Tak­ing the of­fen­sive against tu­ber­cu­lo­sis

Financial Mirror (Cyprus) - - FRONT PAGE -

Tu­ber­cu­lo­sis is one of the world’s dead­li­est dis­eases. In 2013 alone, it ac­counted for 1.5 mil­lion deaths, in­clud­ing one-fifth of adult deaths in low-in­come coun­tries. Although the es­ti­mated num­ber of peo­ple con­tract­ing TB an­nu­ally is de­creas­ing, the de­cline has been very slow. And, given the in­creas­ing preva­lence of mul­tidrug-re­sis­tant TB, the trend could be re­versed.

Nonethe­less, the world now has a nar­row win­dow of op­por­tu­nity to erad­i­cate TB. Tak­ing ad­van­tage of it will re­quire the rapid de­vel­op­ment and dis­sem­i­na­tion of ef­fec­tive di­ag­nos­tic tools, novel drug treat­ments, and in­no­va­tive vac­cines, in con­junc­tion with ef­forts to en­sure that health-care sys­tems are equipped to de­liver the right care. This will be no easy feat.

The good news is that the in­ter­na­tional com­mu­nity seems ea­ger to act. The World Health Or­gan­i­sa­tion’s post-2015 Global TB Strat­egy, which was en­dorsed by the World Health Assem­bly in May 2014, aims to erad­i­cate TB by 2035. The Sus­tain­able De­vel­op­ment Goals, which will be for­mally adopted in Septem­ber by the United Na­tions’ 193 mem­ber states, fore­see achiev­ing that ob­jec­tive five years sooner.

To stem the de­vel­op­ment and spread of drug-re­sis­tant TB re­quires a two-pronged global ef­fort: en­sur­ing early de­tec­tion and ad­e­quate treat­ment of pa­tients with drugsen­si­tive TB, and find­ing new ways to treat pa­tients in­fected with drug-re­sis­tant strains. The prob­lem is that ex­ist­ing tools for TB di­ag­no­sis, treat­ment, and preven­tion have se­vere lim­i­ta­tions.

For starters, there is no fast point-of-care di­ag­nos­tic test for TB. In low-in­come coun­tries, the dom­i­nant di­ag­nos­tic method is spu­tum mi­croscopy, an out­dated ap­proach that fails to de­tect TB in about half of all in­fected pa­tients, with an even lower suc­cess rate for young chil­dren and pa­tients coin­fected with HIV. In­deed, no more than one in ten chil­dren with TB is di­ag­nosed by spu­tum mi­croscopy.

More­over, for pa­tients in­fected with multi-drug-re­sis­tant TB, treat­ment with the cur­rently avail­able drugs is suc­cess­ful only half the time, even un­der the best con­di­tions. And the ther­a­peu­tic process is tough, last­ing at least two years and in­volv­ing up to 14,600 pills and hun­dreds of in­jec­tions – with se­vere side ef­fects.

New TB drugs with novel mech­a­nisms of ac­tion are badly needed, not only to treat multi-drug re­sis­tant TB, but also to shorten the treat­ment time for drug-sen­si­tive TB. Here, there is some promis­ing news: Be­daquiline re­cently be­came the first new TB drug to be ap­proved by the US Food and Drug Ad­min­is­tra­tion in 40 years. But Be­daquiline has yet to prove its ca­pac­ity to treat drug-re­sis­tant TB ef­fec­tively, and there are very few other can­di­dates in the pipeline.

Sim­i­lar prob­lems arise in preven­tion. The Bacille de Cal­mette et Guérin (BCG) vac­cine – the only one avail­able for the dis­ease, and the main pil­lar of TB preven­tion – is only partly ef­fec­tive.

In­deed, while it pro­tects chil­dren from the worst forms of the dis­ease, it does not pro­tect any­one against the most com­mon vari­ant, pul­monary TB. As a re­sult, it has done lit­tle to re­duce the num­ber of TB cases. And, although sev­eral new vac­cine can­di­dates have passed pre­lim­i­nary clin­i­cal tests, BCG will re­main the only avail­able vac­cine for years to come.

The chal­lenges are clearly for­mi­da­ble. But, with mil­lions of lives at stake, back­ing down is not an op­tion.

It comes down to re­search – a fact that the WHO global strat­egy recog­nises. But scal­ing up in­vest­ment in di­ag­nos­tic tools and treat­ments for TB costs more money than has been al­lo­cated. Of the es­ti­mated EUR 1.73 bln ($2 bln) that is needed an­nu­ally for re­search and de­vel­op­ment, only EUR 589 mln was in­vested in 2013.

Mak­ing mat­ters worse, crit­i­cal donor fund­ing – pro­vided by a very lim­ited num­ber of ac­tors, mostly gov­ern­ment agen­cies and phil­an­thropic groups in OECD coun­tries – fell by nearly 10% last year. At present, a sin­gle phil­an­thropic donor, the Bill & Melinda Gates Foun­da­tion, sup­ports more than 25% of re­search on new tools to fight TB.

As for the pri­vate sec­tor, phar­ma­ceu­ti­cal com­pa­nies have been with­draw­ing from TB re­search, as part of a gen­eral trend away from anti-in­fec­tive drugs to­ward the de­vel­op­ment of new drugs for chronic ill­nesses. Pfizer ex­ited TB re­search in 2012, fol­lowed by As­traZeneca in 2013 and No­var­tis last year.

Clos­ing the fund­ing gap and end­ing the scourge of TB will re­quire the in­volve­ment of more – and more di­verse – donors. If the pri­vate sec­tor is un­will­ing to do its part, it is up to gov­ern­ments to step in with a sus­tained com­mit­ment – man­i­fested in di­rect con­tri­bu­tions, as well as ef­forts to cre­ate the right in­cen­tives – to achiev­ing the SDG tar­get to which they have agreed.

In short, erad­i­cat­ing the TB epi­demic pre­sup­poses ef­forts to en­sure that healthcare sys­tems are ca­pa­ble of de­liv­er­ing the right care. And the right care re­quires rapid de­vel­op­ment and dis­sem­i­na­tion of new tools, in­clud­ing quick point-of-care di­ag­nos­tic tests, safe and fast-act­ing drugs, and an ef­fec­tive TB vac­cine.

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