Opinion: How beating TB today better prepares us for pandemics tomorrow

While some pandemics elicit a 100-day mission, tuberculosis has an unfinished 100-year mission. One of the leading initiatives set up in the wake of COVID-19 is the 100-day mission. It is an effort to ensure that new vaccines, diagnostics, and treatments will be available to tackle a novel pathogen pandemic within 100 days of its initial detection. In stark contrast with the kind of attention COVID-19 sparked, the global fight against tuberculosis gets so little attention that we’re looking at a 100-year timescale. After being overtaken by COVID-19 in 2021, early indications are that TB killed more people in 2022 than any other infectious disease. In 2021, WHO estimated that 10.6 million people got infected with TB and killed nearly 1.6 million individuals, mostly in low- and middle-income countries. Yet, we are continuing to use a century-old vaccine — the BCG — that is largely ineffective in adults, and technologies such as smear microscopy that misses over half of all people with TB. What is lacking is any real sense of urgency from the global community to tackle it. Because TB primarily affects people in the global south, as with other diseases such as malaria or HIV, it seems invisible to people and institutions in the global north. The COVID-19 pandemic delivered a massive hit to nearly all areas of global health. Subsequent inflation and rising costs of staple goods has seen hundreds of millions of additional people fall into poverty. But progress against TB was hit particularly hard. One of the reasons was that TB programs were so well suited to taking on COVID-19 that they were majorly disrupted by the pandemic. As a result, the fight against TB has been set back to levels last seen in 2012, with funding falling by nearly 10%. The strength of a country’s response to TB, especially in LMICs, should be considered a core determinant of their levels of pandemic preparedness. --— Yet, despite the fundamental role that TB services played in most countries at the peak of the COVID-19 pandemic, and the enormous impact of the disease, TB is almost entirely excluded from conversations around pandemic prevention, preparedness, and response, or PPPR. There was no reference to TB at all in the zero draft of the new pandemic accord. Not only is this an unconscionable abandonment of the 10 million people worldwide who contract TB every year, it is also a terrible missed opportunity. A new report published today highlights a series of opportunities for dual impact in the fight against TB and the effort to prepare for future pandemics. Three, in particular, warrant closer consideration. First, we desperately need enhanced case detection for TB, since the gap between the estimated number of cases and number of people detected, diagnosed, and treated has grown to nearly 4 million during the pandemic. Undiagnosed TB has pushed up the TB incidence for the first time in many years. Nearly all countries have scaled up molecular testing and genetic sequencing capacity for COVID-19, and this infrastructure can be used to close diagnostic gaps for TB. Similarly, a sustained effort to further expand the reach of diagnostic services to find the missing 4 million people with TB would bring health services, including private and public sectors, to some of the people most at risk in the event of an outbreak of a novel pathogen. An integrated approach to TB/PPPR diagnostics would also see systems built for tomorrow used today for an immediate health impact. Second, we must keep up the innovation momentum created by COVID-19. The pandemic brought brilliant innovation: in digital health tools, in bringing testing closer to people, in home delivery of medicines, and in advances in different vaccine technologies, e.g., messenger RNA technology. The pandemic also normalized infection control measures for respiratory pathogens, e.g., masks, better ventilation, and air purifiers. COVID-19 presented a massive market opportunity, but as the pandemic subsides there is a risk that potentially transformational technology might not complete development. This would be a missed opportunity for TB and for pandemic preparedness because those technologies would not be in wide use when the next pandemic strikes. In the absence of private backing, public funders should step in to make sure that innovations built for and during COVID-19 are used as widely as possible. For example, the mRNA hub in South Africa is an important resource to leverage for COVID-19 and other endemic infections, to bring locally manufactured technologies to the African region. Third, we should consider TB care the canary in the coal mine of countries’ pandemic preparedness. Current pandemic accountability frameworks rely heavily on on-paper assessments and have been unable to reliably predict a country’s readiness for a real outbreak. Any future pathogen that could have the same impact as COVID-19 is likely to be airborne, with generic respiratory symptoms, and affect the poorest and most vulnerable — all of which applies to TB. As such, TB makes a perfect “tracer indicator” for PPPR and the strength of a country’s response to TB, especially in LMICs, should be considered a core determinant of their levels of pandemic preparedness. At its core, the fight to end TB rests on diagnosing and successfully treating everyone who has the disease. At present, the missing 4 million people with TB, these silent victims of the epidemic, are dying from a lethal respiratory pathogen with generic respiratory symptoms, and are not accessing the right standards of health care. Swap TB for a novel coronavirus in that same population, and you have the ideal conditions for a global pandemic. It is only by focusing on the most marginalized and vulnerable populations, those most left behind, that we can end TB and truly protect ourselves from a future global pandemic. Visit the Talking TB series for more coverage on how we can eliminate tuberculosis by 2030. The time for a paradigm shift and a renewed focus on funding, research, and global solutions is now. Join the conversation by using the hashtag #TalkingTB.