for optimism
Tuberculosis (TB), after COVID, the World’s greatest cause of death from an infectious disease, is an airborne bacterial disease that, although commonly associated with the lungs, can affect many parts of the body and around a third of cases of active disease are outside the lungs. The old name for it, Consumption, was well-merited as, untreated, the person will slowly lose body weight and strength, leading eventually to death.
As an infectious disease, it can reach anyone. Still, while it is present in all countries, today, it is primarily a disease of poverty, with the greatest burden found in the poorer parts of the World, among the poorer and more disadvantaged communities in those countries.
Transfer of resources to combat COVID led to an 18% drop in new cases identified by TB care services between 2019 and 2020 but also to a rise in deaths due to TB. The World Health Organization (WHO) estimates that in 2021 there were 1.6 million deaths from TB. Of those individuals, 187,000 were co-infected with HIV, making TB the greatest cause of death among people with HIV.
Multi-drug resistance (MDR)
Multi-drug resistance (MDR) is a significant problem, with 450,000 new cases of TB being resistant to at least Rifampicin, a major component of the standard regimen for TB. One of the regions most affected by MDR is Eastern Europe and Central Asia, with countries seeing around a third of new cases being affected, now exacerbated by the war in Ukraine.
“Health services must be much more effective…WHO estimates that in 2021 of 10.6 million people with new active disease, 4.2 million or just under 40%, were not seen by regular health services.”
An irony of non-accessibility to new TB drugs
An unintended consequence of drug licensing procedures is that pharmaceutical companies are reluctant to incur registration costs for countries where TB incidence and, thus, the market is small. Thus, in Western Europe, Rifapentine, part of a new regimen for drug-sensitive (i.e. regular) TB that reduces treatment time from 6 to 4 months, is not available for use, even if its high cost could be managed. Similarly, child formulations of the drugs in the standard regimen have been available for over ten years but have yet to be accessible in the West.
Working against TB
With political determination and proper funding, COVID went from a new disease to effective vaccines in 10 months. TB, the next most deadly infectious disease, was left to celebrate in 2022 the centenary of BCG, the limited but still today standard vaccine.
Yet, for all that, it seems too often as though all is back to normal with TB half-forgotten, but this is an exciting time for work against the disease:
- Public policy interest in TB is higher than usual, with a UN High-Level Meeting (HLM) (i.e. Heads of government or senior ministers) on TB expected in September.
- Civil society engagement, although still underfunded, is more commonly recognised and encouraged than ever before, adding a layer of support for TB care.
- Research into new diagnostics, drugs, and vaccines has for years been seriously underfunded. Nonetheless, finally, new tools for TB care are beginning to come into service:
- With new drugs for tackling tuberculosis, there is already a regimen that brings the length of treatment for MDR-TB down from two years or more to six months, the same as the standard regimen for regular drug-sensitive TB.
- While a truly short, few days regimen for drug-sensitive TB is still a long way off, WHO has already approved a 4-month regimen, though because it includes an expensive drug, Rifapentine, it is not yet commonly used except in the U.S. Other short regimens are under active research, and it is probable that alternative 4-month regimens, and even 2–3-month ones, will be approved within the next five years.
- Over the past ten years, the use of a new tool offering a rapid diagnosis of TB has come into common usage, bringing the time between test and result down to a couple of hours instead of days. It also indicates whether MDR is present. Yet, partly for cost reasons, it was in 2021 used for only 38% of people newly diagnosed with TB.
Tackling tuberculosis and the elimination challenges
There are further challenges if the elimination of TB is to be achieved:
- Promising candidate vaccines are being tested to replace BCG and its limitations.
- Better tools are needed to treat latent TB – when the person is infected with TB but does not have active disease. A new regimen exists but includes expensive Rifapentine, so it is little used.
- Health services must be much more effective in reaching everybody who may have TB; WHO estimates that in 2021 of 10.6 million people with new active disease, 4.2 million or just under 40%, were not seen by regular health services.
The global ‘End TB’ target of making TB a rare disease by 2030, defined as a 90% reduction in deaths and an 80% reduction in new cases compared to 2015 figures, remains just achievable if new tools become quickly available and are rapidly brought into use. Hopefully, this year’s UN HLM on TB will generate the necessary political will and financing.
References
1. Global Tuberculosis Report 2022, World Health Organisation https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022
