Viewpoint

In the Time of COVID-19: Why Have We Not Declared a Tuberculosis Pandemic?

While global attention is focused on COVID-19, tuberculosis remains the world’s deadliest infectious disease. There should be a more concerted effort to end it.

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“I thought tuberculosis (TB) was eliminated” said my relative when I mentioned I was heading to KwaZulu-Natal, Durban in South Africa, a country that has experienced a rise in drug-resistant TB cases since 2002. As I continued my collaborations with laboratory colleagues, in the summer of 2010, at the University of KwaZulu-Natal, I was surprised as I thought everyone was aware of the catastrophic number of deaths caused by the disease.

A quick search in the registry of clinical trials, developed by the US Department of Health and Human Services and National Institutes of Health, revealed that there are currently more than 4,000 COVID-19 clinical trials. Under that same registry, there are approximately 1,100 ongoing TB clinical trials. It is noteworthy that there are three times as many trials underway for the COVID-19 pandemic as there are for a disease that has affected the world for millions of years.

Just as experts have stated that the way to end the COVID-19 pandemic is the development of a successful vaccine, the same is true to end the TB crisis. During this unprecedented time in the world, I cannot help but wonder why there isn’t a concerted effort to end TB such as the one against COVID-19?  TB causes the highest number of deaths associated with infectious diseases in the world. In 2019, according to the WHO, about 10 million people got sick and approximately 1.5 million people died from the disease. Furthermore, TB kills approximately 4000 people a day.

The first cases of TB may have occurred more than 150 million years ago in East Africa, but the first documented cases were in Egyptian mummies around 2400-3400 BC. From the 1600s to the late 1800s, TB caused 20 to 30 percent of all deaths in Europe and the US. In 1882, Robert Koch isolated the tubercle bacillus that causes TB, which led to the development of the Calmette-Guerin (BCG) vaccine in 1921, and by the 1940’s, four antibiotics were developed to treat TB; isoniazid, pyrazinamide, ethambutol, and rifampin. The vaccine and antibiotics led to the reduction of TB cases in Europe, the US, and other developed nations.

Soon after public health professionals, scientists, and clinicians shifted their focus to other diseases, but TB continued to spread in developing countries in Africa, Asia, and South America, due to the lack of overall infrastructure, weak healthcare systems, low resources, and scarcity of funds towards innovative TB research. While BCG has become the most widely used vaccine and provides protection to children against military and meningeal TB, it provides limited protection against pulmonary TB, which is the most common form of TB. Over the years, the treatment of TB has been further complicated with the emergence of HIV and drug-resistant TB strains.

In 2015, the WHO launched the End TB Strategy to reduce TB incidence by 80 percent, deaths by 90 percent, and to eliminate costs for affected households by 2030. The strategy includes involvement from public health professionals, scientists, clinicians, and government officials.

Even with the widespread efforts, TB disproportionately affects parts of Africa, Asia, and Eastern Europe while the US, Canada, UK, and Australia experience lower rates of the disease. According to the WHO, in 2016, 2.5 million people became sick and approximately 417,000 people died from TB in the African region. India, Indonesia, China, Philippines, Pakistan, Nigeria, and South Africa account for 64% of the TB cases in 2016.

Current treatment for TB still includes many of the original antibiotics that were developed in the 1950s and 1960s. While newer antibiotics have been introduced, they are still used in combination with the original antibiotics, whose side effects cannot be ignored. Similarly, BCG is still the only known TB vaccine administered to children in developing countries.

So why have we not declared a pandemic due to TB?

In the time since COVID-19 spread to the US, the virus has led to outbreaks in all regions of the country, infecting more than 11 million people and causing more deaths than in any other nation. In contrast, in Africa countries have reported lesser number of confirmed cases and deaths. Globally, there are now approximately 54 million confirmed cases of COVID-19 and over 1.3 million deaths.

While the US is battling continued surges of the virus, the response to COVID-19 has been nothing short of amazing. Public health professionals, scientists, and clinicians have come together from various parts of the world to share information and to work together. Communities are helping one another, especially those who are most vulnerable. The response to the TB crisis around the world and the care for those affected by TB should also be same. However, there isn’t a concerted effort to end TB.  Would the response to TB have been different if the countries heavily affected were in the US and Europe versus those in Africa? The fact remains that the countries with resources, funds, and technical capacity have not invested in the field of TB because the disease has not affected them. In contrast, COVID-19 has gained a great deal of attention from those same countries due to fear of the disease and its impact at home.

Rupal Ramesh Shah (SPH‘15) is the executive director of Konbit Sante, a Maine-based nonprofit organizationthat supports the development of a sustainable health system for the Cap-Haitien community in Haiti. Shah, an alum of the School of Public Health, has previously worked in South Africa and Tanzania. She also holds a master’s degree in microbiology.