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HomeBlogTB: Why has it still not been eradicated?

TB: Why has it still not been eradicated?

By: Medix Team
TB: Why has it still not been eradicated?

Tuberculosis is an infectious disease that’s likely to kill more people in Asia this year than Covid-19. But there are finally new treatments and more funding on the horizon.

Does the following disease sound familiar to you: it’s spread by respiratory droplets and largely impacts the lungs, causing inflammation and a potential cytokine storm? It’s also the world’s leading cause of death from a single infectious agent.


But the answer is not Covid-19, which has been responsible for 1.15 million mortalities so far (according to official data reported to the WHO). It is tuberculosis (TB).


The WHO estimates that TB could kill up to 1.8 million people in 2020. That’s 400,000 more deaths than 2019 and three times more fatalities than flu in an average year.


One century ago, TB was the scourge of Europe and the US. These days it’s Asia that’s disproportionally affected, as the disease is still endemic in South East and South Asia (a combined 44% of the global total).


India leads the world with 2.64 million cases in 2019, representing 193 per 100,000 head of population. The figures are even worse in Indonesia and the Philippines on a per head basis, standing at 312 and 554 per 100,000 respectively.


If there is a drop in cases during 2020, then it will not be a positive sign either since the reason is due to a reduction in diagnosis rather than disease. The head of India’s National TB Elimination Programme, for example, reported a 60% decline in case notifications during the country’s lockdown.


Shut clinics means delayed diagnosis and treatment. As the WHO’s director general, Tedros Adhanom Ghebreyesus, recently said: “the Covid-19 pandemic threatens to unwind the gains we’ve made”.  


Back in 2018, the WHO convened a High-Level Meeting between heads of state to formulate a common policy to eradicate TB. The United Nations (UN) also made ending TB a 2030 Sustainable Development Goal: targeting a 90% reduction in deaths and 80% reduction in incidence.


However, researchers writing in The Lancet this October concluded that countries were failing to meet their TB targets even before Covid-19 erupted. The reason lies in how TB differs from Covid-19.


Firstly, it has a bacterial origin: mycobacterium tuberculosis, whereas Covid-19 is a virus. Both infections have a natural reproduction rate above three, if no action is taken to stop them spreading.


However, while patients infected with Covid-19 typically start to show symptoms within two to five days, TB can lie dormant for many years. About one quarter of the world’s population are estimated to have the latent form and most of them don’t even realise it.


TB gets activated and becomes contagious when the patient’s immune system is weakened. The WHO lists the top five triggers as: malnutrition, HIV, diabetes, smoking and alcohol abuse. But any diseases, which leave patients in an immunocompromised state like cancer, for example, make it more likely, as does simply ageing.


The good news is that TB is fairly easy to diagnose even though the symptoms mimic many other diseases: coughing, fever, fatigue, night sweats and unexpected weight loss. Sometimes it can be missed for the 15% of cases where it presents in the lymph nodes (particularly the neck), bones and joints rather than the lungs.  


Latent TB can be uncovered through a skin test involving the injection of a small amount of a substance called PPD tuberlin. For active TB, doctors use the Acid-Fast Bacilli test to analyse a patient’s sputum.


Most forms of active TB are drug-sensitive, which means that they can be cleared with antibiotics.  And there have been new developments, which are changing the way that TB is treated for the first time in almost four decades.


A phase III study by the US Centers for Disease Control and Prevention (CDC) and AIDS Clinical Trials Group reported that a specific four-month long drug regime could be just as effective as a six-month one. Shorter treatment length spells good news for both patients and healthcare providers alike.


Indeed, one of the main reasons why multi drug-resistant TB is growing (up 10% in 2019) is because many patients give up taking their antibiotics before the end of the full course. Some patients also fail to get the right combination of antibiotics because it’s expensive to grow and analyse the bacteria in a lab. Advances in genetic testing of TB strains should help to make this less of an issue.


There’s also the prospect of a new vaccine. The existing BCG (Bacillus Calmette-Guerin) one was named after its developers, Albert Calmette and Camille Guerin, and first administered in 1921.


However, its efficacy varies widely and there’s still limited understanding about why it does, or does not protect individual recipients. It appears to have a much stronger protective effect on children than adults, for instance.


Its existence and the availability of antibiotics are two reasons why TB treatment has not received as much funding as other diseases, which have more limited options. The other relates to geography. TB is now largely confined to developing countries that don’t have the financial resources to devote to the problem as developed ones do.


But earlier this year, the Bill and Melinda Gates Foundation took over the development of a new vaccine candidate, known as M72. Last year, the New England Journal of Medicine reported the full results of its Phase II trials, which showed a 50% drop in active TB cases over a three-year, post-vaccination period.


Other new treatment options include re-vaccinating adolescents. A study, also published in the New England Journal of Medicine, reported a 45% reduction in infection rates among 1,000 South African youths that had been given a second BCG shot.


The UK Medical Research Council is also following up a successful pre-clinical trial on monkeys to deliver the vaccine via an inhaler rather than an injection.


The WHO wants to mobilise an additional $2 billion per annum to invest in TB research by 2022 and $13 billion per annum to improve access to TB diagnosis, treatment and care. This September it released a progress report, which didn’t make for reassuring reading.


So far this year, only $6.5 billion has been raised for diagnosis, half of the target. The WHO acknowledges that progress has been made. But it is not enough and it needs to become far more ambitious if the world is to finally rid itself of a disease that has been around for at least nine millennia.


At the turn of our current century, it was discovered in the bones of a 9,000 year-old mother and baby skeleton off the coast of Israel. Let’s all hope it is no longer in anyone’s bones at the turn of the next!!

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