Tuberculosis Is A Threat To Global Health Security

This article recently appeared in the September 2018 issue of Health Affairs. You can read the original here.

Heads of state gather this month for the United Nations (UN) General Assembly on tuberculosis, the first time in the disease’s 3,000-year history that such a high-level meeting has been held. So why hold one now?

Thanks to the success of treatment in lowering mortality from HIV, TB has recently surpassed HIV as the world’s leading infectious disease killer, with 1.7 million deaths attributed to the disease in 2016. Though slow, progress is under way in reducing TB incidence and mortality. But progress has stagnated in finding and treating drug-resistant TB, including multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB). According to the World Health Organization, only 22 percent of MDR-TB cases globally are being detected, and treatment success is only 54 percent.

One big emerging concern is the increasing importance of airborne transmission in creating new cases of drug-resistant TB, and this reflects the need to change the way leaders need to strategize and act. Recent mathematical modeling by the Centers for Disease Control and Prevention suggests that most drug-resistant TB will emerge from person-to-person airborne spread of drug-resistant TB germs, rather than the long-standing view that most drug-resistant TB results from poor treatment of drug-sensitive TB. This has enormous infection control implications.

Moreover, for every hundred TB cases, roughly twenty are linked to undernutrition, ten to HIV, ten to diabetes, and ten to tobacco. These linkages combine with rapid urbanization, crowding, growing migration, and persistent poverty to create a perfect storm for airborne TB transmission. High-income countries such as the United States could eliminate TB in the short term but later find themselves unable to treat people with latent drug-resistant TB—which would create a new epidemic of drug-resistant TB, as untreated latent drug-resistant infection reactivates. And there is no test for latent drug-resistant TB infection. The world is nearing a slippery slope toward a future scenario in which TB becomes unstoppable.

The UN Security Council has declared an infectious disease a threat to global security only twice—in the case of HIV/AIDS in 2001, when the success of African peacekeeping missions was at stake, and in the case of the devastating Ebola epidemic in West Africa in 2014. Such a declaration for TB would help stimulate the investment needed. But TB is different. It is less explosive and doesn’t grab headlines. Nonetheless, heads of state should act now upon the multisectoral recommendations made by health ministers in the Moscow Declaration to End TB—especially in strengthening the health workforce, the weakest aspect of health systems.

TB has been a priority at Project HOPE throughout our sixty-year history, beginning with the first voyage of the hospital ship SS Hope—a voyage to Indonesia, where a heavy burden of TB was seen in the patients we cared for. Today we continue to work with ministries of health, national TB control programs, laboratories, the private sector, local civil society, and other partners to build local capacity to prevent, detect, and treat TB in the most vulnerable populations, including migrant groups and people living with HIV/AIDS. We look forward to doing more to put words into action toward TB control following the UN high-level meeting.