Tuberculosis (TB) is one of the world’s principal causes of death due to infectious disease. Before 2020, technical innovations in diagnostics, therapies, service delivery, and vaccine development had hinted at a promising future for TB control. But while the annual incidence of new cases had decreased compared to 2015, progress in meeting targets set in the Sustainable Development Goals by 2030 was off track, and the spread of drug-resistant TB (DR-TB), including multi-drug resistant TB (MDR-TB), as well as persistent high rates of TB coinfection with human immunodeficiency virus (HIV), remained key challenges, particularly in lower- and middle-income countries.
Since 2020, the Covid-19 pandemic has worsened the global outlook for TB in multiple ways. As efforts to close gaps, restore health services, and prepare for future health emergencies unfold, it will be important to increase financial commitments for TB programs worldwide, prioritize TB and MDR-TB within pandemic-preparedness initiatives, and ensure that innovations and adaptations from the Covid-19 response inform efforts to address the global challenge of TB.
Following the introduction and widespread use of antibiotics in the mid-twentieth century, improvements in testing, contact tracing, and treatment had led to a decline in TB cases and deaths by the mid-1980s. However, the HIV epidemic, along with political instability, rapid urbanization, and increasing rates of injection drug use in some parts of the world, drove a global resurgence of TB in the 1990s and early 2000s. This turnaround led the World Health Organization (WHO) to declare TB a global health emergency in 1993.
To accelerate efforts to reduce the incidence of TB and its associated deaths, as well as to encourage greater commitments to drug discovery and new service-delivery platforms, the WHO launched the End TB Strategy. Adopted in 2014 by the World Health Assembly, it envisioned a world “free of TB, with zero deaths, disease and suffering due to the disease” by 2035.
The health security risks posed by DR-TB, which account for more than 30 percent of all deaths globally from antimicrobial resistance, also became a greater focus of international attention. At the UN High-Level Meeting on the Fight Against Tuberculosis in 2018—a year in which there were an estimated 500,000 new cases of MDR-TB, with just 187,000 cases detected and only 156,000 of those patients enrolled in treatment—global leaders gathered in New York to chart a roadmap for realizing the ambitious SDG targets and End TB Strategy aspirations.
But while political commitments regarding TB in general, and MDR-TB in particular, had gained momentum, financing to meet global targets was more limited. Importantly, in 2018, leaders promised “to mobilize sufficient and sustainable financing, with the aim of increasing overall global investments” for TB to at least $13 billion per year by 2022. However, in 2020 just $5.3 billion, less than half the target, was committed.
In 2018, just 16 percent of funds for all TB programming globally came from development assistance accounts, with nearly three-quarters of external funds for TB coming from just one source, the Global Fund to Fight AIDS, TB, and Malaria (the Global Fund). The resources the fund allocates to MDR-TB activities in lower- and middle-income countries have tripled since 2015, but these grants still represent a small proportion of overall TB spending, which most governments fund with domestic resources. Through its support for the Global Fund—to which it has contributed more than $17 billion to date—and its bilateral assistance activities in over 50 countries, the United States government is a key donor supporting global TB programs. U.S. bilateral support for global TB programs has steadily increased since 2015, rising from $240 million per year in 2016 to $332 million in 2021.
From 2014 to 2019, TB was the number one cause of death due to infectious disease worldwide. And while TB has dropped to second place due to Covid-19, the gaps in TB notifications and delays in patient access to treatment in 2020 and 2021 suggest that TB may be poised to regain its leading status once the acute phase of the pandemic passes. Recent data show that the annual number of TB deaths globally increased in 2020 for the first time in 10 years.
Pandemic-era lockdowns and the rapid shift of resources from routine TB services to Covid-19 response have undermined efforts to accelerate testing for and treatment of TB around the world—within high- and low-income countries alike. Supply chain disruptions have made access to diagnostic services and medicine a challenge for many TB patients. During the pandemic, some have lost access to routine monitoring and counseling activities that help them adhere to treatment regimens. The TB Preventive Treatment (TPT) enrollment of people vulnerable to TB infection (or activation of a latent TB infection) dropped between 30 and 70 percent in 2020, while the provision of the BCG vaccine to newborns decreased an estimated 60 percent, in part because of the diversion of BCG vaccines for study and use in adult Covid-19 patients.
The decreases in TB diagnoses and notifications in the populous BRICS countries (Brazil, Russia, India, China, and South Africa), where half of all TB patients worldwide live, are particularly alarming. For example, the Global Fund reported that India had 20 percent fewer notifications in 2020. And in northeastern Brazil, a comparison of TB notifications in 2019 and 2020 showed a significant reduction in TB diagnoses following the Covid-19 outbreak.
