Will the world leaders walk the talk to end TB at the upcoming UN High Level Meeting ?

Shobha Shukla, Bobby Ramakant *

Leaders of all the UN member countries are expected to convene on 22nd September 2023 at the upcoming second United Nations General Assembly High Level Meeting (UNHLM) on TB (the first one was held in September 2018). The theme of this year's UNHLM is: “Advancing science, finance and innovation, and their benefits, to urgently end the global TB epidemic, in particular by ensuring equitable access to prevention, testing, treatment and care.”

The theme of the upcoming UNHLM is on spot. But will it turbocharge the fight against TB? One wonders that so far, to what extent the governments have advanced science, finance, and innovation, and ensured equitable access to prevention, testing, treatment, and care?

TB is preventable. Yet it was not for over 10.6 million people who got infected with TB in 2021. TB is curable. But it was not for over 1.6 million people who died of TB in the same year.

Science has gifted us new tools to prevent TB, diagnose TB early and accurately, and treat TB. But are we using these new tools optimally, especially in high TB burden countries, so that we get to zero new TB cases; timely and accurately diagnose 100% of the people with TB; and successfully treat and cure them?

In 2021, only 61% of people with TB were diagnosed and put on treatment. The UN health agency, the World Health Organization (WHO), recommends using molecular tests for diagnosing drug senstivie TB and rifampicin-resistance upfront, but only 38% of people with TB were diagnosed using molecular testing between 2018 and 2021. A whopping 62% of people with TB were instead diagnosed using the 140 years-old sputum smear microscopy which underperforms in TB diagnosis. In India, which is home to the highest number of people with TB globally, only 23% of people got a molecular test in 2022. The most used molecular test in India is Truenat, which is the only point-of-care and decentralised molecular test recommended by the WHO and is made in India by Molbio Diagnostics.

Unless we completely and quickly replace the old diagnostic tools, like smear microscopy, with WHO recommended molecular tests, we will not be able to: 1) diagnose everyone with TB, 2) prevent avoidable human suffering and avert untimely deaths, and 2) break the chain of infection transmission.

The same goes for treatment regimens being used to prevent and treat TB. The one-month long treatment to prevent TB (TPT), the four-month regimen to treat drug-sensitive TB, and the six-month regimen to treat drug-resistant TB are yet to become a reality for a majority of the people with TB worldwide.

In addition, countries are also lagging way behind in addressing the top-5 TB risk factors: malnutrition, tobacco use, alcohol consumption, diabetes, and HIV; as well as in rolling out TB preventive therapy to those with latent TB and at higher risk of progressing to active disease.

High time we adjust the sails!

“The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails,” had said William Arthur Ward. The optimism to end TB by 2030 alone is not enough unless it is matched with action.

Translate scientific achievements into public health impact

Sriram Natarajan, co-founder and Chief Executive Officer of Molbio Diagnostics (that makes Truenat molecular test) reminds us that while important TB-related commitments were made by the world leaders at the first-ever UNHLM on TB held in 2018, it did not end with a powerful-enough political declaration.

"TB can be eliminated because effective TB diagnostic tools, new treatment regimens, and evidence-based approaches that have shown to work, are already there. New tools to fight TB may come soon too. But unless we fully implement the tools with an action plan on the ground, it is not going to happen. And that needs money. World leaders need to follow upon their commitment to end TB with full financing,” added Natarajan.

Eliminate the TB funding gap first

Every US$ 1 invested in TB yields benefits of US$ 46. Still financial crunch ails the fight against TB in many high TB burden nations.

“In Ghana’s national strategy plan, we have a gap of US$ 20 million every year. This is a huge gap. We need this money to do more molecular testing for TB, TB screening by using digital X-rays, and implement better technologies. If we get resources to fill the funding gap in Ghana, then 85% of them will be invested in diagnostics and 15% in programmatic interventions to strengthen the national TB response,” said Dr Yaw Adusi-Poku, Programme Manager, National TB Control, Ghana Health Services.

TB responses should match the urgency and purpose which leaders had demonstrated during the COVID-19 pandemic. “I would like to see world leaders from high income countries to share resources needed to eliminate this curable and preventable disease. I want world leaders from high TB burden countries to optimise utilisation of their resources through equity development and convincing domestic co-financing that is sustainable,” said Dr Nguyen Binh Hoa, Vice Manager of Vietnam National TB Programme and Vice Director of National Lung Hospital.

Agrees Dr Louine Morel, Medical Registrar, Communicable Disease unit, Ministry of Health of Seychelles - which has the lowest TB rates in Africa. She too calls for fully funding the TB response.

TB is a social disease, so it warrants a socially just response

It is high time for accountability. “I would like the world leaders to be committed and be held accountable to end TB within our lifetime. To do so, we have to find undetected TB cases and treat them. Also, we have to optimally introduce new interventions like molecular tests, safer, shorter, and more effective treatment regimens,” added Dr Hoa. “A whole of government and society approach worked for COVID-19, then why is it missing in TB response? We need to expand our perception from TB as a clinical disease to TB as a social disease. We must eliminate the catastrophic costs faced by people with TB.”

