How the U.S. can transform the fight against TB & prevent future pandemics

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Image: Global Fund

As the COVID-19 pandemic continues to disrupt and destabilize health systems around the world, an ancient killer has once again found its footing.

Lockdowns and fear of COVID-19 stopped many from getting tested and treated for tuberculosis (TB). Supply chains for TB medicines and diagnostics have been disrupted. And national TB programs have been pushed to the brink as staff and funding are pulled to the COVID-19 response.

Global progress against TB was already slow and fragile. And now data is showing that 12 months of COVID-19 has eliminated 12 years of TB gains in many countries with high rates of TB.

But this moment of enormous public health challenge is an opportunity to create a better way of working that can fight both diseases. We can invest in systems that will not only find and treat people for both COVID-19 and TB, but that will help prevent future pandemics.

It is a false choice between attacking the current pandemic and preparing for the next one. In many countries, existing TB programs formed the backbone of national and local COVID responses. Infection control, lab capacity, respiratory disease expertise, active outreach, and contact tracing were all capacities built in TB programs.

The challenge is that TB programs were already hugely underfunded, and COVID further diverted resources. With full funding and adequate staffing, resourcing, and testing supplies, these same programs could instead not only bring an end to TB as a global killer, but also provide a respiratory disease response platform for future pandemics.

Domestic country budgets have long been the biggest funders of TB programs, but now those budgets are stretched thinner due to COVID-19 — even as needs have grown. As an established global leader on TB, USAID can play a critical role to support locally led TB programs, rapidly adapt and restore critical TB services during the pandemic, prevent a dangerous reversal of progress, and strengthen TB programs for the future.  

With an increased annual TB budget of $1 billion, USAID could have a transformative impact on TB efforts globally while helping build the systems needed to prevent the next pandemics.

Protecting fragile progress against TB

For decades, TB was stuck at the bottom of political priority lists, allowing it to climb to the top of the list of global infectious killers. Every year, TB sickens about 10 million people and causes about 1.4 million deaths. That burden does not fall evenly. TB disproportionately impacts people who are already in poverty and otherwise pushed to the margins, largely in countries facing the consequences of colonialism, resource extraction, and unjust global lending policies.

COVID-19 was responsible for more deaths globally in 2020, but TB is still one of the biggest public health threats facing many low- and middle-income countries. Both are airborne diseases that primarily affect the lungs. But while COVID-19 is a new illness making sweeping impacts around the globe, people have been falling sick from TB for centuries.

TB is preventable, it is treatable, and in almost all cases, it is curable. Before COVID-19 struck, the global picture on TB was cautiously brightening. The global community had set an ambitious goal to end the TB epidemic by 2030.  And with affected communities leading the way, countries like the U.S. and global organizations like the Global Fund to Fight AIDS, TB and Malaria stepped up to invest in reaching and treating every person with TB, preventing its spread, and scaling up new innovations like diagnostics and drugs.

Now, TB treatment is shorter, with fewer side effects, and it reaches more patients than ever before.  The number of people with TB who were missing out on care declined by 1.4 million between 2015 and 2019. And since 2000, 63 million lives have been saved from TB.

TB systems as a backbone of the global COVID response

Decades of political neglect meant progress against TB was slow and fragile — and now health system disruptions from COVID-19 have left room for the disease to make a comeback.

TB programs — with their contact tracing systems, laboratory infrastructure, and infection prevention and control expertise — formed the backbone of the COVID-19 response in many countries. Tapping into TB-fighting systems and infrastructure added quick capacity to fight COVID-19, but it placed an immense burden on already-stretched national TB programs that were also facing lockdowns, supply chain challenges, and other disruptions.

New data shows that 12 months of COVID-19 eliminated 12 years of progress to fight TB in many high burden countries such as India and South Africa. And a Global Fund survey found similar results, with hard hit countries reporting breakdowns in their ability to diagnose and treat people for TB. Any disruptions in TB treatment could give rise to more drug-resistant, and often more deadly, forms of the disease.

Models project that due to COVID-19 the world could see an additional 6.3 million cases of TB and a doubling of TB deaths by 2025.

Investing in smart ways to fight both TB & COVID-19

This moment of enormous public health challenge is an opportunity to create a better way of working that can help us fight both TB and COVID-19.

The incredible progress made over the past five years to actively find people with TB did not have to evaporate with COVID-19 — when smartly done, the same systems could support both contact tracing for COVID-19 and active finding of TB cases. India, for example, started bidirectional testing — when a person was tested for one, they were automatically tested for the other. At a national scale, this type of collaboration could have an enormous impact on the response to both diseases.

And new technologies could support progress on both TB and COVID-19. Lightweight and portable X-ray machines, for example, can be used in communities alongside computer-aided detection software to help health workers interpret X-rays in decentralized health settings.

We can invest in systems that will not only find and cure people for TB and COVID-19, but that will help prevent future pandemics.

USAID: A difference maker in the global fight against TB

U.S. investment has driven incredible progress against TB in hardest hit countries. Backed by strong bipartisan Congressional support, USAID leads the U.S. government’s global TB efforts, supporting countries to reach, treat, and cure every person with TB, and to prevent new infections.

With a current annual budget of $319 million, USAID has strengthened TB programs in 23 of the highest burden countries and provided technical assistance to 32 others. Its record of success is clear: Since 2000, TB incidence decreased by 29% and TB deaths decreased by 47% in its 23 priority countries.

To accelerate progress, USAID makes critical investments in civil society — helping ensure that people with TB, especially vulnerable populations and those living in poverty, are at the forefront of efforts to fight the disease. The agency also prioritizes innovative strategies and tools, and particularly played a key role in expanding the availability of medicines to treat multi drug-resistant TB (MDR-TB). By backing the Global TB Drug Facility, USAID enabled a 60% drop in prices for MDR-TB treatment since 2013 — helping more countries and patients access these lifesaving medicines than ever before.

USAID also improves the effectiveness of Global Fund to Fight AIDS, TB and Malaria investments by providing targeted technical assistance to national TB programs.

What would an annual $1 billion USAID TB budget buy?

We know that U.S. investment has contributed to incredible progress to reach, treat, and cure more people from TB. Yet current USAID TB funding represents just 3% of the $9.1 billion provided to USAID and State Department global health programs.

TB should be a centerpiece of U.S. global health leadership and pandemic response, both through USAID and the Global Fund. Civil society and allies in Congress are calling for a $1 billion annual TB budget for USAID to rapidly adapt and restore critical TB services during the pandemic, prevent a dangerous reversal of progress, and strengthen TB programs for the future.

We only need to look at the President’s Emergency Plan For AIDS Relief (PEPFAR) or the President’s Malaria Initiative to see that U.S. commitment on a global health issue can have a massive impact.

With an annual $1 billion TB budget, USAID could:

• Support local health workers and programs to save more lives from TB and recover momentum against the disease by expanding access to treatment for all forms of TB, including MDR-TB, increasing its support for TB prevention, and making more investments in TB research and development.  
• Expand its list of priority countries, helping even more national TB programs fight both COVID-19 and TB.
• Expand the integration of TB and COVID-19 testing networks in priority countries by training staff on bidirectional testing, ensuring adequate diagnostic equipment and facilities, and building back up the human resources available to fight both diseases.
• Channel additional resources to community-based organizations, which are now even more important for maintaining and improving TB services.
• Address urgent procurement and supply challenges affecting access to TB medications, as well as diagnostics needed for both TB and COVID-19.

This relatively modest level of annual investment could have a transformative impact on TB efforts globally, while creating health systems that will help prevent future pandemics.