Despite the challenges that Covid-19 poses to progress in meeting global TB goals, it is important to recognize the ways in which existing approaches for TB prevention, testing, and treatment, such as the use of personal protective equipment (PPE), high-flow ventilation, and contact tracing, have contributed to the health sector’s readiness for and response to a pandemic. Likewise, there are several program innovations or adaptations from within the Covid-19 response:
- The widespread use of digital technologies in gathering and disseminating information for Covid-19 has revolutionized some elements of the approach to respiratory diseases with an overlapping set of symptoms. Contact tracing has long been used within the TB field to identify networks of people who may have been exposed to someone infected with TB. But whereas the TB community has traditionally depended on phone calls and direct outreach to find people who may have been exposed, contact tracing methods during the pandemic have been significantly refined, with rapid scale-up of relational databases and geospatial mapping to pinpoint potential contacts of people who have tested positive for coronavirus. Several studies have also shown that the widespread adoption of digital apps to trace contacts and notify people that they may have been exposed to Covid-19 can prompt behaviors that result in significant reductions in infections.
Prior to the pandemic, low- and middle-income countries had already begun to scale up the use of molecular platforms such as GeneXpert to diagnose cases of TB and MDR-TB. Having limited access to tests specifically for SARS-CoV-2, the virus that causes Covid-19, many countries used their existing GeneXpert technology to test for coronavirus while awaiting the arrival of lower-cost diagnostic materials. Using GeneXpert to differentiate among several respiratory ailments and confirm TB diagnosis offers the benefit of being able to screen patients and initiate them on TB treatment as quickly as possible.
The rapid collection and dissemination of data under Covid-19 also has implications for TB. Researchers focused on TB have lamented the slow pace at which information has been made available, often several years after it is collected. However, the accelerated collection, analysis, and public dissemination of Covid-19 data through hundreds of trackers that are updated multiple times a day suggest the potential for observing trends in real time and assessing policy and program efficacy for other conditions, such as TB.
- Pandemic-inspired innovations in the service delivery context have also improved the outlook for some TB patients. During the Covid-19 crisis, medication monitoring and counseling, which previously required patients to meet with clinical staff on a regular basis, have become more irregular. But the shift to telephone monitoring and telehealth visits has improved access to care for some patients who were unable to make it to appointments or afraid to visit clinics lest they be infected with Covid-19. The greater reliance on community networks to support TB patients during the pandemic, whether for diagnostic referrals or to encourage treatment adherence, has also reinforced the importance of integrating local personnel and resources into TB programs.
The pandemic has also accelerated a trend toward decentralized health services, including home delivery of essential medications and multi-month dosing of TB medications—something the WHO has recommended for drug-susceptible cases but which many countries had been slow to adopt. Similarly, lockdowns and social distancing have hastened a shift to the use of WHO-recommended oral drug formulations that can be taken at home instead of injections, which, prior to the pandemic, required many MDR-TB patients to make daily visits to health clinics.
- Finally, during the Covid-19 crisis, private, public, and multilateral institutions have come together in unprecedented ways to rapidly fund and execute research and product development. Examples—including Operation Warp Speed (now the Countermeasures Acceleration Group) in the United States, which supported several companies focused on Covid-19 therapeutics and vaccine development, and the Access to Covid-19 Tools Accelerator (ACT-A), a global effort focusing on developing and equitably disseminating diagnostics, therapeutics, and vaccines—have shown it is possible to speed up access to new products when the financial risks to developers are reduced and manufacturing begins even before regulatory approval.
Given that the number of new drugs developed to treat TB over the last 50 years has been limited, identifying the elements of Covid-19 models that are most likely to lower risk and incentivize TB-related drug discovery and manufacturing will be important, particularly considering that treating patients with MDR-TB could cost the global economy $16.7 trillion by 2050 if no new drugs are introduced. The rapid development and distribution of Covid-19 vaccines—made possible through the unprecedented mobilization of resources and support for research collaborations—also offers hope that with adequate support TB vaccines currently under development can advance more quickly to the final stages of testing and regulatory authorization.
Covid-19 has posed multiple challenges to meeting global goals related to TB prevention, diagnosis, and response. At the same time, there are many program innovations or adaptations from within the Covid-19 response that are worth retaining and building upon to improve access to TB services and improve global health security now and in the long term.
