Tuberculosis kills more than 1.6 million people a year worldwide – more than any other infectious disease – while one-fourth of the population is infected with the bacteria that causes TB.
A disease so devastating, the World Health Organization (WHO) declared TB a public health crisis in 1993. In addition to its toll on physical health, TB has caused economic devastation for families, communities and countries that are hit the hardest. Women, children and those with HIV/AIDS are among the vulnerable.
Yet, TB has flown largely under the global health radar – until now.
On March 20, The Lancet Commission on TB – which is led by UCSF researchers – issued a report that offers a roadmap to eliminate TB, possibly by 2045. It calls for increased investment in evidence-based interventions to diagnose, treat and prevent TB, especially in high-burden countries.
“This report is optimistic about ending TB – a disease that is preventable, treatable and curable,” said lead Commissioner Eric Goosby, MD, UN Special Envoy on Tuberculosis and director of the Center for Global Health Delivery and Diplomacy at the UCSF Institute for Global Health Sciences. “However, there is no room for complacency in our work, and we must act quickly and strategically to save the next generation from TB.”
The Lancet Commission on TB makes policy and investment recommendations to countries with high levels of TB and their development partners. The report is the work of 37 commissioners from 13 countries, including UCSF's Philip Hopewell, MD, Dean Jamison, PhD and Michael Reid, MD. The Commission’s report, “Building a TB-Free World,” is published, in the The Lancet Global Health journal.
The report includes economic analyses and modeling of interventions to counter treatment challenges (drug-resistant TB, HIV co-infection, and treatment within private health systems), which are published in detail in an accompanying research paper in The Lancet Global Health journal.
“People affected by tuberculosis are often among the most poor, marginalized, and stigmatized in their communities, and it is hard to escape the conclusion that the chronic underfunding and underappreciation of tuberculosis are reflections of their social and economic status,” wrote Lancet editors Elizabeth Zuccala and Richard Horton in an accompanying editorial.
“Another 25 years of lost time on ending tuberculosis cannot be an option,” they stated.
While a comprehensive worldwide effort to end TB is long overdue, current momentum and opportunity open a timely window to address and solve the disease.
In the fall of 2018, the first-ever United Nations High-Level Meeting on TB – which included heads of state – made ending the disease a global priority. They adopted goals to treat 40 million people and prevent 30 million new cases between now and 2022.
And the Lancet Commission responded to the urgency by producing its report just five months after that meeting.
“While there are many challenges to ending TB, we have the potential right now to address this problem," says report co-author Michael Reid, MD, of UCSF. " “With sound science, political will and shared responsibility, TB is a solvable problem.”
The report – a roadmap to ending TB – includes key priorities and messages:
Reaching high risk groups, expanding interventions
Many people with TB, especially the poorest, cannot access or afford services, and heath systems are often too slow to identify cases. Currently, more than one-third of TB cases are not diagnosed or treated.
The report calls for delivering patient-centered care, strengthening prevention efforts, identifying high risk groups and bringing them into care, and providing universal access to drug susceptibility testing and medications for all who are found to have drug-resistant TB.
In Moldava, where more than 25 percent of all TB is drug resistant, increasing interventions could reduce TB deaths by 73 percent and new cases by 44 percent by 2045, according to the report.
Identifying and treating the high-risk groups is acutely important for people with HIV, whose weakened immune systems leave them susceptible to TB. In Kenya alone, where HIV/TB co-infection are particularly high, scaling up access to both retroviral and TB preventive therapy can save three million lives between now and 2045, the report estimates.
In high-burden countries, private health care is often the main route for diagnosis and treatment. So, the report calls on donors and countries to engage with the private sector to improve and increase care. In India, the country with the largest TB burden, subsidizing tests and supporting patients to complete treatment could avert an estimated eight million deaths from TB in the next 30 years, according to the report.
Shared responsibility, accountability
The report calls for greater accountability at all levels, from Heads of State to local TB clinics, to drive the change necessary to end the TB pandemic.
Authors call for country-specific report cards to measure progress and to determine where more resources are needed; engaging stakeholders from industry, civil society, government ministries and the private sector; establishing a “Lancet Observatory” to independently evaluate progress; and ensuring that TB survivors and their advocates have a voice in policy-related decisions.
Investing in science, innovation and development
Report authors assert that global research investment needs to increase by up to four times (from $726 million in 2016) to develop treatments and prevention tools to transform TB outcomes.
The report calls for countries affected by TB, donor nations, private sector and philanthropies to devise effective financing strategies to end the TB epidemic. And it urges more public finances be allocated to TB (from raising GDP levels, taxing tobacco and alcohol and increasing health insurance) in addition to increased investment in local expertise and infrastructure.
Ensuring that 90 percent of persons are identified, diagnosed and treated, and ensuring 90 percent treatment success can avert 2.2 million deaths a year. Developing new tools for prevention, diagnosis and treatment could avert the remaining 10 percent – or 800,000 annual deaths –urged report authors.
Solutions and tools to end TB do not have to come from only the countries largely burdened by the disease. With its riches of innovators in academia and the technology sector, the Bay Area can help revolutionize TB care for those who need it the most, said UCSF’s Michael Reid.
“Imagine a world in which public health officials in rural Kenya or urban Mumbai had the data streams of Google, the analytical power of Cisco, the outreach of Facebook, and the delivery capacity of Uber?” said Reid. “If academic partners at places like UCSF, UC Berkeley and Stanford partner effectively with the tech giants of Silicon Valley, there is no reason to think that we cannot rid the planet of this ancient and destructive disease.”
Investing in TB has a strong return on investment, with an estimated $16-82 return for every dollar spent on TB research and development. Similarly, TB control could produce considerable economic benefits for high-burden countries, with savings three to seven times higher for every TB death averted, the report authors estimate.