Opinion: Tuberculosis, an infectious killer that never got its due

Tuberculosis was the top infectious killer before COVID-19. Yet it never made sensational headlines, and it continues to silently take millions of lives around the world. In 2020 alone, TB killed 1.5 million people, according to the World Health Organization’s latest “Global Tuberculosis Report,” while COVID-19 killed 1.7 million that year.

The key difference in these figures? TB deaths primarily took place in the developing world, where communities are faced with multiple barriers to care — including inadequate access to transport, food, social support, counseling, and TB information — and with the fear of being stigmatized.

The disease has been largely ignored for centuries, but the affected TB community has held on to hope in recent years, particularly as promises and commitments were made at the United Nations’ 2018 high-level meeting on TB in New York.

But that hope was short-lived. Governments did not fulfill their promises, and the most striking evidence of this is the lack of financial resources dedicated to TB.

At the high-level meeting, a modest annual commitment of $2 billion was sought for TB research and development, including for diagnostics, vaccines, and other drugs. Yet not even half of this value was achieved in the years to follow, with the highest amount raised standing at $915 million in 2020.

Cumulative funding for TB research between 2016 and 2020 amounted to $4.2 billion, or less than half of the $9 billion financing target called for in the Stop TB Partnership’s Global Plan to End TB 2016-2020. These numbers pale in comparison to the €93 billion — that is, around $100 billion — invested in COVID-19 vaccines and therapeutics alone in 2020. That figure is over 100 times more than the $915 million spent by all funders on TB research that year and over 150 times more than the $641 million spent by governments.

Since the outbreak of COVID-19, pandemic preparedness efforts have been moving in full swing. Increased funding and resources, including public funding, have been given to organizations like the Coalition for Epidemic Preparedness Innovations — yet existing pandemics like TB do not feature anywhere in these conversations. Unless we jointly collaborate in these efforts, ending TB by 2030 will continue to remain a distant dream.

The threat of antimicrobial resistance

Even before COVID-19, an estimated 500,000 people had drug-resistant TB, yet only 1 in 3 accessed treatment in 2020.

With drug-resistant TB on the rise, the disease threatens efforts aimed at fighting antimicrobial resistance, or AMR — the ability of microorganisms to withstand antimicrobial treatments — thus posing a major risk to global public health.

TB currently causes more than one-third of all AMR deaths, yet it continues to be neglected even in this space and is setting us up for future public health catastrophes. TB does not feature in the “critical” priority grouping — nor in the high- or medium-priority grouping — of WHO’s priority pathogens list for R&D of new antibiotics.

According to the publication, “Mycobacteria (including Mycobacterium tuberculosis, the cause of human tuberculosis), was not subjected to review for inclusion in this prioritization exercise as it is already a globally established priority for which innovative new treatments are urgently needed.”

Furthermore, TB is not mentioned — even once — in the 2021-2022 annual report of the Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator. Meanwhile, research has shown that AMR is expected to kill 10 million people per year by 2050. New tools and investments in R&D are crucial in the fight against TB and AMR.

Prevention is key

TB prevention is key to tackling any global health response, particularly with infectious diseases. Political commitments to prevent TB are not being reached. We continue to use a 100-year-old vaccine that is ineffective in preventing TB in adults. Cumulative expenditure on vaccine research between 2018 and 2020 was merely $345 million.

To reach the $3 billion investment target for vaccine research called for in the Stop TB Partnership’s updated Global Plan to End TB, an additional $2.7 billion would be needed over the next two years. In October, the TB Vaccine Advocacy Roadmap coalition asked governments in the G-20 group of nations for $1 billion per year based on previous underspending.

Apart from investments in a TB vaccine, urgent action is needed for national TB programs across the world to scale-up TB preventive therapy, or TPT, to those in need. This includes all people living with HIV; close contact of people with TB, including children; and people who previously had TB. Action is also needed to make it easier for communities to complete TPT by improving decentralized care, as was done for COVID-19.

We call on country leaders to prioritize universal infection prevention and control measures and to use context-appropriate advocacy campaigns to raise awareness about adequate ventilation, as well as the use of masks by the public and respirators by health workers, to reduce the transmission of both COVID-19 and TB.

As the world gears up for the next U.N. high-level meeting on TB in 2023, it is time we hold governments accountable for the millions of lives lost to a preventable and curable disease like TB and the lack of investments to ensure we are on track to meet the 2030 goal to end TB. As members of the affected TB community, we look at the G-20 for leadership and resolve to save these precious lives with effective preventive measures and urgent, necessary investments.