Lancet Commission calls for a reboot on global tuberculosis response
By Mike Reid, MD
As the United Nations High-Level Meeting (UNHLM) on tuberculosis (TB) approaches, a new report from the Lancet Commission on tuberculosis releases recommendations to turn the tide on this preventable, treatable and curable disease.
For the first time in 20 years, there has been an increase in TB deaths — rising from 1.4 million in 2019 to 1.6 million in 2021 — as COVID-19 erased years of reduction in TB mortality rates. Moreover, there has been a troubling decline in the number of people diagnosed with TB. It is estimated that one-third of people with TB went undiagnosed and untreated in 2022. The COVID pandemic had a significant impact on the ability of global health systems to prevent, screen and treat TB. COVID-19 quickly and substantially disrupted TB response efforts as diagnostic infrastructure was diverted away from TB programs and shutdowns led to reduced access to TB treatment services. In almost all high TB burden countries, COVID-19 resulted in health worker shortages and burnout, further diminishing health systems’ capacity to provide essential TB services. COVID-19 also had a negative effect on many countries’ abilities to invest in health, with precious resources for health programs being diverted to respond to COVID-19 and economic disruptions impacting governments’ abilities to prioritize health moving forward.
“Progress on fighting TB has been stalled, but we can and must get back on track. As this new critical report states, we must focus on a new menu of tools that have the potential to revolutionize TB prevention, diagnosis and treatment,” said. Eric Goosby, MD, a professor of medicine at UCSF who was the co-chair of the Lancet Commission and former UN Secretary-General's Special Envoy on Tuberculosis from 2015 to 2018.
Lancet Commission report endorses new menu of tools
New treatment regimens and several late-stage vaccine candidates present an incredible opportunity to make major inroads in preventing TB deaths. Recommendations put forth by the commission include:
- Immediate scale-up in access to molecular diagnostics and AI-assisted chest x-ray technology.
- Sustained investments in research and development to accelerate progress on new tools including tongue swabs, urine-based antigen tests and improved screening tools, all of which are faster and more accurate than sputum tests, which can take one to eight weeks to provide results.
- Addressing malnutrition as a major risk factor for TB with more than a third of annual TB incidence attributable to undernutrition — especially in Southeast Asia. Recent research illustrates the positive impact of giving food baskets to patients with TB and their closest contacts. In a large study in India, better nutrition in patients with TB reduced the incidence of infection by nearly 50 percent while reducing mortality among those treated for TB by nearly 60 percent.
- Endorsement of the 1/4/6x24 campaign, an effort to bring new, shorter TB regimens that are safe and effective to as many countries as possible by 2024. Specifically, the report outlines recommendations for ensuring access to one-month or once-a-week regimens for TB prevention, a four-month regimen for drug-sensitive TB and a six-month regimen for drug-resistant TB.
“The newer, shorter 1/4/6 TB treatment regimens can have a huge impact on adherence and efficacy,” said Soumya Swaminathan, the Commission’s co-chair and a former World Health Organization Chief Scientist. “To maximize the impact of these significant treatment breakthroughs, we need more countries adopting the new treatment paths faster. Adjunct therapies like nutritional support can also go a long way in reducing deaths due to TB.”
Recommendations for The Global Fund to Fight AIDS, TB and Malaria
The cost of inaction on TB is massive. More than 27 million deaths and more than $13 trillion in economic losses will result if there is a business-as-usual trajectory between now and 2050. A recent estimate commissioned by the STOP TB Partnership proposes a near-term target of $15 billion a year, rising to $20 billion in 2025, to end TB by 2030. This estimate considers lost ground due to COVID-19 and acceleration in the development of new tools.
Donor financing plays a significant role in funding TB resources in many low- and middle-income countries. TB receives less funding from the Global Fund compared to HIV and malaria even though TB accounts for 61 percent of global deaths caused by the three diseases. The report recommends that the Global Fund allocate more money to TB based on disease burden and cost-effectiveness. It also suggests prioritizing the increase in TB support for low-income countries with higher TB mortality.
This new report is a follow-up to the 2019 Lancet Commission on tuberculosis. The first report outlined a blueprint for reaching the goals set by the first UNHLM in 2018. While progress has been made in some areas, the targets of the UNHLM have not yet been achieved. Some African countries have sustained declines in TB mortality, but more than seven million people have died from TB in the past five years, emphasizing the urgency to accelerate efforts.
This year’s UNHLM on TB is taking place on September 22 and presents a critical opportunity to mobilize political will and resources to scale up new technology, emphasizing affordability and availability.
“TB advocates and survivors like me know there aren’t a lot of opportunities to shed light on this disease despite its impact on so many people across the world. We are demanding that countries step up and prioritize the funding and technology that will get us to a TB-free world,” said Nandita Venkatesan, TB survivor champion and journalist.
In addition to holding a High-Level Meeting on TB, additional meetings will focus on pandemic preparedness and response (PPR) and universal health coverage (UHC). The Commission highlights several areas where aligning global TB efforts with the PPR and UHC agendas would be mutually beneficial, emphasizing that investing in PPR should be synergistic with efforts to end TB.
Funding: The Lancet Commission received support from the United States Agency for International Development through Supporting, Mobilizing, and Accelerating Research for Tuberculosis Elimination, a five-year cooperative agreement that aims to transform TB prevention and care.
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