Tuberculosis finally catching up to 21st century

This was originally published on Global Health TV on March 24, 2014.

Tuberculosis (TB) treatment, which had been lost in a time warp for a century, seems to be finally joining the 21^st century.

Until recently, there were no new TB drugs on the market in half a century, little progress in the treatment of multidrug-resistant (MDR) and extensively drug-resistant (XDR) forms of TB and virtually nothing new on pediatric TB, according to David Greeley, the president and CEO of Accordia Global Health Foundation, who previously worked for the TB Alliance. The current vaccine, developed more than a century ago, is largely ineffective, he said. TB diagnostics were ancient, too, as is TB itself, which has been around since 4,000 B.C. Current treatment was cheap and sometimes effective but took a long time and misses a lot of people  (like children, and MDR and XDR patients).

Which is why the Stop TB Partnership has made those missing people the theme of this year’s World TB Day on March 24: “Reach the 3 Million.” That’s the number of TB patients the World Health Organization (WHO) estimates are “missed” by public health systems out of the 8.6 million who fall ill of TB each year.  Many of those 3 million live in the world’s poorest, most vulnerable communities and include groups such as migrants, miners, drug users and sex workers. Over 95% of TB deaths occur in low- and middle-income countries. India and China are the countries with the most TB patients.

But much is changing for the better: The number of people falling ill from TB each year has declined for the last decade, albeit slowly, which means that the world has already achieved the Millennium Development Goal to reverse the spread of TB. This week, The Lancet published research that China has halved its TB prevalence in 20 years.

 “I’m much more optimistic than I was five or ten years ago, “ Dr. Mario Raviglione, director of the Global Tuberculosis Program at WHO, told me this week. Dr. Raviglione gave three reasons for his optimism:

• New tools, like “Xpert,” a rapid molecular diagnostic test, which greatly improves the detection of TB.
• Two new drugs, the first in half a century. They are limited to MDR-TB for the moment but could be expanded to normal TB if funding is increased.
• A new push for universal health coverage. “The implication of this on TB is major,” said Dr. Raviglione. “TB is a disease of poverty. Pretending that we can control it without addressing the issue of the cost to the patient and the loss of income during the treatment period is simply foolish. The global push for universal health coverage is a unique opportunity to address TB.”

And now there is evidence that we may be on the verge of a major advance in TB control. Last week, Colorado State University research revealed that even the most intractable cases of TB might be effectively treated with a new drug cocktail combining conventional antibiotics and nontoxic compounds that mimic those found in some sea sponges.

“It’s certainly one of the most exciting ideas that I’ve heard for a long time,” said Dr. Raviglione. “It’s addressing probably the Number 1 crucial point about TB: If people discover how to deal with persisting organisms – what some call latent infection – then we probably will have a solution TB. I don’t dare to call it a paradigm shift. But it’s certainly something that could become a paradigm shift.”

“We need to push TB treatment off this plateau it’s been on for too many years,” said Greeley. “New drugs that can treat TB and drug-resistant TB more quickly, simply and cost-effectively are urgently needed.”

TB is second only to AIDS among infectious diseases and kills twice as many people as malaria. In 2012, 8.6 million people fell ill from TB and 1.3 million died of it, according to the WHO Fact Sheet on TB. While global death rates from some of the biggest infectious disease killers have dropped markedly in recent years, mortality rates from TB have been the same, with 1.5 to 2 million people dying each year from the curable disease. 

In addition to the 3 million people missing from the system, Dr. Raviglione sees three other major issues on World TB Day 2014:

• MDR-TB: Fortunately, 95% of TB cases in the world are not MDR or XDR. But there are pockets – such as Belarus, Ukraine and Uzbekistan – where up to one third of TB cases are MDR. These cases are extremely difficult to diagnose and treat.
• TB associated with HIV/AIDS: TB is a leading killer of people living with HIV, causing one quarter of all deaths. 75% of HIV-TB co-infections are in Africa. There has been significant progress in this area in the last 6-7 years, said Dr. Raviglione. “There is no reason why only 50% of people co-infected with TB and HIV are receiving anti-retroviral drugs,” he said. “It should be 100%.”
• Resources: Around $5-6 billion is spent on TB each year even though WHO believes that $8 billion should be spent, leaving a gap of $1.5-2 billion, said Dr. Raviglione. Unlike the response to AIDS and malaria, where international donors are carrying the load in most countries, 80% of the funding for TB comes from the recipient countries themselves; only 20% comes from international donors.

Dr. Raviglione said there “is no question in my mind that TB is badly underfunded compared to AIDS and malaria.” AIDS gets far more funding than TB despite the facts that the health burdens of the two diseases are comparable, he said, and TB kills more people than malaria.