Agrees Dr Imran Pambudi, Director of Communicable Disease Prevention and Control unit, Ministry of Health, Indonesia who too underlines the pivotal importance of fully financing the fight against TB, rock solid political commitment, whole of government and whole of society approach to end TB within a given timeline.

TB affected people should lead on demand generation

“TB affected communities need to lead on demand generation for WHO recommended best of TB diagnostics, treatment regimens, care and support, and prevention services to reach everyone in need, everywhere. I am calling upon TB survivors to be engines for demand generation. There must be a strong and growing call rising from the ground for the authorities to fund primary healthcare. We have a long way to go but I can clearly see the key: you have to convince people how to keep themselves healthier. I might not design structures anymore, but I know how to design healthier lives,” said Eloisa ‘Louie’ Zepeda-Teng, a former architect and Founder of TB People Philippines who has survived TB of the brain but lost her vision to TB.

Food is the best vaccine to prevent TB

A recent study done in India called RATIONS shows that by providing a pack of food rations to the family of TB patients, TB rates dropped by 39-48%. Dr Arvind Mathur, WHO Representative in Timor-Leste said, “Governments have to tackle malnutrition. Nutritious food plays an important role in TB care and control too.”

“I hope that the political declaration that is being considered by member countries as an outcome of the UNHLM on TB, not only brings together science based practical and actionable suggestions to the member countries, but countries also commit to increased domestic funding. They should look into embracing WHO recommended science-based solutions related to TB prevention, detection, and newer treatment regimens. We look forward to a comprehensive, multi-sectoral response in action, at the country and sub-national level, and also at the level of any individual who may have been affected by TB. All of us have the responsibility to bring detection, treatment, and all support services to that individual to bring him or her back to the normal health he or she is entitled to,” added Dr Mathur.

Healthcare workers are there, but new tools are not

“My message to the world leaders at the UNHLM on TB is to fully support technology and new tools for case detection and for TB management. We have willing healthcare workers, such as me and my team in the field, who are willing to deploy these new tools for TB effectively. I do not want to see any person die of TB. Also, a lot of people do not seek help because of the stigma and because the latest diagnostic tools are at such far-flung places and out of reach for them. By bringing point-of-care and decentralised molecular testing at their doorstep, we can help end TB,” said Dr Samantha Tinsay, Municipal Health Officer, Bantayan Municipality, Cebu, Philippines.

It is everyone’s right to not get infected by TB

“I want that we and our next generation will live free from TB. It should be everyone’s right to not get infected by TB. There should be more investment for TB. Latest diagnostics and shorter, less toxic, and more effective treatment regimens for active and latent TB must be made accessible to all. All of us are not able to access the diagnostics and treatment regimens that are already there,” rightly said Ani Herna Sari, TB survivor and founder of Rekat Peduli Indonesia Foundation.

Are we doing enough to reach the unreached?

The governments in the recent years have tried to plug the gaps in TB response. “For example, introducing New Tools Project (iNTP) of the Stop TB Partnership and USAID has helped in the rollout of a package of latest innovations in diagnostics, treatments, and digital health technologies to strengthen TB care in high burden countries. The use of these new tools under iNTP, which includes Truenat molecular test, has shown the public health impact. It is time for the governments to scale up these interventions, that have proven to work, to help find the missing millions of TB cases. It is only through scaling up the deployment of the new tools for TB diagnostics, treatment, and digital health technologies, that we may see a bigger impact in terms of reaching the unreached,” rightly said Sumit Mitra, President of Global Sales and Marketing, Molbio Diagnostics.

End war

Dr Hiam Yaacoub, who has led the National TB Programme of Lebanon since 2012, said that the TB response cannot remain unaffected by conflicts and wars. Not only social and economic security, but health security is also threatened by them, and this includes the response to TB. She said that “We must stop these wars. Global peace is integral to ending TB too,” and also to all other SDGs.

Dr Yaacoub also echoes the concern on sustainable financing, equity, and TB risk factors: “UNHLM on TB should put TB on top of the agenda, not only by signing declarations and commitments to support us by developing ambitious strategic plans, but by securing funding for us to implement these plans and to reach our goal of a TB free world. I would ask them to make all the latest TB diagnostics, medications, and prevention tools, including the vaccines (currently under research), accessible and available to all, in all the countries. In addition, I would ask them to secure funding to fight the social determinants of TB, like poverty and malnutrition, that are the real drivers of TB.”

Evaline Kibuchi, Chief National Coordinator of Stop TB Partnership Kenya, also echoes the call for a safe and effective TB vaccine that should be rolled out equitably when available.

It’s time to deliver on the #endTB promise

The clock is ticking as the goalpost to end TB draws closer. With less than 88 months left to end TB globally, Molbio Diagnostics co-founder and serial entrepreneur Sriram Natarajan hopes from the upcoming UNHLM for stronger commitments to galvanize the fight against TB. “All said and done, lot of people are dying unnecessarily of TB. These lives could be saved just by introducing the right tools timely and effectively,” he said.

The cost of inaction (on fully converting scientific breakthroughs into public health impact) is unacceptable. Failure to universally deploy the WHO recommended standard tools for TB diagnostics and treatments result in missed TB cases, avoidable suffering, and untimely deaths. In addition, the failure to break the chain of infection transmission threatens to reverse the gains made in the fight against TB.