Like COVID, TB is a pandemic and must be treated as an emergency
Context: In 1993, the World Health Organization (WHO) declared tuberculosis (TB) a global public health emergency. It urged nations to coordinate efforts to avert millions of deaths. In January 2020, the WHO declared COVID-19, another airborne infectious disease, a public health emergency of international concern.
The similarity between the global responses to these two pandemics ends there.
The scientific, public health, medical, and pharmaceutical communities’ responses to COVID-19 in the past two years has been spectacular.
Within two weeks of declaring COVID-19 a global emergency, the WHO had convened a meeting of experts and issued a research roadmap. National governments rapidly committed vast sums of money into research at all levels, from basic virology and immunology to clinical care and prevention. Pharmaceutical companies launched development programmes for new products to diagnose, treat and prevent COVID-19. As a result, diagnostics, therapeutics and vaccines were developed at a dizzying pace, delivering an array of tools to control and end the SARS-CoV-2 pandemic.
The effective and equitable deployment of those tools is a challenge. But no one can say that science has been found wanting in responding to the global crisis.
TB, on the other hand, has not been treated as a true emergency. Yet its worldwide distribution, impact on health, and mortality burden was just as dire. TB incidence remains plateaued at 10 million cases per year.
In 2020 case detection fell by almost 20 per cent and mortality rose for the first time in a decade to 1.5 million deaths. These setbacks are directly attributable to the COVID-19 pandemic.
The COVID-19 pandemic is different from the TB pandemic in many ways, with its sudden appearance, rapid worldwide spread and broad impact on individuals and communities. Nevertheless, TB remains a major killer and the pace of TB clinical research can best be described as glacial.
Triumphs despite long timelines
Even with limited funding, there have been some triumphs in TB research in the past decade:
Molecular assays make diagnosis possible in less than 2 hours
Treatment of multidrug resistant TB has been shortened and made easier
Treatment of drug-susceptible TB has been shortened
Treatment of TB infection has been cut, with safer and better tolerated regimens.
But all of these transformative advances took far longer than they should have.
Funding opportunities for TB biomedical research are fewer and the reviews of TB applications are slow.
The overall timeline for conducting critically important TB research is scandalously long.
Most studies are unnecessarily prolonged by long administrative and regulatory review processes.
The broader problem, however, is much larger than the mechanics of individual funding agencies or regulatory bodies.
First, nobody is treating TB as an actual emergency. As we have seen with COVID-19, when everyone thinks it is an emergency, people act differently, and things move rapidly.
Second, the clinical and public health research infrastructure is vastly underfunded and under-supported. COVID-19 has demonstrated what is possible when researchers, funders, and regulatory agencies unite to confront a crisis. Game-changing trials can be conducted in record time without cutting corners and compromising participant safety and scientific integrity, if everyone behaves like it is an emergency. But to do so requires a radical change in mindset in addition to substantially greater human and financial resources.
How to accelerate progress – The Way Forward
Operating in crisis mode for COVID-19, TB, or any other health catastrophe, is difficult to sustain. But the COVID-19 pandemic has shown what works to accelerate progress against a global threat.
First, substantial funding for priority research multiplies innovation and progress. As a starting point, governments, pharma / biotech companies, and foundations must increase investment in TB research, at least to the levels laid out in the UN High Level Meeting Report and make TB a central element in global pandemic response strategies. Governments and other funders must commit more to end TB by 2030.
Second, the funding timeline can be greatly reduced. If the rationale for faster review of biomedical research in HIV and COVID-19 was that these infections would rapidly spread and kill, then TB grants should likewise be reviewed rapidly.
Third, the regulatory bottleneck must be cleared. There must be more investment in the regulatory and ethics infrastructure (including training and international coordination) so that these vital requirements do not suffocate innovative research.
Finally, governments must treat TB as a central element in global pandemic response strategies. The new focus on pandemic preparedness — most notably the beginning of negotiations at WHO to create a legally binding pandemic treaty or similar mechanism — must include a commitment to end ongoing pandemics such as TB. If an annual 1.5 million deaths due to TB is not a pandemic, then what is?
Ending social stigma: TB is not a health issue alone. It is a broader societal challenge. Patients often hesitate to seek treatment or deny their condition altogether for fear of losing social standing. The consequence is that TB becomes a death sentence for many even though it is a fully curable illness. Women are disproportionately affected with estimates suggesting that 100,000 Indian women are asked to leave their homes every year after being diagnosed with TB.
Conclusion
Advances in TB diagnostics, treatments and prevention need to be pursued and scaled up with the urgency they deserve. If we do not behave like TB is a global health emergency, we will continue to experience unacceptable suffering from a disease that has killed more than 20 million people in this century alone.
Value Addition:
India’s contribution towards eliminating TB
Eliminating TB by 2025: India is committed to eliminating tuberculosis by 2025, five years ahead of the global target of 2030.
National Tuberculosis Elimination Programme: To align with the ambitious goal, the programme has been renamed from the Revised National Tuberculosis Control Programme (RNTCP) to National Tuberculosis Elimination Programme (NTEP
Addressing all co-morbidities and goes beyond medical interventions to tackle the social determinants of TB while minimizing access barriers to diagnosis and treatment.
Through the Nikshay Poshan Yojana, nutritional support is extended to all TB patients for the entire duration of their treatment.
Rigorously working towards Airborne Infection Control in hospital wards and outpatient waiting areas.
Has the provision of chemoprophylaxis against TB disease in pediatric contacts of TB patients and PLHIV patients.
The process is ongoing for expanding TB preventive treatment for the adult contacts too.
‘TB Mukt Bharat Abhiyaan’ has been launched as a people’s movement for TB elimination in India.
India remains committed to supporting countries in its neighbourhood with possible technical support and assistance.
Tuberculosis is a social disease –
Due to overcrowding and malnutrition, it disproportionately affects the poor and the marginalised.
The stigma and myths associated with this disease lead to underreporting and under-diagnosis.
The long-drawn multi-drug treatment leads to poor compliance and drug-resistance, which hamper recovery.
Complications increase with a pre-existing illness like diabetes or co-infection with HIV.
Finally, the chronic nature of the disease and propensity to damage multiple organs increase mortality risk.
Can you answer the following question?
If we do not behave like TB is a global health emergency, we will continue to experience unacceptable suffering from a disease that has killed more than 20 million people in this century alone. Comment.