In this period of heightened discussion related to health security—including on pandemic preparedness, pharmaceutical innovation, data collection and analysis, and service delivery—donors, multilateral organizations, national programs, and advocates can urge increased financial commitments and greater political leadership on TB in four key ways:
- Increase financial commitments for global TB programs through bilateral and multilateral channels. To enhance public health emergency preparedness and reinvigorate progress toward meeting the targets set by the SDGs and the End TB Strategy, there is an urgent need to dedicate additional resources to TB research and programming.
- Rapidly scale up efforts to collect and analyze data regarding TB and MDR-TB diagnoses, treatments, and treatment failures. Country- and district-level data about TB has historically been available several months to several years after it is collected, but the Covid-19 pandemic has shown that it is possible to track and analyze data about respiratory infection rates and vaccine deliveries in real time. To gain an accurate understanding of how Covid-19 has affected TB control and response efforts, updated information is essential.
- Prioritize TB and MDR-TB within pandemic preparedness activities. During the Covid-19 crisis, patients with active or latent TB infections missed testing or treatment due to periods of lockdown and social distancing, the reassignment of clinical staff to outbreak response, and the disruption of medical supply chains. The decreases in TB notifications in 2020 and 2021 suggest a high number of undiagnosed cases, while interruptions in care increase the likelihood of treatment failure and the transmission of DR-TB. Provisions to ensure continuity of TB, DR-TB, and MDR-TB testing, case identification, and care in the context of a public health emergency should be considered essential elements of pandemic planning. Ensuring high-quality contact investigation and case finding for TB, along with improving laboratories’ capacity to test for TB and detect MDR-TB, can also support the development of a health workforce and public health infrastructure capable of responding effectively to a potential pandemic.
- Ensure that research, financing, and service delivery adaptations and innovations within the Covid-19 response inform future efforts to address the global challenge of TB. During the Covid-19 crisis, private, public, and multilateral institutions have come together in unprecedented ways to develop and distribute new products, in part by reducing the financial risks to developers and initiating manufacturing prior to regulatory approval. Identifying the elements of the Covid-19 models that are most likely to lower risk and incentivize TB-related drug discovery should be considered.
Although pandemic-era lockdowns and the rapid shift of resources from routine services to outbreak response since March 2020 have slowed progress in preventing, diagnosing, and treating TB, several policy and program innovations from within the Covid-19 response may help improve the financing, research, and delivery of TB services now and in the longer term. The considerable mobilization of resources, collection and analysis of data, and acceleration of public-private product development partnerships in response to Covid-19 create a window of opportunity to advocate for increased financing for TB research and services. With political will and strong financial commitments—and by integrating TB services into pandemic planning—it may be possible not only to regain ground lost during the pandemic but also to reignite progress in meeting global TB goals over the next decade.
Senior Fellow and Director, Immunizations and Health Systems Resilience, Global Health Policy Center
Katherine E. Bliss brings her expertise in the social sciences, Latin American studies, and international relations to her work analyzing U.S. government support for health programs in low- and middle-income countries. She is particularly interested in how political and cultural perspectives shape approaches to such global health challenges as HIV/AIDS; vaccine-preventable diseases; and access to safe drinking water and sanitation. Trained as a historian, Katherine spent the early part of her career teaching at the university level and publishing books and articles on gender relations and public health in twentieth-century Mexico. A Council on Foreign Relations International Affairs Fellowship enabled her to shift her focus to global health policy, placing her at the U.S. Department of State, where she worked on environmental health issues and the development of foreign policy approaches to pandemic preparedness.
At CSIS, Katherine has previously served as deputy director and senior fellow within both the Americas Program and Global Health Policy Center, where she oversaw a multi-program project on the influence of the BRICS countries on the global health agenda and directed the Project on Global Water Policy. Her recent work has examined the health situation in the context of the Venezuelan political crisis and the challenges facing immunization programs within fragile or disordered settings. Katherine received her A.B. in history and literature, magna cum laude, from Harvard College and her Ph.D. in history from the University of Chicago. She completed a David E. Bell Fellowship at the Harvard Center for Population and Development Studies.Full Bio Here
Research Associate, Global Health Policy Center
Michael Rendelman is a research associate with the Global Health Policy Center at CSIS, where he is responsible for conducting research and coordinating program activities. He focuses on supporting the immunization, HIV, and primary health care portfolios. Prior to joining CSIS, he worked at the Smithsonian Institution as a researcher and interned at the German Marshall Fund of the United States. He has also supported development programming in the Republic of Georgia. He holds a bachelor’s degree from the University of Wisconsin-Madison and a master’s degree from Georgetown University’s School of Foreign Service, where he focused on health and development in the Eurasian region. He is a U.S. Department of State critical language scholar and was selected to pursue advanced coursework in the Russian Federation.Full Bio Here
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