With World Tuberculosis Day on March 24, new reports are shedding additional light on the lethal infection that is often mistaken as a disease of the past. Last week’s reports from the World Health Organization and Lancet remind us that TB remains the world’s deadliest infectious disease and highlight the challenges we face if we are to meet the international goal of eradicating TB by 2030.
More than 10 million people in the world develop tuberculosis disease every year, leading to about 2 million deaths. Because of unrecognized exposure to an infectious patient with pulmonary TB in their homes or in the community, approximately 1 in every 4 people on the planet are now silently infected with tuberculosis.
Two billion members of our global family have what is referred to as latent TB infection (LTBI) and are at risk for developing TB disease and spreading the infection further. Eradicating TB will require much greater effort to identify and effectively treat these individuals.
Patients with active TB disease can be cured, which also greatly reduces their risk of transmitting TB to others. The challenge is that symptomatic patients with TB disease require months of treatment with at least four drugs. In addition, if these patients do not take their medications every day, the TB bacterium can become resistant to the medications leading to the development and spread of multidrug and extremely drug-resistant TB.
New strategies to help ensure that patients take their medications every day—as well as the availability of new shorter treatment regimens—for both active TB disease and LTBI, provide us with some hope. Because of the enormous public health risk it presents, TB is one of the few diseases for which the standard of care involves a practice called Directly Observed Therapy (DOT), in which public health workers must actually watch patients take each dose of their medication.
While this practice is highly effective, the traditional method of performing DOT in person is very costly and burdensome for health departments and patients.
One relatively new tool in the TB eradication toolbox has been the implementation of video technology in DOT, making it possible for health workers to monitor medication adherence for patients remotely. This has proven to be more efficient, convenient, and cost-effective for health departments and patients. Medication adherence is becoming even more important as new drugs are developed with shorter regimens. A recent study in the New England Journal of Medicine reported on a highly effective and safe one-month treatment for LTBI in HIV patients. This is an important advancement because it’s much more feasible for patients to complete treatment in one month compared to the typical six-to-nine-month treatment. The one-month regimen for LTBI could be a game-changer for TB control, but patient adherence must be excellent. Missing a single dose over nine months is not nearly as detrimental as missing a dose in a 30-day regimen.
Great advances have been made in the field, but without a political push for increased funding and stronger advocacy, we won’t be able to scale these innovations to meet our goal of eradicating TB. In 2018, the United Nations issued a declaration at the first High-Level Meeting on Tuberculosis to try to rally an urgent global response to address this global public health threat. Eradicating TB by 2030 is an ambitious goal that would save millions of lives.
There are important recent developments and innovations that can be leveraged to support this effort. But achieving this goal will require a greater sense of urgency and an increase in political will, as well as significant new investments in TB research, prevention and treatment.
These new resources to eradicate TB are needed right now.
Robert C. Bollinger, MD, MPH, is a Professor of Infectious Diseases in the Department of Medicine of the Johns Hopkins School of Medicine.