What it takes to push tuberculosis elimination across the finish line

Tuberculosis continues to cast a shadow over global health. In 2022, the disease claimed the lives of 1.3 million people — making it the second leading infectious killer worldwide after COVID-19. Among the 10.6 million who fell ill with TB, about 30% were never diagnosed.  

In response to the ongoing TB epidemic, the global community has rallied around the World Health Organization’s End TB Strategy, a blueprint from 2015 to 2030 aimed at reducing TB incidence by 80%, TB deaths by 90%, and eliminating catastrophic costs for TB-affected households.

But despite advancements toward the targets, progress remains slow, with some of the hard-won gains reversed by the COVID-19 pandemic.

“By 2025, there should be a reduction in TB incidence by 50% compared to 2015, and we are only down 8.7%,” said Dr. Anand Date, global TB branch chief at the U.S. Centers for Disease Control and Prevention, or CDC. “And in terms of mortality, the aim was a 75% reduction by 2025, but we are only at 19% lower.”

However, promising advancements have emerged amid these challenges, including new innovative screening and diagnostic tools and vaccines on the horizon. Increased investments will be key to scaling these initiatives, Date highlighted.

“When it comes to the global TB response, we have always suffered from underinvestment,” said Date, despite the fact that funding for TB is a good return on investment. “For every $1 spent on TB, you get $40 back by 2050. This is one of the best investments we can make — not only in terms of global health and global health security, but also from an economic perspective.”

Sitting down with Devex, Date elaborated on the current challenges, the key steps needed to end TB, and why eliminating the disease goes beyond individual health benefits.

This conversation has been edited for length and clarity.

Approximately 30% of those who developed TB in 2022 were not diagnosed or treated. With that in mind, are the End TB goals within reach?

It’s very important that every individual who has TB disease is identified, diagnosed, put on treatment, and completes the treatment. In fact, this 30% gap in diagnoses even increases to almost 60% for those who develop drug-resistant TB, as it is harder and more costly to detect and treat. If left untreated, one person with TB can infect 10 to 15 additional individuals each year. In addition, 5-10% of those who are infected will develop active TB in their lifetime. And when it comes to children and people living with HIV, that risk is even higher.

There has been steady progress. During the height of the COVID-19 pandemic, there was an 18% decline in TB notifications, but we’ve seen an increase since then. In 2022, the highest-ever number of people, 7.5 million, were diagnosed and put on treatment. We are getting there, but we must adopt and implement all the tools available to tackle the TB epidemic on all fronts.

At CDC, we work with national TB programs to evaluate new screening and diagnostic tools to improve accuracy of case finding. We also work with government partners to improve the quality of TB diagnostic services and expand quality assurance programs.

TB is more common in people living with HIV. The U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, has launched an effort to detect 2 million active TB cases over the next five years and prevent at least 500,000 TB-related deaths among people living with HIV. What needs to improve to achieve these targets?

Almost one-third of all deaths among people living with HIV are due to TB. In 2022, 167,000 people living with HIV, or PLHIV, died from TB. Implementation of a comprehensive package of interventions targeted toward HIV-associated TB is critical to reduce TB-associated illness and deaths among PLHIV.

Antiretroviral treatment is the most effective intervention to reduce TB-associated illness and death among PLHIV. Therefore, it is critical for all PLHIV to initiate antiretroviral treatment early. Ongoing TB case finding among PLHIV using sensitive TB screening and diagnostic tools, including among individuals with advanced HIV disease and children living with HIV, and appropriate treatment for those diagnosed with TB is critical.

Provision of TB preventive treatment to all PLHIV can further reduce TB-related illness and death among PLHIV. It can also complement and amplify the protective benefit of antiretroviral treatment — reducing TB-related illness and deaths. Finally, infection prevention and control practices can help the prevention of TB transmission in health facilities, protecting health care workers and clients.

CDC and our partners are committed to saving more lives by improving TB case finding among PLHIV by adopting more sensitive tools and expanding access to TB preventive treatment. From 2018 to 2022, CDC supported the initiation of TB preventive treatment for 13.2 million PLHIV through PEPFAR. In 2022, CDC supported TB screenings for 10.2 million people living with HIV.

With any global public health threat, continued investments are always a talking point. Why are increased investments in TB necessary?

When it comes to the global TB response, we have always suffered from underinvestment. We have existing efficient tools to better identify cases and reduce treatment times but are unable to scale to all affected countries. Additional investments are needed not only to scale up existing efficient tools, but also to develop point of care diagnostics, even shorter and better treatment regimen and development of TB vaccine that would help in ending the global TB epidemic.

Investing in TB would not only help us build a robust TB response, but it can also help get us ready for the next pandemic. As we saw during COVID-19, a lot of human resources, such as lung specialists, were critical in responding to the pandemic. And some of the diagnostic tools used for TB were utilized for COVID-19 testing. We don't have to prepare for a hypothetical pandemic, we have a pandemic on our hands — TB. And if we know how to tackle, manage, and end TB, we'll be ready for the next pandemic.

Another point is, all TB services are delivered and provided through the general health system. With any investment we make in TB, we are by default improving primary health care, diagnostic services, and infrastructure. So, it's really helping us not only for TB response, but also strengthening primary health care  as well as contributing toward the broader agenda of universal health coverage.

And finally, drug-resistant TB is a major contributor to antimicrobial resistance. If left unchecked, the spread of drug-resistant TB will lead to tremendous economic burdens and many lives lost. So, a multifaceted TB response has a broad-ranging application and return on investment, not only from an economic perspective but also from a pandemic preparedness perspective, universal health coverage perspective, and antimicrobial resistance perspective. I cannot think of any smarter investment.

A published study, along with historical evidence from TB elimination in high-income countries, indicates that prolonged intensive active case finding may be sufficient to end TB when accompanied by concrete measures to address TB social determinants and health system failures. What is your stance on this?

While finding every person with TB and putting them on treatment is critical to break the chain of transmission, we cannot put an end to this epidemic by simply finding cases and treating them. It needs to be a comprehensive approach including prevention interventions as well as management of social determinants and health system failures.

Even in countries like the United States or European countries which are closer to TB elimination, the current approach is focused on finding those infected with latent TB and providing TB preventive treatment to prevent them from developing active TB disease. You cannot treat yourself out of this epidemic — prevention remains critical. We need to have a comprehensive approach to realistically achieve the End TB targets and Sustainable Development Goals.

Finally, what are your calls to action and takeaways for our audience?

First, if we are serious about ending TB, there must be a comprehensive response. And there needs to be commitment and accountability at all levels.

Secondly, new investments can help to scale up existing tools — like newer diagnostics, drug regimens, and service delivery models — are paramount. We also cannot eliminate any infectious disease without an effective vaccine, and strong commitments are required to achieve it.

From the CDC perspective, we are committed to standing shoulder to shoulder with our partners and ensuring we contribute scientific and technical expertise, epidemiology, surveillance, and enhanced lab systems to cross the finish line and end TB once and for all.

Learn more about CDC’s work to prevent, diagnose, and treat TB globally here.